Podcasts about texas southwestern medical center

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Best podcasts about texas southwestern medical center

Latest podcast episodes about texas southwestern medical center

The Doctor's Farmacy with Mark Hyman, M.D.
The Functional Medicine Approach To Hair Loss

The Doctor's Farmacy with Mark Hyman, M.D.

Play Episode Listen Later Sep 26, 2022 65:26 Very Popular


This episode is brought to you by Rupa Health, InsideTracker, and Pique Tea.Hair loss is a commonly experienced issue and often signals something deeper going on in the body. And as there are many different types of hair loss, there are also many various drivers of hair loss, including hormonal imbalance, metabolic dysfunction, or even autoimmune disease. This is why Functional Medicine practitioners look at gut and metabolic health, nutrient status, and much more to find the root cause of hair loss.In today's episode, I talk with Dr. Elizabeth Boham, Dhru Purohit, and Dr. Cynthia Li about the many different types of hair loss and their associated underlying causes. Dr. Elizabeth Boham is a physician and nutritionist who practices Functional Medicine at The UltraWellness Center in Lenox, MA. Through her practice and lecturing, she has helped thousands of people achieve their goals of optimum health and wellness. She witnesses the power of nutrition every day in her practice and is committed to training other physicians to utilize nutrition in healing.Dhru Purohit is a podcast host, serial entrepreneur, and investor in the health and wellness industry. His podcast, The Dhru Purohit Podcast, is a top 50 global health podcast with over 30 million unique downloads. His interviews focus on the inner workings of the brain and the body and feature the brightest minds in wellness, medicine, and mindset.Dr. Cynthia Li received her medical degree from the University of Texas Southwestern Medical Center in Dallas. She has practiced as an internist in settings as diverse as Kaiser Permanente Medical Center, San Francisco General Hospital, and St. Anthony Medical Clinic serving the homeless. Her personal health challenges led her to integrative and Functional Medicine, and she currently has a private practice in Berkeley, CA. She serves on the faculty of the Healer's Art program at the University of California San Francisco School of Medicine, and she is the author of Brave New Medicine: A Doctor's Unconventional Path to Healing Her Autoimmune Illness.This episode is brought to you by Rupa Health, InsideTracker, and Pique Tea.Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, and Great Plains. You can check out a free, live demo with a Q&A or create an account at RupaHealth.com.InsideTracker is a personalized health and wellness platform like no other. Right now they're offering my community 20% off at insidetracker.com/drhyman.Pique is offering up to 20% off plus free shipping on their Pu'er bundles. Just go to piquelife.com/farmacy for up to 20% off plus free shipping.Full-length episodes of these interviews can be found here:Dr. Elizabeth BohamDhru PurohitDr. Cynthia Li Hosted on Acast. See acast.com/privacy for more information.

Medicine via myPod
The Functional Medicine Approach To Hair Loss

Medicine via myPod

Play Episode Listen Later Sep 26, 2022 65:26


Dr. Mark Hyman This episode is brought to you by Rupa Health, InsideTracker, and Pique Tea.Hair loss is a commonly experienced issue and often signals something deeper going on in the body. And as there are many different types of hair loss, there are also many various drivers of hair loss, including hormonal imbalance, metabolic dysfunction, or even autoimmune disease. This is why Functional Medicine practitioners look at gut and metabolic health, nutrient status, and much more to find the root cause of hair loss.In today’s episode, I talk with Dr. Elizabeth Boham, Dhru Purohit, and Dr. Cynthia Li about the many different types of hair loss and their associated underlying causes. Dr. Elizabeth Boham is a physician and nutritionist who practices Functional Medicine at The UltraWellness Center in Lenox, MA. Through her practice and lecturing, she has helped thousands of people achieve their goals of optimum health and wellness. She witnesses the power of nutrition every day in her practice and is committed to training other physicians to utilize nutrition in healing.Dhru Purohit is a podcast host, serial entrepreneur, and investor in the health and wellness industry. His podcast, The Dhru Purohit Podcast, is a top 50 global health podcast with over 30 million unique downloads. His interviews focus on the inner workings of the brain and the body and feature the brightest minds in wellness, medicine, and mindset.Dr. Cynthia Li received her medical degree from the University of Texas Southwestern Medical Center in Dallas. She has practiced as an internist in settings as diverse as Kaiser Permanente Medical Center, San Francisco General Hospital, and St. Anthony Medical Clinic serving the homeless. Her personal health challenges led her to integrative and Functional Medicine, and she currently has a private practice in Berkeley, CA. She serves on the faculty of the Healer’s Art program at the University of California San Francisco School of Medicine, and she is the author of Brave New Medicine: A Doctor’s Unconventional Path to Healing Her Autoimmune Illness.This episode is brought to you by Rupa Health, InsideTracker, and Pique Tea.Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, and Great Plains. You can check out a free, live demo with a Q&A or create an account at RupaHealth.com.InsideTracker is a personalized health and wellness platform like no other. Right now they’re offering my community 20% off at insidetracker.com/drhyman.Pique is offering up to 20% off plus free shipping on their Pu'er bundles. Just go to piquelife.com/farmacy for up to 20% off plus free shipping.Full-length episodes of these interviews can be found here:Dr. Elizabeth BohamDhru PurohitDr. Cynthia Li Hosted on Acast. See acast.com/privacy for more information. https://www.listennotes.com/e/d2b92eddc5954dcd9a611defcc8962ec/

PRS Global Open Deep Cuts
Dr. Prosper Benhaim: Leveling Up “Eating Your Meat and Potatoes”

PRS Global Open Deep Cuts

Play Episode Listen Later Sep 26, 2022 70:04


In this “Leveling Up” episode of the Award-Winning PRS Global Open Deep Cuts Podcast, Dr. Prosper Benhaim discusses how the movie "The Matrix" and the band Pink Floyd apply to surgery, how to become more efficient at any operation, how he melds orthopedic surgery, general surgery, and plastic surgery styles into his approach, his unique technique for treating Dupuytren's with collagenase, the effectiveness of marcaine for postop pain control, the scratch collapse test, and several technical pearls of distal radius plating, the dorsal wrist approach, zone 2 flexor tendon repairs, trigger fingers, flexor tenosynovitis, and carpal tunnel releases.  Dr. Prosper Benhaim is an Associate Professor and the Chief of Hand Surgery at UCLA in Los Angeles, California. He has written and lectured extensively on the treatment of Dupuytren's contractures of the hands. Your host, Dr. Puru Nagarkar, is a board-certified plastic and hand surgeon, and Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas. Read a recent PRS Global Open article on the topic of Dupuytren's: “Treatment Options for Dupuytren's Disease: Tips and Tricks” by Denkler, Park, and Alser: https://bit.ly/GOXDeepCutsDupuytrens #PRSGlobalOpen #DeepCutsPodcast #PlasticSurgery #LevelingUp

ASRA News
Interview with a Leader in the Field: Ban Tsui – 2022 Distinguished Service Award Recipient

ASRA News

Play Episode Listen Later Sep 23, 2022 13:22


"Interview with a Leader in the Field: Ban Tsui – 2022 Distinguished Service Award Recipient," by  Anthony Machi, MD, Assistant Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas. From ASRA Pain Medicine News, August 2022. See original article at www.asra.com/asra-news for figures and references. This material is copyrighted.   

ASRA News
Interview with a Leader in the Field: Brian Ilfeld – 2022 Gaston Labat Award Recipient

ASRA News

Play Episode Listen Later Sep 16, 2022 15:18


"Interview with a Leader in the Field: Brian Ilfeld – 2022 Gaston Labat Award Recipient," by Anthony Machi, MD, Assistant Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas. From ASRA Pain Medicine News, August 2022. See original article at www.asra.com/asra-news for figures and references. This material is copyrighted.  

The Real Truth About Health Free 17 Day Live Online Conference Podcast
New Findings In Plant Nutrition: Lignans, Olive Oil, And More! - Joel K. Kahn MD

The Real Truth About Health Free 17 Day Live Online Conference Podcast

Play Episode Listen Later Sep 11, 2022 106:30


New 2022 - New Findings In Plant Nutrition: Lignans, Olive Oil, And More! - Joel K. Kahn MD Joel K. Kahn MD • https://drjoelkahn.com/ • Book - The Plant-Based Solution: America's Healthy Heart Doc's Plan to Power Your Health#DrJoelKahn#PlantBaseDiet #Vegan #heartdisease Dr Joel Kahn is a Practicing Medical Doctor, Podcaster and Author.Dr Kahn holds a M.D. in Cardiology from University of Michigan Medical School. He is a Professor of Medicine at Oakland University William Beaumont School of Medicine andfrom 1986 to 1989 took part in Interventional Cardiology Residency Program at The University of Texas Southwestern Medical Center at Dallas.He works as an independent Holistic Cardiologist and manages the Kahn Center for Cardiac Longevity, ** focused on early detection and reversal of heart diseases. In addition to that, Joel is a Columnist at The Huffington Post and Readers Digest.At his core, Dr. Joel Kahn believes that plant-based nutrition is the most powerful source of preventative medicine on the planet. Having practiced traditional cardiology since 1983, it was only after his own commitment to a plant based vegan diet that he truly began to delve into the realm of non-traditional diagnostic tools, prevention tactics and nutrition-based recovery protocols. These ideologies led him to change his approach and focus on being a holistic cardiologist. He passionately lectures throughout the country about the health benefits of a plant-based anti-aging diet inspiring a new generation of thought leaders to think scientifically and critically about the body's ability to heal itself through proper nutrition.One of the world's top cardiologists, Dr. Joel Kahn has treated thousands of acute heart attacks during his career. He'd like all that to stop. He'd like to prevent ALL future heart attacks by breaking through to the public to educate and inspire a new holistic lifestyle. Now is the time to focus on educating the public to eat clean, sweat clean and apply cutting edge science to their lifestyle.On his podcast each week, Dr. Kahn fights for your health with his unique brand of eastern and western medicine focusing on wellness of mind, body and spirit. Each month he will interview a Health Hero and how their journey can help you find wellness, discuss with a leader in heart disease how to reverse heart disease, talk to leaders in the food movement for health, and review the science that can take you to a new level. He is known internationally as the heart doctor not afraid to take on the giants and expose lies, follies, and confusion so you know the path to feeling better, looking better, and living better.Dr Kahn is an acclaimed author whose most recent book is Lipoprotein(a),: The Heart's Quiet Killer: A Diet and LIfestyle Guide Leading medical professionals and best-selling authors Michael Greger, Dean Ornish, Joel Fuhrman, and David L. Katz have lauded cardiologist Joel Kahn on this breakthrough book on lipoprotein(a). An estimated one in five people have elevated levels of a type of cholesterol called lipoprotein(a) which can increase the risk for cardiovascular disease, including blocked arteries, blood clots, and stroke. Dr. Kahn explains how this condition is a factor of genetics rather than poor lifestyle choices, pinpoints who needs to have their levels checked, and which types of tests to request. He also shares research that shows plant-based diets in general provide the best defense against heart attacks, strokes, and cardiovascular disease and can play an important role in protecting individuals with elevated lipoprotein(a) levels. He has partnered with vegan expert Beverly Lynn Bennett who provides dozens of delicious, oil-free recipes that feature foods rich in the nutrients found to be the most protective for heart-health. To Contact  Dr Joel Kahn  go to DrJoelKahn.com CLICK HERE - To Checkout Our MEMBERSHIP CLUB: http://www.realtruthtalks.com  • Social Media ChannelsFacebook: https://www.facebook.com/TRTAHConferenceInstagram : https://www.instagram.com/therealtruthabouthealth/ Twitter: https://twitter.com/RTAHealth Linkedin: https://www.linkedin.com/company/the-real-truth-about-health-conference/ Youtube: https://www.youtube.com/c/TheRealTruthAboutHealth    • Check out our Podcasts  Visit us on Apple Podcast and Itunes search:  The Real Truth About Health Free 17 Day Live Online Conference Podcast Amazon: https://music.amazon.com/podcasts/23a037be-99dd-4099-b9e0-1cad50774b5a/real-truth-about-health-live-online-conference-podcastSpotify: https://open.spotify.com/show/0RZbS2BafJIEzHYyThm83J Google:https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5zaW1wbGVjYXN0LmNvbS8yM0ZqRWNTMg%3D%3DStitcher: https://www.stitcher.com/podcast/real-truth-about-health-live-online-conference-podcastAudacy: https://go.audacy.com/partner-podcast-listen-real-truth-about-health-live-online-conference-podcastiHeartRadio: https://www.iheart.com/podcast/269-real-truth-about-health-li-85932821/ Deezer: https://www.deezer.com/us/show/2867272 Reason: https://reason.fm/podcast/real-truth-about-health-live-online-conference-podcast • Other Video ChannelsYoutube:https://www.youtube.com/c/TheRealTruthAboutHealthVimeo:https://vimeo.com/channels/1733189Rumble:  https://rumble.com/c/c-1111513 Facebook:https://www.facebook.com/TRTAHConference/videos/?ref=page_internal DailyMotion: https://www.dailymotion.com/TheRealTruthAboutHealth BitChute:  https://www.bitchute.com/channel/JQryXTPDOMih/ Disclaimer:Medical and Health information changes constantly. Therefore, the information provided in this podcast should not be considered current, complete, or exhaustive. Reliance on any information provided in this podcast is solely at your own risk. The Real Truth About Health does not recommend or endorse any specific tests, products, procedures, or opinions referenced in the following podcasts, nor does it exercise any authority or editorial control over that material. The Real Truth About Health provides a forum for discussion of public health issues. The views and opinions of our panelists do not necessarily reflect those of The Real Truth About Health and are provided by those panelists in their individual capacities. The Real Truth About Health has not reviewed or evaluated those statements or claims. 

