[SPEAKER_01]: Welcome back to the verbal medicine podcast where we bring modern medicine to strength conditioning and strength conditioning to modern medicine.

[SPEAKER_01]: I'm your host, Dr.

Jordan Fagan Mom and this is the second episode of The Run Down.

[SPEAKER_01]: We catch you up on the list news and health and fitness, science, technology sports and some politics.

[SPEAKER_01]: Got some tepid takes coming for you here.

[SPEAKER_01]: On the other end of the line is the second most handsome doctor in North America.

[SPEAKER_01]: Dr.

Austin Baraki was going on.

[SPEAKER_00]: Hey, doing all right.

[SPEAKER_00]: I just sent you a photo of my, as I called it, Jimmy Rig set up final recording session in my house before.

[SPEAKER_00]: The move, so looking forward to getting going, and I hear you have a trip coming up as well.

[SPEAKER_01]: Yeah, going to Europe, going to Greece.

[SPEAKER_01]: Here's a nice this time of year.

[SPEAKER_01]: And I'm not tan enough despite living in San Diego.

[SPEAKER_01]: So you're going to have to get out there.

[SPEAKER_01]: And I'm excited to see the Acropolis, you know, do the historical things, then go to a beach and then just turn my phone off for a few days and do that.

[SPEAKER_01]: I could probably do that anywhere in the world.

[SPEAKER_01]: I don't need to be [SPEAKER_01]: overseas to do it, but it feels nicer to do it overseas, I think.

[SPEAKER_01]: So, should be a good time.

[SPEAKER_01]: Yeah, before we get into this episode of the rundown, a few announcements.

[SPEAKER_01]: First, hey, look, if you turn the podcast on and you're listening to the ads and you're like, dang it.

[SPEAKER_01]: I hate the ads.

[SPEAKER_01]: Hey, we hate them too.

[SPEAKER_01]: We don't like them, but at the same time they do fund this operation.

[SPEAKER_01]: And there's some costs and time associated with doing these sort of podcasts.

[SPEAKER_01]: And we want to keep bringing them to you.

[SPEAKER_01]: But if you want to support us, and you don't want to listen to the ads, you want discounts on products.

[SPEAKER_01]: You want early access to new services, templates, et cetera.

[SPEAKER_01]: You want articles that are not published anywhere else.

[SPEAKER_01]: You want transcripts.

[SPEAKER_01]: You want support.

[SPEAKER_01]: Maybe you consider subscribing to Barbomedus and Plus.

[SPEAKER_01]: We do that through the supercast platform, so you can go to Barbomedus and dot supercast.

[SPEAKER_01]: dot com, you get your first month free.

[SPEAKER_01]: Basically, the same cost is buying one of us a cup of coffee once a month.

[SPEAKER_01]: And you get all this to support what we do.

[SPEAKER_01]: We'd really appreciate it.

[SPEAKER_01]: You can check that out.

[SPEAKER_01]: And again, first month free.

[SPEAKER_01]: So what's there to lose?

[SPEAKER_01]: And the other announcement, we have our two day health and performance seminar first, one in a few years.

[SPEAKER_01]: It's in San Antonio, September, twenty through the twenty first, myself, Dr.

Baraki, Lea Lutz, Tom can't be telling all be there.

[SPEAKER_01]: We're going to provide some in-depth lifting instruction for you, and as well as [SPEAKER_01]: a number of lectures on everything from like sarcopenia, heart health, et cetera, all the way to nutrition and program and everything in between.

[SPEAKER_01]: And if you've been to one of our seminars before, you know some are great, but we are significantly updating pretty much everything that we do here, not only the lecture content, but also how we deliver them.

[SPEAKER_01]: So some small group outbreak sessions and as well, there's stuff to try to make it more useful rather than just us talking about stuff.

[SPEAKER_01]: Some people want to just hear us talking about stuff.

[SPEAKER_01]: Some people just want to lift the instruction.

[SPEAKER_01]: But we're going to kind of iterate on what we've been doing so far to bring you guys a better product.

[SPEAKER_01]: So, and we're going to hang out.

[SPEAKER_01]: And last time we had like a barbecue type situation, I think after Saturday is like a group sort of dinner thing.

[SPEAKER_01]: I'm hoping we could do something like that.

[SPEAKER_01]: Maybe you know, train with us kind of session on Friday.

[SPEAKER_01]: You want to do that.

[SPEAKER_01]: So we're releasing more details on that to the people who have signed up for the seminar.

[SPEAKER_01]: You can check that out in the link below.

[SPEAKER_01]: Alright, starting off with some Olympic weightlifting news.

[SPEAKER_01]: A few weeks ago, so the end of June, twenty-nine-year-old American Olympic weightlifter Maddie Rogers, who holds U.S.

[SPEAKER_01]: records in the snatch, the clean and jerk, and she competed in the twenty-twenty Tokyo Olympics for us.

[SPEAKER_01]: She posted two or Instagram story that she suffered a transient ischemic attack, also known as a TIA, or a, quote, mini-stroke, some people may call it that.

[SPEAKER_01]: while training.

[SPEAKER_01]: As she posted the story from the hospital saying, while I'm still awaiting answers, luckily I don't really have any deficits lingering and I'm feeling mostly normal today.

[SPEAKER_01]: About a week later, she actually competed in the USA Weightlifting Nationals and she won her class, snatching a hundred and four kilos and cleaning jerking a hundred thirty-seven kilos.

[SPEAKER_01]: Dr.

Barackie.

[SPEAKER_01]: Is this a TA or not?

[SPEAKER_01]: I know how you like diagnosing people from afar when you have no interaction with the patients, but yeah, kind of kind of interesting considering, you know, what is the definition of TA and subsequently she did awesome a few days later.

[SPEAKER_00]: So yeah, it is a admittedly challenging diagnosis to make, especially I would say in this patient demographic.

[SPEAKER_00]: So most people have at least heard of the term stroke and stroke refers to [SPEAKER_00]: You know, a period when an area of the brain is receiving insufficient blood flow and they more common cause of eschemic strokes kind of like a heart attack of your brain.

[SPEAKER_00]: There are other types of strokes where there's bleeding involved and that's not that's a little bit less less common.

[SPEAKER_00]: And when we diagnose a stroke, usually patients have some kind of neurological symptom.

[SPEAKER_00]: They don't always have to, but oftentimes that's how they present.

[SPEAKER_00]: And we can see evidence of that area of insufficient blood flow on certain types of brain MRI sequences.

[SPEAKER_00]: So it is, you know, very apparent on those scans, at least to a radiologist, neuro radiologist who can look at those particular sequences and identify this area is clearly not receiving enough oxygenated blood flow.

[SPEAKER_00]: that correlates with the patient symptoms that they're having and then you can either intervene or in certain situations, you might not be able to intervene and hope for the best in the aftermath.

[SPEAKER_00]: when patients are have a stroke like syndrome where they have some kind of a neurologic symptom, maybe affecting an arm or a leg or speech or something very specific neurologic symptom.

[SPEAKER_00]: And it resolves on its own relatively quickly.

