20 Episode results for "School Of Medicine"
Reliance on single-use supplies can leave hospitals vulnerable to shortages
"I'm dr anthony leiserowitz and this is climate connections during the coronavirus pandemic. Many hospitals have struggled with dangerous shortages of personal protective equipment. But joe sherman of the yale school of medicine and public health says the pandemic is not the only reason. Medical supplies can run short. Extreme weather can disrupt manufacturing or transportation and so essentially as an interruption of the supply chain for example hurricane affected production facilities that make medical equipment in puerto rico causing nationwide shortages of critical supplies. Like iv bags. So sherman says it's important to make hospitals more resilient to these interruptions for example by relying less on single use medical supplies there has been this enormous trend toward everything being disposable from simple devices like a blood pressure cuff or even a patient's pillow to very complex surgical devices. Sometimes single use products are necessary for safety. But sherman says many products can be designed for sterilization and reuse. She says that could reduce hospitals reliance on supply chains that are vulnerable to the effects of climate change or a global pandemic. Climate connections is produced by the center for environmental communication to hear more stories like this visit climate. Action's dot org.
Researchers discover how coronavirus affects brain function
"As washington state prepares to receive more covert vaccine doses from both pfizer and now medusa scientists in the north west of solved. A mystery connected to some of the diseases more. Puzzling symptoms like lasting brain fog and fatigue just burns reports researchers from the university of washington. School of medicine and oregon health and science university used lab mice to test if a key protein in corona virus can cross from the bloodstream into the brain itself. Uw medicines bill banks says there's a barrier that usually protects the brain but every once in a while there's something like a bacteria or parasites that figures out how to trick. Its way into darier. Get in banks says if the protein can get in it probably can cause problems like inflammation and it means. It's likely the whole virus can get into the brain as well. This new understanding of how coronavirus virus works provides insight into possible treatments for the disease. I'm just burns reporting.
Chewing Gum Myth
"Debunking sticky myth. I'm Bob Hershon in this is science update. Listener, Michelle Simms of Alexandria. Virginia says her, parents warned her never to swallow chewing gum because it wouldn't be digested for seven years. We ask Dr Aaron Carroll a health services researcher at the Indiana University school of medicine. If this is true, there's no to the idea that swallowed gum will stand your stomach for seven years. The body is incredibly good at getting things from one end to the other. Even things that aren't adjustable Carroll says gun will normally pass through the system in about twenty four hours. However, he warns swallowing very large pieces of gum could cause emergency blockage. And if you have a science question, give us a call. One eight hundred y is at that's one eight hundred nine, four, nine forty-seven forty-eight. If we answer your question on the show will send you a science update mug. I'm Bob Hershon, triple AS science society.
COVID-19 and Immune Symptoms in Kids
"Welcome back to the healthcare triage podcast today. We're going to be talking to Dr. Jim would from Indiana. University School of Medicine. He's a pediatric infectious disease doctor. We're GONNA be talking about covert and some of the immune syndromes. We've seen in children who seem to have had it. This healthcare podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient CARE I. I School of Medicine is leading Indiana University's burst grand challenge, the precision health initiative with bold goals to cure multiple myeloma, triple, negative breast, cancer and charts coma, and prevent type, two diabetes and Alzheimer's Disease Jim Welcome. Thanks for for having me. So why don't you start by telling us a little bit about yourself? How did you get to be what you are? What do you do? Yeah, so I got interested in pediatric infectious disease, probably when I was a medical student, but Never really knew path. I was going to go down as I went through residency. I found all the cool cases happen to be kids that had infections at least to me, so I had two mentors in residency, and then decided to pursue a fellowship in infectious disease. I went to Vanderbilt University in had. Really good experience. There was some great mentors and just got really interested in both clinical aspects of it as well as the research. Aspects of infectious disease so when you talk about the research aspects. What specifically are you interested in? Yeah, so My interest is in kids that have invasive bacterial infections. That's kind of fancy words for kids that come in with bad kind of common infections of their bones and joints, pneumonia things like that caused by bacteria that often are treated. As. Outpatients in clinics, but sometimes get bad enough where they have to come into the hospital in us. Can you give us a little more information about that? Can you talk about like when you talk about research in that area? What specifically do you want to study that others have not before? Yeah, so things that I'm interested in our standing. Why certain kids get really severe disease, and why other kids don't get much of a have a pretty mild course of disease, and so one of the things that's really interesting to me is is figuring out. kind of markers and kind of clinical signs of which kids are at risk for really bad disease, and then using those markers and signs as doctors and clinicians to help target therapies and improve. Improve the way that kids are treated so one of the reasons we wanted to talk to you. Today was because everyone in the world is focused on the current pandemic and with a Vid, and although this doesn't seem to be affecting kids as much it's still is affecting kids, but before even get into that. Let's just start with in your experience. has this been a disease that seems to be infecting kids? Kids because you turn on the news and some people are panicked. Some people are not what's really going on. I think that you're right the level of panic in the level of kind of anxiety around this is super high and I think what we're seeing is that in general kids from the infection of covid in corona virus are really mildly affected in general, there most kids don't seem to be. Be Getting it in big numbers, and if they do most of them, handle it pretty well. Either have no symptoms at all. Our mild infection that said we have seen you know a handful of kids that have come into the hospital in Ben. Pretty Sick and certainly we've. We've had to take care of those kids as well, but overall kind of big picture. Kids seem to be less affected than adults do. So when they come in they, they seem to be very sick. What are they meeting with Cova? They're they're needing. Respiratory support so that they're needing oxygen. They're needing help breathing. The majority of kids are coming in just having a lot of issues with with respiratory things, especially chest pain in trouble breathing. Are these otherwise healthy kids are the kids who seem to have other come. kind of seeing a little bit of both for the most part. They're healthy kids. The ones that we've seen in particular are pretty healthy teenagers. In general, a Kinda you know anywhere from ten to a eighteen nineteen years of age but really we kind of a mixed bag of kids are pretty healthy, otherwise as well as some that have a little bit more health issues. Do you have any sense of whether? It's that kids are not being infected as much as adults are. Is it just that they're most of them? Don't even notice or just her handling. It well yeah. I. Think that that is a really good question in a bit of a hot topic right now. I think that we don't really know exactly. Why some kids are getting? Getting severe not an end, and why kids as opposed to adult I mean certainly when we know what other respiratory infections young young kids, a kind of the extremes of ages usually are most affected. That doesn't seem to be the case with this. It seems like in general. Kids don't tend to build quite as much of this big inflammatory response that we're seeing an adults. So I think that's interesting. I'm not sure and correct me if I'm wrong, but I'm not sure that everybody understands that it's not just getting the virus that is dangerous. It's in many ways. The body's response can sometimes be so severe and trying to combat the virus that the immune response can actually become dangerous. Yeah, that's definitely true, and that's something not necessarily. NECESSARILY UNIQUE TO CORONA VIRUS although We're really seeing quite a bit in this. where the actual infection itself can be, it can be severe, but more than anything. oftentimes, it's that it's that revved up immune system and inflammation that the body makes that really affects the rest of the body in a particular with this disease. It seems to really affect the lungs in. People that are severely affected. One of the things that's been going around recently is that people are becoming more and more concerned about an immune response issue that seems to be affecting children were seeing in New York, and before we even get into that people are likening this to a Kawasaki is like syndrome, so bring to that? Can you talk a bit about what Kawasaki Syndrome is shore? Yeah, so Kawasaki. Kawasaki Disease and I should have probably mentioned. This earlier is another area of interest of mine in terms of treatment of kids with sake season. We have studies going on at you. Look in Riley. Looking at which treatments are most effective for these kids, but in general Kawasaki Disease is something that was described I in Japan quite a while ago by Dr Kawasaki and it's. For lack of a better term, it's a inflammatory disease or syndrome that seems to affect kids mostly school age. That's triggered by something. We don't know exactly what triggers this inflammation response. There's been lots of studies and lots of hypotheses about what the actual trigger is, but no one's actually found the one trigger. If there is one, there's likely multiple, but it seems like in kids that are genetically. Genetically Susceptible to this syndrome. There's a trigger in the environment which Kinda sets off a cascade of inflammation in their body. The way that we see these kids as they come in with prolonged fever so fever for at least five days they come in with rash. oftentimes readiness in their is can jump device they'll have hands and feet are swollen, cracked in swollen lips, and sometimes they'll have. have big lymph nodes. It's Kinda diagnosis that we have to make just putting all the symptoms and signs together. It's this kind of inflammatory syndrome that kids get. It really seems to affect their blood vessels a good deal the things we love most about and worry most about the blood vessels around the heart. The coronary arteries as we know that those can be severely affected in Kawasaki. Kawasaki Disease So it's this vascular in just big inflammatory response that we seen Kawasaki Disease What Causes Nobody knows there's a lot of work that's been ongoing for a while looking to take on figure that, but it seems like most likely kids that have a genetic predisposition to this get triggered by something and whatever that something isn't. It's probably multiple. Something's they they kind of go down this. This pathway and how to retrieve, so it's treated with a couple of different medicines, one cold Ivig that is a bunch of pooled antibodies, and what that really does is kind of tamp down the immune system. So this is a very inflammatory condition. The IVIG we think works kind of decrease that inflammation in especially protective for those blood vessels around the arc. We also treat it with aspirin so. So. We don't generally give kids. especially young kids aspirin because of risk of of rice in your own, but in this disease in particular, we give kids aspirin because it's been shown to help. decrease their risk of having a clot in their heart, and it also helps in high doses with the inflammation so I mean it sounds serious, is it? It can be serious, especially untreated we. We recognized early. The risk of complications, especially with heart complications is pretty low like less than two percent on when it's treated early if it goes undiagnosed and not treated the risk of coronary artery, inflammation goes way up in so it can be very serious especially, if not caught, but if treated in general, it's it's a very treatable disease. What are some of the research that you're doing? Doing and Kawasaki Disease Then Yeah so it's pretty well established as I mentioned that the treatment for Kelly. Sake is I've E. I, G. AN ASPIRIN. That's pretty much what every kid across the US gets when they had the diagnosis of Kawasaki Disease We know a subset of these kids, probably about fifteen twenty percent, or so end up having symptoms after that first initial treatment so IBM. is as it sounds like an ivy treatment that we give over about twelve hours and about twenty percent of kids. They have fever that POPs up after giving the IVIG. We watch him for about two days after giving them the treatment to make sure that they're inflammation is down a mixture. They don't have fever and the kids that have fever again. There's really not a good or established treatment regimen for those kids, and so what we're looking at as part of a big group of senators across the country is what is the best treatment for kids that have what we call refractory Kawasaki? It is our fever. After that initial treatment were comparing different treatments, one a second dose of E. G. versus a medicine called inflicts. Both of which are pretty potent at decreasing that inflammation. talked me a bit. Then about this this immune syndrome, we're seeing with kids with respect to Kovic and why it should or should not be compared to Kawasaki Disease Yeah. So reasons that it even has come up in terms of the discussion of Kawasaki Disease is just because of the remarkable overlap symptoms and a lot of kids. What we found. Is that in places where Kawasaki Disease We kind of have an idea of the level or Or the number of kids that get admitted to children's hospitals with Kawasaki Disease, and what we started to see these big numbers and clusters of kids that were coming in with a lot of the symptoms that looked like how Asaki disease, so high fever, rash, conjunctiva, itis, crack pans are cracked lips swelling of the hands and feet. All those things and people started saying. Wow, we're seeing these big clusters of kids with Kawasaki Disease. Disease, but what the link was was that all these kids seem to be or most of them, anyway had some association with covert nineteen, so they either had disease, or when tested for antibodies or it look like they had passed disease for it and so that then people started to think okay. Is this an inflammation syndrome that's associated with covert in. That's kind of where we're at right. Now is seeing kids that have had. had this either exposure to or pass or in the minority of kids, present infection with covid nineteen they having this big inflammatory syndrome. The has a lot of the same features as Kawasaki. There are differences It's not exactly the same or seeing kids that are a bit older. The average age is somewhere between eight to ten wearing. Kawasaki. It's a it's a lot younger usually, it's less than five in most of the kids. The inflammation markers were seeing are a little bit different as well in this in this covid related inflammatory syndrome. So are all the kids who've had this syndrome. They've all had covert. Most of the ones that are tested I think some of them you know as as you probably know, and as a lot of folks. No, the testing isn't the best in so Roy. Tom, in the kids that are negative. Negative We're still kind of pursuing that workup and looking to see if we can retest them and see by and large, the vast majority are associated. How common is this? It's rare you know it makes the news because it's a, it's a disease, it's affecting kids, and it's Cova nineteen but in general. This is a rare condition. This is something that a lot of states are seeing but. If we think about how many kids are likely have been infected the course of the whole population This is this is a pretty rare entity. So why do you think then it's making so much news well? There's probably a few different reasons, but. Any time we see a disease that pops up kids it. It gets everybody's scared and rightfully so from the get go with Covid we've said kids are. Not generally severely affected. We've said that Luckily you know we're not seeing big. Numbers of kids admitted to the hospital and boom. We start seeing these kids being admitted with this syndrome, and so even though numbers are low anytime. You have a serious infection requiring kids to be in the hospital especially in the ICU. The hospital it's a big deal, and and it makes headlines. ARE THEIR KIDS IN INDIANA. Who've had this? We have seen kids across the state of Indiana that have this here at. Riley we see a lot of them were actually just talking today? Amongst our group about discussing with you know all the other hospitals across the state to kind of get a good idea of the numbers of cases, the State Department health is collecting that data, but certainly to getting more information for all of us. is also helpful, and what's been going on a New York. It sounds like it's been much worse. Yes, so New York just most likely, because of how Severe Cova nineteen was there. More kids were exposed, and so therefore more kids have this. This link of of having disease and what we're seeing is on average. It's seemingly around for weeks or so after they were initially exposed where they're getting this inflammatory syndrome, so yeah numbers in New York are a lot higher than anywhere else in our country, and that likely because of that exposure to we have to do anything different for the Mercer. Just wait and see so there's been a lot of talk about that, too, and were almost on daily calls with with our critical care, folks with our rheumatology folks with lots of people that treat kids with a lot of inflammation, and were establishing guidelines kind of locally as well as nationally how to treat these kids. The the vast majority of these kids we're treating them very similar to Kawasaki disease so almost all the kids in our hospital, and a lot of the hospitals across the country are getting that same IVIG medicine thirty of them are also getting aspirin and then depending on the situation, some of them are getting other inflammation medicine, anti-inflamation medicine, so steroids and other kind of potent inflammatory medicines to help. Tamp down that response. Is there anything people can do to look for this or prevent it? There's. There's nothing that we know of that can prevent it than obviously trying to limit exposure to covid nineteen so kind of keeping with that social distancing listening to all the you know the health experts in the area about what ways to prevent getting over nineteen, but in general. There's not really a good preventative way to to deal with it. I think the the big thing is for for families in parents to look out for. Is that anytime? Their child has a prolonged fever and that's kind. Kind of a tough thing I realized because a lot of things can gazyeta fever for a while, but this is fever. That's kind of unrelenting three four five six days. That alone should kind of make you start to want. Call Your doctor and just ask you know. Get at least being communication but if you start pairing that with things like rash things like redness of the is one of the big things we're seeing to is abdominal pain so real severe abdominal pain kids along with these symptoms. Symptoms those are kind of some of the distinguishing feature, so one of those on the surface may or may not be the syndrome. When you put all those together. It's certainly something to talk to to the doctor about. Does any of this change your thoughts about how we move forward? Yeah, that's a good question. And I would say that it doesn't really change. the thoughts about how we should move forward to me. Any policies that were put in place should be protecting kids anyway right in so. Despite kids, not having severe infection in general with covid nineteen. Wanted kids to get exposed, and and you know because of that risk of you know we don't know who's GonNa have bad disease so to me. This is just another piece of the puzzle to say okay something to look out for, but I don't really think that. This changes how we move forward. Are there nationwide network set up to watch for this a Sunni Organization for that there are multiple kind of different study groups and organizations that are looking into this Again as part of this network of centres is looking at and studying Kawasaki Disease We. Just recently got information that will be doing a study kind of tracking this, and so we'll be looking at the number of kids that come into each center with with this syndrome. What their clinical features are so kind of what their symptoms are as well as their labs as well as will be looking at some of their bloodwork to look to see what you know some of the features of this syndrome. How is testing going for covert in general, do obviously he's quite a bit depending on where you are I would say in general, we are getting better. It is certainly not great in. It's not where it probably needs to be. In terms of you know antibody testing as well as that nasal swab testing things are getting better and I think that our capacity to do these better, and we're figuring out which tastes are good and bad or better or worse, All of that is getting better, but we're not where we need to be. I know you're actually conducting a study right now. Looking into how prevalent this could you talk a bit about that? We were super interested. As Pediatric Pediatricians and Pediatric Infectious Disease Physicians to figure out within our community and kind of thinking of extrapolating this to the vigor community. How many kids and families are affected by cove nineteen that have no symptoms at all, so we were able to partner with all in for health network, which is a research network within Indiana and within the school medicine to recruit families in the community. And what we're able to do is bring testing kits to these families, so they didn't have to testing center, and so throughout our area around Indianapolis. We brought testing kits and we were able to do nasal swabs on families, especially focusing on kids to figure out how many kids were actually carrying covid nineteen without any symptoms. When are the results going to be out for that? We've wrapped up. This study were hopeful to get the results in the next couple of weeks to think people be surprised that it's more common or less common than than they think, I think, people will likely be surprised that it's less common than they think I think as we hear more and more again, we hear lots and lots about it. The expectation is that most of the population is. Is already been exposed to this and we're covered and we're good, and we should just back on with our lives, but I think that that's really unlikely to be the case. Certainly there is a number of people that had a symptomatic infection or had cova nineteen without ever knowing it, but I think the numbers are likely going to be a lot lower than we think they are. So what do we do about schools in the fall? Yeah, WE GONNA how we're going to reopen school and have it be safe that again is is the million dollar question that we always know and there's not one right way. I don't think I mean it's really gonNA. Be Dependent on. What the local prevalence is into partnering with a local health departments and understanding where we're at in terms of this disease, kind of in the community is going to be super essential to knowing when it's safe to to go back to school when we need to pull back a little bit I mean. Completely understand and recognize that getting kids back to school. Getting them back into the routine is really important Um. We just need to be very careful about. How do that and I? Think that what? That's gonNA mean is going back to school at times in person. If we start to see a big spike in the community, pulling back a little bit and potentially going back to learning or decreasing the amount of students in each school system is going to have to be real thoughtful how they do that and also making sure I think that each school has the resources they need to be able to do that. Is Super Important? Do you think that's going to happen. I mean it's it's funny. 'cause I totally agree I. Think there's so many things we say we need to do, but I can't even imagine how schools would make some of the changes. We've already just told restaurants and businesses they need to. Do you have your capacity? We can't just do that in school or space. Kids out every six feet. How do you do that in his? So are they just GonNa, not or do you think that they're really going to have to make a swing at this? At every single level I think being apparent of a foreign six year old the idea of keeping them. Separated and or masked throughout the day is. Completely unrealistic I don't think that's GonNa Happen. It's great on paper. A lot of things are great on paper, but practically what are we going to do? I think that you know potentially in older kids in high school. Maybe but again there have this feeling of invincibility, so they're probably not gonNA listen to so I think it's really just going to be having to pay attention to what is going on within the community I. Don't know that going half half the students coming in is. A Realistic Way to get around this I. Just it's a really hard logistical thing to do see. This is where take I'm sort of fascinated because I feel like this is a solvable problem like with with enough time money and effort. We could do this we could. Have sent some kids in the morning. Some kids in the afternoon. We could you know send some kids Monday Wednesday? Friday some kids Tuesday Thursday. We could you know figuring out ways to have every kid eat at their desk. The food will be made in. The lunchroom brought to them we could. We could figure out ways to stagger bus. Systems like we could do. It would require money. Don't get me wrong, but we could, but it would require massive amounts of planning and thought and I'm seeing no one do that yet. Do you think that's going to happen or are we going to bury our heads in the sand and then freak out an August and then just throw the doors? Oh. Exactly what you said is a realistic thing, but that that money is you in that whole. How much time that will take if this was something? They could do in a year from now. Heke I think it could be done, but just with school abs, you know in some places the both the restart up in a couple of months. It's going to be. It's GonNa. Be a tough tough sell, thanks. So. Do you think that there's going to be long-term changes to the ways we all behave because of of all of this or do you think will will retrench will someday figure this out, and we'll go back to normal I think there will be a new normal for quite a long time. How long who knows I mean? This is not the first pandemic the world our country has. Has Seen Right and we've all forgotten a not not that most of us were alive back then in those other things, but a lot of the lessons learned and a lot of the things that were done. had had faded away now. How long that took hard to say, but for a long time. We're going to be doing things differently. We're going to be thinking about. Where we go, who we you know how many people are around? But there will be you know there will be a sense of getting back to normal at some point is just that how long man I don't know. Where do you stand on vaccine? Optimistic or pessimistic I am optimistic. Vaccine will be produced in available I am not optimistic. That is going to be. BE A cure all for everybody, but even kind of decreasing. Some of that is being able to provide protection for those at most at risk I think is super important, and I am optimistic. DOTS now the timeframe that's been laid out for that probably unlikely. I mean you know the quickest vaccines that were ever made. You're talking about years, not months and so. It's it's pretty unlikely to me that we're going to be seen vaccine in two thousand twenty now they are going through trial and error accelerating fast, and so that's great, but to me. The safety of these vaccines and the improving the efficacy is really super important and I want. I want to make sure those things are safe and I am a very pro vaccine person. But making sure making sure they're effective in more than anything. Making sure they're safe is going to be important before we roll them out. We talked of all. I agree with you I think there's very little chance we see one in two thousand twenty, but what I think a lot of people don't grasp is there's a difference between the day that the vaccine is approved, and when everyone's going to get one I, mean realistically. How quickly can we make? Billions of doses of vaccines and then get them out to people. In a lot of that will have to do with what vaccine actually makes it to market right, and so there are some vaccines are able to be ramped up pretty quickly in again not days, but like pretty quick, there are other vaccines that take a heck of a lot longer to make, and that just depends on the technology that's needed to make these vaccines and so. I think it's you know it's possible that these things can be ramped up again on the order of like months weeks and months not days but a lot of it will depend on which vaccine actually makes it the market in which technology that we're using. How would you prioritize? WHO GETS THE VACCINE? I yeah, that's another great million dollar question. I think we look at the you know the people that are most severely affected with the disease in a and that's unfortunately not as necessarily fair way to do things, but unfortunately when in a lot of things in medicine when we are pressed with making tough decisions in tough choices, I think one of the important things is making sure that we are protecting the people most vulnerable, so high risk populations, and especially those folks that. That are on the front lines as well as folks that are at high risk for getting severe disease probably should get get the vaccine I. So, what Lessons Have you learned from the syndrome? Yeah, so there's been a few lessons that I've learned in kind of I. Think the whole medical community, learning and one. It's that when a new disease comes out Even when we think we have a handle on what's going on. We always need to be on the lookout and kind of looking for new things associated with it. In general, the medical community has done an impressive job of coming together to send that signal alert of hey, we're seeing something funny here and We want everybody to know about it. Some of the folks in England were the first to report this and it and it started popping up in the US, and in everybody kind came together, and we like I said we've been on calls. Conference calls. With folks across the country, the CDC and everything to really delve into what's going on, and that's been an amazing thing just as open line of communication and kind of breaking down some of these silos that traditionally the medical community has had have been really impressive. The other thing is that improbably probably most important is that although it's a new syndrome are doctors, and especially our ICU folks in critical care folks. They're really good at taking care of sick kids, so they know how to take. Take care of kids with complications around their heart or with their lungs, and so you know. I think that it's reassuring to me that although this is new syndrome, the symptoms and signs are very familiar to folks, and they know how to treat it, and we know how to handle it, and so it's been a really interesting thing to see unfold as we've kind of taken care of these kids as how we're all collaborating together and working together to share information and really treat these kids well. It's important work. Jim. Thanks so much for joining us. Thanks for having me again this. PODCAST is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana beyond by promoting innovation and excellence in education research patient care.
CAR T-Cell Therapy and the Future of Cancer Treatment
"Hi Welcome back to the healthcare triage. podcast this episode of the healthcare cheers. PODCASTS is sponsored by Indiana University School of Medicine whose mission is to advance health the state of Indiana and beyond by promoting innovation and excellence in education research and patient. Care School of Medicine Leading Indiana University's first grand challenge the precision health initiative with bold goals to cure multiple myeloma triple negative breast cancer and Childhood Sarcoma and prevent type two diabetes and Alzheimer's disease. Today we're GONNA be talking to Cherie Virago professor of medicine and medical molecular genetics and also director of the stem cell program. I use school of Medicine. He Generals General's GonNa talk to us today about stem cell. Therapy and car T.. Therapy in particular which you may have heard in the news but before we get to that. Let's start with some basics first of all. Welcome to the program program thank you. Can you tell us in general what it means to be not only a professor of medicine but a professor of medical and molecular genetics so medical Michael Molecular Genetics. It's a very broad term It's it's really looking at the molecular basis of disease Not just inherited a disease but Many of the diseases have a molecular basis. Even if they're not directly inherited had he actually look get to the molecular basis. What kind of research technologies are you using? The biggest technology at the moment is Sequencing genes particularly in in terms of Chewers in my area sequencing can cell's genome to identify particular mutations. That could be targetable identifying mutations Sion's that in future could be Way We could design drugs perhaps decided Also there are ways of personalizing Medicine in a way Way We can identify Because not all cancer even the same kind of cancer is not all Homogeneous there's a lot of heterogeneity so if you can identify certain mutations in a person's at cancer cell you may be able to target that specifically perfect for that person's cancer as opposed to all the people with that kind of cancer. So how do you train to do this kind of work so in your career career how what did you do to get to this point. Well I guess there are various ways of getting there the way I got there. I trained actually in Australia Did all my hematology. Aw called you training in Australia. And then I did a PhD. That was more related to stem cell transplantation rather than molecular medicine at the time and then I moved to Ohio state where I stayed there for about six years on faculty and then the opportunity came to lead the transplant program. Ram At Indiana University. So I moved there in two thousand six. So we're talking about treating cancer. Is it all kinds of cancer or specific kinds of cancer. Turner accident well as a stem cell transplant. we're really focusing on hematological. Kansas blood cancers So leukemia multiple myeloma lymphoma. These are the ones that are amenable really to stem cell transplantation. You talk about what the differences are between those three short so It's really the cell of origin or the origin of the cancer so leukemia we're really talking about Cancers of blood stem cells the bone marrow in multiple myeloma. We're really talking about Cancer cells plasma cells which really part of the immune system in lymph falmouth with talking about cancer cells that are also part of the immune system that the less differentiated cells than the Coloma. So what what causes these. What makes someone developed one of those types of cancer? Well that's a really good question and we don't know all the the answers to that but It the it's silly as with other Kansas to I'll just blood cancers there are Hits in the genome of the the cans of the cells that turns them on to become cancerous essentially and so once they become cancerous. They just start growing multiplying without controls trolls. That the gist of it. Or Yeah. That's basically it they. They're able to multiply without control but they're also able to survive better They have a survival advantage compared to their normal counterparts talking about the history of treatment of those types of cancer. Like what do we do. And what are we. What are we got into now? And specifically of course what is stem cell therapy. Happy at the end. Yes so you know historically the we have been treating and we still the do treat These cancers with conventional cytotoxic agents these agents are essentially cellular toxins that cause DNA damage to the cells and as a result they The cells sells died and they because cancer cells tend to divide more frequently or more rapidly than normal cells and these conventional channel cytotoxic target the proliferating cells more than the Doman cells. So we're able to Mo- selectively kill cancer cells. But they are. They also affect normal cells as well as things have evolved We are now able to. We learn more about the genetics of the Kansas. His when now able to design drugs that particularly targets in pathways molecular pathways. That these cancer cells depend on so Treatment has become Less toxic to the to the patient in general so we're trying to target specifically just killing the cancer while not killing other other rapidly or any other kinda cells in the body. So what is then stem cell. Therapy like what. What's the difference between what skyping there and then going all the way to say? We're GONNA do a stem cell. Trance have so in some cases not all Kansas but some Kansas are also amenable to stem cell transplant therapy. And they're really too broadly. Speaking to approach is one where we use. The patient's own stem cells called tolerance stem cell transplantation. And where we use dona cells or allogeneic stem cell transplantation so with autologous transplantation plantation would really reverting back to the classic cytotoxic approach way we give very high doses of chemotherapy to Kill Oh as many cancer cells as possible. One of the side effects of this is that it will also cools a permanent damage to the bone marrow of people without stem cell support report. They would Essentially die of marrow failure so to collect stem cells. I there on stem cells assuming their stem cells not diseased. Then when you can give high dose. Chemotherapy give back stem cells and allow the marrow to recover so I have a couple questions there first of all. How do you get the stem cells? Out So stem cells live predominantly in the bone marrow But they do circulate the blood so you can either collect directly from the bone marrow but more commonly family today in the autologous approach we give growth factors which can move stem cells to circulate more in the blood and then we collect them. I'm by a process called a ferocious. Where basically they are collected a blood donor machine essentially that will collect them from the blood? How do you how do you how are you sure? You're not collecting cancer cells at the same time you do Some of these stem cell products will be contaminated but to some extent by cancer sells but it seems that most relapses after autologous transplantation occur not because of contamination. But because you really the the chemo a high dose chemotherapy that you've given has not killed the last cancer cell in the body. So how are you also assured that the stem cells are not. Can't where's the cancer come from. If it's not coming mm from stem cells as the simpsons or what about the sort of the the. He met a poetic stem cells. That give rise to the sherm tie. He met a point system. MM-HMM SO For example in multiple myeloma these inadequate ext themselves are not cancerous. Okay and in lymphomas Somali. They are not not cancerous. Can you just give us just a brief description of what the poetic system is so the Humana poetic system is essentially all blood forming cells and immune cells so the very primitive stem cells that give give rise to the humanitarian existent. They give rise to white cells red cells platelets as well as the components of the immune in systems such as B. Cells. T. Cells natural killer cells. We're just trying to figure out in my head and where it comes from. Because if if the are the white blood cells coming from the bone marrow in the stem cells though in development I it depends on the Canada Essentially for example if we take multiple well my Lama so the Within the immune system one cancer cell becomes Transform to become malignant and phones a clone in that clone of actually expands and has sub clones of its own and that's really the cancer but that's not arising from a in the actual stem cell of the very primitive stem cell that gives rise to all the blood forming cells in the Merrill. So then the say let's take lymphoma for instance or your leukemia dumb bass boats. It doesn't matter my head D- it's not that they're coming out of the bone marrow or or out of the stem cells cancerous cancerous. It's that you already have lymphocytes which then becoming cancerous yes basically and then they. Just keep dividing and reproducing amongst themselves exactly. Now that's different to a myeloid leukemia for example with the cancer is really in the stem cell. In the Humana poetic stem cell itself so allergies eligible so Atallah. Transplantation is really not Appropriate full most of these patients. And that's the way you really need to use a different approach. which is the allogeneic stem cell transplant? I alluded to before okay. So that would be like we again. You try to wipe out everything. But you're bringing because the stem cells themselves are somewhat cancers. You'd have to go to somebody else to get. In addition the allogeneic transplantation is also a form of immune therapy because Within the stem cell product. That you collect from Dona. There are immune cells and these immune cells will see the recipients tissues and actually cancer as foreign foreign and mountain immunological attack. Why want to come back to that okay but I have a question before? How do you actually put the stems back in? I mean you can't inject them back into the bone marrow do you you know we inject them actually into the blood. So it's like a blood transfusion germ and they have receptors Where they can locate essentially the bone marrow niche and Go there and proliferate do they go back to sort of all bone marrow or do they preferentially had two different bones. Well I think the in the bone marrow Not old bones are parts of the bones Marrow producing so they will go to the mirror. Producing which which phones are producing primarily primarily the spine the pelvis ribs the proximal pots of the long bones. That's interesting all the medical school and I didn't know that okay so Okay but you mentioned. Before that allogeneic stem cell transplant can be immune therapy because those blood cells will go into tech. Why don't we do that more often than empirically when you look at what? We've tested. Compare tolerance and allogeneic not all cancers Necessarily amenable to allogeneic will respond to the immune therapy associated with eligible transplant as well. What are some of the risks? Probably the main risk is graft versus host disease graft versus host disease is really way the immune cells of the attack the normal body tissues of the recipient so that effect is really a double edged sword so we wanted took effect. They'll kill the cancer but we don't want it to attack the normal body tissues. And how does that manifest acute graft versus host disease occurs surly on in the first Maybe two three months after transplant and That manifests The target organs are basically skin got got and live up. So patients may manifest as a skin rash But probably the most serious manifestations would be guests during testing Estelle with the diarrhea vomiting. And how do you treat that. Or how do you prevent it so treatment at the moment. is is Is really just targeting the immune in system in general trying to damp down that immune response so we use immunosuppressive drugs Well we using suppressive rugs to try and prevent it but then we add more immunosuppressive drugs to try and dampen down that response When it occurs so if you get an allogeneic stem cell transplant? Is it that you need to treat the immune system or suppressive for a period of time while takes root or do you have to wind up being UNAMUNO suppression for life generally we use Immune suppression drugs for about the first one hundred days and typically we would start tapering the immunosuppressive drugs of the next three months of by about one hundred and eighty days is You know people should be coming off that now. If they develop graft versus host disease during that time they will require to remain immune suppression for longer and That can vary because there's also another form called chronic graft versus host disease which can also occur and Again depending on the severity some people can remain on immune suppression for many years and potentially life so how well does stem cell therapy work depends on the cancer for example if Lymphoma is sensitive to conventional chemotherapy dosing In the relapse setting then we can probably cure about fifty percent of patients with autologous stem cell transplantation. In leukemia we probably curing during about maybe fifty percent of patients with allogeneic stem cell transplantation. But that depends a little bit on the Risk factor of the leukemia itself. Because again it's not a it's not a homogeneous Disease so we mentioned immunotherapy before. But certainly that's something we're hearing being more and more about the new so what what technically is immunotherapy and how does it differ from say chemotherapy. Well chemotherapy is essentially use of a drug of some sort Now Immune therapy is trying to use the patients. All the donor's immune cells to attack and kill cancer cells so we mentioned how donors cells could be used. But how can you use a patient's own cells to attack cancer. Early studies really looked that Giving cited kinds which has just really proteins That Stimulate the immune system at trying to broadly and crudely stimulate the patient's own immune system in the hope that in some way we can will the patient's immune system can kill cancer Hansa however Over the years we've learned that Cancer cells can actually mosque themselves and dampen down any immune attack back by the patients on immune system so there are now what are called checkpoint. Inhibitors which have been approved in a number of different doc. Kansas way we can block that Moscow effect so that the patient's own immune cells can attack the cancer. Can I get you to talk a little bit more about. What do you mean by masking asking affect? What are the cancer cells do so they can They do it in a variety of different ways that we know of They can express A molecule on their surface surface that actually inhibits the immune cell so the cellcom attack. They just naturally early figure this out and that just that just evolution or wh- what. Why would that happen well? That's a very good question. I mean it's it's important as part of the normal immune hyun response for example immune response against a pathogen and it's important so that the immune response when it starts it doesn't keep going in an uncontrolled fashion her so it's actually an important molecule in controlling the severity of the immune response but cancer cells have worked out a way of expressing that to their advantage and obviously to the disadvantage of the patient sounds almost devious. That's just I. It is kind of devious. Okay so when you use a checkpoint inhibitor is it is it specifically targeted to help overcome the masking of the cancer cells specifically or the whole immune says yes so so. For example. One of the checkpoint molecules is a p. one and that inhibits molecule Akil on the immune cell called pd one so by giving an antibody that mosques of blocks that interaction then you don't have the cancer cells in addition of the immune cell and that allows the immune cells to attack. How often are we using? Immune therapy like with CIDER kinds right now. Not Very often with cytokines now. That was kind of the early phases. I think there is still a place for them and they are used in some situations. But that's it's not the common thing today. What did we do today? Today we have immune checkpoint inhibitors Like P. One inhibitors and there are other molecules to that are are important and other ones that are where antibodies are still in development but the PD wanted hitters for example for PD l.. One inhibitors Approved in a number of Kansas today. Then there are other ways. Of course that We can turn on the immune system will we can design the patient's own immune sells to specifically attack the cancer cells by manipulating the surface receptors. How do you do that? Well that brings us to the Tesol area. You have to identify a certain molecule on the cancer cells which is is relatively specific? Because you don't want to have that molecule expressed on vital organs for insurance or other vital tissues so it's at the moment that it's not amenable to old Kansas but once you've identified that you can Designer receptor to that molecule expressed on the surface of the cancer cell. And then you can introduce into the patient's own immune cells generally using a viral vector. You can put that the NFL encoding for that receptor into the T. cells DNA so that as the T. cells develop and And They've actually come to express that receptor which then specifically targets the Kansas. I feel like we need to walk through this step by step because it sounds like science fiction so So I you find molecule on the cancer. Did you think this is a molecule. We could attack where you think. It's on the cancer but not on vital organs then and how do you actually create Whatever the next step I mean visit like? How does it actually happen that we create something to attacker attached to that molecule? Walk you'll again. It's it's through knowing the sequence of the DNA sequence that encodes for these receptors than you can construct the that DNA a you can Also attached to that several other molecules that A not so much involved in the recognition of the cancer cells but in the activation and persistence of these Immune cells in the body and then you introduced that fragment of DNA through a viral viral vector that DNA integrate into the immune cells DNA. But how do we Let's even know the sequence. How do you actually like build build a molecule and then attached to it? I mean I imagine. There's not little construction sets that you'd like physically doing it. How do you actually build those things in the make them connect in the right order? Well I think that's that's the whole science of medical genetics. There are ways that you can actually Construct Day DNA with the sequence that you want. So you've now got this molecule. How do you attach these other? Molecules that your time medicine. Just you know how the naturally going to attach if you put them together or do you have to do something else. You officer choose these different molecules and you you know the sequences of these molecules and you can then attach these different sequences in i. I guess in in tandem so that when it's when the molecule is then Produced from the DNA or then it will be sort of like continuous molecule with Lincoln's in between that is expressed on the surface of the immune cell. And then usually there are signaling molecules. That I Also attached so at the end. You have some kind of solution that has a lot of this molecule in it more or less. Okay and then how do you get it to the virus. Like how do you then say. Okay now let's put these into specific viruses assist so there are certain viruses called retroviruses. That can actually integrate into the infected cells genome so these viruses You're attaching that piece of DNA the constructive DNA that of interest into the viral DNA. The viruses introduced first and then it integrates into the cells own DNA and then using the soles on machinery that DNA then is eventually translated translated into a protein That is Expressed ange suddenly the sequence of these proteins important because that allows the cell the the the molecule to be expressed on the surface of the cell as opposed to for example being destroyed within the cell itself so at the end you wind up with a t cell immune cell which is specifically created to go attach to the cancer cell and then signal that this sale should be killed. Yes so you have a receptor. That specifically targets the Immune Cell to the cancer cell and as I said You also attach the sequences. Ince's that allowed those immune cells to survive because if they don't live long enough in the recipient than the effect will not be Gerbil and also also There are ways to increase the activation of these cells once the immune cell recognizes the target cancer. So how does this work. It's actually been quite dramatic because it has you know. The early studies have obviously been performed in leukaemias and LYMPHOMAS and other cancers that are currently being investigated but really in a setting with the Cancer has been resistant to all non therapies. So this is a really hot population to treat so in in acute lymphoblastic leukemia. For example you'll getting remission rates rates of eight thousand ninety percent in lymphoma you'll getting remission rates that are probably in the fifty sixty percent in my Loma you'll getting responses The Not yet approved for my Lama. But you getting responses around the eighty percent mark and those are those are all numbers again specifically on patients nations that were otherwise incredibly hard to treat so that hi mark yes yes. So why are we not using this more and more. Well I think we will. I think We have to really go through the clinical trials Obviously the the early trials to demonstrate safety to demonstrate Not just the. There's a response but the ability of these responses And then really. The next step is to conduct trials earlier in the phases of the cancer and for example in multiple myeloma there are clinical trials ongoing at the moment in an earlier phase of the earlier phases of the disease and even comparing it to standard chemotherapy. That one would use to see which is really better. Is this hard to do. Is it expensive. The production of the COCKATIELS and manufacture of the actual treatment is is quite expensive. Yes why is it expensive is it is let me ask you this. Is this something that like a company is doing or is it every individual lab. That's doing this is there are a lot of obviously volved in in academic institutions. But but I think to be able to Export that technology in a very wide way. You really need to accompany. I don't think universities are you know would design for that. And really they'd taken up the technologists taken up by the companies and They're able all to Build manufacturing facilities And do this in a very broadway And of course you know. Many of them have are also doing their own. research and development in that area but each time. You're making a car T. therapy treatment. It is literally an individualized therapy like. It's only good for one person or is it good. For many people. Taking the the patient's own immune cells introducing these receptors into their own cell. So it is An individualized treatment but the the technology elegy for a given cancer. Is I when I pay my money and I get my cells back. That's for me. Full you only yes. Oh so okay. So how long does that. How long does that take the? The manufacturing process takes about two to three weeks. Okay is it intensive for the two to three weeks there's a lot of it you do some work in DC set for a while and then you take some steps and see it's for awhile. What we do is really collect? The patients on immune cells through the eighth Orissa's process which is similar to the collection of of stem cells. And then we these cells than shipped to the Company which manufactures it. It takes about two to three weeks to due to introduce the virus to expand the cells and then These cells out ship back and Lynnwood ready to treat the patient. We do it and what may when you say expensive. How expensive is well at the moment? for example COTY sell products Full fum patience around the three seventy five hundred one hundred thousand dollar mark that doesn't include of course the actual Other treatments that have to go along with the Infusion of cockatiels and of course it doesn't take into account dealing with some of the side effects of course so when we say those numbers of course sound very high to the general public. Is that something that we would expect to come down as we get better at mass producing this or is it. It really does take incredibly expensive technology. There'd be an it's likely to cost that much forever forever. Well I think there's a difference between cost and charge I'll surely and I think You know that's how much the charge is Sherman. I expect as You know maybe be more companies go into doing this as technology becomes more broad then I think probably the price will come down. I mean this sounds like it'd be a solution for lots lots of things not just cancer that if we could we can figure out ways the design One's own individual t cells to attack diseases. That could work with all kinds of diseases. This infections infections. Yeah yes so it. Is that where the future is. Do you think that's where the future is and I think they're already You know early research research going into that. I think the the you know cancer is just An obvious one CHIRP Kansas hot. It's treat than infections are. Are we using this for solid tumors as well as there are certainly This silly research going into that because there that again you have to identify target that is his specific or relatively specific to the cancer cell that is also not expressed on important issues. And I think that's really the difficulty in trying to apply that technology to Cancer Cells broadly because the antigens they expressed are also co shared by important tissues. What research are you working on right? Now where are your areas of interest. So we have a national trial open at Indiana University looking at the the Comparing chemotherapy versus coty cells. Multiple Myeloma There's also clinical trial that is about to open looking at My lawnmower homer in different phases of the disease including patients who have Essentially failed Most at least approved therapies. And obviously there's A. There's a big effort to be able to develop our own car T. cells PEPs directed against other malignancies for some of the things that we've described. FDA approval is it the now. Are these still third fourth line therapies whereas now that we like okay. Let's just go ahead and you. So it's approved route for example full Subtype of Lymphoma could call the few slots B. Cell Lymphoma and it's approved really in the setting where that lymphoma is is refractory to conventional chemotherapy. It's the approved currently for Pediatric Leukemia Acute lymphoblastic leukemia and in young adults up up to the age of twenty five again in the setting where the leukemia is refractory. I mean you're looking for new research and other areas is it that most of the focus right now is we need to find the target and then we can just go kart tea or is it. All the steps need to be worked out. I think both of those things because To apply lyod broadly to other cancers. It's really identifying a safe target But even with the Current on targets that we have in lymphoma and leukemia. It's really broadening the application to maybe early phases of the disease to Forgotten uh-huh leukemia extending approval to older patients with acute lymphoblastic leukemia. But there are also ways of Modifying defying the current technologies. So that Perhaps instead of one target you can use your design coty cells that have multiple targets doc. It's cockatiels that Can survive longer. coty cells that Maybe not generate as much Toxicity side effects. That was my next question. So what what what when someone receives Cartesian therapy sort of. How does that go? They get an infusion or multiple First you have to give chemotherapy. That is You know designed mostly to deplete the patient's own immune cells because if If you have a depletion of the patient's own immune cells you stop to develop. The body starts to produce a lot of side of kinds that will allow a proliferation of cells. So once you've depleted the patient cells then you can infuse the cockatiels and then you know leverage at that site a kind production to Get those coty cells to proliferate inside the body so that also is associated with drops in blood counts counts because that chemotherapy also affects normal he might appoint excels So they go through a side of peak phase where the council low Usually for a couple of weeks sometimes longer of course and then As these cells the Kathi cells proliferate they and start to actually attack the cancer cells. There's a lot of side kind. Production that produces produces an inflammatory response in the patient. So we call that cytokine release syndrome and that can manifest in in high fevers drops in blood pressure The reduced perfusion to important organ such as the kidneys and and so forth. So you need to support the patient through that cytokine storm And then there are the other main toxicity is Really development of neurotoxicity. That is less well understood but probably related to Cited kinds where patients can become. I'm confused they may have problems Speaking it's almost like Being having a stroke But in most cases it is reversible. And did you this once or do they have to go through multiple cycles of this. It's done wants Unless you can demonstrate that The the cady cells may be have not survived so there may be an opportunity If there's enough coty cells that have been produced To be able to give a second dose but generally speaking it's a it's a one off thing at the moment so we're looking towards the future. What what are you working on right now or what you see going that? You're most excited about. I'm most excited about about Seeing this seeing this application more broadly in because it's really restricted just to to very narrow indications at the moment I think being able to bring those coty cells earlier in the disease phase and more broadly and other cancers this will make a big difference to cancer patients in general and you see this happening in the near future I think so yes well for example in multiple Myeloma. I think of regular chance that we will have. If approval of Kati cells in this disease may be to twenty and then as the other clinical trials finish in the next year or two we may we see Broader application of the the currently existing coty cells in just other types of lymphoma and older age each groups with leukemia. And I'm sure within the next five years we will have coty sells That are targeting other cancers. I mean they already. The exist in very early phase clinical trials. I'm talking about potential approval for these other. Cancers can you tell us what types of cancers for example acute myeloid leukemia. Yeah now that's a difficult. Want to tag right it 'cause the Cadiz L. has the potential to also destroy normal. He might appoint excels because the the targets are not specific to the cancer cells themselves. There are some targets that are specifically expressed by certain sub types of leukemia. Where maybe the target is relatively more specific? I think that remains to be seen but it may be that. Do you have to combine these coty cells with the stem cell transplant. Because you may use the Kathi cells to eliminate the leukemia but in the process you might eliminate the patient's own normal matt choices so you then have to come in with A stem cell transplant to restore Humana opposes how many places in the country can do carty therapy at this point. I think it's very large and expanding I think The the centers mostly these centers. It is associated with Transplant programs And these centers have to be certified by the company They have to undergo some in training. They have to have the infrastructure to be able to Call collect the cells stole them in when they when they received by the company and and also be able to deal with the side effects that I mentioned These You know they can be more of an intensive care okay treatment that's required but is it like most big cities at this point so yes mo- most because this isn't just a couple of places now not not not all but most big cities so for example in Indiana You know we were the first at Indiana University There's the saint. Francis Group is starting also the program granted. They already have a transplant program in existence So there will be two places in Indiana Thank Indiana University School of medicine for their sponsorship. Their mission is to advance health. State of Indiana beyond by promoting innovation and excellence in education research and patient care