BEaTS Research Radio's Podcast
Episodio 117 BEaTS Research Radio - Entrevista con el Dr. Sergio Lavandero

BEaTS Research Radio's Podcast

Play Episode Listen Later Sep 9, 2022 16:04


Deyanira Hdez. de la Universidad de Ottawa habla con el Dr. Sergio Lavandero. El Dr. Lavandero es un científico chileno muy bien establecido que ha recibido reconocimiento tanto nacional como internacional. El Dr. Lavandero mantiene una posición de profesor adjunto en la División de Cardiología en University of Texas Southwestern Medical Center; también es Director e Investigador Principal del Centro Avanzado de Enfermedades Crónicas (ACCDiS ). En este episodio el Dr. Lavandero explica sobre qué es su investigación y su experiencia como director de dicho centro; de igual manera cuenta sobre su experiencia como profesor. Para saber mas, visita https://www.accdis.cl/eng/en/sergio-lavandero/

PRS Global Open Deep Cuts
Dr. Paul Pin: Leveling Up “Doing What Looks Good”

PRS Global Open Deep Cuts

Play Episode Listen Later Aug 29, 2022 61:10


In this “Leveling Up” Episode of the Award-Winning PRS Global Open Deep Cuts Podcast, Dr. Paul Pin discusses the importance of having a detailed surgical plan while minimizing thinking during the actual execution of a surgery, the necessity of being open to learning new techniques at any stage in one's career, the role of honesty in surgery, the benefits of spending time having friendly conversations with patients, the blue button vs the yellow button on the Bovie, his approach to training residents, how he is an outlier in his abdominoplasty technique, and why overreliance on numbers and measurements can be dangerous. Dr. Pin is the Chief of Plastic Surgery at Baylor University Medical Center in Dallas, Texas and is a Clinical Instructor of Plastic Surgery at UT Southwestern Medical School, as well as Clinical Assistant Professor of Surgery at Texas A&M Medical School. He has been in practice for over 30 years, and has been instrumental in the training of many plastic surgeons at UTSW over the years. Your host, Dr. Puru Nagarkar, is a board-certified plastic and hand surgeon, and Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas. Read a recent PRS Global Open article on the topic of abdominoplasty: “Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication” by Sood, Janes, Shah et al: https://bit.ly/DeepCuts_Pin #PRSGlobalOpen #DeepCutsPodcast #PlasticSurgery #LevelingUp

Behind The Mission
BTM80 - Dr. Umar Latif, MD - Help for Heroes Program

Behind The Mission

Play Episode Listen Later Aug 9, 2022 31:11


About Today's GuestUmar Latif, MD is a Fellow of the American Psychiatric Association and a Diplomate of the American Board of Psychiatry & Neurology with board certification in General Psychiatry, Geriatric Psychiatry, and Addiction Medicine. He was selected as a George W. Bush Institute Scholar as part of the 2021 Stand-To Veteran Leadership program in service of improving veteran outcomes.Dr. Latif currently serves as the National Medical Director of Help for Heroes, a multisite specialty program he helped design as co-founder, to meet the clinical needs of active-duty service members, veterans and first responders who are dealing with mental health and substance abuse issues. He also works as the Medical Director of Carrollton Springs Hospital and has a private practice at The Noesis Clinic: an adult and geriatric outpatient private practice that specializes in early detection of Alzheimer's dementia and TMS (Transcranial Magnetic Stimulation).For a decade prior to this, Dr. Latif co-founded and served as the Medical Director of Freedom Care at UBH Denton, which he helped develop. Under his leadership, this program grew into a multi-location inpatient psychiatry program specializing in PTSD and dual diagnosis treatment for active duty military members and veterans referred from 120 plus national & international installations.His other professional roles in the past have included the position of Medical Director of the Telepsychiatry program at Dallas VA Medical Center, and faculty appointment as Assistant Professor of Psychiatry at UT Southwestern Medical Center.Dr. Latif completed his residency training at Wayne State University in Michigan and postgraduate fellowship training at University of Texas Southwestern Medical Center in Dallas. He also earned a certificate in “Executive Healthcare Leadership” from Cornell University. Links Mentioned In This EpisodeHelp for Heroes ProgramPsychArmor Resource of the WeekThe PsychArmor Resource of the Week is the PsychArmor course Barriers to Treatment. In this course, you will learn how differences in military culture affect mental health and how to help service members or veterans overcome barriers to seeking treatment.  You can find a link to the resource here: https://learn.psycharmor.org/courses/barriers-to-treatment   This Episode Sponsored By:This episode is sponsored by PsychArmor, the premier education and learning ecosystem specializing in military culture content. PsychArmor offers an online e-learning laboratory with custom training options for organizations.Contact Us and Join Us on Social Media Email PsychArmorPsychArmor on TwitterPsychArmor on FacebookPsychArmor on YouTubePsychArmor on LinkedInPsychArmor on InstagramTheme MusicOur theme music Don't Kill the Messenger was written and performed by Navy Veteran Jerry Maniscalco, in cooperation with Operation Encore, a non profit committed to supporting singer/songwriter and musicians across the military and Veteran communities.Producer and Host Duane France is a retired Army Noncommissioned Officer, combat veteran, and clinical mental health counselor for service members, veterans, and their families.  You can find more about the work that he is doing at www.veteranmentalhealth.com  

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MIB Agents OsteoBites
Using RNA-Nanoparticle Vaccines to Overcome the Immunosuppressive Tumor Microenvironment of Canine Osteosarcoma

MIB Agents OsteoBites

Play Episode Listen Later Aug 5, 2022 59:43


This episode is sponsored by the Osteosarcoma Institute (OSI), a nonprofit organization led by osteosarcoma experts from top U.S. cancer centers who, together, are concentrating on the cure ® for osteosarcoma. The mission of the OSI is to dramatically increase treatment options and survival rates in osteosarcoma patients through identifying and funding the most promising and breakthrough osteosarcoma clinical trials and science. In addition to advancing research, OSI also provides a free resource called OSI Connect for osteosarcoma patients. Our osteosarcoma experts can discuss available treatments, possible side effects, and provide helpful advice for getting the most out of your visits with your treating physician. This resource is available in English and Spanish and aims to help patients and families find answers to their questions. -- John A. Ligon, MD, is an assistant professor in the department of pediatrics at the University of Florida College of Medicine. Dr. Ligon earned his medical degree from the Baylor College of Medicine in Houston. After he completed his residency in pediatrics at the University of Texas Southwestern Medical Center in Dallas, he pursued a fellowship in pediatric hematology and oncology at Johns Hopkins University and the National Cancer Institute in Maryland. In the following years, he completed a senior fellowship in pediatric immunotherapy at the National Cancer Institute and another in pediatric sarcoma at Johns Hopkins University. Dr. Ligon is board-certified in both general pediatrics and pediatric hematology and oncology by the American Board of Pediatrics. In addition to his numerous original research publications and editorial review appointments, he is a member of various professional societies, such as the Children's Oncology Group and the American Association for Cancer Research. Dr. Ligon has been honored with a variety of awards for his research skills and academic excellence. His research interests include immunotherapy, tumors and bloodstream infections.

The Incubator
#076 - [NeoHeart Special] - Dr. Shawn Sen MD - NEC and CHD, separating myth from reality

The Incubator

Play Episode Listen Later Aug 4, 2022 32:41


Shawn Sen, MD, is an Assistant Professor in Pediatrics in both the Division of Neonatal-Perinatal Medicine and Pediatric Cardiology at Northwestern University in Chicago, IL. After graduating from medical school at the University of Oklahoma, Dr. Sen completed his residency in Pediatrics at Columbia University at the Morgan Stanley Children's Hospital of New York. He then went on to complete two fellowships, one in Neonatology at the University of Texas Southwestern Medical Center and his second in Pediatric Cardiology at Stanford University, Lucile Packard Children's Hospital. Dr. Sen is now an attending neonatologist and CICU attending in both the level IV neonatal and cardiac intensive care units at Anne & Robert H. Lurie Children's Hospital of Chicago and Northwestern Medicine Prentice Women's Hospital. His clinical research interests include neonatal pulmonary hypertension, cardiovascular and congenital heart disease, and hemodynamic assessment of critically ill neonates using echocardiography.Find out more about Shawn and this episode at: www.the-incubator.org______________________________________________________________________________________As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd. enjoy!This podcast is proudly sponsored by Chiesi.

PRS Global Open Deep Cuts
Dr. Elizabeth Hall-Findlay: Leveling Up Breast Reduction

PRS Global Open Deep Cuts

Play Episode Listen Later Aug 1, 2022 54:54


In this “Leveling Up” Episode of the Award-Wining PRS Global Open Deep Cuts Podcast, Dr. Elizabeth Hall-Findlay gives a deep dive into the superomedial pedicle vertical breast reduction, how and why she developed the technique, the use of liposuction, how to manage the inframammary fold, how to transition to the technique if you are not already experienced with it, the modification to the approach in an augmentation mastopexy, and her approach to quilting sutures and TAP blocks in abdominoplasty. Dr. Elizabeth Hall-Findlay is one of the most well-known names in the world of aesthetic breast surgery. She has written and lectured extensively on the breast reduction technique named after her. She is board certified in both Canada and the United States and practices in Banff, Alberta, Canada. Your host, Dr. Puru Nagarkar, is a board-certified plastic and hand surgeon, and Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas. Read a recent PRS Global Open article on the topic of Breast Reduction: “Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study” by Klinger, Klinger, Maione et al: https://bit.ly/DeepCuts_LU_HallFindlay #PRSGlobalOpen #DeepCutsPodcast #PlasticSurgery #LevelingUp

Inside Exercise
Can extreme exercise damage the heart? With Dr Benjamin Levine

Inside Exercise

Play Episode Listen Later Jul 31, 2022 70:05


Glenn McConell chats with Professor Benjamin Levine who has the best global research track record in Sports cardiology/cardiovascular physiology and exercise. He is the founder and Director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, Professor of Internal Medicine/Cardiology and Distinguished Professor of Exercise Sciences at the University of Texas Southwestern Medical Center. He has published over 400 journal articles with a very high H-index of 109. We enjoyed a broad ranging discussion including: - how the main determinant to be an endurance athlete/ to have a high VO2 max (aerobic capacity) is the maximum stroke volume (how much blood pumped per beat). Their heart and pericardium stretch more (more compliant) which allows a large stroke volume. - Athletes big hearts: Which comes first, the training to increase the heart size or need to have a big heart first? -Genetic component to being a great endurance athlete? Can't use genetic profiles, it's a gene-environment interaction. -Eccentric hypertrophy (volume load) with purely long slow distance exercise, concentric hypertrophy (pressure load) with purely strength training. But many activities are a combination of volume load and pressure load. Eg Rowers have the biggest hearts, thick walls and large volumes (they have a combined strength and endurance type training stimulus): they have mean arterial pressures of 250mmHg during exercise! -Resistance trained people do not have a thick walled hearts like one might expect because they only have the high pressure loads during the exercise, unlike people with hypertension that have pressure loads 24/7. -Dallas bed rest study from 1967 then followed up with the same participants 30 years later. Found that 3 weeks of bed rest was worse than 30 years of aging for the body's capacity to do physical work! Aging leads to atrophy and stiffening of the heart and reduced compliance of the blood vessels and life long training prevents this. -Four to five days a week of exercise the sweet spot for optimizing cardiovascular health (one fun easy 60+ min, 2-3 moderate to vigorous, 1 intense plus sone strength training). -If been sedentary for a life time (eg 70 year olds) exercise can't reverse the hearts lack of compliance etc. Starting exercise before the age of 55 is important. -Walking not hard sufficient load to maintain the hearts function. Endothelial function and exercise training: greater dilation of blood vessels after exercise training. -For the vast majority of people competitive levels of exercise is good for heart health. In a small amount of people that do an extraordinary amount of exercise, exercise-induced right ventricular cardiomyopathy can occur (this will be discussed more in a later podcast by the expert on this, the Cardiologist Dr Andre La Gerche). Genetic cardiomyopathies and exercise. Higher calcium/calcification in coronary arteries in some athletes but this doesn't increase mortality and appears to reduce mortality. Higher rate of atrial fibrillation with high levels of exercise training but not greater heart disease risk. -Exercise can't be expected to overcome a bad diet.

NeurologyLive Mind Moments
69: The Widespread Effects of DMT Waste in Multiple Sclerosis

NeurologyLive Mind Moments

Play Episode Listen Later Jul 29, 2022 54:42


Welcome to the NeurologyLive® Mind Moments™ podcast. Tune in to hear leaders in neurology sound off on topics that impact your clinical practice. In this episode, we spoke with Darin T. Okuda, MD, professor of neurology and director of Neuroinnovation and the Multiple Sclerosis & Neuroimmunology Imaging Program at The University of Texas Southwestern Medical Center at Dallas; and Karin Cook, senior vice president of medical strategy and clinical ethnographer, Heartbeat Medical Communications. The pair spoke about their research into the wasted costs associated with disease-modifying therapies (DMTs) for patients with multiple sclerosis, what they've observed at their center, the wide-reaching impact of this waste on the healthcare continuum, and the future solutions that are being worked on for this problem. Click here for more coverage of this story: Multiple Sclerosis DMT Waste Is Staggering, New Study Shows Wasted DMTs in Dr. Okuda's office [Image] Episode Breakdown: 1:45 – Background on the study conducted by Okuda et al. 4:05 – Perspective on the cost driven by DMT waste  6:30 – Current landscape of prescriptions and adherence in MS 8:35 – Disparities in MS treatment adherence 11:00 – The link to the physician-patient relationship 16:40 – The process of choosing a DMT and shared decision-making  23:00 – Neurology News Minute 25:45 – Finding solutions to the DMT waste problem 33:40 – The role of the individual neurologist and patient 38:30 – Access to specialist care and resources 42:40 – Building trust with patients and general medical mistrust 47:00 – Next steps and closing thoughts This episode is brought to you by the Medical World News streaming service. Check out new content and shows every day, only at medicalworldnews.com The stories featured in this week's Neurology News Minute, which will give you quick updates on the following developments in neurology, are further detailed here: Zonisamide Oral Suspension FDA-Approved for Partial Seizures in Epilepsy FT218 Receives Tentative Approval for EDS, Cataplexy in Adults With Narcolepsy FDA Clears Rapid Hyperdensity Tool for Inclusion in RapidAI Platform for Neurovascular Conditions ALS Therapy Tofersen Has NDA Accepted by FDA, Granted Priority Review Thanks for listening to the NeurologyLive® Mind Moments™ podcast. To support the show, be sure to rate, review, and subscribe wherever you listen to podcasts. For more neurology news and expert-driven content, visit neurologylive.com. REFERENCE 1. Okuda DT, Burgess KW, Cook K, McCreary M, Winkler MD, Moog TM. Hiding in plain sight: the magnitude of unused disease-modifying therapies in multiple sclerosis and strategies for reducing the economic burden. Mult Scler Relat Disord. 2022;63:103920. doi:10.1016/j.msard.2022.103920

