Podcast appearances and mentions of Tim Gardner

Subscribe to our YouTube channel: www.youtube.com/gracefellowshipny To give online: gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: gracefellowship.com Facebook: www.facebook.com/gracefellowshipny Instagram: www.instagram.com/gracefellowshipny

Subscribe to our channel: www.youtube.com/gracefellowshipny To give online: gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: gracefellowship.com Facebook: www.facebook.com/gracefellowshipny Instagram: www.instagram.com/gracefellowshipny

Subscribe to our channel: https://www.youtube.com/gracefellowshipny To give online: https://gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: https://gracefellowship.com Facebook: http://www.facebook.com/gracefellowshipny Instagram: http://www.instagram.com/gracefellowshipny

Mike Switzer interviews Tim Gardner, owner and founder of Lula Drake Wine Parlour in Columbia, S.C., recipient of the 2024 Outstanding Wine and Other Beverages category from James Beard.

Beyond the Headlines: Forgotten Stories of the Bible (Week 2) - Tim Gardner by Grace Fellowship Church

Beyond the Headlines: Forgotten Stories of the Bible (Week 1) - Tim Gardner by Grace Fellowship Church

Columbia, SC's Main Street architecture still has much of the charm of a mid-century movie set. There are jewelry stores, restaurants, hotels, and gift shops in buildings that range from the turn of the 20th Century to modern day. Tucked in among the hustle and bustle is Lula Drake Wine Parlor, which eight plus years ago was just another dusty building awaiting renovation. Now it is a gilded lily that comes alive at night like the culinary theater it is. Sommelier Tim Gardner knows his role as the lead actor, greeting guests in a well-tailored sport coat or sliding behind the bar to offer a taste of champagne with a twinkle in his eye. The crowd fills all available seats as plates of pasta roll out of the kitchen and dusk tucks in the windows at the front of this long, narrow space. In a city that still often struggles to know its own culinary personality, Lula Drake is a self-assured wine parlor with a true welcoming air. In 2023, it was nominated for Outstanding Hospitality by the James Beard Foundation, and this year, not only was it named one of the “Friendliest Places in the South” by Southern Living, Lula Drake won the James Beard Award for Outstanding Wine Program. It all comes back to Tim's love of wine and interest in inviting more people to love it too, and that goes way beyond the liquids in the bottles behind the bar.    Other episodes you might enjoy:  Erin Eisele & James Alford: Cork & Cap Bottle Shop (Aiken, SC) Sarah Pierre: 3 Parks Wine Shop (Atlanta, GA)  

This week Emma talks to Tim Gardner, assistant director of policy at the Health Foundation think tank, about what a new Labour government could mean for general practice and the rest of the NHS.They discuss Labour's plans to shift a greater share of NHS funding to primary care and what that could mean for general practice, what the government needs to do to bring down the NHS waiting list, and whether it can do anything to avert collective action by GPs.Tim also explains where the new government might look to for quick wins on the NHS to show progress in its first 100 days, what improvements could be delivered through reform alone and whether Labour's spending plans during the election will add up to make the changes that are needed to the health service.This episode was presented by GPonline editor Emma Bower. It was produced by Czarina Deen. Useful links Streeting commits to increasing general practice share of NHS fundingBMA calls for GP funding to rise to 15% of NHS budget and new 'family doctor charter'RCGP calls on government to overhaul NHS workforce plan to boost GP numbersMost GPs in England back taking collective action, poll suggests Hosted on Acast. See acast.com/privacy for more information.

We pray this message from June 2, 2024 will bless you!! Subscribe to our channel: www.youtube.com/gracefellowshipny To give online: gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: gracefellowship.com Facebook: www.facebook.com/gracefellowshipny Instagram: www.instagram.com/gracefellowshipny

We pray this message from May 26, 2024 will bless you!! Subscribe to our channel: www.youtube.com/gracefellowshipny To give online: gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: gracefellowship.com Facebook: www.facebook.com/gracefellowshipny Instagram: www.instagram.com/gracefellowshipny

We pray this message from our Halfmoon Campus Pastor, Tim Gardner, on May 19, 2024 will bless you!! Subscribe to our channel: www.youtube.com/gracefellowshipny To give online: gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: gracefellowship.com Facebook: www.facebook.com/gracefellowshipny Instagram: www.instagram.com/gracefellowshipny

Tim Gardner is the owner of Lula Drake Wine Parlour on Main Street in Columbia, SC. The story behind the discovery of the location, coming up with the name Lula Drake, and the journey to becoming nationally recognized by the James Beard Foundation is nothing short of magical. Lula Drake is a 2024 James Beard for Outstanding Wine and Other Beverages Program and a 2023 nominee for Outstanding Hospitality.

A new MP3 sermon from Free Grace Baptist Church is now available on SermonAudio with the following details: Title: The Loving Call of Jesus Speaker: Tim Gardner Broadcaster: Free Grace Baptist Church Event: Sunday - AM Date: 3/31/2024 Bible: John 20:1-18 Length: 30 min.

We pray this message from January 28, 2024 will bless you!! Subscribe to our channel: www.youtube.com/gracefellowshipny To give online: gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: gracefellowship.com Facebook: www.facebook.com/gracefellowshipny Instagram: www.instagram.com/gracefellowshipny

Life In The Ruins | Tim Gardner by Grace Fellowship Church

Portland-based NuScale Power has been leading the way for a new generation of nuclear power plants, called small modular nuclear reactors. Last week, the company was in the headlines because it called off plans to build those reactors in Idaho. But what exactly does NuScale intend to do? And why was this news such a big deal? We're listening back to a conversation between executive producer John Notarianni and Reuters energy and environment correspondent Tim Gardner about NuScale's push for a nuclear future. Who would you like to hear on City Cast Portland? Shoot us an email at portland@citycast.fm, or leave us a voicemail at 503-208-5448. Still want more Portland news? Then make sure to sign up for our morning newsletter, Hey Portland, and be sure to follow us on Instagram.  Looking to advertise on City Cast Portland? Check out our options for podcast and newsletter ads at citycast.fm/advertise. Learn more about the sponsor of this episode: The Storm Large Holiday Ordeal at the Aladdin Theater Nov. 24 & 25 Learn more about your ad choices. Visit megaphone.fm/adchoices

In this sermon, Halfmoon Campus Pastor Tim Gardner will guide us through the intricate world of fasting, shedding light on how our expectations can often lead us astray in this spiritual practice. Delve into the nuances of fasting and learn how to align your expectations with the profound purpose it serves in our spiritual lives. We pray this message from September 24, 2023 will bless you!! Thanks for being part of the Grace family!! Subscribe to our channel: https://www.youtube.com/gracefellowshipny To give online: https://gracefellowship.com/give/ To glorify God by making more and better disciples. This is the vision of Grace Fellowship, led by Pastor Rex Keener and based in New York's Capital Region. —— Stay Connected Website: https://gracefellowship.com Facebook: http://www.facebook.com/gracefellowshipny Instagram: http://www.instagram.com/gracefellowshipny

I last spoke to today's guests as part of last year's The State of Reinsurance Special Episode from Monte Carlo. In that documentary-style podcast I spoke to over 20 people, so a one-on-one with this duo to look more closely at their still relatively young business was long overdue. Tim Gardner (left) and Bob Bisset (right) of Lockton Re have been very busy in the last four years since the project to build a challenger reinsurance broker began in earnest. The business has hired over 300 staff, run through $200mn in revenues and became profitable last year and in this episode we check in on how the reinsurance broker's expansion plans are progressing. We also take the temperature on this still relatively hot reinsurance market. The result is a very lively and good-humoured encounter. Tim and Bob are buzzing and are clearly enjoying the considerable challenge of building out and scaling a global reinsurance broker. This is a task others have tried and failed to do and if you listen carefully I think you will hear the tiniest sense of relief in Tim's voice that much of his early vision has been vindicated. I also think that this episode will give you a lot of insight into what Tim and his team are trying to do that is subtly different from some of Lockton Re's peers. Tim and Bob say that getting the people, culture and capabilities right is the key and if you do that the revenue and profit will take care of themselves. That is to say they are just a byproduct and not the goal in itself. Lots of people say these kinds of things, but rarely have I met an executive team that really sounds like they mean it. So listen on and see if you hear what I hear. LINKS: We thank our naming sponsor AdvantageGo: https://www.advantagego.com/

Join us for a spiritually enriching sermon titled "The Essential Checklist for Prayer" by Tim Gardner, Halfmoon Campus Pastor. In this message, we'll delve into the crucial aspects of effective prayer, drawing inspiration from Matthew 6:5-8. Tim will provide invaluable insights on what should be on your prayer checklist to deepen your connection with God and ensure your prayers are not only heard but also answered. Don't miss this practical guide to enhancing your prayer life and drawing closer to the divine.

Meet Tim Gardner, who also goes by the fancier title of Timothy J. Gardner!"Sharing stories of Employees that love what they do, and where they do it"Firstly we delve into Tim's career - from Agency Recruitment, to Internal recruitment, and most recently his transition to being the Employer Branding Manager at RMIT.Being the Employer Branding Edition, we delve deep into the benefits of an effective EVP, and how to bring stories to life without a huge budget.We call out some special mentions, of brands we love - Bunnings, Sportsbet and CSL get some Kudos...We also recommend who you should consult with if you are looking for Marketing Agency support when developing your end-to-end Employer Branding Strategy. Specialist Agencies are the key! Further Kudos to both Businessary and Noble Agency.Finally Tim gives some sound advice to anyone who is currently working in Recruitment, or considering a career in Recruitment. It's a great listen!Enjoy!Join RUBBERBAND today!

On this episode of Public & Society, Ipsos' Kate Duxbury and Anna Quigley are joined by Louise Ansari, Healthwatch, Tim Gardner, Health Foundation and Axel Heitmueller, Imperial College Health Partners. They discuss the current NHS model, trends and developments in the NHS over its 75 years, and what this means for the public and patients. Subscribe to our podcast and YouTube channel to stay up to date with Public & Society episodes and other Ipsos content.

In over 30 major bodybuilding competitions, Ray only failed once to place in the top five. Ray has appeared on more Flexible Magazine covers than any other bodybuilder in the history and also has also featured in many fitness and bodybuilding magazines worldwide. Ray was a co-host on Flex Magazine Workout on ESPN for 5 years as well as hosting bodybuilding competitions for ESPN as a commentator for 8 years. Ray is a prominent spokesman, master of ceremonies and expert commentator for IFBB Pro League & NPC shows, most notably the Mr. Olympia. He is currently the Editor in Chief of DigitalMuscle.com, he continues to promote Hawaii's largest contest, NPC Shawn Ray Hawaiian Classic in Honolulu which he added a Pro Classic Physique Division in 2021z Ray received the Ben Weider "Lifetime Achievement Award" in the summer of 2020 for his contributions to the sport and as an athlete on behalf of the Ben Weider family, promoter, Tim Gardner, Dan Solomon and Ron Wilkins.

DOWNLOAD OUR BRAND NEW REMIX IMPULSE OUT NOW LINK BELOW, www.beatport.com/track/impulse/16359296 Check out this weeks YEAH_UK Radio Recorded LIVE from Brighton & Bristols NO.1 Dance Radio Station DECADANCE Radio. A journey through the medium of Tech House and Techno this set is brought to you by Tim Gardner starting this set by show casing his brand new track - The Night, hopefully out next year! You heard it here first! Keep up to date with our radio shows and more via the DECADANCE APP and the link below, Radio: decadanceradio.com Insta: www.instagram.com/yeah_uk/

We're a sick nation - and the prognosis for the NHS is not good. It's showing all of its 75 years, as patients wait in ambulances outside A&E or struggle to speak to - much less see - their own GP. So what's the remedy? Just more - more money, doctors, nurses, hospitals? Or better systems of provision? And how should we pay for it - could some of us pay when we see our doctor? Tim Gardner, senior policy fellow at the Health Foundation, tells Phil and Roger there need to be tough decisions about how much we value and are willing to pay for our health. Hosted on Acast. See acast.com/privacy for more information.

Thanks for tuning in to this Tuesday edition of RealAg Radio. On today’s show you’ll hear: Mary Robinson, President of Canadian Federation of Agriculture, on a number of different issues from the fertilizer emissions reduction to the upcoming COP27 climate conference; A product spotlight interview with Tim Gardner, market development agronomist with Bayer on DEKALB... Read More

Thanks for tuning in to this Tuesday edition of RealAg Radio. On today’s show you’ll hear: Mary Robinson, President of Canadian Federation of Agriculture, on a number of different issues from the fertilizer emissions reduction to the upcoming COP27 climate conference; A product spotlight interview with Tim Gardner, market development agronomist with Bayer on DEKALB... Read More

DOWNLOAD OUR BRAND NEW REMIX IMPULSE OUT NOW LINK BELOW, www.beatport.com/track/impulse/16359296 Check out this weeks YEAH_UK Radio Recorded LIVE from Brighton & Bristols NO.1 Dance Radio Station DECADANCE Radio. A journey through the medium of Deep House this set is brought to you by Tim Gardner delivering an excellent deep, moody melodic set. Enjoy! Keep up to date with our radio shows and more via the DECADANCE APP and the link below, Radio: decadanceradio.com Insta: www.instagram.com/yeah_uk/

Welcome to this Tuesday edition of RealAg Radio, brought to you by Bayer CropScience. Be sure to check them out at Ag in Motion this week! On today’s episode of the show, you’ll hear: Dr. Andria Jones-Bitton of the University of Guelph, on a recent mental health study from the University of Guelph; Tim Gardner... Read More

Welcome to this Tuesday edition of RealAg Radio, brought to you by Bayer CropScience. Be sure to check them out at Ag in Motion this week! On today’s episode of the show, you’ll hear: Dr. Andria Jones-Bitton of the University of Guelph, on a recent mental health study from the University of Guelph; Tim Gardner... Read More

We pray this message from July3, 2022 will bless you! Thanks for being part of the Grace family! Series: "Fan Fiction", Part 1 of 4 Pastor Tim Gardner Follow us on Social Media: www.instagram.com/gracefellowshipny www.facebook.com/gracefellowshipny www.youtube.com./gracefellowshipny www.gracefellowship.com

This one's for the dads. Whether you have fond memories of time spent with your dad, time spent with a father figure in your life or you remember back to the time you first became a dad. This episode is for you.USA Today's James Brown and Music Journalist Saby Reyes-Kulkarni sat down to discuss the ups and downs, hopes and fears and expectations versus reality of parenting; including becoming a father after 40.Reyes-Kulkarni shares the eye opening moment when he saw himself in his four-and-a-half year old daughter for the first time and what it was like 'arguing with yourself.'Reyes-Kulkarni said of his daughter, "She's very particular. And I like it! Because I have an instant kinship with it, even though it's mostly directed at me."James and USA Today's Tim Gardner discuss what it's like to have and raise twin boys, how priorities shift with children and how his father was a good example of fatherhood.To follow James Brown on Twitter, click here.You can find articles written by Saby Reyes-Kulkarni in Spin, Billboard, Paste, Pitchfork and Bandcamp.To follow Saby Reyes-Kulkarni on Twitter, click here.You can also subscribe to Saby's substack by clicking here.To follow Tim Gardner on Twitter, click here.Episode Transcript available hereAlso available at art19.com/shows/5-ThingsSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

On this episode of the Ipsos podcast, Kate Duxbury and Anna Quigley from Ipsos, together with Tim Gardner from The Health Foundation and Dan Wellings from The King's Fund, discuss public perceptions towards the NHS and Social Care. Some of the topics they cover include: Findings from the first wave of results from the Health Foundation and Ipsos Policy Polling Programme Recent findings from the Expectations Tracker, including the public's current and future expectations of the NHS and Social Care Upcoming findings from the King's Fund British Social Attitudes survey 

Check out this weeks YEAH_UK Radio Recorded LIVE from Brighton's NO.1 Dance Radio Station DECADANCE Radio. Another journey through the medium of Techno! Keep up to date with our radio shows and more via the DECADANCE APP and the link below, Radio: decadanceradio.com Insta: www.instagram.com/yeah_uk/

11/16/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Injectable Peptide BPC 157 can help with injuries joints, muscles and tendons - Is it better to do cardio before or after strength training to lose fat and build muscle? - U.S. Republicans move to decriminalize marijuana at federal level Titan Weekly Newsletter Poll: Do you have any nagging injuries or problems with joints, muscles or tendons? No, none at all. - 13% Yes, I have some issues but nothing major. - 16% Yes, I take OTC medications for it. - 27% Yes, I take non-Titan doctor prescribed medications. - 22% Yes, I take Titan therapies (BPC 157, TB 500, etc). - 19% UPCOMING EVENTS: Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Jan 23: Festivals of Speed St. Petersburg   Our current weekly newsletter: https://conta.cc/3EUy7S0 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bpc #bpc157 #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

11/12/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media -  Prometheus - Lose weight, feel great! - Turns out, energy drinks are even worse for you than we thought - FDA recalls 2.2 million at-home coronavirus tests due to false positives - Computer-controlled brain implant enhances mental function in human trial - Which med specialties have the worst lifestyles? UPCOMING EVENTS: Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Jan 23: Festivals of Speed St. Petersburg   Our current weekly newsletter: https://conta.cc/3EUy7S0 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

11/9/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Prometheus - Lose weight, feel great! - Eating protein 4 times a day combined with fasting may help you burn belly fat faster than calorie cutting alone, research suggests. - Former Mr. Olympia Shawn Rhoden dies at 46. Titan Weekly Newsletter Poll: Is your body summer ready yet? 25% - Yes. 28% - Not yet, I'm still working on it. 46% - No, not yet. I need help, what can Titan do to help? UPCOMING EVENTS: Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Jan 23: Festivals of Speed St. Petersburg   Our current weekly newsletter: https://conta.cc/3EUy7S0 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm injectables #prometheus #fatburn #weightloss #peptide #therapy #libido #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan Medical & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

11/5/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Boost your immune system, recovery, blood flow, liver protection/detoxification & more with injectable Nectar Of The Gods. - Dwayne Johnson Vows to Ban Real Guns From All His Film Sets After 'Rust' Fatal Shooting - Gov. DeSantis Saves Christmas by Rerouting Cargo Ships from California to Florida UPCOMING EVENTS: * Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast
 * Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme
   Our current weekly newsletter: https://conta.cc/2ZG9BFj Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