Multiple Myeloma, Bicycles, and Working Toward a Cure
"Looking back to the healthcare triage podcast? This healthcare Trieste podcast is sponsored by Indiana University school of medicine whose mission is to advance health and the state of Indiana beyond by promoting innovation and excellence and education, research and patient care. I you school of medicine is leading Indiana university's first grand challenge. The precision health initiative with bold goals to cure, multiple myeloma, triple negative, breast cancer, and childhood sarcoma and prevent type two diabetes and Alzheimer's disease. And that's perfect because today we're going to be talking about multiple myeloma our guest this week is rough it up norm. Who's the director of the mile Oma program at Indiana University school of medicine, we're going to be talking today about multiple myeloma? And where the cutting edge research is what people are doing what people are thinking where we might be going. So welcome. Thank you for joining us. Thank you for having me. Could we start a little bit? I've we're always interested in hearing about the backgrounds of our guests. How did you get to this position? How did you get interested in your research? How did you get here? So I started one. To become a transplant surgeon. But then I ended up doing just hematology followership and boomer transplant and I did my research on plasma cells. These are the cells that cause multiple myeloma. And then I started doing, gene therapy. And gene therapy was an exciting and dangerous. I needed to focus on something. So I knew plasma cells and I loved myeloma patients. So I decided to focus on that. So let's say what are plasma cells. So plasma cells are the cells that make antibodies to help us fight infection. We need them. That's how we survive, you know, one hundred years seventy years, whatever so one what happened is at one of these plasma cells become malignant and start reproducing itself and causing harm to the patient. So so there type of white blood cell. Yes, sir. Okay. Where they made. Well, they actually start in the lymph nodes, and then they migrate to the bone marrow where they reside. You know? So you get your first encounter was for example is a Tatton us or, you know, Newman. Yeah. Bacteria in the blood, and then the these cells much sure become plasma cells produce memory antibodies to help us fight infections, as you know, when we get exposed into the new Monia, and they reside in the moment when we need them. You know, they got out they make more new antibodies to help us fight infection. So can you talk a little bit more about how they work when they're working, right? How exactly do they help us fight infection? Well, they produce a specific antibodies. So we have a repertoire of plasma cells that capable of recognizing different pathogens, you know, from the mums to the measles to influenza to the new Monja and. And so every time we get exposed to one of these pathogens these plasma cells proliferate and produce more antibodies to fight the infection. So what happens when they produce the antibodies? What happens next? Well, the antibodies bite to the pathogens, and you just neutralize it or, you know, help other cells gobble it up. Okay. So what happens when things go wrong? Well, when things goes wrong is that one of these plasma cells start accumulating in the bone marrow. So you initially have for example, maybe five percent of normal plasma cells in the boom marrow. They don't cause any harm. We call that condition. Magas monoclonal Gama thief, undetermined significance just have a monoclonal protein doesn't cause harm to the patient. But what happened next is that tons of these cells stock, you know, accumulating in the bone marrow. They have like ten twenty percent, but it's still not causing harm. So we call that condition smoldering myeloma. And then eventually what happened is that these. Plasma cells can affect the patients in different ways. One is that it can weaken the bund so about seventy percent of patient was myeloma will have either osteoporosis holes in the bones or the star breaking bones. So they have you know, they just tried to lift a bag, you know, and then they break a bone in their back or something like that. So myeloma can affect the bones can cause a Nimia can cause very high calcium level because you lesion calcium out of the bone. So the patient become enable to think and may go into a coma or they can actually get kidney damage, so we call these of the crab criteria for diagnosing myeloma, the c is for high calcium, the are renal or kidney failure AMA or bone disease. So you have a lot of these abnormal cells in the and you have one of these criteria. Then we you know that patient has. Multiple myeloma. What makes the plasma cells? Go bad what what goes wrong? So we actually a lot of research going on in term of environmental exposures and just this week got big settlement against roundout because they when patients develop multiple myeloma from using them. So we think there is a toxic exposures farming communities. There's increased risk of multiple myeloma near factories, and you're mining communities, for example, I have patients in your a mine in south west, Indiana, where multiple people who worked in that minds developed multiple myeloma, you know, and the questions of what did they dumped into the water? These people are drinking water. And so I think we think chemical exposure plays a role in making these plasma cells so are become malignant, and multiply, and and you know, 'cause. Harman cosies. Okay. So once somebody is once we have a concern, they've met their the crab criteria. What what happens next to help make the diagnosis? So we do several things number one. Obviously, we need to do blood tests this anemic, they have high calcium or they have kidney failure. The the second thing is that we look for this abnormal protein because myeloma start from one plasma cells the protein, they produce is unique we call it mono clone protein. So we do a specific blood test to check for the monoclonal protein and find it we have to find a monoclonal protein or we find an abnormal part of that protein. Raise recall, it the free light chain. So we check that the second thing that we have to look and see what they have in the bone marrow. So we do a bone marrow biopsy to see the number of these abnormal cells, and what type of cells we do genetic analysis on those cells to see. What they do. Because my my Aloma patients some of them do very well, some of them, do okay. And some of them do poorly and the genetic makeup of the mile Oma can help you distinguish these three groups. So that was actually going to be my next question is sort of all cases of multiple myeloma the same or they already different or do. They fall into a bunch of category. Yeah. I mean, I think that term multiple may not be really because of multiple lesions was in the patients things multiple presentation of the disease. Okay. So I have patients who do very, well, they get one kind of tweet -ment and go on and stay in remission forever. And then we have patients who was in a year or two they relapse and they actually don't do. Well. And then so that's about twenty percent for each group. And then the rest the sixty percent those patients, you know, have multiple relapses, but you can control the disease the can live long life. So what is the treatment for the most part? Yeah. So the treatment has evolved that used to be more chemo. Arab your traditional drugs that cause hair loss or blood counts. Abnormalities? But now, we have these recall them, so our novel drugs, they work on things that influence the proliferation of the cells or the interaction was the neighborhood where they live. So these cells can't, you know, not really find hospitable environment was in the boomer to grow. So these new drugs that in combination have produced amazing results, we still consider high dose chemotherapy and stem cell transplant as part of the tweet -ment to improve the outcome. And some patient may need Menton therapy after you do the stem cell transplant. So for the most part, though, it's it's drugs. Yes is drugs. And so what's the typical course if of treatment? So most patients will require what we call induction treatment, you know, which is trying to control the disease trying to improve the symptoms and. That will take three to four cycles the psychos about four weeks after that, you do the stem cell transplant, which is two components wants collecting this themselves that support the use of high dose chemotherapy, then you give this big dose chemotherapy, which tells everything in the bone marrow. But you have the patient stem cells that make blood cells stored. So the next day you give it to the patients, and these cells will grow and make healthy cells. This is when you're doing a stem cell transplant transplant in the patient cells back into their own body. Yes, how does that work? So what you do is you collect the patient own stem cells I and these cells live in the bone marrow. So what you do is you give specific hormone that stimulates these cells to grow every day for four days on the fifth day. They're blood is full of these stem cells. What you do is you take the blood out, and you do a process like Dallas as a process called a freezes. So you collect the only the stem cells, and you store them you give the blood back to the patients, and you do this in the outpatient and a bloodbath. Four hours five hours a day. Sometimes in one day, you get all the stem cells you need sometimes you need to three days. How do you be sure that you're not collecting bad cells or that those won't turn into bed? So yeah. So we have looked actually we did research on that. So what we looking for is specific marker on the surface of these cells makes them stem cells called CD thirty four, and we look to see if we collect any Milena cells, and we did very sensitive essay and two things. One is the myeloma cells don't mobilize, you know, that effectively and the second things that they don't freeze. Well, so basically the products we give back to the patients, very unlikely to contain any Milena cells knowing that the stem cells could then are you assured that the stem cells won't then develop into cells, which will turn back into my or is that just you just have to take this stem cells are the cells that make white cells red blood cells on platelet, right? And the process of developing multiple myeloma doesn't really start at the stems. Okay. Stems stock to probably around, you know, when they sort of mature to white cells, and before they divide into lymphocytes or neutrophils different part of the white cells. It's the lymphocytes level when you know, they become B cells of the B cells become plasma cells. So maybe it's between the B cells and the plasma cells. So I guess I'm reading this question. Maybe totally naive given that we know that whatever was in this person to that such that their cells could develop into myeloma cells would they be better off with someone else's stem cells that dose sales are less likely or is that just too hard to do. Well, it's very hard to do. So we have done what we call allogeneic transplant donor stem cell transplant. The problem is that most patients in was multiple myeloma are in their late sixties. So I'll genyk transplant is very risky. We actually lose large number of these patients and despite doing an allogeneic transplant some patients have relapsed. So it's not really a route. Eighteen Lee us approach maybe in the young patients, and you may concern allergenic transplant. The issue was allergenic transplant is the risk of a graph versus house disease that immune cells from donor. Do not like that where the living in the new in the patients, so you get damage to the skin liver and the intestine, but the other thing is that the advantage of allergenic transplant used to be the graft versus disease and fortunately, the myeloma cells tend to hide from the immune system. And we don't get very good graft versus myeloma affect when allogeneic transplant. Okay. So patients get around of drugs and then stem cell therapy. And how what what's the usual course after that? So after three months later, they recover from the stem cell transplant, then some patients are considered for Menton insz therapy. So two things one we give him medicine to keep their bone from breaking down. We do that as an infusion or injection once a month, and then sometimes. We give pills of these novel chemotherapy drugs that will help maintain the, you know, the response, I think that research should be focusing on what to do after transplant when the patient have minimal residual disease. How can we improve the patient immune response to radically the residual disease is that the chemo pill, or is it some other strategies that we try actually to explore here? How many different types of drugs are available. I mean is it did everybody gets sorta the same octave of drugs or is it individualized? So when I started working on multiple myeloma, we had only this traditional chemotherapy in two thousand and three the first in class drug was approved which is a protease inhibitor and protease inhibitor is just thinking about it like a, you know, you have a garbage disposal, and you just clogging then you just accumulation of toxic stuff, and you know. The cells start dying. So that's how it works. And these are amazing. I mean, these drugs have changed the course of the disease now there are three drugs in that class available and in two thousand six we got a class of drugs approved called the immunomodulators drugs. So and the first in class was the drug thalidomide drug that cause a birth defect. When it was used in the fifties for motion sickness and nauseous associated with pregnancy and this drug we didn't understand how it works for a long time. But so and that but the problem was using thalidomide for a long time it can cause nerve damage. Okay. So the company that makes drug start developing next generation of that drugs that caused less neuropathy. We actually have to drugs in that class now. So we have three immunomodulating drugs three inhibitor. And then more recently the FDA approved drugs. We call him monoclonal antibody. So these are drugs that recognize the surface of myeloma cells, and sort of, you know, help eradicate these myeloma Celso protein that bind to the myeloma and bring immune cells to try to radically them Saturday decide which of those to us. Well, that's a great things. That's why we do clinical trial and in clinical trials, we find the best combination. So first of all we now know that one drug is not enough you have to use a cocktail of drugs. And so we just you know, the good things for patient today is that you have different cocktails so based on their medical condition, you can find the right combination therapy. So when you say their condition, what specific example, if somebody has significant nerve damage, you went to avoid drugs that cause further nerve damage if somebody have advanced kidney failure you and avoid the drugs that can be too toxic. If you have kidney failure. So that's a good news for the patient is that we can tailor. The therapy to were there conditions, and they're actually desire. I mean, some people would like only oral regimen. They don't wanna go to envision the can really go twice, you know, week to the clinic to get chemotherapy, we have oral regimens for them. So when you say they're cocktails a multiple drugs in a class or you're picking drugs from each different class. Exactly we pick drugs from different class. So basically what we do is synergy was at overlapping. Toxicity. Okay. And so what does the usual course, you have your dream Indra maintenance how to most patients too. So most people as I told you, you know, they really do. Well, they stay in remission for a long time. You know, now the average, you know, time in remission, maybe five to seven years, but unfortunately, we have these about twenty percent of patients who relapse was in the first two years, we call these are high risk risk of what risk of shorter remission shorter survival. That's where really a lot of research going on to try to improve the. Outcome of these patients. Do treat them again. Yes. Which read them again, we tried to find novel combinations. We tried to find clinical trials for these patients. We trying to employ some newer strategy. For example, one of the nearest strategy will be what we call Carty cells, which is basically taking the patient own immune cells expand them, genetically modify them to make sure that they can recognize myeloma and kill it. So we put to Sheen's one to recognize my Loma and one killer jeans. So that's why we call it kind Merrick receptor Antillean T-cells Carty cells. So these cells are I mean, these kind of therapy is now used and clinical trial in relapsed patients, but we may be able now to use it in a clinical trials for the higher spacious affront before they get to you know, relapse and have a horrible disease that how to control how hard is it to do that. So first of all you have to collect the patient and. T cells lymphocytes that become the killer cells. So basically, it's like we collect the stem cells. We do a free says we take the blood out separate the white cells from the rest of the blood. And then when you take these to the lab, I mean to the processing manufacturing facility, you separate the specific cells, we call them T cells. And then you incubate them was a virus that get two genes inside the cells after you expand these cells, and then you bring them back into getting back to the patient. So it's very expensive process. And you know, the FDA as, you know, approved to Carty saws one for lymphoma in one for leukemia that are very expensive. But there's a lot of different companies are working on it. We at Indiana University school of medicine put together grants, and we have a center the Brown center for immunotherapy. We almost ready to recruit the director. Of that. And our goal is to try to improve on the safety of these products, the specificity of these products and improve the sort of sustainability. I mean, unfortunately, if you look at some of the clinical trials the cells lasted about a year that's not good enough. Because if they start relapsing a year and you give them very expensive therapy. So our goal is to try to make Carty sells more specific safe and maybe less expensive house pensive visit. Well, I mean for the commercial products is almost four hundred thousand dollars charge for that. If we produce it locally, and may cost us probably forty thousand dollars, you know. But that's why our goal is to see if we can start making your own cartoons. What what's the usual prognosis for for a patient of developmental model? Really has improved significantly. If you look at patients when they were diagnosed fifteen years ago twenty years ago, he uses say you can live on average to three years now. Think if you look at patients depends on their station, you know, so if you have stage one disease, you know, you would think the spacious should live at least fifteen twenty years, you tell us what stage one is. So sage one is the we look at certain things we look at the chromosomes and the side of the bone marrow. The are they good chromosome backrooms? And we look at something called L D H is of you know, enzymes in the blood. We look at albumin. So if these are normal and there's another protein, we look at the blood called beta to micro glob, and so these are normal and the signings. Good one that's a stage one and these patients, you know, if you look at their five year survival more than ninety three percent of a life at five year. So the statement, you know, influence chirp how long they live, but we are seeing more patients living was myeloma and starting to die from something else. Compared to what we did ten fifteen years ago. What did the other stages so sage two and three? So three is the high risk where you have high beta to micro gloveman, high L D H. Hi, low albumin and bad cytogenetics in the bone marrow. Okay. So it it's more about the state like the actual chromosomes, and what the cells look like then how quickly you caught it or how much I'm obviously metastasized surely different. Meaning. Well, yeah, I mean myeloma is always sorta detected, you know, at a advance or all over the body. You know, so, you know, unlike you know, other tumors assist, always systemic disease. But it's you know, if you detected early stage before you have a lot of Milo, my you have a lot of bone destruction. I think you're gonna do. Well, now the trick is what we're doing is that a lot of research going on is first of all as I told you my only go is preceded by two conditions mug us and smoldering myeloma. So why don't we treat all smoldering myeloma treatment can have? Side effect. And we don't know if you'll really can cure patients, if we have a curative regimen, then we can use it early on and take some risk. So only specific group of smoldering myeloma, which we call him high-risk for progressing in a half of them will rely progress to my Aloma was in two years. We doing clinical trials on them and are to kind of clinical trials one use the combination chemotherapy that we have the novel, Asians, you know, the monoclonal antibodies that proteome inhibitor we put them together. And what we trying to do was in two years to see how many patients are we putting in really solid remission with the hope to cure, these shrines the other approach to the higher swelled among multiple myeloma is that can we actually make this myeloma cells visible to that mean system can we make that new system recognized myeloma? And so what we're trying to do is actually generate vaccine from these myeloma cells, and then inoculate. The patients was this vaccine was the hope that they develop immunity that will eradicate the myeloma. So the vaccine battalion individually each patient or just kind of vaccine for everybody. Yeah. So we take the myeloma cells generate a vaccine from their Milo myself. So it was that the kind of thing that's just going to have to be you think will be commercially like Dobie a company that does that. Or is that we're just you need to go somewhere. That's doing it in a lab, I think we should be commercially available. That's the hope is that you can generate a vaccine that for each patient's unique just send the cells, and they process it, and they send new vaccine, what do you think the most exciting works being done right now. Or what what is the most? What area I'm not saying we're in the country. I mean what area? Do you think is the most exciting for me? For example. I am actually looking at trying to figure out can we prevent the development of multiple myeloma. So I'm doing clinical trial in patient was monoclonal Gamaa, a thief undetermined significance, and I'm trying to see if we can actually prove, you know, prevent him from developing multiple. Milo moment. So let me tell you the background of that. So in my practice. I see a lot of monitoring gum with even determine significance. And I have seen patients who lost the mock Logam up at the so how did it disappear? So in the six to eight patients I have seen the lost weight and by weight loss, they lost the monoclonal gum up. Really? So we think obesity is an inflammatory state can stimulate plasma cells. So what we doing? Actually, we putting a trial together we start accruing here. We're gonna look at patients who undergoing weight reduction surgery, and what we're gonna do is screen them for Magus. And then those are positive for the monoclonal mafi. We're gonna follow them after the surgery and look at the group that lose weight versus the group doesn't lose weight. Sure. Are they going to lose the mug us or not? So if we can prove that they hit LA. Lost this abnormal protein. That's a good things. And we're gonna try to explore and see why is it you know, because they lost certain inflammatory proteins when they lost the weight or not. And so that will be a crate advances. And so basically a known risk factor for myeloma. Yes, if patient who are appea-, let me tell you if somebody has monoclonal Gama Pathy, and if you know, and they are obese they have four and a half a chance of developing multiple myeloma compared to non Opie obese patients. Yeah. So this is a big study that was done at Saint Louis VA hospital because they have records on patients who developed myeloma, and they have, you know, they know their weight, and they know if they had manga so not so that will be four and a half time just type two diabetes tied up in that too. Or is it just the obesity? I think just the obesity. I haven't looked at. I'm not familiar with any day down diabetes. But so besides the prevention what else is so prevention, I think the other thing is that we really need to screen. I mean, we need to see in this area that we talk about the higher scary near farming community near mining community near factories that was dumping a lot of these chemicals. Can we understand how many? People do have these premium conditions will be interesting to understand that. I mean, because then we will source study the impact of you know, this environment on these preconditions. And then what we would like to see is predisposing factor. In addition to the chemicals, if you have certain gene, will you get myeloma when you're exposed to certain pathogens. So I think that's exciting to us. And then finally can we find a way to deal with high risk Milo. My thing that's really the most frustrating. You know condition we deal with and Michael is to really understand the immune makeup of these patients and try to understand how we can enhance it to help us radical the disease Howard. I mean, just because clearly we live locally how are patients doing here. Locally. And what are we doing? What kind of studies are we doing locally to to try to help? So that's a great questions as you know, Indiana University issued this gr- gr-. Grand challenge. Grant, trying to really cure three diseases and cancers in Indiana and multiple myeloma was selected as one of these diseases. And so one of the proposal that we have is that we want to understand how myeloma patients do in Indiana. We want to understand their diagnosis their treatment their outcome their side effect. In addition, we want to understand their genetic makeup and also understand the myeloma genetic makeup and environment. So we putting together what we call a cohort of patients. We want to analyze one thousand patient was myeloma and Premio on condition in Indiana. We started actually accruing patients in November. And we have more than one hundred seventy patients thus far enrolled. So what we do is we looking at their sort of baseline genetic in formations. You know, we take saliva. We take a blood, and when we do a Blencoe biopsy. We take the mile cells and the neighborhood where they live inside the mirror cells. And we tried to analyze them. And the goal is to try to understand do. They have a predisposition to certain things what is their immune profile? Was there ability to metabolize certain drugs or not, and then sort of correlate the natural history of the disease was their genetic makeup, the myeloma genetic makeup and the micro environment was in the Bom omega. Are you looking at their broader environment as well where they live might be exposed to exactly. So we are doing that in collaboration with group down in Bloomington because you know, by zip code, you can figure out what they live what they exposed to and things like that. And we have sort of a that we ask the patients to help us understand, you know, their occupation. Whether they grew up things like that. So how long do you think that'll have to take to to get all the patients you want? So as you see I mean since November, you know, that's about four four months. Five months. We have one hundred. Seventy patients. So I'm hopefully, we can accrue all these patients was in two two and a half years. There's all new diagnoses or picking up pay our patients, you know, fr newly diagnosed relapse stations how common is myeloma to begin with. So my is about one and a half percent of all cancers, and we trying to figure out the exact incidents in Indiana's probably about twelve hundred new patients diagnosed a year, clearly the NIH has to you know, give money to this. But how else do you put money together? Dacians how else does myeloma research kit done as an avid runners, you know, I of about fifteen years ago, we were sitting with patients and trying to figure out how we can you know, sort of support myeloma research at Indiana University. So one of my patients said why do we just do five K for myeloma? And I said, well, everybody has a five K for mile on how about we do something different. You guys come to me from all over Indiana for a second of. Opinion, why go to your community and spread sort of word about the disease? And they said, wow, that's exciting. So how you know? But I'm not going to be writing a car to go there. I'm just gonna run, you know. And I year, you know, I wanted to go run to Fort Wayne. Okay. That was a huge far away twenty. Not really, you know. So what do we did is we saw in the first four years? We split it. You know, one day of frightening and one day of cycling, tell me about fifty miles off reading in the rest of cycling. So that's how miles for myeloma started. And then because the distance are getting like two hundred two hundred and fifty miles is just two days or three days of cycling. Okay. So we have, you know, come from Saint Louis, Indianapolis from Columbus, Ohio to Indianapolis miles for my we've raised almost five million dollars. But the most exciting thing about the whole thing is that we have patients who ride with us. It's organized by family of patients that do that. And so the thing about it is that makes me really excited to see you. My Loma patience writing. And I still remember one day because you know, you get these guys who wants to write was you. And they very really amazing cyclists. And they just you know, this is not a race. This is a group of people trying to write together to support each other and spray. Adored about my lowest. So if you have somebody already in Indianapolis, and the the other person's still in Tara hold is not fun now, it's hard. So I remember one time it was like I want to tame the group down a little bit. So I stopped everybody. And I said, do you know why we're doing this because of my Aloma? What we going to do about it? You know, we're going to spread the word we're going to try to raise awareness. We wanted to make sure that everybody understand this disease need to be cured. So I said how many of you writing was myeloma today, and there were two people. And I said how many a few writing, you know, was myeloma and still on treatment for myeloma one guy. I said, okay. So this guy is going to lead us and everybody has to follow him. Right. Do not pass this. So I was kind of probably doing it because I was tired when it's slow the pace down a little bit. So this guy grab a bottle of water? Pour it over his head, and we actually stopped at the bottom of a hill. And this guy was climbing so fast. I was like working hard to stay was when they say, oh my gosh. Why did I say that? But it was amazing to see how excited he was how aggressive he was climbing that hill, and it just makes me know that, you know, today myeloma patient can live a normal life. They is not, you know, a disease that stop you from living your life, and that's what we need to tailor therapies, so they can live healthy quality life, and hopefully, we can find a combination that cure them. So they're gonna stay on treatment forever. This healthcare podcast is sponsored by Indiana University school of medicine whose mission is to advance health and the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care. I you school of medicine is leading Indiana university's first grand challenged precision health initiative with bold goals to cure, multiple myeloma, triple negative, breast cancer, and childhood sarcoma and prevent type two diabetes and Alzheimer's disease. Thanks again to our guest raff avenue. Our for our discussion of multiple myeloma. What causes it doing about it where things might be going in the future? Listen to the healthcare trash podcast each and every month for information about health health policy health research, we'll see next month.
Medical education during the COVID-19 pandemic
"Welcome to the clinic. I'm Dr Sanjay Caca across the world. One of the biggest changes forced by the COVID nineteen pandemic was in the field of education. Really all programs were rapidly moved to a distance learning module, online and remote instruction has his own unique challenges, and that was certainly true here at Mayo. Clinic joining us to discuss education that time of covid nineteen is the Dean for Student Affairs in the? Mayo, Clinic Alex School. School of Medicine in Minnesota Dr Alexandra will key spinner welcome to the program Dr Spinner. Thank you very much Dr Car happy to be here so pre covid nineteen. Tell us about what medical school education was like. Interestingly, medical education has not changed very much over one hundred years of back in nineteen ten Dr Flex. Producer, report described how medical education should be optimized so before that we thought of the. Apprenticeship model where medical students or other individuals who were trained to become doctors were essentially at the bedside of the patient together with the doctor, and so they learned through modeling and demonstration. But he determined that it was important to establish some foundational principles and so medical school from that point on became what it is currently today two years of. Scientific foundations so within the classroom anatomy dissection. Pathology G. and just essentially the main sort of organ systems, and then the following two years, or actually at the bedside, so the clinical portion of the training where students are now learning really side by side with physicians, so traditionally She said this full years. How many medical students are actually involved in classroom? Education also hospital rotations. So within the Mayo Clinic, we actually have a relatively small medical school as you know, we do have three campuses campus in Arizona and a campus in Florida is well. The Florida campus is a two year campus, a clinical campus so years three and four. The Arizona campus is a full for your campus and he'll be graduating class in twenty twenty one so if you include a at all individuals within the school we have. have roughly one hundred, two hundred and eight medical students per year multiply that by four within the Minnesota campus we have roughly fifty four students per year, and so years one and two at one hundred and ten individuals in the classroom, and the same amount within clinical rotation, so either in the outpatient clinics or in the hospitals. Clearly, that's a lot of students across not just in in Rochester Minnesota or across the country. And that takes a lot of organization to ensure their educational needs met S, and then march happened, and so tell us what happened there to ensure air education was done safely quite early on the. C. Which is the Accrediting Association of Medical Colleges which oversees medication United States, and in Canada essentially released some recommendations, and they felt that it was important doctrine poll medical students from clinical rotations to essentially a optimize their safety in the setting of Colbert, especially in a very fluid situation where issues such as P P or becoming problematic. And so we did in fact, follow suit, and so early on about mid-march students were pulled from clinical rotations, and subsequently students who actually hold as well from the on campus, large classrooms, fifty plus individuals all huddled together setting because of the potential risks associated with that, it was quite incredible to see Zillions of our faculty of our students of our administrative staffing of everyone, our leadership in the medical school. We just sort of all pulled together, and made it happen, and so our dean of Academic Affairs Dr Darcy read quickly transitioned all of their learning. Virtually some explain what that meant. The first two years where most of the education is within the classroom setting essentially lectures were taught through blackboard or zoom, and our faculty really stepped up. They were extraordinary and so exams could be delivered obviously remotely that kind of thing for students who were in clinical rotations as I stated they were polled, and then it quickly what we What the the academic affairs brands able to do is develop virtual alternatives. So for example there was a model that was created regarding Kobe, and so, what aspects of Medical Education were important to occupy continent setting. Typically. Those who are at the bedside were consistent with what we call hybrid rotations where they were going to do a portion virtually, and as soon as the clinics were opened, the rest was going to be completed at the bedside is one I wanNA make about? The majority of medical schools across the country to continue advancing the student, and their curriculum switched to all virtual learning, which meant that a large number of medical students really never may have had that clinical exposure to some core rotations, but we at the Mayo Clinic Alex Kroll of medicine. The leadership disgusted and we felt that our priorities were twofold. One was to really prepare students to be to be a well prepared physicians so to make sure that we did not decrease. Decrease those core educational opportunities to make very competent and second is to keep the students safe. We were happy to to to find out that extra students are returning to the clinic in June and so now having completed for example few weeks of psychiatry virtually. They're going to be going to the bedside. Currently We think that that will advantage them as well in our match up more importantly that it's preparing them to be competent physician a great point that you make. In terms of the hands on education is critical, not only for the students, but the patients themselves. I think the patients really enjoy that and as a practice is opening up safely as we've seen as you said through June. The students will be back. I think that's a that's a welcome relief for them. Tell us. Education can be stressful and you know. Wellness is an important part of how a students go through their training, or what have you done in the medical school to ensure the wellness of our students? We built program a few years ago called the Thrive Program which essentially is an acronym that stands for training medical students to become a humanistic. A professional individuals who are resilient and healthy. Who are! Innovative DOT leaders. And who also experienced individualized success to people casually excellent, and so we don't view our responsibility to end when they graduated, responsibility is to launch them in their careers I wish I had been taught self care when I was going through medical school and residency and fellowship, and so we feel that knowledge and procedures are important, but at concept of how do you balance? South here so that you can actually be more effective as a physician and decrease the chances of of burnout, which we know is associated with inferior patient outcomes. Were lucky because we already had a strong program in place, and so what we did is we just transitioned it to being virtual? So, we created opportunities for check INS on zoom for our students. We have a program called seawall student wellness activities where students can apply for two hundred fifty dollars to participate in wellness activities, and they've been very creative from baking, too. You Know Basketball tournaments to dragon racing up in the cities which I admit I had up. It's boat race I didn't know that was, but now they're doing it virtually, so they're buying online games that they can then engage with one another and check INS. Were they all order a cookbook and the recipe together at the same time? Time we also make sure to be interfacing with them, so we have virtual hours where they can connect with us. Town halls class meetings where everybody comes together, because that's social support is so important especially during cove where people feel isolated it's interesting you mention that about the social distancing and things like that, but as you said, everybody has innovated, and actually now the touch points in human connection through technology and virtual learning is actually probably enhance their education as opposed to previously where you're sort of all pigeonholed and doing several things at the same time. It's so true. You bring up a related on I. Think what we've discovered with. Medical Education is there are pearls and silver linings to be aimed, and we've planned to continue to implement those going forward a you mentioned Lansky spinner about the match. Can you tell people about what the the the match archly is? Many may not be familiar with that sure, so the match essentially is referring to a a process through which a senior medical students choose a specialty and then go through. Application process and interview process to eventually match into residency. So. Medical School is foundational, but then and is essentially the same for all students within a school, but then they decide what they want to become. They want to be north of Pitas such as yourself do. They want to be a hematologist? Such as myself could Cetera, and so there's obviously many specialties they can pick from, and so that is what the match I to and The actual matching process occurs in March when they find out where they're going to be going now. That takes a lot of traveling as you can imagine a traveling for electives to explore programs what we call additional electives, especially in competitive surgical fields impeded surgery plastics, etc. The second dimension is traveled for interviews. And so once again the WGC to their credit as well as other accrediting bodies have stated that they do not recommend any in-person abuse. They're going to be virtual and they have also recommended that there'd be no at a distance if you will audition electives, and so we are having to strategize, and ways were so lucky that our students are at Mayo because they can easily extend their training time within the specialty in fourth year from one month to two months. We have the capacity. We have top programs in all specialties. It's harder for smaller institutions who may be rely on community, hospitals or Affiliates who perhaps do not welcome medical students, because they're dealing with their own crises during Kovin, and so it's different. Students are nervous. We don't know what's going to be were still we're building. Bridges were walking across it this year, but as you said, this may be something that's here to stay into a hybrid program where you have a little bit of virtual, but also face to face connection, because as you said the travel aspect, the time aspect that that's dedication for the students to come back and forth and expensive. Student spend over five thousand dollars during the interview process well. Alex anything else that we should talk about that. We didn't touch upon. I'll just say that it has been a learning experience for all of us I. think that we have gone through the four stages of grief during. Kobe. I'm glad to say that I feel that we're on the other side. And, we're looking at how we can actually thrive through this I think that four students for all children and teenagers who are having to adjust to virtual learning They've learned to be more reliant self reliant They've learned to be more self accountable and I think that it's taught them. A tremendous amount of resilience which I think ultimately leads to better. Health. And more more joy and happiness in life so again, perhaps another silver lining thanks to dog tags on underwear, lansky spinner Dean for Student Affairs at the Mayo Clinic Alex School of Medicine in Minnesota who's been talking today about how innovative measures have been taken to protect US students and ensure their wellbeing their education dot Alexander Will Lansky, spinner, thank you for joining us. Thank you for having me today. Mayo Clinic Q., and A. IS A. A production of the male clinic, News Network and is available wherever you get and subscribe to your favorite podcasts to see a list of all the Mayo Clinic podcasts visit News Network Dot Mayoclinic Dot. Org then click on podcasts. Thanks for listening in be well. We hope you'll offer a review of this and other episodes when the option is available in comments and questions can also be sent to Mayo Clinic News, network and Mayo Dot Edu.
"A Choice to Destroy Lives"
"He everyone welcome back. I am your host Saadia and we are kicking off with her new season of recurrently. I am so excited You probably noticed. We took a small hiatus in recognition. That so much is happening around us and like you be needed. Time to adjust and grappled with what this nation and the globe is experiencing think. Everybody is feeling a mixed bag of emotions. Some people are anxious even fearful others like me are physically and mentally exhausted and then there are those who are hopeful hopeful that this is a reset button sort of forced acknowledgement of what has escaped gratitude. I know it's a weird time but the only silver lining in basis fat right. Now all of us are in a week contradicting the robotic. Hectic schedule that we have normalized as productivity. At least. That's how I see it. Do All the New Yorkers who are still in the city? I just want to let you know I am with you. I am learning how to be present with myself and as I am staying. In my house and letting health professionals lead the charge against this pandemic. I'm also thinking about other stories that needs some attention. Covert nineteen isn't the only news percolating and we can't let these other stories go unnoticed. So today's episode off immigrants will be on backup and the agent deals surrounding it. Supreme Court case now we will explore together the programs recent past its current status and its future prognosis and as we explore this topic alongside the historical context. It's extremely important that we include primary sources and we've done that in this episode so basically scattered in this episode are audio snippets of brave daca students who that sharing data expedients will garner awareness and mobilize communities into action. This species sound completely unrelated. But I want to start by talking about numbers and you may be thinking. Why are we doing that? But there is a reason and the connection will soon be clear. I think begin all somewhat agree that people process things in numbers because numbers are short and simple. I do that for one. Numbers help US Chart History. This shed light on phenomenons. That a couple of words are honest. Even sentences cannot do justice to while they are not the entire story. I must say that numbers. Indicate his off systematic change or reasons for systematic change. Now I would like to share some of my findings on Daca from sources including news outlets and research centers. So that when be implored. It's because the facts do so you know. The thing that we are creatures of habit could also be said about logic. I would at least like to think that we do feel more confident. When any of our arguments are backed not only by whatever like social economic cultural and political opinions we give but also by empirical facts and here are some startling so priests yourself. Some of you may already know what there are around. Seven hundred thousand DACA recipients living in the country. These are your friends. Your neighbors your children's friends or co-workers if DACA gets Wolverton the projected job loss for New York City. Only in two years would be over twenty five thousand two huge number. California one hundred sixty thousand and for those born and troop packers fans the at least six thousand in the state of Wisconsin. I know some of you may be rationalizing jobs. Lost means jobs available right Actually not quite. These numbers were calculated in December. Two Thousand Nineteen when the employment rate would add low of three percent. Losing these dreamers would mean a pronounced disruption to a host of businesses and industries retail restaurants health care and education to name a few nine thousand qualified. Teachers would lose their jobs and seventy five percent of the top twenty five fortune. Five hundred companies would be safely before St- to replace qualified employees and the physicians. And the trainees at risk with serve an estimated five point one million people in the course of their career. I would like to think these numbers honestly to even the most pathetic listeners. Now to be honest what matters to me is not just these numbers as an immigrant. I really believe that we are the country of multiple origins. We are a country of collective narratives. Now some of those narratives may be more trouble than others. Some of US may be documented others undocumented but all of us have one thing in common. And that's our dreams take listen to what these dreamers have to say hi. My Name is Christopher Ponce Medical Student the Oregon Health and Science University School of Medicine and I'm also a student so since the DACA program was established actually had a pretty phenomenal experience with it. The DACA program only allowed me to step out of my comfort zone. Set alight and advocate for immigrant. Students like myself at my university but also some of the work that I've done in DC. It also allowed me to pursue a career medicine because without the DACA program of would now be medical school right now. My name is Amanda. I am twenty four years old and a docker scipion. I migrated from Peru when I was six years old. I grew up in Orange County. California DACA law school graduate from California State University. Fullerton DACA has really opened up pathway. That I never imagined were available to me. Thank Sadaqa I was able to find an internship in Congress working with Congressman bielsas in the nineteen back for fellowship at forty. Us and I have stayed on ever since as a fulltime staff member. Not only has Jaakko allowed me to pursue my career goals but has provided me the piece of nine that I am safe for at least two years. The thing to do is the Daca is not just about employment and citizenship. The way I see it it's basically a referendum on our sense of existence as a nation and do we want to be a nation of discrimination and violence or do we have to be a nation of Amnesty and growth his Daniella. Hi My name is Daniele Vieira and I'm a doctor recipient. Daca has been extremely important to me. I've had it since two thousand twelve and need empowered me to go to college. It allowed me to work through school to help me pay for to get internships throughout school. And then now at enables me to work in my field of corporate finance. Don't even know what it would mean. If I were to lose it. I think I would no longer be able to work and I would no longer be able to provide for myself and my family and I would say that no matter what the Supreme Court decides we are still a community of emigrants and we're still going to continue to support and protect each other and fight for each other. So we are more than our immigration. Status is say that we are. And that's that's what matters the most so far we have talked about what will happen if DACA is resented. But let's look at the historical context of Dhaka now DACA was enacted in two thousand twelve. As one of Obama's executive actions on immigration shot for deferred action for childhood arrivals. It's basically an initiative available certain undocumented individuals who by the way game to the US before they were sixteen so they were basically children when they came and they have lived here for more than five years and by the way the requirements for Dhaka are stringent common misconception even among liberals that daca equals citizenship. No it's not a guaranteed to permanent residence. It's only temporary protection hookah guys. Let's pause here. Take deep breaths and recap some of it. I want to emphasize temporary. Now for those born in America. Imagine having to refile your citizenship. Save every two years and I've been through immigration process in America. It's extremely arduous. Along and annoying. Imagine the uncertainty. The headache constant. What if I mean for twenty four months Doug protects the grantee from deportation and yes it makes available work authorization and opens applications to social security but all of this is not greedy forever? Which many of us take for granted? Now my husband and I also went through immigration process from f one to each one to green God's citizenship all but at the end of the day we got our passports we nationalized citizens. Unfortunately Doug does not give that guarantee to me. It seems more like a faulty safety net with a lot of institutional holes his Daniella again. I have renewed my Daca way earlier than I needed to. Because I've been worried about the Supreme Court decision so at the end of November. I submitted my Daca renewal and two weeks ago. I got it in the mail. The experience was stressful. Like it always says because there's a lot weighing on it. I'll let's talk about what happened. After trump administration took over in two thousand seventeen. The trump administration announced that it was ending Daca. Fortunately a band of people organizations and states pushed back thank God for that on June twenty eighth two thousand nineteen two years after trump's initial threat. The Supreme Court decided to review these legal propositions now fast forward to November twelfth. Two Thousand Nineteen on this T-. The Supreme Court held oral arguments. Now the transcript. Arguments is available on their website. And it's basically on cases delivered by Solicitor General Noel Francisco. He challenged Daca on three main fronts and I would really urge you guys to go and check out these transcripts if you are interested. The first objection was based on legality. Basically that the executive branch does not have power to enact such an initiative. The second insisted. Dhaka has no limiting principle that affects the influence of other government divisions like the irony which also deals with immigration. And here's for the third now. This one is real GEICO and I quote because DACA actively facilitates violations of law by providing advanced forebearance on-court. Now I am not ally as most of you already know so I had to do a quick Google search. Here's what I discovered now for parents in its legal context means to not enforce a claim by contract date so in my opinion in Layman's terms and especially in this situation it means to tolerate access to certain benefits like social security without due process by the decision on Daca is expected no later than June. Twenty twenty so basically. It's two months away. Here's how I see it. Keeping Daca not only affirms the livelihood of hundreds of thousands of young Americans but also keeps our nation intact are these young dreamers are Ytl to the economy our health and care and basically the essence of America. And as Judge Sotomayor bluntly and Faye brilliantly summarizes the situation and I quote. This isn't about the law. This is about our choice to destroy. Lives Unquote by descending DACA. I believe the government is literally trying to destroy lives of these dreamers. I know all of this is extremely intense and heavy. And we've been dealing with a pandemic and you must be thinking. What can we do? So here's what we can do together. Stay informed that's the most important thing if you're documented and not immediately connected to people on Daca I would really suggest that. Use Your privilege to support and educate others about Daca knowing the status of Dhaka and it's Supreme Court case is one thing sharing it's important so are the grassroots organizations nonprofits even state legislatures big up news and organized to locally protect. An advocate is far-reaching and extremely necessary now for those whose lives are more directly impacted. I I want to say this. You're not alone in this week and fight and his advice from Christopher. I really do implore Daca students who are listening to this to please please renewed application. I do not see the Supreme Court hearing and ruling as reason to not do it. There are many resources online. I know informed emigrant Dot Com has a website where a map we can find immigration clinics that provide pro bono services but also a lot of organizations that are providing financial assistance for those who cannot afford the application feet. So I really do juice that we should continue to be active negations political environment and showed garment that we're going to keep pushing forward and diversify strategies and in order to do that we have to save by renewing application. So that. Thank you all so I want to share some tools out there for those who are motivated to learn more about and stay informed on. Daca you guys can basically check out forward dot. Us and Pew Research Center for Trustworthy. Research reviews a news not just on Dhaka but other immigration issues and also rises Texas another great organization that immigrants has always supported mean bio informed immigrant as mentioned by Christopher is an online resource in both English and Spanish for immigrants seeking assistance in the renewal process. And this is very important. The website will link you to a local renewal clinic and also contains resources on immigrant rights. The Doug Application Process and to legal council and in the end. I urge you to sit with this story considerate. And all else twenty twenty has propelled us into. Perhaps you will open a tab and check out the sources or perhaps you share about Daca at dinner with your family guys. Whatever you decide. Please keep the conversation going. This is an issue that should matter to everyone. Resenting DOT COM means turning back the clock on progress and giving in to a system that we know by now is plagued with elitism and prejudice. So I'm basically asking you to push back because I believe in growth and I also believe in recipients and qualifiers of this program. I strongly believe that they make our community richer and they make our ideas better and they also informed the vase stories that weave together our communities in the end. I want to thank everyone for listening. You are the best. Thank you for coming back every week. If this was your first time. Welcome to our show. I hope you guys come back for either brilliant stories. I also want to give a shoutout to forward dot. Us for collaborating with us on this particular episode to wall the brilliant daca recipients who shared their perspectives and to our content writer. Ud who did all the research and created this amazing narrative until next time when we have another incredible story take care.