Circulation on the Run
Circulation July 26, 2022 Issue

Circulation on the Run

Play Episode Listen Later Jul 25, 2022 35:45


This week, please join authors Mikhail Kosiborod and Christian Schulze and Editorialist Stefan Anker as they discuss the original articles "Effects of Empagliflozin on Symptoms, Physical Limitations and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial" and "Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients With Acute Decompensated Heart Failure (EMPAG-HF)" and the editorial "SGLT2 Inhibitors: From Antihyperglycemic Agents to All-Around Heart Failure Therapy." Dr. Carolyn Lam:             Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley:           And I'm Dr. Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam:             I'm so excited about the feature discussion this week. It is a paired feature along with their editorial and it's all focused on SGLT2 inhibitors. The first, results from the EMPULSE trial, Effects of Empagliflozin on Symptoms, Physical Limitations and Quality of Life in Patients Hospitalized for Acute Heart Failure; and the second, the EMPAG-heart failure trial, The Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients with Acute Heart Failure. Incredibly important topics, incredibly important discussion. Wait up for it. We're just going to tell you a little bit more about two other original papers in today's issue, and I'm going to go first, Greg. Is that okay? Dr. Greg Hundley:           You bet. Dr. Carolyn Lam:             Now, really interesting topic here. We have strong evidence supporting the effective blood pressure and cardiovascular disease risk lowering properties of healthy diet such as the DASH diet, Mediterranean diet, and so on and so on. But what about the diet consumed by a fifth of the entire world's population? The Chinese cuisine. Interestingly, today's paper addresses just that. This is from authors, Dr. Wu, from Peking University Clinical Research Institute and colleagues who performed a multicenter patient and outcome assessor blind randomized feeding trial among 265 participants with baseline systolic blood pressure of 130 to 159 in four major Chinese cuisines. And these are the Shandong, Huaiyang, Cantonese, and Szechuan cuisines, and here's how they did it. After a seven day run in period on a control diet matching the usual local diets, participants were randomized to continue with the control diet or the cuisine based Chinese heart healthy diet for another 28 days. The primary outcome was systolic blood pressure. The study developed the first heart healthy Chinese diet that fits Chinese food culture and emphasizes its palatability by involving master shifts in developing the recipes. Dr. Greg Hundley:           Oh wow. Carolyn, this is really interesting, especially one fifth of the world's population in studying a heart healthy diet. So did it work? I can't wait to hear the results. Dr. Carolyn Lam:             Well, the change in systolic and diastolic blood pressure from baseline to the end of the study in the control group was five millimeters mercury and 2.8 millimeters mercury reduction, respectively. The net difference of change between the two groups in systolic and diastolic blood pressure were a reduction of 10 and almost four millimeters mercury, respectively. The effect size did not differ among cuisines, and so in summary, with a patient and assessor blind randomized feeding trial, this study really demonstrated that the blood pressure lowering effect of the Chinese heart health diet could indeed be substantial, and importantly, be compatible with medications while palatable and affordable in Chinese adults with high blood pressure, and so these results support the idea that food is medicine and will give many patients with high blood pressure the confidence to adopt heart healthy diets in their lifestyle treatment. Dr. Greg Hundley:           Wow, Carolyn, that is really an interesting article. So many of these articles today could all be features in and of themselves. That was just outstanding. Well, my next paper comes to us from the world of preclinical science, and it's from Dr. Sean Wu from Stanford University School of Medicine. So Carolyn, immune checkpoint inhibitors are monoclonal antibodies that are used to activate the immune system against tumor cells. Now, despite their therapeutic benefits, immune checkpoint inhibitors have the potential to cause immune mediated adverse events such as myocarditis, a rare but serious side effect with up to 50% mortality in affected patients. Now histologically, patients with immune checkpoint inhibitor of myocarditis have lymphocytic infiltrates in the heart implicating T-cell mediated mechanisms. However, the precise pathologic immune subsets and molecular changes in immune checkpoint inhibitor myocarditis are unknown. Dr. Carolyn Lam:             Wow. So insights into the etiology of these immune checkpoint associated myocarditis cases must be very important. So what did they find? Dr. Greg Hundley:           Right, Carolyn? So clonal cytotoxic, TEMRA CD8+ cells were found to be significantly increased in the blood of patients with immune checkpoint inhibitor myocarditis corresponding with an analogous increase in effector cytotoxic CD8+ cells in the blood and hearts of PD-1 deficient mice with myocarditis. These expanded effector CD8+ cells had unique transcriptional changes, including upregulation of the chemokines CCL5, CCL4, and CCL4L2, and they may serve as attractive diagnostic therapeutic targets for reducing life threatening cardiac immune related adverse events in immune checkpoint inhibitor treated cancer patients, and Carolyn, just like so many of our articles, there's a very nice accompanying editorial by Professor Gianluigi Condorelli that also offers an update on current research pertaining to non-systemic steroid therapy to treat immune mediated myocarditis. Well, Carolyn, how about we jump to some of the other articles in the issue? Dr. Carolyn Lam:             Oh, you bet, Greg. There's an exchange of letters between Drs. Madias and Knops regarding the article “Efficacy and Safety of Appropriate Shocks and Antitachycardia Pacing in Transvenous and Subcutaneous Implantable Defibrillators: The Analysis of All Appropriate Therapy in the PRAETORIAN Trial.” Dr. Greg Hundley:           And also in the mail bag, Professor Mark has a Research Letter entitled “Effect of Empagliflozin on Kidney Biochemical and Imaging Outcomes in Patients with Type 2 Diabetes, or Prediabetes, and Heart Failure with Reduced Ejection Fraction, The SUGAR-DM-HF Study,” and our own Tracy Hampton has several synopses from articles published elsewhere in our piece on cardiovascular news. Well, how about we get onto that feature forum discussion, two papers, two editorialists. I can't wait. Dr. Carolyn Lam:             Me too. Let's go, Greg. Dr. Greg Hundley:           Welcome, listeners to this July 26th feature forum discussion. So remember, listeners, for forum discussions, we have several manuscripts that focus on a singular topic and we bring together the authors, our associate editors, and also an editorialist, and today, I want to introduce, we have with us Dr. Mikhail Kosiborod from Mid America Heart Institute in Kansas City, Missouri, Dr. Christian Shults from University Hospital Jena in Germany, Stefan Anker from Charité in Berlin, Germany, and our Associate Editors, Brendan Everett from Brigham and Women's Hospital in Boston, Massachusetts, and Justin Grodin from University of Texas Southwestern Medical Center in Dallas, Texas. Welcome, gentleman, and we'll start with you, Mikhail. Could you describe for us the background information that went into the preparation of your study and what was the hypothesis that you wanted to address? Dr. Mikhail Kosiborod:   Well, thanks very much, Greg. The background for the study, which was the secondary analysis of the EMPULSE trial was patients that are hospitalized with acute decompensated heart failure represent a very high risk group. We know that they have high risk of death and hospitalizations, and we also know that they have very poor health status that's very high burden of symptoms, physical limitations, and poor quality of life, and so addressing those treatment goals, trying to reduce the risk of clinical events like death and hospitalizations and improve the symptoms and physical limitations in this patient population are very important treatment goals. Now we previously demonstrated in the main results of the EMPULSE trials that using empagliflozin initiating empagliflozin SGLT2 inhibitor in this patient population as compared with placebo provided a significant total clinical benefit, which was a composite of total death, repeat hospitalizations for heart failure, or a change in a Kansas City cardiomyopathy questionnaire, which is a kind of a gold standard measure of patient's health status. What we tried to do in a much more granular fashion in this study is to understand the effects of empagliflozin as compared with placebo on this very important outcome, the Kansas City cardiomyopathy questionnaire, and we actually evaluate all of the key domains and composite symptoms, physical limitations, as well as quality of life. Dr. Greg Hundley:           Very nice, and Mikhail, can you describe for us what study population specifically, and then what was your study design? Dr. Mikhail Kosiborod:   Well, this was a population of patients that were hospitalized with heart failure and that EMPULSE was unique in its design because first of all, previous SGLT2 inhibitor trials mostly focused on patients with chronic heart failures that were in an outpatient setting, including prior trials of empagliflozin, and EMPULSE really focused on acutely hospitalized patient population, but it included patients regardless of ejection fraction. So as they were hospitalized with decompensated heart failure and reduced or preserved ejection fraction. They were enrolled regardless of if they had type 2 diabetes, they were enrolled essentially, regardless of kidney function, only patients with EGFR of less than 20 were excluded, and also importantly, was this study and a unique feature of the study in particular was that we enrolled patients whether they had acute de novo heart failure. That means that was a new diagnosis of heart failure that was bad enough for them to be hospitalized or worsening chronic heart failure requiring hospitalization. So it was really an all-comer trial for patients acutely hospitalized for heart failure. So we had just over 500 patients and they were randomized in the hospital. After a brief period of stabilization, we use empagliflozin, 10 milligrams daily or placebo and treated for 90 days, and the primary outcome at 90 days was a total clinical benefit that I described that was a composite, hierarchical composite of total death hospitalizations, repeat hospitalizations for heart failure and changing KCCQ. In this study, again, we focused predominantly on KCCQ, trying to understand the effects on health status, again, symptoms, physical limitations, and quality of life. Dr. Greg Hundley:           Excellent. And Mikhail, what were your study results? Dr. Mikhail Kosiborod:   Well, what we observed, a couple of things. One is we first examined the effects of empagliflozin on the primary endpoint across the range of KCCQ and baseline, and what we found was that regardless of the degree of symptomatic impairment and baseline, empagliflozin was consistent in providing them total clinical benefits that I described previously, and then kind of shifting to what I think is the most interesting findings, the effects of empagliflozin versus placebo on KCCQ, what we found was that as you would imagine in this population of patients that were acutely hospitalized with heart failures, that had very poor health status, very low KCCQ at baseline, and within the first 90 days, which was observation period, both groups of patients had substantial improvements in KCCQs. As one would expect after acutely decompensated episode of heart failure and treatment in a hospital, everyone got better. But patients treated with empagliflozin had significantly greater improvement in KCCQs than those that were treated with placebo, and that was first of all, a very substantial difference between the two groups. It was more than five points in favor of empagliflozin already at 15 days and was highly statistically significant, and it was maintained throughout the 90 day treatment period. So the fact that we saw both a clinical meaningful and statistically significant improvement in just 15 days, I think is a very important clinical message, and then finally, I guess what I will mention is these benefits of empagliflozin while main outcome we looked at was KCCQ total symptoms, we're focusing on the symptoms, but it was consistent when we looked at physical limitations as well as quality of life. So really, all key domains of KCCQ were impacted in a similar way. Dr. Greg Hundley:           Very nice. So in acute heart failure, marked symptomatic improvement after the administration of the SGLT2 inhibitor empagliflozin at 10 milligrams per day. Well, now listeners, we're going to turn to our associate editor, Dr. Brendan Everett, and Brendan, again, you have many papers come across your desk. What attracted you to this particular manuscript? Dr. Brendan Everett:      Well, thanks, Greg, and I think this manuscript caught my eye because of the importance of the clinical question, and Mikhail outlined why I think that was really relevant. So we understand that this class of medications or SGLT2 inhibitors have important effects on outcomes like re-hospitalization in patients with heart failure, and what was particularly striking about this paper is that it took patients rather than those with chronic heart failure, but as Mikhail mentioned, enrolled a patient population that was actually in the hospital, and I think this was an important frontier for this particular question about when to start the SGLT2 inhibitor and what kind of benefits there might be. Furthermore, I think the fact that they did not select the population based on ejection fraction was particularly striking, and of course, I think is remarkable, but now old news, they did not select on the presence or absence of diabetes as well. And so those three components really attracted me to the paper. I also think the outcome is one that really is valuable and worth exploring, and specifically, I'm talking about how patients feel on the medication after a hospitalization for heart failure. Appropriately, we focused on re-hospitalization for heart failure and cardiovascular death in prior trials in this space, and I think we need to embellish those findings or further deepen those findings with a perspective on how patients actually feel when they get the medication, and of course, it goes without saying that what's particularly important here also is that it was a randomized placebo controlled trial, and so the results have some element of internal validity that I think is really important. So those were the things, Greg, that really attracted my attention as I read the paper for the first time. Dr. Greg Hundley:           Thank you so much, Brendan. Well, listeners, we've got a second paper today and we're next going to hear from Dr. Christian Shults, and he also is focusing on really another aspect of the administration of empagliflozin in patients with acute heart failure and that pertains to the renal function of the patients. So Christian, could you describe for us the background pertaining to your study and what was the hypothesis that you were intending to address? Dr. Christian Schulze:     Thanks, Greg. Well, it's great to introduce all study here in this running. So our study impacted those in acute decompensated heart failure. The impact HF trial was a study based on the hypothesis that we wanted to test, whether empagliflozin has effects in acute decompensated heart failure, and we focused on the patient population that was not addressed in EMPULSE, patients that came to the ER and needed to be treated right away, and we wanted to know and this was our main hypothesis, but are the diuretic and [inaudible 00:17:11] effects of the SGLT2 inhibitor on this case, empagliflozin, actually had an impact on diuretic regimens and kidney functions since this is one of the main end points that limits treatment, and also is one of the outcomes of patients with acute decompensated heart failure in the hospital. Dr. Greg Hundley:           Very nice. And so Christian, what study design did you implement and who was included in your study population? Dr. Christian Schulze:     So we also used the randomized two arm study design. We included patients with acute decompensated heart failure independent of left ventricular ejection fraction. Patients needed to have an NT-proBNP of more than 500. The average NT-proBNP in fact was 4,300 in our entire patient population, and we included patients within 12 hours of presentation. So many of these patients have been recruited in the ER, they presented two hour cardiology heart failure service, and then were immediately randomized to the trial in the two arms, and we tested not 10 milligrams of empagliflozin. We actually tested 25 milligrams of empagliflozin based on in-house data that 25 milligrams potentially had a stronger diuretic effect compared to 10 milligrams. Dr. Greg Hundley:           And what did you find? Dr. Christian Schulze:     So we followed patients for five days. It was a relatively short period of time. It was designed to address the in-house phase of patients with acute decompensated heart failure. The mean duration of stay was 6.3 days in the hospital so this was exactly the time that we wanted to test. We had a 30 day endpoint for safety issues, and what we could see is that patients on 25 milligrams on empagliflozin on top of standard diuretic regimens and medical care had 25% higher diuretic outputs compared to patients in the placebo group. We also found no differences in markers of renal injury dysfunction, and could in fact confirm that after 30 days, patients in the empagliflozin group had a better EGFR compared to patients in the placebo group. On top, we saw a more rapid decrease in body weight and also a more profound decrease in NT-proBNT values. Dr. Greg Hundley:           And Christian, just for our listeners to put a little bit of this in perspective, what was the range of serum creatinine for the patients that were enrolled in your study? Dr. Christian Schulze:     So the main EGFR in the entire population was around 60 and the creatinine values were around 107 on average in the entire cohort. So this is a very typical population. We had around 30% of the population with de Novo heart failure, around 20 to 30% of the population was pre-treated for preexisting heart failure. So very typical population of patients with heart failure presenting to the emergency room. Dr. Greg Hundley:           And did you have any kind of lower level EGFR cutoff, I mean, for enrollment into this study? Dr. Christian Schulze:     So when we designed the trial, we actually still had the sub classification of diabetes or impaired glucose or homeostasis as an inclusion criteria. We dropped it before we started the trial because the data came out that this is actually, in fact, not a critical issue for patients with heart failure. So diabetes was not a subgroup in our trial and the lower limit of EGFR was actually a thoroughly defined protocol. Dr. Greg Hundley:           Very nice. Well, listeners, now we're going to turn to our second associate editor, Dr. Justin Grodin from University of Texas Southwestern Medical Center in Dallas, Texas, and Justin, similar to Brendan, and you see many papers come across your desk and so what attracted you to this particular paper by Christian and his colleagues? Dr. Justin Grodin:            Well, Greg, I think first and foremost, and I think very similar to Brendan, but I think what's always striking is if I may just take a step back, decompensated heart failure in the United States is the number one cause for hospitalization among Medicare beneficiaries. So I think really, the brunt and really the truly public health message of the disease is very important in the applicability, and even though that decompensated heart failures is one of the most common things that we ever encounter when we practice, internists, cardiologists, et cetera, we have very, very little clinical trial guidance that tells us how to decongest individuals when they're hospitalized with swelling and heart failure and a lot of these individuals can be quite ill, and we have some clinical trial data, but largely, we have a lot of negative studies or inconclusive studies in this space. So certainly, what drew me to this trial was definitely that context, and obviously, based on the mechanistic data with SGLT2 inhibitors, I think one of the natural questions, which Christian addresses, is that we know that up front, they do augment natriuresis. So I think it's very compelling to marry those two together because this is what many of us that use these medications regularly have been asking is whether or not they would have some efficacy in that regard, and then another thing that caught my eye and me as a cardiorenal investigator was, just as Christian highlighted, was we have a clinical trial that randomly assigned individuals, really that were ill and many of whom were not stabilized within 12 hours of presentation, and we're talking about patients that are coming into the hospital at all times during the day in and I think that's very remarkable that we have something with standard... We have a study with standardized assessments where we're really trying to ask a very practical, pragmatic question, which is do these therapies lower the sodium balance in individuals with decompensated heart failure, and I think what's important is largely, we've got a lot of medications that supplement loop diuretics, which are the class of drugs that the majority of us use, and we have a lot of other therapies that we use that really have very little data or poor data that guide us such as thiazide diuretics, carbonic and hydrase inhibitors, mineralocorticoid receptor antagonists, and so here, we have a clinical trial that asks a question that's on many people's minds. And then we do have very compelling, at least short term pragmatic and mechanistic data that does tell us that these individuals do have a greater natriuretic effect when empagliflozin is used as an adjunct to standardized loop diuretic therapy. So it's a very practical clinical question, and I think what's very important, and we could debate probably all day about the implications of GFR change and kidney function change while we're decongesting somebody with diuretics, but I think what's reassuring to all the clinicians is we really didn't see an effect on kidney function despite a greater natriuretic effect or enhanced diuretic effect, if you will, with the use of empagliflozin. Dr. Greg Hundley:           Very nice. Well, thank you, Justin. Listeners, now we have an editorialist and as you know, editorialists really help us put the scientific presentation of an original manuscript into the perspective of really the global theme of a topic, and we have Stefan Anker from Berlin, and Stefan, can you describe for us how do we put these two manuscripts and results that we've heard about really in the context now of moving forward with the use of SGLT2 inhibitors in the management of patients with acute decompensated heart failure? Dr. Stefan Anker:            Thank you so much. Really, I think these two papers, on the one hand, enhance our certainty about early use, and on the other hand, possibly show us that there might be even more to achieve by, on the one hand, moving even earlier with the application of SGLT2 inhibitors or possibly consider the higher dose. Now let's take one step back. These drugs were developed in type two diabetes and the first successful trial was the [inaudible 00:25:42] outcome trial. Many people have forgotten that this trial tested two doses and not only one, the 10 and the 25 milligram dose, and of course, with the success for improving kidney outcomes and heart failure hospitalization outcomes, we move forward into these two specialist areas, on the one hand, broadening it to the non-diabetic communities, but on the other end, narrowing it by focusing on the 10 milligram dose regardless of whether there is [inaudible 00:26:12]. And we basically now learn A, to use these drugs even earlier than we did in the big trials and we can now be sure to start their use in the hospital, and if you take the average change in quality of life results seen, you actually get a better result for the patient on quality of life when you start earlier than when you start late in the ambulatory studies where basically, in the chronic setting, maybe you have one and a half to two points difference. Here, you now have four and a half points in the study shown by Mikhail, and of course, it's also good to know that you can start this in any type of patient, regardless of their quality of life. The impact study from Christian, they basically moved it now even earlier, moving into the hospital space is possible based on EMPULSE. Moving it into the acute admission space is at least a consideration now based on what Christian here has shown. And he is actually addressing the one question I hear very often in my presentations about SGLT2 inhibitors, what about this 25 milligram dose? Is there a place for this in cardiology as well, and a possible place is shown here, not only that this is a safe thing to do, but also you get urinary output. Of course, we may in the future, want to see this compared, directly compared to the 10 milligram dose, but of course, the world is not created in one day, but needs more than one and so really, I think these two studies, on the one hand, address an important issue, when to start using them. On the other hand, show us a little bit of a glimpse to the future. Dr. Greg Hundley:           Very nice, Stefan, and listeners, we get to take advantage of having these authors, editors, and editorialists together and ask them what they see as the next study to be performed in this sort of sphere of research. So Mikhail, we'll start with you. In 30 seconds or less, what do you see as the next study to be performed in this arena of research? Dr. Mikhail Kosiborod:   I think, Greg, what we've learned recently, including from the EMPULSE trial, we have this population of patients in a hospital with heart failure's a huge issue as Justin mentioned, and until recently, we had very little [inaudible 00:28:31] for them beyond the usual kind of decongestion with loop diuretics and trying to make them feel better, but you look at outcome data. It really was a dearth of effective therapies that have meaningful impact on important outcomes. Now that's changing, SGLT2 inhibitors is one example. There are some other recent examples in this patient population, like a firm HF and iron deficient patients with heart failure. But the bottom line is it's no longer kind of a desert, if you will, of positive trials. We now have something we can do and I think what this proves is that we need to actually invest more, both in terms of resources and time to really do what we we're being able to do in other areas of heart failure and those patients with chronic, half and half where we can start developing pillars of therapy that can actually truly improve outcomes with this patient population and there is a lot going on that makes me optimistic that's going to be the case in the coming years. Dr. Greg Hundley:           Very nice. And Brendan? Dr. Brendan Everett:      Well, I think both trials mentioned today really pushed our understanding of this population forward. I think the biggest clinical question that I face when I'm caring for these patients is that we have four, at least, guideline directed therapies, right? We have beta blockers, we have ARBs, ACE inhibitors and ARNIs. We have mineral receptor antagonists and we have SGLT2 inhibitors. So which do we use in what order and how do we start them, and what kind of parameters do we use to guide us if we're limited either by renal function or by blood pressure or by some other factor. And we often, if not always, have one of those constraints that we're dealing with and so I would say the next step for me is trying to sort out which of these therapies and what order ought to be our highest priority for patients with acute decompensated heart failure as we move quickly from the acute decongestion stage towards discharge and a chronic therapy that will then be followed as an outpatient over the ensuing days and months. Dr. Greg Hundley:           Very nice. And Christian. Dr. Christian Schulze:     Thank you again, and Brandon pointed out very nicely. I mean, we have good evidence now for chronic heart failure treatment. We have the four columns of heart failure medical therapy. Questions that remain open is what do we do with all these patients that are now guideline medicated, come to the hospital with an acute decompensation? Should we carry on with the medication? Should we terminate and in particular, should be carry on with full dose, 50% dose of SGLT2 inhibitors, and the next question is, what dose should we use, in fact, for SGLT2 inhibitors? Is it in group effects or is sotagliflozin comparable to empagliflozin, and then is there a role for a step by scheme that we initially have in high dose therapy that we then downgrade to 10 milligrams on the chronic heart failure treatments, and then of course, quality of life is very important. We should ask this question also in this patient population that is early on treated, do we see benefits that carry on in the outpatient setting and do we see an effect of early treatment on long term benefits? Dr. Greg Hundley:           Justin? Dr. Justin Grodin:            Well, I would have to agree with all of my colleagues here on this call. I think all have raised really good points, but I think one very simple, and I'll echo some of Brendan's statements, but one very simple question is we know that when we decongest people and initiate a negative salt balance in the hospital for decompensated heart failure, we cause neurohormonal activation and there are a lot of downstream untoward effects from chronic decongestive therapies, and I think one of the more compelling things is we still yet have defined what is the best way to decongest individuals with swelling or volume overload in the hospital. Here, we have compelling studies with SGLT2 inhibitors for quality of life and really, the way patients feel. And this is really what's important to them, and then something very pragmatic to clinicians and let's make people pee more, but I think one of the compelling questions, and I don't know if it will be answered, is we have a lot of choices for supplemental therapies and different diuretic strategies when patients come in the hospital for decompensated heart failure, and I do think that these studies do move the needle with SGLT2 inhibitors. I think that's abundantly clear, but we still don't know what is the best way to dry out my patient or make my patient pee so that they feel better, but I do think that these studies do at least set the stage that there's some compelling advantages to SGLT2 inhibitors. Dr. Greg Hundley:           And then lastly, Stefan. Dr. Stefan Anker:            Thank you. Besides the detailed points mentioned by many, and Christian, totally support 25 versus 10 milligram, how long 25 milligram, if at all in the future. Besides this, I'm interested in the big picture question. So what about the post myocardial infarct congestion/heart failure situation, and there will be two trials in the next 18 to 24 months that report on this, and my pet kind of area is actually to treat heart failure where nobody thinks it is heart failure, and what I mean is for instance, advanced cancer patients, cardiac wasting cardiomyopathy. So the heart failure in sick cancer patients, and indeed, we are planning to do exactly that now in a study focusing on hospice care patients to really improve the quality of life, the very thing focus here on the EMPULSE trial. Dr. Greg Hundley:           Well, listeners, we want to thank our authors, Dr. Mikhail Kosiborod from Mid America Heart Institute in University of Missouri, and Christian Shults from the University Hospital in Jena, Germany. Also, our associate editors, Dr. Brendan Everett from Brigham and Women's Hospital in Boston, and Dr. Justin Grodin from University of Texas Southwestern in Dallas, Texas, and also, our editorialist, Dr. Stefan Anker from Charité in Berlin, Germany for bringing us these two manuscripts pertaining to two randomized clinical trials regarding the administration of the SGLT2 inhibitor, empagliflozin in acute heart failure, demonstrating first, marked improvement in heart failure symptoms and health related quality of life. And second, in those with estimated GFRs greater than 30 mls per minute, an augmentation of natriuresis in the setting of the co-administration of diuretics without deterioration in renal function. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