11/2/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Boost your immune system, recovery, blood flow, liver protection/detoxification & more with injectable Nectar Of The Gods. - Can Specific Foods or Diets Boost Your Testosterone Levels? - Startups Are Rushing to Prescribe a New Weight Loss Drug, But Questions Remain Titan Weekly Newsletter Poll:  Do you take anything to boost your immune system? 34% - Titan Therapies (Nectar of the Gods, Titan Complete, Glutathione etc) 38% - Over the counter supplementation, oral vitamins, gummies, etc. 11% - I don't take anything for my immune system, please give me more info. 15% - Do I really need to worry about boosting it? UPCOMING EVENTS: * Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast * Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme   Our current weekly newsletter: https://conta.cc/2ZG9BFj Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm glutathione #antioxidants #therapy #libido #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/12/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - ECA Stack Plus: Boost energy & focus! - Recap of our Olympia 2021 Weekend! - Switching to reduced-sodium salt may reduce stroke risk - Study finds synthetic chemical in consumer products linked to early death Titan Weekly Newsletter Poll:What's your favorite energy/fat burning aid? Exercising regularly - 14% Energy drinks - 25% OTC supplements - 28% Titan Therapies - 31% UPCOMING EVENTS: Oct 23: Tim Gardner's NPC Hurricane Bay Oct 31: Festivals of Speed Orlando at the Ritz-Carlton Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/3v2rVU5 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm olympia #news #therapy #biotin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/22/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Take your bedroom fun to the next level with our Wonder Woman & Superman Libido Enhancers - Apple Will Require Unvaccinated Employees to Undergo COVID-19 Tests Daily - Eating mushrooms seems to lower depression risk - Former US Pres Trump to Launch TRUTH Social That Could Rival Facebook/Twitter - Netflix co-CEO on Dave Chappelle fallout: I screwed up. UPCOMING EVENTS: Oct 23: Tim Gardner's NPC Hurricane Bay Oct 31: Festivals of Speed Orlando at the Ritz-Carlton Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/3aLaIFq Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #libido #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/19/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Take your bedroom fun to the next level with our Wonder Woman & Superman Libido Enhancers - Protein identified as key link between appetite suppression and obesity - U.K. study: Prior Covid Infection Is As Effective At Preventing The Virus As Vaccination Titan Weekly Newsletter Poll: Do you enjoy using libido enhancing products? Yes! I love them! - 36% (11) I've never tried them, can I get some more info? - 30% (9) No, I don't need them. - 23% (7) Occasionally when I need the extra help. - 10% (3) UPCOMING EVENTS: Oct 23: Tim Gardner's NPC Hurricane Bay Oct 31: Festivals of Speed Orlando at the Ritz-Carlton Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/3aLaIFq Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #libido #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/29/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Injectable peptide CJC 1295 with Ipamorelin can help increase your IGF-1 levels, muscle mass, energy, performance, & more! - THIS WEEKEND: Oct 31-Festivals of Speed Orlando at the Ritz-Carlton - FDA panel greenlights vaccines for kids, paving the way for authorization - Florida invites In-N-Out to open in Sunshine State as restaurant battles California's vaccine mandates - McDonald's and IBM could bring AI-powered drive-thrus to more restaurants - Americans would rather go celibate than wash dishes UPCOMING EVENTS: Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/2Zs5tbJ Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/26/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Injectable peptide CJC 1295 with Ipamorelin can help increase your IGF-1 levels, muscle mass, energy, performance, & more! - This Is why you're always constipated. - How much the Bitcoin Tom Brady gifted fan is worth. - THIS WEEKEND: Oct 31-Festivals of Speed Orlando at the Ritz-Carlton Titan Weekly Newsletter Poll: If you could only pick one choice, what would it be? Total Responses: 94 Weight loss - 25.5% (24) Muscle gain - 22.3% (21) Cognitive enhancement (more clear minded) - 7.4% (7) Better performance in the bedroom - 9.6% (9) Improve overall quality of life - 6.4% (6) UPCOMING EVENTS: Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/2Zs5tbJ Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #libido #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/15/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - ECA Stack Plus: Boost energy & focus! - An Ohio woman was denied a life-saving liver transplant after refusing to get a COVID-19 vaccine - Netflix Dealing with ‘Unprecedented' Internal Revolt as Employees Threaten Walkout over Dave Chappelle - iPhone 13 Camera Power Is So Great: Ophthalmologist Using Pro Max for Eye Treatment, Ditches $15,000 Device - They found a lump. Doctors said not to worry. These are the stories of men with breast cancer. UPCOMING EVENTS: Oct 23: Tim Gardner's NPC Hurricane Bay Oct 31: Festivals of Speed Orlando at the Ritz-Carlton Nov 19 & 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/3v2rVU5 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #news #therapy #biotin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience #bodybuilding Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/5/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media Titan Weekly Newsletter Poll: Did you know that HRT (Hormone Replacement Therapy) works for men and women? No - 43% (10) Yes - 56% (13) UPCOMING EVENTS: Oct 7-10: Olympia 2021 in Orlando Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 23: Tim Gardner's NPC Hurricane Bay Nov 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/2Ya4lII Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm olympia #news #therapy #biotin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

10/1/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Biotin Injectable or Oral Therapy to help boost your hair, nails & skin health! - Museum gave artist $84k, he took the money & left blank canvases titled: “Take the Money and Run” - R. Kelly has been found guilty of sex trafficking. - (MA) State Police troopers will resign over mandatory COVID vaccine mandate, union says - NBA issues big threat to unvaccinated players UPCOMING EVENTS: Oct 7-10: Olympia 2021 in Orlando Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 23: Tim Gardner's NPC Hurricane Bay Nov 20: Tim Gardner's - NPC Atlantic Coast Dec 4: Cars & Couture: 11th Annual Collector's Gala James Bond Theme Our current weekly newsletter: https://conta.cc/3obnVPS Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #news #therapy #biotin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

This week's episode features highlights from Circulation's 2021 Cardiovascular Surgery Themed Issue. Join Executive Editor James de Lemos along with Associate Editors Marc Ruel and Michael Fischbein as they discuss all of the articles found in this special issue. Dr. James de Lemos: Hi, my name is James de Lemos. I'm a cardiologist at University of Texas Southwestern Medical Center in Dallas, and the executive editor for Circulation. And I'm standing in for Carolyn and Greg today to host our annual cardiovascular surgery-themed issue podcast. And I'm delighted to be joined by Marc Ruel, professor and chairman of the Division of Cardiothoracic Surgery at the Ottawa Heart Institute, and the director of cardiac surgery content for Circulation, as well as Michael Fischbein, associate professor of cardiothoracic surgery at Stanford and the director of the thoracic and aortic programs there. Marc, thanks for all that you do for Circulation with cardiovascular surgery content and let me turn it over to you to introduce the issue. Dr. Marc Ruel: Well, James, thank you very much. We're very delighted to introduce this 2021 cardiovascular surgery-themed issue. We already feel that this is going to put together some of the very best science at the interface between cardiac surgery or cardiovascular surgery, I should say, because there's some peripheral vascular topics as well, cardiology, and as well, mechanistic research. I think you're going to find that this is really a very jam-packed issue that has a lot of important messaging that will change the field going forward. Dr. Marc Ruel: Also, this year, I want to highlight a couple of changes in the preparation of the issue. I want to first thank the tremendous contributions over the years to Circulation and to the entire field of cardiac surgery of Tim Gardner. Really, Tim, is an absolute giant. I think he's the only person known to me who was both president of the American Heart Association and of the ATS in the field of cardiac surgery. Dr. Marc Ruel: Tim has really paved the way for us to develop and enhance this issue over the years, and I think 2021 is a testament to his legacy, because I would argue it's our strongest issue ever. And I also want to introduce Mike Fischbein, James and everybody, who's associate professor at Stanford. Mike is a thoracic-aortic surgery expert, also runs a translational lab, so has a very dedicated, basic science and translational surgical science expertise. So we're very, very happy to welcome Mike to the themed issue of Circulation. Dr. James de Lemos: Well, thanks Marc. We'll do is follow the order of the issue so that our readers and listeners can really get a sense of the content and its various types that we're publishing this year. And the issue starts with a provocative frame of reference piece from Verma and colleagues discussing the surgical left atrial appendage occlusion. Marc, what were your thoughts on that piece? Dr. Marc Ruel: It's obviously a game changer in cardiac surgery. I was privileged to serve as a part of the BSMB for this trial, and we can now say we toyed with the decision as to stop the trial at the appropriate time. And that's always a very difficult BSMB decision, which, frankly, you want to get it right, and you don't want to err on either side. Anyways, LAAOS III was recently published and we have a fantastic editorial in Circulation from Subodh Verma, Deepak Bhatt, and Elaine Tseng saying, which essentially highlights the importance of the trial for practice of cardiac surgery. Dr. Marc Ruel: It probably is that no patient who comes to cardiac surgery with a history of atrial fibrillation should, based on those findings, not have their atrial appendage ablated. There's already very little caveat, the trial has not shown what was feared prior with regards to an increased incidence of heart failure or symptoms. And really, the surgery has been effective. The ablation of the left atrial appendage is very effective in diminishing the primary outcome or of stroke, ischemic stroke or cerebral hemorrhage. Dr. Marc Ruel: And essentially, this was, in most cases, a surgical ablation, so cut and sew. So we don't have all the information about either endovascular devices or even ablative devices at the time of surgery. But it was a very large trial, it was a publicly funded trial. It is really the authoritative information in the field that's available so far. Dr. Marc Ruel: Mike, what are your thoughts around this? Do you now come to any one of your patients needing a cardiac surgical cooperation with a history of atrial fibrillation and thinking that I now need to address the left atrial appendage? Is that what you get out of this paper as well? Dr. Michael Fischbein: Yeah. Thanks, Marc. I think that's an excellent question. Yeah, now, every patient after this trial, I talk to them ahead of time and offer them to have their appendage ligated in this setting if they have a history of atrial fibrillation. I don't think this adds much to our operation, it doesn't increase much the clamp time. And especially, although the trial was more surgically excising with some of the newer clips out there, it really doesn't add much time to the operation. So I think this is really an important paper that will change what we do as surgeons. Dr. James de Lemos: Can I just comment that I think the trial has indirect implications well beyond surgery, because the demonstration of combined benefit for oral anticoagulation with left atrial appendage occlusion really suggests that, even for patients not going for cardiac surgery, at some point in the future, we may be thinking about not and either/or between the devices and anticoagulation, but maybe both. Dr. James de Lemos: Mike, let me come back to you. There's a really fascinating paper by DeCarlo evaluating penetrating aortic ulcers that really change my thinking on this. Can you talk a little bit about this paper and your thoughts? Dr. Michael Fischbein: Thanks very much, James. I think this is really an important paper that's going to change what we do as surgeons. As you know, symptomatic penetrating aortic ulcers are grouped with dissections in tremula hematoma where we treat those patients immediately. None of us know what to do though with the asymptomatic aortic ulcer, which is actually more common. A lot of us are basing our reports on some observational studies. Many of these studies are mixed, symptomatic and asymptomatic. And so the treatment really varies, from watching them conservatively to treating them with open or endovascular approaches. Dr. Michael Fischbein: However, this paper by DeCarlo's really excellent. They followed 273 asymptomatic penetrating ulcer patients over time following their CT scans. And they really had two key important findings. One that these ulcers really didn't change much over time, and two, the risk of some complication occurring, whether that's rupture, symptoms or progression of disease was very low at 6.5% over 10 years. And so I think this is really going to be important, because we know that these asymptomatic penetrating ulcers, we can watch them conservatively. They do have to be still followed, but we don't have to go immediately to perform some surgical procedure. Dr. James de Lemos: Marc, any thoughts from you on this paper? Does this change what you guys will be doing in Ottawa? Dr. Marc Ruel: Absolutely. Yeah, I think this is, as Mike was saying, a very germane finding that's very helpful. I think the key word here, as Mike was alluding to, is really the word asymptomatic and how do you define that? Right? I mean, many of these findings are incidental findings. Someone comes in with a bit of shortness of breath or this or that, gets a PE protocol CT scan and then a penetrating aortic ulcer is found. Dr. Marc Ruel: So where do you draw the line between symptoms that may be a small left lateral effusion or a bit of shortness of breath. And it's also, I think that nuance will have to be determined going forward, what is truly asymptomatic versus a few symptoms that may be less specific and perhaps not relate to the penetrating aortic ulcer. But I think it's tremendously helpful in guiding practice going forward. Dr. James de Lemos: Fantastic. Thank you both. Mike, I want to come back to you on another really important paper from the vascular surgery standpoint, which is the paper from the Voyager investigators on the combination of rivaroxaban and aspirin for patients with surgical treatment of peripheral arterial disease. Dr. Michael Fischbein: Yeah, no, I think this is another or provocative paper. And as you know, peripheral arterial disease is a really highly-significant clinical problem. We say that affects 200 million people globally. And this includes patients with claudication, arrest pain, limb threat ischemia. And currently, the treatment for this is to either a open surgical or endovascular revascularization of the lower extremity. And the problem is while these patients, they have immediate symptomatic relief where you can save their limb, we say that one out of five will develop some sort of symptom or limb ischemia by three years. Dr. Michael Fischbein: And so the field is really looking for some sort of adjuvant therapy to help prevent these occurrences later on. And so the Voyager trial randomized over 6,000 patients who underwent surgery, whether it was open or endovascular, and then they randomized to either receiving rivaroxaban plus aspirin, versus aspirin and a placebo. And they showed that if you received riva, that those patients had a significant reduction in the instance of their primary endpoint, which included ischemia, limb loss or symptoms. And importantly, there was not an increase in major bleeding risk in these individuals. Dr. James de Lemos: So fascinating. I mean, this does this change practice and is this now the standard for surgically-treated peripheral arterial disease? Dr. Michael Fischbein: Yeah, I think there's still some questions that we have to answer. Yeah, I think definitely this, I think will be used after the bypass surgery, but some of the things in the trial that we would have to figure out is how applicable is this to everyone. In the trial, the open surgical arm had patients with less risks. Also, some patients received vein conduit versus a prosthetic conduit. And so, I think we'll have to look at some of the sub-analysis to see who we can apply this to. Dr. James de Lemos: Fantastic. Marc, any thoughts from your perspective on this one? Dr. Marc Ruel: Yeah. Mike provided a great summary. I think one other take-home message to me is that, really, these patients should be viewed as having panvascular disease, a little bit like our CABG patients. And essentially rivaroxaban or DOACs in general have a role, like in the COMPASS trial, in preventing other complications. So here, part of the composite endpoint was myocardial infarction, right? And we know that these peripheral vascular disease patients are very much at risk of it. So it may have an effect locally, but it really, probably, has most of its effect with regards to the panvascular disease that these patients present. Dr. James de Lemos: Excellent. And I'll just point out that just today, the FDA released news that they've granted an indication for this combination therapy for patients with peripheral arterial disease. Let me come back to Marc for a really interesting randomized controlled trial, from China, evaluating no-touch vein graft interventions for cardiac surgery. Marc, can you talk to us about this trial and your impressions on this? Dr. Marc Ruel: Absolutely. Thank you, James. So this is a trial from seven hospitals in China that randomized 2,600 patients between April, 2017 and June, 2019. And patients were randomized with the use of saphenous vein grafts between a no-touch technique and a conventional saphenous vein graft harvest technique. And I'll explain a little bit what this no-touch technique is. It actually consists of two things. You take the vein by a complete incision. Often, in fact, it's more invasive, and you take the actual saphenous vein with a surrounding layer of fat and connective tissue around it. And because of that, it's not easily amenable to endoscopic vein harvest or even using small incisions. Dr. Marc Ruel: The other component of no touch of vein harvesting is to really preserve the anterior layer by not using any syringe inflation and letting the conduit be rinsed, but flow naturally and not be distended at all. So the trial was positive, and the trial already showed a lesser incidence of saphenous vein graft closure at both three months and 12 months on CT scan. So to give you an example, the three months saphenous vein closure was 4.8% in the conventional harvest group, versus 2.8% in the no-touch group. Dr. Marc Ruel: Now what's interesting to here is twofold. There may be a couple of aspects in the benefits of the therapy, and one may relate, in fact, to the lack of pressure syringe dilatation. So it's hard to tease out, is it really the surrounding layer of fat or is it the fact that the syringe dilatation procedure is not being performed in the no-touch group? The second issue is the technique is definitely more invasive. The authors found in the trial more local complications, about 50 to a hundred percent increase in terms of a local numbness, exudation, et cetera, delayed wound healing. Because you have to make bigger incisions and you have to take more tissue around where the vein that you're harvesting. Dr. Marc Ruel: So it is a very intriguing trial. Obviously, graph patency is something that's tremendously important around the CABG operation. But unfortunately, it steers us towards a more invasive approach. In a nutshell, it is a positive trial, but it does require the surgery to be slightly more invasive, albeit, in most cases, with addressable issues with regards to delayed wound healing and exudation. But it would be ideal if we could combine the benefits of a no-touch technique with a less invasive approach to harvesting. Dr. James de Lemos: Mike, this is fascinating to me because you've got a procedure that probably improves the long-term outcomes of the operation, but is associated with a longer surgical time and more local complications. Mike, I'm wondering, what are your surgeon's going to do at Stanford? Are they going to adopt this or is this too difficult and associated with too much inconvenience for the patient to become something that's done routinely? Dr. Michael Fischbein: Brilliant, great question, James. Because I think, often, our patients, previous to endoscopic vein harvesting, they often complained more issues with their leg incisions than their actual sternotomy. And I always tell my patients now, though, one of the incredible things is that we can take their vein endoscopically. And now, we're talking about, while we do have improvement in graft patency for the vein, we're going to go backwards and maybe have some of these wound issues again. And I'd be curious what Marc thinks, though. We are trying to do more and more arterial grafts. And so, if we're just using one vein, is it worth accepting these higher wound complications? Dr. Marc Ruel: It's a great point, Mike, and perhaps exactly, as you say, perhaps an increased use of arterial grafts can be combined with lack of a pressure syringe dilatation of the vein after harvest, right? And there's already some data suggesting, as provided in the excellent editorial by Vidal, that this may be mechanistically important to enhance patency. So the study is very intriguing and still remains to completely unfold. Dr. James de Lemos: Excellent. Really important contribution to the surgical science. Marc, I want to come back to you with another important randomized control trial, this with a really novel therapeutic compound designed to address kidney injury after cardiac surgery. Marc, can you talk about the trial with the small interfering mRNA for renal protection? Dr. Marc Ruel: Absolutely. Thank you, James. This is an important trial, in my opinion. It's a Phase II study of a compound named, teprasiran, which is a interfering RNA, which modifies the p53 mediated cell death response in the renal tubal cells. So what does that do, essentially, is that the thought is that it may prevent acute renal injury after cardiac surgery. We know that's a tremendous problem. Most busy cardiosurgical ICUs would have at least between 15 to 25% of the patients requiring dialysis postop, depending on the level of risk acuity that your unit is presenting. Dr. Marc Ruel: And it's no different whether you're in Stanford or Ottawa or Germany, in my opinion. So we need solutions here. And this is a relatively simple compound, which is administered within four hours of completion of surgery. So for instance, if the surgery was performed on pump, it was given within four hours of completion of surgery. So, for instance, if the surgery was on-pump, it was given within four of hours completion of CPB, cardiopulmonary bypass. If it had been performed off-pump, it was within four hours of the last anastomosis. Dr. Marc Ruel: It's a two-minute infusion, 10 milligrams per kilo, and essentially in the trial, it was not associated with any safety concerns. And quite conversely, it was actually associated with the benefit, with regards to the development of early acute kidney injury, which was 50% prevalence in the patients who were treated with placebo, versus 37% in patients who received the compound, again, named teprasiran. So I think this is quite important. It has led to a Phase III which is currently ongoing, and I think this is a very instrumental finding in the field. Dr. James de Lemos: Fantastic. I mean really a testament to the progress in clinical science for cardiac surgery, that we've got these randomized controlled trials moving through a development phase that may be actionable in years to come. Let's finish the discussion of the original research articles, Mike, with a review of the Yang paper, really, which also, I think, is in Circulation's real sweet spot, where we're highlighting the very best of basic and translational science coming from Surgeon Laboratories. Can you talk about that paper for us? Dr. Michael Fischbein: Thanks very much, James. I think this is really an exciting paper. Qiong Yang's lab at University of Michigan, they're studying Loeys-Dietz syndrome. As you know, Loeys-Dietz syndrome is one of the connective tissue disorders. There's five subtypes, and these individuals form aortic root aneurysms. Importantly, it's specific to the aortic root that these aneurysms primarily develop. Although later on, you can see them in other locations, including intracranial and some of the branch vessels. Dr. Michael Fischbein: But these root aneurysms can dissect and this is life threatening. Currently, the only treatment strategy for these individuals is surgical, where you perform a prophylactic replacement of the aortic root. Unfortunately, there are no real medical therapies, primarily because we don't understand the mechanisms why these aneurysms form. So Dr. Yang's lab, they model this disease using a induced pluripotent stem cell model, where cells are differentiated into the different embryologic origins of the aorta. Dr. Michael Fischbein: The aortic group comes primarily from the second heart field. And so, when they studied these smooth muscle cells, they were able to show that there is lineage-specific smooth muscle cell defects, and they discovered some interesting pathways that might explain why aneurysms form specifically in the root in these in individuals. They also came up with some potential pharmacologic strategies to block some of these mechanisms. Dr. Michael Fischbein: And so, I think this is really exciting because this is using pluripotent stem cells more as a model to study disease states. And I could see the potential, also, for precision medicine, where you take an individual cells, make their iPSCs and study that individual's mechanisms, and perhaps come up with unique medical strategies for that individual. Dr. James de Lemos: So let's, Marc, finish, that's really all of the original research articles we covered. Really, an amazing spectrum of clinical translational and basic science that is a Testament, both to what you all have done to recruit content, but the tremendous growth in science and the surgical specialties. Marc, let's talk a little bit about the two terrific in-depth reviews that you picked for this issue and what their contributions are. Dr. Marc Ruel: Thank you again, James. We have two excellent reviews in this themed issue of Circulation. One is a frontiers piece about cardiac surgery in women in the current era, going over what are the gaps in care. And this is spearheaded by Leslie Cho, from the Cleveland Clinic, and it really goes over, very comprehensively, many of the issues around not only clinical trial enrollment of women, but specific issues pertaining to the care, and which goes back even to basic science of the sex and gender of animals being used in research for reasons that I said, that are very comprehensively, again, I want to emphasize highlighted by the authors. Dr. Marc Ruel: And I'll give you an example, for instance. In off-pump surgery, there are some discrepancies with regards to the use of off-pump versus on-pump surgery between males and females. And we off-pump surgeons know that there are really two very different ways from the surgery. Women, for instance, have a smaller heart which is easier to expose, for instance, for lateral and inferior territories. But in the same token, the coronary targets can be smaller. So there's really a number of discrepancies here, which can be anatomic, it can be sometimes due to the disease presentations. Dr. Marc Ruel: For instance, women have more tricuspid valve disease, and at a certain age start having an increased incidence of aortic problems versus males. And there's also some what I would call logistical issues with regards, for instance, to clinical trial recruitments from VA centers that typically have very, very few women being eligible for enrollment there. So these issues, again, are comprehensively addressed by Dr. Cho and her colleagues. And it's a very interesting read. Dr. Marc Ruel: The other piece you were referring to is a state-of-the-art paper around the use of transit time flow measurements during coronary bypass. And I think our cardiology colleagues and everyone in the cardiovascular field will be very interested to learn a bit more about this. Because essentially, when we perform bypass surgery, we don't have a validated easy way to ascertain whether the grafts that we just built are doing their job. And you may say, "Well, the surgeon's great at cutting and doing anastomosis," but as I like to tell my trainees, there's much more than suturing that might be happening. Dr. Marc Ruel: An anastomosis may have an unforeseen flap into it. There could be a small clot that's blocking something. There could be a kink or a twist in the graft that's not readily recognized. So I think it's very important to have a thorough assessment in everybody. I'm the last author of this piece, so I'm obviously somewhat partial to it. But I think it is important for the field to have quality checking of all grafts that are performed at something, especially something as invasive as bypass surgery. The patient should come out with functional grafts and that should be validated and objectively verified. Dr. James de Lemos: Fantastic. Marc, and we also have two research letters in this issue of Circulation. These are small pieces, but they pack a really powerful punch. Do you want to just briefly tell us about those two? Dr. Marc Ruel: Absolutely. Thank you, James. As a surgeon, I love research letters. I think they are a great venue. They're under a thousand words. Certain, sometimes we're busy, we don't want to always read a 5,000-word manuscript. And they're really, they are well-suited to what I would say are surgical follow-up studies. Once a technique has been described and you want to look at what are the late outcomes of this technique, I think they're an excellent format for that. And precisely, this corresponds to the two research letters that we have in the 2021-themed issue. Dr. Marc Ruel: One is a long-term, 10 year analysis of the SAVE RITA trial by Kim and Kim in South Korea. The SAVE RITA trial is a fairly famous trial in our specialty, which essentially, randomized patients to have a Y graft on the left internal thoracic artery, using either a saphenous vein conduit or the right internal thoracic itself. And essentially the early results were neutral. So the two groups were comparable, which is naturally neutral. I would say non-inferior for the saphenous vein graft. Dr. Marc Ruel: Now we have 10-year data in over 200 patients, equally randomized between receiving a saphenous vein graft versus the right internal thoracic artery. And the results are 10 years are equally excellent between the saphenous vein graft and the right internal thoracic artery. So this is quite non-intuitive to many. Essentially, what we're showing here is that a vein graft at 10 years has amazing patency. We're talking 90%-plus in those patients who received an angiogram. So I think there's a couple of messages to remember here. Dr. Marc Ruel: There may be a biologic role of connecting a saphenous vein graft onto the left internal thoracic artery with regards to nitric oxide dilution. Also, technically, the authors have readily acknowledged that the harvest the vein, again, back to this saphenous vein harvest issue, they harvest it from the lower leg. Therefore, the diameter of the vein is more suited to a Y graft. And, in fact, using a vein over right internal thoracic artery may have technical advantages, because the diameter is a little bit more facile to use with regards to complex composite grafting. So it may actually be something that, if you can maintain it with patency based on say, nitric oxide dilution, is a little bit easier to maneuver and build at the time of surgery. Dr. James de Lemos: Marc, can I ask a question here? Does this change your practice with regard to how often you're using Y graphs, in general, and the vein on artery Y? Because, Mike, outsiders experiences that these graphs aren't used and do these data suggest that we should be using why Y graphs, in general, and this particular type of Y more often in surgery? Dr. Marc Ruel: Absolutely. I think these data suggest precisely that. Whether the adoption will follow is another story. There's not a lot of groups, much to your point, that are using this configuration, but it's used commonly as a bailout strategy. Let's say, one of the arteries has been injured or is not available, or you have a porcelain aorta, I think based on these important data, you can now know that you can, if well-constructed, use a saphenous vein graft as a Y graft onto the LITA with relative impunity. In fact, excellent results, if done in the way that Kim and Kim are reporting. Dr. Marc Ruel: Our second research letter is actually a follow-up of hybrid palliation for hypoplastic left heart syndrome. This comes from the UK, where a number of centers had used several years ago the concept of a hybrid palliation in patients who were mostly high risk for hypoplastic left heart. So here, again, much to the research letter format, we have a follow-up series with regards to following all these children who had received either a initial Norwood approach or a hybrid approach progressing to a Norwood stage two. And essentially, the overall survival, which is about, between two thirds to 75% of children at three, four years, is no different between an initial Norwood stage one approach versus hybrid palliation. Dr. Marc Ruel: So I think this is obviously very intriguing data. It's used to be that a hybrid palliation would only be used in very high-risk cases. I think this would provide credence to using it in a more liberal fashion. There's still the possible caveat that the centers that use hybrid palliation have a little bit of a "expertise bias," if you will, because they have both modalities being available. But I think this is a very important and very intriguing data for this extremely challenging condition. Dr. James de Lemos: Well, thank you. And I'd like to thank both you, Marc, and Mike for just tremendous insight. I think for somebody that doesn't live in the cardiac surgery world, having the privilege, not just to hear you explain these terrific studies, but also provide your insights in pearls about cardiac surgery and vascular surgery care in 2021 has been invaluable. And I think our listeners will feel the same way. I'd like to turn it over to you, Marc, as our leader in cardiovascular surgery to close us out today from a wonderful podcast. Dr. Marc Ruel: Well, thank you very much, James. Again, I want to reiterate, I think this is really a tremendous issue. It's our best ever. And I want to thank you, James and Joe Hill, as well, our Editor-in-Chief, for your support of surgery within Circulation. I also want to thank Sarah, Molly, Nick, and Augie, really, for their in their indefatigable support of our issue. I want to, again, extend our gratitude to Tim Gardner and to Mike for their tremendous help with this issue. I think this is, again, very important. Do send your best work, and I'm speaking to our readership community and all surgeons to Circulation. Dr. Marc Ruel: Circulation is our premier journal and surgery's tremendously important. And the interface together is a strong one, because Circulation realizes that surgery provides, and I'm a bit biased when I say this, but I think it is true. It provides the most robust and durable treatment for advanced heart disease, so it is very important to be featured prominently in Circulation. And I think this is what our current leadership and staff at Circulation are supporting, and I'm tremendously thankful on behalf of all surgeons. 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. This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit ahajournals.org.