Dr. Lloyd Minor: Why we shouldnt panic about coronavirus, and should start taking precision medicine seriously
"This episode is brought to you by US studio. You're listening to us. So you know how effective podcasts are. Getting your message across. Give your team the information. They need with US studio. You Studio manages host distributes podcasts for businesses. They keep your messaging secure and private and streamline information so your team has fewer emails and meetings take your company to the next level go to use studio dot com today to request a free thirty day trial. That's the letter. You Studio Dot Com. This episode is sponsored by MB. Show a trade show where technology meets entertainment and media the NABC show floor opens Sunday. April nineteenth is a place for innovation and disruption across all forms of content and features the startups and market leaders defining the future of entertainment platforms. See what's next in content creation and delivery at N. A. B. Show April Eighteenth through twenty second go to N. A. B. Show Dot Com to learn more and to register for a free exhibits. Pass use the code recode. This free offer expires April fifth. That's an ABC show dot com and use the Code Rico for a free exhibits pass. Hi I'm Tara. Swisher editor at large recode. You may know me as someone who could probably be a very good neurosurgeon. I'm used to getting into people's heads but in my spare time I'm just a reporter and you're listening to Rico decode a podcast about power change in the people you need to know. Were part of the VOX media podcast network. Today in the Red Chair is Dr Lloyd. Minor the dean of the Stanford University School of Medicine. He's also the author of a new book called discovering precision health predict prevent and cure to advance health and wellbeing which comes out March twentieth. We'll talk about the big public health issue. That's on everyone's mind right now. Which is the corona virus outbreak as? Well as how tech is changing the study and practice of healthcare doctor minor. Welcome TO RICO. Decode for your. I'm going to start going to go into your background. But let's talk about right now. The Corona virus anyone who has any ability to talk about it intelligently? We love to talk about having tomorrow having Ron Kline. Who was the? Bolas are you're under the Obama Administration. Talk a little bit about where you think we are. And how Stanford is handling this because I think every probably every major medical center is discussing this at length. I think this is a serious public health concern. But it's not a cause for panic specifically to your question about Stanford we're prepared None of us knows the extent of the spread but we just opened two wonderful new inpatient facilities children's hospital. We opened about two years ago. A new adult hospital. We open just this past November. They're equipped with private rooms rooms. That are ready to take care of patients with infectious diseases Our staff are trained. We have supplies of personal protective equipment. So we've been in preparation for this or an event like Cove in nineteen since before the current problem with this virus began. So when you say not panic what. People are panicking. Although the stock market's getting affected people are canceling things. What do you how do you? How do things like this player? We just don't know because everyone talks about this idea of the big one. I've been reading stories but some day. There's even big when this may not be the big one but tunnel but what. How do people not panic. What is the thing to do? What is the responsible thing to do? I think the way not to panic is to focus on the things that we know. Prevent the spread of the virus number one. We should wash your hands. Twenty seconds With soap and water. Also we should avoid touching our face Something that we do commonly But that we know that The spread of the virus by largest through mucous membranes. On our face nose eyes mouth so those are two relatively straightforward but requires some intention and planning Things that we can all do that have been shown to curtail the spread of viruses like Cova nineteen and specific virus. Exactly what about this cancellations quarantining because it shows shown up? Now it's a New York. I guess this is the viruses spreading and this one seems to seems to stealthily. Stay somewhere for a while right. We we I think other organizations are watching carefully recommendations from the CDC from local and county health departments with regard to how we advise our employees with regard to how we plan events the CDC did last night issued a recommendation that education's look at abroad programs consider bringing students back from those programs. So that's something. We began to look at immediately as well as determining where we have. Students will watch carefully the recommendations coming from national organizations local organizations and act accordingly right and and so people should not be hoarding masks. This is something that This surgeon general said. I've heard lots of doctors talk about it. This idea that that will protect you. That's not the case correct. That's correct the Specific recommendations from the CDC and other organizations is that just wearing a mask if you're not infected if if you're just wearing it because you're thinking it's going to prevent you from getting infected that's not likely to be effective and also it's likely to prevent the mass from getting to the places they need to get matches and taking care of patients who do have the effect y will not prevent that because the microbes get in. Is that correct right? What we what we know so far. And this is changing by the hour Not to mention by the day Is that this virus like other virus. Specific viruses in the family of Corona viruses is spread by droplets so the virus gets into particles of Saliva or other bodily fluids and then it's transmitted either Through a cough or a sneeze or through close contact with a surface that is had droplets on it a mask. Although you know in some sense it might be effective. It's not the principal way we prevent the spread of the yourself. It would prevent the cough from going outward. Actually sick it does right. But if you're trying to prevent the infection again it's handwashing avoid touching your face right because membranes right so the mass to be used for healthcare workers and people who are sick who actually want to prevent from coughing on a table or or more of that is central to. That's what it should be used for. If you're actually sick so screw you should wear. If you're not. You should not correct right okay. So do all spent a lot of time thinking about this idea of the big one. The idea that there is there is a virus or or a play. That's going to affect humanity. We now want to get into position because medicine's changing too at the same time exactly. I think what's happened over the past month. Period past couple of weeks with regard to corona virus really underscores the importance of needing to focus much more attention on infectious diseases. Those emerging in those. That are already here. There's been very little work done. A new vaccine development In recent years. There's lots of reasons for that In terms of the business model in terms of the amount of R. and D. Cost Required to develop new vaccines. We need to rethink that and we need to learn a lot more about human immunology and how it is that we four vaccines how it is that we can mobilize the immune system in each of us to fight off infections like the infection from corona virus. Our knowledge of human immunology in the human vaccine response is still fairly primitive. That's an area. We focused on a lot at Stamford. And we'll continue to focus on in addition to the work. That's going to go on an industry. I hope To develop a vaccine for cove in nineteen and also better vaccines for the flu and and other related viral illnesses. Hi this is a good segue into talking about the yearbook described precision medicine. The idea that can help us in this way. I mean I wrote a column about about the things obviously working from home and things. There's a lot of technologies now that prevent people from hitting each other. But you're talking about something else. Explain precision medicine but what you mean and where How it's going to help our health. We are strategic vision in Stanford Medicine we describe as precision health and we call it health whether the medicine for the following reasons in the United States. We have a great sick care system. In terms of organ transplantation the latest treatments for cancer for goodness sakes. If one of our family members has a disease like severe heart disease or cancer. We want to get the very best individualized treatments and we do relatively well within the United States. But shouldn't we be taking those same enablers of genomics and data science and applying the much earlier on to predict and prevent disease precision health? Therefore for is about healthcare. It's about learning how to keep us healthy. Get Sick we want precision medicine which is about sick care which we for sure do at Stanford but the way we know we'll be successful a decade. We'd been successful a decade from now and our vision for precision health. Is that a lot of the severe acute diseases we treat today. Like cancer and heart disease will either be prevented in the first place or they'll be less severe because we will have detected and treated them earlier therefore they're three components. The precision health predict prevent and cure. But really in that order. Because we're if we're able to predict The likelihood that you are I will get a disease. We're much better equipped to prevent it from occurring in the first place and we can't prevent it if we diagnose it much earlier we'll be able to treat it more effectively than if it was diagnosed at a very late stage. Cancer provides a good example. Knowing are risk factors is going to be increasingly important and advanced diagnostic tests that are focused on detecting cancers like pancreatic cancer ovarian cancer much earlier. Should have an effect on the outcomes because today those two cancers in particular pantries and ovarian cancer are classically diagnosed very late in their course and therefore have a relatively poor outcome if we detect them earlier we should be able to treat them much more effectively. Talk about how that comes gets. Precision medicine is defined as individualized medicine. Correct is that. Am I wrong about that? You're right and really. The term precision medicine began right here in San Francisco Back Two thousand thirteen two thousand fourteen when sue Desmond Hellman was chancellor UCSF? She hosted a national conference on precision. Medicine is the first time I'd heard those terms us. Then President Obama pick that up as being an overall national goal and precision medicine is about using genomics and data science to personalize the treatment of the best example. Is Cancer Today for example? Our Treatment Outcomes in breast cancer much better than they were a decade ago because no one with breast cancer gets off the shelf treatment. Everyone with breast cancer has a treatment protocol. That's individualized to the disease works. Because I think people in our city that they medicine has been sort of a a kind of I. Don't see spray and pray but off the shelf. This everyone gets the same thing in this. Testing is done. Everyone is not the same let so the idea of precision medicine. Is that you tailor. The medicine to the individual person based on their genomics and other thing. That's right we can continuing Example of breast cancer there three very important receptors that are tested in every breast cancer. Patient that therapy for that patient is determined based on whether or not the person has receptor or not also the status of any notable any involvement of lymph nodes impacts the choice of therapy so whereas in the past like maybe fifteen to twenty years ago the treatment would have been you know. Mastectomy dissection radiation therapy same thing. That's not the case today. And as a result the outcomes are better because we are able to tailor the treatment to what we know will work best in the patient with that particular disease right and not and not treat every person the same so that has been a big boom for cancer what other areas cancer being. Probably the most notable one but also in heart disease today a lot of advances in predicting and preventing heart disease and also intriguing severe heart disease and heart disease points out how we can make progress in reducing the incidence of a deceased quite a bit and of course last twenty twenty five years. It was a study begun now sixty years ago. The Framingham study in a suburb of Boston. That defined the risk factors for heart disease high cholesterol high lipid levels the relationship of high blood pressure as a result drugs like lipid lowering drugs were developed and we also had a renewed attention reducing the incidence of smoking. Better control of blood pressure. All those factors coming together have reduced the incidence of heart disease. Should we be able to do the same thing for other types of disease? I swear the risk factors may be a little bit harder to deduce than they were for heart disease but still now particularly with data science with the ability to aggregate large amounts of data. We should be in a much better position for each one of us to know what our likelihood of developing a disease is and how we can best prevent that disease. Let's talk about that idea. So the you take a patient precision health that would be to to figure out. I've heard lots of these companies now and a lot of tech people are going to them what they're going to die off. They're going to find out what they're probably going to die of. Based on this this idea of what your risk factors talk about how that works individually and then we can talk about it for everyone out for for lots of people are genome plays a big role in determining what we're at risk of It's not everything though you know. It's a sad fact in America today. The best predictor of life expectancy is not our genetic code. It's Zip Code in which we live and I think that's something we're going to have to see the social environmental behavioral determines. I write about them in. The book are going to be areas that we have folks a lot more attention on in academic medicine in the US healthcare delivery system than we have in the past that being said our genome does give us insights into our risk factors for variety of diseases. That's a starting point. But it's really only a starting point as we look at the interaction between the genome and things in the environment. That's where we're going to get a much more. Robust picture of what risk factors are and what we can do about it all right when we get back. We're talking about how you do that. How you do that. And how you spread it out to most people in this country and we'll talk a little bit about for not Medicare for healthcare for all in doing that when we get back. We're here with Dr Lloyd Minor. He's the Dean of the Stanford University School of Medicine. We'll be back after this. This episode is brought to you by command line. Heroes a podcast about the tech. You're probably using right now. Mainframes personal computers floppies smartphones everyone. Some of these machines succeeded while others failed or hardware got smaller and smaller while processing faster and faster command line heroes. The award. Winning podcast from Red Hat is back for its four season and this one is all about the history of hardware host Ceron Youth Barak. Brings you the story of the people who attempt the extraordinary and persevered in the face? Major obstacles head over to the podcast platform of your choice to listen and subscribe to command. Line Heroes. You'll find the first episode of this latest season which begins with a look back at the mini computer and features interviews with some of the subjects of Tracy kidder's classic books. The soul of a new machine. 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Indeed gives you smart tools to help you make hiring decisions quickly and be confident that you're making the right hire for your team. Post your job today at indeed dot com slash decode and get a free sponsor job upgrade in your first hosting that's indeed dot com slash decode terms conditions and exclusions apply offer valid through March. Thirty first twenty twenty. We're here with Dr Lloyd Minor. He is the dean of Stanford University School of Medicine. We're talking about. His new book called Discovering Vision. Health predict prevent and cure to advance health and wellbeing. Getting precision also talk about you. Were talking about certain things vision medicine which is when there's certain illnesses you zero in on them. After you know about at this is before you know about it. Correct is that is that the way would put it or not. That's correct Matt. It's about developing is about the science of prediction prevention which classically hasn't received as much attention as the science directed at curing disease. After the fact right but for example after it's been diagnosed as Everson diagnosed oftentimes at a very late stage for example. There's a revolution going on right now and diagnostic testing with the application of data science and analytic methods to detecting a small signal in the midst of a lot of noise. We should have in the not too distant future an array of diagnostic tests. That will give us better insight into whether or not we have an early stage of a disease that I think could be revolutionary. We talked before about cancers. We classically diagnosed late payments and ovarian cancer. We should be able in the future through blood tests to see and diagnose those conditions much earlier at Stanford. We've been a leader in the revolution in Molecular Diagnostics. Goes back more than a decade. When Steve quake and his colleagues were the first to use micro fluid ix to do a chromosome analysis of a fetus from a simple blood test in the mom and as a result of that technology and related technologies today the use of amniocentesis which an invasive procedure to take flu right today. The use of amniocentesis dramatically reduced. Because we can get a comparable amount of information from a simple blood test. That's one of the mother of the mother right Which for those who have not had it. It's very invasive it's not a little invasive amniocentesis right exactly because it has a risk to the fetus The blood test works because there's a lot of DNA from the fetus. That circulates in the MOM. But you can apply that principle other conditions. Dna from a tumor from a cancer. That circulates in the blood. And then how do you detect that DNA? It's not as much of it as there is DNA from the fetus but still with with advanced analytic techniques. We have today. We still should be able to perfect these diagnostic tests and roll them out. So how this is not the way. Our healthcare says it is about sick care. It's about the cure. It's about finding out you have a disease and being surprised by it because most people die of something right you know talk about the way it set up and then later I want to get into the question of data like what do you do all this data but talk about the way we think of healthcare because it is about cures after the fact essentially several reasons for that one is the way we finance healthcare in America which still at his base is fee for Service System. That is we pay for units or increments of care we pay for the doctor's visit the Blood Test The radiology study increments of care that are not necessarily. Our payments system is not necessarily linked to outcomes therefore there has been a move which continues today and I think needs to continue even more in the future a move towards linking payments outcomes and move towards bundled payments and ultimately a move towards being responsible for the health and wellbeing of people who were in a health plan or in a delivery system. What are the reasons that there hasn't been as much focus on early stage diagnostics or prevention? Is that those. Don't necessarily translate into increments of CARE. There is a code for every office visit for every blood test There's not necessarily the same type of code to doing the type of nutritional counseling that perhaps could help to better control their diabetes or lower. Their Blood Glucose level. It's in that area that I'm really excited about advances in digital health. A lot of those going on right around us here in the bay area and that is we know that technology has disrupted pretty much every aspect of our lives except for health and healthcare tarnishing. Yes finance would be the other one right right. Oh you know we we. We do online banking today but the way we order goods and services. Everything's different but still by and large you know. Pick up the phone and call to make a point of doctors. We still transmit health records by fax machines. I can't believe it but we do Where the only industry that really still uses fax machines. We need to move beyond that. We need to leverage the benefits of technology. And bring them to people. But we have to do that while being cognizant of the security of the data and the privacy. That's most when I talked to doctors as most of the excuse for it is that is hippo or whatever talk a little bit about that explain hippo for those they they. They were protecting health records. Essentially that's right. Hip is making sure that a doctor healthcare delivery system doesn't go out and sell your data to someone else and reveal your health status to ensure something like that without your permission it also requires doctors dated and delivery systems to maintain the security of data. So that it can't be hacked or or stolen. The intentions of hip are absolutely correct. We also have to figure out ways to combine and aggregate data defying it but to extract information from the data. We have to bring it together and I think a lot of the work. That's going on now through the national coordinator of Health Information Technology moving forward with regulations. That will require more open architecture. Still protecting the security of data and and the role of patients decide how their data is being used but to require that when I want my health data shared with someone else or when I want to access it I can in the way I want to access it. Those types of requirements need to move forward when they do they will enable us to share data in an appropriate and safe way better than we can today. Whatever the reason is because of this. What is the reason given all these other changes across society and sharing of data? What is this just this or or what? What is the problem? Is that the payment system. If you had to point to it there are lots of factors but one is that there haven't been the incentives in place to make data interoperable interchangeable in the way that there have been the incentives and other industries for example. You mentioned Fintech before you and I can use. Atm Card Pretty Much any team on the planet today right. Imagine a financial services organization that said. Well we'll give you every customer a card but you can only use it at our. Atm's would we stick with that organization. No I think there's a strong role for consumers to really be pushing our doctors our delivery systems that I would access my data when I want to access and I wanted to be portable in the ways that I wanted to be portable. I want to be the person in charge of making those decisions. I think consumers pushing for that will help ultimately to drive the regulatory changes and also this shift more towards bundled payments so that there's there aren't as many incentives for delivery systems to prevent their Their enroll leased from looking at other opportunities when it comes to preventative health. You don't have that that's not done. And why is that from your perspective? The idea given and then we'll get into people carrying devices and knowing what they're walking and things like that but the idea that the system is more oriented towards the end versus the beginning of couple of reasons why prevention hasn't received the same attention as treating and curing disease one is. That is fundamentally about behavior. I mentioned avoiding. Oh seventy percent of the determines health or social environmental and behaviorally related. I moved here from the East Coast over seven years ago and when I was getting to meet people in the ecosystem I met with prominent biotech venture capitalists and I said well. Is there something they've if you hear a pitch about something you say thank you? I'm not interested. You know you're wasting my time. And he said Yeah anybody who comes to me saying that they have an idea for how to change behavior. I'm not interested in it. Became very discouraged because it is fundamentally about be up. Now fortunately we've seen Startups that are doing that. Particularly in the diabetes space. This is where we need to go it. It isn't easy but what we know is that technology can help in creating communities and communities can help support behavior change so one reason it prevention has not received as much focus first of all it's hard and insist viewed as being soft because it is so closely linked to behavior and social environmental factors. We need to get over that. And focus a lot more of our time and attention on the science of prevention and a leveraging digital technologies to help prevention about those digital technologies. Because they've been a boom in them everyone's carrying in carrying different fitbit's whether it's that or there's all kinds of groups That and companies. That have started to do that. To be constantly monitoring people how do you look at that trend? Well I think the opportunities are great. The risks are also significant. And we have to figure out how to leverage the opportunities but also always protect the privacy of individuals and the security of data. We we collaborated with Apple. Using Watch to detect the most common arrhythmia atrial fibrillation area. There was there was a number of companies that that's right A. Fib oftentimes goes undiagnosed until it causes a big problem stroke. Now this is a a a hardy retired. The heart beats irregularly right and The coordination between the top chambers of the heart and the bottom chambers is distorted and as a result people can form blood clots which can go on 'cause strokes and other problems since it isn't a rib mea. Th you measure heartbeat if you measure measure rhythm you should be able to detect when it occurs we conducted a clinical study a clinical trial enrolling over four hundred thousand people and using watch as an alert and then for people who got the alert that they might have a Fib. They were given the opportunity to receive a patch. Ekg where that for about six days. Send it back in. And then we could coordinate and and compare what the watch says to what the watch was saying. There was a strong concordance about eighty four percent of the time when the watch said the person has a fifth the EKG said that that's the case also so that was encouraging apple's going to extend that study with other collaborators Johnson and Johnson and others every time you and I fly on an airplane. Those jet engines are being monitored hundreds thousands of times. A minute why can't we have the same sort of thing for our health particularly for those who are at risk of something. Like a major heart rhythm abnormality. We should be able to do that. It's within our grasp today and we don't do it because it because I think Cost one thing because when the iphone came out it was only a small segment of the population had access to a smartphone right. Mitt and that's not the case today Most people have smartphones. I think the same thing will occur digital health monitoring devices. There hasn't been. I think it gets back to. There's been less emphasis on prediction and prevention than there has been on cure. There's been less investment in that area but that's changing digital health startups now. There's a robust investment ecosystem. We have seen in the past year to some exits of those early stage. Companies in meaningful ways that should keep investors interest in digital health. But I think it's going to be a combination of the investor segment of getting us as consumers more comfortable with measuring things like our heart rate and and having that going in the background and also getting us is delivery systems really viewing ourselves as partners with our patients and helping our patients decide how they wanNA monitor their health and how we can help them do that. So when you're talking about all these digital companies they they're they're pretty widespread. Though they're I mean they're probably spend more widespread amount a group of people a wealthier group of people who are monitoring. Their health is obviously here. A lot of people. I've I've Whether they're carrying the fitbit's whether they have the things on the wrist whether they're doing all kinds of diabetic stuff. How does it get out to the larger group of people right? I think it it makes sense. Then you have a lot of data yes exactly. I think it will get out to a larger group of people just as smartphones got out to a larger group. They started with a small segment of the population as they began to deliver more and more useful information the adoption of smartphones grew. I think we'll see the same thing with personal monitoring devices also. I think we'll see more and more delivery systems working with patients who wish to use a device to enable them to do that in a way that it's not interfering with their life so we know that the most useful devices the ones that actually have the greatest stickiness are the ones that don't require a lot of effort on our part because most of us don't want to spend a lot of time and effort on it and that ability to operate in the background and monitor our health in the background should increase. As time goes on a couple of things I write about in the book that are encouraging still early. Stage not available for general use. Today is a Smart Mirror for example. Most of us in the morning. We're looking at a mirror. We tell a lot about our health about how. How're facial? Appearance? May Change over time so that we have you look in the mirror and for example. If you're becoming jaundice that'll show up in your is The amount of adipose tissue fat that you have in your face is an indication of your overall health. There's lots of different things that if you're making a measurement repeatedly over a long period of time very subtle changes can become significant. And that's the notion behind a smart meter smart toilet also operating in the background. That can look for early indications that is going on with our health brought by measuring this. We're going to get back talking about this when we get back. Especially around the data implications and the privacy implications where here talking to Dr Lloyd. Minor? He's the head of the Stanford Medical School Essentially And he's written a book about precision healthcare. We'll talk about that and more when we get back. This episode is brought to you by. Us Cellular. There's never been a better time to switch to US cellular. 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Mar APP is designed to work with most new. Hp Printers Beach P. Smart APP is available in Google. Play or the APP store visit. Hp DOT com slash. Get real to shop compatible printers. That's HP DOT com slash. Get Real or here with Dr Lloyd. Minor his book is called Discovering Precision. Health predict prevent and cure to advance health and wellbeing. We're just talking about smart mirrors and smart toilets. People make fun of people for doing that. In Japan there there was always like. Oh they have these independents. The do you imagine people will embrace. Those are the idea that they should be constantly monitored to see how they're doing you know in order to prevent something further on down the line. I think some will and some won't to adoption I believe will be determined ultimately by how useful it is if it if if we're able to win my say when we're able to show that this really does have an impact on health that you can detect diseases earlier and treat them far more effectively than I think. There'll be more people adopted smart mirrors smart toilets which again They Monitor your evacuation essentially of all kinds to look for what? What does that looks for? And look for early indications of Cancer. you can look for Indications of other diseases of the metabolism Monitoring Diabetes will be enhanced by that but a lot of diseases that progress should be able to be detected much earlier right as well as for example a decade ago. Not many people monitor their activity level. We know that twenty minutes of moderate exercise a day has an enormous effect on our overall health and well being now more people are either closing their circles or doing something to look at their activity level and can serve as a nudge And back to behavior change these micro nudges or or reminders or small indications during our day that if we do something might change our how we feel our well being those have been shown over and over again to be the most effective ways to To actually impact behavior and by monitoring things like our steps other things in the background will be able to live. More informative nudges when we want to receive them. If we don't then we don't have to write this all sounds great the idea of monitoring all the time but us being monitor and social media is being monitor movements Geography everything else has been become controversial Recently just this week. Walmart is getting into healthcare working On a prime competitor Walmart. Plus it's an idea They're trying to That you pay a certain amount to get different things. But one of them is Walmart. Healthcare the piloting a health clinic with services. Hubs against rivals. Health hubs and things like that At the same time Amazon is also Getting into healthcare. That's what everybody thinks that they will do a lot of stuff like that and obviously they will focus on preventative. Because I would imagine. That's exactly what they'll focus on. This idea of these big companies and apple is is in here Probably the most privacy friendly the protective of privacy friendly company talk about what this happens because when these companies get in obviously prevention will be an important part of this because they are going to try to try to up end in disrupt the healthcare system as it is. I'm encouraged because I think each in. Its own way can bring new ideas new approaches to health and healthcare. I mean let's take Walmart as an example. I think roughly seventy four hundred stores Walmart stores in some of the most underserved health areas of the country. Walmart is opened a as you mentioned. Health clinics at a couple of stores in the Atlanta. Suburbs I think they'll study those intensively but bringing primary care and vision services and dentistry in an affordable way in an easy to access way to communities should go a long way and identifying predicting and preventing diseases and and those clinics are going to be focused on doing exactly that I mean. How can we identify High Blood Pressure or high glucose levels and and treat those people now as to whether or not it's Walmart or it's Amazon or it's apple I mean each of course comes at it from a bit of a different angle given their core business model but I think that's going to be good for consumers now what we have to make sure in all of this is that the interests of the patients have to be? I interested in consumer has to be first and that is that I hope we never get to a situation where health related data is viewed as simple social media data. There may be some people who want their health data accessible in that way but I think most people will not. We're to make sure that it's protected. Privacy is protected and but when they when have a big these big tech companies get into it has changed the current environment is? That's what's necessary to change this because it isn't really working under the current insurance system with big giant insurance companies where nobody's concerned with prevention essentially now as much as they need to be That's one thing that I think. One of the many things that I think can come in a very constructive way from the focus of these large companies on Health Walmart began many years ago. They are the largest employer in the United States and for their employees who need a series procedure like heart surgery. Or maybe they have back pain. They began establishing centers of excellence and they monitor the health outcomes of those centers of Excellence. Very very closely. That's a win win situation. It's a win for the company because they're getting the best outcomes and in usually better outcomes are associated with lower cost showers for sure a win for the employees because when they go for and maybe they have to travel one hundred two hundred miles to get heart surgery. Walmart pays for that but they can be sure that they're getting it done by by surgeons in delivery system with those outcomes being very very closely monitored so they're going to get the best care that's available that spirit needs to permeate more of the healthcare delivery space in I think we'll we'll see more of this linkage to outcomes to payments both in government insurance plans and increasingly commercial plans as well all right. It's a win these big getting one of the things that's Problematic is getting healthcare to everyone and obviously one of the issues in this election is Medicare for all whether there should be a single payer system all kinds of things. How do you get And it makes perfect sense that we should have precision health. It should be early. It should be preventative How do we get to that with all this political rancor around healthcare in general there are two principles that I believe are fundamental to revamping the US healthcare delivery system one is? I believe that every American needs health insurance now how that's finance where that's medicare for all or the exchanges. I mean they're variety different ways to do it but everyone needs a basic form of health insurance. That's number one number two or health plan. That's right the way we think of it. True true a health plan but something that provides them with a basic level of care and it also takes care of them if they develop a major illness that provides for the care they would need nutrient that. Ls because what we see today. Is that people all people who either have no insurance or they have very poor insurance. They delay the delay and delay and delay and getting something addressed and then they only encounter. The healthcare delivery system after that collision has progressed. That's just bad. It's bad for the patients. It's bad for the delivery delivery mechanism because their care is going to be much more expensive in have much poor outcomes when without delay. So that's why everyone needs some form of health plan health insurance but something that provides basic care second is that we need to continue this. Move Away from fee for service medicine and more towards bundled payments and towards alternately. All of us on the delivery system side being responsible for outcomes and by moving away from the incremental payments or to pay for each unit of care and more towards outcomes based reimbursements. That will help us to drive value. That is better outcomes for lower costs and we'll also align the financial incentives with what we want the incentives of the delivery system to be which is keeping US healthy. And when we do get sick providing it's the best treatment that will give us the best outcome sue to finish. What are the key? I want to understand from you? What the key things in the next five years. That are happening. Some of the key. Tha especially technology trends. That are happening. That will bring us to this the diagnostic tests. And then how you would look at it twenty years from now if if we had had the ability to know was coming down the Pike and do something about it before it got the worst possible you know. We're in the worst possible situation on the technology side. I think we'll continue to see the development of of monitoring device bartering devices. Also we'll see much better electronic health record systems today. Electronic health record systems don't provide much decision support. They don't furnish you and me. With data and the forms we would like it to be a lot of entrepreneurial activity going on in that regard and I think we'll see a lot of improvements in the way they function in the future. Also I think technology will enable us to monitor our health in ways. We've never been able to in the past. Not everyone will want to do that. Those who do will be able to do so without a lot of friction without having to the most is having something on your body right not so much. The smart toilets and Smart Mutual. Just one way but mostly is right. That's where most of the innovation is going on right now. That's right as well as in early diagnostics which are technology enabled but usually involve looking for very small amount of cancer cells or another Molecule in in the blood or urine that could be tested very easily and very inexpensively when it scaled all of that in the three or five year timeframe. Then looking more broadly once that's deployed. I see us moving away. From just after the fact medicine and much more towards the prevention and prediction that will enable us to drive better outcomes and that would include. What how would that? How would that look for a patient going in for example? And you wear a monitor device you so your your heart is being monitor. Your blood is being monitored a regular basis or you engage in other ways the healthcare delivery system where you don't come in for an appointment you have a virtual visit with Lifestyle coach or nutritionist. At night you know when you're at home rather than having to take off a work. We're doing that today. And our delivery system and many others are as well but we lower the friction. We lower the amount of effort. Each of us has to take in order to engage in our health. And if we make those methods of engagement better and more accessible than we increase the likelihood that everyone's going to take advantage of them right now and get. It gets back to these other determinants of Health. We still within miles of where we're sitting today. We have food deserts. We HAVE COMMUNITIES. That don't have access to healthy food. Technology can help with that to bring food into communities to identify the areas where there aren't shopping. Opportunities enable people for the same amount of money to get healthy foods. All of this should be much more robust as we apply technology. And the way that it can and when you think about The idea of advance healthcare. You talked about predict and prevent. How does that cure is it? The amount of data that we understand how things lead to things. Or what is where. Where's the curing part? The curing part I think is best. Represented. What's going on in cancer today. into roughly thirty years that I've been involved in some way or another with medicine. I've never seen anything like the past seven eight years in the advances in immunotherapy. And I really feel that we're still at the early stages the fact that you know former president. Jimmy Carter is alive and doing at least for the press reports. Relatively well today with stage four melanoma. That was diagnosed over three years. Ago is nothing short of amazing. That just would not have happened before the type of checkpoint inhibitors that we've been told he's taking that have arrested as melanoma. We're at the early stages of that. But but I believe that there is a revolution going on in the treatment of cancers. And we're going to be able to leverage it much more effectively because we have a foothold and how to engage the immune system in treating cancer. That does beg the question. Should we all be living that long? It does a lot of a lot about this and they're talking about health span rather than lifespan. And that you're healthy up until one hundred and two and then you die healthy. You know in a relatively healthy man. I want to end on that. The implications of that if we are able to keep ourselves healthy and obviously in Silicon Valley. There's a lot of people who just don't WanNa die Who are looking into all kinds. There's there's all kinds of concepts around that and you know you know whether it's Google and Calico and different things like that. How do you look at that? The idea I mean you're talking about having healthier lives until you die. But how do you look at the concept that a lot of people are talking? Which is not dying or doing other things to prevent push off dying. Certainly I hear that and in the environment we live in worked a lot. I think that's a relatively small sector of of society is thinking in those terms what I'm most excited about. Is that through what we've been talking about in this interview? The technologies we've talked about the other advances. We should be able to make health and healthcare much more gala -tarian than it is today in our country Coming back to statistics that I just find appalling that I think is a mandate for us to change in that. Is that our ZIP code? Which we live in is more of a determinative. Our life expectancy than our genetic code. We should be able to change that and make health and healthcare much more egalitarian. And yes some people are GonNa want to look at how they can extend that life span. Other people are going to be quite happy having a healthy life until whatever happens that in the life all right thank you so much. I really appreciate it. This is Dr Lloyd Minor. He's the Dean of the Stanford University School of Medicine Book is called discovering precision. Help predict prevent and cure to advance health and well being Thank you for coming on the show. You can follow me on twitter at Cara. Swisher my executive producer Eric Anderson an Eric America my producer. Eric Johnson is Hey. Es J. Dr Minor where can people find you online Dina Meyer Dot Sanford. Edu and the book will be out as soon as you can find that everywhere if you liked this episode. You really appreciate it if you shared it with a friend to make sure to check out our other podcasts pivot reset recode media and land of the giants just search for them in your podcasting. App of choice or tap the link in the show notes thanks also to our editor Joe Robbie. Thanks for listening to this episode of Rico Decode. I'll be back here on Friday tune in then.