[SPEAKER_00]: And at the same time, when you do that kind of brain MRI scan, there is no evidence of that type of eschemia, meaning that the brain MRI scan looks pretty normal.

[SPEAKER_00]: There is not evidence of an area of brain that is not receiving enough oxygenated blood flow.

[SPEAKER_00]: then sometimes that is labeled as a transient ischemic attack or a TIA.

[SPEAKER_00]: And so that is part of the definition is like your scan has to be normal.

[SPEAKER_00]: Now, that is a much more plausible diagnosis in my usual patient population, the older folks who have a bunch of, you know, plaque in their arteries or atherosclerotic disease or they might have, you know, many other risk factors towards like, yeah, I'm not at all surprised that this person might have had a very brief, again, as people colloquially know it at many stroke.

[SPEAKER_00]: In a younger patient, [SPEAKER_00]: It's a bit more challenging.

[SPEAKER_00]: There are lots of other things that can mimic what can look like a stroke and might not actually be a stroke.

[SPEAKER_00]: And so yeah, it would be very presumptuous of me to override whatever diagnostic label she received, presumably she would have seen some skilled clinicians, ideally a neurologist at the institution.

[SPEAKER_00]: And if that is their final determination, I'm not in a position to challenge that, but rather [SPEAKER_00]: You know, when I first read this, I said, well, there's like, that's like a hard diagnosis to prove, especially in that what I would call like a low pre-test probability patient, meaning somebody who doesn't have a ton of vascular risk factors or reasons to have, you know, an eschemic event like that.

[SPEAKER_00]: And there are other types of things that can mimic it.

[SPEAKER_00]: There are cerebral, like, vasospastic issues.

[SPEAKER_00]: There are complex migraines.

[SPEAKER_00]: You can have migraines that have neurologic symptoms.

[SPEAKER_00]: You can have migraines without headache.

[SPEAKER_00]: Weirdly enough, there's a lot of other things that can mimic it.

[SPEAKER_00]: And so I was just kind of, [SPEAKER_00]: curious about how confident that label was because, you know, that's a pretty significant thing to tell someone, especially when they're twenty nine is you had a, you know, because people will all that will hear is the word stroke and that'll like stick with them for the rest of life and they'll tell all the doctors they see for the rest of the life.

[SPEAKER_00]: Oh, I had a stroke when I was twenty nine and then that changes the way that their subsequent doctors think about them.

[SPEAKER_00]: Whether that was accurate or not, it's just because this is not a diagnosis that can be definitively proven.

[SPEAKER_00]: which was my take.

[SPEAKER_00]: So a tricky situation, glad she recovered well and seemingly performed very well at the subsequent meet.

[SPEAKER_00]: If she did in fact have that, you would really want to get a sense of what was the underlying cause, your predisposing factor, does she have a clotting disorder, does she have a vascular disorder, being the prime causes of something like that, or does she have some sort of cardiac issue, [SPEAKER_00]: And so presumably, those would be either have already gotten evaluated or will be getting evaluated.

[SPEAKER_00]: I hope they already were if she was clear to go and compete in the aftermath of this.

[SPEAKER_00]: But it's just, yeah, when I read it, so that's a tough diagnosis to prove in that patient.

[SPEAKER_00]: There's a lot of things that can look just like that.

[SPEAKER_00]: I would be cautious with applying that label.

[SPEAKER_00]: Or if I told somebody that it might have been the diagnosis, I would like [SPEAKER_00]: severely caveat it as a you know sometimes not confidently provable diagnosis so they don't think that they have a stroke disorder for the rest of the life when maybe they do maybe they don't if I'm not able to find a reason for it.

[SPEAKER_01]: Yeah, I mean that you kind of summarized or stated nicely what I was thinking is is that.

[SPEAKER_01]: If this was, in fact, a TA, whatever was labeled that, you'd one identified the potential cause or causes of it.

[SPEAKER_01]: And then at that point, if you were like, yeah, look, you're at minimal risk of having a repeat episode, you can go ahead and compete, which for that to take place within like five or six days, seems unlikely.

[SPEAKER_01]: And so I'm like, thank, kind of dissent it.

[SPEAKER_01]: And so I imagine it's parallel universe where somebody posted on our forum, [SPEAKER_01]: Hey guys, had these strange neurological findings presumably.

[SPEAKER_01]: During training, went to the hospital.

[SPEAKER_01]: They said I had a TAA and I got discharged.

[SPEAKER_01]: When can I get back to training?

[SPEAKER_00]: Yeah.

[SPEAKER_01]: We'd be like, me with a lot more information here, please.

[SPEAKER_01]: Totally.

[SPEAKER_01]: And fair enough, it's private information.

[SPEAKER_01]: So she's not, you know, she doesn't need to disclose that.

[SPEAKER_01]: And ultimately, I think we're both happy.

[SPEAKER_01]: She did well.

[SPEAKER_01]: And obviously crushed it at nationals.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: I'm just more like, [SPEAKER_01]: Huh, puzzling, puzzling, for sure.

[SPEAKER_01]: Yeah, she made a comment also about not having insurance and which it makes this more challenging as far as like follow-up goes and like making sure that she's, you know, if there are risk factors that she has or something going on, making sure that those are, quote, optimize, that's going to be challenging without insurance.

[SPEAKER_01]: So definitely empathetic towards that situation, in addition to just being fearful.

[SPEAKER_01]: Like I, I consider myself, you know, I'm not like a, [SPEAKER_01]: Man, I'm super hard.

[SPEAKER_01]: I'm like, you know, whatever.

[SPEAKER_01]: Face anything overcoming it.

[SPEAKER_01]: They like have some self-belief, but that's not out of proportion.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: If I had something like this, I don't know, man.

[SPEAKER_00]: Like a week later, I'm probably not going to nationals to like, yeah, I mean, I don't know how much nationals would or wouldn't directly impact your risk, but it is known that in patients who do have a legitimate actual TIA, they are at a significant increased risk of stroke in the subsequent couple weeks.

[SPEAKER_00]: And so when we confidently diagnose the TIA, [SPEAKER_00]: Then we might actually put patients on medicines to reduce that risk.

[SPEAKER_00]: In general, there's a bunch of big picture categories of stroke issues with your larger blood vessels, smaller blood vessels, issues with your heart, other medical conditions that can cause stroke.

[SPEAKER_00]: And then this last kind of nebulous category that's called cryptogenic, meaning you had a stroke and we don't know where it came from.

[SPEAKER_00]: And then when you apply all those in my usual, sixty, seventy plus age population, that's where I'm more comfortable with this.

[SPEAKER_00]: When you apply all those same things to the young and you say, I have a cryptogenic stroke in a twenty nine year old.

[SPEAKER_00]: I'm like, oh boy, that's a [SPEAKER_00]: That's a really challenging proposition to work through.

[SPEAKER_00]: Could they have lupus?

[SPEAKER_00]: Could they have all sorts of other things that can contribute to it?

[SPEAKER_00]: It needs a lot of work is the bottom line to get to the bottom of it.

[SPEAKER_00]: If, in fact, that's what it was.

[SPEAKER_00]: Some send out labs for sure.

[SPEAKER_01]: That's going to be back.