9/21/21 Titan Talk with John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Peptide MK 677 - Grow and gain strength! - Obesity and weight loss: Why overall calorie intake may not be so important - Tampa General CEO slams Biden administration over coronavirus treatments Titan Weekly Newsletter Poll: Have you ever used peptide therapies? Yes. - 48% No. - 37% I've thought about it and I would like to know more information. - 6% I'm taking them now. - 6% UPCOMING EVENTS: Oct 7: Olympia 2021 in Orlando Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Nov 20: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/3kkWmBi Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #thymosin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

9/24/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Peptide MK 677 - Grow and gain strength! - FL's new surgeon general: Students exposed to COVID can still go to school if asymptomatic. - 2 dead, at least 12 injured in shooting at Kroger grocery store in Tennessee - Linda Evangelista says CoolSculpting left her ‘brutally disfigured' UPCOMING EVENTS: Oct 7-10: Olympia 2021 in Orlando Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Nov 20: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/3kkWmBi Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #therapy #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

9/28/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media - Biotin Injectable or Oral Therapy to help boost your hair, nails & skin health! - A pill to treat Covid-19 'We're talking about a return to, maybe, normal life' - Did you know the DEA Still Insists Marijuana Has No 'Accepted Medical Use'? Titan Weekly Newsletter Poll: Do you have trouble keeping your hair, skin or nails healthy and shiny?? Yes - 57% No - 42% UPCOMING EVENTS: Oct 7-10: Olympia 2021 in Orlando Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Nov 20: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/3obnVPS Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #biotin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #medicalscience Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

Titan Lifestyle: Live Q&A - Injectable Titan Up - events & more! 9/17/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Therapy Of The Week: Injectable Titan Up! MIC, B-complex, B12, Leucine, & L-Carnitine. - Self-Driving Ford Vehicles Might Deliver Your Next Walmart Order - A fitness influencer and bodybuilder was charged with 6 counts of drug possession after investigators say she received a package of steroids - Los Angeles County to require vaccination proof at bars, large events - Florida landlord says tenants must get vaccinated against COVID-19 or move out - This weekend: WCFL 30 MMA fights & Hall of Fame UPCOMING EVENTS: Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Nov 20: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/3liCopV Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #bodybuilding #therapy #thymosin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

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9/14/21 Titan Talk with John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Therapy Of The Week: Injectable Titan Up! MIC, B-complex, B12, Leucine, & L-Carnitine. - DeSantis says Local governments will face $5K fines for imposing vaccine mandates. - Mammoth-elephant hybrids could be created within the decade. Should they be? - This weekend: Saturday WCFL 30 Anniversary MMA event & WCFL Hall of Fame Show. Titan Weekly Newsletter Poll: How would you rate your overall experience with Titan Medical Center (as a patient)? I am very happy, Titan's service is top notch! - 64% I'm not a patient yet, but I am planning on becoming one soon! - 14% It's okay. - 14% Not happy at all. (Please contact us directly if you checked this) - 7% UPCOMING EVENTS: Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/3liCopV Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #thymosin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

9/3/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Titan in Clearwater Florida! - Our healing Peptide TB-500 helps heal injuries & tissues faster! - Apple giving residents of 8 states ability to add license & state ID to iPhones for TSA airport security checks - Apple in Talks With Toyota About Apple Car Production Starting 2024 - As mandates roll out, some may ask for medical exemptions. What's really valid? - Turkesterone is it really all the hype? UPCOMING EVENTS: Sep 9-11th:St.Pete Art & Fashion Week Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Our healing Peptide TB-500 helps heal injuries & tissues faster! https://conta.cc/2UVM7t8 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #live #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

9/7/21 Titan Talk with John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Optimize your health & build your immune system with Thymosin Alpha 1 (TA1) - What is the healthiest fish to eat? The best choices for you and the planet - Dennis Rodman would hit weight room after games, “he was bionic” - This weekend: St.Pete Art & Fashion Week! Titan Weekly Newsletter Poll: Have you watched any of our live stream social media shows? Yes, I've seen them all at least once! - 44% Yes, I've seen Titan Talk Tuesdays at 6pm on social media. - 22% Yes, I've seen Titan Lifestyle on Fridays at 2pm on social media. - 11% No, I've never seen any of them! - 22% UPCOMING EVENTS: Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/2WXQO6h Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm therapy #thymosin #livestream #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

9/10/21 Titan Lifestyle with Big Dru & John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Optimize your health & build your immune system with Thymosin Alpha 1 (TA1) - This Saturday: St Pete Art & Fashion Runway Show! - Understaffed Dallas restaurant rents robots for $15 a day to serve guests - Facebook debuts $299 'Ray-Ban Stories' smart glasses - Tesla locks down a patent for using laser beams as windshield wipers - FBI releases documents on an attempted murder-for-hire plot against Koby Bryant's rape accuser UPCOMING EVENTS: Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Our current weekly newsletter: https://conta.cc/2WXQO6h Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #therapy #thymosin #livestream #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

8/24/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Try DSIP (Delta Sleep Inducing Peptide) to help get the good quality SLEEP you DESERVE! - George Mason grants professor COVID vaccine mandate exemption after ‘natural immunity' lawsuit - Jetsuits for cops being tested in the UK, how well will they do? Titan Weekly Newsletter Poll: Do you get good quality sleep without waking up during the night? Yes, I sleep all the way through the night. - 14% Yes, but I do toss and turn occasionally. - 42% No, I hardly get any good sleep, I am up all night long. - 42% UPCOMING EVENTS: Sep 9-11th:St.Pete Art & Fashion Week Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Try DSIP (Delta Sleep Inducing Peptide) to help get the good quality SLEEP you DESERVE! https://conta.cc/3Dc1OO7 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm biden #Schwarzenegger #tyson #live #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

8/27/21 Titan Lifestyle with Big Dru & John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Try DSIP (Delta Sleep Inducing Peptide) to help get the good quality SLEEP you DESERVE! - Sha'Carri Richardson declares ‘I'm not done' after finishing last in major race - Pro Bodybuilder Alena Kosinová Passes Away - OnlyFans reverses ban on sexually explicit content after backlash from users - Watch a Guy With Bad Knees Get Superpowers With a Powered Exoskeleton UPCOMING EVENTS: Sep 9-11th:St.Pete Art & Fashion Week Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Try DSIP (Delta Sleep Inducing Peptide) to help get the good quality SLEEP you DESERVE! https://conta.cc/3Dc1OO7 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #live #currentevents #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #liveshow #contentcreaters #podcast Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

8/31/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - Our healing Peptide TB-500 helps heal injuries & tissues faster! - Chicago judge tried to revoke custody of child from a mother because she was unvaccinated - Chinese kids now have very limited video gaming time under new government rules Titan Weekly Newsletter Poll: Did you know that you can inject peptides to heal your injuries faster? Yes. - 71% No, can you tell me more. - 28% UPCOMING EVENTS: Sep 9-11th:St.Pete Art & Fashion Week Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast Our healing Peptide TB-500 helps heal injuries & tissues faster! https://conta.cc/2UVM7t8 Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm biden #Schwarzenegger #tyson #live #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

8/10/21 Titan Talk with John Tsikouris: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - It's time to take your results to the next level! Try the Titan Trifecta! - Schwarzenegger's message to anti-maskers “screw your freedom” - Mike Tyson says he lost 110lbs using psychedelic toad venom! - Biden administration to announce most Americans will need covid booster shots Titan Weekly Newsletter Poll: Do you take (injectable or oral) vitamins or amino acids? No, do they really work? - 25% Yes, I've tried over the counter supplements. - 25% Yes, I take my Titan therapies!! - 35% No, I don't think I need them. - 14% UPCOMING EVENTS: Sep 9-11th:St.Pete Art & Fashion Week Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast It's time to take your results to the next level! Try the Titan Trifecta! https://conta.cc/3iUAKuZ Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm biden #Schwarzenegger #tyson #live #immunesystem #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

8/20/21 Titan Lifestyle with Big Dru and John: - Our social media: https://linktr.ee/TitanMedicalCenter - Live Q&A on @Titanmedical social media! - It's time to take your results to the next level! Try the Titan Trifecta! - OnlyFans will start prohibiting explicit adult material in October - Mother on flight from Disney World told to “glue” mask to 2-year-old child's face - Sha'Carri Richardson will race Olympic medalists after ban from competing in Tokyo - Washington football team narrows list of possible new names down to 3 final choices UPCOMING EVENTS: Sep 9-11th:St.Pete Art & Fashion Week Sept 18: WCFL 30 Anniversary Show Sept 19: WCFL Hall of Fame Show Oct 13: Tampa International Airport Annual Employee Health & Wellness Event Oct 7: Olympia 2021 in Orlando Oct 23: Tim Gardner's NPC Hurricane Bay Nov 13: Cars & Couture: 11th Annual Collector's Gala Dec 4: Tim Gardner's - NPC Atlantic Coast It's time to take your results to the next level! Try the Titan Trifecta!s https://conta.cc/3iUAKuZ Text: titanmedical to: 22828 to get on our emailing list! Titan podcasts: https://titanmedicallifestylepodcast.fireside.fm bigdru #druborden #livestream #johntsikouris #titan #titanmedical #health #medicalcenter #peptide #aminos #vitamins #fitness #news Click here for our link to the New patient Paperwork to get started with Titan & our full list of social media! https://linktr.ee/TitanMedicalCenter And of course you can call/text anytime for more info: 727-389-3220 or http://titanmedicalcenter.com/ We service NATIONWIDE! Text:titanmedical to:22828 to get on our emailing list About Titan Medical Center: We offer Hormone Replacement Therapy, Medical Weight Loss, Injectable Vitamin & Amino Therapies, Relationship, Bedroom Enhancing Therapies, On-Site or Nationwide Blood Work Testing, Peptide Therapies, In-House IV Therapy, & Primary Care. We are based in Tampa, Florida but YES we service NATIONWIDE! We can help you enhance your life and performance while operating at optimal health levels. We have medical doctors and start with blood work testing to get you on the right track! Some of our therapies are available without blood work testing. Call Titan Medical Center to learn how you can have a healthier, stronger life. We offer telemedicine (via FaceTime or Skype) from the comfort of your own home where you will see a licensed medical provider. Our Titan therapies are doctor prescribed & shipped directly to your doorstep from a licensed US pharmacy!