How New Drugs Are Developed
"Hi, welcome back to the healthcare trash podcast this healthcare. Chaz podcasts in all podcast. Sponsored by Indiana University school of medicine whose mission is to advance health in the state of Indiana. I'm beyond by promoting innovation and excellence in education, research and patient care. I school medicine is leading Indiana University. First grand challenge the precision health initiative with bold goals to cure, multiple myeloma, triple negative, breast cancer, and childhood sarcoma and prevent type two diabetes and Alzheimer's disease. Table going to be talking about Alzheimer's disease, specifically drug development. I'm super excited today because our guest is dance Grabotski president of Lilly research laboratories and chief scientific officer for ally Lillian company, I've known Dan for years. We actually went to medical school together at the university of Pennsylvania school of medicine. Did you graduate with us in nineteen ninety eight or was it later took me a little bit longer because I stayed on to get a PHD as well. So for seven years. Oh, well, let let's start with that. I'd love. To talk about how you got to this position given that we both started in the same place, which was at university of Pennsylvania in nineteen ninety four. So when I took off in one thousand nine hundred eighty eight what were you doing? So I was working towards my PHD working in neuroscientist on basic mechanisms of Alzheimer's disease them, what did you do after getting your PHD and MD? So I continued my training through residency and surgical pathology. And then I went onto fellowship training in neuro pathology where was that? I was all at the university of Pennsylvania. Oh, great. Okay. And so then you finished in what year? So all of that training took me about to hit must have been a two thousand five. Okay. I think and then at that point I took a different path instead of continuing sort of in the academic research path in in which I had been working for many many years at that point. I took an entrepreneurship path and took one of the projects I have been working on even. A graduate student and started a company around it. How do you do that? Well, at the time, I actually didn't know the answer that question how I do which was probably helpful. Because it's it's a difficult thing to do particularly. So you even more than today back, then I think it was it was a bit more unusual for someone from Accademia to God. And start a company at the time. I put my father's three big things you need to have a company one. Is you need the technology. And in this case, of course, the technology, which I'd been working on was co inventor of had all been invented at the university. So belonged not me and the other vendors, but to the university how things work so you have to get that. But of course, you go to the university and say, hey, we want to license it, and they say well, great. We license acknowledges two teams. So show us the the people who's your team and you need money. So show us the money to to develop. Of course, I didn't have those other things. So then I went and said, okay. Well, maybe I could go hire some people and. Started talking to experience drug developers and see if I can put a team together. And of course, they said, well, we sounds like an interesting idea, but you don't actually have the technology, and you don't have any money. And so then I said, okay, let me try the money side. And you go out and talk to venture capitalists. So you want to invest in the psychology? And what do they say we need a team, and we need to get the pick -nology. So the the first year or so is trying to get those three things together. And how do you assemble those resources the people that technology the dollars? So you can get started. And eventually I had some traction there put together team which grew to be over one hundred people and over time worked on this. This idea that we had an academic. How I I'm I'm somewhat what muscle to flex like how do you even start to? How was this? Like you thought that you could do this. Or did you have some other people that were with you a week do this or how does that happen? It was mostly me, actually. So I I had friends. Who had different experiences some who had more on the business side than I did. And so I mainly ask them for free advice, which they gave me, and and then just started reading on the internet and making phone calls and driving around in my car to meet people and how much venture capitals, it take to get something like that started well to get started. It's it varies in my case. It was a million dollars that made me think that it was going to be real which just shows little I knew at the time right on because now, I know a million dollars isn't actually very much for this kind of endeavor. But but at the time, I I remember the day very very well where I after, you know, intense work negotiation at closed on on a million dollar financing. And I kept calling my Bank, which was just my neighborhood Bank. Because again, that's that's what I knew they were open on Sundays. And that's what I needed. And so I kept calling my Bank, and and saying his is my money there and the teller should okay. Now, see a new balance in your accountant. She's like it's one hundred ten. Oh, no. It's a million. Wow. One hundred it's like, okay now at now, I've made it, and of course, so we went on to raise nearly I must been sixty or seventy million dollars to to develop this product. So that was just just the very beginning. Right. Okay. So that was about what year two thousand and five naive accompanying. Now, you want to develop drugs what what do you do next? So when I started my company, we working we haven't said yet what we're doing which is we're working in Alzheimer's disease and our goal. There was to develop a drug that could be an imaging agent to see the plaques in the brain of Alzheimer's disease and help detect the disease diagnosed the disease. So the first thing we needed was chemistry because we had to design create a molecule, so I hired some chemists and. The first chemist I hired a said, okay. Our our first job is to build a laboratory. So we can make molecules and he and I went around and bought equipment initially. We even went to companies that were going bankrupt in selling all their use laboratory show up. There might truck in literally with a Bank check because it was sort of a cache type transaction, and we say, okay, we want that machine in that machine that one and load them up and take him back to the lab and see if we can I'm working or not. And so we we spent some time building a lab, and and then hiring more chemists and getting to work. Okay. And then how do you actually make? I mean, I'm sure there's multiple steps here. But a part of what I'm trying to how do you? Then what do you do? I mean. Now, you've got a laboratory. So you wanna make this? We call it a dry it doesn't sound like a drug drug. Yeah. Okay. But it, but it's for diagnosis. So what you now have all these people. What would you do? So we started making molecules making chemicals that have the properties that we were looking for and then testing them in different ashtrays in the laboratory and trying to get closer and closer to a molecule with the ideal properties. And. The goal of of that stage of research is to get something. Good enough that you can eventually test it in people and see if it works. So does it I in would with cells or animals where where did you start? Some of the initial screens were what we call in vitro grants or just in a test tube using different chemicals and extracts to test them. And then another stage screening was using human tissue from people who had died without timers donated their brains to research, and then we're able to see okay, if this is supposed to detect amyloid plaques in living people can at least see it on postmortem tissue from from people who had died. So that was another level of screen, and then you can go to animal models like mice said say, okay, what needs to get into the brain. So when we injected into the blood does it travel into the brain and get in there. So the those are the types of experiments that ultimately can lead up to human testing. And this came from. Your work as a graduate student. You're saying, yeah, I'd actually started this project at the tail end of my graduate training, my train his PHD in the night continued to work on it through some of my postdoctoral training. How did you even come up with the molecule to begin with? I mean where where did it come from? Yeah. So my background is I'm a neuro pathologist, and in neuro pathology one of the things that we have relied on for almost a hundred years is histo-pathological stains that are essentially dies that came from the textile industry that people discovered could stain different kinds of tissues in different ways. In one of those stains that you might remember for medical school was called Congo. Red attractive name that the textile industry gave it to make it seem more attractive Congo red binds, it turns out to amyloid plaques, and it was just sort of empirically discovered by histopathology many many years ago. And so the idea that we had was to take that die which must have. Some affinity for these plaques and start modifying it and see if we can make it thousands of times better at doing it. In fact, there was another dial also called Thia Flavin that had the same kind of property, very different chemical structures. So we're working on that as well one of the breakthroughs came when we saw that structurally we could have elements of each of the two molecules combined. Okay. And that was one of our breakers. Then led to the ultimate compounds that we developed, and you're just synthesizing compounds trying to get them to fold the way you want. I mean, all the way back to again chemistry. It's organic chemistry chemists. Adding will what happens if we add oxygen in this position or nitrogen in this position and over time. And this is still this is how we do drug discovery even lily is you start to develop a a an understanding, and we call it a structure activity relationship or S A R, which is okay. If I modify the molecule in certain parts in certain directions to the left side becomes bigger, for example. Than that seems to work better bonds better if the right side becomes smaller that works less. Well, of course, there's many many different properties that's a gross oversimplification, but the chemistry team combined with the biologists who are testing these molecules start to develop that kind of an understanding, and then they can make rational decisions about how to modify the compound. And of course, we're always trying to change optimize for many different things. At once. One is how tightly does it bind your target? But that's not enough. You also need to make sure that it gets into the target organs on this kiss. Does it get into the brain? And sometimes those things will be conflicting when you make a compound that works better binding does work as well. Getting the brain. And other thing might be metabolism. Your body has all kinds of ways of metabolising chopping up foreign molecules make sure it doesn't get chopped up too quickly or in a bad way. Optimizing for safety. It has to be something that is is safe often in drug discovery. We're looking for things that can be taken orally and those properties are often. Been very unique and different. And so the job of the medicinal chemist is to make modifications that can simultaneously optimized for all of these properties months. We have something good enough. We go onto him testing. Okay. So you've got not to the point where you feel like you've you've got something you've been testing it. You think it binds? How do you know, you're ready for human testing? Yes. So you set criteria at the beginning of any campaign say, okay, if I get a molecule that he hits these criteria certain level of Finnity, brain, entry, etc. We'll go on tested in humans, and we had one. And and on it went one wrinkle here is that the first molecule we tested didn't work in Pearl human. So it was a bit of back to the drawing board. How do you even do the human testing nominee account? Obviously, you don't put out a shingle and say we want to want to give you pillar shots. How how do you actually get that done? Yes. So so drug companies big companies and small companies, although we we sort of say we do human testing. Of course, what we really do is is collaborate generally with academic physicians as well as private physicians who see patients who do the testing on our behalf. So in this case, it was in in typically in early drug testing, it's very specialized so there are specialized physicians who can do that kind of testing, and they have all of the safety precautions and the apparatus set up to to be able to do it in our case that also required brain imaging. So a. A very complicated thing to do. So we worked with academic centers that could do that kind of brain imaging, and they found patients injected the compound for the first time, which is kind of nerve wracking because you don't want to hurt anyone, of course. And we're very very happy that we we never did. But testing a new a new drug in a patient is always a carry some risk. And and then look at the brain scout. And see if it works on right? Okay. So you did it originally did not work. That's right. And so what do you do next? So we had a strategy to test multiple compounds nearly in parallel. So we had a number that we're going to come forward. Almost regardless of what the first one. Did we knew that we would take a few attempts to to optimize? And eventually we had a few that looked pretty good. We pick the best one and took it through longer stage testing ultimately became a drug. What do you do next? Yeah. So the next big goal is to get medicine approved by the FDA. And this global regulators around the world that are that work like the FDA doesn't the United States. And so at that point. There was lots of discussions with the FDA will will how should we demonstrate that this really works because we're trying to diagnose Alzheimer's image, something in the brain in Alzheimer's disease hasn't been seen before one thing. You can do is say, okay, I'm gonna I'm gonna image ten twenty people who have a clinical diagnosis Alzheimer's in ten or twenty people who don't in show, you there's a difference too. And of course, we did that that's early testing in. What you see is that most of the people are Alzheimer's show that they had a brain full of plaque. But some of them didn't our view was those are people that the clinician is making a mistake. They don't actually have Alzheimer's. That's why we want to develop a new test as the diagnosis isn't so good. And when we took older patients who don't have a diagnosis, Alzheimer's damage them again, you can image twenty of them a few of them. Look like, they did have and. Would say, okay, we'll those are patients who are likely to go on to get Alzheimer's disease. And maybe the physician hasn't noticed the changes in their their cognition yet. So anytime you're developing new diagnostic tests like that that's supposed to be better than anything else. That's out there. What do you compare yourself to show that you're actually right? And we call that a truth standard. What is your true standard? So lots of discussions with with the FDA on on that culminating in what's called an advisory committee where the FDA calls a panel of its top advisors, and we present our ideas. And at that meeting, we presented an idea that we would do something. No one had done before which is image people's brains and see whether they had the plaques or not and then follow the people over time until they died. These would be people who've agreed in advance to donate their brains to research, and then we would look at their brain under the microscope and see was the test. Right. So the gold standard would be the neuro pathology at autopsy that was a difficult idea on a difficult trial too. Deduct and so we went to hospices, and to researchers who are studying Alzheimer's disease in said, we're looking for people who are have perhaps cognitive decline or maybe not when you both kinds. But also have another reason why they might be near the end of life. So do they have cancer or heart disease or lung disease? And so we were able to find a people like that which was really meaningful that these individuals said, I I know I'm in the end of my life. But I want to do something to help science and helpresearch some of them had family members without numbers some had Alzheimer's selves in their family members that this is this is what my wife would want to in her in her final days to be able to give something back to research. So really touching in meaningful contribution from people who sent me at the end of the study. Photos of their loved ones in poems. They had written in articles in newspapers that they had contributed everybody. I think wants to help out on Alzheimer's disease. And so able to conduct a study and and show that it was successful. And then bring that data back to the FDA here. Look at it really works out. Well, and then ultimately got it FDA approved. And it's now available has been for for several years. Unfortunately, it's not covered by most insurance payments, which has been a deep disappointment for me, and for many people with Alzheimer's really just because it's it's expensive to do. It a test like this involves a very specialized scanner and radioactive drug and physician to read. It means it's been out of reach for most people just too bad. Yeah. So what what do you do even at this step? Yes. So we little lucky to to contract with national companies that can make the radioactive. For us the imaging agents. And so we have been able to make available for for people around the country. But again that facility needs to get paid and had the doctor who administers it in the doctor who owns the scanner or the hospital owns a scanner and the physician that reads the scan. So that's been a barrier. We worked over the years with Medicare because that's the primary there for for elderly patients worked with Medicare and were gratified to get some progress with coverage with evidence development where they paid for for people who were involved in research and. Thousands and thousands of more than ten thousand people have gotten access to it through that which which is something but still out of bounds for most people. What is their rationales or what's how do they make the decision about whether to cover it or not this is these are tough decisions? And they're they're people who whose job it is to decide whether or not certain medical technologies in procedures are paid for by insurance. Or not in this case. I think the the basis of their decision was we don't really know that whether diagnosing Alzheimer's disease earlier, more accurately will result in changes in care and changes in outcomes for patients. So that's interesting. So tomorrow, we came up with a drug that they said, well, if you get this early it would prevent Alzheimer's, then all of a sudden, I might be a very different. Calculus course. Yes. Yes. And that was that's sort of always been the the end goal. Here is. While it's very important to detect Alzheimer's Israelis possible. This is what one of the things that neurologists been oughta time doing because they can offer counseling to patients, and they can offer different therapies to patients. None of them are cure, but can have important impacts on people in when it's not Alzheimer's, that's important to know too. But ultimately our goal is is to say how can we help develop a drug that can really meaningfully stop or stop or meaningfully slow down the progression of the disease would still sound like the drug that we've been talking about this conversation is super important for research because how else would you pick up the patients who are potentially at high yesterday. And well, it's been deeply disappointing that it has been available to patients for me. It's been extremely gratifying that just about every modern Alzheimer's clinical research trial uses this to find the right business to treat or one of the related technology in their to others came out after are, so okay. So you've done that you're next. Yes. So that that pathway led me in two thousand and ten. I sold my company to ally lily of Melita in Alzheimer's disease research who who shared our vision for what we could do in Alzheimer's disease and saw the value of this for patients, but also for research, and I became part of of this company and then over the years from from the until today, I've had different roles inside company learning and leading different parts of our research organization in then for few years leading the drug development organization research is how we discover drugs development is how we test them in in patients, and now I have the privilege of of leading research and development being the head of our indeed lily, so I brought my head around the story of how you got to your drug or the one we've been talking about where we know that the stains were can we manipulate this Dana make work. But how is that? Is that the story for most drugs is that I mean, how do how do you come up with the drug the so? Yeah, that's right. There's a couple of different. As to to find new medicines. But you often have to think about what's a reasonable starting point in. And sometimes it's something that's out there in the literature. That's not very good. But gives you an initial handle on where to start another way. We can do it which is a lot more sophisticated than anything. I had available back. Then is we can actually determine the structure of the target. So if you have a particular protein in mostly we're we're trying to drug proteins. So that we can talk about other ideas in a minute. You can do what's called crystallize it which then allows you to determine the structure, and so you're seeing the structure of the molecule almost at an atomic level. So you can really understand the shape of it. And the drug is supposed to fit into a particular groove on the molecule, and you can actually see the groove and then using sophisticated computer software and simulation as well as know-how medicinal chemistry. Can say, okay, I can design a molecule with this particular, shape and pattern of charge that could fit into that grew very tightly in. So we call that structural enabled a drug discovery where we actually know the structure that we're working on. We're not it's not just trial and error. Right arc. And that represents a great deal of what we do. Now that I understand that. Why does it fail? Like why? Why can't you just nail it? Yes. So there's a couple reasons why actually, unfortunately, there's many many reasons, right? Dr joy discovery. It's been said that developing a drug is not rocket science. It's actually much much harder in most of our our attempts to fly a fail Hambo flu. We learn from each one. So. If we have a target that we want to make a drug to actually most of the time not always given enough time and money, and we'll have large teams of chemists working on things for many years. We can find a molecule that can impact it. That's because we choose our targets carefully. And there are some targets that we just know our undrivable, we don't know how to make a molecule, and so we just avoid those. But the ones we go after we generally have an idea of how we're going to be able to make a molecule and given enough time we can make a molecule that that can hit it. But it turns out that many these won't be safe and will fail because of safety that even in preclinical models will see well. Yes, it inhibits protein exit you're going for. But also why z which are dangerous or sometimes we'll get all the way to human testing. And we'll discover that there's some safety abnormality which we hopefully in unusually thankfully detect. Early that a particular enzyme in the patient might go up that is an indicator that if we kept at this could cause long term harm we stopped in. And sometimes it just turns out that our understanding the biology that we know that hitting protein x might be a good idea to stop a disease, but we were wrong about that. And actually, it's really an important target for normal bodily function or it's not an important target for the disease. And so the biology lets us down a lot and those sort of the the two basic paradigm is sometimes you've got a great drug that perfectly in cleanly hits the target you want. But the biology was wrong that that target is in great to hit. And sometimes you have a great target. But you can't make a drug that cleanly hits it because the chemistry is too too challenging it's not not cleanly drug -able. Of course, the the beautiful targets are the ones that have both really great biology that we totally, you know, at least we think we totally understand that hitting this'll will have a beneficial effect in. In. They're clearly drug -able. We know how to make a drug inset. Those are the golden targets. They go fast. Anytime someone has an idea you can imagine most of the pharma companies will jump on that in the first one or two will have a medicine the rest of us will will step back because we don't need six drugs against a given target. So what are you trying to do with most of the targets who tried to block them? You're trying to make him. Go fast. You're trying to break him. What are you trying to do mostly were good at turning things off? So it's a target. We look for targets that are overactive. So that we can turn them down the other thing that that we sometimes can do is his supplement the activity of target. But that's as you can imagine a little harder to make something work better than Nature Genetics. It it's often easier to make it work less. We we're often in the inhibitor game. But sometimes we can do activators. You know, I talked a lot about chemistry in in in small molecules, we call them because they're relatively small compared to proteins which are big molecules. But. We can also sometimes more and more use what we call biologics, which are now they're not made by chemists, but they're made by cells, and we can engineer cells to be our laboratory to make new medicines and often those will be proteins themselves or a specific temperature called an antibody, which is what your body uses to fight off infection. We can actually create antibodies that can turn off in in some cases, turn on signaling pathways in yourself. And then that becomes the medicine is is antibody itself. This is almost all over Wilma. How do you? How do you figure out? What thing to do for what disease or what is it just all throwing the kitchen, sink it everything? Or is it more thoughtful it has to be more thoughtful because it takes so long and it's so expensive. We who he has a company spend between five and six billion dollars a year in research and development to discover new drugs where is that money spent his that on like Queant labs people it's mostly on. The clinical testing costs a lot to run these trials which involve thousands and thousands of people volunteering to participate in research all over the world. But for that investment, we and other companies that are size. We hope if we're wildly successful. Our goal is to deliver to new medicines. Every or so six billion five or six billion dollars in two medicines out. So that's that's what it costs. Of course. It's it's also time delimited. So we it the money might be spent many many years before you have the medicines. So you also have to think about the idea that a dollar ten years ago is much more valuable than a dollar today. So that's that's the business. We're so we have to make careful decisions because failures in drug development, particularly in late drug development are extremely expensive. Which means we have less money for the next project. So we we spend a lot of money and time. Trying to understand biology of disease. So one way of doing that. It's genetics and understanding. Okay. People with a change in certain gene, might be more predisposed to to certain disease. That's an important clue. Yep. We'll also do things like systems biology, which will be study specimens from patients with the disease. So maybe we're studying at patient with Krones or also have colitis inflammatory bowel disease and take a little biopsy from their intestine in look at all of the things that are dysregulates. Okay. All of these things. It's like traffic is flowing in different direction in this city. And how can we reverse the flow of traffic? So instead of understanding disease is a single abnormality. It's a system pattern of things look for the the nodes that can reverse from from diseased to healthy tissue. So that's another way that we approach thing. And then we're careful observers of clinical data as we test our molecules in in patients, we always learn and see what's impacted and and how he co an a new direction. From there. How do you decide whether biologic is the answer versus small molecule versus something else? So biologics mostly antibodies. These are really big the great opportunity is that because we can kind of use a biologic process to make them the specificity is exquisitely high. So what that means is that if you have a a protein target, and we develop an antibody to it the antibody most likely will buy jest that protein target and nothing else. It's very very clean. The downside is because these are big they don't get inside of cells. So they can only hit targets that are on the outside. So we say see something on the cell surface. That's a very good target for antibody. But most of the action most of the proteins in yourself on the inside and for those we can't use biologic. So we focus on small molecules. So even when we go to small because I mean, given that there are so many cells and then so many molecules in so many says. How's it possible that we'd give a drug it can affect enough molecules all over the body that it works? Yeah. That's it is somewhat magical to think about this. Right. And one of the ways that this happens is is it's driven by very high affinity. So we kinda talk about although this analogy doesn't work perfectly. We talk about a lock in a key that that this is a key that fits a particular lock. But now, you have to imagine a room full of doors, right, and the and one locked that sort of floating around, and it's literally just floating around being bounced around by Iran enforces that eventually fits into lock and turns it so when it fits better stick there and stick really tightly. So that it doesn't have to find it again. Because most of the time it's not gonna find. It's it's lock now. I mean when you get down to fill level, amazes me any drug works at all. Like, I mean, just how does it get to all the sediment all the molecules even people have to take the take the medicine for to work and often? That's why you have to take every day with to keep the blood levels such. Certain concentration of this small. So it can find all of its its targets. The problem isn't often that the target is too rare. It's actually the other way round if the target is too frequent if there's lots and lots of that keyhole with that particular lock then you're going to need a lot more keys, and then you start overwhelming the system with that Zoe. I think about that as well. So your job today is I would say, I mean, you tell me if I'm wrong. I'd imagine much more overseeing a lot of research going on. So what do you do now at lily? We work across a couple different therapeutic areas. Of course, diabetes is our our longest standing and largest therapeutic area. Diabetes includes the complications of diabetes, heart disease, and kidney disease, and liver disease, called Nash in altogether. Of course, that's still the biggest killer in society, heart disease, and and then complications of diabetes important 'cause of Avila's. So that's one area on college. All the different cancers is another area that we work in immunology, which is disease is where your own immune system attacks, your body for various reasons and causes disease like psoriasis rheumatoid arthritis inflammatory bowel disease that I mentioned before these are all examples of immune diseases, and then in our science we continue to work under general diseases like Alzheimer's disease, Parkinson's disease as well as the area of pain. In fact, pain is the number one reason people go see the doctor something doesn't feel right? And it hurts and so we work in headache like migraine recently launched a drug for migraine as well as chronic pain, like back pain and osteoarthritis pain. It's an area that pharma didn't pay much attention to a for many years, and then recently has become much much more important organized by diseases organised by symptom is organized by the types of drugs. Get developed. Here's where the biologic so organized, you can imagine a matrix or grid and across the top you could write the different disease areas, and then those could be the columns, and then the rose could be that therapeutic modality. And so we'll have scientists who are focused on a particular technology and other scientists who are focused on a particular pathway of biology or particular disease, and so perhaps the person working on psoriasis who's really interested in the biologists rice in particular one pathway will then find a person who's really good at making biologics because they'll think oh, we need a biologic for this target. And then that starts to form a team around a particular target. So you need all kinds of expertise, and I greatly simplified it to say, they it's just those those two, but people I mean, you might have the examiner would like how many people are are working in labs. Yeah. Well, we have over six thousand people working in research and development at at Lillian on all my different teams. And of course on any individual project is much smaller. But I guess I'm trying to think like how much how many people in labs trying to develop each we talked about. There's Kim the two us. I think it was Doug drug development. And then drug discovery discovery. Okay. So how many how get to buy? Yes. I don't I don't think I have the exact numbers for discovery and development, but it's probably around four fifths of our resources are in drug development. So few said okay in a given year if we spend about five billion dollars three and a half to four of it is is going to be on on drug development and one or one to two will be on on drugs. Isn't that blows me way? Because it feels like we should be able to do that more efficiently. Lake. There's just gonna be a better way to do the testing because it would seem that the the hard part. Maybe I'm just naive. Again, would be the come up with the actual drug, and then there should be some kind of machine not I mean less physical machine, but some kind of organizational machine to to do the test. I agree with you drug drug development seems more straightforward. And yet it's such a major investment in in time in money. We can certainly get better than there's lots of ideas and lots of investment to try and make things better. But right now clinical trial starts with going out and finding hundreds of investigators who are interested in particular research project, explaining the protocol to them in getting all the ethical could sense to to start the research. And then they go out start looking for patients and they start with zero. And then they asked him onto you want to participate this trial on and so forth. So we spend a half the time in drug development, something like that just looking for patients to participate in research. So that's a major focus. How can we start a clinical trial with a list of people who already to consent wanna participate because they're known? They're out there. If you start an Alzheimer's trial. Of course, there's so many people who have symptoms of Alzheimer's would love to respect in research. Why do we start? Why can't we start with a list of those people clearly lily does amount of partnering with academic institution. I mean all across the table lilies. In indianapolis. We're sitting here in Indianapolis. I work at Indianapolis. I use school of medicine. It's an Indianapolis. So this is I mean, I see connections all the time. Do most of those happen on the discovery phase or most of those connections on the development phasers of both. It's both. I don't think we we could proceed in in drug development without collaborations with academic institutions at all because that's where many patients are seen in academic hospitals. And. Academic institutions have a long history of of doing clinical research on the discovery side. There's certain things that academic is to Sion's are more focused on certain things that pharmaceutical companies are more focused on. So for example, the idea of how do we identify a new target and understand its biology a lot of that happens in academia, some of it happens in pharma, the question of how to make a drug that hits that target and changes its activity that mostly happens in pharma, sometimes a little bit in in academia. So we have collaborations with academic institutions around the world, including a few here in Indiana. But it's the partnership. I think that that creates great ideas. So besides small we mentioned small molecules, we mentioned biologics. Is there anything else that's new and big the trick sided about. Yes, there there is there are new modalities of making drugs. Most of the drugs nearly all the medicines. That are valid. They say are either small molecule or biologic. Genuine antibody protein or peptide? But now for the first time, we have a new ways of of making medicines that actually involve using DNA and Arnie, particularly which are the genetic material that ourselves us, and we're particularly interested now in our in a based therapeutics and probably most people know that DNA is the genetic code, and it sits in the nucleus of the cell and termines the the fate of the cell, but all of the action happens in the site applause plaza in the main body of of the cell. That's where the the proteins are made and function. So how does the the cell get the signal out of the nucleus and tell the cell what to do it uses a short piece of nucleic acid called Aren a a particular kind of Arne called messenger Arna because a carries? The message from the from the nuclear DNA to this applies in and now we we've learned how to turn. Off and in some cases, turn on particular messages. And then change what the cell is doing so turn on and turn off gene transcription in an ultimately or translation in some cases in an alternate -ly impact the cell. So that's exciting in opens up whole new classes of things that might formerly had been undrivable. Right. That we can now impact humane example, like what what something that would be been drug -able than I think might have some promise. Yes. So. There's different. Challenges to this technology. So of course, there there's vantage I just talked about which is now you can turn on on off any particular genes. One of the challenges is directing it to the right tissue. So a lot of times these for various reasons get directed to organs like the liver, and so you can turn on and off genes in the liver, but many diseases are outside. So we're we're trying to work on getting it outside of the liver. But initially you've seen we've seen a lot of progress on some some of the rare genetic diseases where you know, it's a particular gene, that's gone awry, and might only be one in one hundred thousand or one in a million people who have this gene that's gone awry, but they've got a mutation. And now you can specifically turn it on her or turn it off. We're trying to apply that same idea to to larger diseases because we're we're focused on on helping as many people as possible. But diseases like a cardiovascular disease in particular disease, deliver called Nash are important targets that that we're working on with this technology. We're also interested though in in how to get this into the brain. And there there are diseases like Alzheimer's Parkinson's where we know that their particular genes that get turned on that are mutated that can cause the disease in in some small groups patients in greater population. Those same gene seemed to be important disease. If we could just turn them off. And so that's what we're trying to do in in diseases like Alzheimer's Parkinson's. And and these are things that we otherwise wouldn't be able to get to the biologic or small molecules. So that's why we're using our technologies. So a lot of promise it's still very early. There's there's just a handful of examples of our drugs now that have been approved by the FDA and other related technologies, actually modifying the DNA, and that's called gene therapy. And you can put a new. Gene in or you can perhaps all of this hasn't yet been there are no drugs like this yet. But you could perhaps modify a gene change a gene in a person from from a bad one to two good one if you know the mutation. So that's an exciting new area of research is well, well, this has been fascinating independence to do. I have about a million more questions. And there's a lot more. I could ask. So unfortunately, seems to happen. Almost every episode. I'd love to have you back at the time the future, we could talk more about this because there's just tons of other questions about hotels, but thank you so much for being on the show. It's been it's been absolutely fascinating. Thank you are. It's been fun.
BrainStuff Classics: How Does Sleepwalking Work?
"Instead of ad today I wanted to tell you about another podcast that I think you might dig. It's called history verses in it mental floss editor in chief and pretty cool. Human Aaron McCarthy Explores the the inside stories behind history's ultimate fighters who changed the world as we know it season one tackles Theodore Roosevelt. Very famous figure who did a ton of not-so-famous so famous stuff like he almost died exploring uncharted territory in the Amazon and he modernized American football episodes launch weekly on Sundays. So Oh listen to history versus Theodore Roosevelt on iheartradio APP apple podcasts. Or wherever you get your podcasts. Welcome to brain stuff. A production of iheartradio. Hey Brain Steph. I'm more in vocal bomb and I've got another classic episode for you today from our former host Christian Sager. This one is about the phenomenon of sleepwalking gain. I myself used to sleep walk sometimes when I was a kid but I grew out of it and as it turns out. That's not all that uncommon. Here's Christian Hi. I'm Christian Sager and this is brain stuff. Have you ever seen someone sleepwalking. It's creepy right. They're just sort of shambling around like a Zombie and not one of those Super Fast World War Z.. Type zombies but more of the slow clumsy walking dead type. They might even even have glassy eyes or a bland blank expression and when they wake up. They won't remember what happened. What the heck is going on with sleepwalking? How does it work? Who Does it affect? And what are the common misconceptions about it. Well first. Let's define sleepwalking. If you WANNA get fancy you can call it. Some NAMBU lissome. It's a type of parasol. Omnia or abnormal disruptive behavior that occurs during sleep this category also includes stuff like bed wetting thing and teeth grinding. Sleep walkers may also act out a number of activities during this process. These could be simple things like eating more complex processes like like driving a car. Yeah driving for centuries people have been trying to figure out what's going on with sleepwalking and while scientists haven't fully cracked back to the case. We do know more and more about this phenomenon and it's helping US bust some myths one sleep walkers probably aren't acting out their dreams we know this because most sleepwalking occurs during the first third of the night when your body is in N. rim or non rem sleep. This is the deepest part of your sleep cycle. It's a time when your body repairs itself and releases hormones. You're not dreaming while this goes on and because your brain will resist awakening in the state. It may be difficult to snap asleep walker out of it but don't be afraid to try because here's another fact you can safely wake sleep. Walkers don't do it violently of course but you're not going to kill them either now that we know some facts. It's time to figure out who's taking these he's midnight rambles weirdly enough. Children tend to have a higher likelihood of sleepwalking. This Para Sonya appears to run in families and it occurs more often in boys than in girls and sleepwalking. In general is more common than you might think a study at the Stanford University School of Medicine found that one in twenty five. US adults are prone sleepwalking. And that twenty nine point two percent report some form of it since Childhood Para Sambas have been called the era in timing and balance in the brain more technically it could be called a disorder of arousal meaning that something triggers the brain into awakening from deep end rim sleep stage so the person is in a transition state between sleeping and waking. So why do kids experience it more often and why do they grow out of it. Some researchers argue that kids brains aren't mature enough to fully comprehend sleep cycles or that areas of their brains don't develop at the same pace and since Enron sleep is a period of hormone release. It's possible that hormonal releases may have something to do with sleepwalking. Most adults who walk in sleep did the same as children exhaustion stress. Some medicines illnesses an alcohol can all contribute to sleep walking. And there's one last myth to bust. I hear sleepwalking really can be dangerous. It's been linked to seizures as well as disorders like Parkinson's Alzheimer's. Some people throughout history have even even argued successfully that they killed someone while they were sleepwalking. Today's episode was written by Christian. I'm pretty sure and produced by Tyler. Crying brain stuff is production of radios stuff. Works to hear more from Christian. Check out his pop culture podcast super context and of course for more on this in lots of other topics go visit our home. PLANET HAS TO DOT COM plus more podcasts from iheartradio the heart radio APP apple podcasts. Or wherever you listen to your favorite shows how do our food stories change during wartime Johnny Bistecca. Private the first class our veterans share. Where they who they thought they ate and what they missed? The military had eggs and aided those powdered eggs. I heart radio is number one for podcasts. And it's easy to see why join US inservice stories of hunger and more on apple podcasts. The IHEARTRADIO APP or wherever ever you get your podcast as the first thing we did.
Hack or not, now is the time to update Facebook settings
"Talking tech is brought to you in part by northwestern. University offered in partnership with north Western's Feinberg school of medicine. The program prepares students for emerging opportunities across the healthcare spectrum. Details are at SPS dot northwestern dot EDU slash informatics. So on Wednesday, Facebook and Instagram was down for quite some time. We don't know the exact reason for the attack, but they were attacked which means, hey, if there's an attack maybe now would be a really good time for you to update your password in your credentials and make your Facebook account just a little stronger. We've got as Sheesh Gupta. He's the CEO of bug crowd with us. It's a security firm, and he's going to offer you some tips on how to make your account stronger. Yeah. You know, I keep my updated all the time. We got into what's going on outside, and it's really important to think about some basic safety measures with anything you do. Digitally. Okay. So I think that probably most people on Facebook have an old password that hasn't been updated in a while. How are you on? Now. You know, you always want to update it, or do you just believe that that as long as you have a unique password could strong password that's not in use anywhere else that that's puts you in good shape. Now, look allow the most digital aggregations allow for a couple of things that I warn to printing is unique bash which have the complex passer characteristics. Is a good thing to have doing us on every site bigger newgen, remember one conflict after make sure that you make them actually unique for the site. So that you have that sedimentation of your past with us, the second thing, I find very helpful to the two factor indication aware, never password the change, and you would your mobile information in. So it sends you a little a test that you have to put in a court for allow for people to even do things with your password or changing passwords without you knowing especially should be better second way of authenticating for authenticating. Authenticate or apps. Do you like SMS do you like Email? So I've been doing that travel a lot and told me the to me on my mobile phone, but it really attracting that people might have for themselves. The key here being that if you do do make about fast food chains. Don't wait too long to pen together. So make it all one action. If you will how do you characterize what a good password is how would you? How'd you spell it out generally wanna have a complex password with character, gaps letters not sequences that are continuous in nature? Doing start using names. And but obeys and things on those lines. Because a lot of to do that. I just don't think I don't do that. So it's just a suggestion. I would make the naked complex and mega truly complex without just easy sequences to remember our get. So if you haven't taken the time to update your Facebook settings now may be good. You're really great one as she. She a CEO of bug crowd. Jefferson Graham with USA thoughts on online security love to hear it at Jefferson Graham on Twitter, you've been listening to talking tech. Please subscribe at the show wherever you listen to online audio and I'll be back at you tomorrow with the latest quake hit on tech land. Talking tech is brought to you in part by Northwestern University. The huge amounts of healthcare data available today as well. As advances in technology are making a profound impact on healthcare. Students enrolled in northwestern university's online master's program in health informatics, build the expertise needed to use that data and deliver more efficient ineffective patient care offered in partnership with north Western's Feinberg school of medicine. The program prepares students for emerging opportunities across the healthcare spectrum including specializations that are perfect for healthcare. Bill. Business and IT professionals. Details are at SPS dot northwestern dot EDU slash informatics.
Of Zebrafish and Diabetes - Healthcare Triage Podcast
"Hi, welcome back to the healthcare podcast. This podcast is sponsored by Indiana University school of medicine whose mission is to advance health in the state of Indiana beyond by promoting innovation and excellence in education research patient care is school medicine is leading Indiana university's first grand challenge. The precision health initiative with bold goals to cure, multiple myeloma, triple negative, breast cancer and childhoods coma and prevent type two diabetes and Alzheimer's disease. And today, we're gonna be talking about type two diabetes diabetes in general. Our guest today is Ragu MIR Mira professor of pediatrics and medicine at Indiana University school medicine, I'm gonna let him introduce himself. Thank you very much, Aaron I'm the ally. Lily professor in pediatric diabetes in the departments of pediatrics and medicine is school medicine. Fantastic. I wanna start basic could you just tell everyone. What is diabetes. Yes. Diabetes. I think most people understand diabetes. Being a disorder of high blood sugar, and it's affectively when your body is unable to utilize the nutrients that you take in and your blood sugars go up because your cells can't take up those nutrients particularly glucose, and and it's typically when you don't have enough insulin circulating or the insulin. That is circulating doesn't act. Very well. So what is insulin do so insulin causes yourselves, particularly your muscle and fat cells to take up nutrients, especially glucose, which is one of the fundamental nutrients. Okay. And so why do we need glucose so glucose is used primarily to create all of the components that are important in the cell. So they're used as fuel storage. They're used to create protein. It's used to create fat. So glucose is really a fundamental component of our nutrition and all living cells use it so annoyed. Normal functioning body that has no issues. I soon we eat food the body absorbs glucose from that food. What happens then so it it enters the bloodstream through the gut, and then the first organ that sees it one of the first organs that see it as the patriots. And when the pancreas senses the glucose that's present in what you eat it releases insulin along with that glucose, and then the insulin does what and then the insulin then travels throughout the body to different cells. And then it binds to those cells literally interacts with the cells, and then it causes those cells to send a signal that allows them to take off the glucose, so the glucose Romley go from the bloodstream into the cell. But if there's no insulin it just winds up sitting in the bloodstream crack, and that's why get super hot. That's right. And then the only way you get rid of it is through your P. And that's the reason why people with diabetes have such high blood sugar in their urine. So. Is the high blood sugar bad? Well, it's bad. Because as I said, the cells need the glucose to produce the nutrients, like the proteins and the storage form of energy. When can't do that your body, literally starves. So even though there's plenty of even though there's plenty of sugar circulating around your body starves because it can't take that sugar. Okay. So why would people not have enough insulin? Well, there several reasons for that. The first reason is that you could have an autoimmune disease that destroys the cells that produce insulin. That's what we typically call type one diabetes, but there are other forms of diabetes typified by type two diabetes in which your body does produce the insulin. But it doesn't produce enough. So that the cells don't really see enough insulin and take it up. So why I mean is it just an autoimmune disease or is it that they get that from? Earth. They get an infection. What causes the body to go after the that's a that's a very interesting question. And that's one of the hot areas of research today is why why does this happen and who does it happen in? And when does it happen? One thing we know is that typically happens to most people not in their infancy, but typically after one or two years of age, so that means that you're born without that problem, and then it develops over time. So we think that something in the environment must trigger that process. So that's one thing. Another thing that we know triggers the process of not producing enough insulin is what you eat. So if you eat very high fat diets, and you get obese you have a problem utilizing that insulin. I wanna stick the type one diabetes for a few more minutes, which type two so is it genetic is doesn't run in families. So it is genetic. We know that there are certain genes that are associated with it. But even having the jeans isn't enough. So we know that it does run in families. But it skips sometimes many generations. And sometimes you don't see it in brothers and sisters. So we know that you have genetic risk. But then beyond that genetic risk. You have to have some kind of environmental exposure could be virus. It could be something that we eat. We don't really know. Maybe something that we don't eat. So whatever it is that combination of the genetics and the environment, you know, just triggers this process and certain individuals. So does is it ever stop? Or once it starts killing off the tanker, sells it eventually kills them. All that's the thinking in general is that once the process starts. It's very hard to stop it. We've tried a variety of different drugs that have been in clinical trials to try to stop the process. They seem to slow it down. But in general, the process proceeds no matter what we do. How do we treat that? I know that just of it is give insulin. Clearly, but but is that the mainstay I mean is that just all we can do for type type one diabetes. The only real drug. We have right now is insulin. So how are things change stay in thirty or forty years because clearly we've been using insulin for a long time. So the things that have changed the kinds of insulin that we use. Now, we have an ability to find tune how quickly the insulin ax. We have the ability to also fine-tune how we deliver it. So typically, we used to do it by just syringe bottle drop insulin injected, but now we have a variety of different pumps that can inject it continuously. And even were moving to the point where there's very little sort of involvement of the individual himself or herself. Because now we have pumps that are connected to sensors and that they can use these fancy algorithms to determine how much insulin to give and win do people still need to correct for what? They're eating or is it gotten so good that now just runs on autopilot. No, you mean the pump systems. No, we're not that good yet. I think that's alternately where we're trying to go with a lot of that technology. We still have to do a lot of monitoring. We have to be careful what we and how much of the carbohydrates or fat that we eat. And and when we so all of these are still variables. So we're not quite at that. Stay not. I mean, it just seems to me that that we should be able to. I mean, if the pancreas is working by detecting insulin, and then releasing insulin in detecting glucose, excuse me. And then releasing insulin response to it. Why can't we set up monitors that detect glucose in the blood, and then just administer the amount of insulin for it? So we have those kinds of systems than reasons they're not as perfect as we'd like, partly is the technology. But the other part is the physiology because insulin goes right into the bloodstream, but when we injected it goes. Under the skin, and it takes time to reach the bloodstream the same thing with the sensors that we have for glucose is ideally, we'd like a sensor sitting right in the bloodstream where we can detect how much glucose levels are. But they're actually sitting underneath the skin. So it has to defuse, and then we have to use mathematical algorithms to figure out if the blood if the glucose in that skin is so much how much does that mean it is in the bloodstream so these are complex, and you can imagine it varies from individual individual shore. Is there any work towards I know artificial pancreas putting actually in there that would detect and then release inside the bloodshed. There definitely is as you can imagine any of those types of devices are more invasive, they're prone to infections and so forth. But you know, when we had these large devices that that that can actually be sitting inside of, you know, the bloodstream detecting everything, we know we can control things much much better. So. Where where's the sort of research going for? I don't want to type one diabetes. Where's the research going and type one diabetes? I mean is it just to refining the way that we deliver and technology. Let's call it. How how can we better deliver and sense glucose and and deliver insulin? So another area that people are getting very excited about is creating new cells that produce insulin. And there's a couple of ways to do it. So one way is to trigger the body to produce new cells. We know that these cells exist, we know that you're born with them. But then the immune system kills them off. Why can't they grow back? So part of the research in particular research. My live is doing is trying to figure out how come we cause these cells to grow again? And then if they grow again, then then the other question is how can we get them to evade the immune system? So those are things that we're working on. Another approach is a transplantation. So we can take cells from your skin convert them into insulin producing cells, we can give those house right back to you without immune suppression. And they could produce a lot of insulin. So we can do that. We just haven't gotten to the point where we can produce a pure population of insulin producing cells that the FDA says a safe enough to give back to you. But that would seem to be cured. If if you could I think either of those that I had just mentioned growing your own cells in their native pancreas or being able to produce new cells from your skin would be curative out to think we're close to that. Well, I think that we have challenges. So for example, if you can cause your cells to grow again, or cause those cells from your skin to become insulin producing cells. How can we ensure that they won't become cancerous? Right. Right. So that's a big concern because causing things to grow. So we're worried about that in animal models. When we do this. They certainly cure diabetes. But then, you know, long-term animals don't live very long humans level lot longer. So how can we ensure that we don't cause cancers or tumors? So I think that that is going to be one of the biggest hurdles to ensuring that it's safe enough for delivery into him. And so we have the technology the biologic technology to do this. The the challenge is our safety. How do we get there? Like, what do we need to do to ensure that need long-term trials or is it? No, it's not going to be long term trials because even trials we have to make sure that it safe in worse. Right. So it's going to actually be more technology. So if we can cause a sow to grow how can we control it? So can we cause that cell to stop growing when we want it to stop growing? And so now, there's a lot of using gene editing technologies that people have heard about and other sort of fancy. Molecular tools are able to try to control. Oh, that tempo of growth of these cells. And then literally be using genetic switches to turn these cells off when we want them to. So that's where some of that technology from the molecular side is going. It's fascinating help out. Is there any working towards if we can catch people before the entire pancreas has gone to stop the stop the destruction of final sells? That's another area where the school of medicine school of medicine is focusing a lot of its efforts. First thing we need to do is identify who's going to develop diabetes because the risk of developing diabetes is pretty small it's less than one percent in anybody. And even if you're high risk meaning that you have the genetic risk. It's still maybe two to three percent in your lifetime. That's not a lot. But it's enough that you'd say jeez. I wish I had a simple blood test. That can tell me I'm going to get diabetes or not. So part of what we're working on. Now is denting blood test because we're gonna dentist by a blood test. That says, hey, your likelihood of getting diabetes in the next five years is very high. Then we could potentially than us medications that can turn off the immune system or temp at down to prevent that from happening, which of these avenues we've talked about. You think is the most promising is is that the replacement cells. I think they're all promising. I think that's part of the reason why there's so much effort put into all these areas in prevention in technologies and then in cell replacement, and so there many funders of this type of research, the national institutes of how eighty are f the ADA a lot of private organizations are putting money into this. So, but they're doing it in a way where they're saying. We're not putting all our eggs in one basket. And I'm also struck by it seems some of them are. Men are geared towards how do we find a good way for you to live with this versus curative, which is completely