[SPEAKER_01]: Anyway, glad you're doing well.

[SPEAKER_01]: Congratulations on the win.

[SPEAKER_01]: Moving on.

[SPEAKER_01]: All right, in a medical breakthrough, I don't know if you heard about this, a child diagnosed with a rare genetic disorder has been successfully treated with a custom CRISPR gene therapy by team at CHOP that's children's hospital Philadelphia and pen medicine.

[SPEAKER_01]: This is baby KJ, my national news.

[SPEAKER_01]: It was born with a rare metabolic disease [SPEAKER_01]: known as severe carbamoyle phosphate synthetase, one deficiency CS, CPS, one deficiency now.

[SPEAKER_01]: This is an inborn error of metabolism in the urea cycle, which is what humans use to detoxify the ammonia product that's happens with normal protein metabolism.

[SPEAKER_01]: Now, this disorder typically causes very high levels of ammonia and subsequent neurological issues among others.

[SPEAKER_01]: The presentation can vary.

[SPEAKER_01]: And so if you unfamiliar with what CRISPR is, this is a gene editing technology.

[SPEAKER_01]: The acronym stands for Cluster regularly interspaced short palindromic repeats.

[SPEAKER_01]: Try to remember that.

[SPEAKER_01]: Good luck.

[SPEAKER_01]: But ultimately, it edits genes and can produce nicely correct disease causing variants that are due to genetic disorders.

[SPEAKER_01]: Now, there are CRISPR-based therapies currently available for like sickle cell disease and beta thalsemia, and others are still in development.

[SPEAKER_01]: Now, of note, it took about eleven years to develop the CRISPR therapy for sickle cell, but it only took six months to develop this custom therapy for baby cages, baby cages, faulty enzyme.

[SPEAKER_01]: So two questions to you, Dr.

Barackie.

[SPEAKER_01]: Is this awesome?

[SPEAKER_01]: And what's next?

[SPEAKER_01]: You know, I'm just thinking about maybe some genetic disorders like look, well, we can come up with something bespoke in a couple months and you're on your way.

[SPEAKER_00]: Yeah, this is, I would say, mind-blowingly awesome.

[SPEAKER_00]: I think that just a testament to the skill, the expertise, decades of research and work that has gone into this.

[SPEAKER_00]: It's difficult to even explain like the level of scientific advancement and technology that is involved here.

[SPEAKER_00]: It was despite all that though, I would say a predictable outcome.

[SPEAKER_00]: I remember within the past decade, once CRISPR started to become a hot topic of conversation, this is not a brand new topic.

[SPEAKER_00]: We're starting to talk about it actually a decent number of years ago.

[SPEAKER_00]: As soon as that happened, I think that at least my thought was that this type of thing, it was almost a matter of time.

[SPEAKER_00]: before it was feasible at all and then as these things naturally tend to go once it becomes feasible the speed and precision and and things like that just naturally tend to improve such that the you know whereas as you said it took eleven years to do the sickle cell one but only a few months for this one.

[SPEAKER_00]: And that time frame I expect is going to continue to shorten and shorten as more resources and expertise and experience get poured into this area.

[SPEAKER_00]: It will of course only be maximally useful upfront in kind of more monogenic situations where there's a single gene with a simple defect that you can just, you know, backspace put in the correct code there and restore kind of normal physiologic function.

[SPEAKER_00]: more complex polygenic disorders and certainly those that are, you know, more complex in terms of gene environment interaction like obesity, for example, common obesity will call it.

[SPEAKER_00]: Those are going to be a lot trickier and I don't anticipate, you know, CRISPR playing a strong role in conditions like that, at least anytime soon.

[SPEAKER_00]: It still remains plausible that there could be some role for that in the further distant future, but I think that generating almost like, you know, I'm imagining a scenario like pre, prenatal screening, [SPEAKER_00]: or, you know, the standard newborn screen.

[SPEAKER_00]: And then you might be able to like rapidly turn that around and, you know, address, you know, more dangerous, potentially lethal inborn areas of metabolism.

[SPEAKER_00]: Then there's the last interesting topic of you take that to its natural end.

[SPEAKER_00]: I think, you know, where I'm going with this, almost like a gaddict style, you know, ethical conversation of where do we stop gene editing and [SPEAKER_00]: And the ethics of editing may be non-lethal variants, picking and choosing.

[SPEAKER_00]: That's a, you know, that was a all-time great movie to start nerding out on science fiction stuff like this back many, many years ago.

[SPEAKER_00]: So yeah, that's kind of where I see things headed, but this was like a really remarkable story.

[SPEAKER_00]: I think I shared with you a pretty good podcast on the topic, playing English with Derek Thompson had did a excellent report on this and interviewed [SPEAKER_00]: one of the main researchers who was involved in this work, and so that was a great discussion of the topic for anyone else who's interested.

[SPEAKER_01]: Yeah, link that in the show notes below.

[SPEAKER_01]: I'm just more curious.

[SPEAKER_01]: Can I get a milestone at CRISPR update, like I just a little reset, or maybe like an active in a, or something like that?

[SPEAKER_01]: Like, hook me up.

[SPEAKER_01]: I suspect, you know, the logical end in, you know, traditional medicine is going to be designer babies, right?

[SPEAKER_01]: But in sport, it's going to be like, oh, yeah, well now we're just making people, you know, [SPEAKER_01]: ACTN-One, you know, homozyagus, so now you're super powerful, and now you, and you got a milestone knockout, and so you're super jack too, and it's like, then what?

[SPEAKER_00]: Yeah, yeah.

[SPEAKER_00]: I mean, you think about like PED testing, how are you going to test for genetic modification?

[SPEAKER_00]: Especially if it was done somehow, like, it's a vague answer to a point where it was maybe even pre-made.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: You were born like this.

[SPEAKER_00]: It's like something like that.

[SPEAKER_00]: You were born.

[SPEAKER_00]: Yeah, just give you one with one of the other adjacent fields here is something we've talked about actually for a couple of years now.

[SPEAKER_00]: There's a cardiology kind of community that's applying these technologies to blood lipid management as it relates to cardiovascular risks.

[SPEAKER_00]: So we've been following [SPEAKER_00]: a couple companies, some of which have been doing things like gene editing as it relates to LDL management such that you can get like a one-time treatment and it will confer a lifelong blood lipid lowering and aiming to confer a lifelong lowering of cardiovascular risk.

[SPEAKER_00]: And so that's currently being tested.

[SPEAKER_00]: I forget what phase it's in right now, but certainly some promising results really dramatic blood lipid lowering this persistent [SPEAKER_00]: And so we'll see kind of where that goes in the future as compared with people needing to take a medicine every day or every week or every month or a couple of times a year with some of the other options.

[SPEAKER_00]: If there's a one-in-done sort of thing for cardiovascular disease, that could be interesting.

[SPEAKER_00]: TBD, we'll see.

[SPEAKER_01]: TBD.

[SPEAKER_01]: All right, so out of the medical world and into [SPEAKER_01]: The fitness influencer scene, liver king is back in the news.