My preference in work was not towards optimizing machinery, but helping optimize work processes for people. Tim Gardner, Former Organizational Development Consultant at Kimberly-Clark (retired)   We're Only Human -- Episode 112   If you're an introvert in HR, you're not alone. Recently I shared a piece on LinkedIn about introverts in HR and the value of introversion, and the piece received thousands of likes and comments. Apparently my own preference for introversion is in good company! In today's podcast discussion, Tim Gardner, an admitted introvert and experienced organizational development leader, talks about designing work around people instead of forcing people to bend around the work. His background as an engineer (yes, really!) gives him a unique and powerful perspective on HR, process design, and business operations.  Towards the end of the discussion, I ask Tim to talk about legacy and impact, and it's a great set of ideas for all of us as we think about the lasting impressions of our work and relationships on the world.    Connect with Tim: https://www.linkedin.com/in/timjgardner/  Learn more about We're Only Human and see show archives: https://lhra.io/were-only-human-podcast/ 

Check out this weeks YEAH_UK Radio Recorded LIVE from Brightons NO.1 Dance Radio Station DECADANCE Radio 20/02/21. The week Tim Gardner takes over with a beautiful sounding vocal, melodic techno set. Keep up to date with our radio show and more via the link below, decadanceradio.com/artist/yeah_uk/ Be safe & well MATT & TIM

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 Greg Hundley, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam : Greg, today's feature paper is a research letter, but, oh my gosh, it is so interesting. It's about surgical explantation of transcatheter aortic bioprosthesis. TAVRs we know is on the rise and so is the rise of surgical explantation cases and we really need to understand it better. Hang on, we're coming to that, but maybe, let's start with some other papers in the issue first, shall we? Let me go first, you go grab your coffee and listen because we're going to talk about the efficacy of ertugliflozin on heart failure related events in patients with type II diabetes and established atherosclerotic cardiovascular disease in the results of the VERTIS CV trial. Dr. Greg Hundley : Carolyn, tell us a little bit about the VERTIS CV trial. Dr. Carolyn Lam : Sure. The primary results of the VERTIS CV trial have already been published. This cardiovascular safety trial was actually performed to satisfy the 2008 guidance from regulatory agencies for new antihyperglycemic agents. It found that patients with type II diabetes and atherosclerotic cardiovascular disease randomized to ertugliflozin achieved the primary objective of non-inferiority to placebo in time to first major adverse cardiovascular event or MACE, a composite endpoint of cardiovascular death, non-fatal MI, or non-fatal stroke. The first secondary outcome in the hierarchal testing sequence was superiority for the time to composite of cardiovascular death or heart failure hospitalization, which was not met and therefore formal hypothesis testing ended with this endpoint. Now in today's paper, the authors led by Dr. Cosentino from Karolinska Institute and Karolinska University Hospital in Stockholm, Sweden, present the results from pre-specified analyses of the effect of ertugliflozin versus placebo on a series of heart failure related outcomes from this VERTIS CV trial. Dr. Greg Hundley : Ah, Carolyn. Tell us what were the results of this new study. Dr. Carolyn Lam : Of more than 8,200 randomized patients, almost 24% had a history of heart failure and almost 61% had a pre-trial ejection fraction available, including 959 patients with an injection fraction less than or equal to 45%. While ertugliflozin did not significantly reduce first heart failure hospitalization or cardiovascular death, it did reduce first and total hospitalization for heart failure events with a relative risk for first heart failure events being similarly beneficial number one, in those with versus without a history of heart failure and number two, in those with a history of heart failure with reduced ejection fraction or preserved ejection fraction. However, the risk reduction tended to be greater for those with an ejection fraction less than or equal to 45%. Although, the test for interaction by injection fraction was not significant. The effect of ertugliflozin on risk for first heart failure hospitalization was consistent across most baseline subgroups with a greater effect in three populations, including those with impaired kidney function and those taking diuretics. Now, this is discussed an editorial by Doctors Faiez Zannad and Martin Cowie. You must pick it up and read it. Dr. Greg Hundley : That's great, Carolyn. What a fantastic another piece of information on the SGLT2 inhibitors. Dr. Greg Hundley : Well, my first paper comes to us from Dr. Peter Liu from the University of Ottawa Heart Institute and his colleagues. Carolyn, this article focuses on cardiac hypertrophy, which as you know, is a key biological response to injurious stresses such as pressure overload. Also as you know, when cardiac hypertrophy is excessive, it can lead to heart failure. Innate immune activation by danger signals through intracellular pattern recognition receptors such as nucleotide-binding oligomerization domain-containing protein 1, or NOD1 and its adaptor receptor interacting protein, RIP2, may play a major role in cardiac remodeling and progression to heart failure. These authors hypothesized that NOD1 and RIP2 are major contributors to cardiac hypertrophy, but may not be sufficient to fully express the phenotype alone. Dr. Carolyn Lam : I like that, NOD1 and RIP2. What did they find? Dr. Greg Hundley : These authors found that innate immune NOD1/RIP2 signaling was a major contributor to cardiac remodeling following stress. This process was critically joined by and regulated through the mitochondrial danger signal protein adapter MAVS. The authors found that this novel complex coordinates remodeling, inflammatory response and mitochondrial energy metabolism in stressed cardiomyocytes, thus NOD1/RIP2 MAVS signaling complex may represent an attractive new therapeutic approach toward modulating LV hypertrophy mediated heart failure. Dr. Carolyn Lam : Very nice, Greg. Now in the next paper, do you remember the VOYAGER PAD trial? Well, it was the trial that demonstrated superiority of rivaroxaban plus aspirin versus aspirin alone to reduce major cardiac and ischemic limb events following lower extremity revascularization. Now clopidogrel is commonly used as a short term adjunct to aspirin after endovascular revascularization. However, does clopidogrel modify the efficacy and safety of rivaroxaban in this setting? Well, that's the question that today's paper is addressing and it is led by corresponding author, Dr. Hiatt from University of Colorado School of Medicine. Dr. Greg Hundley : What did they find, Carolyn? Dr. Carolyn Lam : Well in the VOYAGER PAD trial, rivaroxaban plus aspirin reduced the risk of adverse cardiovascular and limb events with an early benefit for acute limb ischemia, regardless of clopidogrel use. The safety of rivaroxaban was consistent regardless of clopidogrel use as well, but with a trend for more ISTH major bleeding with clopidogrel use more than 30 days than a shorter duration. These data support the addition of rivaroxaban to aspirin after lower extremity revascularization, regardless of concomitant clopidogrel with a short course of less than 30 days associated with less bleeding. Dr. Greg Hundley : Very nice, Carolyn. Well, my next paper comes to us from Dr. Hinson from the Jackson Laboratory for Genomic Medicine. Carolyn this paper focuses on a particularly challenging heart failure associated sarcomere gene, cardiac troponin T, that is encoded by TNNT2. Remember Carolyn, this is a thin filament protein that functions in the tripartite troponin complex, where calcium binds and triggers twitch force. Relative to other sarcomere genes, pathogenic TNNT2 variants are associated with poor prognosis as they carry an increased risk of sudden cardiac death that is disproportional to myocardial remodeling. The investigators used human pluripotent stem cell derived cardiomyocytes in cardiac microtissue and single cell assays and functionally interrogated 51 TNNT2 variants, including 30 pathogenic likely pathogenic variants and 21 variants of unknown significance called VUSs. They utilized RNA sequencing to determine the transcriptomic consequences of pathogenic TNNT2 variants. Dr. Carolyn Lam : Wow. And so what were those consequences, Greg? Dr. Greg Hundley : They found that hypertrophic cardiomyopathy associated TNNT2 variants increased cardiac microtissue contraction while dilated cardiomyopathy associated variants caused decreased contraction. Both of which parallel changes in myofilament calcium affinity. Transcriptomic changes, including NPPB levels, directly correlated with sarcomere function and could be utilized to predict TNNT2 variant pathogenicity. In summary Carolyn, this research found that number one, inheritance of pathogenic TNNT2 variance is a leading cause of cardiomyopathy and number two, the majority of TNNT2 variants identified in the human population are classified as those VUSs or variants of unknown significance, which limits their clinical utility in genetic testing. As such, reclassification of TNNT2 variants would improve cardiomyopathy risk determination and treatment responses for individuals harboring these variants. Dr. Carolyn Lam : Nice. Thank you, Greg. Well, in this next paper, I think the title summarizes it all: “Is There a Sex Gap in Surviving an Acute Coronary Syndrome or Subsequent Development of Heart Failure?” Well, Dr. Justin Ezekowitz from Vigor Center, University of Alberta in Canada and his colleagues used a large population based cohort of more than 45,000 patients with MI between April 2002 and March 2016, to examine the incidence and geographic findings, treatment and clinical outcomes of patients with a first time and MI. To elucidate the difference between sexes, a series of multi-variable models were created to explore all MI and non-ST elevation MI versus ST elevation MI over time. Dr. Greg Hundley : What did they find Carolyn? Dr. Carolyn Lam : Well, some attenuation of differences in clinical outcomes over time had occurred. Women maintained a higher risk than men of dying or developing heart failure in the subsequent five years post both STEMI or non-STEMI, even after accounting for differences in angiographic findings, revascularization and other confounders. Dr. Greg Hundley : Well, Carolyn, how about we get to some of the other articles in the issue. And I've got a really nice Research Letter from Professor Damien Bonnet entitled, “Addition of Corticosteroids to Immune Globulins is Associated with Recovery of Cardiac Function in Multi-inflammatory Syndrome in Children.” There's also a Research Letter from Professor Peter van der Meer entitled, “Human Pluripotent Stem Cell Derived Cardiomyocytes of Peripartum Cardiomyopathy Patients Reveal at Aberrant Regulation in Lipid Metabolism.” And Carolyn, finally I have an ECG Challenge entitled, “Wide QRS Complex Tachycardia in a Young Pregnant Woman, is it SVT or VT?” The age old question from Dr. Gunaseelan. Dr. Carolyn Lam : Nice. Well, there's also an exchange of letters between Drs. Ross and Loupy regarding the article, “Identification and Characterization of Trajectories of Cardiac Allograft Vasculopathy after Heart Transplantation: a Population Based Study,” and a beautiful Perspective piece by Dr. Verma entitled, “Two Tales, One Story and that is talking about the EMPEROR-reduced and DAPA-HF trials.” A beautiful summary there. Let's get on now though to that feature discussion. Shall we, Greg? Dr. Greg Hundley : You bet looking forward to it. Dr. Carolyn Lam : Transcatheter aortic valve replacement or TAVR has indeed become an established alternative to surgical aortic valve replacement for patients with severe aortic stenosis. Now, while the TAVR usage has increased, so has surgical TAVR valve explantation. However, that's not been really well described its clinical impact or outcomes well until today's research letter in Circulation, which represents the largest series of TAVR explants from a national database. And I'm so pleased to have with us the first and corresponding author, Dr. Shinichi Fukuhara from University of Michigan to describe the study as well as our associate editor, Dr. Tim Gardner from University of Pennsylvania. Welcome, gentlemen. Shinichi, if you don't mind for non-interventionists and non-surgeons like myself, why would you need to explant TAVR in the first place? Maybe you could start with that and then tell us about your study. Dr. Shinichi Fukuhara: First of all, thank you so much for the kind invitation. It's a great honor to be with you and Dr. Gardener. That's a very good question and a very timely question actually. When we started implanting TAVR valves probably about nine years ago or so, that was when the TAVR valve was FDA approved, we were not thinking about second TAVR procedure after the initial TAVR valve fails. And then as time goes on, we started to recognizing, some patients' TAVR valves started failing and these failure patterns can be paravalvular leak, can be structural valve degeneration, can be endocarditis. Not all patients with a failing TAVR valve can be treated with a second TAVR valve procedure and the most common driving factor at least in my program at the University of Michigan is unsuitable anatomy for a second TAVR valve and the most common anatomy pattern is a risk of a coronary artery obstruction by the second TAVR valve. These are the common scenarios where patients need TAVR valve explantation scenarios. Dr. Carolyn Lam : Thank you so much for that as a background. And as you nicely set up in your paper, as we do more TAVR, obviously there are going to be more situations like this. Please tell us what you found. Dr. Shinichi Fukuhara: First of all, what we found from this project, first, surgical TAVR valve explant procedure is not as simple as people thought it would be. I remember back in 2014, 2015 when I was still a trainee, people were talking about, which is better TAVR SAVR TAVR or SAVR TAVR SAVR? However, based on what we are just starting to see, TAVR SAVR sequence may not be a good option for younger people based on the present study data. The fact that more than 50% of patients who require the major simultaneous procedures such as aortic repair and the mitral procedures is a something TAVR implanters in our community should be more aware. Tim Gardner: I think it's very important for Shinichi to tell us to emphasize the mortality rate that you saw with the SAVRs following TAVR because that's really, I think the sobering information here. This is not comparable to doing a redo aortic valve or redo SAVR. Just tell us about that, Shinichi. Dr. Shinichi Fukuhara: First of all, these STS database. We have a STS predicted risk of a mortality, which is available for patients undergoing isolated SAVR procedure. And then based on the even isolated the SAVR procedure, the OE ratio of observed to expected mortality ratio was actually higher than 1.5 for isolated SAVR procedure in patients requiring TAVR explant. More importantly, patients who are requiring TAVR explanted SAVR, as well as a concomitant cardiac procedure are demonstrating almost close to 20% mortality rate, which is to me very striking after we analyze that data set. And this is something our community, the TAVR implanters in our community should keep in mind. Dr. Timothy Gardner: Yeah. Obviously not only is the surgery, the removal of the TAVR device and replacement with a surgical valve, not only is that complex anatomically and technically, but the associated mortality seen in this series of patients that they reported is higher than expected and actually quite high in terms of absolute operative or hospital mortality. I take this important research letter as a sort of a warning message to all of us, in particular, the cardiology community, to realize that once a TAVR valve is placed, it is more difficult and riskier to remove that and replace it with a surgical aortic valve replacement, if for some reasons such as endocarditis or valve failure or whatever comes to play. Dr. Timothy Gardner: And obviously as Shinichi has already said, when you're looking at a younger patient, patient under 60 for example, who needs an aortic valve procedure, you need to keep in mind whether as he said earlier, it's might be safer to do a SAVR first. And then if there's another procedure required, that could be because of valve failure, a TAVR could be done rather than just assuming that the TAVR is going to be there and that it can be easily replaced or taken care of. At any rate, I think that's the very important point of this paper. And I think this is really the first report and not only by the way, does it show that this is happening, but in the most recent year of your report, Shinichi, how many SAVRs after TAVR were reported, number of cases? Dr. Shinichi Fukuhara: The 2018, the last year of this study period was actually the highest obviously and it was a close to 300 cases reported. And then the number of case is a steeply increasing as I demonstrated in the figure one in the paper. Dr. Timothy Gardner: That really emphasizes obviously TAVR volume is increasing. TAVR is now being placed in younger patients who have perhaps a greater chance of requiring a second procedure. And if it has to be explantation of the TAVR because of the complexity and the inability to use another TAVR to fix the valve, the technical challenges and the operative risks are much higher. Dr. Timothy Gardner: Well, I just think that this is a warning call that we have to be realistic about the secondary requirements for patients that have TAVR and we don't yet even have a much more than a 10 year experience with TAVRs and we're seeing an increasing number of patients just in the STS database who are having to come back for TAVR explant and it's a difficult, challenging procedure. One point that Shinichi made in his article is that this technical challenge of TAVR explant may be something patients requiring this procedure may need to be referred to surgeons and hospitals with high aortic surgery volume. This is not necessarily a procedure that a surgeon can get experienced with and comfortable with doing two or three a year. That's another bit of the message here. Dr. Carolyn Lam : Thanks, Tim. And Shinichi, what would be your take home message to the clinical community listening in? Dr. Shinichi Fukuhara: Thank you so much. Yeah, this is a little bit redundant statement, but I think that another important message from this paper is that these low risk younger patients choosing to have a TAVR procedure as the initial valve therapy should be informed of the future procedure risks of a TAVR explant which frequently requires more of device explanating and the possible unplanned concurrent procedures and for these reasons careful assessment of aortic root anatomy and the feasibility of a repeat TAVR procedure should be part of with the initial TAVR workup. If we decide to proceed with TAVR for younger patients and then therefore heart team approach remains extremely important in the TAVR practice, that's my take home message. Dr. Timothy Gardner: And I'd like to reinforce that. This is, as we know, the heart team concept has been so important in providing optimal care for patients with aortic valve disease and this is a reminder of part of the discussion that should be happening at the heart team level. Dr. Carolyn Lam : Thank you so much. Clear take home messages that you've got right here on Circulation on the Run. Dr. Greg Hundley : This program is copyright the American Heart Association, 2020.  