JAMA Author Interviews: Covering research in medicine, science, & clinical practice. For physicians, researchers, & clinician
Can Omecamtiv Mecarbil Improve Peak Exercise Capacity in Patients With Heart Failure With Reduced Ejection Fraction (HFrEF)?

JAMA Author Interviews: Covering research in medicine, science, & clinical practice. For physicians, researchers, & clinician

Play Episode Listen Later Jul 19, 2022 20:38


Exercise limitation is a cardinal manifestation of heart failure with reduced ejection fraction (HFrEF), but it is not consistently improved by any of the current guideline-directed medical therapies. JAMA Deputy Editor Gregory Curfman, MD, discusses whether omecamtiv mecarbil can improve peak exercise capacity in patients with HFrEF with Gregory D. Lewis, MD, from Massachusetts General Hospital, and Mark H. Drazner, MD, MSc, from University of Texas Southwestern Medical Center. Related Content: Effect of Omecamtiv Mecarbil on Exercise Capacity in Chronic Heart Failure With Reduced Ejection Fraction: The METEORIC-HF Randomized Clinical Trial Omecamtiv Mecarbil as a Therapy for Heart Failure With Low Ejection Fraction

PRS Global Open Deep Cuts
Dr. Fred Menick: Leveling Up Nasal Reconstruction

PRS Global Open Deep Cuts

Play Episode Listen Later Jul 18, 2022 74:33


In this “Leveling Up” episode of the PRS Global Open Deep Cuts Podcast, Dr. Fred Menick talks about his time in practice in Guam, how to identify the normal, why the subunit principle of nasal reconstruction works, how nasal reconstruction is like skeletal reconstruction, the importance of not using local anesthetic and always having a lifeboat ready, and why being meticulous is the most important thing in surgery. Frederick J. Menick, MD was called "the finest nose maker in the history of medicine" by Dr. Burt Brent, himself a master of ear reconstruction. He is a two time winner of the James Barrett Brown Prize from the American Association of Plastic Surgeons, presented annually to the author of the most significant contribution to the specialty of Plastic Surgery. His book, Aesthetic Nasal Reconstruction - Principles and Practice, a two volume work published in 2018, has set the standard of care for nasal reconstruction. Dr. Menick started in practice in Tucson, Arizona in 1983 and retired in April 2022. Your host, Dr. Puru Nagarkar, is a board-certified plastic and hand surgeon, and Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas. Read a recent PRS Global Open article on the topic of nasal reconstruction: “Two or Three? Approaches to Staging of the Paramedian Forehead Flap for Nasal Reconstruction” by Oleck, Hernandez, Cason, et al: https://bit.ly/DeepCutsNasalRecon #PRSGlobalOpen #DeepCutsPodcast #PlasticSurgery #LevelingUp