[SPEAKER_01]: Just when he thought he was gone, Brian Johnson, not the snake oil guy, but another guy named Brian Johnson, that's liver king's real name.

[SPEAKER_01]: Well, he was arrested and booked into Travis County jail in Austin, Texas on a terrorist threat charge after he made threats against Joe Rogan on his Instagram.

[SPEAKER_01]: He said, Joe Rogan, I'm calling you out.

[SPEAKER_01]: My name's liver king and man to man, I'm picking a fight with you.

[SPEAKER_01]: He said in a video that he posted a few weeks ago.

[SPEAKER_01]: He says, I have no training in jujitsu.

[SPEAKER_01]: You're a black belt so you should dismantle me, but I'm picking a fight with you.

[SPEAKER_01]: Your rules, I'll come to you whatever you're ready.

[SPEAKER_01]: Police said they contacted Rogan the following day and he told them and he had never previously interacted with Brian Johnson and considered the post to be threatening.

[SPEAKER_01]: He subsequently arrested and booked in a bizarre twist.

[SPEAKER_01]: So he, you know, obviously got out on bail or whatever.

[SPEAKER_01]: In a bizarre twist though, he apparently staged a second arrest a few days before we're recording this.

[SPEAKER_01]: So the question to you is, what's wrong with this guy?

[SPEAKER_01]: Oh boy, never go full carnivore.

[SPEAKER_01]: Yeah, maybe maybe carnivore induced dementia.

[SPEAKER_01]: See ideas this like a new pathology.

[SPEAKER_00]: No, I mean, on one hand, it's just his whole trajectory.

[SPEAKER_00]: His whole character arc has been amusing, irritating, just patently absurd.

[SPEAKER_00]: On the other hand, to whatever extent, there is legitimate underlying psychiatric illness.

[SPEAKER_00]: You feel for the guy for digging himself into this situation.

[SPEAKER_00]: I think I saw, like some before and after photos of him, like before he went full, ancestral hardcore carnivore eating raw cow.

[SPEAKER_00]: Organs at home and like having his family do the same thing and like trying to live this lifestyle.

[SPEAKER_00]: And yeah, among many other performance enhancing substances and things like that.

[SPEAKER_00]: And he, you know, looks substantially worse now.

[SPEAKER_00]: Of course, and I don't think that many people look terribly glamorous in there.

[SPEAKER_00]: mug shots and that includes him.

[SPEAKER_00]: But yeah, so it's hard to say if there's legitimate psychiatric illness, he deserves treatment and some empathy for that.

[SPEAKER_00]: Social media is a tough thing when you're in that type of position.

[SPEAKER_00]: And so might have led to some of this, but still just absurd start to finish and unfortunate.

[SPEAKER_00]: And I think the health and fitness scene is best with no liver king around.

[SPEAKER_01]: Ooh, yeah, yeah, I would agree with that.

[SPEAKER_01]: Yeah, the world, yeah, I don't know the world's a better place, you know, without Brian Johnson, but ever King, we could, we could leave that behind.

[SPEAKER_00]: That character, yes.

[SPEAKER_01]: Yeah, that character as well.

[SPEAKER_01]: The caricature, yeah, maybe twenty twenty six is the year of no liver king.

[SPEAKER_01]: Yeah, maybe the refined king.

[SPEAKER_01]: That's fine.

[SPEAKER_01]: Alright, moving on, a cure for type one diabetes may be just around the corner.

[SPEAKER_01]: The results of a recent phase one and phase two clinical trial on the mislical.

[SPEAKER_01]: A stem cell derived therapy are very promising.

[SPEAKER_01]: This agent is designed to restore pancreatic islet cell function.

[SPEAKER_01]: That's where insulin is made.

[SPEAKER_01]: So it's a small study.

[SPEAKER_01]: These base one and base two clinical trials typically are the Ted twelve total subjects.

[SPEAKER_01]: Ten out of twelve of the subjects who are studied no longer required insulin at one year and they were able to keep their blood sugar within the target range.

[SPEAKER_01]: of more than seventy percent at the time.

[SPEAKER_01]: As an aside, the pharmaceutical company, who did the R&D here, that's vertex pharmaceuticals, they actually came up with a CRISPR based therapy for sickle cell disease.

[SPEAKER_01]: So is this going to be a game changer for those with type one diabetes?

[SPEAKER_00]: I also think it's almost a matter of time before we get this figured out.

[SPEAKER_00]: It's really remarkable, you know, to think back a century to pre, you know, before having any kind of insulin at all, and then the history of this, the journey of [SPEAKER_00]: the discovery of insulin and the use of insulin to manage patients who had this condition, diabetic comas, as it was typically, you know, thought of at the time and waking them up from that kind of thing and then progressively better and better management of states of insulin deficiency.

[SPEAKER_00]: And of course, now, you know, I use and prescribe not personally use, but prescribe insulin on a more than daily basis to patients with type one, type two, and other situations as well clinically.

[SPEAKER_00]: And so [SPEAKER_00]: It's almost again, like I was saying with the earlier case, if you have the imagination to think forward and think about the state of knowledge and expertise and technology and how we can apply here, it feels to me like it's a matter of time, whether it's this company's solution that ends up cracking this or if it ends up being someone else.

[SPEAKER_00]: Whenever it does happen, yeah, I do think it would be a game changer living as a child as an adolescent.

[SPEAKER_00]: or even with adult onset type one.

[SPEAKER_00]: I mean, it is a completely life-changing diagnosis in so many ways that all of us who do not suffer from this condition take many things for granted, including our pancreases, as well as our kidneys and our eyes and our nerves and all sorts of things that can go wrong with longstanding poorly controlled diabetes, not to mention the day-to-day requirements of what you have to do to live with it and keep it well controlled in order to live a normal lifespan without those disabled and consequences.

[SPEAKER_00]: So that would be super exciting.

[SPEAKER_00]: I've seen [SPEAKER_00]: just some of the most horrific suffering that I've seen has been in patients with these types of conditions.

[SPEAKER_00]: Some things like severe diabetic gastroporacis as one in particular that just seems utterly miserable where, you know, the diabetes damages the nerves to your stomach and your gastrointestinal tract basically stops moving.

[SPEAKER_00]: And so you just have constant nausea and vomiting all the time, which is one of the worst fates.

[SPEAKER_00]: that somebody can live with day-to-day and it's really difficult to manage as just one example among many.

[SPEAKER_00]: So certainly hope this ends up being the game changer.

[SPEAKER_00]: It's still given that it's phase one right now.

[SPEAKER_00]: It would still be years before this is fully introduced.

[SPEAKER_00]: But in the meantime, we have other options, not just [SPEAKER_00]: you know, people drawing up insulin syringes and sticking themselves, you know, many times a day.

[SPEAKER_00]: We have, you know, more advanced combination insulin pump, CGM, what's so called like closed loop systems, where the glucose monitor talks to the pump.

[SPEAKER_00]: And it almost functions like a quote unquote artificial pancreas.

[SPEAKER_00]: It still has some, you know, drawbacks and is not ideal in certain ways, but it's still way better than, you know, more historic treatment options for this condition.

[SPEAKER_00]: But then you need an adequate insurance coverage.