Welcome to Neurotech Pub, hosted by Paradromics Inc and SynBioBeta. In this episode, host and Paradromics CEO, Matt Angle, speaks with Tim Harris, Cindy Chestek, and Philip "Flip" Sabes about the big programmatic challenges in neurotechnology. We talk about the differences between labs, startups, and large research consortia. We discuss the difference between neuroscience and neuroengineering, and Tim explains how one of the biggest breakthroughs in neurophysiology was the product of….lawyers.Check out full video with transcript here: https://www.paradromics.com/podcast/neurotech-pub-episode-1-biologists-engineers-and-lawyers 2:04 Jester King Brewery, Dripping Springs, TX | 3:03 Bell Labs | 7:31  Michael Jordan | 9:05 Krishna Shenoy and Reid Harrison | 9:49 Stevenson's Law | 12:10 The Utah Array | 13:43 Neuropixels | 14:06 Dendrites by Nelson Sprusten, Greg Stuart, and Michael Häusser | 24:47 Low-power neural signal processing by Chestek Lab | 26:54 Spike sorting, Dimensionality, and Decoding | 27:30 Neural Task Complexity | 28:43 A 16-beam system that records ~1,000 neurons @ ~10 Hz | 32:16 The Braingate clinical trials | 34:15 Using Muscles as Bioelectronic Amplifiers in Peripheral Nerve Applications | 35:28 Jack Judy, University of Florida | 37:59 Touch Sensation | 38:06 DARPA HAPTIX Program | 39:22 Muscle Taco | 41:22 Janelia Research Campus | 45:59 Steliglitz Lab | 50:50 Power Consumption | 54:31 Eddie Chang and Chang Lab | 55:20 Buzsaki Paper | 55:45 BioRxiv pre-print on the Paradromics Argo System | 56:16 NeuroGrid: Recording Action Potentials from the Surface of the Brain | 1:01:30 Physical Principles for Scalable Neural Recording | 1:02:03 Pierebone lab's work with DARPA |1:04:18 Carbon Fiber Ultramicroelectrodes | 1:05:05 IMEC work with nanolaminate | 1:05:05 Picosun and Brown University |1:05:16 Stuart Cogan | 1:05:18 Michel Maharbiz | 1:07: 08 Takashi Kozai and Daryl Kipke | 1:09:44 Utah Array, Blackrock Microsystems | 1:12:29 DBS for Depression | 1:18:37 The Sewing Machine | 1:22:32 Paradromics Laser Surgical Tool | 1:22:42 Recent Papers from Schaefer and Melosh Group | 1:23:46 Tim Gardner's work on Carbon Fiber Arrays | 1:23:54 Mechanics of Microwire Penetration | 1:25:38 FDA scientists work on Accelerated Aging | Want more? Follow Paradromics & Neurotech Pub on Twitter  Follow Matt A, Tim Harris, Cindy Chestek, and Philip "Flip" Sabes on Twitter

Dr James de Lemos: Hello, my name is James de Lemos. I'm the executive editor for Circulation, and I'm delighted to be joined here by Tim Gardner professor of surgery at University of Pennsylvania and our long-term associate editor in charge of cardiac surgical content at Circulation; and Marc Ruel, who is professor of cardiac surgery at University of Ottawa and the chair of the department there and who for many years has led the cardiac surgery supplement issue. Mark, Tim, welcome. Marc, please introduce this issue for our listeners. Dr Marc Ruel: Thanks so much, James. It's a very exciting year academically for cardiac surgery. We've had a lot of great developments from new data on long-term patency and outcomes with radial artery graphs through the results of the ischemia trial. And I think the 2020 themed issue around cardiovascular surgery is exactly in that framework. I think it will garner wide interest. It has a number of original papers, six original research articles, two more translational papers included in those six. We have two research letters. We have two frame of reference papers as well. And one state-of-the-art piece on exynos transplantation. We always keep in mind to have those issues very relevant to surgeons and to gather the very best cardiovascular surgery science. But in the same token we also want to make sure that they are relevant to the wider cardiovascular community. So I think, and I hope that everyone will enjoy this issue as the very best that's happened in cardiovascular surgery over the year. Dr James de Lemos: Well, thank you, Mark. Let's get started with discussion of the first paper and one that I'm actually quite excited about. This is long-term results of the radial artery CABG in clinical outcomes trials. What did the investigators look at in the study? Dr Marc Ruel: I think this is a very important paper, which adds to the increasing data around long-term benefits of arterial grafts, multi arterial grafts, and more specifically the radial artery. So here's a paper mostly from Australia. First author being Professor Buxton, who is a very well-known senior surgeon who has been really a grandfather in this field. And the last author is David Hare who is a cardiologist, also professor in Australia. And essentially there were two radial artery comparative trials that have been undertaken many years ago, well over a decade ago, when we now have 10-year data on those two trials. One of the trials compared the radial artery to the right internal thoracic artery. And the second trial a little bit smaller to the saphenous is vein grafts. So it holds 400 patients in the first randomized comparison and around 225 in the second, i.e. the radial versus saphenous vein. So it's wonderful that this is very long-term data. We have 10 year patency data, not on all patients. There was a distribution as to when the angiogram or the CT scan would be performed for patency over the course of the 10 years of the study. But the follow up is excellent and there are actually patency as well as clinical differences between the groups. And maybe I can say a couple of things around those. So, in the radial versus right internal thoracic artery cohort, there's both a patency and a mortality as well as a major adverse cardiac events benefit for the radial artery over the right internal thoracic artery. And yes, you've heard right, the comparator is the right internal thoracic artery. Now a couple of chatty it's all the Redis in there had to be done as a free graph. So they are connected. This is an art technique that everyone is very comfortable with and you have to use a six or seven Oh one friable internal thoracic ultra. So it may not really provide or present the call the way at its best advantage. If you will, there may be some benefits or a loss for not having it as a pedicle, but nevertheless, and in the second comparison, looking at the radio versus 225 patients, there was a patiency advantage for the radio Herceptin in Spain. But partly because the comparison was less power than the first, there was no major adverse cardiac event or even mortality difference. So I think again, aligns with the data that we know the arc trial, as we all know, 10 years was neutral. There was no benefit to internal thoracic arteries versus small one, which regards to anything repeat revascularization based mortality. And we know have 10-year data recently published that shows that the radial artery in pooling patient level data from many randomized clinical trials leased their survival benefits. So I think it's fair to say based on available data now with this team issue in 2020 in the fall, that the best second RGO is very likely or radio RV and too many people surprised. Dr Timothy Gardner: Yeah. If I could just add my perspective, there's an editorial by Steve brings on this. This really does solidify the data about long-term radial, artery patency. And that was when I came away with, it's not so much the comparison of the radial on the right internal thoracic, but the fact that the radial artery would be like held up very well. Dr James de Lemos: If you're referring a young patient or considering a young non-diabetic patient for cabbage at this point, was you select a radial artery or right internal memory? Dr Timothy Gardner: Well, I probably would favorite as a second graph the right internal thoracic artery rather than. As a free graph, but I certainly wouldn't hesitate to use the radial artery as the second graph there as a third grade. My competence in the radial artery continues to grow in this report reinforces that. Dr James de Lemos: Excellent really important study for both the cardiac surgeons and the cardiologists that read our journal. Let's switch gears and talk about bowel surgery, Tim, the camera Cardiolite study drills deep into different strategies for repairing the mitral valve. What did we learn there? Dr Timothy Gardner: Well, first of all, this study, which comes from Mark Raul's unit Benson Chan being the first author and address the issue that repair with resection of the mitral valve made me to functional stenosis of the valve. And that has been a concern among surgeons and that has led some surgeons to prefer non-lethal the resections repair. And this study was very carefully done and actually demonstrated that the data did not support the fact that resection versus preservation is this okay with the riff? So I think that, you know, there are various ways to repair the valve. And if you go back to the original descriptions of mitral valve repair resection was a major component for many people in many studies. And this is a reassuring study that either approach appears to be effective without badly under sizing the annulus that there should not be residual mitral stenosis. Dr James de Lemos: Tim is one of these materially easier to do in the operating room. So then it would emerge as the preferred therapy or is it really going to be surgeon dependent. Dr Timothy Gardner: I think it’s fairly surgeons dependent. I mean, we have technical variations for a lot of operations, and I think it's when the surgeon is comfortable with Mark. You might want to comment on that point. Dr Marc Ruel: Yeah, I agree with both of you. I think it's very reassuring because there's the orientation of where the last issue is. Small. The patient's exposure is not knowing that you can use theater technique and in some cases not have to go on to the pathway. We Muscle is a reassuring avenue. So I think every surgeon has her or his preference, but it's nice to know that both these can be used interchangeably without any drawback to the patient. Dr Timothy Gardner: Let's switch gears and talk about a paper that I think has pretty profound implications for both of our specialties. And this is an observational analysis from the RS trial, evaluating the association of postoperative atrial fibrillation in the long-term risk of stroke. Mark, what did you think of this paper and its implications? Dr Marc Ruel: This is a very interesting piece that comes incidentally from the heart trials. So non related to what we were Just discussing before the 3000 patients or so of the art trial were followed at 10 years. Mostly with regards to major adverse cardiac events, et cetera, anything that's related to the question at stake at the time, which was single internal for us, incidentally, the authors have ready data regarding the incidence of stroke at 10 years. And they were able to use those and go back to those stations who have postoperative atrial fibrillation and see if there was a correlation, even when accounting for other factors in the patient profile. So interestingly about 24% of patients have had post-op and post-op you, is defined in variety of ways for this particular study, it was defined as 30 seconds at least of atrial fibrillation or atrial flutter during the index hospitalization after the operation. So I think this is a very fair and square type of definition and those patients and those who have the CBA incidents by 10 years was 6.3% versus those who did not have postoperative 3.7%. So this is obviously a significant numerical and also statistically significant higher risk for those patients who have post-operative a-fib. So there's a number of caveats around that. All the risks for post-doc are often the same ones that may lead to the risk of stroke over the long-term. So I think we should see this not as probation. But that should be not even as an association. But certainly as a correlation, but it is really unique data that has not been produced before. Like postoperative is so common after cardiac surgery. It affects many of the patients that both the cardiology and cardiac surgery individuals have to treat. And I think the more information on it, the better, there were a number of interesting observations warfarin, for instance, even though the incidence of post-op 24% was used in only about 8% of the overall trial. So one may debate, have these patients being anticoagulated enough also, would there be a way to provide enhanced surveillance to patients who have post-op in order to maybe catch them prior to them having a cerebral aspir event? So I think it's really very interesting data. I would like to briefly provide one last tidbit of information, which I thought was very, very fasting. So the authors used the CHADS two score in order to kind of ascertain your overall risk attributed to which regards to stroke in those patients. So this is probably the latest and best iteration of the Chad score if you will. And they found that in patients with a score of less than four, so it was zero to three. There was no difference with regards to the incidents of CVA or in signers versus those who have post-op after the operation. However, when the score rich four or higher. This is rare to you where the risk was concentrated. So that particular cohort of patients seemed to be the one where I think the efforts with subsequent studies should be concentrated in order to intervene and hopefully catch these patients who may have atrial fibrillation without having it. Dr James de Lemos: Does this change your practice at all? Do you think, I mean, I guess it's interesting for me because obviously I see a lot of these patients back from surgery and I've tended to candidly ignore short episodes of peri-operative atrial fibrillation. And this really raises questions as to whether that approach is wise and needs to be revisited. Dr Timothy Gardner: I agree completely on the other hand, I think that targeting patients, I mean, I think the last point that Mark made about the patients that ended up with problems with higher AFib and with consequences had other risk factors associated with their risk of stroke. So this continues to be a really tough group to manage. I think that one question that we all have is do the, the, the new novel oral anticoagulant agents provide better long-term protection. As a topic for another important study that should be coming down the pipe pretty soon. Dr James de Lemos: And I'll just point out to our listeners that at the American heart association meeting in November, that late breaking trial will be presented called search AI cardio length that will evaluate extended monitoring creature fibrillation after surgery. And I think that will build off, of this theme that perhaps atrial fibrillation after cardiac surgery is a more important tissue than many of us considered. Let's move to the next paper, Tim, this is really right in your wheelhouse in terms of surgical. So specialization. And this is an interesting paper. I thought evaluating variation and congenital heart surgery outcomes across centers in the U.S. and this group really evaluated a large proportion of dissenters doing congenital heart surgery in the U S. Dr Timothy Gardner: Yeah, absolutely. And they made use of the STS database. They've got good data and it is a multi-institutional review group, really looking at how to optimize outcomes. And I think that, the assumption is that regionalization with more attention to high volume centers, especially for the most high risk say neonatal heart surgery is the way to go. But this study actually while demonstrating significant hospital variations also demonstrated that and reading their conclusion. Now a substantial portion of potential improvements that could be realized on a national scale are related to variability among lower risk patients. And this makes me think back to Dr John Kirkland, who was maybe the first one in our field to actually develop a checklist of important steps and management strategies during the surgical procedure in the early post-operative period. He worked with IBM on that. And I think that lesson here that I take away from it is that volume may be important, but not just for the high risk neonatal population, but for all congenital heart surgery patients. And it really is an important specialty. And there may be some opportunities for improvement just by standardizing sort of management of even the lower risk patients. This is one of several reports from this multi-institutional group that is focused on data from the STS database in congenital heart surgery. Good job demonstrating these variations in outcome. Dr James de Lemos: Yeah. And I think tremendously important, right? Because these lower risk in general procedures may be more like other procedures that cardiac surgeons do. And I think you make a great point that these systems based approaches to minimizing variation do seem to matter. And I wouldn't have thought that the, this is another one of the theme really here in the issue where we have a lot of studies that are challenging the way we thought about, common medical and surgical problems, really a fascinating piece. Let me take a moment here to introduce a new member of our team for the themed issue. Mike Fischbein, who's a surgeon scientist at Stanford, a practicing cardiac surgeon on the faculty there, but also runs a large and very successful basic science laboratory. And he has joined the surgical team for the themed issue to add his particular expertise in the evaluation of the basic science papers. Mike, welcome to the team. I think our readers and listeners will really benefit from having your perspective. And I'd like to have you now please talk about the basic science papers here in the issue. Dr Michael Fischbein: Thank you very much, James. It's really a pleasure to be part of a team. The paper that I'd like to discuss today is a feature of basic science paper entitled a Single cell Transcriptome Analysis Reveals Dynamic Cell Populations and Differential Gene Expression Patterns and Control and Aneurysm Human Aortic Tissue. This is from Scott LeMarie group from the Department of Surgery at Baylor College of Medicine. I think this study is very important. It's focusing on the ascending, thoracic aortic aneurysm, as you know, ACE and aortic aneurysms are the second most common aneurysm after abdominal aortic aneurysms. One of the risk factors of ascending aortic aneurysms is that as they grow, they can tear dissect or rupture. Both of which are life-threatening currently the only treatment option is prophylactic surgery. And this is really based on size criteria alone. Now, while over time, we've established that smooth muscle cell loss and exhale and matrix breakdown are important during this process, really the molecular mechanisms or pathophysiology is poorly understood. Therefore, limiting development is novel drug regimen, and this manuscript, the authors use single RNA sequencing to compare the aneurysm wall to normal control. Aorta is taken from transplant recipients. One of the benefits of single cell RNA sequencing is that allows one to identify the cellular components or heterogeneity within the aortic wall. And it also allows us to see the aneurysm relevant transcriptome changes in the major vascular cell types within the aorta. The authors identified 11 major cell types in the aorta, including a number of different smooth muscle cell subtypes and to Celia's cells, fibroblasts and inflammatory cells, including T-cells and macrophages. They found over 500 altered genes comparing the aortic wall to normal control. Mitochondrial dysfunction seemed to be altered in several gene types and they identified a transcripted factor ERG, which stands for Erythroblast Transformative, specific Related Genes to be important in maintaining the normal aortic wall function. And this was reduced specifically in smooth muscle cells, fibroblasts and endothelial cells. This is really an exciting target that may lead to drug development in the future. So thank you very much, James, for allowing me to participate in the group. And I think this will be an exciting paper for the readers. Dr James de Lemos: So Mike, thanks so much. Really appreciate your perspectives here. Another really interesting area that is quite forward-thinking Mark is this idea of 3D printing. Theotic roots and conduits. Tell us about this paper from Joe Woo’s group. Dr Marc Ruel: This is another great contribution from Joe's lab. Looking at the issue around bell spring, and many would call it bear hair because essentially they preserve and surgeons go to great pain and great strides to try to recreate if you will be normal slash nets, these geology and aortic root sinuses. And many of us, when we do this operation are taking great minutia and creating those. And there's a number of things that happen. And all of these techniques vary from the more approach of just taking a straight to, and essentially reinventing the native aortic valve and connecting the coronary buttons. So Joe's lab wanted to study this with regards to the translationally relevant outcome of opening velocity and closing gossip with regards to the RP pal. And they've done this 3D printed biomechanical study, aware they have used for signing LT. Val, that'd be put into these different configurations, some including Neil, if you will, some including what we call a bell solver type of breath and using the natives or signing as a control in the same 3d biomechanical model. And essentially the conclusions of the study, which is free, elegant be performed and Bree compelling from a data point of view is that a simpler appears to be better too many. I'm sure the investigators I'm sure what will be many readers price. These trade routes' configuration without Neil sinuses seem to have the lowest coast opening and closing velocity. So it would suggest that this may translate into longer term durability of the valve. Now, there are other reasons why someone, for instance, the one I do this operation, I like to use Valsalva graft. It's not because I so strongly believe that Neo sinus type should be there is because it also gives enhance an easier reach to the corny about adding a vertical followed by a horizontal type of pattern I find is a bit more reliable and it may not really matter what the opening and closing philosophies are because those files are not intrinsically abnormal. So they may last for many decades going forward. But nevertheless, I think this is a very important study and series of experiments, and we're very happy to include it in the theme this year. Dr Timothy Gardner: Yeah. And if I could just add the thing that I admire most about this study is that not just how they come up with this innovative, 3D printing way to model, but the team included mechanical engineers and bioengineers at Stanford, and that's adding real substantial science to what some surgeons have theorized about. So this is a small study, but the results are quite interesting. Let's talk now. Dr James de Lemos: It's about this remarkable Primer that we've had on critics, transplantation. This is something I wouldn't have imagined five years ago would be something we'd have even considered close enough to clinical application to publish in circulation. But what's different about this now and what should our readers look to in the future with this technique. Dr Timothy Gardner: This paper comes from a group at the Mass General [Hospital]. They've continued to work on Xenotransplantation as a possible solution to the need for new donor organs. And I think the most remarkable thing is after almost silence for 10 years, they have outlined the possibility much more realistically now of coming up with Xenotransplantation as a usable alternative, based on some very important basic science work that others have done in baboons and that they have model into additional experiments. This is what was a very informative article for me. And it's still some ground to cover, but they've really worked away at the science and think that they believe that they're nearing the point where they know transplantation or for cardiac replacement is a possibility. Again, amazed I sort of thought Xenotransplantation was an impossible dream 10 years ago. And here we are, perhaps at the point where it is more of a realistic possibility. Dr James de Lemos: Really remarkable. When you think about these technologic advances that are getting so much closer to clinical application. Well. Dr Timothy Gardner: Thank you both. I'd like to take just a moment to recognize Sara O'Brien in [the] Circulation Editorial Offices in Boston for her remarkable contributions yet again, to pulling this issue together and keeping Mark and Tim and Mike and myself on task to bring this issue home. And thank Mark Tim and Mike for pulling together. What I really believe is far and away, our finest issue. We're talking here in my opinion about multiple studies that changed the way we think about cardiovascular surgery and its complications, including atrial fibrillation that affects all of us in cardiovascular medicine. Dr James de Lemos: Marc, would you like to make some final comments as we wrap up today? Dr Marc Ruel: Absolutely. I could not agree more with your statement, James. I think this is a team effort and I want to be cognizant to the leadership of Circulation for as the premier cardiovascular journal, recognizing the importance of cardiovascular surgery in the field and dedicating an issue through what is best that's happened over the last academic year or so. We want this issue to continue for all time. And I think it's very well started and it's growing nicely. And thanks to the efforts of many, including of people on this call today. I hope that our readers will like it and I foresee it will garner interest even beyond the strict fields of cardiovascular surgery but to the entire cardiovascular community. Dr Greg Hundley: This program is copyright American Heart Association, 2020.