Circulation on the Run
Circulation July 12, 2022 Issue

Circulation on the Run

Play Episode Listen Later Jul 11, 2022 22:40


This week, please join author Ambarish Pandey and Editorialist Linda Peterson as they discuss the article "Frailty Status Modifies the Efficacy of Exercise Training Among Patients with Chronic Heart Failure and Reduced Ejection Fraction: An Analysis from the HF-ACTION Trial" and the editorial "Heart Failure With Reduced Ejection Fraction (HFrEF): ‘The Importance of Being Frail.'" Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast, summary, and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, associate editor director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature article, Heart Failure Reduced Ejection Fraction in Evaluating the Efficacy of Exercise Training. But guess what? It appears it may be more efficacious in those that have high Frailty Index scores, as opposed to those that may not. But before we get to our feature discussion, let's grab a cup of coffee and go through some of the other articles in the issue. Would you like to go first? Dr. Carolyn Lam: I would love to, and this first paper is one that defines epigenetic biomarkers of lifelong cardiovascular health exposure and really contributes to our understanding of their roles in cardiovascular disease development. First though, a little quiz for Greg. So, Greg, what does DNA methylation mean to you? Dr. Greg Hundley: Well, Carolyn, DNA methylation. So, what I understand is these methyl groups get involved with our DNA and actually affect change over time that leads to phenotypic expression of, maybe, new traits. But I don't know. Maybe I'm not quite up to date. Dr. Carolyn Lam: Oh, you're perfect. Indeed, DNA methylation is a widely characterized epigenetic modification, which means exactly as you said. It's a regulatory modification to our DNA induced by environmental exposures and can affect gene expression. And this is the topic of today's paper by Doctors Zheng, Hou, and Lloyd-Jones from Northwestern University Feinberg School of Medicine and their colleagues. So, what they did is they studied blood DNA methylation at over 840,000 methylation markers measured twice over five years in participants of the CARDIA study. Epigenome-wide association analyses on a clinical cumulative cardiovascular health score were then performed in both CARDIA and compared in the Framingham Heart Study. Dr. Carolyn Lam: The authors identified 45 midlife DNA methylation markers associated with clinical cardiovascular health metrics, such as body mass index, blood pressure, blood glucose, and total cholesterol longitudinally measured since young adulthood. The methylation markers were located in genes involved in lipid metabolism, insulin secretion, and cytokine production, which could not be fully attributed to genetic factors. So, they proposed and validated in summary a methylation-based risk score to promote a personalized cardiovascular disease risk evaluation beyond traditional cardiovascular risk factors. Dr. Greg Hundley: Oh, wow, Carolyn. Interesting, a methylation-based risk score to promote personalized cardiovascular disease risk evaluation. Wow! That's really exciting. Dr. Greg Hundley: Well, I'm going to go to the world of preclinical science, and just like last week where we had a really nice article on myocardial regeneration, this week, we've got another. And so, Carolyn, early neonates of both large and small mammals are able to regenerate the myocardium through cardiomyocyte proliferation for only a very short period after birth. This myocardial regenerative capacity declines in parallel with withdrawal of cardiomyocytes from the cell cycle in the first few postnatal days. No mammalian species examined to date has been found capable of a meaningful regenerative response to myocardial injury later than one week after birth. Dr. Carolyn Lam: Interesting. Now, I see that these investigators worked with possums. Could you tell me why they did that, and what did they find, Greg? Dr. Greg Hundley: Right, Carolyn. So, this work was led by Dr. Wataru Kimura from the RIKEN Center for Biosystems Dynamic Research and their colleagues. The reason they studied possums, so the marsupial possum maintains cardiomyocyte proliferation and a capacity for myocardial regeneration for at least two weeks after birth. Remember we stated before, all the other mammalian species, it's only one week after birth. So, this appears to be the longest postnatal duration of such a capacity among mammals examined to date, and AMP kinase signaling was implicated as an evolutionary conserved regulator of mammalian postnatal cardiomyocyte proliferation. Dr. Greg Hundley: And they additionally found that in a separate mouse experiment, the authors noted that the pharmacological inhibition of AMP kinase signaling was sufficient to extend the postnatal window of cardiomyocyte proliferation in neonatal mice, so really exciting work in the area of cardiomyocyte regeneration. Dr. Carolyn Lam: Wow, indeed! And I've learned now about possums. Thank you, Greg. Dr. Carolyn Lam: So, Greg, have you ever asked yourself, what is the frequency, penetrance, and variable expressivity of dilated cardiomyopathy-associated gene variants in the general population? Well, guess what? This next paper addresses just that in more than 18,600 UK Biobank participants who had undergone whole-genome sequencing, ECG, and cardiovascular magnetic resonance imaging. Dr. Greg Hundley: Wow, Carolyn, another really interesting study from the UK Biobank. So, what did they find? Dr. Carolyn Lam: So, this study is from Dr. Chahal from the Center for Inherited Cardiovascular Diseases Wellspan Health in Lancaster, Pennsylvania and colleagues, and they found that approximately one in six of adults with putative pathogenic variants in dilated cardiomyopathy genes exhibited early dilated cardiomyopathy features potentially associated with the genotype. And it's most commonly manifesting with arrhythmias in the absence of substantial ventricular dilation or dysfunction. Dr. Carolyn Lam: Among individuals with putative pathogenic dilated cardiomyopathy gene variants, ECG or CMR-detected early features were nearly four times more common than clinically manifest dilated cardiomyopathy or early features. Over 90% of subjects with these gene variants in dilated cardiomyopathy-associated genes did not have a prior history of dilated cardiomyopathy, and the overall clinical or subclinical penetrance of dilated cardiomyopathy-associated single pathogenic variants was highly variable between genes ranging from zero to 67%. And so, in conclusion, a genotype-first screening approach for dilated cardiomyopathy using a large genetic panel is currently not suitable in the general population due to incomplete understanding of the genetic architecture and reduced penetrance of the associated genes. Dr. Greg Hundley: Very nicely said, Carolyn. Wow! Well, let's take a look and see what's in the mailbag. And first, there's a Research Letter from Professor Huguenard entitled, “Frequency of Screening Detected Intracranial Aneurysms in Patients With Loeys-Dietz Syndrome.” And our own Bridget Kuehn has a really nice piece on Cardiology News. Dr. Carolyn Lam: Nice. There's also an On My Mind paper by Dr. Sattar, McGuire, and Gill entitled, “High-Circulating Triglycerides Are Most Commonly a Marker of Ectopic Fat Accumulation: Connecting the Clues to Advanced Lifestyle Interventions,” and an exchange of letters between Dr. Groothof and myself, Dr. Lam, regarding my article on “Efpeglenatide and Clinical Outcomes With and Without Concomitant SGLT-2 Inhibition in Type 2 Diabetes: An Exploratory Analysis of the AMPLITUDE-O Trial.” Dr. Carolyn Lam: Ah, that was awesome. Well, thanks, Greg. I am so excited to get to the future discussion that you queued us on so well, frailty in heart failure with reduced ejection fraction. Here we go. Dr. Greg Hundley: You bet. Dr. Greg Hundley: Welcome, listeners, to this July 12th, 2022 feature discussion. And we have with us today, Dr. Ambarish Pandey from University of Texas Southwestern Medical Center in Dallas, Texas, and Dr. Linda Peterson, an editorialist for this article from Washington University in St. Louis. Welcome to you both. Well, Ambarish, We're going to start with you. Could you describe for us basically the background information that went into the preparation of your study, and what was the hypothesis that you wanted to address? Dr. Ambarish Pandey: Thanks, Greg, for having me on this, and thanks to Circulation for publishing our article. Yeah, I think the premise for this study stems from the longstanding known benefit of exercise training in patients with heart failure with reduced ejection fraction. Now, that was shown in the HF-ACTION trial, where individuals with chronic stable heart failure with reduced ejection fraction underwent exercise training, and there was demonstrated benefit in quality of life and adjusted analyses. There was a protocol-specified adjusted analysis that did demonstrate improvement in some of the key primary endpoint. Dr. Ambarish Pandey: Based on these results, CMS has approved exercise training and cardiac rehabilitation in patients with chronic stable heart failure with reduced ejection fraction. However, despite this mandate from CMS and generally well-accepted benefits of exercise training in heart failure with reduced ejection fraction, the uptake of exercise training has been pretty low, and there's a lot of heterogeneity in the improvement in outcomes that is associated with exercise training. Dr. Ambarish Pandey: So, we wanted to see whether frailty, which is a well-characterized syndrome of reduced physiologic reserve and impaired homeostatic tolerance to stressors and is common in patients with HFrEF, we wanted to see how frailty modifies the beneficial effects of exercise training in HFrEF. And based on the existing literature and some of the prior works we have done, we hypothesized that individuals who are frail and who have more functional impairments are going to have more targets for improvement in their functional status and thus would be more likely to benefit from exercise training. And we looked at this in the HF-ACTION trial itself and using the Rockwood Frailty Index and the difference in primary outcome and treatment effect of exercise among frail and non-frail individuals. Dr. Greg Hundley: Very interesting, so really sort of a look back in HF-ACTION data. Describe a little bit more for us that study design, and then specifically, what was the study population that you used to test your hypothesis? Dr. Ambarish Pandey: Right. So HF-ACTION was a randomized control trial multi-centered that was sponsored by NHLBI and was conducted in the early 2000s and basically focused on chronic stable patients with heart failure with reduced ejection fraction who have not had a hospitalization in the past six weeks and have ejection fraction less than 35% and class II to IV. And these participants were randomized in one-to-one fashion to getting aerobic exercise training followed by some home-based exercise versus the usual care. Dr. Ambarish Pandey: And in our study, what we looked at was we looked at the effect modification by baseline frailty status on the treatment effect of exercise training. So, we calculated the frailty index, which is a well-established measure of frailty using a Rockwood Index Model, and we stratified patients by frail versus non-frail status based on a Frailty Index cut-off of 0.21, such that higher index identifies more frail participants. And then, we looked at how the treatment benefit of exercise training on different outcomes was differential across the frail and non-frail strata. We looked at qualitative interaction, and we also looked at the Frailty Index, so the continuous variable to assess the benefits of exercise across the spectrum of frailty in the study population. Dr. Greg Hundley: And so, before we get to your study results, how many patients were in your study? Give us an idea of what was the range in age, and then also the composition of sex? How many men? How many women? Dr. Ambarish Pandey: Right, so this is really important because that's addressed to the generalizability of the study. So, the study included around a little over 2,100 participants. The mean age was 59 years. 28% were women, and 32% were self-reported black individuals with chronic stable heart failure. That was the demographic distribution. The age was slightly younger than what you've commonly see in observational studies with heart failure, and that is largely because the study recruited patients who were able to do exercise training and were able to do exercise tests with peak VO2 and peak VO2 peak excess capacity assessment at baseline and follow-up. So, that kind of selected for a slightly younger population. Dr. Greg Hundley: Very nice. And so, what were your study results? Dr. Ambarish Pandey: So our study results are, indeed, pretty interesting. We identified that around 60% of patients with chronic stable heart failure with reduced ejection fraction who were in the trial were actually frail based on the Rockwood Frailty Index Model. And we observed that among the study participants, the exercise training was associated with significant improvement in the primary composite endpoint of all-cause hospitalization or death in frail participants, but not in the non-frail or less fail participants. And there was a significant treatment interaction, such that baseline frailty modified the treatment effect of exercise training for the primary composite endpoint. Dr. Ambarish Pandey: Now, this was largely driven by a significant reduction in all-cause hospitalization among frail individuals who underwent exercise training, and not so much by an effect on mortality. And we did not see a significant difference in the mortality component of the primary composite endpoint across frail versus non-frail status participants. So, in a nutshell, baseline frailty did modify the treatment effect, largely driven by substantial reduction in the risk of all-cause hospitalization among frail participants more than non-frail participants. Dr. Greg Hundley: And before we get to Linda in her interpretation of your study, Ambarish, did you see the same effects in frail men, in frail women? And also, what about in individuals that might be a little older versus those that were perhaps younger? Dr. Ambarish Pandey: That's a really important question, and we were a little bit limited to do further subgroups because we are dealing with around, I think, 2,000 participants and we had frail, non-frail, and we did not do a further subgroup stratification by sex or by age. The age range was rather narrow. It's 58 years plus/minus 13 years, so we didn't really have a lot of older individuals above 75, something like what REHAB-HF Trial has shown in the news, a recent trial. Dr. Ambarish Pandey: We couldn't address the question of whether the effect modification was further modified by sex or age, so I think that's the two-level interaction. But I think that is something that would be interesting to test perhaps in a pool analysis of multiple exercise training studies, which is something we are considering. Dr. Greg Hundley: Thank you. Well, listeners, now we're going to turn to our editorialist, Dr. Linda Peterson, from Washington University in St. Louis, and, Linda, very provocative results here, heart failure reduced ejection fraction. And certainly, we like to go to things like cardiac rehab, but we're hearing this it seemed to make a difference if you were frail versus not frail. Dr. Linda Peterson: Right, I think that's an important distinction here in this article as Ambarish has so eloquently put forth, and it's especially important because other articles have shown in looking at the PARADIGM-HF Study and ATMOSPHERE it appears that one out of two patients with HFrEF are actually frail. And so, the magnitude of these findings and the importance of these findings is highlighted by that study. And this frequency of frailty is roughly double that of community-dwelling adults who are over age 90, so we're thinking of frailty usually as much older adults, but in HF-ACTION, actually, the patients' average age was 60 in the patients with HFrEF. Dr. Linda Peterson: So, there's almost an accelerated aging phenotype we're seeing here in a large proportion of the patients who have HFrEF. I think this has an enormous impact on a lot of the patients that we're seeing with HFrEF, and we should be alerted to looking for frailty and potentially screening for frailty. And I think another highlight of this study is that it points out the importance of frailty because frail patients have a 50% higher risk of hospitalization and death, according to some other studies, particularly one by Faray and their group and also by Yang and their group. Dr. Linda Peterson: And so, it highlights the importance of getting patients who are frail with HFrEF into cardiac rehab or getting them some sort of aerobic exercise training. But paradoxically, frailty is also associated with a lower likelihood of those particular patients on getting into cardiac rehab and also getting on goal-directed medical therapy. And that was shown by Phil Ades and his group. So, I think the importance of these findings by Ambarish and his group are to be commended, and they're very important for a large proportion of our patients with HFrEF. Dr. Greg Hundley: Very nice. Well, let's turn back to Ambarish, and then follow up with Linda. Ambarish, what do you see as the next study that should be performed in follow-up to your study? Dr. Ambarish Pandey: I think that's a great question. And I think we are just beginning to realize the magnitude of impact that frailty has in the care of patients with heart failure. And this goes across the spectrum of ejection fraction, both HFpEF or heart failure with preserved ejection fraction and heart failure with reduced ejection fraction. Indeed, the burden of frailty is higher in patients with heart failure with preserved ejection fraction, and they are more of the accelerated aging phenotype. Dr. Ambarish Pandey: And I think the next study basically should look at a targeted approach to exercise training or category of intervention among patients who are most likely to benefit from it, which would be patients who have a high frailty burden or patients who have HFpEF. I think they go hand in hand when it comes to frailty and HFpEF. So, I think that's the next study to do is to see to what extent we can actually identify and target exercise training in the highest risk individuals who are most likely to benefit from it because that subset of highest modifiable risk is indeed identified by frailty and when you look at other subtypes by HFpEF which has a lot of high frailty burden. Dr. Greg Hundley: And, Linda, from your perspective, what do you see as the next study to be performed in this sphere of research? Dr. Linda Peterson: Yeah, I think this study really provides a springboard for future studies in HFrEF, in particular. One, what hospital interventions can be done in patients to get them moving more, and really assess is there a possibility of different types of exercises to get patients less frail even while they're in the hospital when they're enroute to going home? And then also, how do we have different mechanisms by which we can get more patients into cardiac rehab? Clearly, our national average of getting patients who qualify for cardiac rehab, which is a class I indication is 20% at best, and the aim from the AHA is 70%. Dr. Linda Peterson: There's a big gap there, so interventions looking at implementation and getting patients to cardiac rehab or looking at other types of aerobic exercise training, such as home-based cardiac rehab for patients who don't have a cardiac rehab center next to them, I think the field is wide open for different studies to springboard off of these findings. Dr. Greg Hundley: Very nice. Well, listeners, we want to thank Dr. Ambarish Pandey from University of Texas Southwestern Medical Center in Dallas, Texas, and our editorialist, Dr. Linda Peterson, from Washington University in St. Louis, for bringing us this research study, highlighting that among patients with chronic stable heart failure and reduced ejection fraction, that baseline frailty modified the treatment effect of aerobic exercise training with a greater reduction in the risk of all-cause hospitalization. Dr. Greg Hundley: 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. Speaker 5: 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.

Pediatric Meltdown
AAP Blueprint for Youth Suicide Prevention: A Roadmap

Pediatric Meltdown

Play Episode Listen Later Jul 6, 2022 62:42


In February of 2021, the AAP, NIMH, and the AFSP convened, along with over 100 clinicians, a workgroup with a shared goal and dream of compiling a roadmap for youth suicide prevention, and in March of 2022, the AAP Blueprint for Youth Suicide was released. This comprehensive body of work provides clinical pathways, initiatives for community partner collaborations, resources, and advocacy materials. Additionally, there is an extensive section on the epidemiology of youth suicide informed by a health equity lens. The panelists share the story of the creation of the Blueprint along with practical information on the navigation of the site.   Today we are joined by Dr. Lisa Horowitz, Dr. Christine Moutier, and Dr. May Lau   Dr. Lisa Horowitz is a Staff Scientist / Pediatric Psychologist in the National Institute of Mental Health Intramural Research Program at the National Institutes of Health. The major focus of Dr. Horowitz's research has been the detection of suicide risk in the medical setting. She is the lead PI on six NIMH suicide prevention protocols that involve validating and implementing the Ask Suicide-Screening Questions (ASQ) in the ED, inpatient medical/surgical, and outpatient primary care settings. Dr. Horowitz is collaborating with hospitals, outpatient pediatric clinics, and school settings around the country, assisting with the implementation of suicide risk screening and management of patients who screen positive using the ASQ Toolkit and Youth Suicide Risk Screening Clinical Pathways   Dr. Christine Yu Moutier, Chief Medical Officer of the American Foundation for Suicide Prevention, knows the impact of suicide firsthand. After losing colleagues to suicide, she dedicated herself to fighting this leading cause of death. Dr. Moutier has served as UCSD professor of psychiatry, dean in the medical school, medical director of the VA Psychiatric Unit, and has been clinically active with diverse patient populations, such as veterans, Asian refugee populations, as well as physicians and academic leaders with mental health conditions. She has presented at the White House, testified before the U.S. Congress, and has appeared as an expert in The New York Times, The Washington Post, Time magazine, The Economist, The Atlantic, the BBC, and CNN.   May Lau, MD, MPH, is an Associate Professor in the Department of Pediatrics at the University of Texas Southwestern Medical Center and the medical director of the Adolescent and Young Adult Program at Children's Medical Center Dallas, where she provides care for adolescent females and males, including sexual and gender minority youth. Dr. Lau co-chairs the American Academy of Pediatrics (AAP) Texas Pediatric Society (TPS) Committee on Adolescent and Sports Medicine, has been elected to the AAP Section on Adolescent Health Executive Committee and is a fellow of the Society of Adolescent Health and Medicine. She educates fellows, residents, and medical students on the specialized care of adolescents. Her research focuses on a variety of areas including adolescent mental health and gender-affirming care. Dr. Lau has spoken at national meetings on a variety of adolescent medicine topics including mental and sexual and reproductive health.          Key Highlights:     [00:00 - 18:43] Pediatricians Tackle Suicide Prevention The project, which was called the "Blueprint for Youth Suicide Prevention," was spearheaded by the American Foundation for Suicide Prevention and the National Institute of Mental Health and was completed in March 2019. The summit, which was held in February of 2019, brought together a diverse group of pediatricians to discuss ways to prevent suicide in youth. The final product of the summit was a blueprint for suicide prevention that has been implemented by many different organizations. [18:43 - 27:10] Pediatricians can use this blueprint to screen for suicide in their practice...