[SPEAKER_00]: You actually need enough like cognitive.

[SPEAKER_00]: You need to be able to understand these devices and how to use them and how to troubleshoot them.

[SPEAKER_00]: So some patients are deemed like ineligible for some of these things on that basis.

[SPEAKER_00]: So there's still a tricky diagnosis to navigate for now.

[SPEAKER_00]: But if we can restore people's pancreas is in the future, I'll be awesome.

[SPEAKER_00]: And I think we will.

[SPEAKER_01]: Yeah, I also wonder if there's going to be some application maybe even to those with type two diabetes because as you know, you know, after diagnosis and onset, it's almost like a ticking time bomb where the pancreas is kind of pickled.

[SPEAKER_01]: Yeah, which is a medical term.

[SPEAKER_01]: Yeah, obviously.

[SPEAKER_01]: And so I wonder, I mean, if it's a stem cell derived therapy, I'm thinking it's like, it says, hey, I let cells.

[SPEAKER_01]: I mean, you get back to work, man.

[SPEAKER_01]: Wake up.

[SPEAKER_01]: Wake up, bro.

[SPEAKER_01]: And they're like, oh, shoot.

[SPEAKER_01]: Yeah, dang.

[SPEAKER_01]: I knew I was, I thought it was late for something.

[SPEAKER_01]: Yeah, so it would be cool to see what other applications are for either this agent or similar agent or whatever, but kind of cracking this code as far as how to target themselves.

[SPEAKER_01]: That's, uh, this bill.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: I agree.

[SPEAKER_01]: Thank you.

[SPEAKER_01]: All right.

[SPEAKER_01]: I'm going to shift over to the NBA Austin UN NBA fan.

[SPEAKER_00]: From time to time, I wouldn't call myself a hardcore NBA fan, but I generally am interested in lots of different sports and respect the athleticism watching a bit of Wimbledon right now.

[SPEAKER_00]: The Tour de France just kicked off yesterday, so paying attention to that as well.

[SPEAKER_00]: Yeah, yeah.

[SPEAKER_01]: I'm more of a college basketball fan than NBA, but yeah, it's still amazing what these folks can do anyway.

[SPEAKER_01]: Oklahoma City Thunder, while they recently clinched the NBA Championship in a game seven win over the Indiana Pacers.

[SPEAKER_01]: Now, in that game, Pacers' star-point guard Tyrese Haliburton tore his right Achilles.

[SPEAKER_01]: Tended, making him the seventh player in this NBA season to go down with an Achilles' injury.

[SPEAKER_01]: Now, seven and a year may not sound like a lot, but remember the NBA only has about four hundred fifty total players.

[SPEAKER_01]: And additionally, between the years, nineteen ninety to two thousand twenty three eight total of forty five NBA players have sustained on a Killy's tendon tear or a rate of one point three six per year.

[SPEAKER_01]: So seven is much much higher.

[SPEAKER_01]: So the question to you, Dr.

Barack is why are a Killy's tears so common now in the NBA?

[SPEAKER_01]: I don't know.

[SPEAKER_01]: All right, moving on.

[SPEAKER_00]: Yeah, that's next.

[SPEAKER_00]: I mean, yeah, this is the injury as we've talked about before, a super multi-factorial.

[SPEAKER_00]: I would actually be interested.

[SPEAKER_00]: I don't know if you want to ping, you know, Dr.

Miles and see if he has a thought or a take on this based on his understanding of this condition, rehabbing folks with it.

[SPEAKER_00]: It's pathophysiology, but I think that in general, as with most, you know, acute injuries like this that we see be at tendon tears, ligamentous injuries, muscle tears, things like that.

[SPEAKER_00]: A lot of it has to do with [SPEAKER_00]: some sort of imbalance between the training or the playing stress that's being put on the person and their kind of recovery ability outside of traumatic situations.

[SPEAKER_00]: And so I don't know enough to say there are more traumatic situations happening, for example, like you could imagine a scenario where there's a rule change allowing certain things that lead to more traumatic bumps between people that can increase this risk versus just the overall [SPEAKER_00]: playing load, the amount of time on court, the amount of games per season, which as far as I'm aware has not significantly changed.

[SPEAKER_00]: But it makes me think, for example, about like how a major league baseball.

[SPEAKER_00]: Within the past few years, there have been several rule changes that were deliberate to try to make the game move along a little bit faster and to make it a little bit more exciting.

[SPEAKER_00]: So if I recall, they like made the bases a little bit bigger to encourage more stealing.

[SPEAKER_00]: And so there's some potential traumas that can happen when more bases are stolen and certain kind of slides are attempted and things like that.

[SPEAKER_00]: And then they also included the pitch clock.

[SPEAKER_00]: And so now, you know, I more recently, I'll see a baseball game on TV.

[SPEAKER_00]: You know, if I'm someplace and I'm like, man, that picture is like immediately getting set up and ready to throw.

[SPEAKER_00]: Just because I'm so used to having grown up with baseball, where it was just like super, like a days ago and slow and they would take a ton of time between pitches.

[SPEAKER_00]: And now there's like almost no time at all.

[SPEAKER_00]: I can imagine that there is some sort of impact as far as that stress on pitchers outside of just raw pitch count.

[SPEAKER_00]: And how that might impact their risk of aches, pains, injuries, things like that.

[SPEAKER_00]: So those would be the kind of areas where I would look first to try to get a sense of an explanation for this, be it time on court or shots or traumatic things, things like that.

[SPEAKER_00]: But would be interested if you have any thoughts or, again, if a, you know, director or anybody else on our team has any thoughts on this would be interesting to hear.

[SPEAKER_01]: Yeah, I did ping Dr.

Miles just to see if he had a take on this.

[SPEAKER_01]: So if he gets back to me before this podcast goes up, you'll hear that audio now.

[SPEAKER_01]: And if not, it'll just be too guys.

[SPEAKER_01]: So a couple things I looked into like one, I was like, well, maybe like advancements in training, medicine, and maybe financial incentive, whatever has made the average aid of the NBA higher.

[SPEAKER_01]: And so maybe this is like a some age related country.

[SPEAKER_01]: contribution will actually the average age in the NBA's trending lower so I kind of like all right well that was fruitless and then I thought about same thing as you talked about maybe the plane load is too high which would include practice competition whatever now that you know the length of the season hasn't gotten any longer [SPEAKER_01]: Right and it's challenging to know how much playing time people are actually getting and further like what is the playing load is it?

[SPEAKER_01]: Minutes played and does that accurately capture like how many shots they took how many rebout or whatever, you know, there's because just playing is different than like actually you had more rebounds less rebounds.

[SPEAKER_01]: You read the court more or less like it's just challenging.

[SPEAKER_00]: Yeah, and it probably varies a ton by position.

[SPEAKER_00]: You know, what are the demands on each player per minute based on what position they play?

[SPEAKER_00]: That's going to be really variable.

[SPEAKER_00]: You have to you have to stratify by that too.

[SPEAKER_01]: Yeah, so the three things I came up with that might are my leading three theories and it's unlikely to be just, you know, one smoking gun.