What does too much risk look like? In personal terms, it's a wobbly bridge or old gas station sushi. But for insurance, this is the possibility of a client's needs to cost more than their payment. Listen to Lockton Re CEO, Tim Gardner, as he talks about this age old conundrum and how his team is meeting it everyday. Learn the basics of reinsurance, while gaining a broader understanding of the latest in Lockton service.

7.19.20 Sermon - Tim Gardner by Grace Fellowship

Matt Stone & Tim Gardner are two DJ/Producers based in Southampton, UK. Today, they bring you their monthly instalment of Tech and Techno #tech #house #techno Follow YEAH on their socials below: Soundcloud: https://soundcloud.com/yeah_uk Instagram: https://www.instagram.com/yeah_uk/ Facebook: https://www.facebook.com/YEAH-1085414244807175/

Tim Gardner is the relatively new CEO of Lockton Re and has been tasked by the Lockton group with building up a challenger reinsurance broking operation of significant scale. The MMC-JLT and now Aon-Willis M&A activity has given this venture a significant timing boost and there is a palpable sense of a once in a generation opportunity for independents to stake their claim on a share of this lucrative global market. I quizzed Tim on every aspect of his strategy to make Lockton Re a credible new player in the reinsurance broking space. He was clear and forthright in all his answers, so I commend this episode to anyone looking to get an inside view of the current reinsurance intermediary landscape.

TIM Gardner Minshew's Off Season RV Roadtrip by 102.9 The Hog

Dr James de Lemos:        My name is James de Lemos. I'm the executive editor for Circulation and I'll be filling in today for Carolyn Lam and Greg Hundley, and delighted to host the podcast for the annual cardiac surgery themed issue. I'm joined today by Tim Gardner from the University of Pennsylvania who leads the surgical content in Circulation year-round, as well as by Dr Marc Ruel, who's the guest editor for this issue and the Chief of Cardiac Surgery at the University of Ottawa and has really led the development of this issue. Marc, Tim, welcome. Dr Timothy Gardner:      Thank you. Dr Marc Ruel:                    Thank you. Good afternoon. Dr James de Lemos:        And Marc, thanks for all you've done to bring this issue home again this year. It's really wonderful to see this thing develop. Why don't you start us off and tell us how this issue came together and what the purpose of this is? Why do we publish a specific issue focused on cardiac surgery? Dr Marc Ruel:                    We're really delighted that Circulation has taken the stance as the cardiovascular community's premier cardiovascular journal. I think as an important piece of this is the fact that cardiovascular surgery already has a resurgence intermediate with importance despite new percutaneous options and medical therapies available. There's more and more patients who find himself in need advance path if you will, of an advanced cardiovascular disease and surgery can be performed with safer and better outcomes constantly.                                                 So, I think this issue obviously aims to gather the very best of cardiovascular surgery, not only including cardiac surgery, but also there's actually one of the papers on peripheral vascular surgery. Dr James de Lemos:        We'll start Tim with you if you don't mind. I'd like to talk about two papers. One from Stanford that focuses on inter-facility transfer of Medicare patients with Type A dissection and then a research letter that studies hospital volume effects with abdominal aortic aneurysm surgery from Salvatore Scali and colleagues at the University of Florida. Can you walk our readers through these papers and lead the discussion on these? Dr Timothy Gardner:      The first paper focused on inter-facility transfer of Medicare recipients with Type A dissections. First off, underlines the fact that this is a very difficult, serious condition with mortality rates in this series there ranging between about 22 and 30%. And the purpose of the study was to analyze how these Medicare patients with acute aortic Type A aortic dissections are managed and whether the effect of high or low volume hospital experiences influences the mortality. As I think we might expect, patients who receive care at high volume aortic surgery centers have a lower mortality. Then the question is, what is the effect of transfer from a low volume or from a hospital without aortic surgery capabilities? What is the net effect there? The benefit of care and a high volume hospital is pretty clear. The mortality rate is significantly lower and the need to transfer or the actual fact of transfer does not increase the risk to the patient.                                                 It's an interesting challenge because we do know that patients with acute aortic dissection, if their repair or surgery is delayed, we'll have a predictable accumulating mortality. However, what this study shows is that the benefit of transfer and the importance of experience with this complicated aortic surgery. And it really brings up this very challenging issue of regionalization, of acute care or specialized care.                                                 We really struggle with this in so many aspects of surgical care, medical care in general, but especially procedural care. We realize that we need to be able to provide emergency care in many areas and we don't want to suggest that that smaller hospitals may not be able to care for patients with acute complex illnesses. But on the other hand, if transfer can be accomplished and if the availability of high volume experience can be achieved, that this is something that we really need to look at carefully. I think that this study brings that into pretty good view. Dr Marc Ruel:                    James, I think that Tim has already captured the essence of this paper. The results are impressive in this excellent series and the really carefully led analysis. This is an important paper and it's very thought provoking.                                                 There’re two clans among surgeons. Those that believe that every cardiac surgeon who was named as such should be able to perform safely aortic dissection repair and another client and somewhat sustained or supported by the data from this paper that says that this is a special expertise that should be or regionalized and put through centers of excellence. So this paper would support the latter theory. Dr James de Lemos:        The next paper, which was a research letter, sort of adds fuel to this fire of regionalization, doesn't it? At least insofar as we're talking about the more complex procedures. Dr Timothy Gardner:      Yes, this paper studies the hospital volume effects on surgery for abdominal aortic aneurysms, an even more common and somewhat less lethal, but very morbid condition. And this analysis of center volume for care of these patients is complicated even a little bit more because as we know, endovascular repair of abdominal aortic aneurysms is now the most common form of treatment.                                                 Interestingly, in looking at the outcomes in a variety of centers with varying volume procedural volumes, there was no difference in outcomes when endovascular repair was done, but there was inverse relationship between volume and outcomes after classical surgical repair. This really highlight a change that's occurring in vascular surgery where, with endovascular repair being done more commonly, surgeons are having less exposure unless experience with open repairs. This is particularly a challenge for training programs where you have a surgical resident or fellow for two years and he or she may experience relatively few open repairs.                                                 So, this again, the data seems to suggest that higher volume vascular surgery centers, where the numbers of open repairs are done, have better results and that this is not nearly as much, in fact, it wasn't an issue for endovascular treatments, but it again highlights the procedure of volume outcomes relationship. I think this is something we're going to have to deal with both in terms of optimizing patient care, even considering when we're training new or young avascular surgeons, they may have to move to different centers to ensure that they have the kind of exposure to classical surgical treatment for those complex patients who are not candidates for endovascular repair. Dr James de Lemos:        Let's change gears. We've been talking about two systems of care issues, but let's get back to the complicated patient themselves and talk about a paper Mark from Kato and Pellikka from Mayo Clinic, focusing on hemodynamic and prognostic impact of concomitant mitral stenosis in patients undergoing surgery or TAVR for Aortic Stenosis. Dr Marc Ruel:                    As you say, this is an intricate clinical problem that we not uncommonly meet when we provide care for patients who have severe aortic stenosis. These are not young patients. These patients in this particular series of 190 patients with severe aortic stenosis, they also had some significant degree of mitral stenosis. These are patients that had a mean age of 76 years. I think we've all encountered these patients estimations, so someone has severe aortic stenosis and has some form of calcific mitral stenosis. And indeed in this series, more often than not, the vast majority of those patients had calcific MS as opposed to a Rheumatic MS. So, a different type of pathology probably to what we see in the elderly patients coming in with some degree of inflow obstruction.                                                 So, the authors took their 190 patients, mostly from the Mayo clinic, but also from Tokyo, about five patients contributed from Japan, and matched in one to two with some controls who also had the same degree of severe aortic stenosis, the same age, same gender, same left ventricular ejection fraction, but didn't have mitral stenosis. And then compare their fate over a couple of years. Essentially, what the authors found is that in patients with severe MS, which was defined as a trans-mitral gradient of equal or higher than four millimeters of mercury, the midterm survival was decreased. The hazard of death was increased by about 90% or so. And there was also a classification, the sub classification based on the fate of the patient with regards to the echocardiographic findings, as to whether the patient truly had mitral stenosis at the time of presentation. So prior to the aortic valve replacement or whether the patient had pseudo-mitral stenosis. How the authors classify this, is those patients in whom the mitral valve area remained less than two centimeters square before and after aortic valve replacement were classified as having true mitral stenosis.                                                 The authors provide a number of maybe predictors, if you will, or correlates perhaps a more appropriately termed as such, of patients who would be generally believed as having true mitral stenosis. And these included, for instance, in the mitral valve area was less than 1.5 centimeters square at the time of presentation, if calcium involved at both the anterior and the posterior leaflet on echo. And there was also the concept of Andler excursion. So, basically the distance between the apex and the analyst of the mitral Valve, half of the patients had true mitral stenosis and the other half saw an increase in the mitral valve area above two centimeters squares after aortic valve replacement.                                                 I think still that we don't have an answer to the question as to whether the mitral valve should already be intervened upon in this series. It was an observational series, so there's no arm where the mitral valve was actually intervened on, and we know that often this intervention is not easy to do if it's by TAVR, there's not a lot we can do on the aortic valve and if it's at surgery, often these patients may have extensive mitral annular calcification, which is not an easy undertaking to fix at the time of surgery.                                                 So, whether these patients, even the ones with true MS are better served by just addressing the aortic valve or adding a mitral valve intervention in addition to the AS treatment still remains an unresolved or unanswered question. But I think this paper helps tremendously with regards to identifying patients who may have the true mitral stenosis concomitant problem at the time of presentation with a severe AS. Dr James de Lemos:        This was news for me actually. The high prevalence of pseudo MS in this context, I think many of us are very familiar with this with aortic stenosis and low output, but to see this in the context of serial valve lesions was really instructive for me. Tim, what are your thoughts? Dr Timothy Gardner:      I think this is a really important observation to remind ourselves of in this TAVR era. If you have the heart open and you're doing the aortic valve replacement and you notice this, you can get a picture of this severity of the mitral stenosis or the mitral valve involvement, but I think that in the TAVR era, this finding, this possibility of significant mitral stenosis related to a more severe aortic stenosis has to be accounted for and taken into account. Dr James de Lemos:        Excellent. The next paper I'd like to talk about is another original article from Shudo and Joe Wu at Stanford. Remarkable series really of almost a thousand heart-lung transplants that were done and reported in UNOS. Tim, can you walk us through this paper and its implications? Dr Timothy Gardner:      heart-lung transplantation was done first at Stanford and actually by one of my close colleagues. Bruce Reitz in 1981. It was a really an operation and in the tradition of the innovation there in transplant surgery at Stanford. The operation, primarily for patients with end stage lung and heart disease, was done reasonably often at adventuresome and well-experienced transplant centers in the eighties and nineties and it's used less often today because we found that even in patients with end stage lung disease and concomitant ventricular failure that many of those patients can be treated successfully with double lung transplantation.                                                 So, that has resulted in a decline in use of heart-lung block transplantation. The other problem is that as they mentioned in the article that a donor becomes available and you can get two or three patients treated by taking the individual lungs and the heart for three recipients rather than using the whole block for one. That's been another reason why it's been harder to get these heart-lung blocks. But for some patients with end stage heart disease and irretrievable lung disease, this is a great option. There's a few patients with end stage congenital heart disease who have developed irretrievable Eisenmenger's complex with severe pulmonary irreversible form of hypertension who are still candidates for this, but this analysis of the 30 year experience at Stanford and using the UNOS database as well is very interesting and shows the importance of donor selection as a really significant effector of outcomes. Dr James de Lemos:        Yeah, well I was also struck by the recipient factors too. It looks like selection in both directions is so important. The group that was remarkable to me was the markedly poor outcomes in the group that had heart-lung transplant after ECMO, that five times increase in mortality. That really struck a chord, particularly given what we're seeing now with ECMO accelerating somebody's status on wait lists. I don't know Mark or Tim, do you want to comment? Dr Timothy Gardner:      That's a very useful observation and where an individual patient ends up on the acuity list as a potential recipient with UNOS rules, it is ECMO support does get them to a higher level of urgency and yet, as is shown in this series, the morbidities or co-morbidities associated with a patient who requires ECMO support prior to transplantation is pretty consequential. And as you said, those were the features of the recipient, the degree of co-morbidities or co-morbidity complications also impact the outcome.                                                 We're still struggling to find the best way to deal with rescue patients both with mechanical support and with transplantation, organ transplantation, and even in the case of heart failure, with destination therapy with mechanical devices, we're still struggling in an area where the challenges are high, and the best practices are not always as well clarified as we would like. Dr Marc Ruel:                    And I would echo those concerns. I think the prohibitive results that we see after ECMO reflect the reality that there's not a lot of intermediate therapies available for patients who require heart-lung transplants. We have them for the heart now. We can move from ECMO and not go directly to an LVAD or to a transplant because we have implantable axial devices that can be put in percutaneously and basically can arrest the inflammatory response and the major cascade derangements that we see with ECMO.                                                 Unfortunately that is not available to replace both the heart and lungs, so I think there's still some medical advances, surgical advances that are necessary to bridge the gap because that gap right now is real and it's not a gap, it's a cliff. Dr James de Lemos:        Great discussion gentlemen. Let's talk next Marc, about a research letter that was a case series from Cleveland Clinic from Donnellan and Desai, focusing on a fairly large group of individuals that had received mediastinal radiation therapy previously and then underwent valve surgery for radiation-induced valve disease. Dr Marc Ruel:                    We were happy to receive this research letter from the Cleveland Clinic because clearly that institution, and maybe a few others around the world, have a special expertise in dealing with the uncommon, but very, very challenging issue of patients with the surgical radiation-induced mitral valve disease. And in fact, radiation-induced carditis. On average, these were patients who were seen about 17 years after their chest irradiation and I guess the main message that can be seen from this paper is that there's often multiple cardiac issues in those patients. They don't just have, for instance, a single valve, in this case the mitral valve, being affected. But the vast majority all tolled of around 80, 85% of patients required not only either another valve, but valve plus bypass or bypass surgery to be performed as well.                                                 So, there are clearly patients where there's been a lot of physical/irradiation damage, not only to the mitral valve, but to the entire heart. It's also, when you look at this series of these 146 patients, you can see that many had an increase in the right ventricular systolic pressure on echo and probably some degree of RV dysfunction as certainly we've seen episodically in our practices.                                                 So, hospital mortality outcomes are pretty good, but the results are humbling. 51% mortality at 2.8 years. And these patients were on average 60 years of age. So looking at U.S. life tables, when someone's 60 years, I've made it to 60, they usually have at least another 20 years on average to live. But these unfortunate patients, despite their cardiac operation performed, having been performed safely, have about an 18% death rate per year.                                                 I think the jury's still out as to which are clear indications to offer these patients surgeries with the humbling results that we see even at a center of excellence by the Cleveland Clinic. But I think this is a foray into a very difficult cardiac problem for which there was limited literature before and certainly that's something that's very relevant as we refer to very advanced cardiac surgical therapies for patients with advanced disease. Dr James de Lemos:        Mark, you're actually a coauthor on our State-of-the-Art piece, evaluating arterial grafts and CABG, reviewing after the publication of art and radial. What were the main conclusions from your review and interpretation? Dr Marc Ruel:                    Essentially, there's a discrepancy right now with regards to the use of multiple arterial grafting. The observational series have almost uniformly showed that patients who receive multiple arterial grafts live longer and do better, et cetera, but I think this has to be taken for what it is. There's an inherent indication bias or confounding by indication that goes into allocating that therapy to patients who are perceived to have the potential to do well in the long-term. There may also be an expertise bias at the institutions that provide this and those patients may be receiving better secondary medical therapy or guidelines directed medical therapy, etc. So, maybe a halo effect that comes into play.                                                 In counterpart, the randomized control trials of which the latest was the arterial revascularization trial. Now available with data at 10 years, have shown essentially very little difference which regards to the use of multiple arterial grafts on long-term outcomes. Even looking at cardiac-specific outcomes like myocardial infarction. Actually the more compelling data came from their Radial Alliance, also led by Mario Gaudino who is the author of this, State of the Art paper.                                                 The conclusion of the article is that we need a trial and we need to include the radial artery. The answer may not necessarily lie with the use of mammary arteries, but it may be that the radial artery is more user friendly and more robust. So the new ROMA trial has been designed with that in mind. Comparing one arterial graft versus as many arterial grafts, as long as it's more than one in the test group that the surgeon wants to use. And the surgeon, she or he can use the right internal thoracic artery or radial artery in order to complete the revascularization.                                                 That trial is ongoing. Enrollment is on track and hopefully should provide answers to this very relevant question. Dr James de Lemos:        You know that discussion about the limitations of clinical trials, Tim, I think leads really nicely into the frame of reference you received from Eugene Blackstone and Cleveland Clinic, doesn't it? Dr Timothy Gardner:      Yeah, and it was really an article worth everybody reading. It's a short opinion piece and he points out the fact that we really have competing standards for choosing therapy. Sort of the standard traditional evidence based medicine, evidence-based medical care versus precision medicine which focuses on individual patients risk factors and so on. It's sort of the average treatment effect that we may be able to demonstrate well in randomized clinical trials versus real world experience with various therapies based on the risk profile of the patient. It's a really excellent article and as many of us know Gene Blackstone is a very thoughtful student of statistics in surgery and this is, I think, an excellent article. I'm really grateful for his doing this opinion piece for us. Dr James de Lemos:        The last opinion piece we have is from Mike Farkouh in the group in Toronto. Can you just give the readers and listeners a bullet about what they might expect in that piece? Dr Marc Ruel:                    I think it's one of the remaining big questions, if you will, in myocardial revascularization as to what should be done with diabetic patients in multi-vessel coronary artery disease who have an acute coronary syndrome and require revascularization. A very well written piece and certainly that instructs what probably the next five years we'll see in terms of big study questions in coronary REVASC. Dr James de Lemos:        First I'd like to recognize Sarah O'Brien from the Circulation Editorial Office for her tremendous work for pulling this issue together. She's really the glue that brings this issue together every year and thank as well Marc, for your leadership again of this effort and Tim for your ongoing leadership at circulation with our cardiac content and vascular content as well as liaisoning with our surgical colleagues.                                                 Dr Marc, you get the last word. Can you please summarize the thoughts you'd like to leave our listeners with? Dr Marc Ruel:                    Thank you, James, for your generous comments and also for your support of cardiovascular surgery in and of the team issue. I think again, we have a fantastic issue this year and we really want to gather the very best of cardiovascular surgery and we want to get the highest impact papers. Circulation is home for the best data, the best outcome, say the most interesting answers to important clinical questions that are around cardiovascular surgery.                                                 There's definitely an editorial desire to help with the best of cardiovascular surgery science. And I think I want to again launch a call to cardiac surgical investigators and cardiovascular and surgical investigators in general to consider circulation as your home. Dr Timothy Gardner:      Yes. And if I could just add to that, not only are we interested in a surgery-themed issue annually that really highlights some of the best articles that we have to publish, but we also want some of the best surgery science during the course of the year. And just remind our surgeon colleagues that the particular advantage to having a paper published in circulation is the exposure of that study to a broad cardiovascular community. Not just surgeons, the predominant readership obviously of circulation, or cardiologists and other cardiovascular specialists. So that's the big advantage you get by having your best work published in circulation. We'd love to see more of it. Dr Carolyn Lam:                This program is copyright American Heart Association 2019.  