Cancer.Net Podcasts
2022 Research Round Up: Prostate, Testicular, Bladder, and Kidney Cancer

Cancer.Net Podcasts

Play Episode Listen Later Jun 30, 2022 49:09


ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests' statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field and explain what it means for people with cancer. In today's episode, 4 Cancer.Net Specialty Editors discuss new research in prostate, bladder, kidney, and testicular cancers presented at the 2022 Genitourinary Cancers Symposium and 2022 ASCO Annual Meeting. This episode has been adapted from the recording of a live Cancer.Net webinar held June 15th, 2022, led by Dr. Neeraj Agarwal, Dr. Timothy Gilligan, Dr. Petros Grivas, and Dr. Tian Zhang. Dr. Agarwal directs the Genitourinary Oncology Program at the Huntsman Cancer Institute at the University of Utah. Dr. Gilligan is an Associate Professor and Medical Oncologist at the Cleveland Clinic Taussig (TOSS-ig) Cancer Center. Dr. Grivas is the clinical director of the Genitourinary Cancers Program at University of Washington Medicine. He is also an associate member of the clinical research division at the Fred Hutchinson Cancer Research Center. Dr. Zhang is an Associate Professor of Internal Medicine at UT Southwestern Medical Center and a medical oncologist at the Harold C. Simmons Comprehensive Cancer Center. Full disclosures for Dr. Agarwal, Dr. Gilligan, Dr. Grivas, and Dr. Zhang are available at Cancer.Net. Greg Guthrie: Good afternoon, everyone. I'm Greg Guthrie, and I'm a member of the Cancer.Net content team. I'll be your host for today's Research Round Up webinar focusing on cancers of the genitourinary tract. Cancer.Net is the patient information website of the American Society of Clinical Oncology, known as ASCO. So today, we'll be addressing research from 2 2022 scientific meetings, the ASCO Annual Meeting held in Chicago in June and the Genitourinary Cancers Symposium held in San Francisco in February. Our participants today are all Specialty Editors of the Cancer.Net Editorial Board, and they are Dr. Neeraj Agarwal of the Huntsman Cancer Institute in University of Utah, Dr. Timothy Gilligan of the Cleveland Clinic Taussig Cancer Center, Dr. Petros Grivas of the Fred Hutchinson Cancer Research Center and University of Washington, and Dr. Tian Zhang of the University of Texas Southwestern Medical Center. Thank you, everyone, for joining us today. So starting us off today is Dr. Agarwal who will be talking about research in prostate cancer. Go ahead, Dr. Agarwal. Dr. Agarwal: Hi. Thank you, Greg. So I'd like to start with 2 studies. They both are in prostate cancer which will be followed by my colleagues presenting studies in other cancers in bladder cancer and kidney cancer. So I'll start with this abstract, which was highly discussed by the doctors at the ASCO Annual Meeting a few weeks ago, and it has a lot of relevance in our practice. So this is abstract #5000 presented by Dr. Michael Hofman, and this was the update on a clinical trial which compared lutetium PSMA-617, or lutetium PSMA, to put it simply, with cabazitaxel in patients with metastatic castration-resistant prostate cancer who had disease progression after receiving docetaxel chemotherapy. So, who were the patients who were enrolled on the study? These patients had, as I said, metastatic castration-resistant prostate cancer, who had disease progression after docetaxel chemotherapy, and who had to have high PSMA-expressing prostate cancer. And the way they assessed the presence of high PSMA expression was by using a specialized kind of PET scan known as Gallium 68 PSMA-11 PET scan. In addition, they made sure that these patients do not have another type of prostate cancer, also call it dedifferentiated prostate cancer, by making sure that those patients did not have a traditional PET scan-positive disease. So this was a highly selected patient population who were expressing PSMA on their prostate cancer. Prior to this presentation, the earlier presentation had shown that lutetium PSMA was superior to cabazitaxel as far as progression-free survival is concerned and also was associated with lower incidence of grade 3 or 4 side effects. In this update, after a longer follow-up of 3 years, Dr. Hofman and Dr. Davis, who is a senior author, they presented the data on overall survival, which was a secondary analysis, and overall survival was similar with cabazitaxel as well as lutetium PSMA in the range of 19 months. We did not see any new safety signal. So, what does it mean for us? What does this mean for our patients? My key takeaway message here is, lutetium PSMA is a suitable option for men with metastatic castrate-resistant prostate cancer who are expressing high PSMA on their prostate cancer after they had sustained disease progression after docetaxel. However, cabazitaxel is also a valid option in this setting. I would like to add my own view in addition to this because lutetium PSMA was better tolerated and was also associated with better progression-free survival. In my patients who are progressing on docetaxel chemotherapy, I would like to use lutetium PSMA first followed by cabazitaxel chemotherapy. So that would be my key takeaway from this abstract. Now we can move to the next abstract. This was also an update, a much longer update, on ENZAMET trial. If you recall, ENZAMET trial was one of those trials which established that deeper androgen blockade, or deeper androgen signaling inhibitors such as enzalutamide, apalutamide, or abiraterone, these trials were conducted in 2015 onwards, and all these trials showed that upfront using deeper androgen signaling inhibitors at the time of metastatic hormone-sensitive prostate cancer onset improved survival. So ENZAMET trial used enzalutamide, and it showed in the first analysis, which was presented by Dr. Davis and Dr. Sweeney in the 2019 ASCO Meeting Plenary session, that adding enzalutamide to androgen-deprivation therapy in patients with metastatic hormone-sensitive prostate cancer significantly improved survival. In this longer follow-up of 68 months, so we are talking about almost 6 years of follow-up, now, these investigators from ENZAMET trial, as presented by Dr. Davis, showed that the combination of enzalutamide with androgen deprivation therapy or testosterone suppression therapy continues to significantly improve survival in patients with newly diagnosed hormone-sensitive prostate cancer or metastatic prostate cancer. One interesting part of this unique aspect of this trial was that patients were allowed to receive docetaxel chemotherapy concurrently to the protocol treatment. And in this trial, 45% patients actually receive docetaxel chemotherapy. So 503 patients exactly out of 1,000-plus patients. So if you look at the subgroup analysis of those patients who received docetaxel chemotherapy, enzalutamide does not seem to benefit those patients from the overall survival perspective. So on the face of it, it looks like enzalutamide is not helping those patients who are receiving docetaxel concurrently. But there are some caveats with that kind of subgroup analysis. The first one is this is not a randomized assignment of docetaxel chemotherapy. Patients were determined to have docetaxel chemotherapy after discussion with their respective oncologist. This was not a prespecified analysis that so many patients with docetaxel will receive enzalutamide. Also, this was not a randomized assignment of docetaxel. And third, that I don't think this trial had enough power to look for that subgroup analysis. So my take on this trial is that updated results from this trial, almost 6 years of follow-up now show that enzalutamide continues to improve overall survival with a 30% reduction in risk of death in patients with metastatic castration-sensitive or hormone-sensitive prostate cancer. Furthermore, the effect of enzalutamide, in my view, on overall survival is independent of the receipt of docetaxel. If you look at the whole trial population for which the trial was covered for, enzalutamide improved survival for all patients. And based on these results, I feel more confident in saying that upfront intensification of treatment with deeper androgen inhibition remains a standard of care for our patients with metastatic hormone-sensitive prostate cancer and should be offered to all eligible patients with this condition. With that, I would like to wrap up the prostate cancer abstracts. Thank you very much. Greg Guthrie: And thank you, Dr. Agarwal. Next up, we will have Dr. Gilligan, who is going to be discussing testicular cancer. Dr. Gilligan: Thank you very much. So I have 2 studies I want to talk about and then just give a headline of some interesting things that I think are kind of coming down the road. Both of these abstracts have to do with improvement over time in specific patient populations we used to worry about. I'm not saying we don't worry about them anymore, but things are looking better now than they had 1 or 2 decades ago. So the first topic addresses late relapses in testicular cancer. And historically, we have been concerned that these patients did worse and had worse outcomes. And late relapse could variously be described as after 2 years or after 5 years. In the current study, they defined late relapse as being after 2 years and very late relapse as being after 5 years. And what was special about the study was that it captured the entire population of patients with testis cancer in Norway and Sweden so that it wasn't based on a center of excellence that gets selective referrals. It was actually a population-based study. And the key conclusion of the study was one I found, once again, that late relapses are rare. So for stage I patients, 2% of patients will relapse after 2 years, 1% after 5 years, and 0.5%, so 5 out of 1,000 patients, after 10 years. So if you're 2 years out, the likelihood of a relapse is quite low. And if you're 5 years out, it's half of that. In patients with metastatic disease, similarly, 3.6% relapse after 2 years, 1.6% after 5, and 0.8% after 10 years. And what was interesting to me was that if you looked at the more recent patients who were diagnosed after 1995 - I know that doesn't sound very recent, but they had even earlier patients also in the study - the very late relapse rate almost resolved and went away. It went from 2.2% all the way down to 0.8%. So I think with modern imaging, modern care patterns, we're seeing less of this than we used to. But overall, patients were doing better even if they do relapse late. One thing that was interesting in the study to me also was for stage I disease, we typically recommend surveillance rather than active treatment. So active treatment with non-seminomas would be a retroperitoneal lymph node dissection or more surgery or chemotherapy. With seminoma, it would usually be chemotherapy or radiation, although surgery is being investigated there now. And they did find that in men who chose surveillance, which we still recommend, the late relapse rate was a little bit higher, but it was still affecting a small percent of patients. So the relapse rate beyond 2 years was 4% rather than 1%, but out of 4,000 patients, there were only 3 deaths from late relapse. So this isn't changing the recommendation for surveillance, but it is an alert that patients who are on surveillance for stage I disease have a slightly higher risk of late relapse and that may affect how we follow them and specifically how long we follow them. One of the things that was interesting in the study is in the United States, we often stop scans at 5 years, but in the SWENOTECA countries, they continue scans all the way out to 10 years. I don't know that U.S. guidelines are going to change, but it was a provocative finding. The key thing, as I alluded to at the beginning, was that 61% of patients with late relapse were alive 10 years later, and while we would like that number to be higher, it used to be around 50% in older studies. So it's a significant improvement from where we were before. A particularly interesting thing to me was that patients relapsing 2 to 5 years out actually had the best prognosis. Patients who relapsed in years 1 to 2 had a worse prognosis and patients relapsing after 5 years had a worse prognosis, whereas the patients relapsing 2 to 5 years had a better prognosis. In the end, I think what this means for us is that patients are doing better. It's not going to really change our treatment patterns, but it's reassuring that we shouldn't be pessimistic about late relapses, and we still have a solid chance of curing them. So again, bottom line, most men with late relapse is cured and late relapse is less common now than it was earlier, particularly in non-seminomas. Let's go to the next study. So this is a different group of patients who had a particularly ominous prognosis historically and still we have a lot of room for improvement. These are patients with non-seminomas that start in the mediastinum. So in the chest, under the breastbone, under the sternum typically. And patients are treated aggressively upfront, they are considered poor risk at the initial time of diagnosis, and they're treated aggressively at the time with 4 cycles of BEP or 4 cycles of VIP chemotherapy. And then they go for surgery to remove any residual disease. And the hope is they're cured at that point because historically, if there was a relapse after chemotherapy and surgery, it was almost impossible to cure them. Indiana University published their results using high-dose chemotherapy in this population, and they reported that 30% of men who were treated with high-dose chemotherapy had no evidence of cancer after 2 years, and 35% were still alive. Obviously, we need longer follow-up, but most of the relapses you're going to see are going to be in the first 2 years. So while again, there is significant room for improvement here, this indicates that high-dose chemotherapy is a good option, and that has been a question. So this is reassuring in that regard. But it is a good option for men with relapsed mediastinal non-seminomas of the germ cell tumors. So there's hope there where in the past, this has felt a little bit helpless. The thing I wanted to also highlight was that there are 3 things I think are going to be interesting to keep an eye on over the next year. One is the use of surgery for early-stage seminomas. There are a number of papers out about that. I still think this is an investigational approach, and so I didn't want to go into great detail about it, but it is looking like that RPLND, or retroperitoneal lymph node dissection, will likely or may be an option for stage I and stage II seminoma in the future. We are getting more evidence for that. It's not quite as promising as we had hoped until there's more data that's needed, but it's looking like that will become an option. So for men with early-stage seminoma, at least raising the question whether surgery is an alternative to chemotherapy or radiation, is an important discussion to have with your oncologist. Secondly, MRI rather than CT scans for surveillance. So to keep an eye on men who have been treated or men who are just stage I and are being followed and typically come in routinely for CT scans, which expose people to ionizing radiation, which theoretically has a risk of causing cancer, there's more and more data that MRI is just as good as CT, and MRI does not use ionizing radiation. So there's probably going to be an expanding role for MRI as an alternative to CT scans. And lastly, the use of microRNA rather than just depending on serum tumor markers. So right now, we use the blood tests alpha-fetoprotein, beta hCG, extensively to monitor for relapse, and there's more and more evidence for using what we call microRNAs instead. It may be more accurate in multiple different settings. So it'll be interesting to see how that evolves and that's what I wanted to cover today. Thank you very much. Greg Guthrie: Thank you, Dr. Gilligan. And now we have Dr. Grivas, who's going to discuss some research in bladder cancer. Dr. Grivas: Thank you so much, Greg, and thanks Cancer.Net for the great opportunity to discuss this for our patients. We're very excited about the data from the ASCO Annual Meeting, and I would encourage the audience to review as possible other presentations as well. I'm going to cover 3 highlights. I'm going to start with the QUILT-3.032 study. This trial reported the final results of a clinical trial that took place in different centers and involved patients with what we used to call “superficial bladder cancer.” And the modern term is “non-muscle-invasive bladder cancer.” Bladder cancer that does not involve the muscle layers, not that deep in the bladder wall. Non-muscle-invasive bladder cancer is usually treated by our colleagues in urology with installation inside the bladder with an older form of immunotherapy which is BCG. And that's the most common way we treat this disease. And proportion of patients may have tumors that may not respond to BCG that may come back or persist despite the installation of the BCG in the bladder. And these patients usually have a standard of care of getting what we call radical cystectomy, meaning, removal of the bladder and the lymph nodes around the bladder, radical cystectomy and lymph node dissection. However, many patients may not have, I would say, the opportunity to get the surgery because the body may not be that strong to undergo that significant procedure. Very few patients may have that challenge because of other medical conditions or what we call poor performance status. Or some patients for quality-of-life reasons may try to keep their bladder as long as possible. And for some of those patients, that might be an option. And we have been looking for those options in the last few years. Intravesical, inside the bladder, installations of chemotherapy have been used with some positive results in some other studies. So that's an opportunity. We call this intravesical, inside the bladder, installations of chemotherapy, and the other option is an FDA-approved agent given intravenously inside the vein called pembrolizumab, which is in the form of immunotherapy. Of course, research continues. And this study I'm showing here from Dr. Chamie and colleagues, looked at this combination of BCG plus this molecule called N-803. This is another form of immunotherapy, and this was tested in patients who have this BCG-unresponsive, as we called it, non-muscle-invasive bladder cancer. The results were very promising. I would say impressive that it was a high response rate if we focus our attention on patients who had the superficial form carcinoma in situ, about 70% had no evidence of cancer upon further evaluation of the bladder. And in many of those patients that this response lasted for more than 2 years. 96% of patients avoided to have worsening of the bladder cancer in 2 years for those who had a response, and about 9 out of 10 avoided cystectomy again from those patients who had received the response. So it was 70% of all the population. And as you see, all patients, 100% were alive without dying from bladder cancer after 2 years, which again is a very promising finding. This combination, to conclude, this inside the bladder installations of BCG plus the N-803, looks very promising. For those patients with BCG-unresponsive non-muscle-invasive bladder cancer, that might be an option down the road, we have to see. Now I'm going to shift my attention to patients with metastatic or spread urothelial cancer. I want to point out that I'm a co-author in this abstract and I participated in that survey I will show you the results from. This is a population of patients who have spread cancer from the urinary tract, either the bladder was the most common origin or other parts of the urinary tract, for example, what we call kidney, pelvis and ureter, or rarely the urethra. The urothelial cancer that starts from those areas, again more commonly bladder, if it spreads, if it goes outside the urinary tract system, usually those patients get chemotherapy, what we call with an agent called cisplatin if they can tolerate that chemotherapy drug or carboplatin if they cannot tolerate the cisplatin drug. And usually either of these, cisplatin or carboplatin, is combined with a drug called gemcitabine. That's the most common chemotherapy used as initial therapy for patients with spread metastatic urothelial cancer. In this abstract, Dr. Gupta and colleagues tried to survey 60 medical oncologists, including myself, who treat urothelial cancer that considered experts in this disease type, to see if there are any features that could deter us from using chemotherapy in those patients. In other words, are there any features that may make us think that chemotherapy may be too risky for our patients and we should not do it? We should give immunotherapy instead. This is probably a small proportion of our patients, maybe 10 to 20% in our practice, may not be able tolerate that chemotherapy. And which are those features? Poor performance status, meaning the body is very tired and the patient is not moving too much, is confined in the chair or the bed most of the day, and rely on others on daily activities. This is what defines the performance status of ECOG 3. Peripheral neuropathy, meaning that there is numbness or tingling or weakness in the hands or the feet that impact the quality of life. And patients may have trouble buttoning buttons or tying laces, so impacting the quality of life. That's grade 2 neuropathy. Symptomatic severe heart failure, there is a grading system, like New York Heart Association Class III or IV that is significant, notable heart failure symptoms. And also, patients with kidney failure with what we call creatinine clearance below 30 cc per minute. That's a marker how we measure kidney function and the creatinine clearance more than 60 is usually close to normal. As the creatinine clearance drops and goes below 30, chemotherapy with these platinum agents may become a challenge by itself or if it's combined with the ECOG performance status of 2, which means more patients are not moving most of the day. So those features again have to do with the functionality of the day-to-day life. The presence of significant neuropathy, heart failure, and poor kidney function may potentially make the oncologist recommend immunotherapy versus the standard of care, which is chemotherapy, in those patients. And I would say if someone gets chemotherapy, which is the majority of patients, usually they may get immunotherapy later. So pretty much I would say discuss with the medical oncologist what is the right treatment for you. Most patients get chemotherapy up front, followed by immunotherapy. Some others may need to get immunotherapy, and those criteria help us make that patient selection for the right treatment at the right time. So I just alluded to you that most patients with spread or metastatic urothelial cancer, most of them receive chemotherapy. We discussed some criteria in the previous studies that we may use immunotherapy upfront instead of chemo, but for the vast majority of patients, chemotherapy is used upfront and that was based on the results of phase 3 clinical trial called JAVELIN Bladder 100. This was presented at the ASCO Annual Meeting in 2020 about 2 years ago, and it was published in a big journal. And that study showed that if you give chemotherapy upfront, those patients who can tolerate the chemotherapy, of course, who do not have the previously listed criteria, those patients benefit and live longer, so longer overall