different? I mean that would just be amazing. Well, I think curative is you know, the long term goal, but managing diabetes is the short term chore. How do we keep people with very brittle? Diabetes blood sugars, go up, they go down one of the biggest risks in diabetes. I mean, certainly there complications we talk about him kidney disease, I disease, but the real big risks are low blood sugars because they can kill people very quickly. You're driving your blood sugar goes low you get into an accident, for example, or your slightly older. You're an elderly person you have a low blood sugar having a heart attack. So so what we're trying to do with a lot of the work. That's literally hitting you know, people today is how can we manage the blood sugars better keep these ups and downs? How can we predict low blood sugars? How can we prevent low blood sugars are there better insulin's that can prevent that. So that's really the direction that we're going in right now that can affect somebody year from now, whereas the cell replacement probably looking realistically ten fifteen twenty years. So most people diagnosed with type one diabetes when their children. So that's what we used to think. And we used to call it a disease of childhood. But I think what we are learning. Now is that type one diabetes is a spectrum of diseases. It it becomes most obvious and children, but adults get it too. And we often misdiagnosed them as having type two diabetes. And then what we learn over time is that they actually slowly behave more like type one. And so what we're learning is that depending on the age in which you get it the severity of the onus the the repeatedly of onset of the onus varies so older. People might have the disease and not recognized. It's type one diabetes are like to shift gears. What's what is type two diabetes, and how is it different than type one so type two diabetes. I think most people associate type two diabetes with obesity. Uh-huh. Right. It's not exactly completely true. But it's true for the majority of people and what we know. Now is that when you get overweight and obese your cells for reasons that were still figuring out don't seem to respond to the as well to the insulin that you have. In other words, your body needs to produce more insulin to get the same effect. It would get if you were lean. So it's not as much problem with the pancreas cells to produce insulin as all the rest of the cells that are necessary to absorb it. So a little of both because it turns out that you can imagine if you can climb up a hill the higher that hill the slow harder it becomes to climb because you poop out, right? So if. The pancreas is trying to produce a lot of insulin because the cells don't respond to it as well. Eventually it poops out. So if we had a really powerful pancreas that can produce as much insulin as we need despite how how much the body needs. Then you wouldn't have a problem. So why do we associate it with obesity? What why is it wisn even matter? So it matters because the majority of people that have type two are obese. Okay. But there are people who are thin that can also have it because they have other reasons for this resistance to insulin. What we should call it. But it is also the case that people with type one diabetes can be obese is well, and for that reason sometimes we miss associate that disease as being type two. So so the the reality is that as the population is getting more obese the the prevalence of diabetes is getting greater and so we. We know that what you eat. How much you eat, and how much you weigh have a direct impact on how whether you are going to get diabetes or your risk of diabetes. So how do we treat type two diabetes? And how's that different than I want alternately, you can treat type two diabetes the same as you treat type one. So you can give insulin. But because as I said your pancreas still produces insulin. There other drugs that we have that can help your pancreas. So we have drugs that can cause your pancreas to produce more insulin. We have drugs that can actually cause your body to respond to the insulin better. And then you know in any kind of lifestyle changes you can make to reduce weight can help as well. So things that those things you can't do with type on why does reducing weight help? So what we know is that when you reduce your weight, your cells become more sensitive to the amount of insulin that you're already producing. So the amount of insulin that you're making. Ng then acts better. Why is that what we know is that as you get more obese your cells when they see insulin. They have to you know, what we call in the molecular field transducers that signal what that means is it has to see the insulin. And then has to convert that insulin in a way that can allow that cell to take up the glucose, right? So it turns out that at that molecular level when you get obese for reasons that are unclear still that ability to transducer that signal that ability to see that same amount of insulin and caused that cell to respond in the same way is impaired. So people can lose weight can they cure their type two diabetes. So many people who lose enough weight can and fact be free of insulin free of any medications to control their diabetes. Do we say their diabetes is cured? I I would say it's hard to say. Say that they are cured sort of once you have the disease you have the disease, which means that you're always at risk forgetting it again. So I what I usually say to my patients is that. I encourage them to lose weight because then they don't have to take all these medications, but they have to keep that way down or the diabetes will come back. What are the other types of medications besides insulin that we would use? Yeah. So there are other injectable medications. They're not insulin. But their medications that you can inject in that literally caused the pancreas to produce more insulin. Some of those medications also cause you to eat less. So you lose weight, so those classes of medications called GOP one receptor agonists, so that's one class and it's an injectable medicine. So is that a one day injection or is that every time you eat type of injection? So that is either a once a day or once a week. So you don't have to inject that every time you eat. So that's actu-. Early. A reason why that drug is very popular in it gets used quite a bit. So it is a popular medication. But again, people sometimes require additional medications beyond that when that doesn't work, and what are other types of Medicare. So there are pills that we can take for it. So we've got pills that can cause your pancreas to produce more insulin. Those pills have been around for decades. We know they work, but the problem with those pills, they're called self Anneli, they caused people to gain weight, and that's not as attractive as some of the other pills that we have now. So we have another pill. That's also been around for decades. Many people know it it's called metformin. It's a tried and true medication. It's relatively inexpensive. And in fact, it we call that either a weight neutral or slightly wait negative drugs. So it could cause some people to lose weight. It doesn't stimulate the pancreas to produce more insulin. But it causes your cells to respond to the insulin better. It's very good medication, and it's well, tolerated by most people, and then we have other pills that do similar things, but maybe not in the same manner. So we have medications called DP four inhibitors drugs that inhibit an enzyme and that cause your body to respond a little bit better to insulin. We have another class of medication called SGLT two inhibitors and what they do is. They basically cause your kidneys to just get rid of the excess blood sugar. So your blood sugar's fall, but largely because your kidneys are getting rid of more of it each of these medications works, they lower your blood sugars and in large part, they can protect you even from getting heart disease and some of the other complications of diabetes, but they each have side effect profiles that work well for some people and not well for others. How do you decide which to use? So I think that there are many ways people go through algorithm. So to speak what we like to do in our clinic is personalized therapies, so we like to ask the very simple question. You know, what are the features of any given individual. Maybe there are psychosocial features. You know, there's things that some people are afraid to use needles. Some people, you know, like taking pills once Dave versus three times a day. So one of the things we liked to do is personalized therapy as much as we can we like to go with inexpensive therapies or some people that don't have, you know, a lot of disposable income that they can put in medications, and they're very tried and true drugs that that that are very inexpensive. We tend to like to start with pills, okay for type two diabetes and we'd like to start typically with metformin because it's it's cheap. It's easy to take you have to take just twice a day. So that's. Good pill to start with. And I think for the most part we like to start almost everybody we can on that pill, and then where we go after that. I think is you know, on a case by case basis. I think we'd like to keep people away from insulin for as long as we can because many of these medications are as I said can cause you to lose weight insulin by the time you get on insulin. Most people start gaining weight on that medication. So we like to avoid it. If we can someone with type one diabetes constantly monitoring their blood sugar adjusting, their insulin is the same kind of mechanism and type two you have to keep checking your blood sugars or more, you take the pill, and you just hope for the people are on pills. We don't require that. They check their blood sugars frequently. It's nice to have them check their blood sugars just to see where they're at. But you know, what I like to do with blood sugar taxes? I, you know, people will do blood sugar checks when they know that they have to respond to it. If you're just asking someone to do blood sugar checks three times a day, and they do nothing with that information. They're less likely to continue their blood sugars, so so people on pills. I don't necessarily ask that they check their blood sugars three times a day. But somebody who requires injections where they need to use that information to determine how much insulin to inject. We do require asked them to check it three to four times a day so type two diabetes. You hear more and more people talking about what you should try to prevent should try to stop from having. How do you prevent someone from getting diabetes? So one thing we do know is that lifestyle intervention can prevent the disease. Probably is the best thing we can do to prevent the disease. So obviously diet and exercise can and has been shown to prevent Taibbi eighties. Right. The problem is that most people can adhere to these types of regimens for only so long. So the reality is that what we're not doing is preventing. Disease delaying but a delays important. None the less. It's less time. You live with the disease. They're probably medications that can help as well. So met forms of medication that when used perhaps an individuals who have prediabetes can actually delay their progression to diabetes. What do you mean by prediabetes? So we defined diabetes, very strictly by blood sugars. So if your blood sugar is less than one hundred fasting in the morning, we say that's a normal blood sugar. If it's between one hundred one hundred twenty five we call that prediabetes. And if it's over one hundred twenty five we call that tubbies. So there are basically three different states. You could be and we know if you take all the people with prediabetes and diabetes combined. That's probably close to fifty percent of the US population dough my so fifty percent of all or is that fifty percent of adult, sir. Fifty percent of everybody overall. All in different age groups that can it can vary part of me, you know, the FDR saying well fifty percent people have something then it's normal. Yes. It's been increasing. Okay. It's been increasing. And so, you know, these data have been coming out from smaller scale studies that then are extrapolated into the US population. And so so a lot of them. Now, come from better data that that result from not just fasting blood sugar measurements. But from what we call oral glucose measurements. So we give somebody a a load of glucose, and you measure their blood sugar over time. And so many studies have collected these data, and when you go back, and you look at these data what you find. When you separate across age groups is that over the years, more and more people have been falling into the criteria of prediabetes and diabetes. So and many people don't know they have it. Right. When we say lifestyle changes, and we say diet and exercise we we talking about something radical. Or are we talking about, you know, exercise, the usual, thirty minutes a day five days a week and. Just eat healthy. That's basically what we're talk is. Always fascinated me. Because that's what we tell me what to do anyway. So what's the point of checking for prediabetes? And then tell be able to do it instead of just saying doing any, and I think that makes it great deal of sense. Absolutely. So you know, there are symptoms today. Beatty's? And so I think certainly if you're aware of those symptoms that you should definitely inform your doctor feeling thirsty all the time frequently urinating getting up in the middle of the night to urinate fatigue. Those are things that could be a sign of diabetes, but they may not show up so easily in many people because the disease just progresses over time. And so they don't notice these things happening. So, you know, obviously having a good lifestyle can prevent this. Do we screen everybody? No. We don't screen every you go and see your doctor two in the afternoon. We don't you're not fasting. When you walk in. So we don't do tasked routinely and people that says, hey, you have prediabetes. Diabetes. But there are some people in which you can probably predict might be at risk for prediabetes. Those are people who leave sedentary lifestyles were overweight. Those are individuals that you've probably can say, you know, there's a strong likelihood you could have prediabetes. And if you think you're going to do something about it could be worth checking, otherwise those people that you would say this is a good time to start leading a better lifestyle. Is there any diet? That's better than any other. So diet is very controversial area depends on who you talk to him. Right. There are some people that advocate, you know, low carb diets key Todic diets, there's a variety of different diets the American diabetes association, which is really sort of the, you know, the professional authority in this area has no specific. Conditions on which diet is better than another. Because the data are controversial anyone that you look at. I think the the bottom line is it's better to go with the diet that you can stick to right because you know, if you don't if you if you basically are being asked to take a, you know, a very high fat or high protein diet, and that's not what you normally eat the chances that you'll adhere to that or much lower. So where's the cutting edge stuff and type two diabetes right now. You know, a lot of the cutting edge stuff is in new medications right weight loss medications, we know that losing weight can have a dramatic impact on diabetes. So there are, you know, obviously, drug companies that are working on a variety of different than new drugs, and you probably know in the past decade, the number of new drugs for type two diabetes has been coming. Probably every. Couple of years there, obviously new drugs and the goal of many of these drugs is to lower blood sugar without increasing weight. And that's a big goal. The other goal and type two diabetes. Medications is that the FDA requires that many of them be tested longer term to look at risk for cardiovascular disease. Right. So we're not looking to reduce it. We're just looking to make sure these drugs don't increase that risk to have some of the ones in the past increase the rest. Yeah. There have been some in the past that suggest that it could increase risk again. A lot of its controversial. We sometimes look at the data and relocate the data. So there have been a class of drugs that we don't use very much called thighs Ola dean dions teasing dis. And at least one of those drugs has been suggested to increase the risk of heart failure that's concerning. And then when we re look at some of that data. It turns out. Well, maybe wasn't quite as convincing as we thought the first time, but there are some people that will say that. It's correct. There's some people say won't even something as simple as the cell finale RIA drugs that have been around for decades and large epidemiologic studies suggest they may increase the risk of heart disease. So so there's controversy that surrounds them. But one thing we do know from a lot of these studies that have been done with cardiovascular outcomes is that some of the newer drugs may actually reduce the risk of cardiovascular disease in addition to making your diabetes better. So the SGLT two inhibitors, for example, seem to lower the risk of what we call secondary, cardiovascular events does sort of obesity surgery help with type two diabetes. So that's another area. So what we call bariatric surgery? There's at least three different types of bariatric surgery. And at least two of those three seemed to be very effective in causing weight loss. But even before the loss in weight, we see dramatic improvements in diabetes. What is what are some things are labs working on? So our lab as I mentioned earlier has been interested in figuring out ways, we can cause insulin producing cells to regrow, and so we've been working on looking at the molecular pathways, and then seeing if we can identify new drugs that stimulate those pathways to cause these cells to grow the reason, I liked drugs is that for most drugs. They can induce the growth of beta cells, and then when you stop giving the drug the betas growth stars. So it has sort of a benefit that you can control, you know, how much and how long those cells regret so with type two or you trying more to stimulate the cells there as opposed to Richard describing before was to get sell the body that weren't there. And that's what we're trying. To because we know that they're they're they're they're good cells. They still secrete insulin. Really really we need to go. After those cells that are there, whereas type one you just don't have those cells can is it that we're working you're working on this animals is that where you are. So we're working on it in actually three different sort of model systems. If you well one is to or model systems on his not, but we're working on it in we start in zebra fish. So our lab, the the nice thing is the zebra fish have pancreas like humans do actually looks a lot like human panther. They produce insulin. They can get diabetes. And but the nice thing about zebra fish is that they allow us to screen for drugs. So if we have a hundred drugs that we think might have an impact do we want to be giving all those drugs to mice or pigs or large animals because that's expensive takes a lot of time. How do we screen? So what we do is. We screen zebra fish. We can screen thousands of of zebra fish in a very short time thousands of different drugs. How did just how is that something? You're lab, desserts is just the known zebra filter something that are let figuring out zebra fish. So other people have figured out zebra fish. We've been able to incorporate the technique in to our particular research, so zebra fish are really convenient because they develop on the order of days, mice take weeks and humans take years. So the nice thing about zebra fish is imagine the human compressed down to just three days. And that's the period of time that we can do an entire study in zebra. And then you just put in the drug in the water. That's all we do. That's fascinate, and the zebra fish are not the kind of fish that you see in your tank there the larva so that tiny little things that you can barely see with the naked eye, and but they have pancreas. They have. Insulin, and we have a variety of different colors that we are now able to take zebra fish with where we can color, the different cells. So we can actually see this growing in real time. We and the nice thing about zebra fish. They're translucent. You don't have to kill zebra fish, actually, look at its pancreas. So so you're not actually been sacrificing them to look at the Panthers or what we're watching them right under the scope in real time that it really is. It's really cool. And when we find drugs that work in that model system, we then like to move to mice mice are rate model system to work with they take longer, but we have good models of type one and type two diabetes in mice. And and I think that in the in the world of the pharmaceutical industry that is sort of the gold standard gotta show something in a mouse. And if you can show it in mouse, you don't often even have to go to any larger animals, you can go right to humans. How do you give the mice diabetes? So there's a couple of ways you can do it. So like in humans, you can cause a mouse to overeat. Okay. High fat diet they get obese and and they can get diabetes. That's that just like in humans and that takes about eight eight to sixteen weeks in that range to to get a mouse become diabetic. But that that's pretty good. And then we also have mice have a hyperactive immune system that killed their own insulin producing cells, and so they spontaneously developed diabetes after about, you know, fourteen eighteen weeks of age. So we know exactly when they're going to get diabetes. So we can do prevention studies or we can do curative studies in those animals depending on their age. And you said you had a third system is that different. Or is it? Well, the third system is humans. Okay. So we do studies in humans and an a great example was a study that I'm collaborating on with Linda Maglione, who's a pediatric endocrinologist who. Studies type one diabetes and believe it or not it started in zebra fish. So we identified a drug that is used today. Clinically in certain cancers that in zebra fish seemed to be protective of the insulin producing cells, and when we showed that we then moved into the mouse model, and we showed that we could feed these mice for four weeks for a period of time before they develop diabetes, then stop the feeding and then their risk of diabetes is reduced dramatically. And then because the drug is already on the market. And it's and it's marketed as a drug called f Florida theme we were able to use a low dose of that drug. Get file what's called a in a investigational new drug application to the FDA. And and then we did a dosing study in people. With diabetes and with the simple goal to find out. If we gave this drug for about six weeks in these individuals, can we see an improvement in insulin. Secretion do you? So we don't have the results back yet. The study is almost done. It was funded by the J D R F, and and it was done at three different sites. One here in Indianapolis, one in Milwaukee and one in buffalo, and and so those three sites recruited patients put them on the medication for six weeks. So we'll have that data probably by this time next year. It sounds like with the mouse model it was somewhat prevention as well though. I mean, yeah, that was what we were doing. So we're not doing a prevention study in humans, although that's the direction that a lot of people are going is in prevention studies, and what we did in this human study was asked to simple question, if it can prevent diabetes in the mouse because it protected the beta cells, which are the cells that produce insulin. Can we give? Them to humans with the disease and show some improvement in the function of those cells, and if we can then that would sit strongly suggest it could work, and then we would go and do perhaps a prevention study in this type two diabetes. This is type one. Oh, it's like one one. So so you're trying to bring back beta cells them from. Yeah. So that's interesting. So we're not trying to bring them back from death because that that would be hard to do. Right. But what we have learned with a lot of the studies we've done in humans in the past five years, we've been able to get pancreas from donors who've given their their pancreas to to sort of the scientific community after they passed away that even though we think of these cells all dead. They're not even somebody said diabetes for fifty years. There's actually insulin producing cells floating around not a lot. But they're they're in the pancreas. So they're not completely gone. And so what that means in our mind is that there's the potential to re-grow those cells. That's fascinating. How about just flat out Packers transplants? They worked pretty well. Pancreas transplants. Due reverse diabetes. There are some centers that do a lot of pancreas transplants are studs here in at you. And the people have had pancreas transplants. Of course, they have to be on immune suppression drugs, right because otherwise reject it. But those who've had a pancreas transplant on our stably on pink on that transplant are effectively cured of their diabetes. What about oral insulin? Can is there any movement in that? Yeah. So that's very interesting oral insulin. Insulin is not something we normally would give somebody or all right, right? You have to inject it. And the reason for that is that insulin protein. Yeah. And if you ingest a protein, your body breaks it up slow, right? But there is a thinking that that started many many years ago that suggests that if you can give somebody enough of it some small fragments of that insulin enter the bloodstream, and when it does it does something that call the is. Called tolerating the immune system. So that means that it it sort of educates the immune system to say, this is okay. The insulin. The insulin is okay. Don't don't go after it. Okay. So that it doesn't then go an attack the cells that produce it and that has been the thinking, so so it's a tolerance Asian technique. So it's not so much that you're taking the insulin to dose yourself within on us to teach the body to leave the pancreas. That's exactly what it home now works. So it's not. But there's been a lot of effort that's been put into that. There have been at least a couple of major trials the first trial. That was done. You know, you know, felt that well, maybe we just didn't use a large enough dose because it seemed like we might be there in in in preserving the the pancreas, but even the second trial that was done with a larger dose. There wasn't really a positive effect overall. And so I think. That a lot of the energy surrounding oral insulin is kind of fizzed out a bit. Where do we get all his insulin? When insulin was first discovered, the only place, you could get it was from animals, right? So pigs and cows. And so in the old days, they were you know, what we call beef and poor sign insulin. But even then did they have to sacrifice animal animal than just take what they could get in the pancreas, or would they have sort of them hooked up to machines and continental and get out, and it was all sacrificing the animals taking the paying out many of them would go to slaughter houses. Anyway, so you can take the pancreas out. And then literally you squeeze out the pancreas of all the insulin. That's in the and then you have to kind of crudely prepare it. And that's the reason why we dose insulin in units because in the old days when they made insulin. They didn't know how much they had because they had a lot of junk that came with the insulin. And so the only way they could measure insulin is by its activity and so. Now, we call that units and so ever since then we've kind of stuck to that dosing regimen. So we don't use milligram micrograms. Like, we do with every other we use the term units. Then, you know, a revolution came about in the seventies. When it was discovered that you can engineer bacteria and yeast and micro-organisms to actually produce the insulin and not only can they produce. So they can produce an insulin that identical to what humans produce. So now, you don't have to worry about, you know, not being able to take pig insulin because you have an allergic reaction to it. Right. So now, we produce human insulin. And then in the nineteen nineties came a new revolution. And that was well, you can take the human insulin you can tweak it a little bit. And when you do that you can change the way that insulin ax. Does it act fast? Does it act slow and so then ushered in in the nineties era of what? We call insulin analogs. And then now here we are in the two thousand two thousand tens almost everybody's on some form of human insulin analogue, or when did they figure out that we could take animal insulin and give it to human beings and inject them. And then this would work that happened in nineteen twenty two and I'm just like for a while just imagining it must have been incredibly difficult to to to engineer build up the system where you could produce enough insulin to actually treat decent numbers of people. So you know, that's where Indianapolis became famous. So the famous experiment was done by two researchers go panting. Invest in nineteen twenty one and they were able to take the pancreas out of a dog 'cause diabetes, and then extract the insulin from that pancreas and give it back to the dog and effectively in those days, they said cure the dog of diabetes. Right. And so they said, well, this should work in principle in humans and in nineteen twenty two the first Hugh. Human recipient received insulin in North America. And that was in the city of Rochester, New York, and and that that individual famous individuals names, James havens was the first recipient of this sort of insulin. And when word got out that the James havens, diabetes was, you know, quote, unquote, cured lily ally, Lillian company went to Toronto to effectively license the technique, and then to then bring it to the masses how many units of insulin. Can you get out of a cow's pancreas? That's a great question. Because again units are defined by actively. So it all depends on the size of the cow. You know, the technique that you use to isolate the insulin thinking like I started a magic how many cows they have to kill go. Probably, you know, they were you know, it's hard for me to say because we don't do it anymore. And I can't give you a number. Right now, there's about one hundred units per milliliter in a bottle of insulin. Oh, that's way, more than I thought. Imagine. Like, you get cowed kill it, Pinkus and ten units you'd get a lot more than that. Okay. Get a lot more than that. So right now, a bottle of insulin that you buy over the counter or not really over the counter. But in the pharmacy has a thousand units in it, so ten miles ten milliliters at one hundred units per milliliter tip. That's typical fastening. So why so expensive? Now, why is it like not just so easy to make cheap? It is easy to make it is relatively cheap. There's costs and production. There's Costin purification. There's cost and quality control. But they're not a, you know, unlike a lot of other drugs that go into the generic phase where it's produced by you know, you know, goes out of patent. It can be produced by anybody. And that brings the cost of these. Medications down not true with insulin's. There really are. No what we call. You know, third party, insulin producers, it's basically to comfort three companies in the country for the most part that produce insulin at Sanofi Novo and lily, and they kind of you know, are the only ones because they have gone through the trouble of setting up. You know, the fermenters that it takes to produce the bacteria or the yeast that produced the insulin, you know, and go through the entire process of quality control. Whereas, you know with many pills. It's not that difficult, right? Reduce right pills are easy to produce insulin's or more expensive. So we haven't really had any other players get into the game. And so what that means is that, you know, I it's largely the cost of insulin a largely controlled by three companies each company, and there's only three of them right now that produce these insulin's, you know, make insulin's that. Slightly different from one another and for different individuals. It's only that particular insulin that works really, well, we know why? Well, again, you know, it's because you know, everybody's a little bit different and their bodies react to these insulin's differently. Sometimes in some cases, it's, you know, some people have an allergic reaction to a particular insulin made by particular company. So they gotta go to somebody else that also some People's Insurance is, you know, have contracts which are companies, and and they'll say, they'll basically mandate, you know, if you want insurance coverage for this insulin you have to use this particular companies and Solent or this particular type of insulin from that company. No, I would imagine that this would be a market someone else would want to enter. Yes. But I think that there is an incredible up front cost in setting up the infrastructure to produce insulin at that at that sort of level. So somebody has to see that there is, you know, real. Value to be gained. I mean, this is a business. And and so the question is really is there going to be away to to pull one of these big companies, you know, off their thrown and then come in with a generic insulin. And I think there has been there's been encouragement for this. I think the FDA's encourage the government is encouraged, but there just aren't people willing to invest in it. So I think that that is a big challenge there is if I might add a company that is now here in Indianapolis that was brought in here by one of our recent recruits to the precision health initiative that I you his name is Michael Weiss, and Michael Weiss is world famous for deciphering, the structure of the insulin molecule, and and he started up a company with all the research that he's done where he has now produced what's called the heat. Table insulin. So this is an insulin. That doesn't have to be refrigerated consid- outdoors on your table. Top for months and still be fully active doesn't need to go in a refrigerator. So imagine what that means now to particularly parts of the world where refrigeration is not easily accessible is that it then becomes possible to give people insulin who could only get insulin under certain circumstances and certain times of the day. So that then you just need to engineer, the bacteria two to produce this particular kind of insulin fascinating. So given the many many options we've talked about today. How do you figure out which what each person needs personalized to them? So the precision health initiative, I use school medicine was really designed around not just looking at an individual and saying well based on everything that I know about you. This is the best therapy. That is. Really precision medicine that is just using good clinical site precision medicine is about really taking objective data on a patient. Not knowing anything about them personally, except for some data that you can obtain whether it's from their blood or maybe their weight or their height or something and say based on information that we have this is the best therapy for you because you're most likely to respond to this therapy. So part of that now is is about doing Geno mix studies. So let's let's just say that you had a clinical trial where you put somebody on drug a verses a placebo, and you found that there was a difference. And that the drug seemed to improve diabetes, but it only improve diabetes in a subset of people. There are still some people. Got the drug that didn't benefit, but the overall group showed a benefit right? So that's great. But that's still means that if I put somebody on that drug they may not respond, right? And so the question is how do you then teased down further to say, okay, that there are individuals within that group that didn't benefit and the reason they didn't benefit was because they had a particular gene that every time somebody didn't respond was associated with that, gene. Right. Right. So precision health can be interpreted in a way that says, hey, if we can sequence all jeans, and you're in your in your body, we can do that relatively inexpensive. Now, can we find a combination of genes that we know that you have that would say you just need to be on this medication or this medication? And the likelihood that you'll respond very very high, and we're working towards that. We don't have that. Now, we don't have that. Now, we're working towards that. So what the? Precision health initiative is about is taking maybe samples that have been stored from studies like that, right? And then doing not just genomics, but what we call functional genomics. It's not just the genes that you have. But the genes that are active or even other proteins that are circulating in your body. And using a combination of all of the stuff using what we call informatics to then tease out. You know, a quintessential set of what's called the markers that would suggest you would respond or not respond to a specific therapy. And knowing all that information, we could say that you should be on a combination of this pill and this pill, and then it's likely in six years, you're going to need this pill or you're going to need this injection. How far are we away from that? So I think we're probably a lot closer to that than we might think because we have the technologies to do all the genomics and functional genomics, we have, you know, blood and urine and other things stored up. From multiple clinical trials that you don't have to actually start a new trial. This you can actually go to the freezer banks, and then do these kinds of studies. And so, you know, you know, we have a very large bio Bank here in Indiana, Indiana, Via Banque that has stored a lot of tissue samples blood urine from people from different studies. And we have other trials that are ongoing here Indiana University where we've done that precision health initiative in part with in terms of diabetes is about going to those banks without actually doing all the studies over again and saying, you know, what can we learn today with the technology. We have now from a study that might have been done ten years ago. And so that's going on now that is going on now. Well, we'll look forward to hearing results in the future excited to report on them to regulate. Thank you so much for joining us learned to done as I said before as more results come out. We'd love to have you back. My pleasure. Thank you for having me.
Global Health and Malaria with Dr. Chandy John
"Welcome back to the Healthcare Trieste podcast this. PODCAST is sponsored by Indiana University School of Medicine, whose mission is to advance health in the state of Indiana beyond promoting innovation and excellence in education research patient. Care I, you school of Medicine. Leading Indiana University's first Grand Challenge, the precision health initiative with bold goals to cure multiple myeloma, triple, negative breast, cancer, childhood, Sarcoma, and prevent type, two diabetes and Alzheimer's Disease Today we. We have with US Dr Chandi John He is the Ryan White Professor of Pediatrics and the Director of the Division of Infectious Diseases in global health at Indiana University School of Medicine I should note that this episode was recorded before the pandemic started since then. Dr John's Infectious Disease Expertise helped lay the foundation for to covert related studies tactic, which is looking at how many. People in Indiana Wade. Actually be infected and discover which is looking at how immunity responses occur. After people are infected, we should also note that his research about sickle cell anemia, African children was recently published in the New England, Journal of Medicine and people might want to check that out as well Chandy. Welcome, thank you so you're the Ryan Way Professor Pediatrics. Who Is Ryan White? And what does he have to do? With Indiana Ryan White is in Indiana. Indiana heroes everyone in Indiana and the United States should know about him. Ryan White was really the first child in the United States, who was publicly known to have issued in make a secret and the reason he got into the news was because we lived. They didn't want him attending school with all the kids and he insisted on going to school. This is a very brave individual and kind of push this where a lot of. Of other people just kind of shrunk into themselves and bring it up because it's one of those things where it's like I remember I did live in Indiana at the time, but I remember it being in the news for people old enough. It was a huge huge deal I mean because up until that point. It felt like it was a pretty stigmatized disease were many people were blamed, but he seemed to be the face. If I'm remembering correctly. Correctly like the first quit I'm putting in quotes. Nobody else can see my equity. You're like innocent. Where we sort of public in this child at a big deal that everybody was so public about it. Yeah, it was a huge deal is very brave of him because he got a lot of discrimination and hate mail, and the rest of it, or you know hateful comments right to his face where he lived but he refused to sort. Back away from that and also I. Think very importantly. He also refused to be the quote unquote innocent face of it. He said that everybody who has HIV is say they should be respected. However, it was easier for the public to handle that than maybe to handle gay men who they thought of as other or or something he really did in the United States help to give face HIV that many people could relate to more And I'm the Ryan White Professor, of Pediatrics, and I always mentioned this because our whole division was supported. By an endowment for the Indiana University, Dance Marathon, and that endowment and the Indiana University dance, marathon itself were started by Ryan White's best friend from High Yeah To Stewart I believe her name was, and so she started at more than twenty five years ago and to start, it was started in honor of him, so he was supposed to start at you that fall and died before he could start the started, and she organized a dance marathons, and they've evolved this massive huge. Yeah, and if your local Indiana's a big deal with your kids and these guys are amazing, high school kids in college, kids and they raise funds for Hospital for children, but for the first many years they raised it just for our division, and so that was amazing. It's funny because I knew I knew there is money for Riley but I didn't know it was for that purpose and I. It's funny. One of those I knew Ryan White was, but when I moved here I was like. Why do they have the professorship year? Like didn't know He. INDIANA. No, it's it's amazing, and so now the funds from the Indiana. Brisy dance marathon go to the whole department of beating. US For the first twenty years it was to raise his endowment, and so when people ask me who this rich donor was, who gave the endowment that allowed us to create this amazing or build this amazing division It was It's the college kids, and and I should also very important dimension. The connection there is that writes. Doctor was Marty climate. Who is the? The founder of our division, so that was when they wanted a way to honor Ryan White and and support the things that were important to him. The sought out Dr Climate. He said supporting research in this areas is critical, and that's what they did. Well, that's great and not just completely veer directions, but you know the time what we wanted to talk about. About. Today is global health. So I like to always start by talking to you like. How did you decide? This is the area that what you wanted to be in in studying not just infectious diseases, but how they the impact, the world, not just even the United States. How'd you get here? Yeah, so there are many answers that question, but the beginning always starts with. With my parents so My parents are from India. They came here to do their residency I. always mention because this is a fact that. When they came here, they were paid to come here, so there was a doctor shortage. So when people are talking about all these terrible foreign medical grads and stuff boy. The US has relied on those foreign medical grads and. Show all the time. Yeah, it's it's a big deal and they've added a lot to the country. research wise clinical is an in every aspect of so. They came here for their residencies, and then they went back to India to work at a mission hospital and so we sort of went back and forth from the United States indie when I was a kid, but when they were there this mission hospital, its mission was to serve the poor, and so they would take us on rounds or to the hospital on a fairly regular basis because they really wanted us to be sure to see why. Why they were doing what they're doing. Their lives were very busy. They both doctors and so They were at the hospital a lot and you know kids could sort of feel like hey, why aren't you you know here with me? But we never felt that way because we saw what they were doing, and it was important, so that sense of those who have have a responsibility to serve those who have less because none of us earned what we have. It's all just you kind of like what we started with. was very strong in my parents, and they pass that onto us and so. The idea of doing something for underserved populations, and then when you think about places like India and Africa. Have you know the under served there are. An Order of magnitude, more underserved than those in most other places and so that led me into thinking. What could I do for that population? That medicine was kind of an obvious path, because my parents were doctors, and they loved what they did, and I could see its immediate impact Then you probably don't know about me, is that my big interest was in writing? It still is my first love was writing, and so I wanted to do something with writing, but I couldn't figure out a way to do that and serve that population now I? Know there are many ways you could do that, but back then I haven't. And so so when I was thinking about this, you know my mom was sort of giving me advice and she said. If you decide later that you want to be a doctor, it's going to be hard to do that where you can keep writing even if you decide to go into medicine. So that was what I did, and it was more of a pragmatic decision than a love of medicine to be totally honest, but like would. There you go. I could do something with. This wasn't sure that I really as kind of like I didn't like blood, and God's but then of course I got into it, and it's amazing like professional. Madison is just incredible and. Being part of people's lives and especially pediatrics than these kids get better and in our domain of infectious diseases. They almost always get better, and so that's very fulfilling. How did you decide to do infectious diseases? Though yeah, so it was the same thing I wanted to do something globally and historically, and to this day the biggest problems globally for sure infectious diseases and so. So why spent a couple of months at a mission hospital in Bangladesh when I was a fourth year medical student, and then in my residency added chance to do this. and I wonder if you where'd you go to Medical School University of Michigan was that was that common that people would go? No, no, it wasn't so. University Michigan was the most. Medical School I just loved it there and so was such a privileged to be there and in-state tuition was amazingly low, and it was just it was a marvelous place to be, but at the time I was there. They were not a big global health center. They are now have rectified that that problem, but back then they weren't so. It's a little unusual to do the rotation to sort of work things and then in residency. Residency I did I spent nine months. Nigeria as an absent international health, and that was really radical, because it was taking a break from residency to do this and was kind of like I. Don't know the recipe was totally happy with me for doing it, but they did support it so I give them serious credit for that. Because I'm residencies would have just said no, you're. We're not going to do that but they. They supported me and so I was doing a med peas, razzies in Nigeria the getting to the point of why did I do infectious disease? I saw all these kids with malaria was by far the number one reason for both inpatient admissions and outpatient visits at that time, if a kid had fever in pretty much any African malaria endemic region, you just treated them without a malaria. You didn't even do any other work and then. Then, if they didn't get better, you do the other workup unless there was some clinically obvious reason that was actually who standards was you gave an malaria for fever. That's how calm and it was. And at that time there were very few pediatricians doing research on malaria. In the United States, there were. There are a number of good malaria research program. Almost none in pediatrics just so hard to believe I mean. Malaria is a major. War. Back then it was like maybe number or three. There are more than a million kids every year. I mean and the statistics, and how like mosquitoes killed more people like anything else? On Evan, it's a it's an online and a lot of them are clearly children's. Why why I don't know why. It was one of those you know to be honest. I love our disappointed pediatrics, but I think we have lagged behind internal medicine and some other disciplines in terms of the global health aspect of things in some aspects. No, because if you think of vaccines, that's very much. And in pediatrics, pediatricians largely leading the way they're and they're probably the. Biggest medical in most successful medical intervention absolutely yes, so in some ways you know right there for global health for a lot of problems like this pediatricians weren't doing that and when I talk to people who like Oh is this career suicide? Nobody's out there doing this. It's kind of out there and these kinds of responses. I would get from some people. There are definitely people that are supportive. So I think that pediatrics took a little while to kind of grow into wanting to do more in the research space of global people were thinking more about volunteer things and stuff like that, which is important, but even when? When we talk about even I think clinically go. I see I see a fair number. Medical students even see a fair number residents who say they want to do it and spend a month or go, but it feels almost as if it's vacation destination. He Yeah, not now like dedicating lot. Which is why I'm always impressed by. You know people who are like I'm going. It's a hard road like you had make it. No one was saying we have a plan. That says he'll do a a month here and then nine months here. That's how you get to to do that so I mean especially I think. Years ago it probably took a fair amount of effort to carve out those kinds of careers yeah. I mean it was much less much more of the road. Less traveled within pediatrics I I'll happily say things are vastly different now and I feel like pediatrics is in many ways leading the way in education in terms of those very things you talked about that global health work should never be medical tourism that there should be a. Mutually beneficial partnership in every case, I think they're really outstanding pediatricians at every level education and research rent doing now, but back then kind of across the board. It was just it was hard to do so You had to be pretty. determined that this was what you wanted to, but that was the one thing that I will say is I was determined and and. I if I like if there is somebody listening to this, who's starting or whatever I think you know like I'm not the smartest person on block. I'm not the most you know like the have the brightest ideas but I work hard and I was willing to persevere, and I think those things matter more than anything, especially global health because you just have to. Just have to like there's a lot of things that go get a lot of things. Do not succeed. You Know Rachel Freeman, who is one of our? We've had a props. My my fellow when she declared that this is what she wanted to doing entered our fellowship in a completely different path, but this is where I want to. Make my life, I remember not trying to talk her out of it, but being like I have literally no idea what muscle to flex to make any of this work. You'll be entirely on your own and the story. She's telling me about what she had to do to get stuff done. In Kenya where I think most of her work is one of the things I focus on how hard it is to get people healthcare in the United States of America, which is a pretty wealthy research country, and it's so difficult I can't even fathom how hard it must be not only get healthy, but research done in some of these settings I mean the number of extra steps and things that you have to do it. It's impressive. Anyone engages with it. Let alone succeeds, and it's such testament I think to how people are willing to work. Yeah, I think. Rachel's like the poster child for dedication and perseverance in the face of obstacles because she knew what she's doing was in is important and and I think that's just it. Is that you if you're in that setting and you have a research type of mindset, you see the possibilities for the difference that research can make in those populations, and that along with really great partnerships with incredibly smart and engaged people in the country. who kind of provide mentorship in how to do this and. And what you can contribute I always say if everything is being contributed by your partners overseas, and there's really no room for you so you should have something to contribute as well, but she got an I got so much mentorship with the people outside are like. Hey, this is what you should focus on. This is what's important. Here's how to do it in this setting, but then you work with them, and you see the difference it can make an I will say you know like the people that are working there the people that she works at people that I work with could have jobs anyway. and they work in what can often be an extremely. Frustrating and difficult system day in and day out whereas we're going there, but we have the support of a US university, and so it's a real tribute to them that this work gets done. Because ultimately, that's what matters is that people on the ground have the know-how and expertise to work with you to get it done, and they're willing to just keep going I. Think I remember now when Rachel was on the program, we talked about empathic general, but but in university has a long standing relationship with. My correct entire hospital systems yeah, yeah, Kanye Ghia talk briefly about it. Just people that haven't heard about absolutely so amp hat stands for the APP academic model to provide access to healthcare, and I should say up front I came here from the University of Minnesota so I work together with path, but I'm not really You know one of the Path physicians or researchers or educators, but I decided to move to Indiana University in part, because path is here because it's such an extraordinary program and I think what set set apart from every other program. I believe every other academic program in the. The United States is two things. One is that the decision was made right at the beginning to focus on access to healthcare who it is not primarily a research group. Amazing research gets done with it at like Rachel's cameras and and many others, but that is not be that is a goal. The primary goal is providing access to healthcare, so that is unusual, and so it's a university using its knowledge in partnership with another university more university to work on access to healthcare, and then the other thing is Indiana University. When right when this started, it was an academic model, so it was not just Indiana University and No, you know universities are wonder places to work, but they're kind of territorial. People want to the glory to come to a you, so they started from the beginning. This is a model and any university that wants to be a partner if they meet these criteria for partnership, and so multiple other universities I won't. Remember them all, but Brown Mount Sinai do University of Toronto University Massachusetts. Many others are part of this consortium so together they're working to provide access to healthcare, and then within that they degrade research and education programs. It really is just amazing. One of those things that the more you hear about it, it's just it's stunning. I mean just what they've accomplished and. You know not that great appeared at time is just amazing. It's incredible. I mean the the this whole model to provide access to healthcare. They're now working with the government of Kenya which wants to provide universal healthcare to help model how that could happen, and how could work within the areas where they work? There's a huge amount of work in HIV, and they've revolutionized care of. Of HIV they're now working in chronic diseases cancer center. I mean it's really a a most extraordinary program and great things for me as I try to recruit people within our Pediatric Infectious Diseases Division. An Path is a huge draw because work in that setting is just you know it the opportunities to do great things or so I think didn't draw from at the medical school. Medical since all the time where this is. What drew them? Which is amazing? Yeah, it's fantastic. Let's shift course a little bit I WanNa talk about malaria, 'cause it's other things where again worldwide such a massive problem. It's not the United States. I'd be plenty of people. Don't even know what it what it is. So what is malaria so malaria as a parasitic infection that is spread by mosquitoes it. Can't be transmitted person to person in general I can get it from blood treasurers, but it's really ninety nine point, nine nine nine percent of it is spread by mosquitoes which take infected blood from one person and injected into another, and this parasite goes into your liver, and then escapes from your liver into your bloodstream, and when it gets into your bloodstream, it causes symptoms, so you can get a very high fevers from it, and if you get really sick from it, you can go into coma. Severe Anemia, you can get very bad respiratory distress, a bunch of things, and if you don't get treatment, you can die from it, and it is still one of the leading killers of death in children, which is just again just stunning I mean just the because it's. Can't we worry about all these things that are so dangerous and it's still one of the top five I'm sure. Yeah, I think it is although I like one very happy thing, and in the course of my career is seeing. The progress has been made in malaria, I wish I could say it was all do. Not But but you know bednets and better drugs and other things have reduced the death toll estimate when I started working two million deaths a year. Pretty rough estimates. It's now down to under five hundred thousand, so it's even if it was a million. It's a massive decrease in the number of so, why is it such a big problem in other countries, so many reasons if I talk about Africa specifically It turns out that the African malaria, mosquito, vector or vectors are much more efficient transmission than ones that occur elsewhere, so we have an awfully mosquitoes in the United States, and there was malaria here up till night the nineteen forties, so it was a problem here. interesting sidelights. CDC was started as the office of War Research to combat malaria don't. But it has its genesis in the word. Combat Malaria Yeah. So so CDC has a long history with malaria, but The African vectors are much more efficient transmission, so that's one big problem. and then access to health care is a huge issues of people are living in rural areas more often occurs in rural areas most of Africa's still rural so That's a problem, and then they can't get to the care they need to in time. and things that worked here, so we had malaria here and it's gone. wising gone in Africa will it's a long. Long story but a number of things that worked here are harder to implement across the sub continent of Africa than they were in the United States and a lot of it has to do with a public health system that's able to detect cases and then treat those cases in anyone near those cases kind of across the board so many different factors, but those are some of them, but I would see the biggest thing probably as the public health system in access to healthcare so when it's the public health. Health system is it. Is it prevention from getting bitten? Is it not getting rid of mosquitoes enough? Is it that we don't treat people fast enough? And therefore that allows a mosquito transmitted from, or is it all? It's all of those so in the US. When they were getting down to the end, anybody who had malaria got to the House of that preside malaria, the treat everyone there they might even do spraying of the areas. It's very intense campaign at the end to get you know. Get things down to zero. Zero, so that's difficult to do. Especially in rural areas in Africa, to that same extent and then if you're in a rural area, if the healthcare facilities are far and few between, then people may not come in anti. It's quite late in the meantime. Not only. Is it bad for them? Because it's caused severe disease, but they've had a chance to transmit it to more people, so many of these things together see, said bednets I mean. How much is it? Is it nighttime when a real problem? Yes. It's a female off mosquito that. and She Bites at night so What bednets themselves are not that effective, but insecticide-treated bednets very effective, and they're effective, because the mosquitoes land on them and die They don't get a chance to bite the child, so they going a transfer transmit, and they don't get a chance to transmit to others, either so it's not just the prevention of biting the child. It's also killing. The mosquito on contact is prevented medication I mean. Is there a way I? AM asking totally out of ignorance. Yes, so the next time you come to Kenya Uganda. Aaron inviting you now. Many times just trying to find the time and then. You will take malaria prophylaxis I guess if you want. Now even around elder at their mosquitoes. You Good Nairobi. There's just really there's I mean. There are mosquitos, but there's really no transmission of of malaria. The guidelines will save. You're going solely tonight, roby. You don't need take perplexes, but pretty much. If you're going to Uganda Kenya, you take prophylaxis to prevent malaria medications to malaria, and they're quite effective. They're not one hundred percent, but anywhere from eighty to ninety five percent effective every time I go to Uganda or Kenya I, take a medicine and There have been campaigns to have this in Africa. And there are there is actually so the difficulty is in many places. The whole populations expose e have kids going on this medicine for years and sometimes it's a you can get away with weekly medicine, but that's as long as you can do. Some of them are daily, and so it's tough to. It's tough to do that in a population, but there are W recommended regimens for places that. That have seasonal malaria that during the malaria season, the youngest children will take chemo-prevention in pregnancy. Women are more susceptible to malaria, and it's bad for them and for their fetus, and so there's also recommendations that all pregnant women Milan daycares. Get Chemo friendship, so there are these targeted populations again. Clearly, we radically for the most part in the united. States was that because we just treated so much just. killed it off while there are