It's really tempting to use attendance as a gauge for success. Numbers matter, but they aren't the only thing that matters. Tim Gardner, high school pastor at Faith Church, is talking through some ways his team measures success. Even if you don't operate in a youth ministry context, we think you will find these helpful. Mentioned in this episode: EDA Move Leadership Conference! Full Transcript --> https://edamove.com/do-numbers-matter-8-ways-to-measure-success-in-ministry/

The unedited keynote of Tim Gardner, CEO of Riffyn at the un-conference, "Software in the Life Sciences - Development, Usability, Sustainability"

Tim Gardner, former Director of Organizational Effectiveness at Kimberly-Clark, shares his experience managing layoffs that resulted from change initiatives. Learn when you should tell people that a layoff is coming, how to keep up the morale of those who stay, and how to deal with the inevitable guilt as the change agent responsible.

Episode 4 is now online, with our guests Tim Gardner and his wife Lorie Gardner and his brother Stan Gardner – part of the Lula Drake Wine Parlour team. Lula Drake Wine Parlour in Columbia is a unique spot to enjoy natural wines. Tim Gardner fell for the grape while in grad school at UCLA....

James de Lemos:              Welcome everyone to Circulation on the Run my name is James de Lemos, I am the executive editor for Circulation based at UT Southwestern in Dallas and I will be filling in for Carolyn today as we discuss this year's surgery themed issue. I would like to welcome Dr Marc Ruel, the chairman of cardiac surgery at the University of Ottawa and a long-time editor of the Circulation of surgery themed issue, as well as Dr Tim Gardner, professor of cardiac surgery at The University of Pennsylvania and our leader at Circulation on the editor team for issues related to cardiac and vascular surgery. Marc and Tim, welcome and thanks for all your tremendous work in this issue. Dr Marc Ruel:                    Thanks James for having us. Dr Tim Gardner:               Thank you. Glad to be here. James de Lemos:              Why don't we start Marc with your thoughts on how this issue comes together, how it came to be, you picked the papers and how we ended up with this terrific issue. Dr Marc Ruel:                    It’s been a really important year for surgery and for this issue, as some of you may know the supplement which used to be the old designation of this issue has been changed to the surgery themed issue in about 2014 or so where the new Circulation leadership and what we tried to do every year is to bring the very best, not only of cardiovascular surgical science but also of clinical care and pearls around clinical and surgical care. So, I think this year we have had probably more than 60 submissions sent to us. Tim and I have looked at those very closely and you as well, James, we really wanted to get the feedback and the approach from not only cardiac surgeons but also from cardiologists and cardio vascular care specialist around those. We've tried to select the best of science and also some papers that we feel would be very useful with regards to providing new clinical pearls for surgeons and anyone in the circle of care around cardiovascular surgery. Dr Tim Gardner:               If I could just add, James, of course we have other papers that have been submitted by surgeons that are published or that deal with cardiac surgical or vascular surgical topics during the year, this particular issue is very much focused on cardiac surgery but throughout the year we have plenty of submissions of manuscripts by surgeons about surgery about surgically related topics and so on. So, I am actually kept quite busy reviewing and commenting and consulting on manuscript submissions of Circulation. There are plenty of papers over the course of the year that relate to surgical topics. James de Lemos:              Wonderful, I think you will see, as we talk about these papers, really that what Marc and Tim are talking about in terms of papers that are broadly relevant to cardiac surgeons and cardio vascular providers really rings true. Let’s walk through the issue, its set up like most of our issues begins with a couple of opinion pieces, a brief frame of reference, articles about important topics. Marc, do you want to talk about the Domanski paper, talk about revascularization for ischemic cardiomyopathy? Dr Marc Ruel:                    Absolutely, we've asked experts, namely Mike Farkouh and Micheal Domanski, to provide us where their thoughts regarding the optimal treatment on patients with LV dysfunction and severe coronary disease. What many of us would call an ischemic cardiomyopathy, which may be construed as a misnomer or as an accurate term, I will not debate on this today, but certainly it remains a very vexing clinical problem. I think we could all agree that the last niche where we still see very high in terms of treatment for coronary disease this is probably mortality and kind of an inability to provide for a tangible result.                                                 Once LV dysfunction has set in and the present of CAD the outcomes are poor, and it took years and literally almost ten years for the STICHES trials to show a benefit for surgical treatment. This is relatively all study now and it has to be put in context and I then that Mike and Mike are doing this extremely well in terms of providing the caveat, for instance, STICHES at its inception added had a 5% mortality rate around CABG, so we know that the modern outcome are probably better than that. It’s very difficult to actually decipher what sound be the mainstay of treatment for each challenging patient and I think the frame of reference provided by Dr Farkouh and Domanski is extremely useful in helping with that. James de Lemos:              Tim we have another frame of reference that is also provocative. Trying to make a case that we think about in patients with hypertrophic cardiomyopathy with obstruction early surgical procedures to relieve the obstruction. Do you want to tell the readers a little bit about this opinion piece and what your thoughts on it are? Dr Tim Gardner:               Sure James, this is a really nice frame of reference article from both doctors Martin and Barry Maron and then their European contributor Paolo Spirito and the point of their opinion paper is that the surgical art for managing this very difficult obstructive cardiomyopathy syndrome has reached the point where we really shouldn't wait until patients are in extremist or in class 3 or 4 status in term of syndromic problems and can consider earlier surgery for these patients. They make the very important point which I think we have to except is that for patients to do well with this operation they need to be in a center where there is experienced surgery and experienced surgeons, but the point is now that the state of the art for managing obstructive cardiomyopathy is as such that good result are obtained and patients should be offered this surgery when appropriate, but earlier, in order to avoid the challenges of end stage cardiomyopathy and difficulty relieving the obstruction, so this is a really important opinion piece. It’s great to see our cardiology colleagues who are experts in this field make this point based on well published data from centers like the Mayo Clinic. James de Lemos:              Moving now to the original articles, we've got 5 original articles, maybe Marc we can start with your thoughts on 2 articles related to revascularization, one in coronary disease and one identifying a really novel approach for treating type A aortic dissection with malperfusion. Dr Marc Ruel:                    I think that's well said James, the first of these original papers will be likely somewhat controversial. The first author is Dr Bo Yang and essentially it is a series from Michigan where they look at just shy of 600 patients with acute Type A Aortic Dissection, of whom 135 were identified to have malperfusion syndrome. Essentially defined by the authors as something slightly different than malperfusion per say but really malperfusion accompanied with evidence of necrosis in one of the organs. Their approach has been new and somewhat controversial in that they have brought these patients first to the interventional radiology suite in order to fenestrate in many cases or at least open the culprit artery or the culprit perfusion territory that leads to malperfusion syndrome and then depending on how the patient is doing they would then proceed to open repair as soon as 24 hours afterwards or they may wait longer in someone where there is no sign of improvement yet prior to moving to the ER, so they have found this has not only improved the results with regards to in hospital mortality after operative repair type A aortic dissection, but also to allow them to better discern or differentiate should I say between patients in whom malperfusion may lead to a futile situation and who then may be avoided from undergoing a very complex and difficult OR so would argue this is probably the first such large organized, well documented series of such an approach and I think it will lead to some head scratching, this being said it must be remembered that the goal standard for Type A aortic dissection is dealing with the intrapericardial aorta first and hoping that the perfusion gets better from this and everyone knows that the results of this approach are not fantastic. We know that even in the best centers, including the latest data from Germany such an approach has about a 20% mortality rate so clearly there are ways that we can improve with Type A aortic dissection and this paper may be a strike in the right direction. James de Lemos:              The other revascularization paper addresses that, I would say also a quite controversial topic which is how many atrial grafts are optimal in patients that are undergoing surgical revascularization? Dr Marc Ruel:                    This is a paper from Toronto where the Ontario ICES database was used and several papers actually dozens and dozens of papers have come out previously from this well established and well allocated database. Steve Fremes who is the senior author and one of his trainees, Dr Rocha and the team of authors got together and decided to look at the impact of 3 versus 2 arterial grafts in patients undergoing cabbage with regards to survival. They have very nice, very compelling follow up information and they basically carry out 2 exercises. First, they wanted to see if the 3,000 patients or so had 3 or more arterial grafts had a better outcome than the 8,000 patients or so who had 2 arterial grafts and frankly they found there was no significant difference with regards to survival at 8 years and freedom from MACCE at 8 years. However, when they compare those 9 or 8,000 patients or so who had 2 arterial grafts to the rest of 40,000 or so patients who had 1 arterial graft and completions with veins they found that again there was a survival benefit. This last finding is not new and its obviously subject to indication biases as well as expertise bias as we've seen in many of the observational perspectives studies around multiple arterial grafting. But I think the concept of comparing 2 versus 3 arterial grafts is very novel in surely in this paper is being addresses with very high scientific related from the numbers and the quality of the follow up that's been brought to the exercise. James de Lemos:              I've really been struggling, I love your thoughts and Tim, your thoughts on how to reconcile the data in space. I really am having a hard time getting my head around what seems to be conflicting data about the number of arterial grafts in what an optimal CABG looks like in 2018 with the evidence that we have. What are your thoughts on that question? Dr Tim Gardner:               I think that this supports the concept that 2 arterial grafts whenever possible for some patients, younger patients perhaps 3 but I think the important point is, multiple arterial grafting should be attempted and carried out whenever possible. I leave the is 3 better than 2 to some future study or future review that can be more precise about that. Dr Marc Ruel:                    This being said I think we don't view efficiently coronary surgery as being an area of expertise and many centers including very strong academic centers may not necessarily marry the concept that coronary surgery has to be something with the dedicated expertise. I think when we look at those observational perspectives series we see the effect of it may be the expertise bias, but it may be more than just 2 or 3 arterial grafts, they may be the whole wrapping of care that comes with it including optimizing beta blockers and managing diabetes etc. So, I think it may be more than purely conduits but definitely, as Tim said, 2 arterial grafts are probably better than just 1 and the jury is still out on whether 3 is better than 2. James de Lemos:              Excellent. Switching gears now Tim, an area that obviously you have tremendous experience and expertise we've got 2 innovative papers addressing surgery for individuals who have congenital heart disease. Can you update us on what we are publishing here? Dr Tim Gardner:               Sure, the one study focuses on the risks of pulmonary valve surgery in adult patients who underwent a correction of tetralogy of Fallot earlier in life. This is a growing population actually we refer to as young adult with congenital heart disease and in many centers they are more numerous in terms of the patients groups than infants because this group has been successfully treated early in life, but this particular group of patients, patients who have had tetralogy of Fallot repaired and end up with what the author calls right ventricular outflow disfunction generally regurgitation through the outflow tract pulmonary valve sometimes obstruction, these patients then face significant clinical challenges in death from heart failure, right ventricular failure or arrhythmias in their late 20's and 30's. We have been focusing now on the timing and the type of pulmonary valve replacement. Dr Tim Gardner:               Now there is catheter replacement options available, but when to do this and how to minimize risk is really the focus of this one paper that describes a four multi-center study looking at predictors of risk for these patients. Sort of a hypothesis generating paper, but it is an important study none the less, focusing on how to identify patients with right ventricular out flow tract dysfunction and who should have pulmonary valve replacement and when that should optimally be done. It a very good study. The other important study that we have is that the other age spectrum of neonates and this is a study that is based on a review of data from the pediatrics heart health information systems database, led by the group at the Children's Hospital Philadelphia. Looking at variations in pre-operative care and management of neonates with transposition of the great arteries. This was a little controversial actually when we reviewed it among the editors because the suggestion is that earlier surgery this would be in the first week of life and more perhaps aggressive use of atrial balloon septostomy seems to improve outcomes. This is a generally low risk population, the point of the paper is that these pretty good results can be improved by paying more attention to the timing of surgery and the appropriate use of balloon septostomy. It’s sort of a quality improvement perspective based on a large database and I think it’s a very nice study and undoubtedly creates additional attention to this particular area. James de Lemos:              Marc, our last original paper is a really novel issue engineering approach to creating vascular conduits, can you tell the readers briefly what happens to her in this paper? Dr Marc Ruel:                    Indeed. It’s a paper from Stanford, from Joe Woo’s lab and the first author is Daniel von Bornstädt. Essentially, as you say it’s a very innovative novel approach to try to recreate a bioengineered blood vessel. We surely know there's quite a need for such off the shelf conduits, not only in cardiac surgery but also in vascular and vascular surgery and even for things such as AV fistulas and others. It’s really interesting to see that this is what I would call transitional science at its best and surgeons have had an important role over, as you know, centuries in helping develop this and many discoveries have come from surgical labs, especially a few decades ago. In any case, what Joe and his team have performed is to try to use clinically applicable methods to derive and create a bioengineered blood vessel and they started first with human aortic smooth muscles cells and skin fibroblasts which are literally easy to get and they used those to constructs bi-level cell sheets, they then used a 22 gauge angiocath needle so that the sheets would be wrapped around this in order to lead to a tubular vessel construct. Then the next problem has been traditionally that those bioengineered vessels would burst out with atrial pressure. What Joe's team came up with is to use a commercially available adhesive, so a glue essentially, which is dermabond which typically we use after any form of surgery to keep the incision together and they put dermabond on the surface of this sheet wrapped around an angiocath needle to act as a temporary external scaffold. They then led this into a bioreactor and implanted it in series of 20 rats as a femoral artery interposition graft. The results were excellent. Essentially, patency was perfect and there was a full vascular maturity with all 3 layers of blood vessel that you would expect including an intima that had been formed as a result of the experiment. I think this is all very promising because none of the methods here are involving something that would have non-autologous issues, or you could easily see this being used with a patient’s own cells in order to achieve an autologous. I think this is obviously small vessels, there are 22-gauge needle is not a big conduit, you’re not going to bypass an LED with this, but I think it’s a start and it’s all done using transitional or clinically applicable methods. I guess the next step would be moving to a large animal model and certainly I think we should stay tuned to see where this leads us. James de Lemos:              I think that's exactly my thinking as well about that discussion and really leads us into some of the issues that come up in the review paper that you are a co-author on new strategies for surgical revascularization. I think this basic in translational science piece is designed to address some of the limitations of current revascularization and you all did a really beautiful job covering some new more clinically ready strategies in your papers. Can you just tell us very briefly what you all covered in that review paper? Dr Marc Ruel:                    Indeed, this is a paper that was kind of aiming at being a state of the art around CABG and rapidly the focus was reshaped towards kind of new strategies around surgical myocardial revascularization. Initially we have a section on OPCAB on this and that and minimizing the inflammatory effects of the pump and quickly it became apparent that the desire of Circulation and this themed issue was to focus it more on really what are the up and coming improvements around surgical coronary revascularization. This paper focuses on essentially 4 main areas. One is hybrid coronary revascularization, the second one is less invasive coronary surgery, the third one is the use of multiple arterial grafts to which we eluded a little earlier during this podcast and fourth is the use of an aortic coronary surgery, essentially meaning bypass surgery performed without any manipulation of the aorta. James de Lemos:              As we think about innovation in terms of conduits, the procedure itself, the other aspect that's covered in our last paper is can we make the procedure safer perhaps by modifying our use of anti-platelet therapies based on meshment of the platelet phenotype and Tim do you want to bring us home by just telling us a little bit about what we learned from Paul Gurbel and his group of platelet experts? Dr Tim Gardner:               Well we learnt a lot about platelet science and appropriately so Dr Gurbel is a well-recognized expert in platelet physiology or platelet management and this is a really quite a challenging area because many of our patents come to surgery especially for coronary surgery already on platelet inhibitor agents and what Dr Gurbel and his co-authors showed in this paper is that although there is somewhat limited data there can be and should be platelet function testing and with an appropriate understanding of platelet inhibition drugs that we may be able to limit the time between removal of these or discontinuation of these platelet inhibitor drugs and the necessary surgery which will improve outcomes and reduce bleeding in patients requiring urgent CABG surgery. It’s a very useful update and it is a good example of a paper that isn't written by surgeons, but really applies very much to the cardiac surgical treatment of coronary artery disease James de Lemos:              I really like the very practical tables and figures that lay out the potential tests that surgeons or anesthesiologists may consider for assessing this and even how one might implement. I would like to bring us to conclusion now, first I want to acknowledge, Sara O'Brien at the Circulation office for her amazing work together with Marc and Tim pulling this issue together, making sure that we have a consistent high quality issue with wonderful figures and tables and it really came together beautifully and thank you both for joining me today and the podcast I think it’s obvious that we've got an issue that all of you listen to this podcast need to actually pull out the issue or download it because we have a co-host of wonderful papers to look at and cardiac surgery thriving at Circulation. As we've talked about this is the tip of the iceberg, this themed issue, we've got great content coming, issue after issue. We are already open for business next year’s issue, so please send us your best cardiac surgery research. Please pay attention to these important papers and apply them in your practice because I think many of them are already directly applicable. Marc given your leadership role in the issue do you want to bring us home and make any concluding remarks? Dr Marc Ruel:                    I think your points are very well taken James and I want to reintegrate that if I speak on behalf of the cardiovascular surgical community, we are very thankful to the leadership with Circulation. James, Joe, Tim and many others and obviously the support from the staff in clearly establishing that cardiovascular surgery is a very important therapeutic mentality and the overall scope in the broad scope of cardiovascular therapeutics. Dr Carolyn Lam:                You've been listening to Circulation on the Run. Don't forget to tune in again next week.  