[SPEAKER_01]: I think it's probably multi-factorial.

[SPEAKER_01]: That's just a hedge and sort of a doctor speak like that.

[SPEAKER_01]: Well, it could be multiple things.

[SPEAKER_01]: I think that there are a number of injuries that are happening and people are returning from those injuries too soon due to the incentives to do so.

[SPEAKER_01]: Whether it's, you know, potential glory from like a postseason birth or something like that or winning it winning the playoffs, something like that.

[SPEAKER_01]: But if people come back from too injury, they're more vulnerable to re-endery, which would make sense.

[SPEAKER_01]: Particularly if it's like an ankle injury, foot injury, other lower extremity injury, and perhaps that, you know, increases the risk of tendon rupture.

[SPEAKER_01]: The game has certainly changed over the last few decades.

[SPEAKER_01]: It's more open now with less defense, so there's more running.

[SPEAKER_01]: And so perhaps a similar total like duration of time spent on court will now maybe the actual load is higher.

[SPEAKER_01]: So I kind of favor those two things.

[SPEAKER_01]: And then also, [SPEAKER_01]: And I actually didn't, there's no real data on this, but I would like to see a lot more people who are in low tops than high tops.

[SPEAKER_01]: And you know, there's like, I think there's a cadaver study looking at like the tensile force of the of a that's imparted upon the Achilles standard with low top versus high tops and yeah, it's higher on low tops.

[SPEAKER_01]: So perhaps I'm like mechanical type type contribution as low tops or maybe people like the way they look or they like the freedom.

[SPEAKER_01]: I don't know.

[SPEAKER_01]: I mean, personally, if I'm playing basketball, [SPEAKER_00]: I don't know that the footwear matters.

[SPEAKER_00]: That's not your limiting factor.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: I'd be curious if it's more a stylistic preference or a player's feel that like maybe the mobility that they have in lower top sneakers is better, but maybe that comes out of a trade off of a little bit more of that Achilles stress.

[SPEAKER_00]: Hard to say.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Also, can't rule out the possibility.

[SPEAKER_00]: This is just artifact.

[SPEAKER_00]: Like sometimes you're going to have a bad year.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Maybe an extra little river to the mean, you know, that'd be in for lower.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: There was no Achilles injury.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah.

[SPEAKER_01]: All right, moving on, the American College of Cardiology is now recommending anti-obesity medications like some aglytide enters epitide as first line treatment to reduce the risk of heart disease.

[SPEAKER_01]: Now in their expert consensus statement on medical weight management for optimization of cardiovascular health, that's a mouthful.

[SPEAKER_01]: They state that modern obesity medications have proven more effective than lifestyle interventions alone at not only weight loss, [SPEAKER_01]: but at reducing overall cardiovascular disease risk, with fewer risks than procedure-based interventions like metabolic bariatric surgery, which we've covered on this podcast.

[SPEAKER_01]: For now, prior guidelines have recommended trying lifestyle interventions alone before beginning medications, but this new guidance recommends considering these medications as a first-line treatment.

[SPEAKER_01]: option for eligible patients.

[SPEAKER_01]: Dr.

Olivia Gilbert, she's the chair of these clinical guidelines and a cardiologist at Wake Forest.

[SPEAKER_01]: Well, she said that patients should not be required to quote, try and fail lifestyle changes prior to initiating pharmacotherapy.

[SPEAKER_01]: Nonetheless, lifestyle intervention should always be offered in conjunction with obesity medications.

[SPEAKER_01]: Any thoughts on this update, Dr.

Barackie?

[SPEAKER_00]: Yeah, honestly, something I've been wanting to do for a long time, maybe we can collaborate on this is basically draw the highest quality data that we can on these anti-obesity drugs, which I think that that's even a bit of a narrow classification given how many health effects that they have to just call them that.

[SPEAKER_00]: Get the highest pull together the highest quality data on these medications, potential benefits, potential risks and costs, et cetera.

[SPEAKER_00]: And then pull together the highest quality randomized trial evidence on lifestyle interventions in a real world context, not where you're like locking people up in a metabolic ward and forcing them to do things, but just like you institute.

[SPEAKER_00]: You know, the type of guidance that maybe fitness influencers really want doctors to do, the things that they say your doctor is not doing.

[SPEAKER_00]: How effective is that potential benefits?

[SPEAKER_00]: What are the potential risks of that costs, et cetera?

[SPEAKER_00]: And then kind of, I don't know, anonymize as the right term, but basically like blind it to what the actual intervention is.

[SPEAKER_00]: Just show the raw numbers.

[SPEAKER_00]: and offer it to people, which would you choose?

[SPEAKER_00]: Would you choose A or B without knowing what the interventions are?

[SPEAKER_00]: If you get this potential benefit, this potential downside, this cost, that potential downside, that costs, which makes more sense to use, or ideally use them together rather than forcing one of the other, right?

[SPEAKER_00]: I think that it would not be a terribly difficult decision for most people if they're just looking at these things.

[SPEAKER_00]: However, as soon as you actually are unblinded and you know what the interventions are that people are talking about suddenly we get this really frustrating discourse to have to navigate out there where people do feel like everyone should try lifestyle first and it's like that's fine.

[SPEAKER_00]: I think that the position being recommended here [SPEAKER_00]: is not that we force everyone onto these medicines no matter what, but rather that they are a feasible option up front together with lifestyle interventions that you can offer people as part of what will call a shared decision-making process rather than saying rather than gatekeeping the medicines and saying [SPEAKER_00]: you cannot enjoy these potential benefits until you prove to me, you like, you know, earn the right to use these by not having success with lifestyle.

[SPEAKER_00]: It's a very, you know, perverted kind of way of approaching this.

[SPEAKER_00]: I think that, you know, obviously they're [SPEAKER_00]: would need to be discussions around the cost aspect because there are tons of people who are potentially eligible for these and at current costs, you know, it is something that is unlikely to be sustainable for the healthcare system.

[SPEAKER_00]: Those types of calculations have been done to show like at what price point do these medicines become more worthwhile as far as like saving more by preventing these complications than they cost up front.

[SPEAKER_00]: And I actually don't think that we're quite there right yet.

[SPEAKER_00]: as far as the costs in the US go.

[SPEAKER_00]: These medicines can be had much more cheaply in other countries and there it's like actually a no brainer because of how much morbidity and preventable death that it prevents that relatively low costs.

[SPEAKER_00]: So those are my thoughts on this.

[SPEAKER_00]: I think it's totally super extremely reasonable to offer upfront along with recommendations for lifestyle management.

[SPEAKER_00]: Instead of forcing people as that physician said, forcing them to try and fail before you like earn the right to have some benefit [SPEAKER_00]: And this is especially in the context of what we know about cardiovascular risk as a cumulative lifelong kind of process.

[SPEAKER_00]: So if you force people to do the lifestyle and fail first, well, maybe that how long does that need to happen for?

[SPEAKER_00]: Is three months enough?

[SPEAKER_00]: Is six months enough?

[SPEAKER_00]: Does it have to be a year?

[SPEAKER_00]: Well, if they fail after a year, that's a year of exposure.