many different factors, one was as good housing and kind of drainage of swamped areas and things like that, so kind of good general public health measures and better health overall tend to decrease rates of malaria pretty substantially themselves that just by itself. Then there were campaign so a lot of things we wouldn't do now like spring with Paris Green and DDT. Who's your pretty toxic and they do it and sprayed everywhere, but it works. So if you get it down if you get it down to a certain level, then that can sort of take zero I mean many years in Africa. There are some more focused spraying efforts, but they're so much higher than we were that. You'RE NOT GONNA get it down to zero like it works for a while, and then the b-actor comes right back, so the spraying campaigns toxic have been had their effect, and then it was the public health component of if somebody comes with malaria. Go out to that house. Treat the people. So what are your research interests? Overlap in malaria, so three major areas one is to figure out why kids get severe malaria. WHY CERTAIN CHILDREN GET Severe Malaria? Because some kids get very bad Blair hospitals in some kids don't and why you know. Can we prevent severe malaria? another is that a major complication of severe malaria is Noor Developmental impairments of kids, not thinking as well functioning. Functioning as well as they could be, so, why does that happen? And what can we do to prevent that and that so those are sort of on the sick child with malaria side, and then and in Uganda, and then in Kenya, the work focuses on an area, very low transmission. That's gotten lower over the twenty years. We've been there and my original work. On trying to understand how immunity changes as your exposure to malaria goes down, we're still looking at that because we're interested in. If you wanted to vaccinate a population like that where there's not much malaria, how would a vaccine work versus where the areas where it's traditionally tried which have a lot of malaria, because it may be quite different, your immune system may respond differently to the vaccine but now we're in addition to working on that. We're working on while we've gotten malaria down so low. How can we actually get to know local transmission because it's really low, but then periodically they'll be outbreak, so it seems to me like we have to get to to to know malaria the area, but the complicated part of that is that the areas surrounding it have much higher transmission. Transmission so you have to do something. That's both effective and sustainable, and there's not an easy answer to that, but I feel personal commitment I in the one area of Kenya. I've been working there for nineteen years now. and we've just watched this trend with malaria and I felt like okay. The time has come for us to work with the Ministry of Health. Really get it down to zero. Zero. There's one other area that I work in a again back in Uganda which is infections, the kids with sickle cell disease, and the Genesis of this is actually that the reason we have sickle cell. Disease is because of malaria hemoglobin, A. S. or one copy of the sickle gene is highly protected against severe malaria. How is that? Yeah, it's amazing so well I get the genetic. Trait with exists, but how does it work? Yeah, so there are many different reasons why it's positive that it works which have a fair amount of evidence for them, so the having hemoglobin as sickles yourselves a little bit when the parasite goes in and so it makes the red cell less hospitable to the parasite may get cleared by the spleen. It seems to decrease oxygen concentration in the cell, and to that's less good for the parasite, and it helps decrease parasite burden and decrease parasite load, and there are a number of other factors like nitric oxide. It seemed to be altered by. Sal that has hemoglobin in it, and so they never were almost never get sick. Cling crises, but they do have alterations in their cells that make them less hospitable to the parasites, and so I mean is the reason we have sickle cell disease today because of malaria it is, there's no the it's incontrovertible evidence, because if you look at where malaria historically has been and where sickles, all diseases including outside of Africa it's a perfect overlap. That's just so may yes is sickle cell disease exists because Hemoglobin A.. A. S. or sickle cell trait was protective protected against malaria, and what we we've done. These studies of severe malaria that is telling you about, and we get group of control children from the same neighborhoods or households as the kids with severe malaria to look at what how they think, and how is that different from kids with severe malaria? That's how we get our our population norm and only looked at the prevalence of hemoglobin, A. Astor sickle cell trait in the control kids versus the kids with severe malaria. I think eighteen percent and the control kids and two percent and the kids with severe. We rediscovered protective effect that's I. Mean that's just so I mean it's just so amazing to see such a concrete example of how natural yeah, natural selection at work, so what happened though is of course that if you I mean and places where the most malaria, there's almost twenty percent prevalence globally ass. If you do the math that would mean roughly four percent, ish of kids would be would have been s s, and historically these kids get a diagnosis. And they died before the age of five from infection or complications, other complications of sickle cell disease, and so I was working in these malaria democ areas. Caisley kids with sickle cell and not know what to. To do with them and you know like they were pretty neglected population in Uganda. When I started working there there was a very foresighted doctor named Professor Christopher Undo Gua who, in nineteen, sixty nine started sickle cell clinic. I'm Malaga Hospitals? That's more than fifty years ago now and it was one of the first clinic of its kind, and so he identified that this population was a population in need and got them good clinical services, and so the kids who are attending that clink did better than kids in general, but still there were many things that were available here. That were not available in Uganda, because the research had been done or. Or whatever, and so, that was what drew me to looking about population was it was such a such neglected population, and there were simple things that could be done. That were not being done yet. How did you choose to work in Uganda boy? That is a long story that will shorten by saying that I was working in Kenya for many years before I started working in Uganda. and I had an opportunity to do a slightly longer version of the story when I was in Nigeria. I worked at a mission hospital there with a doctor named Cindy Howard is a pediatrician. One of my kind of life influences cindy after she had finished her work. Work in Nigeria started working in Uganda, so she had some connections there when I would meet her, she'd say should meet these people that are working Uganda, some of their amazing. There was one resident I work. He was incredible. I was at Case Western at the time. This resident incredible resident one research award. He decided to want to come out to case Western because Case Western was doing TB. Studies and Uganda said they were well known university there. I met him and he's a I was trying to highland hospitalized. Malaria study in Kenya wasn't working out for complicated reasons they said well. We have islands in Uganda. Why don't you come work there? So I did? we switched the study to Uganda and then an opportunity came up between residency and fellowship I decided that I've been on the fast track do long, and I wanted some time to write and travel and do some global health work and so I worked as a PDD docking to pick you up again for those that are listening like. It's always good to go out in the real world and be away from academics for little bit. Bit. I felt like they gave me some really good. Like critical thinking. I doc on the on site skills. I spent time in Laos helping setting pediatric residency in Laos and when I came back the person who sent me out their car and Olmos who is an amazing global health. Person said we should talk to Michael Boivin. He's going out there to look at cognition in these kids with malaria. You talked just to you know like. Let him know what your experience there was, and what he should be triggered, so he was in Michigan, I was in Michigan. We talk. And then he came to case Western instead like we should study cognitive impairment in these kids with severe malaria, and at that time was like now. He just needs to get rid of malaria. Let's not you know like I don't think we should do that, but he veered and convince me like his his line, which was absolutely true was, but you're still seeing these kids severe, so it's not gone yet. Yet! Are you going to do something for them? So I said yes. You're right and so together. We put in this grant and I decided to do it in Uganda. Because my hospital based connections were much stronger in Uganda. And that's how I ended up in. You KINDA. How do you go about setting up these things I mean they sound I can't even I don't know what muscle to flex. How do you do it yet? So it was learning experience for me. My Mentor Case Western. I went to Case Western for fellowship. Precede on! On their Jim Zara was real master at this, he worked in Papua New Guinea in and we worked together. In Kenya, and it's all about knowing the people locally and areas, they identify important the first study for example been working this highland area for a long time as I told you and it start because Kenyan colleague of Jim's while these highland areas, they keep getting outbreaks. Do you think that could have anything to do with them? Losing Immunity Jim said will you're starting as as a fallow and you know like you're interested in learning. Learning lab stuff. Why don't you think about how you can look at immunity? These populations you can work on this study with me and John Uma was our Kenyan colleagues name, so it starts with identifying what's important to your local collaborators? You know the situation far better than you do. Sometimes there are requests for applications. Nih and you have to see if it fits what they want. And then I think it's identifying good people. It's very important to me to always talk about The people I work with in Uganda and Kenya in. The? Baba? Poke is my main clinical EPI research collaborator Paul Bungee Rana is by primary neuropsychologist claburn. He actually got are his PhD with our project. And now he's a pin is own on several. That's granted Richard Rose. Collaborator and we have some up and coming collaborators ruth nause is our hematology collaborate so these are amazing people, and they all have different strengths, and so as a question of we like each other. We like the work that the others do. How can we work together to address an important problem? Israel local people yeah. They're all bracket Democrats in the United States. No, no, they're all based at mccarey university, and then in in Kenya my main collaborator is. Is Georgia Yodo who works with Kanye Medical Research Institute and with a university there Jaramogi Oginga Odinga, university and so he and I been working for many years in his strength was actually genetics, but now he's doing more epidemiology work, but in all cases we enjoy the work together, and we've always been able to figure out roles for each of us, and for the people like for me, junior faculty or post, docs or PhD students and For them the same thing on the Ugandan side. Like how can this work so it helps both groups, and it leads to the bigger goal so I I was like dimensioned them. Just because I think that people think like you go out there and you do these projects, but you don't know it's the people they're doing the project and you are doing your part of it. That can be useful to them in the project. What are you most excited by right now? Where do you what things are coming down the pike that you have the most optimism for a very excited about the reduction in cases and deaths of malaria, and I think it can go further there are vaccines in development. There's this possibility of genetic modified Mosquitos. or mosquitoes with other organisms in them that make them. Them less hospitable to to the parasite, there are campaigns of mass treatment that can reduce the population burn overall, even things we've used for a while like bednets spraying still have their place, and so there are many different ways in which we can very actively work to reduce malaria, so I think that we're going to keep seeing reductions and I'm I'm optimistic about that. That, the flip side of that is that we've stalled the last two or three years, and so I'm also worried like drug-resistance like malaria. They can big die from the fifties in seventies, drug-resistance came at the tail end of the sixties and Seventies. It just skyrocketed again and so I feel like I feel like the pressure is on for us to be aggressive about interventions. Interventions and research now because we have this opportunity to keep driving down, but if we get satisfied, it will come back in in blaze. Can you any more than once oh? Yes, okay, so then. How would a vaccine work? That's a great question because we don't have a great vaccine for malaria, so designing a vaccine for a parasite, which is much more complex or Bacteria or virus is very difficult. There's never been a successful human parasite vaccine. The vaccine is that we have for malaria have worked, but it's been like maybe thirty percent efficacy. There are some vaccines right now. That seemed to show in very small trials, maybe more efficacy, but you have to give him intravenously. That's obviously not a great thing for you know mass deployment. The trick with a vaccine is to end up. Generating response. It's better than the parasite itself generates, and it's been really hard to ensure its and yeah, and then things at work here and people that are completely malaria naive may not work as well in kids who are not totally malaria Ni- because they've been prime, maybe have immune tolerance, whatever, so it is quite tricky thing, but the goal with the vaccine is actually improve on. On the natural response, so the wouldn't get repeated episodes. So this is going to be totally naive again, but what about better? Just mosquito repellent? Yeah, well, that's being worked on. It's not naive at all. There's big studies looking at spatial repellents and other ways of using it has to be something. Probably, that's not something that people are going to be on themselves because they just won't. Is that I was going to that biggest issue. I'm speaking from experience like. People in the United States, spray them say yeah. Yeah. People don't want to do it and so something that would repel, but doesn't require the person to do it every day I. think that's the key. repellents are being used as well so there's a lot of things I mean it's really an exciting time to malaria because he's been a lot of success and is kind of promised success, but there's also the specter of like. You Take Your foot off the pedal a minute and suddenly are. Just I I mean I know upset, even multiple times in this conversation, but it's one of those things where I don't think people understand how big a deal it is. Yeah, it's a huge deal and what we've shown like, so you always wonder like what is your contribution like any of our work? Really Reduce Malaria because that wasn't what we were focusing on implementation. Implementation we researched, but what I can say is that some of the work in Uganda show that there's this big cost of child neurodevelopment from Severe Malaria, and we actually are doing a study right now we're. We're taking the three cohorts. We enrolled to study this and following them anywhere from five to twenty years after the had the episode, said now we can. Can See things like. Is there a health related quality of life caused? Is there an economic cost? Is there a cost academic achievement? Kids who had are they less likely to go to college, and we have a control group that's from the same households or neighborhoods, so they're pretty good control group for all these other factors might affect that so we're trying to. To define that for the very long term bet, even like as far as two years out. We shown a cost here and so there's a cost in terms of debts, but there's probably a societal cost that's as substantial when you look at all the survivors, and what happens to their brains. The other thing that I'm very excited about is sickle cell disease because. We, did this studied yeah of of using hydroxy Rio which is used for kids here in sickle cell with sickle cell disease and we've. There was no reason to believe it wouldn't be effective. It's very effectively reducing complications and probably prolonging life. There's enough data to show that yet, but it's likely because it produces end organ damage, but there was reason to believe that maybe it would be harmful in. In terms of making kids more at risk for severe malaria for severe infection, and so the long, the short of it is the study that we did it was first placebo controlled Rcti Roxie and kids in Africa and it showed that and it was done with our with Baba told you about in our collaborate Russell where his pediatric hematologist. That was another thing I wanted to study. Sickle cell disease, but couldn't study it without an expert in sickle cell disease research, we had the experts in clinical disease, and Uganda, but we needed the research expert, which was Russell, where and so Russell joined us, and we did. The study together showed hydroxy was not only effective, but safe and so that's actually one of the more satisfying. These ever been involved with my usual stuff is like what happens with immunity, or what happens renders not an immediate translational step, but the Ministry of Health has actually already proved hydroxyurea for using sickles these it was a cancer drug before to cancer drug and now it's expanding the guidelines and we're there trying to get subsidized Roxy Rea-, so kids who need it can get it so I feel like within five years. Most kids with cycles of these. Will be on hydroxy. It can have side effects, so you need. Do it right like if it's just given out like water, no one's falling. These things can be bad, but that's another thing that Bob and a colleague. Here at a you are studying together. How can you do this so that it's effective, but also safe follow up in resource, poor areas, but it's exciting to see it being used. Be Used at all when we started. And now it is so I, feel like and we're doing a study on zinc to see if it can prevent infection kids with sickle cell disease so. We, yes, so it turns out that people can't see like a mega face. The United States so this is so interesting to me. Because the few things I think one is that there were studies done in the United States that suggested that there was an effect. on preventing infection and a large effect, and then there was another study, but they were all done in adults or older children, and then there was another study that was dining India, that showed it had a large effect as well I'm talking like fifty to eighty percent reduction. I'm like I think really it's I would be thrilled. Don't get me wrong I. Want to see yeah, so so and the reason why? Why it may work, is that when kids with sickle cell disease bone crises is all stuff I learned from my colleague. Nutrition Syracuse. She sort of brought this up because I'm not a nutrition expert and I I like parenthetically. That's the joy of academics as you collaborate with super sharp people, and they give you new ideas that are like really inspiring. She found this data that I never knew about we were. Were writing a book chapter ever and it was like. Don't write book taxes terrible, but we writing books. I agree to, and like she found this data on zinc, being productive in sickle cell disease, more looking at it turns out in bone in these basically crises that they have when the cell cycle and they they clot off circulation to the bones, the bones released zinc, and it goes out into the bloodstream. Bloodstream and kids with sickle cell disease often have some renal impairment, and so it sort of escapes in the urine as well even without renal impairment it can be excreted in the urine, and so there are studies that show that kids with sickle cell disease, low zinc plasma levels, but there's reasons to believe that their actual whole bodies glowed is even lower than what you see in their plasma, so they are. Zinc deficient for a reason, and this is why zinc might okay, so that makes a lot of sense versus just the whole like. Just that someone. But but the great thing about it is if it works, we have Ecuador's. We don't sure there's a couple studies showing that it does. They were an older kids. Maybe the younger kids don't have as much zinc deficiency but if it worked, it's almost completely nontoxic. Yeah, and it's easy to take and it's cheap as dirt already got it for less than a sent a pill, so if it worked here be an intervention that you could give. It's like it. You wouldn't require any monitoring and if he also just take the pill, and it's like three bucks a year going on now. Yes, going on now. We want to have you back. Yeah, exactly. Hopefully it won't be to say like didn't work now. Sean we take negative results but. Healthcare Trash podcast, is sponsored by the School of Medicine whose mission is to advance health state of Indiana beyond by promoting innovation and excellence in education, research and patient care. They're also leading universities first grand challenge, the precision health initiative with bold goals to cure multiple myeloma, triple, negative breast, cancer, and Childhood Sarcoma and prevent type, two diabetes and Alzheimer's disease.
March 5, 2019: Hour 2
"This message comes from here. And now sponsor indeed if you're hiring with indeed you can post a job in minutes set up screener questions then zero in on your shortlist of qualified candidates using an online dashboard get started at indeed dot com slash NPR podcast. Search teams continue to look for survivors in eastern Alabama. After those powerful tornadoes killed at least twenty three people in a news conference today. Lee county coroner Bill Harris said the victims ranged from six to ninety three years old just keep those families in your prayers. There's one family was connected in her over seven people this man laws one seven in one family. Well, our next guest says this tragedy highlights a unique vulnerability in the south Victor genie is a tornado researcher Ed northern Illinois university, and Victor you were watching radar tracking of these tornadoes. What were you thinking as you watched? Well, honestly. Early your stomach. It's heavy, and you know, as a researcher what's happening at the surface. Well, and as you point out storm prediction center's head out looks for two five days in advance tornado watches were issued people like you around the country were seeing this. What's the disconnect? Why did so many people die in your opinion? I think it comes to the unique question of exposure. And vulnerability we have a big challenge in the southeastern United States as we have a lot of trees in the way, it makes seeing tornadoes very hard. We have another big problem though. And that's we have a lot of mobile homes, and you're if you're in a mobile home when a tornado strikes, I you're very likely to be injured or or perhaps even killed my colleague here at northern Illinois, walk rashly and another colleague Steven Schrader at Villanova university of looked a lot at mobile homes, and what we generally see is over half of all tornado fatalities occur in mobile homes. And yet they only account for roughly. Seven percent or so of the United States housing stock. So we have this disparity where a lot of folks are getting injured or killed in mobile homes. And so we ought to start thinking of potential whether it's legislation or some mandates to require these mobile home parks to have safe shelters nearby. So these people have access to safety, but that only really I think addresses one issue of the problem. The second issue is were making really good forecasts. But are people actually getting the warning? And if they do get the warning are they actually willing and able to take action, and that's another thing that, you know, if you think forecasting, the weather is hard forecasting human behavior is sometimes even harder. Well, let's talk about that. Because Gershman who's with the university corporation for atmospheric research, very bluntly said, maybe we need more funding for social science to actually figure out the psychology of people because the messages are going out and some people complain I don't want that. Interrupting my television show, I couldn't agree more. We absolutely need more research on how people respond to our watches our warnings. And even our severe weather outlooks. Again, the science is getting very very good at predicting at least general locations of where severe weather is likely. But we still have this disconnect as we saw a couple of days ago people's lives in those regions, especially in Lee county, Alabama will never be the same. Well, we certainly not blaming the victims are trying to figure out a way to get that message across. So there's that, but we've also been hearing today the concern that and it's not even tornado season yet some have mentioned that April will that's coming up. Maybe even worse. What do you say to that? I am always very careful to use the two terms tornado alley in tornado season. Because I think when you use those terms you lead people to believe that severe weather is only going to happen or is only likely to happen in a certain area of the country or to certain time of the year. And as a researcher, I know that that's not. True tornadoes happened in all fifty states, and they can happen any time of the year. And while the southeastern United States doesn't have a focused tornado season. They have a very broad risk over the entire year. And that means you can never really let your guard down for these events. And if you do you become complacent to the hazard, and unfortunately, if you become complacent, you may become of the of the sort of mindset that you know, these are not of that are going to happen to me, and I shouldn't worry about it. When they issue a watcher a warning. And unfortunately, it just takes one tornado to really, you know, produce what we saw couple days ago. Victor, we are hearing terrible stories out of Alabama apparent holding six year old son who was just ripped from his arms because of the strength of the wind. Another man they were hiding in the basement and the dog got very quiet. So he went up to see opened the door, and almost was vacuumed out with the force of these winds, if until mobile homes in particular, get more shelters, what would you what should a person? Into if they find themselves suddenly there, they are and the tornadoes coming hit the floor get under something. I mean, what can you do? Well, you can't wait until the houses. Collapsing on you to try to think about what to do, you know? But if you're an attorney to warning in you do think that your, you know, your your property or your life is in jeopardy, you really need to get indoors get to the lowest floor in put as many walls between you and the tornado was possible. You know, I'm telling you even people now to in your emergency kit. Put a bike helmet in there. Because a lot of the injuries that we see our blunt force trauma to the head. And you know, I think a bike helmet could actually go a long way in your emergency disaster kit when you're thinking about severe storms. Victor Jen Seaney tornado researcher at northern Illinois university in the sad. Terrible aftermath of the tornado in Lee county, Victor, thank you. Thank you, Robin will the actor Luke Perry is being remembered today by many other Hollywood stars who worked with him over the years. He was most famous for his role on Beverly Hills nine oh, two one. Oh, Perry died yesterday after suffering a massive stroke a few days earlier, the CDC identifies stroke is the fifth leading cause of death for Americans with one hundred forty thousand dying from strokes each year. And joining us now is Dr Mona bay who who is assistant professor of neurology. At Johns Hopkins School of medicine, Dr welcome and let's start with the basics. What is a stroke, and what causes it? So a stroke is caused by any disruption of blood flow to the brain the brain is the only organ in the body that is reliant on a constant flow of oxygen and nutrients to keep the sales of the brain functioning. So stroke can really happen in two different ways. One is when the blood vessel gets blocked, therefore, reducing blood flow to the brain by an inclusion or blockage of the blood vessel. The other way stroke happens is the bleeding kind of stroke, a hemorrhagic stroke when the blood vessel itself breaks, open and blood leaks out in during the brain tissue around it. And the fact that Luke Perry was just fifty two years old is that unusual for somebody to have a stroke of fatal stroke at such a young age. Yeah, you know, stroke definitely increases with each decade of life above age fifty five, but it's not uncommon for a young patients to have stroke. So probably on the order of ten to fifteen percent of stroke patients are really under the age of fifty five. And are certain people more at risk than others. There are definitely risk factors that put people at risk for a stroke. Some of those risk factors include high blood pressure smoking. Atrial fibrillation condition where the heartbeats irregularly and increases the risk for sending a blood clot from the heart to the brain high cholesterol, poor diet and lack of exercise some of those will put you at much higher risk for stroke. There are genetic and family causes, but those are much fewer and far between and how likely are you to die from a stroke, or if you do survive one what is lifelike afterwards. You know, we've really made great gains in how in the United States. We've helped patients to survive through the stroke stroke used to be the number two leading cause of death in the United States and now is down to the fifth leading cause of death. That said probably between ten and fifteen percent of stroke patients will die from the stroke. That really depends on the type of stroke that the patient is having a. And the size of the area of brain tissue as affected by the stroke. So the larger the area of stroke, the larger the area of damage of the brain the more chance for death equally. Some of the hemorrhagic stroke types, have an increased likelihood of death, depending on the cause of the hemorrhagic stroke, and then what is life like afterwards for people who've survived a stroke once you've survived the first few days after a stroke, all efforts really turned to helping you recover from that stroke. So, unfortunately, although we've improved survival from stroke. We haven't really moved the needle on the level of disability that stroke leaves people with once they've experienced it. So the patients who have strokes can have physical abnormalities, meaning some patients can't walk. Some cannot move their arms to take care of themselves, including activities of daily living, some strokes steal people's ability to talk or communicate in that can mean effect the ability for the words to come out properly or. Even the ability to understand the spoken word to them. Some strokes steal the person's ability to see completely. So some stroke patients will have a loss of vision in one part of their vision different types of strokes may cause trouble with balance. And so while people do recover from stroke and can get back to meaningful life. There are a lot of stroke related disabilities that persist when you can survive the first few days of stroke water, the warning signs for people. I know that there's an acronym called fast that that people should follow when they're trying to identify. If a stroke is occurring, and what to do about it. Yeah. It's really critical that people know the signs and symptoms of stroke. Now, the fast acronym is really great because it encourages people to remember that this painless process you should respond quickly and fast stands for face weakness. So if you see somebody who's face drooping on one side that could be the sign of a stroke, a stands for, arm weakness. So if somebody who was previously moving their arms, well, suddenly has weakness in one arm that. Could be a sign of the stroke S, stands for speech. So if you noticed that someone is having trouble talking or understanding, the spoken word, all of the sudden and t- means time time is of the essence when you have an schemic stroke or the stroke that is caused by a blockage of a blood vessel. We have a very narrow time window for which treatments can be rendered. So calling nine one one and getting to the hospital as quickly as possible as essential. That is Dr Mona bay who who's an assistant professor of neurology. At Johns Hopkins School of medicine talking with us about strokes after Luke Perry died yesterday following a massive stroke just a few days earlier. Doctor. Thank you. Thank you. In two thousand three fine art photographer. Kevin, boo. Bruschi was on assignment in a peaceful Syria to take pictures of places like the ancient Sook in Aleppo, a center of commerce for some two thousand years and people like the small boy hugging the long, hard sheep. He was tending. This was eight years away from the uprising than civil war than proxy war and battle against ISIS. That would kill four hundred thousand people forced twelve million more to flee and reduce much of Syria to rubble in two thousand fourteen we spoke with Syrian scholar Amer I'll awesome about the archaeological losses. I've just seen photographs from a site close to Raka lodge trenches dug up with these bucket diggers, you know, and the damage is phenomenal and it's gone forever. It can never be returned or retrieved. Well, now Azam has written the forward to a book of Kevin boob. Riske's photographs from two thousand three legacy in stone Syria before war, we start our conversation. With Kevin boob risky, who's at W, AMC and Albany, New York. Kevin welcome. Thank you very much described. The Syria, you've visited my writer friend, Lou Werner, and I we arrived at night, and Damascus, and it was a Tober of two thousand three the American war in Iraq was six months old and our intention was to visit Syria because of the proximity of the war and to tell a story of some sort of the deep history and the living culture of Syria. And so we ended up on our way to Aleppo to do photographic portraits. And then the stories of the people who live and work in the souk selling olive oil soap wedding dresses spices. It was an incredible endless labyrinth of alleyways vaulted archways. We'll have pictures it here now dot org. But does it still exist as the war started in two thousand eleven there were street battles throughout Aleppo and the Suk became know a hot point of the conflict. Fires and then bomb barred -ment as well as you page through the book, turn these beautiful columns. These arches how did those stones hold up? Are they gone everything has been damaged to some extent. Some things have been entirely destroyed. There are eminent that are still there. But it's very hard to know. Exactly. What's left? Isis had occupied the ancient city of palmyra for two years. They use the beautiful old Roman theatre as a backdrop for mass executions, they blew up and totally destroyed the magnificent monumental arch the incredible immense. Temple of Bel was also thoroughly destroyed. This was a a direct assault on the cultural history of place and also the multi-ethnic cultural histories because there were the ancient Romans and the early Christians and the Byzantine world followed by the early Islamic world and all of that was targeted by ISIS and others. What were you? Thinking when years later, I mean, you were there in two thousand three and one years later, you're watching the news, and you're hearing that ISIS is as you said impel Myra Palmira is a town known historically for its role and the silk route servicing caravans, what was it like for you, very disturbing? It's very hard to see the unravel -ment of places that have been somewhat stable for such a long time. I mean in two thousand three Lou learner, and I went to serious. We didn't have the idea of a big story. We just wanted to be in touch with people that were there to show that people were having regular lives. And then I realized I'm in Syria. Now, I've got to take my time and get out to what are called the dead cities in two thousand three you could go through that area and just come upon these glorious abandoned roofless limestone structures to three stories tall with a beautiful carved rock, so as a photographer just taken with that. That the interplay of light and shape and stone. We're looking at some of them, and again, we'll have him at here now dot org, but there's San Simione which is part of the dead cities. There's a church there. Bill to glorify this relatively new faith of Christianity in the your four fifty nine beautiful pictures of these they look like very crude crosses do. You wanna go back? Of course. I want to go back. But I also know the dangers all the I is all the unexploded explosive devices, not also all the political difficulties of being an American going into a place like Syria. So at some point. Yes, I would love to go back. Well, meanwhile, I'm looking at one of the pictures. This is a souk in Aleppo, and you see a huge stone wall on the left and along rows and rows and rows on little plastic hangers of babies outfits. Little onesies some gentlemen with leather jackets who look like they could be walking down a fancy street and Italy a woman covered head to toe. You've done all of this in black and white, and they they. I do feel like ghosts. These photographs go from two thousand three, but my wife, and I were in Syria in two thousand nine and going into the mosque of Damascus in two thousand nine was like being in the pizza. San Marco in Venice. It was just a collection of people from all over the world. There was no sense of division or discrimination. And so that's also an image. I like to keep with me. I don't think of my images is ghost. I think of them as a testament to the resilience of culture. And so I think we have to believe that there's going to be a future for Syria for their people for the cultural legacy as well. I'm not seeing images as ghosts. But as solid factual evidence of what Syria can rebuild itself toward that's photographer. Kevin Uber risky. His new book pictures taken in Syria in two thousand three legacy in stone Syria before war, Kevin. Thank you. Thank you so much, Robin. Well, now, let's bring in honor. I'll awesome again, he's professor of Middle East history and anthr- apology at shawnee state university in Ohio, as we mentioned we spoke with him in two thousand fourteen about the archaeological losses in his country, Syria. And now he's written the introduction to Kevin Buber skis book, and professor your thoughts. When you first saw these prewar pictures, do they look like ghosts too. You know, I mean for me it was almost like jumping on on these phones in Omaha. Thank god. Somebody's recorded this because this is all that we have left the original monuments themselves, whether it's the old souks of Aleppo or the temple Belen palmyra, and and other such monuments when now destroyed or just damaged beyond repair. So having these fabulous beautiful photographs really then for me became almost like a beacon of hope that future generations will still be able to see. See what I had seen with my own eyes, at least and still marvel at their beauty. I'm surprised that you are as hopeful as you are seeing the photographs because you said to us that without this tangible proof of the past which is now mostly rubble. There is no future Syria. You have to have it for a Syria to rise from these ashes, a cultural heritage derived from a common shared history is critical to establish a Syrian identity that takes account of ethnic or sectarian or tribal differences. Yes, indeed. But series is very fortunate in that it is an extremely rich region in terms of the amount of cultural heritage that we have so even as we have lost such amazing beautiful sites and monuments. There's still a huge amount left. My concern is that our ability to then make sure that future generations can see feel and experience the same things that we. We have in if not the same way in just as equally meaningful manner. You are also when we spoke with you fighting for UN resolution to ban the trading of some of these items. You also spoke volunteers who are protecting for instance, mosaics on the floors by sandbagging would become even more of a problem for is not just the deluding is happening in the this. But look at the way in which social media platforms like Facebook like watts out. These are one of the primary ways in which looters, and you know, would be terrorist organizations. And and would be buyers are interacting on the same page is yesterday. I was just looking at a page one page out of fifty sixty pages. At least that I've been able to identify where they're over eighty thousand members of this page and the page specifically is set up to invite people to basically show their goods, and if a sale occurs, you promise to pay a dividend or or something to the organizers of. The page, but have you been able to get any kind of resolution banning that there are several, you know, we've had bills posses in the, you know, the house we've had there are international laws that that try to restrict the trade in a lot of our work is campaigning to raise awareness about the danger of buying or dealing or trading in looted antiquities, just at the very least warning the general public that. When you buy an antique witty, just make sure they'll just that. It's a funding or Fe. But that also it's not looted recently that some terrorist is not just made a lot of money. Thanks to the fact that you've just bought this professor back to the photographs can't imagine. I'm trying to think what it'd be like to have mount Rushmore completely toppled and destroyed. What's it like to for you to linger? Oh these photograph. You know foot across can be very beautiful. But there is something about being there. If you think of the temple bell, for example, one of the features of the temple of Bally's that you go early in the morning, just as the sun is beginning to rise in the template self is quite dark, but as the sun rises from the east it climbs, slowly, and at one moment, it will hit those windows and room will explode with light blinding light that sensation of light that feeling you can never recreate that in an image. And what really really breaks my heart is that, you know, future generations of young Syrians, including my own daughters will never be able to experience this. They will look at the pictures. They'll read about it. Sure. But they will never be able to experience that feeling that sensation of that light exploding just as the sun hits those windows. That's amore. I'll Azam professor of Middle East history and anthropoid at shawnee state university in Ohio, professor, thank you so much. Thank you. And again to see the beautiful pictures from Kevin's book Syria before go to here now doubt Bork. This message comes from here. And now sponsor indeed when it comes to hiring. You don't have time to waste you need help getting to your shortlist of qualified candidates fast with indeed post a job in minutes. Set up screener questions then zero in on qualified candidates. And when you need to hire fast, accelerate your results with sponsored jobs. New users can try for free when you sign up at indeed dot com slash NPR, podcast, terms, conditions, and quality standards apply as the twenty twenty presidential campaign gets underway. Major donors are deciding where to put their money that includes big tech companies like Google, apple and Facebook, which all spent millions during the two thousand sixteen campaign, but after so many scandals over privacy and election meddling, silicon valley's reputation is not what it was and donations could be a liability for more. Let's go to our weekly guide to the world of tech. Recode? Teddy's life. Her is senior editor Recode. Hi teddy. Hey, five minute. So it's early yet. But how has Silicon Valley already been weighing in? Do. They have a preferred candidate. You know, I spent the last couple of weeks talking with ton of big democratic donors democratic fundraisers. And you know, I think that in some ways this is kind of the opposite of the two thousand sixteen campaign for Republicans where you saw a lot of energy early behind Jeb Bush here in twenty twenty we have a similarly sized democratic fields. But there's no early money moving very quickly. You get the sense from talking to some democratic donors democratic campaigns that Silicon Valley money isn't really what used to be right? I mean, take someone like Sheryl Sandberg. Big democratic donor in the past. Obviously extremely influential household name what a democratic candidate want Sheryl Sandberg, another F E filings anymore because of all the problems she had at phaser. Okay. Even though she is the lean in author. She wasn't very transparent. About some of the company's activities. Right. And I think you know, that speaks to the broader issue here of like Silicon Valley donors in Silicon Valley marquee names will raise questions about are you too close with Silicon Valley. And I think a great example of that is Cory Booker, the New Jersey Senator and kind of, you know, mid level democratic candidate right now long close with lots of important people in Silicon Valley. He's an app to answer questions throughout this campaign about EC two close to tech. Right. And he might be asked those questions by other democratic candidates in the debate. One activist. You spoke with called the tech industry. Our generations big tobacco not just for these scandals. But you know, there are people questioning whether a lot of the technology that were living with is good for our health. So there's a divide there. Right. Yeah. I mean, this was an activist by Cory Booker. He felt that he was a Manchurian candidate for Silicon Valley and Booker might be at one end of the spectrum. You know, you have other candidates. Like Amy klobuchar. The Minnesota Senator who's actually been pretty tough on big tech would even she's coming here to San Francisco and a couple of weeks for fundraiser. According to an invitation that we've seen so even if you are, you know, very strident and in your opposition to tack in a lot of criticisms of it, a reality of democratic politics is that this is where the money is. So you gotta show up. Well, and just briefly because there's just one candidate right now on the Republican side. But last week the conservative political action conference CPAC had Senator Josh Holly, the Missouri Republican hosting a panel blasting Facebook and Google and Twitter for what he called a left wing social agenda last year at the same event, you had Facebook and Google with product demos and open bar events to whoop conservatives, so Silicon Valley seems to be having a, you know, a break-up with the right, right? And the left, right. Yeah. That's the challenge. That's the challenge for the value. Right now is there's you know, they used to have some comfort with Republicans because they're free. Arket big companies that have produced time innovation east of comfort kind of with the left culturally, right because of their progressivism on social issues. And now, you get the sense the valley has really no political allies. Teddy Shlaefer senior editor for finance and influence at Recode teddy. Thank you for. Thanks. Did you use shampoo this morning? If you did it probably lives in a plastic container that you'll discard when it's done what about your ice cream. That's probably in a container that you'll eventually throw out which brings us to a new idea to get products like that into containers that you'll put out on the porch after you. So they can be refilled the company that wants to do this is called loop. And it's already got buy in from Nestle Unilever and Procter and gamble loop. Is the brainchild of Tom Zaki? The CEO of the recycling firm Tara cycle. He joins us as part of our series of conversations with leaders called view from the top, Tom. Welcome back to here. Now. Thanks for having me and tell us first about how this would work. Exactly. Well, the idea of loop is to solve waste at the root cause which we know we think release idea of using something once or disposability, and so the general idea would loop is that instead of the consumer owning the packages at the end when the remedy it's always owned by the manufa. Factual. And so instead of it going to waste or recycling. We simply pick it back up from the consumer clean it and around. It goes again sort of like the way milk used to be delivered a back in the nineteen fifties. And in some places still is, but are we talking about in addition to ice cream and shampoo? What else? Well, the idea is to bring this re-use model to absolutely everything from your laundry detergent to your mouthwash from your orange juice to your granola. I mean, truly everything in partnership with the world's biggest manufacturers to really try to shift consumption from a disposable system to a circular one who comes in picks it up and drops it off. However, you normally buy your products today whether on ecommerce or whether in store, it would happen the same. So if you buy online, you can access loop say from loop store dot com or other places it's delivered to you say by UPS, and then it's picked up by those same delivery vehicles in store version. You bite at the store and then take it back to the store. Now, as you know, when you buy something at the supermarket right now almost everything has a seal on it. So that you know, it hasn't been opened before would you be able to do that with container that's being reused over and over again. This is a really good question. You know, a lot of these things that have been really thought about in design really from a disposable perspective have to be reengineer when you think about it from a durable point of view. So when you get your delivery case instead of there being taped, there's a zipper. So we need to put a little latch on the zipper to make sure, you know, no, one in the transportation is tempered with what's inside then for the products themselves in beverages. Some caps will give a little click sound when they opened. So you know, that no one's tempered with it. But there's a lot of innovation. We have to do here to make sure that that type of work can go to any type of container. Now. How did you get Nestle and Unilever to go along with this idea because? They're they're part of the beta testing here. That's right. And it's you know, what I'm really thrilled. With is you know, beyond Nestle Unilever, PNG Coca Cola, Pepsi Mondays. I mean, the list just goes on to most of the world's biggest producers, then what got these major companies excited is that loop doesn't just solve for the idea of waste. But it also enables them to bring out innovation that they've always dreamed about. But simply couldn't in packaging that is owned by the consumer. So let's take for example, the Nestle Haagen Dazs ice cream container. So today ice-cream comes to us, basically encoded papers the same thing as a coffee Cup, and it's generally unfunctional and also not recyclable in most recycling systems, the new Haagen Dazs container is double wall stainless steel. So it's an elevations of design. It's like the most beautiful ice cream package out there. But it also because of its double while nature keeps your ice cream frozen from multiple hours on the go. So if you take it. Out of the freezer. It'll look beautiful on the kitchen table, and you can have it out there for the whole dinner, and it won't melt now that may seem like a trite innovation but in the world of ice cream. That's quite game changing. Now, I imagine another upside for the companies that are involved in this is that it kind of locks consumers into a specific brand. Because if you're going to be using this container over and over again in its Haagen Dazs ice cream, then you will send it away and come back with more Haagen-Dazs. You're not going to switch over to Ben and Jerry's. In the meantime, while you're absolutely right. One of the neat. Things about reuse models is we have a sense of what comes back and so in the online systems you can turn on a function that allows your empty product. Let's say you're empty Tropicana to trigger an order of a new one, and that is incredibly convenient for consumers. So they don't have to worry about ever buying their orange juice again, nor do they have to worry about having too much which is one of the challenges with traditional subscription models that it's like a box every month. And then if you've turned on your orange juice and locked in the Tropicana, the chances of you staying with that brand, or of course, elevated, and that's good business from the companies who adopted what is the biggest challenge for you in all of this though. I mean, we've talked about a lot of the different things that make it difficult to change consumer behavior to change something that people have been doing forever and make them do something different. But what's the biggest one for you? What's the biggest hurdle? You know with loop. It's a re-imagined nation of the entire way products are made. So I think there's like an inertia challenge where companies when they develop these packages have to invest quite a lot of resource to develop them, and then build the entire operational capability to be able to fill them have them. Go around those are quite big challenges to surmount. And then when it comes to the consumer the biggest thing, we've learned is that we and I say this even as myself, really as consumers, we prefer things that are cheap and convenient. And so for us to scale what we've realized is the easier we make loop and the more it feels like disposability the more it will succeed. And so we're really trying to make it feel like, hey, you can just throw out your container when you're done don't even have to clean. It was just throwing it into a reu- spin at the end and not a garbage bin the part. I'm optimistic about is the suppose ability has only been around for seventy years. So I think there's a really good opportunity to. To look into our past look for the wisdom in the past. But then to think about how to modernize it and make it something that really is first century that is Tom Zaki, and we will link you to more about loop at here now dot org. Tom, thank you know. It was my pleasure at great the Chattan look for to chatting against some time. And Luke plans to start testing its products in Paris, London and parts of the northeastern United States in may, you can see what these containers. Look like adhere now dot org. Well, as people like TOMS Aki, try to bring us into the future native Alaskans are sticking with traditions that have been around for generations on the far northern coast of Alaska. Preparations for spring wailing are in high gear that includes making a traditional thread called Eva, Lou from caribou tendons, which are used to sew together the seal skin boats, which are basically canoes that can slide on the ice. Ravenna Canaan of Alaska's energy takes us to an evil workshop. Diana Martin is the first to arrive at the new Piot heritage center for Neva Lou workshop that will be going on most of the day. I have my sinews on the floor because then needs to stay cool. So you've got a plastic bag in what is that? It's a caribou tendons. They need to be split it prepared to make strands the work actually started months ago collecting tendons from family members who brought home care Buddha attendants had to be dried outside in the cold for several weeks. Now, they almost look like stocks of a plant beige and kind of stringy they crunch when you split them apart. After their split, the strands will be braided into thread this whole process. Takes a ton of time and energy one skin boat can require over fifty tendons and some years. There are a lot of votes to make thread four at one time. There were seventeen that were sewn in one spring five of Martin's twelve siblings are whaling captains. So for the past two decades, she's had her hands full almost every year making sinew thread for their skin boats. She also lends a hand to other captains when they ask her. She's one of the teachers at today's workshop. Hi, nancy. The other is Nancy Levin. An elder and a whaling captains wife workshops, like this one have been held for the past few years to teach others how to make the threat we learn how to split the sinew we're going to clean it for the lady who would like to learn let it says the splitting stages, especially difficult because the tendons are tough. Sometimes it takes two people to pull them apart. It visibly muscle. It's like a you go to the gym, except your arms work lot and your feet work. If you can't pull it with your hand, you put it on there. And let it steps on one part of the tendon and uses her arms to work on splitting apart of it away. She actually enjoys the work in part because it's so all consuming everything just falls into place. The problems the stress the thought to have most of them just disappear and all the effort pays off when whaling crews get home safely with a new season of whale to feed the community for here. Now. I'm Ravina chaotic in you'd Kavak. Oregon's new I in the country's statewide rent control. Law was signed last week and is now in effect. It caps rent increases to around seven percent plus inflation with buildings below a certain size exempt as his new construction Oregon's governor Kate Brown said the law will give immediate relief to Oregon's struggling to keep up with rising rents will maybe some immediate relief. But what happens long-term, not everyone agrees Rebecca diamond is associate professor at the Stanford graduate school of business. She researches rent control and joins us now, professor diamond, Rebecca, welcome. Thanks so much for having me. And I have a guess that what you're going to tell us about this research this irrefutable quenching of numbers isn't going to be popular with a lot of people who believe that. Of course, rent control is good because we see how rents are just skyrocketing in cities, and this will enable more people to live in places they can afford. I mean that is thinking, right. So I think the research does support in the short term, right one ranked control laws. Come in those initial renters. They are helped, you know, the level of rent increases, limited it enables people's to stay in their home. But in the long run is when you start to really worry about rent control and think about how landlords might try to recoup. Some of these rental losses that rent control takes away from them, and that can really undermine rent control in the long run. Well, as you say it in the long run rent control. Decreases affordability fuels gentrification creates negative externalities on the surrounding neighborhoods so start with you were talking about, you know, property owners who have long said when they protest rent control that if I can't raise my rant. I can't afford to take care of property. I'm going to turn around and sell it and take it off the market. Do you find that? That's what happens. So when we studied this in the context of San Francisco, that's exactly what we saw landlords are going to find uses of their. Property that are more profitable in rentals. And that's gonna lead to less rental supply. Yeah, we'll talk about some of the other affects because, you know, rent control as we said again, it's about affordability people. It's been called insurance for people. They can invest in a community because they know that their rent isn't going to skyrocket. So they become a big part of the community send their children to school participate. And that's what advocates have rent control of always pointed to you're right. It's insurance for those people who get access to rent control right away. But as the landlord start taking their properties off the rental market. There's going to be even less supply of rental housing, that's affordable. And then the shortage of rental housing. We'll just get worse. And when there's a shortage that drives up market, rents you end up actually getting higher rental rates when you initially move into an apartment because there's just less housing to go around the other element of rent control that people may know about anecdotally. Yes, we may know people who could not afford to be in. You know, certain neighborhoods if they didn't have a cap on the rent, but people abuse it. So I think a great thing to consider with rent control is to note that it's for everyone. It's not targeted at the people who have you know, really tight affordability constraints. If you're a high income earner, you still get rent control. So you could imagine their ways to improve policy that could still make affordable housing available to a more financially needy population without expanding to everyone will as you say rent control leads to mismatches between tenants and rental unit. Somebody may secure rent controlled unit men, then never leave it. That's exactly right. You face this tradeoff, if you've been in an apartment for a long time, maybe you have a child now or you have a spouse, and you need an extra bedroom, but you may not move and get that correct type of housing because you don't want to give up your rent control. So that ends up putting people in the wrong types of housing in the long run. Yeah. Then what is the solution to? These serious housing crunches in places like Oregon, they have people living in tents and cars, what is a solution if not capping the rent so that they can live there. So I see that there's a short run solution on a long run solution and the long run solution is a fundamental need of more supply of rental housing so easing land. Use restrictions that make it easier for developers to supply that affordable housing and not make it so expensive to comply with all of the local regulations to build that housing is the real long run solution in the short run, you could imagine policies like rent control. Maybe the band aid that you need, but the doesn't necessarily mean you have to force that subsidy payment right directly, idle landlord in other words, allow landlords to raise the rents as, you know, hopefully, not gouging. But in ways that they feel make it worth it for them to have the rental units and not take them off the market, but provide deserve. Tenants with some sort of subsidy to to be able to pay those rents exactly because when you do these types of subsidies through a more traditional government channel, then you can do things like condition them on being low income or condition them on other characteristics of the household, which we do for many other programs and actually Ty the subsidy to people who need it the most. And meanwhile, you mentioned land use loosening restrictions on land use. And that's a huge issue in Oregon where you know, keeping land open is a part of the character of the state. And so, you know, building more affordable housing is a big challenge there Rebecca diamond associate professor at the Stanford graduate school of business a researcher of rent control. I'm sure people are gonna have a lot of Indians about your findings, professor diamond. But thank you. Thanks so much for having me. Get again, Oregon becomes the first in the country with a statewide rent control law, your thoughts. Welcome here now dot org. Here now is a production at NPR and WVU are. I'm Robin young. I'm Jeremy Hobson. This is here now.