survival, meaning they live longer, and they have longer progression-free survival, meaning they live longer without worsening of the cancer if they get immunotherapy with, immunotherapy drug is given through the vein, called avelumab. If that is given after the end of chemotherapy for patients who have a response or stable disease, meaning no progression on chemotherapy. So if you get a complete response, meaning that the CAT scans look normal after chemotherapy as at least we can tell visually. Partial response, meaning that the CAT scans look better, but still we can see some cancer spots. Stable disease, meaning that the scans look stable compared to the beginning before we start chemotherapy. If someone has worsening of the cancer in chemotherapy, then the concept of maintenance therapy doesn't apply. So it's only for patients with complete response, partial response, or stable disease, SD. And the poster we had, and I can tell you - I was a co-author in the abstract and co-investigator in the trial, as a disclosure - was sort of the benefit of the patient with avelumab as maintenance therapy after chemotherapy was notable in patients with complete response, partial response, and stable disease. So in any of these 3 categories, avelumab immunotherapy should be offered as level 1 evidence and benefit patients in terms of overall survival and progression-free survival as long as there's no progression to the upfront initial chemotherapy of the patient with metastatic urothelial cancer received. Many other abstracts on these cancers were presented, and I would encourage you to look at them. Thank you so much for the opportunity today. Greg Guthrie: And thank you, Dr. Grivas. Next, we have Dr. Zhang who will discuss some research in kidney cancer. Dr. Zhang: Hi everyone, glad to be here today. I'll be discussing 2 highlights from ASCO 2022 in kidney cancer. The first one we wanted to highlight was a trial called EVEREST: everolimus for renal cancer ensuing surgical therapy, a phase 3 study. And in context, this study is a trial of evaluating everolimus, an mTOR inhibitor, in the post-surgical context. And we do have in the landscape 2 approved therapies, sunitinib and pembrolizumab. And as we have seen, some effective therapies in the refractory setting, many of these therapies are being tested in this postoperative space. So this particular study of EVEREST looked at patients with renal cell carcinoma who underwent resection for their primary nephrectomy and looking to evaluate postsurgical treatment. So everolimus has been approved as a treatment on its own in the refractory setting as well as in combination with lenvatinib. And so this question of whether everolimus alone could delay or prevent disease recurrence in the postoperative setting was tested in this EVEREST trial. The study ultimately enrolled more than 1,500 patients and assigned them to receiving either everolimus or placebo in the postoperative setting. Of these patients, 83% had clear cell kidney cancer and the remaining had non-clear cell kidney cancer. And the follow-up was quite long, over 5 years, and actually over 6 years, and the researchers looked at time until disease recurrence. And risk of recurrence was actually decreased by 15% in patients who were treated with everolimus compared to placebo. But the prespecified cut-off for a statistical significance was not quite reached, and the researchers took a specific look at a group of very high-risk patients defined by larger tumors, invasion of the perinephric fat in renal veins or invasion of nearby organs or known positive disease. And those patients with very high-risk disease had more benefit from everolimus compared to placebo. Of note, 37% of patients who were treated with everolimus had to stop treatment due to their side effects, and the most common severe side effects included mouth ulcers, high triglyceride levels, and high blood sugars. So ultimately this particular study did not show sufficient benefit of everolimus given the toxicity and lack of statistical significance. And so this is a balance between potential benefit in delaying recurrence versus treatment toxicities that we must have in this adjuvant setting. So what does this particular study mean for patients? Well, it was certainly a large phase 3 trial performed in the cooperative group setting and through the generosity of 1,500 patients and the principal investigators on the study, we learned this answer for a very important question of whether everolimus makes a difference in this postoperative setting. I think we're not using this in clinical context currently, but in this postoperative setting, we are always balancing this risk of toxicity with the potential for benefit and discussing the potential treatment options. I do not think this particular trial changes the standard of care in this adjuvant setting. And then I think finally for today's prepared talks, this abstract on depth of response and association with clinical outcomes with CheckMate 9ER patients treated with cabozantinib and nivolumab. So this was a post-trial analysis of patients who had kidney cancer with disease spread and treated with cabozantinib and nivolumab compared with sunitinib in the CheckMate 9ER study. And the context, this was the phase 3 trial in which the benefit of cabozantinib and nivolumab was established in the first-line setting and gained the registration and approval of this combination in the first-line treatment of metastatic kidney cancer. This particular analysis, presented at ASCO this year, was a post-trial prespecified analysis evaluating this depth of partial responses and associating those with clinical outcomes of time until disease progression as well as time until death. These depth of responses were defined as 80 to 100% for PR-1, 60 to 80% for PR-2, and then 30 to 60% as PR-3. And as we saw in this analysis, the deeper the responses on cabozantinib and nivolumab, the more correspondence with higher 12-month rates of disease-free progression compared with those same depths of responses from sunitinib. And there were similar 12-month overall survival rates for patients with similar depth of responses for either the cabozantinib and nivolumab combination compared with sunitinib. So I do think the degree of partial response in these settings is productive of time until progression and establishes further the efficacy and benefit of cabozantinib and nivolumab compared with sunitinib. And what does this trial mean for our patients? I think that early on, as we're looking for responses and radiographic changes for our patients on cabozantinib, nivolumab in the first-line setting, these deeper responses are associated with longer time until disease progression, and we can counsel patients, to discuss whether cabozantinib and nivolumab is working for them. This could be an early indicator for how patients will do overall on this combination. So with that I'd love to wrap up and turn it back over to you, Greg. Greg Guthrie: Thanks so much Dr. Zhang. And now it's time to move on into our Q&A session. This is for you, Dr. Agarwal. So the question is utility of triple therapy, ADT plus docetaxel plus ASI and metastatic hormone-sensitive prostate cancer given ENZAMET was inconsistent with PEACE-1 and ARASENS. Would you give ASI concurrent or sequential after chemotherapy for tolerability? I'm assuming ASI here is androgen suppression, correct? Dr. Agarwal: Yes. Great question. There are 2 questions here. Number 1, if I would use triplet therapy given the negative subgroup analysis of the ENZAMET trial, and number 2, what is the role of triplet therapy in general? The answer to the first question is ENZAMET trial, subgroup analysis is very different from preplanned, prespecified, well-powered analysis from PEACE-1 and the ARASENS trial. So yes, we saw discrepant results, but my impression from ENZAMET trial is enzalutamide is an effective option for all patients regardless of the receipt of docetaxel chemotherapy because that was a subgroup analysis. So I don't think it really affects negatively the results of the ARASENS and the PEACE-1 trial. But a bigger question here is triplet therapy versus doublet therapy? Is triplet therapy for all or doublet therapy for all? Answer is no. Triplet therapy trials only showed that adding a novel hormonal therapy or deeper androgen blockade to the backbone of ADT plus docetaxel improves survival. These trials did not answer the question, if adding docetaxel chemotherapy to ADT plus, for example, enzalutamide or darolutamide or apalutamide, will improve survival. We do not have that question answered by any of the trials and unlikely any other trial will answer that question. So my take ADT plus docetaxel is replaced by ADT plus docetaxel plus these deeper androgen blocker therapy. So wherever I was going to use docetaxel chemotherapy, so those are the patients with visceral metastases or in my practice, when I do comprehensive genomic profiling, I see those molecular aberrations which predict lack of response to deeper androgen blockade such as baseline AR variants. Or if I see 2 out of 3 mutations of p53, RB loss, p10 loss, if I see 2 out of these 3, I tend to think about docetaxel chemotherapy. So in those patients where I'm using ADT plus docetaxel, I would add another androgen receptor blocker such as abiraterone and darolutamide. But when I'm using enzalutamide or apalutamide which I use for majority of those patients, my patients with metastatic hormone-sensitive prostate cancer, I do not think about triplet therapy. Greg Guthrie: Thanks, Dr. Agarwal. We actually have a follow-up question, and this is, what is the role of oncology in low-stage early prostate cancer? Can neoadjuvant chemotherapy reduce the number of people who end up with metastatic prostate cancer? Dr. Agarwal: This answer is very simple. There is no role of neoadjuvant chemotherapy in high-risk localized prostate cancer or any localized prostate cancer setting. Greg Guthrie: Great. Thank you. Next question. I believe that this is for everybody. How long will it be until the information from the trials discussed will be used in the community clinics? What can patients do to bring this information to their less experienced doctors? Dr. Grivas: So, Greg, just to clarify the question, is it about the translation of the results of the clinic from ASCO to clinical practice, generically speaking, or any particular tumor type or any particular data results? Greg Guthrie: The way I read this question, it's more just kind of a broader scope question about just like, how long does the results of clinical trials make it to community practice, and what role can patients have in perhaps fostering this transmission of information? Dr. Grivas: Of course, I can start briefly, and then my colleagues can add. I would say the world we live in right now, the information travels very quickly. It's much faster compared to the past. And I think there is much more alignment, in my opinion, in terms of information access between academic oncologists and community oncologists. If, for example, a trial result comes at ASCO being presented, and then there's a follow-up approval authority from a regulatory agency, this agent may be accessible to both community and academic practices. Of course, there are always opportunities for education, and Dr. Agarwal is the director of the ASCO Daily News, and he knows that well to disseminate the information well, broadly, in an equitable manner across academic oncologist providers and community providers. And I think CME, continued medical education practices, can help in that regard. And obviously, the other aspect of that is the ongoing clinical trials and how we can do a better job disseminating the opportunity for equitable participation in clinical trials across racial groups, ethnicity groups, minority groups, to give them the chance to participate in ongoing clinical trials that may change the practice down the road, which are just early thoughts. But other colleagues can comment. Dr. Zhang: Yeah, if I could chime in. I think these continuing medical education programs, particularly in the context after large symposia like the ASCO Annual Meeting we just had, are particularly important. And the Best of ASCO series, as well as ASCO Direct Highlight series - I believe Dr. Grivas and I are hosting 2 of these - are very helpful, I think, to bring the latest findings from the ASCO Annual Meeting to our community colleagues. And they really are our colleagues. We work together with our oncologists within the community to take care of our patients, oftentimes for standard of care treatments. Patients can access them more in their backyards. And I think from a patient standpoint on the second part of the question, they're able to hear these from patient-friendly platforms and to bring that to the attention of their oncologist, wherever that may be. It all helps in the grand context of clinical care. So I hope that these trial results and the latest findings from ASCO can get inseminated very quickly.   Dr. Grivas: And to also add very briefly, the role of patient advocacy groups, and in the bladder cancer work, there are many, for example, the Bladder Cancer Advocacy Network, World Bladder Cancer Coalition, and many others can help also in that regard and teaming up with all of us to disseminate information and also clinical trial access. Greg Guthrie: Great. Thank you, everyone. We have a question for Dr. Grivas. After the survey results in the study you described, is there any plan to make a guideline or tool to make sure we standardize the definition of cisplatin/platinum ineligibility? Dr. Grivas: Great question. Just 1 more thing on my prior answer, kudos to Cancer.Net for serving that mission, Greg and Claire in that-- or the previous question to have a complete answer. Answering this new question here, which is very important. I think the next step is to try to publish the results of the survey. The survey like the previous one done by Dr. Galski about 10 years ago-- it's a survey on expert oncologists, and it's a consensus-based definition. It's criteria that we came up with together. And I think the next step here is to publish this in a peer-review process. And our hope is by publishing these results, we can have a more formal definition to help guide our practices in academia, but also in the community oncology practices and make sure that we have a standardized way that we approach this therapy selection and of course, to help design clinical trials that for this particular patient population in order to improve outcomes in this setting. So hopefully publication will come soon. Greg Guthrie: Thanks, Dr. Grivas. I'll just drop a really quick pitch there. Here at Cancer.Net, we do have a very broad array of information on clinical trials. And patients can come visit us at Cancer.Net and learn about clinical trials, what they mean, and how they help advance cancer research. We now have a question for Dr. Zhang. Based on the results of EVEREST and other trials approved systemic therapies in the adjuvant setting like sunitinib and pembrolizumab, are there ongoing other trials in this setting and is risk stratification used? Dr. Zhang: The short answer is yes. There are ongoing adjuvant trials that build on pembrolizumab in the adjuvant setting. There's one that is looking at the addition of belzutifan with pembrolizumab in the adjuvant setting. So that trial is a global trial which is about to get started, if not enrolling already. And in the context of adding on in the adjuvant setting, I do think we really need to discuss with our patients how much of a benefit the treatment will have versus the real toxicity in the postoperative setting, many patients will not have symptoms from their cancer, so they may have some pain or healing side effects from surgery, but they won't have symptoms from cancer. So any toxicities from medications can be further amplified, so are we truly giving a lot of benefit in that context or not. So that's an individualized decision, and I do think conversations must be had to make that decision together. Greg Guthrie: Thanks, Dr. Zhang. I want to ask a question myself of Dr. Gilligan. You had mentioned that microRNA is an emerging field of study, and I've heard about this in other types of cancer as well. I wonder if you could discuss that a little bit more. Dr. Gilligan: Yeah, microRNA, the promise that holds is being a more accurate detector, specifically of testicular cancer. So the problem we have with alpha fetoprotein and beta HCG is half of the testicular cancers may not make 1 or both of those markers. So people can relapse without the markers going up, even though markers are most commonly what we see, there are a couple of different scenarios. Someone has stage I testicular cancer, which means their testicles removed and all their scans show no evidence of cancer. We know that 25% or so of non-seminomas and 20% or so of seminomas will relapse, even though we can't see what the cancer is, and the markers are negative in that situation. MicroRNA may be able to detect those people who still have cancer much, much earlier. So we know that they're, in fact, not stage I and that they need active treatment right away. So that's one place. Another place that we're seeing evidence is that men who've had metastatic testicular cancer. They go through chemotherapy, and they have residual masses. And we're wondering if there's cancer in those masses or is it all dead scar tissue or is it teratoma? MicroRNAs may be able to allow us to determine who needs additional treatment, who needs surgery without having it. Right now, we typically go in and operate just to figure that out. So there are a number of situations in which we could more accurately stage patients and figure out who's cured and who's not cured much earlier in the course of disease. And for a patient, this would be fantastic, because right now, if you've got stage I disease with non-seminomas and you go on surveillance and somebody says you have a 25% risk the cancer is going to come back, that's a 1 in 4 chance that at some point in the next 2 years, most likely, or longer, you're going to have to suddenly drop everything and go through months of chemotherapy. If we knew on day 1, it looks like you're cured, but in fact, there's cancer hiding there somewhere, and we need to treat you now, that would be helpful to know so they can get it over with. And the other men, we could say we're really extremely confident that there's not a 25% risk, it's a 5% risk or something much lower. So there are a number of ways, if this really gets proven and there's emerging data that's promising, I think we could reassure men, treat them more appropriately, spare them unnecessary treatment, and give them more peace of mind. Greg Guthrie: Great. Thanks, Dr. Gilligan. I think we have a question from Dr. Grivas now. Dr. Grivas: Thank you, Greg. This is a great panel. I like to learn from my colleagues here. One question for Dr. Zhang, you have done so much work in the field, leading the field there, Dr. Zhang. Any comments about the ideal end points in the adjuvant setting in kidney cancer, urothelial cancer, disease-free survival or overall survival? Would you comment about how we design trials, and what will be an acceptable benchmark? And what is meaningful for patients, too, in the adjuvant treatment after radical surgery for kidney cancer and urothelial cancer? Dr. Zhang: Oh, that's a great question, Petros. Thank you so much for asking. We have discussed this many times together because you and bladder cancer and myself and kidney cancer, we're thinking a lot along the same lines right as new immunotherapies get approved in the postoperative setting, so disease-free survival as an endpoint and recurrence-free survival as an endpoint is a valid endpoint. It's a direct result of the randomized treatment on the trial, so I do think that is the valid endpoint, and it's an endpoint that the FDA has approved the sunitinib and pembrolizumab indications in kidney cancer, nivolumab and bladder cancer. So I think it's certainly a valid endpoint to delay disease recurrence. How much of that is meaningful degree of improvement for an individual patient? Their own measure of recurrence is either yes or no. It's much more binary than population effects. So how much does that translate into benefits for the patient? I think that warrants deeper individualized discussion. But these disease-free survival endpoints in all of these studies is a valid endpoint to see whether the treatment is worthy in delaying disease recurrence in each of these disease types. Greg Guthrie: Thanks, Dr. Zhang. We have one last question here, and I believe this is a follow-up for Dr. Gilligan. And what is the time frame for the rollout of microRNA 371 to the community? Dr. Gilligan: I don't know the answer to that. I'm not sure that we have enough data right now that it's going to get approved. I think we're headed in the right direction, but it's very hard to know what the timing of that is. There are trials going on, so I don't know at the moment of exactly what the scenarios are in which people are going to be, which patient populations are going to be eligible, but there are trials going on. I think I'm hoping within the next 2 years or so, but I really don't know what the time frame is, unfortunately. Dr. Grivas: And if I may add a more generic comment to Dr. Gilligan's wonderful answer is that when we have what we call biomarkers that are like metrics that can give us information about how the patient does over time, it's important to tease out what we call prognostic, meaning how can this biomarker give us a sense of the chance of recurrence, as Dr. Gilligan said, or death from the cancer. But also, the bigger question is, is it going to give us information to predict benefit from an individual therapy? And that's a bigger question in oncology that is a harder one. This predictive question and try to identify biomarkers and validate them to make sure they have, they're clinically useful. They can help us make treatment decisions in the clinic. And I'm very excited about what Dr. Gilligan discussed about the promise in the future. But more trials are needed for many biomarkers. Dr. Gilligan: I think when we do this update next year, we'll have significantly more data then, I'm hopeful. Greg Guthrie: Thank you to you all. Thank you, Dr. Agarwal. Thank you, Dr. Grivas. Thank you, Dr. Gilligan. Thank you, Dr. Zhang, for sharing this great research with us, as well as your expertise. It's been a real pleasure this afternoon. And to all of our viewers, thank you for joining us. You can find more coverage of the research from ASCO Annual Meeting and other scientific meetings at the Cancer.Net blog, which is at www.cancer.net/blog. And if you're interested in more Cancer.Net content, please sign up for a monthly Inside Cancer.Net newsletter or follow us on social media. We're on Facebook, Twitter, and YouTube where our handle is always @CancerDotNet, with dot spelled out. Thank you all, and be well. Thanks. ASCO: Thank you, Dr. Agarwal, Dr. Gilligan, Dr. Grivas, and Dr. Zhang. You can find more research from recent scientific meetings at www.cancer.net. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care. And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology. Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds lifesaving research for every type of cancer, helping people with cancer everywhere. To help fund Cancer.Net and programs like it, donate at CONQUER.ORG/Donate.