[SPEAKER_00]: to obesity, to elevated blood pressure, to elevated blood lipids that could have been prevented and addressed a lot sooner, and there's a magnifying downstream risk at the end of their life that you are cutting out by treating them earlier.

[SPEAKER_01]: Yeah, yeah, I mean, again, I think if you did like a side by side comparison, again, that was blinded, you know, for folks they'd be like, wow, this option C, which in that case would be combined anti-BC medications, which maybe need a rebrand and lifestyle stuff.

[SPEAKER_01]: Like, wow, that's way more powerful than one one or the other.

[SPEAKER_01]: It does get more interesting, I think, when you have to pick between just lifestyle and just medications.

[SPEAKER_01]: It's, I don't know, like the best data we have on lifestyle stuff alone for weight loss, for example, it's just not, it's not that good.

[SPEAKER_01]: And as a person who started a kind of fitness and health company, like I don't want it to be that way, I want to be able to tell you, like, look, no matter who you are, where you come from, what your background is, what your resources are, we can help you, you know, a lot.

[SPEAKER_01]: And while I do think we can provide some benefits, exercise improves a lot of outcomes, for example, independent of weight, changing your dietary pattern to be something more health promoting can improve outcomes regardless of what happens to your weight.

[SPEAKER_01]: All of that is true.

[SPEAKER_01]: But if I wanted to quote, optimize somebody's health trajectory and reduce the risk to the maximum amount, it's probably going to require some pharmacotherapy.

[SPEAKER_01]: It may not necessarily be an anti-PC medication, but it might be a blood pressure medication, it might be a lipid lowering type medication, you know, whatever.

[SPEAKER_01]: We can use both.

[SPEAKER_01]: As you have, and I've kind of co-op to this quote, you don't get a gold star for going through life.

[SPEAKER_01]: without any help.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: So I thought this was an evolution of the grumblings and the thoughts around these agents and where they should be used.

[SPEAKER_01]: I really didn't love the idea of tri lifestyle first and fail it.

[SPEAKER_01]: And then we can add some help.

[SPEAKER_01]: Why would you do that?

[SPEAKER_01]: You don't do that for blood pressure medication, right?

[SPEAKER_01]: Especially if somebody has been elevated for like a while.

[SPEAKER_01]: because you want to get it down to normal.

[SPEAKER_01]: So people reduce that exposure immediately, same thing with lipid lowering, same thing with blood sugars, I mean, whatever.

[SPEAKER_01]: What other condition are we like?

[SPEAKER_01]: Yeah, it's like let this thing persist potentially for an unknown amount of time.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: And make sure that you fail first and don't want you to feel bad about it.

[SPEAKER_01]: And then we'll give you a helping hand.

[SPEAKER_00]: You know, here's an interesting, more hot take than tepid take is if the fitness folks, the influencers here who, you know, cry and moan about this all the time, if they wanted to be logically consistent.

[SPEAKER_00]: Then they should also be telling people, you should try to do all of this health fitness diet exercise stuff on your own.

[SPEAKER_00]: First, yeah.

[SPEAKER_00]: Before I am willing to help you because I'm like a higher level of intervention or a more intensive intervention, just like the medications.

[SPEAKER_00]: are more intensive intervention.

[SPEAKER_00]: And so I will not actually coach you until you prove to me that you need coaching, be it by failing on your own.

[SPEAKER_00]: That would be logical consistency.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: I don't think that we're likely to see that.

[SPEAKER_01]: Somebody slides into their DMs and they're like, hey, I'd really like you to coach me.

[SPEAKER_01]: Like, oh, if you try it on your own.

[SPEAKER_00]: Right.

[SPEAKER_01]: And sometimes like, no, no.

[SPEAKER_01]: I need you to do it for a year on your own.

[SPEAKER_01]: And make sure that you fail as evidenced by these criteria.

[SPEAKER_01]: And then I'll consider helping you.

[SPEAKER_03]: Yeah.

[SPEAKER_03]: Yeah.

[SPEAKER_01]: That's the logical consistency.

[SPEAKER_01]: So let's see it.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: All right.

[SPEAKER_01]: Hey, speaking of heart disease.

[SPEAKER_01]: Did you know Dr.

Baraki that heart attacks are no longer the leading cause of death in the United States?

[SPEAKER_01]: I did since I sent this to you.

[SPEAKER_01]: That's true.

[SPEAKER_01]: Well, based on data collected from nineteen seventy to two thousand twenty two using the U.S.

[SPEAKER_01]: Centers for Disease Control and Prevention, Wonder database, this tracks all recorded fatalities in the country.

[SPEAKER_01]: In two thousand twenty two, heart attacks accounted for twenty four percent of all deaths in the U.S.

[SPEAKER_01]: down from forty one percent in nineteen seventy.

[SPEAKER_01]: This decline is largely thanks to almost ninety percent decrease in heart attack deaths, which were once the deadliest form of heart disease.

[SPEAKER_01]: Is this an incredible breakthrough or are we missing something?

[SPEAKER_00]: No, this is an incredible breakthrough, but also I don't even actually call it a breakthrough.

[SPEAKER_00]: This is also unsurprising to me.

[SPEAKER_00]: This is something that I have expected and was predictable for many years at this point.

[SPEAKER_00]: I think that heart attack or acute myocardial infarction where you have a sudden, you know, atherosclerotic plaque rupture and you get a clot in one of your coronaries and [SPEAKER_00]: insufficient blood flow to your heart muscle and the heart muscle dies unless you get a heart catheterization and potentially a stent put in as soon as possible.

[SPEAKER_00]: That is kind of the situation that we're talking about and the incidence of that has indeed been going down as in particular deaths from heart attacks has been going down as well.

[SPEAKER_00]: And this is because we're getting much, much, much better at a couple things.

[SPEAKER_00]: We're getting better at prevention.

[SPEAKER_00]: And so that relates to all of the risk factors that we talk about all the time, especially blood lipid blood pressure and most and very importantly here smoking related issues.

[SPEAKER_00]: And then additionally, the actual treatments for this when they do happen, when these heart attacks do happen and patients show up to the hospital, we are far better at treating these things now than we were in prior decades.

[SPEAKER_00]: This is both due to advancements in the technology of intervention and the stance and an interventional cardiologist's skills and also the medications that are used around and after that procedure to prevent the risk of death and complications from it.

[SPEAKER_00]: that kind of very acute event and death from it, that death has declined from that, very unsurprising to me.

[SPEAKER_00]: But the other concern is what replaces it as far as the leading causes of death.

[SPEAKER_00]: And instead of the much more acute, sudden heart attack induced death now, it's much more chronic heart disease related issues, especially things like heart failure.

[SPEAKER_00]: And for me, if you took someone like me and internist who's actively practicing in the hospital setting, [SPEAKER_00]: You know, many decades ago, they would be seeing heart attacks left and right all the time because of how common they were.

[SPEAKER_00]: Actually, you know, I still see them from time to time, but they are not like an absolute daily occurrence that I'm seeing all the time, whereas the more chronic forms of heart issues like heart failure, I do see near daily all the time.

[SPEAKER_00]: So we're preventing them much more acute.