57. Sarah Reck MD and Her Anesthesia Residency Mishap
"You are listening to the fancy free podcast where my girlfriends and I tell our most embarrassing funny stories so that we all feel less alone in our imperfections I'm Joanne Jarrett and I'm your host and today I have with me a neutral friend that I met on a physician facebook group. Her name is Sarah Wreck md. She's an anesthesiologist she went to medical school at the University of Wisconsin. Madison did a General Surgery Internship at Indiana University. School of Medicine and her anesthesiology residency at Northwestern University school. Of Medicine in Chicago she has four children. She's an avid exerciser runner and Pella tonner. She loves spending time with her family and traveling and she blogs Sarah Wreck MD DOT COM. She's active on facebook and Instagram, and she writes about fitness nutrition medicine in parenting. So clearly, she doesn't sleep. Sarah. Thank you so much for being with me today. Thank you so much for having me. Absolutely so fill in the Blake's what did they miss about who you are and what you do by think you'll hit just about everything. So I currently practiced anesthesiology Milwaukee Wisconsin and otherwise I think you hit the highlights and all four of my children are boys which people find to be a very interesting fact about me because they think that I'm absolutely crazy. Well, you can't really control that you know can't they keep asking me if I'm GONNA have another one to try for a girl and I'm like absolutely not four boys is enough I. Think you're crazy yeah, exactly. Actually get that question too i. have two girls just the other day I was in Dillard's getting abroa- fitting 'cause. You're supposed to do that once a year I haven't denigrate fifteen years and I I was I was completely gobsmacked by the way at the results but whatever there's probably something I should do I. Don't think I've ever had a BRA fitting. That's. Four kids and nursing for kids. That sounds like a recommended thing. One should do kind of like a yearly paps. Mary. Totally. Because if you're wearing the wrong broad, not only are you not looking flattering as you can in your clothes, but it's not as comfortable. However, I do have to say that unfortunately, the Bras that I purchased are not going to work I wore one yesterday and I've never been in such brought pain all my life I was like, well, this is the way Lebron's are supposed to fit them I reject. Yeah seriously the whole reason I bring that up is because the sweet gal that did my bra fitting by the way if you decide to go for a profiting, it's embarrassing they just measure you around. You don't have to stand there with your boobs out for the girl she just Gone faster shirt on if you're really modest good to know. Yeah, and then they just bring you in a bunch of different stuff. So you don't have to go back and forth and then you find one you like. But Anyway, she said Oh you have two girls or you going to try for a boy I'm thinking to myself your is work I'm forty seven years old. Done exactly and that would be the other part of it is physician user to think about all those risks I had my last one I was six weeks shy of being forty and I was like, Nope, not happening again for multiple reasons. Yeah. Yeah. So that's another reason why you're braver than I am because I was like bape if we don't have a due date before I turned thirty. By then it's not happening just can't. Yeah. But I do have a girlfriend from college. He's forty eight and pregnant with her third and every sign I. Know I think about it like every day I'm like you're so amazing I can't be pregnant right now I feel exactly the same way I didn't start until I was thirty four and then few how four obviously it takes a little bit longer. I can't even imagine starting over at this point in my youngest is not quite two and a half and I'm just like, no, we're we're on the growing up phase now. You're still in the throes of potty. Training? NAPS. That's About a decade passed that thing. Good. Well as you know, the point of this podcast is to share are not so fancy moment so that everyone listening feels less alone and can kind of nod in Giggle and say me too and. Maybe they'll be encouraged to share their funny stories with people around them so that we just create this ripple effect of laughter enjoy an connectedness. So what do you have for us today what has happened to you? That is not so fancy is so my embarrassing slash it's funny. Now it was super embarrassing at the time goes back to when I was A to resident and just for those who either aren't at Madison Center aren't familiar with the terminology in a siege as a four year residency. A you do a one year internship and then you start your PG wire postgraduate year to you start your anesthesia. You do your PG by one year, and then you're PG I two years you're see A1 or clinical anesthesia first year. So basically, my third year residency. But my second year of anesthesia training I was up at our children's hospital and I haven't been feeling bolic's had some sort of upper respiratory infection but nothing that I wasn't going go to work for because obviously, we work through anything. Oh. Yeah. I crave gastroenteritis because I'm like. If I have that exactly I never got it. Yes is just enough under the weather that I didn't want to be at work, but not so much that I couldn't be so I went and I was assigned a day of ent, which basically consists of a lot of super fast turnover cases. So especially, at a children's hospital, this can be a day of literally twelve or fifteen cases because they're super fast. It's like tonsils and Adenoids or a lot of ear tubes. Ear Tubes are literally about a fifteen minute case and we we don't intubate the kids we just mask them. And so it's totally noninvasive zero blood. There's no idea and I was. Masking the kid there in the middle of the case and I passed out just. Pass out cold in the operating room could boom. Yeah. My Gosh, right. My attending wasn't in there at the time because they're not all the time they're running more than one room and I was perfectly capable of doing this case and I'll operating rooms have emergency system. So of a patient is coating, you hit the button. A bunch of people come running in. It's a little bit different from the code system and a usual hospital because you don't want the entire co- team running into the are swift it's for the itself. So the circulating nurse didn't know what to do. It's the code button I come to on the floor of the operating room with all of my attending standing over me staring at me. I am more you. Mortified and I felt it coming on I. Think it was probably more of a Vasil Bagel than anything else like I was a little dehydrated from being sick or an annoying taken some sort of cold medication that probably didn't agree with me. So I come to on the floor of the operating room the patient was fine. By the way. Did. I luckily passed out away from the anesthesia machine and not into it because otherwise I may have had a head injury. But I'm laying there embarrassed and I'm trying to insist that I'm totally fine. I'm just a little under the weather can I please just help some juice and go sit down and they insist that I have to get on a stretcher and go to the emergency room and I'm like, no, I'm fine. I. Just like I just need to rest and drink some juice while they sent me to the emergency room, which again mind you is a pediatric emergency. Room. And you like I'm huge. Right well, and the gets worse because if they wheel me to the emergency. Room. And they get down there and one of my best friends from medical school actually did her residency at that children's hospital I used to play volleyball with a bunch of them. So insanity as the pediatric resident, who's a guy on the volleyball team I play with and I'm like. High. So go through the whole story, the my vitals and they're freaking out because my heart rate is forty something because I'm training for a marathon and being a pediatric hospital anything less than ninety makes them go haywire. So they get an ekg which freaks them all out because my low heart rate, and then of course, being a young female who passed out what you have to get the. Tiles. Yes so I get up go to my pregnancy test I'm walking back to my room in the Er with my urine sample in my hand. And the chair of the Anesthesia Department who is being very kind. He was coming down to check on me which I appreciate he's the nicest man in the world. He also happened to be the president of the American board of anesthesia at the time. Wow. So mocking backs my room, he's coming to check on bump into him. I'm holding my urine sample I'm now even more and more. So, glad you didn't spill your that one I know, right? I wasn't pregnant by the way. So everything checks out but they're still really up in arms about my heart rate and I'm trying to insist that I'm a runner and this is fine and I just need to go home rest and I had this upper respiratory infection and they're literally talking about ambulance chasing me. So the Children's hospital at the time was about six miles north of Armenian hospital downtown. And they're talking about ambulance me down to the main hospital and I'm like I don't need that bill I'm fine. Right. To insist that you stand down at this rate. I think the other issue is that I didn't really have anyone to take me home you need to go home they're not gonNA. Let you drive off right I think even ridden my bike to work that day for whatever reason. So the pediatric resident who had come to see me called my friend that I knew from medical school and she happened to be in clinic and he's like Hey. Can you come down and help her out to think he knew that I didn't really need to go to main hospital. So he really did a favor without telling me. So she came in and they agreed to release me of she would take me to my regular physician to follow up on that. So thank goodness they let her out of clinic it all ended up working out in the and. Other than the fact that I was completely mortified the chief residents both texted me later that day. Are you? Okay? Is there anything we can do? Can you work tomorrow and it was like I am fine. You guys so needless to say and I'm sensing the fact that you don't like to be the center of attention. I mean I'm GonNa, see geologist we tend to be okay with not being the one getting all the glory but certainly in that situation and then like I'll never forget you know after the dust settled and I went back to the Children's hospital my fourth year residency may see three year and I'll never forget I was in the day everything was fine and in walks my attending he's like I know who you are. You're the one who passed out like Bringing it all back. Thanks Yup. So. Yeah. I thought it went down in history, but it all worked out in the end and now it's something that I can look back on and laugh at and I story to people and they they certainly get a kick out of it. My Dad's a neurosurgeon and he has a scar on the bottom of his Chin because when he was in medical school, they were drawing blood on each other the guy that was driving his blood messed up in the blood started going everywhere. My Dad's stood up to try to I don't know do something and he hit the deck. He's like that took me a while to get past. The fact that you're the one you've passes out at the sight of blood. It wasn't because I saw the blood that was because I stood up and riot. Vegas I have this really embarrassing overactive vasovagal reflex, which has embarrassed me probably every ten years my entire life It's just so annoying. So to the listeners who don't understand what that is if you get startled or if you're in pain in your heart rate amps up, then there's this reflects that your heart can turn on that slows it down a little bit. I. Guess It's really designed. To keep your heart from beating out of your chest or keep your heart from going so fast that it's inefficient or your vascular system and my Vase Bagel reflects is bossy and overbearing, and so it'll lower my heart rate so low for like no good reason that I have to pass out and the same thing happens my dad's so yeah, I'm like, Gosh I hope my kids don't inherit that because. Really, inconvenient. I'll feel my heart rate go down to thirty and it's like I'm I'm toast. Stop It. If I can put my head real low rate, get the blood back up their own everyone said to me to a They kind of assumed that it was the sight of blood or something that made me pass go you're going to be very good anesthesiologists. Kidding those like I've done a ton of body cases. There was no blood involved in what was happening. It was just a totally out there coincidence it was a case of coincidental timing. It didn't even matter that I was in the. Yeah. Exactly. It could have been standing in line at the grocery store and the same thing would have happened. Totally yes. I've overcome that I have not ever passed out in the operating room again. So make sure you hydrate. You know it happens I. Mean this is one of those things that our body has built in mechanism to level are muscular system. Should we need to be level because brain does not tolerate a lack of oxygen very well yet at the top of our. Society just got down. Right. Oh, my gosh. I'm so sorry that happened to you but I'm glad you can laugh about it now. I know I think to probably take a good month and that I was able to be like all right. We're just GONNA get past this. something. That happened and you know what? Like if there's any medical students are listening this half of the people I've seen so many medical students come into the operating room and you're standing there for a long time and it does get worm under the lights on if you are a little bit off and you haven't eaten at something to drink I mean it happens to a lot of people. I've seen attending editions step away from the operating room table for whatever reason and I always say it's more important to recognize that it's going to happen then to pass out flat into the field so. It happens medical school is a really really crazy time where you're requiring totally unnatural things of your body as you never know when you're gonNA eat sleep or drink right. But yet you're required to be on the top of your game every second right and I hate to admit it but one time I was in the Va and we were doing a really long. No I don't think it was in the was in Vegas and we doing a really really long case and I was retracting the liver and it's it's hard. It's hard work. Yeah. And they were switching. This was what it was such a long case and I can't even remember what we're doing on any of the details but the such a long case that literally the O-, our team switched out. Yeah and here here I am a medical student I'm just still there nobody cares nobody thinks to care about. The way it is is what will we signed up for exactly and I was so tired that I literally fell asleep had a dream woke up and had not moved a muscle I was like I was looking around like, oh. My God Oh God. was full of adrenaline and then I was fine. But Oh my gosh, it's just who I could have I. didn't see it coming I'm so glad it didn't hurt me one but like nobody's nobody's looking out for you. So you just have to kind of look out for yourself right? Here yourself a little bit. Yeah. What do you have in terms of life hats for us today? Obviously, I have four small children to feed who eat a lot I am pretty crazy about eating healthy and make most of our meals and stuff and with my crazy call schedule on just not always knowing when I'm GonNa get home whenever I cook a meal and do a lot of meal prep. But anytime, I cook a meal that I know can be frozen while Lake Mary Cheese Angela's any sort of casserole I, double the recipe and then I. Freeze half of it. Nice and it's a lifesaver because number one, the kitchen getting dirty the first time anyhow. So to just double ingredients, throw it in another pyrex dish than throw it in the freezer. I, can tell you the number of times I've come home from work exhausted and been like I. Don't feel like cooking. You have a chest freezer in our basement. I can just walk down to the freezer grabbing meal thought and where it goes euro dishes zero us so I would highly recommend that anybody. Awesome. Especially, if you know MOMS, I feel like moms who are pregnant and having kids are i. was like, what should I do to prepare them like freeze meals freeze yourself meals that's such. A good advice you're thinking, Oh, I'm just going to have a baby. I'm going to be home and able to cook. Well, you're not feeling good. You're race Ostad and that may be super demanding more than you can even know, and the other thing I see all the time to is people saying, well, what should I give so and so for like a second baby gift or a third baby gaff when I had. My fourth, my mother-in-law, my sister-in-law spend today cooking and they came over with a freezer full of meals and they shoved them in my freezer and it was a godsend. So that's what I always tell people. Yeah it was amazing like I didn't need more baby clothes I didn't need any. This is what I needed. I needed food need help like concrete. Yes and so that's what I. Always Tell People I'm extent food give him Pinera Gift Card and that's what I do I when people have the baby now I took them food I cook one meal to eat tonight and one meal to put in the freezer. That's awesome. You know I think is another really good baby gift is grocery delivery yes. You live in an urban area Schimdt s-h-i-t is one of the companies of course I have access to that and you can get groceries delivered from anywhere like yeah. If you're on vacation you're staying in a hotel suite, you can get groceries delivered to your suite. So your instinct cartoon I think they deliver from target Walmart all those places. Yeah. You can get anything you can diapers and stuff it's almost like Amazon prime for yes even I In the middle of nowhere do my groceries now on WALMART DOT COM in. An ice schedule it to get to work at I'm like if I'd have this when my baby's. Life would have been easier. Fresher. What have you been lovingly that you think the listeners might lead to you. So I have two things. The first one is a book that I. Actually just started reading last night. Called the lot eighth actor and I heard about it. I was listening to reach a Hollis his podcast because I'm a podcast listener in the car when I'm commuting. I. Get bored with a radio. So I listen to podcasts all the time. Is Listening to reach Hollis's had cast rise and she had David Bach. WHO's the author of this book on He's a financial adviser by training. But now he's gone off and done a lot of his own things right in a couple of blocks and it's basically like teaching people how to think about money differently, and the book is a super easy read. I'm almost done with it. But as physicians we always say we don't get taught finances Ya when we come out with all these loans and you know I'm lucky I have a business minded husband and we have a financial adviser, but he dumps it down to a way that I can read it and be like that. Totally makes sense and it's called the law tape factor because it follows this young girl, she's twenty seven who is struggling with their finances. She lives in New York City, and she meets this gentleman who owns a coffee shop and he starts teaching her about money and he says, you know if you want to buy those, it's Your Law Tae factor basically saying you know add up all of your extremely expenses in a day you buy coffee every day a muffin everyday you're buying you're buying water that's like twenty five dollars. If you put even half of that into a 401k pre-tax, like this is how much money is gonNA end up being after X. amount of years and again. That I know but it was just put in a fashion that it really made sense to me and I think for anybody young in college who doesn't understand money who doesn't understand the concept of a 401k and pre-tax versus post-tax or even how a small amount of money I'll make a huge difference over a long period of time. Really Good Buck, and like I said, super easy read all finish tonight probably highly recommend. Okay. That's GONNA be my new. We're having a gift theme here. Apparently that's going to be my new college or high school graduation gift guests along with you know you can get that book and then you can write him a check and the check can be the bookmark like here's the many and here's some advice on how. This money. The proper thing exactly exactly and it's and it's the Nice thing is that it's it's very digestible amounts of money. He's not saying take a thousand dollars and put it aside. So it becomes he's literally saying twenty five dollars a day. So absolutely I'll link to that book the show. Yeah for sure and then the other one I was going to mention I'll just mention this really quick the podcast reconciling medicine Doctor Rene Paro does it with her husband Dr John Farrow they just talk about. How they've quote unquote reconciled Madison with their lives and how they've managed to find balance and they talk about a lot of other topics while they talked about the OPIOID crisis a couple of weeks ago hover really nice report with each other and they're fun to listen to and so it's a great podcasts for pre medical students who are kind of wanted to listen to people's journey through medicine they have personalities, but they're very upbeat on that medicine to calm I feel like there's a lot of downtrodden. How and the just are really trying to put it in the context of a lot of this is what you make of it. So it's a nice listen. It comes out on Friday mornings. It's called reconciling medicine and I would give listen. Awesome. Okay. I'll linked to that one in the show notes to do you think if somebody's not in medicine that would be interesting to or is that more niche for people who are in Kim, go both ways and you can certainly pick and choose. I mean, they talk a little bit of medical school on how they may choices and residency and the couples match. The first season was a little bit more about their journey to where they are. Now they're both attending physicians. This season has been some other topics that aren't necessarily just related to medicine. So yeah, I think it could go either way if you wanna hear to doctors talking about something that's going on right now right probably be a really interesting. Yeah. Even for a non medical. Yeah. What is the best piece of advice you've ever been given? It's more of a life lesson. I had this attending when I was a thirty year medical student, WHO's on my internal medicine rotation. At the VA which I hated by the way, I'm not an internal medicine person but I get props everybody who is but at any rate he used to make us. Sit Down at the end of the day, and we would do paper rounds just go through and talk about all the patients and one of the things he always said to us is as we went around, you have to tell me one thing you learn from this patient, and of course, as a third year medical student, you're racking your brain for like the most significant medical piece of information at this patient has taught. You know they're all I learned all about craton scenes from this patient or what substances from this patient, and he always said, no I don't want you to tell me something you learned medically I want you to tell me something the patient taught you. So it's really more of a lesson of the idea that everyone has something to teach you and it was really hard to do because you wanted to focus on the medical side of it but it was more like this patient taught me humility or this patient taught me how to die peacefully or you don't like these things that are really big lessons that are hard. To put a grasp on as a medical student because you're trying so hard to learn that Madison. This is always stuck with me. Sometimes, you have to step aside of really look at what someone's teaching you even like your kids rallied you'll you're catching there's so much. You can teach me the joy UC in life for the we you see thing sitting just this idea that. Everyone has something to teach you. You just have to look for it and that's always stuck with me like I'll never I'll never forget sitting in that room in the va every afternoon and you would try to be like Oh my God. I have to think well, the streets Tommy you're trying so hard to learn by the Senate dwell and get the A on the rotation. Looking back on it. It was a really good lesson his you start to see those little things that that make you remember that patients are people too, and they're not just a number on the paper kind of always causing you to go back to the human side ex exactly. Yes. I think we can remember that in just all of our interaction back to the Latina thing. When, you drive up to a coffee hut and you're ordering coffee from someone just to look at a person in terms of being someone who has something to teach you who has a wealth of human experience that is different from yours. Super Valuable. What is one surprising thing about you nobody would be able to tell just by looking for five years after high school and throughout my college years I worked at a summer camp for kids with disabilities northern Wisconsin. You know so many people who are going into Madison work in the lab or they do hospital volunteering but. had. Worked at this camp, and so I started working at the year after I graduated high school and ended up working there for five summers and we'd served kids with cognitive disabilities. So let don't syndrome kids, blind kids and then also deaf and hearing impaired kids. So I actually know a little bit of sign language. My skills are very poor right now it's just not something people ever thing of anybody doing i. Think they probably don't think these kinds of camps exist and it was obviously a great experience because I spent five years working there. That's funny. Now, because one of the girls that I was her counselor when she was six years old is now married and we kind of keep in touch on facebook because she interestingly grew up like literally two miles down the road from where I live now and so it's just kind. Of A. Neat Full Circle to see how she's thrived and she's doing great. She has gone back to work at this camping for the people who have been there really is a profound experience and something I'll never forget and I'm glad that I dead even though it wasn't the typical pre medical student thing to do I think that's a great little golden nugget for people who are considering going into medicine if you don't. Have time to fit something into your school year that is a volunteering situation how enriching would that be for your life and for the life of the kids at camp of you could just spend some time volunteering at or even working that wouldn't even have right on tiered position at a special needs camp what a great. Yeah. Oh that's awesome. One I think it also goes to show that you don't have to do. The typical thing I mean, I, think. So many people I have to work in the lab I have to do the volunteering to do this. And really gave me something to talk about an interviews where I'm sure that people interviewing had heard about a million people working in a lab at something different and it makes you sick out in their mind a little bit interview medical students anymore. But when I did, it was always that person who had a little bit different of the story that you remembered because everybody else's cookie cutters. So it's actually a stick out a little bit. That's a really great idea. Wonderful. Well, Sarah. Thank you so much for being with me today. This was really fun. It was really fun. I'm no longer a podcast Newbie so I feel good about that. Now you're a pro and I think you're a natural and so I definitely think it's a good way to expand your readership for your blog. Excited tell the listeners how to find you online. My blog is just my name www dot Sarah rack m d dot Com and I blog about mostly about being a working mother but within the context kind of fitting in workouts, how not to feel guilty being away from your kids healthy eating that type. Of, thing I'm also on Instagram and that's also Sarah Rack md and then I also have a facebook page for my website is rack md finding your fantastic I kinda double post on instagram there just to put it in both places. So if you WanNa find me, that's where you can find me and I love to answer questions about being a mom and a moment medicine and working, and breastfeeding, and nursing, and pumping and all that great stuff. Thank you so much for listening today's episode of the fancy free. PODCAST. I just love talking with. Sarah it was so much fun to reminisce about medical school and medical training, and if you happen to have someone who is considering going into medicine share this episode with them, you can just go to whatever podcast APP you're using, and there's usually a share function where you can just text. Or E. Mail the link to the episode right to the person because I think she had not only some really fun insight into training but also some good tips as far as things that you can do to set yourself apart when you're applying for medical school, make sure to check out the show notes for today's episode Number Fifty, seven at fancy free podcasts dot com slash episode five. Seven to get all the links that we discussed today's show so that you can learn more about, Sarah, also listen to the crazy I date compilation episode at Fancy Free Podcast Dot com slash date three to find out how Sarah met her husband. She tells that story on that episode and it's called thirteen crazy first-aid stories. Next week on the show, we have Audra powers who you may. Remember from thirteen crazy for state stories. She told us a story that can find the most amazing coincidence with the best for state, and that is just a story not to be missed. But on her feature episode next week, she has a funny story about a parking lot fiasco when she was trying so hard to make a good first impression and you're gonNA love hearing more from Audra. If you have a story to tell email me at not fancy fancy free podcasts, dot com, and if you want more connection laughter and sharing, please join our fancy free facebook group. We have so much fun laughing together in connecting over there. The question of the week this week is have you ever passed out and if so what happened I'd love it if you've followed fancy free podcast on instagram until at least one friend about the show this week have a wonderful week and remember no one is a Spanish as they.
The Forefront of Surgical Innovation with Carla Pugh, Professor of Surgery at Stanford University School of Medicine
"Welcome to the outcomes rocket podcast where we inspire collaborative thinking improved outcomes and business success with today's most successful and inspiring healthcare leaders and influencers and now your host so marquez welcome the maximum podcast that i have the privilege of hosting dr carla pugh. She's a professor of surgery at stanford university school of medicine. She's also director of the technology. Technology enabled clinical improvement center. Her clinical area of expertise is acute care surgery and her research involves the use of simulation and advanced engineering technologies to develop new approaches for assessing and defining competency in clinical procedural skills. Dr pugh holds three patents on on the use of sensor and data acquisition technology to measure and characterize hands on clinical skills currently over two hundred medical and nursing schools are using being one of her sensor enabled training tools for their students and trainees her work has received numerous awards from medical and engineering organizations in twenty eleven eleven. Dr pugh received the presidential early career award for scientists and engineers from president barack obama at the white house. She is considered to be a leading international. Oh expert on the use of centers and motion tracking technologies for performance measurement in two thousand fourteen. She invited to give a ted talk on the potential uses of technology to transform how we measure clinical skills in medicine recently dr pugh was introduced into the american institute for medical and biological engineering as as well as the american college of surgeons academy of master surgeon educators so it is a true privilege to hear her thoughts today's podcast we're going to be focusing on what she believes is most important in healthcare and hearing some of her ideas and beliefs on where healthcare is going today so without further ado just want to give you a warm welcome dr few thank you so much saw i look forward to <hes> our minutes and time together that we have this morning so excited to be here. Thank you. It's a privilege now. I i'd love to ask you what is it that got you into the medical sector that happened when i was five one of those sort of street and focus the persons who after hearing a number of family i'm stories about my great aunt and great grandmother grandmother one on my mom's side one of my dad's side of the family they were actually midwives and veterinarians <hes> both of them you know on the farm farm in the rural south and as a five year old my interpretation of what they did and the stories heard about them. I assume they were doctors and so ooh that was gonna be like those two abeysinghe women. You know that was my interpretation and never gave up that is wonderful. I i love that story and and it's so neat that you just got fixated on and said this is what they're doing. I'm inspired and i'm going for it and you haven't looked back since out crackling awesome. That's so neat in one of the things that i find really interesting about your work. Carla is is your focus on sensors and measuring today. Were were in this value based care world where we're trying to get there so measurements have never been more important. I'd love to hear from you what you believe needs to be on health leaders agendas and how you're approaching that well i it's two areas i mean everything to me centers around data and creating being new data streams that actually quantify things that were previously or currently only qualitative and and you know i think when you look at what guides some of our healthcare decisions treatments and policies today it's based on years years of what i would say good data but there's still a fair amount of subjectivity and different ways of interpreting that data and i think we've learned a lot but i think that now instead of trying to improve upon some of those areas patient surveys and things like that for example. There's different data. There's different technology that enables us to collect data that kinda takes out the human and turpin nation emotion part of it and i and i don't see mean to be one of the young persons who totally believes in data and the world takeover new data and get rid of the old. I think there's i think you have to pay history. I think that there is some truth definitely truth in qualitative and survey and interview data and policies that were handed down but i think if you take a look at the decisions we've made based on that data and combine it with new data. We could get a lot further and it's such an interesting thought and so oh. I love to hear some examples of what you're thinking here. Well i mean i think just for example. Wow there's one thing that i've just funny because it just happened sort of serendipitous lee but weak in my life there was just a preponderance of comments questions a news articles and things that have come up regarding blood pressure and simply me as a physician who uses sensors for everything i came in for my physical collect zam and had a nurse practitioner take my blood pressure and it was just searching interesting experience for me to be aware eric how she placed the blood pressure on my arm. I thought it was loose but anything yeah. I didn't say anything. I'm like wow that's interesting. I teams a little more loose within the previous. Ten years of you know going in with year to get an exam and a team more loose than other times too. I just let it go because 'cause i was curious like what blood pressure she would come up with when it was loose. I don't even remember what it is 'cause. It's not a big deal but all i know is that when i got home because i have a home blood pressure cuff i did the <hes> miniature experiment in one i put it on tight and looked at the blood pressure and i put it on loosely and looked at the pressure and there was a thirty point difference in nisa thirty point. I was blown away. That's a big difference. So then i go back to okay great. There are a whole lot of companies that have have it is the mainstay for people that have high blood pressure or wanna know they buy these cars from walgreens and c._v._s. and all these places and there are millions millions of people who are taking their blood pressure at home. Yeah that's interesting so is there. A system is is based on yes. Take the blood pressure but we haven't gone back and look at. Are we actually getting accurate data and now we're i mean we're giving medications for years based on a protocol. You take the blood pressure three times. If it's elevated then that means you actually have high blood pressure and then you start your medication that is really interesting so this gap ride and is very very ability right. A lot of folks are saying hey take the variability out and you'll improve <music> outcomes. I mean how do we do that in this particular instance. There's so many devices out there yeah. I mean it's so so there. There are what i was excited to see. Is that the a._m._a. Again that same week like i said it was to syrian deputy and i was inundated with all of these things but the a._m._a. American medical association team week put out this call for proposals in terms of local health systems making it their focus to try and get could blood pressure and it was just interesting you know this and this is after you saw the article it was after i saw article after i had just come from there and then did my own personal experience experience but anyway i think all that to say that the conversation has come back to surf isn't looking at what we've done in the past and i think there was an article that came out that that said there's two parts of it one people who take their blood pressure medicine at nighttime actually have lower blood pressure during the day and that was one of the recommendations and then there were some arguments about what is considered hypertension and revisiting all of that data and should it be you know should be shooting for one twenty over eighty or should we actually be shooting for one ten head and then others said it should be when thirty should be more lose. What's so amazing to me is that all of those recommendations and this is the example. All of those recommendations are based on manual blood pressure cuffs or even the computer blood pressure cuff but there's still a human in the loop in terms of applying that cuff right and so then i'm looking at all of these companies that are trying to get into space of using sensor technology to actually capture blood pressure so forget because but some of them as i looked more deeply they're actually just miniaturizing the blood pressure cuff and putting it on your wrist. I think there's a company omron that has an it looks like it looks like a watch and it's really cool but when you get down into the specs of it actually it's still a blood pressure cuff but even that instance because it's a watching because it standardized raced that means that you're actually not you know once you decide. You know what loophole to watch fits your wrist. Then at least it's consistent data if that makes sense uh-huh so that just kind of is an example where all of our research for the past thirty years on blood pressure is based on <hes> using a blood pressure cuff and with the story that i told you that we know that it's inconsistent but if you think about a wearable blood pressure sensor that can actually change the whole game right because now we we don't really know what could only only data that we have of continuous blood pressure monitoring is invasive ace of monitoring within a hospital system when we actually put catheters inside your artery yeah but those are usually under it's usually when you're in the intensive care unit then you're very sick. Obviously we can't do that. Invasive study on a healthy person but now i'm like this whole week i was like oh i wonder what my blood pressure is over twenty four hour period or are- month period and how's it different when i'm exercising and on my game it really getting you know my five days a week exercise in or what is it like when i in writing a grant for n._i._h. For four weeks of the bro and not sleeping exactly like like and then i believe that we actually have to challenge our system like our i mean our health our body and so some of those challenges to your body probably actually makes it better so when is high blood pressure sure for a certain number of hours okay. We have no idea 'cause we don't have the data so anyway get off our high horse on that but i would expect him to go down that route but that's interesting and it's a perfect example to me of how we've done things to story clearly we have years and years of this excellent research but it's based on a specific way of capturing information that does have some human in the loop potential and now there's new technology and new data dad that actually could completely revamp some of that research but also further there'd be searched that we could do so what's the potential of having a sensor that that does measure blood pressure again. I think that we don't even have a picture of a twenty four hour period in the life of a healthy person. What what is their blood pressure in fact. I actually have spoken to a few companies again. It just kind of crazy. I just got inundated which i think when that happened that means. I need to get in their space jason do but i did meet a company did meet a company. That has a wear bowl sensor. That's actually not a tough but it's really it's i can't disclose clues all the details but it's just a sensor that can actually detect blood pressure and do it continuously without actually having a press a button library fast fast and they it's a start up and they actually got over a hundred adults to wear it and they were shocked. They compared none of them have been diagnosed like knows exactly but none of them have been diagnosed with high blood pressure but there were times during the day when their blood pressure was high and i think that it gives us a potential to have a better understanding yep human physiology and how the environment impacts our bodies and i think spark research in other areas you know how does your your lungs respond when you're spinning a week and downtown new york and a you know an area that has car exhaust versus middle of wisconsin in the woods like how does your body adjust. I mean i think our body does work lungs cleanup dirty particles and and we're fine afterwards but it's different for someone who's visiting someone who lives there. You're situational factors i think about have you ever seen the movie emily. I'm ali. I'm ali. Yes a french movie a so. It's one of our favorite song to add that yeah. It's a quirky film and it's discworld. Bags are grows up in in in france and in paris and it's her story break. It's a really neat story but the thing that came to mind as her her father a physician would examine her and because he never touched her like he never like showed her her love or anything like that the only time he would touch her was during her examinations and her heart would just like pound very rapidly and because of that he felt like she had a heart condition goodness no dad you're freaking me the hell out because like everyone has some anxiety because you actually wanna know you want comfirmation formation immediately that you're actually doing okay so that's interesting yeah. I have to watch that when i left those kind of stories. I think you'll enjoy it. It's it's one of our favorites. It's a really good one but regardless yeah. I mean you bring your bringing up some really great points right and so we're going to have to really examine i and some of the basic assumptions that have been made for to us like you said you know quantitative over the qualitative that we've been using for while this data atta so maybe you can share with us <hes> a project or research that you've done. That's helped improve the way that we do things in healthcare. Wow i think that i like that. You feel that i've done to improve health care. I see myself as very much a researcher and despite all of the amazing being opportunities awards and high accolades i am. I feel like i was still just beginning seriously. How about a project out as like this. This is wonderful like this is something that you felt proud of. Oh i have a lot of those i'm i'm i i will i mean i because it is so exciting. I'm i'm kind of mad scientist type and then you know we go out. There are sensors and do things and learn in every single time we go out. We find something that ah we are truly excited about so sticking with cardiovascular health. We had a project where we in a simulated environment heart simulator. We partnered with <hes>. There's a company called a kind heart and they make pretty sort of like hybrid simulations and i think okay i'll just be clear so similar to airline pilots where they have flight simulators to learn you know rare and unusual circumstances stances in case you have to land on the hudson river right <hes> they practice those things and so they've been doing that to the nineteen i but i think the link <music> system came out like the nineteen thirty nineteen forties but healthcare and medicine. We've only really started getting into simulation probably around the nineteen eighties so they've got fifty year lead on us but this one company called kind heart and has a high band right right. I mean it's a standard everyone standards exactly there or some standards that are coming in you know in a different areas but it's definitely not a holistic standard across healthcare and medicine so that's why i mean once that happens then. I feel i will have a chief michael. I that's the answer to that question. Why don't believe that i've arrived yet because it's not but it's not as a standard across all of healthcare to use relation training before we interact or to complement our healthcare training. It's it's not a standard so the example kind heart does hybrid simulations where they <hes> three d print body cavities out of you know various if silicon's latex and hard plastic material and then they actually use <hes> bovine organs that they get from the butcher talk about dual use their eating beef or bacon or whatever we actually go and get some of the other part of that people don't eat so that we can actually practice procedures on so they found a way to actually fuse a bovine heart and actually give it electrical signals that make be like a heart so you're looking at this heart that's sitting in fabricated human chest and they have done a great job of being able to train and assess assess heart surgeons that are in their early stages of their career cardiothoracic fellows and so what we did and was put motion sensors on the fellows as well as the assistance when they're putting be simulated patient on cardiopulmonary bypass and we did it for three early heart surgeons and three very experienced senior heart surgeons with fifteen eighteen years of experience under their belt row measuring for we were looking we were just looking at their movement how they use the right hand how they use your left hand what what is it that they're doing digitizing all of the steps and maneuvers that they make when they're placing a patient on cardiopulmonary bypass wow oh it confirmed for us as it has using sensors and motion tracking data that there is a signature almost is like a beautiful faux painting. There is a specific signature. That's created for each medical procedure that may do when you're doing it correctly directly. It looks a certain way at the every time if it's yeah wow every time what's really amazing about that. Is that if you ask the surgeons what they do. They always think that they do things differently than others because they were trained differently. They're trained to do this or do that. Use this type of instrument start on the left wbt and progress to the right and other say we always start on the right and progress to the left and you know we use the right angle we use a tunnel cramp and so when the surgeons describe gripe what they do they tend to use descriptors that focused on their tools and their steps whereas the motion data actually really is more pure data that it just shows the direction and the velocity of their movement and it's really cool as the direction of the velocity of their movements movement's ironically has nothing to do with this surgeon itself but it has to do with the anatomy and the hearts always in the same place mostly unless if you have a disease where your heart on the wrong side but what that means is that doesn't matter if you start on the left doesn't matter if you start on the right but because you're still doing a sequence of maneuvers around the heart the final ping ping are pitcher is the same zero zero painting <hes> it is. Is that what i call them painting because that's the easiest way to explain it because you have to see the data so when i'm going in the the painting that's created. It's like great. It's like two painters to paint tattoo artists talking about painting the mona lisa right. I wonder where all yellow okay good for. You and i'm gonna use this size brash and all variations of yellow yellow tones well great. I'm gonna i used orange tones but in the end if it all looks like the mona lisa who cares about the color right right until that has been well you talk about data the data that exist in healthcare regarding hands on procedures in medicine when is verbal data that physicians shouldn't dictate in a use their own descriptors because there's no standard. That's interesting well. You know what would be interesting to hear from you. New carlisle is is is now that you have this data set. Is there a way to save do a test to determine aptitude in potential capability ability of a student. That's take a career down a certain path definitely nice. There's some people that are gifted in terms of their happening haptic ability of touch perception and situation awareness. There are some people that are we've seen it a medical student. You can't tell by looking the at them but you know when they're coming in what comes out of their mouth that would you see their touch data. It's amazing yeah. That's fascinating well. I appreciate you and taking us down that road and and folks you're sitting in your car or maybe you're running listening to this working out and you're like wondering what would happen but if you put some centers on me right now and that's lead dr pugh does she she dives into the things that later become and technologies that change healthcare for the better and so give us a an example carla of of a time when you set back and what you learned from that wow i had that all planned out. You know i'm like yeah. Failure is the key to success and like i've made a whole bunch of mistakes. I'm human right and and i've learned a lot along the way and i kind of think about failures. If you will for me it's setbacks in terms of achieving my dream in an efficient manner so must've my failures for me or actually defined because i'm impatient. I wanna you know once. You have some level of success. We've found this. Let's go team and i was like okay. Let's cute so for me. I look at i love them. You know failures of communication <unk>. I that's the biggest thing like so. That's been my you know. How do i learn how to communicate. How do i learn to tell the story in different ways such that the engineers see this is really cool and that this is something that they can actually derive career and making a huge discovery and partnering with the same thing with the data scientists and those that are doing artificial intelligence so i think that when you are passionate in an area that's not quite quite mainstream have to slow down and find ways of communicating that such that you can then uh-huh build the team and the interest in the support to carry it across the finish line. Love it yeah that communication's key so if you had to say out of all the neat things that you're working on dr pugh if you had to say decide on one which one would you say is the most interesting and exciting project right now yeah. There's something something. I can't tell because i have i._t. At attendee and it's very tempting because the communicate <hes> i i think that people are starting to get it regarding the use of sensors to assess human performance broadly so whether it's human physiology or whether it's actually surgeons performing complex procedures in the operating room. I think that what's been most exciting is that there are a number of people who have looked at motion tracking data and i find it interesting right because that's the golf swing data at the same thing right right but to apply that process to healthcare which is what we're doing. We've done it for a number of different procedures. The one that's been newly exciting for us is to applied in the field of ophthalmology and the reason being is that all of the other procedures teachers we had done to date have large gross motor movements moving your hand putting in sutures grabbing instruments from a table using using a variety of instruments for a variety of different movement and so when we had an ophthalmologist express interest for like oh my goodness what am i they do because they're under the microscope and they have these instruments in their field. Is this so much smaller even their operative deal to smaller or the eyeball right. I'm in the abdomen women around with my whole hand there with the eyeball like such a smaller steeled. That's one thing smaller instruments and then really really fine motor movements so we were a little intimidated and weren't sure we were wanting a failure but then we were so curious areas so yeah. It didn't take long. We thought about it for like nanoseconds. Okay great. Let's do it yeah. We'll say five days no no. We're kind of compulsive not this. I mean we thought about it for five nanoseconds. It took five days scheduling away so to get across campus with our equipment. We went to and you know this. Ophthalmologist already had a cataract surgery stimulator like a perfect so very forward thinking partner you found yes and already kind of thinking about beta and using artificial artificial intelligence to analyze <hes> his operative data and so we went in we went to his lab. We looked at what he had. We instrumented him be instrumented his instruments and we instrumented the cataract surgery simulator and we're smiling to this day so yeah yeah so it's the same it's the same they have. I wish i could i need to partner with an artist so that i could name all of these standard pictures that come up with motion data from surgical procedures 'cause it all they all look different but they're meeting the heart. Surgery cardiopulmonary bypass beta create a pattern that looks different than a cataract surgery but i need. I need a partner with some artists to help me name these things because they're just amazing but to be able to capture that data and obviously we had to increase the gain so that we can actually see all the interesting idiosyncrasy. The nuances bounces within the data that actually represent what he was doing. It's beautiful so that was really exciting because that was a bar indyk stream of different surgical movements. It's yeah no that's <hes> the other end of the spectrum as far as movement <hes> space where the surgeon is working. Can you get a similar output that obviously looks different because of the particular type of surgery but fascinating fascinating motion data people. This is a okay fascinating place to be working today. A so this interview while i'm just looking at the time and it's already flown so let's dive into the lightning round got a few questions for you in a lightning round fashion and then we'll we'll finish that with a favorite book that you recommend the listeners snazzy ready sure okay. What's the best way to improve. Healthcare outcomes. Get better outcomes definition. Outcome metrics redefined the outcome metrics. What what is the biggest mistake or pitfall to avoid blanket application of results from qualitative or mixed data. That's not validated of that one. How do you stay relevant as an organization despite constant change listen collaborate and create a culture of innovation. What's one area of focus that drives everything in your work that data is. It's all about the data about the data like these next two or more on a personal note. What's your number one. Health habit may never when health habit interesting so i am currently hacking my sleep habits nice using the oregon. Oh which one's the arranged. Oh you are a oh okay and data ever. Unfortunately i have no <hes> no <hes> i was gonna say unfortunately i haven't invested in the company. I have no ties with it but <hes> it has the best sleep data ever and kelly compared compare this data they wear both or ring and the fit bit little less on the exercise because it does have an accelerometer but it's only on your finger okay so if you're using a stairmaster we're not moving your arms or something you know last but temperature heart rate movement the they've phases of sleep. It's amazing and i can tell jill how my sleep is affected by what i eat after six p._m. Wow they don't know that i know it right. They don't have they don't have any envy until creation but never had the food data right but i'm a foodie and believe that food like from a health perspective. The definite based intake of food affects your health in so many ways and it definitely affects sleep fascinating the orange. Something look definitely put it on my list and what's your number number one success habit number one success habit. Oh try try again. Reflect forgive yourself. Forgive others do it again yeah and do it better well. That's that's a great message. And what book would you recommend to the listeners carla. Oh my goodness. I have one that i had right from childhood. I know people like new books all the time but my all time favorite siddhartha by hermann has love that i think that's been recommended once other times. It's poetry right. Oh it's a story. It's a game taken of a different book than yeah. No sit arthur is kind of a life journey story story and just amazing yeah <laughter> with him you know you have to it's a short read too and so something you you can read it in a weekend but it's it <hes>. I think what's interesting. Is you know that book was probably written over forty years ago and it's still the life lessons and the story is still applicable. Today is that right of that or a great recommendation folks for all of the show notes <hes> from today's meeting with dr carla a pew goto outcomes rocket that health and type in carla in the search bar. You'll see a full transcript as well as links to sidharta and and also the work that dr pugh up too so make sure you check that out at outcomes rocket that health search bar type in carla and carlo wow this has been a a really fun conversation and love if you could just leave us with the closing thought in the best place where the listeners could learn more about you and your work yeah no my my closing thought is really back to you. Thanks so much for reaching out and thanks for taking the time and i'm a static that you have insight and interest in to to the work that we're doing being in helping that communication thing that we've been working on terms of getting the word out and collaborating. I think yeah there's no way to hide my professor at stanford university. You can find me carla c._p._u. Per day eighty you outstanding will appreciate you very much carla and appreciate you sharing in your your passion and the insights gained and definitely looking forward to staying in touch thank you thanks so much have one day thanks for listening to the outcomes rocket podcast be sure to visit us on the web at w._w._w. Dot outcomes rocket dot com for the show notes resources inspiration and so much more.