Dr Carolyn Lam:                Welcome to "Circulation On The Run," your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr. Carolyn Lam, Associate Editor, from the National Heart Center, and Duke National University of Singapore. Our featured paper today is so important for cardiac surgeons and their patients. It answers a question of whether targeting a higher versus a lower blood pressure during cardiopulmonary bypass helps to prevent cerebral injury. Curious? Well, more soon right after these summaries.                                                 In the first original paper this week, MicroRNA-22 is shown to be a novel mediator of vascular smooth muscle cell, phenotypic modulation, and neointima formation. Co-first authors, Drs. Yang and Chen, co-corresponding authors, Dr. Zhang from Zhejiang University and Dr. Xiao from Queen Mary University of London and their colleagues used wire injury mouse models to show that MicroRNA-22 controls vascular smooth muscle cell phenotype and injury-induced arterial remodeling by modulating multiple target genes, including methyl-CpG-binding protein 2, histone deacetylase 4, and ecotropic virus integration site 1 protein homolog.                                                 The authors observed that MicroRNA-22 expression was suppressed in human femoral arteries with atherosclerotic plaques, and that there was an inverse relationship between MicroRNA-22 and its target genes in healthy and diseased arteries. Furthermore, local delivery of MicroRNA-2 in the injured arteries prevented adverse arterial remodeling, thus suggesting that site-specific delivery of MicroRNA-22 mimics may be a potential therapy for in-stent restenosis.                                                 The next paper adds to our understanding of the pathobiology of pulmonary hypertension related to left-sided heart failure and importantly adds histomorphometric evidence from human lung specimens at autopsy or surgery.                                                 First author Dr. Fayyaz, corresponding author Dr. Redfield, and colleagues from the Mayo Clinic studied patients with heart failure with preserved or reduced ejection fraction and pulmonary hypertension and compared these to normal controls, as well as patients with primary pulmonary veno-occlusive disease.                                                 They found that patients with heart failure and pulmonary hypertension had global pulmonary vascular remodeling with thickening of the media and intima in arteries and thickening of the intima in veins and small pulmonary vessels compared to normal control subjects.                                                 This venous and small-vessel intimal thickening was more severe than the arterial intimal thickening in heart failure with a pattern that was similar to patients with pulmonary veno-occlusive disease. In fact, the severity of pulmonary hypertension correlated most strongly with venous and small vessel remodeling rather than arterial remodeling.                                                 These findings expand our understanding of the pathobiology of pulmonary hypertension in heart failure. It also suggests that pulmonary venous remodeling in heart failure may predispose to worsening alveolar edema with pulmonary vasodilators as in primary pulmonary veno-occlusive diseases.                                                 Are there sex and race differences in the lifetime risk of HFpEF versus HFrEF? First author Dr. Pandey, corresponding author Dr. Berry from UT Southwestern Medical Center, and their colleagues used participant level data from two large respective cohort studies, the Cardiovascular Health Study, and the Multi-Ethnic Study of Atherosclerosis to determine remaining lifetime risk estimates for heart failure with preserved and reduced ejection fraction at different index ages.                                                 They found that compared to women, men have a higher lifetime risk of HFrEF, heart failure reduced ejection fraction with a similar lifetime risk of HFpEF, or heart failure preserved ejection fraction. Compared with blacks, non-blacks have a similar lifetime risk of developing HFrEF but a higher risk of HFpEF.                                                 Lifetime risks of HFpEF and HFrEF were similar and substantially higher in those with versus without antecedent myocardial infarction.                                                 In summary, these findings provide novel insights on sex and race differences in the lifetime risks of HFpEF and HFrEF, and may help health policymakers in appropriate resource allocation for targeting HFpEF and HFrEF specific preventive therapies at the at-risk population.                                                 What are evidence-based blood pressure targets during pediatric cardiopulmonary resuscitation? Well, first and corresponding author Dr. Berg from Children's Hospital of Philadelphia and his colleagues studied a multi-center population of children with invasive arterial blood pressure monitoring during in-hospital ICU cardiac arrest, and the Collaborative Pediatric Critical Care Research Network Intensive Care Units, between 2013 and 2016.                                                 They found that a mean diastolic blood pressure greater or equal to 25 millimeters of mercury during cardiopulmonary resuscitation in infants, and greater or equal to 30 millimeters of mercury in children 1 year old or greater, was associated with a 70% greater likelihood of survival to hospital discharge, and a 60% higher likelihood of survival with a favorable neurologic outcome.                                                 On the other hand, survival rates were markedly lower with mean diastolic pressures less than 20 in infants and less than 25 in children 1 year or older. Thus, clinicians should consider targeting diastolic blood pressure of 25 or greater in infants, and 30 or greater in children 1 year old or older during cardiopulmonary resuscitation when invasive arterial blood pressure is monitored.                                                 That wraps up our summaries for this week. Now for our featured discussion.                                                 Does a higher versus a lower blood pressure target during cardiopulmonary bypass surgery reduce the risk of cerebral injury? Well, the feature paper today provides some answers, and we have the first and corresponding author, Dr. Anne Vedel from University of Copenhagen with us today, as well as our associate editor, Dr. Timothy Gardner, who's a cardiac surgeon from University of Pennsylvania.                                                 Thank you so much for being with us today and this was a terrific trial, a very difficult trial to carry out. Could you please tell us a bit more about it? Dr Anne Vedel:                 Cerebral injury is an important complication after cardiac surgery with the use of cardiopulmonary bypass. Up to half of our patients suffer these perioperative silent strokes. Therefore, in Copenhagen we conducted a trial investigating the importance of two distinct blood pressure levels during cardiopulmonary bypass. Now, on this subject of optimal perfusion strategy during bypass, there are many opinions, but also a stunning lack of convincing evidence, for instance, when it comes to blood pressure management.                                                 Now, the question is whether normal physiological principles, such as cerebral autoregulation therapy, whether they apply during bypass, or if perfusion pressure indeed does play a less important role when blood flow is mechanically provided in an uncomplicated and sufficient way by the heart and lung machine.                                                 So, in a patient on the assessor-blinded randomized trial, we allocated patients to a higher or a lower MAP target, 70 to 80, or 40 to 50 millimeters of mercury, respectively, by titrating intravenous norepinephrine during bypass.                                                 Pump flow levels were set at 2.4 liters per minute per square meter of body surface, and our primary outcome was the total volume of new ischemic cerebral lesions, expressed as a baseline MRI, and opposed to the difference between the baseline MRI and the postop MRI on day three to six. Secondary outcomes were a number of new ischemic lesions and newer psychological test evaluations.                                                 Now among the 197 patients enrolled who were scheduled for coronary artery bypass, or heart valve repair surgery, or a combination of both, we found that 53% of patients in the low target group as opposed to 56 in the high target group had new cerebral lesions on their postop cerebral MRI.                                                 The primary outcome of volume of new cerebral lesions was comparable between groups, and so was the total number of newer lesions. No significant difference was observed in stroke rates in frequencies of postoperative cognitive dysfunction, or in severe adverse event rate.                                                 Therefore, we concluded that among patients undergoing on-pump cardiac surgery, targeting higher versus a lower mean arterial pressure did not seem to affect the volume or number of new infarcts. Dr Carolyn Lam:                Wow, thank you so much, Anne. Tim, you think about these issues a lot more than I do as a non-surgeon. Could you tell me what your insights were? Dr Tim Gardner:                You know, it's a very difficult study to do a randomized control trial in this environment, and they're really to be congratulated for doing it. As Anne acknowledges, this is not an area where randomized trials are very frequent.                                                 The first thing about the trial, I think, is a growing awareness among all of us that there seems to be a lot of imaging evidence of what we call injury or changes based on diffusion-weighted imaging in patients after cardiopulmonary bypass. This is not the first study that shows that.                                                 But the question is are these incidental, trivial lesions? I'd have to, again, ask Anne to clarify how many of the patients in either group, what percentage had what we would consider evidence of overt strokes? Dr Anne Vedel:                 Well, overt strokes, as opposed to silent strokes, 1 patient in the lower target group had stroke and 6 patients in the high target group, which corresponds to 1 as opposed to 7%. Dr Tim Gardner:                That was not quite statistically significant difference but headed in that direction with the assumption that if you have a larger sample size there might be, in fact, some association with overt stroke using the high target vasopressor approach, is that right? Dr Anne Vedel:                 We can only speculate. But as you do, yes, I agree. Dr Tim Gardner:                To go back to the original question, the significance of these, well, you were referring to as silent strokes. Can you comment on the clinical significance there? We hear of silent heart attack. What is a silent stroke and what are the implications of that long term for patients? Dr Anne Vedel:                 In other fields of research on the silent strokes, it's been shown that they correlate to both frequency of postoperative cognitive dysfunction and also later development of mild cognitive impairment and dementia. But these kinds of results, there isn't enough research in the field of cardiac study for us to say the same. But those are the implications from other research fields. Dr Tim Gardner:                But you can understand from the perspective of a cardiac surgeon, and this concern has been expressed and talked about in the literature for 20 years or more, the possibility that even what seems to be, with no injury apparent and no overt stroke, there may be some neurological consequence to cardiopulmonary bypass.                                                 So just to move on from that because I agree that we just don't have any reliable information that these silent strokes result in late or permanent injury, I think again the finding that manipulating the blood pressure, which seems to be intuitively beneficial in patients, especially elder patients, did not, in fact, show any benefit and, in fact, may have been associated with a slight increase in overt stroke. Is that a fair conclusion from your study? A summary of your study? Dr Anne Vedel:                 I would say it is a fair conclusion, and surprisingly so. The question is whether it is the blood pressure or the means that we apply to have this increase in blood pressure that is the point of interest here. Dr Tim Gardner:                You mean whether, in fact, using the norepinephrine, the vasoconstrictor, to increase the blood pressure whether that itself, it certainly didn't benefit, it may have been a problem. Dr Anne Vedel:                 Exactly. That's what I speculate might be the case. But I also think it's fair to say at this point that this is somewhat artificial physiological scenario, the cardiopulmonary bypass. Dr Tim Gardner:                I agree with that, that you're controlling blood flow and the patient is exposed to a lower hemoglobin and oxygen-carrying capacity and so on. But I think what struck me about your findings, or strikes me about your findings, is what appears to be in many of the patients, the low target patients, pretty effective autoregulation of the cerebral circulation, despite the artificiality of cardiopulmonary bypass.                                                 I think that's, again, something that has been not well known or well accepted by many people, thinking that if you lower body temperature, you lower hemoglobin, autoregulation may not be enough to maintain good cerebral perfusion. It looks like this study shows that in these patients, autoregulation worked fine. Is that fair? Dr Anne Vedel:                 Yes. Or sufficient blood flow was delivered. All in all, what's new in our study, I think, is that hypertension per se shouldn't necessarily be considered a proxy for hyperperfusion during bypass. Dr Tim Gardner:                Yeah, that's a very good qualification. So none of your patients, despite being in their mid to late 60s had evidence of carotid artery disease or whatever? Those patients were excluded from the trial, is that right? Dr Anne Vedel:                 No, that's not correct. We didn't screen for carotid artery disease because we don't routinely do that in our institution. As we describe in our discussion, we included quite a heterogeneous study sample by enrolling the patients that came to us. We didn't screen and we didn't exclude these patients that you mention. Dr Tim Gardner:                Do you know how does your group handle a patient that is known to have carotid artery disease, comes in with a known either prior endarterectomy or established disease? Do those patients, are they treated any differently either as a result of the study or just in general?                                                 Because that is a targeted group of patients, at least in my own experience, that we would be more concerned about allowing autoregulation to be the determinant, feeling that if there is a fixed stenosis in the carotid artery that we might need to increase the mean arterial pressure. Dr Anne Vedel:                 I can certainly understand your point and, of course, it is a concern in our center, as well. But having said that, there were no patients in the PPCI trial that came to us with a history of carotid artery disease, so it wasn't a concern for us in this study. Dr Tim Gardner:                That would be one point that I would make that we probably should pay attention to patients who do come for surgery and have known significant obstructive extracranial disease, but I understand that you didn't specifically have those patients or were aware of those patients.                                                 I think that this is a very useful study for us concerned about the possibility of inducing cerebral injury with cardiopulmonary bypass. To some people it's sort of counterintuitive that increasing perfusion pressure didn't improve the tolerance of patients to cardiopulmonary bypass but that's why you did the study. I think it's a very notable and important report that's going to be in circulation.                                                 The significance of these "silent infarcts" is merely something that we have to sort of sort out. I know you said that silent infarcts, as I agree, are associated with or presumed to be predictive of later cognitive dysfunction, dementia and so on. It really is a concerning message if that's the main message that comes out of these imaging studies. Because these are patients that, obviously, didn't have heart surgery for no reason, there was obviously a compelling indication for patients to have it.                                                 You would hate to re-ignite this concern as we had in and around year 2000 when the group at Duke was talking about writing about patients who had cognitive decline after cardiac surgery, were going to end up being demented five or 10 years down the line, so, that's from the perspective of a cardiac surgeon. Let's stick with the evidence but let's follow-up and see how predictive these silent infarcts are and what the consequences are long term. Do you think that's fair, Anne? Am I making a fair statement? Dr Anne Vedel:                 I absolutely do think it's fair. And for a cardiac surgeon as yourself, I would find it very interesting to see that these kind of studies are also conducted in TAVR patients where you have sometimes a 200% incidence of these silent strokes.                                                 I mean you have a good taste as a cardiac surgeon if you only see them in 50% of your patients, understand me correctly, but I don't necessarily think that this high incidence, it's high, yes, but compared to other patient groups, such as TAVR patients, it's not necessarily that bad. Dr Tim Gardner:                Right. Anne, I don't know whether you've seen the editorial that's going to accompany your paper, but it's very good. It's very supportive of your study and has some good comments. You'll be pleased with the editorial, I believe, if you haven't seen it. Dr Anne Vedel:                 Thank you very much. I'm happy to hear that. I know we do things a bit controversially over here in Copenhagen, compared to many centers in the U.S. Dr Tim Gardner:                That is not what the editorialists think. An anesthesiologist from Stanford and a neurologist from Penn, they have a very good commentary on your study and the whole field, so you'll be pleased. Anne Vedel:                       I'm very happy to hear that. Thank you. Carolyn Lam:      Well, listeners, I'm sure you learned a lot. Thank you for joining us today, and don't forget to tune in again next week.

This show is a balls to the wall all out man show. Since regular host Sarah Williams is honeymooning and Keirsten Greggs is taking a break, I am stepping in as host with special guest Tim Gardner, Justin Harris and very special guest Victorio Milian, Listen up as we talk about sensitive issues that men must deal with at work like the dress code policy, sexual harrassment, and the Wussification of the workforce. We will also touch on the shooting and violence in our country and we will remember Muhammed Ali.Other topics include - PMS as a benefit, Men demanding more time off, the interns who banded together to ditch the professional dress code, hear how it turned out for them.Join us as we let loose. 

This show is a balls to the wall all out man show. Since regular host Sarah Williams is honeymooning and Keirsten Greggs is taking a break, I am stepping in as host with special guest Tim Gardner, Justin Harris and very special guest Victorio Milian, Listen up as we talk about sensitive issues that men must deal with at work like the dress code policy, sexual harrassment, and the Wussification of the workforce. We will also touch on the shooting and violence in our country and we will remember Muhammed Ali.Other topics include - PMS as a benefit, Men demanding more time off, the interns who banded together to ditch the professional dress code, hear how it turned out for them.Join us as we let loose. 

Today’s guest is Tim Gardner. Tim's wife Emily contacted Anne and asked if she could do a little literary matchmaking for Tim. They'd both realized that a little reading break at the end of the work day made for a smoother transition between work and home, but he wasn't sure what to read next. They came to the right place. Click over to the podcast website for the full list of titles discussed in this episode, and leave us a comment to let us know what YOU think Tim should read next!Connect with Anne: Blog | Twitter | Facebook | Instagram | WSIRN Instagram

Purple Heart Homes helps wounded veterans purchase, manage, & adapt homes to aid them in their lives after service. A group of High Point University students made an amazing discovery while stargazing. Tim Gardner is makes world renowned banjos with traditional techniques. Eustace Conway promotes NC heritage & simple living on his Turtle Island Preserve.

PIC Takeover with Justin Harris @unlikelyHRguy, Tim Gardner @timjgardner & Kyle Jones @kylemj6977 @DriveThruHR      DriveThruHR was designed to be a captivating and easy-to-digest lunch discourse that covers topics relevant to HR professionals.  Each 30-minute episode features a guest speaker who shares her or his knowledge and experience in human resources. Our hosts and special guest cover a wealth of topics, including HR Technology, Recruiting, Talent Management, Leadership, Organizational Culture and Strategic HR, every day at 12:00 pm Central Time.  The radio program is hosted by @williamtincup, @Thehrbuddy@TheOneCrystal & @MikeVanDervort..  The #1 HR show, with amazing HR conversations and follow us on the twitters at  @drivethruhr and #dthr. http://www.facebook.com/drivethruhr http://instagram.com/drivethruhr  

Join Tim Gardner as he talks sports and talks gibberish. 

We welcome super promoter Tim Gardner to the show for details on his upcoming IFBB Pro Tampa Pro and Ryan Walters (coached by Jose Raymond) chimes in to report what happen at USA’s. … Read more about this episode...

In this episode we recap the all the big winner’s of the first annual Chicago Pro promoted by my good buddy Tim Gardner. We are also joined by IFBB Pro Don Long to discuss his latest client as he preps him for the Heavyweight class for the upcoming USA’s- Tony Ferriera. … Read more about this episode...

@TimJGardner .....Tim Gardner visits with Bryan Wempen and William Tincup about HR and whatever else keeps him up at night with Corporate America. DriveThruHR more than not talks about Human Resources with HR professionals every day at lunch time for 30 minutes. Give us a listen at (347) 996-5600 and share your thoughts on twitter using #dthr or @drivethruhr. We talk HR along with lots of clever bantor and thoughts every day at 12 Noon Central time at "DTHR".

Co-Hosts, Bryan Wempen @bryanwempen and William Tincup @williamtincup will be talking about real Human Resources (organic HR) with HR practitioners' every single day. Give us a call with your thoughts at (347) 996-5600. The window opens at 12 Noon at "DTHR". We always start out with bite-size business sliders from the top stories world-wide. Weigh in with your thoughts, we care a whole lot sotweet, call or message us with your comments at #dthr or directly to @drivethruHR

Co-Hosts, Bryan Wempen @bryanwempen and William Tincup @williamtincup will be talking about real Human Resources (organic HR) with HR practitioners' every single day. Give us a call with your thoughts at (347) 996-5600. The window opens at 12 Noon at "DTHR". We always start out with bite-size business sliders from the top stories world-wide. Weigh in with your thoughts, we care a whole lot so tweet, call or message us with your comments at #dthr or directly to @drivethruHR