PRS Global Open Deep Cuts
Dr. Steven Moran: Leveling Up “Blue Collar Surgery"

PRS Global Open Deep Cuts

Play Episode Listen Later Jun 20, 2022 53:17


In this “Leveling Up” episode of the PRS Global Open Deep Cuts Podcast, Dr. Steven Moran discusses why he calls himself a “blue collar surgeon,” creating the defect, how to teach a resident to put in a K wire, why some things can only be learned at the school of hard knocks, the nuances of harvesting the MFC flap and reducing a distal radius fracture, the critical little details in pediatric hand surgery, and how to be a lifelong learner. Read a recent PRS Global Open article by Dr. Moran and colleagues: “Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution” by Banuelos, Abu-Ghname, Bite,  Moran, et al:  https://bit.ly/DeepCutsMoran Dr. Steven Moran, MD is a hand surgeon, microsurgeon and reconstructive plastic surgeon at the Mayo Clinic in Rochester Minnesota, in the Division of Plastic & Reconstructive Surgery. He is the Surgical Director of the Essam and Dalal Obaid Center for Reconstructive Transplant Surgery and the Director of Hand Transplant as well. He is the present chair of the Division of Plastic and Reconstructive Surgery at Mayo, and the recipient of the Godina Fellowship from the American Society for Reconstructive Microsurgery. Your host, Dr. Puru Nagarkar, is a board-certified plastic and hand surgeon, and Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas, Texas. #PRSGlobalOpen #DeepCutsPodcast #PlasticSurgery #LevelingUp

allergytalk
Disparities in Atopic Dermatitis Miniseries: Episode 1: Current Evidence for Disparities in Atopic Dermatitis

allergytalk

Play Episode Listen Later Jun 14, 2022 19:03


This episode will review racial, ethnic, socioeconomic, and geographic disparities related to atopic dermatitis. Disparities in Atopic Dermatitis Miniseries Host: Payel Gupta, MD, FACAAI Expert: Anil Nanda, MD, FACAAI Expert: Andrew Alexis, MD, MPH Expert: Marcella Aquino, MD, FACAAI The miniseries is hosted by Payel Gupta, MD,  a triple board-certified specialist and the Medical Director for Allergy, Asthma, Immunology & ENT at LifeMD.com. She is practicing in New York City and is an assistant clinical professor at SUNY Downstate Medical Center and Clinical Instructor at Mount Sinai Medical Center.  She is a volunteer national spokesperson for the American Lung Association and co-host of The Itch Podcast. Joining her are Anil Nanda, MD, who is in private community practice at the Asthma and Allergy Center in Lewisville and Flower Mound, Texas and is Clinical Associate Professor of Medicine, at the Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX; Andrew F. Alexis, MD, MPH, who is the Vice-Chair for Diversity and Inclusion for the Department of Dermatology and Professor of Clinical Dermatology at Weill Cornell Medical College in New York City. He is the former Chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West. Having served as Director of the first-of-its-kind Skin of Color Center for over 15 years, his work has helped to advance patient care, research, and education pertaining to dermatologic disorders that are prevalent in populations with skin of color; and Marcella Aquino, MD, who is an Associate Professor of Pediatrics at the Warren Alpert Medical School of Brown University and staff at Rhode Island Hospital/Hasbro Children's Hospital. Her interests include allergic skin diseases particularly allergic contact dermatitis, atopic dermatitis, and drug allergy. She has presented on these topics at national meetings and published in textbooks and peer reviewed journals with a focus on contact dermatitis including patch testing, the role of contact dermatitis in atopic dermatitis patients, drug allergy challenges/desensitizations and the use of simulation for the instruction of anaphylaxis/allergic emergencies. Dr. Aquino was awarded an implementation grant by the ACAAI Foundation looking a multi-level contributing factors to racial and ethnic disparities in urban children in asthma and atopic dermatitis. This podcast series is supported by Pfizer.  

allergytalk
Disparities in Atopic Dermatitis Miniseries: Episode 3: Improving Access to Treatment for Atopic Dermatitis in Minority and Underserved Populations

allergytalk

Play Episode Listen Later Jun 14, 2022 19:34


This episode will describe best practices for addressing disparities in care for patients with atopic dermatitis and how to implement specific health equity strategies to improve access to atopic dermatitis care and increase patient adherence to treatment. Disparities in Atopic Dermatitis Miniseries Host: Payel Gupta, MD, FACAAI Expert: Anil Nanda, MD, FACAAI Expert: Andrew Alexis, MD, MPH Expert: Marcella Aquino, MD, FACAAI The miniseries is hosted by Payel Gupta, MD,  a triple board-certified specialist and the Medical Director for Allergy, Asthma, Immunology & ENT at LifeMD.com. She is practicing in New York City and is an assistant clinical professor at SUNY Downstate Medical Center and Clinical Instructor at Mount Sinai Medical Center.  She is a volunteer national spokesperson for the American Lung Association and co-host of The Itch Podcast. Joining her are Anil Nanda, MD, who is in private community practice at the Asthma and Allergy Center in Lewisville and Flower Mound, Texas and is Clinical Associate Professor of Medicine, at the Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX; Andrew F. Alexis, MD, MPH, who is the Vice-Chair for Diversity and Inclusion for the Department of Dermatology and Professor of Clinical Dermatology at Weill Cornell Medical College in New York City. He is the former Chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West. Having served as Director of the first-of-its-kind Skin of Color Center for over 15 years, his work has helped to advance patient care, research, and education pertaining to dermatologic disorders that are prevalent in populations with skin of color; and Marcella Aquino, MD, who is an Associate Professor of Pediatrics at the Warren Alpert Medical School of Brown University and staff at Rhode Island Hospital/Hasbro Children's Hospital. Her interests include allergic skin diseases particularly allergic contact dermatitis, atopic dermatitis, and drug allergy. She has presented on these topics at national meetings and published in textbooks and peer reviewed journals with a focus on contact dermatitis including patch testing, the role of contact dermatitis in atopic dermatitis patients, drug allergy challenges/desensitizations and the use of simulation for the instruction of anaphylaxis/allergic emergencies. Dr. Aquino was awarded an implementation grant by the ACAAI Foundation looking a multi-level contributing factors to racial and ethnic disparities in urban children in asthma and atopic dermatitis. This podcast series is supported by Pfizer.

allergytalk
Disparities in Atopic Dermatitis Miniseries: Episode 2: The Influence of Skin of Color in Diagnosing and Managing Patients With Atopic Dermatitis

allergytalk

Play Episode Listen Later Jun 14, 2022 21:39


This episode will describe the influence of skin color in diagnosing and managing patients with atopic dermatitis.   Disparities in Atopic Dermatitis Miniseries Host: Payel Gupta, MD, FACAAI Expert: Anil Nanda, MD, FACAAI Expert: Andrew Alexis, MD, MPH Expert: Marcella Aquino, MD, FACAAI The miniseries is hosted by Payel Gupta, MD,  a triple board-certified specialist and the Medical Director for Allergy, Asthma, Immunology & ENT at LifeMD.com. She is practicing in New York City and is an assistant clinical professor at SUNY Downstate Medical Center and Clinical Instructor at Mount Sinai Medical Center.  She is a volunteer national spokesperson for the American Lung Association and co-host of The Itch Podcast. Joining her are Anil Nanda, MD, who is in private community practice at the Asthma and Allergy Center in Lewisville and Flower Mound, Texas and is Clinical Associate Professor of Medicine, at the Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX; Andrew F. Alexis, MD, MPH, who is the Vice-Chair for Diversity and Inclusion for the Department of Dermatology and Professor of Clinical Dermatology at Weill Cornell Medical College in New York City. He is the former Chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West. Having served as Director of the first-of-its-kind Skin of Color Center for over 15 years, his work has helped to advance patient care, research, and education pertaining to dermatologic disorders that are prevalent in populations with skin of color; and Marcella Aquino, MD, who is an Associate Professor of Pediatrics at the Warren Alpert Medical School of Brown University and staff at Rhode Island Hospital/Hasbro Children's Hospital. Her interests include allergic skin diseases particularly allergic contact dermatitis, atopic dermatitis, and drug allergy. She has presented on these topics at national meetings and published in textbooks and peer reviewed journals with a focus on contact dermatitis including patch testing, the role of contact dermatitis in atopic dermatitis patients, drug allergy challenges/desensitizations and the use of simulation for the instruction of anaphylaxis/allergic emergencies. Dr. Aquino was awarded an implementation grant by the ACAAI Foundation looking a multi-level contributing factors to racial and ethnic disparities in urban children in asthma and atopic dermatitis. This podcast series is supported by Pfizer.

Tests and the Rest: College Admissions Industry Podcast
346. TUTORING FOR TEENS WITH ADHD

Tests and the Rest: College Admissions Industry Podcast

Play Episode Listen Later Jun 14, 2022 27:46


Students with attention disorders have difficulty staying on task, sustaining focus, and staying organized–all of which are critical to academic and testing success. Amy and Mike invited educator Jenn Cohen to share strategies for tutoring teens with ADHD. What are five things you will learn in this episode? What kind of learning challenges do teens with attention deficits face? What strategies are most effective in helping students with ADHD excel academically? What makes standardized testing so challenging for teens with ADHD? What should students with ADHD know about testing accommodations? Of the SAT and ACT, which tends to be better for ADHD students? MEET OUR GUEST Jenn Cohen has been in the test prep trenches for over 20 years, but she prides herself in never feeling too comfortable calling herself an expert. She is always learning from her students, families, other pros and the research literature. She's a lover of art and science, and believes the world is a better place with both. Meeting Neil deGrasse Tyson is on her bucket list.  Jenn has been featured in The Dallas Morning News, ADDitude Magazine and Good Morning Texas, as well as numerous blogs around the web. She has also been a presenter at the Learning Disabilities Association national conference, as well as a speaker at high schools and parent associations. She currently serves as Treasurer of the Learning Disabilities Association of Texas. She is a graduate of Duke University, and completed graduate work in clinical psychology at the University of Texas Southwestern Medical Center at Dallas. She is a hardcore Duke sports fan, and general sports junkie, so she gets a particular kick out of her student's sports victories.  Jenn lives in Dallas, TX with her husband and business guru, Gary, and her daughter, Erin. She enjoys cooking, museums, '80's bands and reading Harry Potter with Erin (with voices, of course)!  Find Jenn at launchpadeducation.com. LINKS Ace the ACT: College Admissions Test Tips in ADDitude Magazine Test Prep Planning for ADHD/LD Students 8 ADHD teaching strategies RELATED EPISODES EXECUTIVE FUNCTION AND ADD/ADHD TEST PREP FOR STUDENTS WITH ACCOMMODATIONS THE SCIENCE OF MEMORY ABOUT THIS PODCAST Tests and the Rest is THE college admissions industry podcast. Explore all of our episodes on the show page. ABOUT YOUR HOSTS Mike Bergin is the president of Chariot Learning and founder of TestBright. Amy Seeley is the president of Seeley Test Pros. If you're interested in working with Mike and/or Amy for test preparation, training, or consulting, feel free to get in touch through our contact page.