Why Do People Get Cancer?
"This is why a fun cast for curious kids from Vermont, public radio. I'm Jane Lindholm on this podcast. We take questions from kids kids just like you and we find answers. We've done episodes on all kinds of things like, why do we need sleep? How do fish breathe? Why our feet and hands get all wrinkly in the bathtub. And we've also talked about more serious topics like how babies are made and if it's ever okay to break rule and then lie about it. In this episode, we're talking about a serious and sometimes scary illness. We're going to answer questions that you've sent us about cancer. We're going to talk to a doctor and get the science behind cancer, how it happens and how to treat it. When someone you care about is really sick, it's not just the science that's important to talk about. There are a lot of emotions you might have to our next episode after this one is going to be w-. Twin sisters who are eleven years old. One of them has a type of cancer in her brain. So we're going to talk to the two of them about their lives and feelings and experiences. But for this episode, we're going to stick mostly to the science questions. You've been asking adults. There shouldn't be anything scary in this episode, but if cancer is something your family or your little ones have been dealing with, you might wanna give it a listen. I just to make sure it's appropriate. Here's who were talking with today. Don small and on the director of pediatric cancer at Johns Hopkins, University school of medicine, pediatric means kids. So pediatric doctors or pediatricians are doctors who work to help children get and stay healthy. Another big word you might want to know is on college. That's the study of cancer. So a pediatric on colleges, which is what Dr small is, is a doctor who researches and treats children's cancer. Okay. Here are. I two questions. My question is how do you get sick? Not from other people. Hi, my name's six years old. Noah live in Lockport annoy Mike Klis Trinity's. How do people get cancer. Now, some illnesses are what are called contagious like a cold where germs get passed from one person to the next, and that's how you get sick by the way, washing your hands frequently really is the best way to try to avoid catching a cold or getting other common germs, but some illnesses are not passed from one person to another through germs. Cancer is one of those illnesses. It's hard to imagine how you can get a disease that you don't get from other people or from dirty things. But it turns out that when we're growing ourselves have to divide and that's how we get bigger, and sometimes the cells make a mistake and they grow out of control. And that's all that that cancer is is a disease of the cells growing out of control. If that's what happens that the cells are growing out of control, how does that start? How do people get it? That's a great question. And. And it's something that there's a lot of people doing research on, but it turns out that with children theirselves are growing so quickly for us to go from being a tiny baby in our mother's belly to an adult that the cells have to divide over and over again to make more and more cells. And sometimes the cells make an error when they're dividing. And if that error, let's them grow faster than other cells. They outgrow the normal cells. And so just these abnormals cells growing fast is what cancer is. You mentioned that kids are growing so fast. A lot of adults get cancer and they're not growing quite the same way that kids are, but it's the same process. So an adult, it actually is a very different process by which they get cancer. Their cells are not growing. So actively. F- for some cells like the cells that make up the blood, but their bodies also are being exposed to things like cigarette smoke and other things in the environment and over many, many, many years. These can cause damage to the cells and sometimes the damage cells and up growing when they shouldn't be growing. And so that's why the adults that get cancer have their disease. And so it's actually very different in adults versus children, but there are ways that children can decrease their chance of getting cancer, and that is to never do things like smoking and to make sure that they wear sunblock when they're out in the sun, and these kind of things can decrease the chance of children getting cancer. So there are some things that we can do, whether we're or adults to help prevent cancer. But I wanna be clear. You're not saying Dr small that when someone gets. Cancer, it's their fault. No, no, it's it's. It's never their fault when they get cancer. And there are many, many cancers that we do not have the ability to prevent at this time. And so in those patients, it's a matter of the sell getting damaged. Because as the patient gets older and older, they're just tends to be more damage to the cells and sometimes they start growing out of control. So there are some cancers we can prevent by not being exposed to things like cigarette smoke, but there are other cancers that we can't prevent no matter what we do. We're talking about cancer, but sometimes people will hear certain names for cancer, whether it's lymphoma or pancreatic cancer or breast cancer, or other words, what's the difference between different kinds of cancers. So all the different types of cancers really get there. Name from the type of cells that they come from. And we've actually found out that some of the damage in different types of cancer is actually made up of the same type of damage, but we basically give the cancer the name, depending on what kind of sells it comes from so cells that come from the lymph nodes, we call them foam a- sells the come from the blood cells. We call leukemia cells that come from the brain, we call brain cancer. And so that's how all of the different cancers get their their names. And so it's actually not one disease. It's actually many, many, many different diseases. Well, that leads us to another question about this idea of treatment and different kinds of cancers trust in his seven. I wouldn't Yuba City California, and my question is, why does cancer not have a cure? Why does cancer not have a cure? And you often hear that Dr small, the idea of finding a. Cure for cancer, but is it just one cure will? I think that's a great question from trust in and we wish that we had one cure that would cure all of these cancers. But because cancer so many different diseases, it would be impossible really to have one cure for all of them. They're very different from each other, and there's much research that's going on to show how we can best cure each different types of cancer. Some of the cancers we actually have very, very high rates of cure. Almost everyone is cured of certain types of cancer, and we have others where were not very successful yet and where they're still lot of research going on to try and improve that rate of cure. But unfortunately, I think there will never be just one cure for cancer. It takes a combination of different drug treatments and using the body's own immune system to fight the cancer and many other ways of of targeting the cancer. And that will alternately be the the hundred percent success rate that we wanna have for each of the cancers will have to be a little bit different for each one coming up. We'll talk about some of the treatments you might hear people talking about when it comes to cancer and how you can support people in your life who are sick. But first message for the adults listening. We have support this back to school season from Vermont smoke and cure. Many eat sticks crafted in Vermont, with simple ingredients, antibiotic, free meat, and one gram of sugar or less. They are one nutritious snack that won't come home in the lunchbox use coupon code, but why lunchbox to save twenty percent at Vermont smoke and cure dot com. This is. But why a podcast curious kids I'm Jane Lindholm and today we're answering questions you've sent us about cancer here at, but why we believe you should be able to ask any questions you want and get serious thoughtful answers. We're talking about cancer today because you've been asking questions and we want you to have those answers. We hope though that if your family or someone in your life is dealing with cancer, that you have an adult, you can talk to about how you're feeling. It's okay to ask questions. Sometimes adults might not want to worry the kids in their lives by talking about a big medical issue like cancer, you can tell them that it's okay and that you want to know more. And sometimes adults don't actually have all the answers either. So you might need to reach out for more help. Cancer is a serious illness. And as we heard earlier, there are lots of different kinds of cancer to repeat the basics. Your whole body is made up of. Sells cancer is a disease that happens when the cells in your body grow in an abnormal way, kind of out of control as these cells continue to grow out of control. They can make you sick. Sometimes the cells are in your bloodstream. Sometimes they're in another part of the body, and they make what's called a tumor. Sometimes the cells are in your bloodstream or in the center of your bones. Sometimes they're in another part of the body and they make what's called a tumor, and sometimes they can spread to other parts of the body. Sometimes cancer is treatable and sometimes it's not. There are a lot of big words that surround talk about cancer. We're not going to go through all of them, but let me help you understand a few words that you might have heard or might hear at some point. Chemotherapy. That's a form of medical treatment that is sometimes used to try to help someone with cancer. It uses powerful drugs, powerful medicine to try to kill the cancer cells in someone's body and prevent them from spreading radiation or radiotherapy uses powerful radio waves to target a group of cancer cells that sometimes form what's called a tumor. It's also designed to kill the cancer cells. Sometimes surgery is also used to try to remove a tumor. A benign tumor is not cancerous and won't spread a malignant tumor is cancerous and is likely to spread, and you might hear the word metastasis or metastasized that means the cancer is spreading. And again on college is the study of cancer and cancer doctor is called an on college issed. That's what Dr. Donald small is he works at the Johns Hopkins hospital in Baltimore, Maryland, and he's been answering questions about cancer. We also asked him to talk a little bit about how he discusses this kind of thing with children when they have a diagnosis of cancer. When you talk to children who have cancer diagnosis themselves, that can be very, very scary, and it can sometimes be life threatening on everybody survives cancer, and the treatment can be difficult. How do you address children who get a cancer diagnosis in are very scared. We understand that the children are scared by that diagnosis. It is a very serious illness, but what we tell them is that we have very excellent means of treating the cancer nowadays, and we're actually able to cure most children of cancer seventy to eighty percent of all children with a cancer diagnosis get cured and go on to live a full life through a dull hood into a normal age. And so I think that's something that makes the children feel better that they know they actually have a very good chance of surviving the cancer and living a normal life. If you know someone who has cancer and they're getting treatment, sometimes things happen to their body that changed the way they look and one of the frequent ones that people noticed. Sometimes people who are getting treatment for cancer lose all their hair. Can you explain why that happens and how we might talk to somebody who looks a little bit different who's going through cancer treatment? Yeah, that's that's. Great question. The drugs that we use, what we call the chemotherapy kills rapidly growing cells and some of those rapidly growing cells in our body are the cancer cells. But there are other rapidly growing cells in our body and that includes the hair cells. And so that's why they came therapy causes the the hair cells to die in the heritage fall out. So it's great when kids can be supportive of of other children, their friends that are going through cancer therapy by not making fun of them by asking them about what their treatment is and how they're feeling. And I know that makes our children going through cancer therapy feel really good when their friends come and visit them and and talk to them about how they're feeling. I think can be scary for all of us to know how to talk to somebody who's going through a difficult thing when we don't really understand it or we don't want to say the wrong thing. But it sounds like talking to your friends and being a good friend. And checking in with them, and maybe they can't do everything that they used to be able to do at least not for now, but you can ask them what they can and want to do. Absolutely. The these children that are going through treatment for cancer, they want their friends to still come and see them. They wanna play with them and most of their days, they're feeling pretty good. There might be some days where they're feeling too tired or too sick to be able to play, but they love it when their friends still come to visit them and where they still get to to play with them and where they asked them about what they're what they're going through and how they're feeling. They absolutely love that you deal with treatment and how to address cancer and how to fix it and how to make people well. But I'm sure you've thought about a deeper philosophical question. This idea of why do people get sick and sometimes people say this person, this person I love is such a good person. Why did they have to get cancer when you think about that. At what? What do you decide or what do you think about? Well, first of all, we, we feel obviously that cancer is an incredibly unfair disease because no one is at fault forgetting their their cancer. They haven't done anything wrong at all, and it's there's no rhyme or reason as to why someone gets cancer, and someone else does not. It's a random event and we wish that no one had cancer and maybe one day in the future. There will be ways to look for any signs of cancer developing even before it develops and be able to prevent it. But right now, unfortunately, we have to just treat it as as best we can. And as I say for children's cancer, we do very very well and some adult cancers, they're doing better, but there's still a long long way to go. And that's why research is so important. That's the way that we make treatment better over time. If any of our young listeners. I think they might want to do that kind of research. What do they need to do in school now to get them on the path to being a cancer researcher. It is a long path to become a cancer researcher. They need to do very well in school and then go to college and study very hard and do very well in college and then apply to and the accepted into medical school. And again, worked very hard in medical school, and then they need to train either pediatrics or adult medicine. And then they need to do further training beyond that to become either a pediatric or adult cancer doctor and to do research and have their own ideas about how they think they could find out more about cancer. Why it why? What causes it? Why grow so quickly and better ways of killing those cells. So it's it's a long, long path, but we definitely need more and more children to come down that pathway and help too. Completely cure cancer to the point where everyone that gets it gets cured. That's it for this episode. Big, thanks to Dr Donald small and Johns Hopkins Medical school for helping us talk about cancer. We hope that knowing more helps you feel, perhaps less afraid. If you have someone in your life who's getting treatment for cancer, I want to make sure that all of you listening understand that getting cancer isn't someone's fault, and it's not something you can catch like a cold. Also cancer in children is very rare. And as Dr small said, most cancer that happens in kids is treatable seventy to eighty percent of kids who get cancer, go onto live long, happy healthy lives after their treatment. In our next episode, we're going to talk to a kid who's gone through treatment as well as her twin sister who does not have cancer. They offered to talk to us about what their experience has been like. So stay tuned for that conversation and. Always if you have questions about anything, feel free to send them our way. Have your adult record you using a smartphone. Tell us your first name where you live and how old you are and what you hope we'll answer then send the file to questions at, but why kids dot org. We will always let your adult know before you're in an episode. So you get a heads up if you're going to be featured in one of our upcoming episodes, but why is produced at the studios of Vermont public radio by me, Jane Lindholm and by melody Bo debt. Our theme music is by Luke Reynolds. We'll be back in two weeks until then stay curious.
Suicide Rates and Insights from Medical Sociology - Healthcare Triage
"Hi, this is Aaron Carroll. Welcome back to the healthcare trash podcast this week will be talking about precision health for the masses very exciting. This healthcare Josh podcast as many of our healthcare podcasts or sponsored by Indiana University school of medicine whose mission is to advanced health from the state of Indiana beyond by promoting innovation and excellence in education, research and patient care. I you school of medicine is leading Indiana university's first grand challenge. The precision health initiative, which we will talk about in detail today with bold goals to cure, multiple myeloma, triple negative, breast cancer, and childhood sarcoma and prevent type two diabetes and Alzheimer's. Our guest today is Bernice Pescalido, a distinguished professor of sociology from Indiana University. Bernice, welcome, thank you. So you are a sociologist. Yes, I am. What does this sociologist too? Well, I'm a medical sociologist. So that that gives you a particular type of sociology, which is we try to understand people's environments their identities. Their neighborhoods at how in this case it affects their health. So before we even get to this. What what are some of the work that you've done in the past as a sociologist that we could rapper headroom? Well, given the rise in suicide that's happened in the United States recently for the first time in about forty fifty years. One of the things I work on his trying to understand the roots of suicide. I also look at how people travel different pathways to get to a doctor at failed to get to a doctor, and I also work on issues of stigma surrounding illnesses that have been marked as different and have people suffered not only from the disease or disorder that they have. But also from people social reaction to it. So I want to actually go back to what you just said. The first refers there about about suicide. Yeah. So can you tell us a little bit more about that? Like, how do you actually go about trying to find out information about how or why people commit suicide? Well, that's a tough one because unlike clinical studies, or the kind of social survey worker interview work that we. Do there's obviously no respondent that you can talk to. So what you have to do is find out as much as you can about that person and about the circumstances in which they lived. And so there are some new unique data that the federal government has put together that we've been able to create a patchwork that really helps us describe the circumstances that a person was living in when they took their own life. So most of the work that I've seen surrounding suicide looks I think people who tried but did not I don't wanna say succeed. But did not yet leat. There Suzanne you can't talk to them. So you're actually looking at data on people who did completes. Absolutely. How do they get data and who's putting that data together? Well, it's important to look at both people who attempt at people who complete because one of the things that we know is that they're not the same people. And so you have to be very clear which of the two phenomenon you're looking at. And so the all deaths have to be reported in the United States. And they're reported by corners and medical examiners to the centers for disease control, and those then become aggregated into data sets that are held by the National Center for health statistics. And so we start with that. But that's not enough because as it turns out, there's not very much information on a death certificate. And so what we do is we start piecing together different aspects of their lives. Like, we piece together information from a study that's done every ten years on what kind of religions exist where the person was living. We also go to the American community study, which has detailed data on household income and on race, ethnicity and other things that we know are implicated in differences in who takes their own life. So still a lot of it is getting it sounds like secondary data. We're not actually talking to we don't, but one of the new things. Well. It's not not new. But since I started studying suicide many years ago the centers for disease control. Now does something called the national violence death reporting system, and what they do they started the project a while ago. And it's now in about forty two states, they started with a pilot of about seven states, but what they do is when anyone dies from violent death. They find either the next of kin or someone who knew that person. Well, and they go in they interview them, and that gives us a lot more personal information about the person who died by some kind of violent death and suicide is included in that data set. Those are called follow back studies, psychological autopsies, and what they do is is try to get a sense of the struggles that a person was having at that point in time. So for example, whether or not they were undergoing financial stress or relationship breaker, and they were if they had a mental illness. So the national violent death reporting system provides us with a lot of personal information about people who die from violent deaths so things like whether or not they were under financial stress or whether or not they they a relationship had broken up. Or if other people had died around them things that we know make people rethink their life, and and and affect whether or not they're tied to their community or they're sort of alone. So then you compare this to people that didn't commit suicide or is there a comparison group. Yes. Well, that's the novel thing about what we're doing here at Indiana University. So usually people either if their clinical scientists they work with hospital records or the death records themselves, and they work at the individual level or social scientists have tended to look at suicide rates. And so we would look at you know, what are the death rates in Indiana versus California or Alaska one of the things that that unique about what we're doing here at Indiana University is. We've put together information now on both individuals, and where they live, and that has given us a unique challenge of trying to harmonize the data from different places and really get a sense of a fundamental question that we haven't been able to ask before in the United States. So for example, we know that individuals who are unemployed or greater risk for suicide. But what we didn't know until we completed our first part of this analysis is that it matters what the unemployment or employment profile looks like where you live. So if you live in a place where lots of other people are unemployed, then your risk is not as high as we thought. But if you live in someplace where everybody is working, and you're the one that's unemployed. Then your risk is much higher source that sort of the Tako message what you found or whatever nursing things have you found. Well, we found that that kind of situation is also true for having physical problems. So if you live in an. Area where other people are having physical problems versus in a place where everybody looks like they're in southern California. Then that tends to increase your risk. So we actually found two different kinds of effects one is that having others like you around. So that even if you're going through divorce or stresses of unemployment or having physical problems if there are others like you around the tipping point seems to be about twenty percent of the population. Like, you then your risk is really dampened on these traditional risk factors for suicide on the other hand, one of the things that was really unique is that in some places suicide becomes the norm. And so if you look at places like native American reservations or allow the Alaskan islands off of Alaska there. It's the case that if you are members of native American population or Asian. American population Alaska native population, then your risk is even in increased if you live in those kinds of ethnic enclaves. So the society in which you live or the culture in which you live can either dampen the respecters for suicide or they can actually push you further toward that as an option. It's interesting. I remember from twenty years ago. There were some studies that talked about how health was related not just to like, whether you know, just what your socioeconomic status was. But how much of a disparity there was in the place that you live the places with higher levels tired differences between those who are the richest and those were the poorest were associated with worse health outcomes than if you were just in a poor area. Yes. Which just that somehow it is also the how different are you from those who are much wealthier that actually had a more significant effect on health. We've done just that. So that's interesting. Yeah. We know that poverty kills. Yeah. But what we didn't know is the roles of things like income inequality. Exact and the roles. Of not having other people who look like you Nick like you in an area because one of the things that the CDC has pointed to and this comes straight out of sociology is that connectedness is one of the fundamental aspects having to do with suicide. So what do we do about that? Well, I think it depends because you know, we tend to think we always talking about loneliness and loneliness is a risk factor. No doubt. But in fact, it's also the case that you can be to connected to a group. And of course, the classic example of that would be something like Jonestown, so what we have to strive for our communities in which there's both attachment to each other. But we're there is not a clenching up of the society in such a way that people don't have individual freedoms. So you you have to have a moderation of network ties. I want to transition if we can't to one of the second things mentioned was looking at how people have difficulty getting to physicians rice from getting into the healthcare system. So what are some of your work in that area? Well, our big steady on that was actually done here in Indianapolis. It's called the Indianapolis network mental health study, I think one of the big things that we found there was that the traditional way that people try to understand who gets to the doctor, and who doesn't wasn't very useful. In other words, one of the major images of people when they get sick is that they weigh the costs and balances of how sick they are. And whether or not how they have insurance, and whether or not they trust doctors all of those things matter, but in fact, the question of of what kind of pathways they traveled depend upon the social networks around them. And again, it's not you need more and more social networks because sometimes network will people in your network will push you away from care. We did a study comparing we didn't compare. Annapolis to Puerto Rico. But we did two studies one after the other. And in Indianapolis, having more networks got you into mental health care sooner. Because on average one of the things that we know is that it takes about seven years from the onset of a mental health problem for people to get services. And the question is what's happening all that time. Well, they're trying to figure out what this is. And is it just something about their personality? Is it something that will go away? Do they know other people have had these kinds of symptoms, and it takes a while to figure those things out? What what do you mean? Exactly by a network like when you say, they have more networks. What does that mean? It's really about who you talk to about your problems. And it's specifically who you talked to about your health because it turns out that if you talk to people who have had prior contact with the mental health system, they have a lot of information, and again, depending upon their experience in the mental health system. They'll. Tell you exactly where to go or exactly where not to go. And so those people matter, and sometimes it's the people closest to you. But we have to remember that the people closest to you also tend to have the same information you have. So sometimes it's that person at the Y that you walk around the track with who happens to be a nurse who can give you the information that your family doesn't have. So it's really about your health network contacts people you talk to when things come up. So I that totally rings true. Because I have no doubt that people who know me have far greater access to those people who don't and given that I'm a real proponent of therapy and mental health care. I've know I've helped many people probably push them to do that. And I can imagine the people I know do that as well. So how do you measure though, that like how do you measure the network to know like are you looking at individuals? How do you do that? Well, you have to start out with finding people who either have a problem, which is very hard or people. Who have entered the system, and then ask them just to tell you the story of how they got there. Because if you ask them to tell you, what are the reasons that they came they will like anyone else lay out a rational set of reasons of why they got their you know, they had insurance and their boss told them they had to go. But in fact, if you say if you ask it a little bit differently. If you ask them, not the way a medical history is taken. But the way we would tell stories to each other and say how did you end up at this hospital? They tell you a story that is very people'd, and you start to learn who are the people that matter in translating a symptom into a concern that requires medical help. So then when the announces gets done, did you try to trace it back to say like, well, these are key people in this whole group, or is it is it quantifying the number of networks, or is it a combination of both know we quantify it what's different about the storytelling approach is that. Instead. Head of having a list of things that you ask them about you use the story itself and code information out of that that you then quantify so let me give you an example of what I think one of the interesting things out of our Indianapolis study was most research that looks at people using services is called help seeking research. And right there it implies that people are out looking, but what we found in. The Indianapolis study is that there are actually three pathways to care just fewer than half of the individuals at some point made a decision to go. So that would be the help seeking pathway. So another way that about a quarter of individuals who end up in the mental health system. Get there is through coercion. Now, we can talk about two kinds of coercion. The obvious thing is when people are picked up by the police and brought into the psychiatric emergency room. Or when individuals are required by the court to. Seek healthcare. But there's also there's also the guilt factor. There is the mom, right? Who tends to be on both one of the ways we get networks as we ask people who do you talk to about these problems? And we asked them not only how much support they provide. But how much they hassle them and mama tends to appear on both. Right. And so you need people not only who support you. But people who put the pressure on you to take care of yourself or to do something about a problem. Sometimes it's the bosses who say you have to now go get a physical and see what's going on. But the third way that was really the most interesting was something that we called muddling through. And that really helps to explain why it takes seven years on average for people to get mental health care because in our study, there were people who couldn't really even tell the story or they told the story from a third person point of view like they weren't even the person taking the action. We had one person for example who was brought in as. Aside attempt and he talked about how in the front of his heart. He knew he needed something. But in the back of his heart. He just couldn't face it. And he ended up attempting to take his life, and he was brought in and successfully treated, and he told the story after that from the point of your sister who was a nurse in another town who his mom, call to sort of manage the system. So he sort of muddled into muddle through mental healthcare, neither committing to it or being very resistant against it. How many people do you have to get into a study like that? Well, we had about it's it's tough because you have to get people who are making their first major attempt at rare because having an illness changes your social networks, and so about took us four years to get one hundred and seventy two people who used either the major public or private hospital in Indianapolis funds that kind of work nationalist who'd have mental health. Yeah. And so they were very interested in trying to find other ways to understand how to get people into healthcare because the traditional models weren't really working that. Well, do they then take it and actually implement change? Or is that down the line? That's not clear to me on that issue. You know, on some of the suicide work that I do or the stigma work that I do it has much greater translation potential than sort of coming up with a new theory of how people get into care, although it does have implications for how you think about changing the system, and how you think about getting people to be more aware because going after individuals is probably not the way to do it. It's better to go after networks, and some of the work that's being done at the national human genome research institute is actually trying to figure out who in a network is sort of the CEO of the family of the medical in the medical CEO of the family and trying to. Figure out then how to educate them in things like understanding DNA and the role what that means for family and genetic testing, and so we're finding that in even in the United States where we think of the power of individuals is so strong. It really is about the connections. Among people the social aspect of their lives that have a lot of impact on what they do to stay healthy. And what they do when they are sick. That's as good a point as any of the transition into the precision health initiative. So this is a new project from what I gather where you're trying to actually collect information on a whole bunch of people just a random in order to try to to see if there are new connections between some of the things we're talking about other factors that you might measure and health. And so can you tell me a bit about that? Yes. And at think, it's very important what sociology and social science bring to the medical school studies because you know, precision medicine impart. At least when we think about it. Most people think about the role of genetic Sherm, and how genetics can if we know about your genetics. How can we help you either not get sick or find a way to treat you differently in a more precise way for you as a specific human? But one of the things we know is that only about ten percent of diseases are actually clearly genetic most diseases. There are hundreds if not thousands of genes involved, and so one of the things that we're finding is that the conditions in which you live can either trigger those genes or can depress those genes or silence those genes, so you don't get sick. And so what we're doing is. We're getting new information from people in the state of Indiana about the circumstances of their lives. And that means not only where they live how much they make where do they work? But also, how do they think about? Things what's the their cultural values? What did they think? Indiana should be doing about issues in health and healthcare will they listen if somebody tells them that there are genetic treatments. So all of these things are not available in most studies. Right. So how are you getting that information? I mean, clearly that's not being collected and is not in databases nine medical record. So how do you get it? Well, what we do is a what we call a population. Based study we carefully select households and so people worry right away about how do you know my name? How did you get this? Well, we don't what we're trying to do is get a Representative picture of the entire state of Indiana. And we know through social science and statistical research that if we interview two thousand clearly or specifically selected households we can talk about the whole state, you know. So if we do it, well, and we. Tend to call. This Representative sampling rather than random sampling because everybody doesn't have a chance of being selected. Right. It's it's we're trying to to pick a set of people that went put together have the same profile as the people in the state. So how are you? Where are you getting the information from how are you picking those people? So we're working with the university of Chicago who does this all the time for lots of studies. They have a whole bunch of data sets from the census bureau and other studies, and what they do is they take a map of our state, and they break it into segments, and they know about people in those segments from the census bureau, and they can figure out if they take so many households from, you know, Marion county, and so many from Scott county in so many from Monroe county, and if they if we use a particular way of selecting the people once we get to the households we can with. You know, very few cases considering how many people there are in Indiana with two thousand cases, we can talk about the state as a whole. So when you get is soon, they plug into the computer crunch the numbers, you get two thousand names. Then what then what happens, then that's the fun part? Right. So they do the they do the formal part up at the university of Chicago. But what we do is we work with interviewers who are trained, and they they are heavily trained in a set of questions, which we call an interview schedule that we have developed to get at the information that we want that we think is important to to assist, the researchers using DNA and clinical data. So that we can now add their environmental data and their cultural data, and we go to their house, and we sit down with them for an hour or so, and we ask them these questions. Call him ahead of time. Or are you just show? We send them a letter. Okay. So people should not be concerned about this. If. Received a letter. There is also, you know, if you don't want somebody showing up at your door, you can call us the the number is on there, and we can schedule an appointment, and you don't have to have it in your house. If you don't want people in your house, we can go to the public library. We could go to McDonald's shirt somewhere where it's private enough that other people aren't overhearing what you're saying. Because we were protecting your privacy at all costs, and we want all the information to be confidential because we are interested in the people of the state of Indiana. But we're interested in them as a Representative person. So once we get the information, we take all the information that identifies that person, and we put it lock it away in a file, and we use what we call the de identified data to help the people doing the genetic and the clinical research understand the circumstances of these people's lives. So you're collecting then hard biological data. All of these. Yes. Because one of the things not everybody has participated in the the school of medicine bio Bank, Indiana University has a bio Bank where they have samples and there are about eighty thousand samples as I understand it. But that's not everybody in the state. And so if we want to connect a person's health to their DNA to the circumstances in which they live we have to have all that information on one person. So you're trying to collect we have lots of biological samples. We've lots of DNA samples, but we don't obviously have all this other data that's collecting so where you're talking about collecting all this other data, and then also trying to get the genetic data. I got for me, it seems much clear that we can tell a lot by talking to two thousand people about the social data than than genetic. I mean, there's so many variants I'd imagine in the genetic data. I don't do do the people on that end of it believes that they're going to see real like data that they're gonna be able to use to to try to talk about precision medicine from the genetic standpoint or is. Much more focused on the social data that we're connecting. Well, I think I think there are two things one we know that social factors matter heavily and people's help. So for example, let's take all timers, which is one of the diseases that precision the precision health initiative is targeting. Well, it turns out there's a whole lot of research that shows that again your social networks affect how fast the disease progresses, you have Alzheimer's. And if you have good social networks the disease does not progress as quickly. There's also an thousands of articles trying to understand the genetic roots of Alzheimer's, but the problem is nobody has put these two things together because we work in different worlds. But in fact, Indiana University now has a grant from the federal government to put these kinds of information together. So at least there are groups from the social sciences and groups from the genetics that do believe. That this has a lot to tell us about what triggers the because we can have the exact DNA profile, and yet one person gets the disease in the other doesn't well what's going on. Then what has to be something else? It has to be something about their physical environment or their social environment. And those things matter, and I would like to add one thing that I think that people don't understand, which is we talk about social factors. We know that loneliness or isolation is a quivalent to smoking eighteen cigarettes a day in terms of your health. So if you think about that eighteen how many people smoke eighteen cigarettes a day now. Right. But how many people are feeling isolated totally believe that? And so if they have the same effect on your health, we should be marking that and trying to understand how that affects their DNA. So what kind of questions are you asking that data? We don't already have. Well, we're asking a lot. We're starting out by asking them. What problems are they facing? We don't know that about people in the state of Indiana. You know, we at the university we come up with these ideas from the statistics, we have from the state, and we say, oh, this is the problem. Right. But is that how people see the problem, and we also ask them? What do you think? What could we do to make better for you? Right again. I think if you are doing research to try to improve the health of population who should be talking to the people you're trying to help and see what their perspective is on what they need. And we learned this very heavily from doing stigma research, you know, where people with mental illness often suffer prejudice and discrimination. And you know, that turns out to be almost as formidable an obstacle to recovery as the disease itself because it it might might turn into losing their family. It might turn into losing their job and those things become very important for their health and. And so we really need to think about how these things work together. I think it's the case that many if not most researchers believe now that it is really the combination of what the person brings to the table, and the the DNA that they've inherited that really matters for their lives. I couldn't agree more preaching to the choir. I just I'm always fascinated by the fact that the entire medical system and our data gathering each ours completely focused on one side of that. And completely ignorance of the other. And even as we know all of this stuff matters. And that the social determinants matter all the metrics that we still measure in terms of quality and everything else in the healthcare system are almost entirely focused on not patient centered outcomes. But the outcomes that we we still think for the physicians and others in healthcare think are important. So how do we change that? Well, I can't say that sometimes it isn't frustrating to be a social science because medicine is clearly a very powerful. Institution in our society. But they start with a person having a disease and disorder, and it really is the social sciences and public health that tried to stop people from having to go to the doctor. And so medicine does a great job at what it does. They get somebody who's sick. And they try to bring them to health, but doctors are not as trained in how to keep the population healthy. And there you really need to think about the circumstances of their lives. Now, there's a great deal of emphasis now on individuals. Right. An individual should run they should drink tea. They should take to Merick. They should do all these things. But I think that's really a very shortsighted view of what helps individuals stay healthy because we tend not to think about the larger factors like income inequality like poverty, like a pollution that really has an effect on their lives. And I remember reading a study. Once that kindergarteners in Los Angeles already have a great deal of scarring on their lungs. And so are you going to blame those children for that some people? Yes. I'm with you. So the cynic in me is is look again, we do episode of episodes. I could not agree with you more. But there's you know, there's money to be made in treating illness. There's not as much money to be made in prevent to. How do we change? How do we change the way that the healthcare system is financing? I mean, these are huge questions we're grappling with all the time. But part of the the frustration is that everything you're saying makes absolute sense to me. And I just don't know how we, you know, move the three plus trillion dollar industry that exists that that doesn't think this way into moving in that direction. Well, I think it's always an uphill battle. Because quite frankly, you know, I was born in the fifties. And I I wanna magic bullet. And I think, you know, there was a deal made, you know, in the deal was give profession the profession of medicine, a great deal of power and resources, and we will take care of your ills. Now it. We know that it's not that simple. Right. That magic bullets can't cure everything. Maybe we will. Maybe we'll find out in the end that you know, mental illness is a result of a leaky gut. You know who knows? But but point is is there are people dying now, and there are people suffering now. And there are things that we know about the conditions of life that matter, and so I don't think that this is going to be a very popular view. And I think the best way to think about it is I think the recent statistics said something like the National Cancer Institute gets ten times or one hundred times can't remember was a huge number the amount of money that the National Institute of mental health gets. So it's not only, you know, you know, medicine versus people in the population in the community. But there's also a pecking order of diseases and cancer has made tremendous strides mental health has not. But if you have a, you know, a third of the fire. Finances to work with what would you expect Saint make his Clinton about public health? Absolutely. A tiny percent of of how we do. But we know that the return on investment is so great. So how's the study going? It's going. Well, I think that people right now are little hesitant about opening their doors. It's a time when well at least compared to twenty years ago, we've been doing these studies for a very long time. And what we're seeing now is people are a little bit more reticent to participate. But it's critical that they do and they should feel comfortable calling us. It's really critical that they participate because they were picked verse specific reason, and they're really important. But I totally understand people being concerned. We what we're trying to do is do it neighborhood by neighborhood and letting the neighborhood associations. No. And leading what we right now. We're doing a lot of work in Marion county, but we will be going to. Rural areas of the state, and we are working with the rural associations on that. So we're trying to get information out in different forms of media. So people know we're in your area now. And so that they should be on the lookout for and there are numbers to call in the letter that you receive saying your household has been selected call us ask us any questions. So this is unfortunately, not something that people can just decide they want to be a part of the half to receive the letter that is a big difference between medical research and social science research medical research takes people who come in the door and social science research, if it really is going to represent the community it's got to represent the community because we know there's a difference between people who volunteer for medical studies than people who don't. So if we want to say something about the state of Indiana, we really have to talk to different kinds of people from the state of Indiana. And I think it's important that if you want your views represented. The and you get selected then you should just tell us exactly what you think they have no specific dog in the hunt. We are not looking for this particular answer that particular answer we want you to tell us what is affecting you and your family and your community. We want to know what you think about it. We wanna know who are the people. How do you feel you know, one of the medical concerns? You have what do you think we can do about them who are the people that you can trust in your life to talk to about these issues all of those kinds of things that just don't appear in medical records. They don't appear in census documents. And the only way to get them is by talking to the people, and we think of this study as representing the voice of the people of Indiana. And that's why it's so important that you participate, but that use if you feel at all uncomfortable. Really, call us at have chat with us about this because this is being done with the highest levels of human. Subjects protection. And for the good of the state. We, you know, we're not interested in prying into your private life. We're interested in knowing about your health, and the circumstances of your life that is making your life wonderful or not so wonderful and providing that information to people not only to the medical school that can then use it with the DNA information and the clinical information they have. But also thinking about other projects that could be done in communities that will improve them sounds like super important work Musha the best of luck. Thank you. Well, Bernice thank you so much again, our guest Bernice Pesca Cellino, and we'll look forward to hearing about the results. This thing moves forward. Great. Thank you. Erin healthcare trash podcast is sponsored by Indiana University school of medicine whose mission is to advance health in the state of Indiana and beyond promoting innovation and excellence in education, research and patient care.
COVID Questions: How Should My Family Handle a Coronavirus Christmas?
"Presented by the salvation army in a year with fewer red. Kettles helped rescue christmas for the most vulnerable to give ask your smart speaker to make a donation to the salvation army or donate at salvation army. Usa dot org covid questions. How should my family handle a coronavirus. Christmas by jamie ducharme today. Jay b. from new jersey asks every year for the holidays. My aunt and uncle come up from florida and stay with my seventy year. Old parents who host a large extended family dinner on christmas eve. My aunt and uncle both had covert nineteen early in the summer and tested positive for antibodies in july. Their plan is to donate blood in early december to see if they still have. Antibodies then fly up from florida to new jersey. They believe they can't get covid. Nineteen again or spread it to others. As long as they have antibodies. My cousin also wants to fly from north carolina to new jersey. Spend christmas with our family and then visit with other family members. The only precaution he wants to take is getting a cove nineteen test before flying. He says he doesn't go out too much. Is it unreasonable to consider telling either or both of these relatives that they should not travel and stay with my parents this year. This is undoubtedly an issue on lots of people's minds. So thank you. it's also a complicated one. So i consulted to experts. Dr kelli michelson director of the center for bioethics and medical humanities at northwestern university feinberg school of medicine and a physician at lurie children's hospital and akiko iwasaki a professor of immunobiology at the yale. School of medicine to answer your last question i. It's not at all unreasonable. To consider asking family members to skip the trip or to skip a big christmas eve dinner entirely as painful as that would be at seventy. Your parents could develop serious complications if they were infected with covid nineteen. It's never easy to forego a tradition but with the virus surging across the country. It's a possibility with seriously discussing with your family now for the details. Your question about your uncle in florida essentially royals down to do. Covert nineteen survivors. Still need to take precautions was ocoee says the answer is yes. It's true that people who have recovered from coronavirus are probably at a lower risk of getting the virus again or spreading it to other people but there have been documented cases of people getting covid nineteen twice. And there's a lot that scientists still don't know about covid nineteen immunity including how long antibodies last estimates. Run anywhere from a few months to a year plus and however prevent subsequent infections. If you're at and uncle tested positive for antibodies right before travelling. It could offer a little bit of comfort that they won't get sick or infect others iwosaki says but it's not a guarantee false results are common with antibody tests and researchers are still figuring out how well antibodies prevent future infections a positive test result doesn't definitively mean. Your aunt and uncle are completely protected or incapable of infecting others. Iwosaki says if your aunt and uncle do make the trip they just like any traveler should try to quarantine for ten to fourteen days. Preflight michelson says and once they arrived they should still wear masks and practice social distancing that brings us to your cousin in north carolina. Michelson says she has a lot of concern about his plan. Getting a single test before flying really isn't enough to rule out infection. He could be exposed to the virus the moment he leaves the testing center or if he was exposed shortly before getting tested there might not be enough virus in his system to show up on the swab by the time he shows up for christmas eve dinner though he could be contagious if he then goes to see more relatives he risks infecting even more people. Michelson says if he plans to make the trip your cousin should follow the same precautions mentioned before the same goes for local relatives who may be planning to attend christmas eve. Dinner for the record. People driving from a few miles away are just as capable of spreading the virus as people who are flying if they haven't taken precautions beforehand to make a long answer short the safest choice and the one recommended by the us centers for disease control and prevention is to skip holiday. Travel this year and get the family together. Virtually if your family wants to gather everyone should try to quarantine beforehand and continue to take precautions throughout the visit. That's not a very fun. And festive answer. We know these choices are extremely difficult for everyone. It's easy to say we shouldn't be doing this that the other behavior. It's very hard to actually not do. Those things. michelson says for whatever solid. It's worth though. Michelson says that she can imagine a possible return to group gatherings by next summer with effective vaccine seemingly headed toward approval. Hopefully that serves as a little motivation. This season it would be really sad. Michelson says to have one of the people you love get sick knowing that if you had waited five or six months things would be different.