[SPEAKER_00]: heart attacks and the death from them, but rather patients are left dealing with the consequences of it longer term with like weakened hearts, for example, as a simplified way to think about it for very long periods of time.

[SPEAKER_00]: Now, even the treatments and the management of chronic heart failure has improved a ton, such that [SPEAKER_00]: You know, death has improved that decline in the rate of death from heart failure has actually unfortunately plateaued a little bit in recent years and hospitalization from it.

[SPEAKER_00]: And I think a lot of that has to do with kind of uptake of some of our best medicines that we have to manage it as well as like the increasing burden.

[SPEAKER_00]: Patients are sicker, more complicated.

[SPEAKER_00]: They're living longer with more medical conditions.

[SPEAKER_00]: They're on more medicines to manage these things.

[SPEAKER_00]: and sometimes it can be very challenging to handle these situations.

[SPEAKER_00]: But the short story is not surprising the very acute death decreasing.

[SPEAKER_00]: The chronic heart disease continues to rise and it's a pretty significant burden.

[SPEAKER_00]: So that's what I spend a ton of my days actually managing is the more chronic forms.

[SPEAKER_01]: Yeah, and the American College of Cardiology actually just recently updated their heart failure sort of scientific consensus and similar sort of thing to what they were talking about with with heart disease generally speaking.

[SPEAKER_01]: They're like, look, instead of just lifestyle alone.

[SPEAKER_01]: You know, try in that and failing it.

[SPEAKER_01]: Maybe we'll let's do some these anti-obescent medications because they recognize the potential benefit.

[SPEAKER_01]: There as well.

[SPEAKER_01]: I do suspect that we'll get to some point.

[SPEAKER_01]: We'll just keep kicking the can down the road.

[SPEAKER_01]: Yeah, right.

[SPEAKER_01]: I do suspect that heart some type of chronic heart disease related thing is still going to be like the leading caught.

[SPEAKER_01]: Something's got to be the leader, right?

[SPEAKER_01]: I think it's going to be some sort of chronic heart disease, but at some point it's not going to be heart failure.

[SPEAKER_01]: At some point it's not going to be like hypertensive related cardiovascular disease or related to lipids.

[SPEAKER_01]: We're just going to catch all that stuff and have great interventions and there's going to be good uptake.

[SPEAKER_01]: Just kick the can down further and further and further.

[SPEAKER_01]: I think if at some point it's like [SPEAKER_01]: Yeah, these are just structural abnormalities that we couldn't pick up.

[SPEAKER_01]: That would be a great place to end up getting.

[SPEAKER_01]: Anything that we could reasonably prevent, predict, identify, and intervene upon.

[SPEAKER_01]: We've nailed that.

[SPEAKER_01]: And so now we're at a more even more complex sort of situation.

[SPEAKER_01]: Do you screen newborns for these structural abnormalities?

[SPEAKER_01]: And if so, how do you fix them?

[SPEAKER_01]: We'll see.

[SPEAKER_01]: We're doing this another ten years from now.

[SPEAKER_01]: Maybe we'll have an update.

[SPEAKER_01]: All right, last topic here on the second edition of the rundown, more AI news, since you're our resident AI in medicine expert.

[SPEAKER_01]: Well, you know more than I do in which case that makes you the extra, you know?

[SPEAKER_01]: Yeah, like I said, third best, third best, right?

[SPEAKER_01]: Let's be catalytic.

[SPEAKER_01]: So Microsoft is claiming that their MAI diagnostic orchestrator, this queries several leading AI models.

[SPEAKER_01]: Let's say that they can diagnose patients more accurately than human doctors.

[SPEAKER_01]: This is a pre-print.

[SPEAKER_01]: It hasn't made its way into peer-reviewed research yet, but I suspect it will.

[SPEAKER_01]: The Microsoft team used three hundred and four case studies, source from the New England Journal of Medicine, [SPEAKER_01]: And in their experiment, either a physician or their AI begins with the short case abstract, and then they iteratively request additional details from a gatekeeper model.

[SPEAKER_01]: Basically, they ask a discrete question, get an answer, they may run a test or ask an additional question, they keep going back and forth.

[SPEAKER_01]: They're saying their AI model outperform human doctors achieving an accuracy of eighty percent compared to the doctor's twenty percent.

[SPEAKER_01]: It also reduced cost by twenty percent by selecting less expensive tests and procedures.

[SPEAKER_01]: So the question is, are we, are we cooked?

[SPEAKER_00]: I'm going to say not yet with the heavy emphasis on the yet.

[SPEAKER_00]: So I looked a little bit at this [SPEAKER_00]: this news story because it obviously intrigued me.

[SPEAKER_00]: It is, you know, something that I do day to day is diagnosed, right?

[SPEAKER_00]: That's what we do these with these mystery cases.

[SPEAKER_00]: And if an AI can just very easily handle these things, then yeah, might be cooked, man, as to your point.

[SPEAKER_00]: But there were a few issues that I saw with this particular study as well as some of the conversation around it among physicians.

[SPEAKER_00]: Those case studies in the New England Journal of Medicine, I read them every week.

[SPEAKER_00]: I think they come out every Thursday.

[SPEAKER_00]: They're excellent mystery cases.

[SPEAKER_00]: They are, there are a few things about them.

[SPEAKER_00]: They are in general challenging.

[SPEAKER_00]: They're not putting the simplest things there.

[SPEAKER_00]: Pretty specialized, too, also.

[SPEAKER_00]: Yes, as an aside.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: I mean, that's a big part of where I nerd out on these things and how I have gotten better at doing this is by reading and learning from those things every week.

[SPEAKER_00]: The other things about those cases are that they are published and there is, I don't know, if it was reported, whether these AI models were trained on that material.

[SPEAKER_00]: So if they were, then they already knew the answers effectively because they were trained on that on that material, right?

[SPEAKER_00]: So it wasn't truly a mystery in that sense.

[SPEAKER_00]: But that aside, all those cases are published because they have a clear diagnosis and conclusion.

[SPEAKER_00]: And for anyone who is a regular listener including to our last episode where we said sometimes medicine is messy and there's not always a clear answer or even the CIA conversation that we had earlier today where things don't always have a clear concrete diagnosis at the end of the case.

[SPEAKER_00]: And so that does impact things quite a bit.

[SPEAKER_00]: But all they were using were cases that had a concrete diagnosis.

[SPEAKER_00]: For example, there were no just like completely healthy patients.

[SPEAKER_00]: All these people had a final definitive diagnosis.

[SPEAKER_00]: Sometimes people have a headache and it's just like stress related headache.

[SPEAKER_00]: It's not an underlying brain tumor or something like that.

[SPEAKER_00]: So there were no essentially healthy cases mixed in with this that it had to try to differentiate.

[SPEAKER_00]: It was only on these kind of rare diagnostic ebras that we talk about, where you keep testing and testing and testing because there is a final diagnosis.

[SPEAKER_00]: At some point in clinical practice, when you're seeing patients at some point a physician has to make an assessment of, at what point is it the correct answer to stop testing for now, maybe?

[SPEAKER_00]: to stop searching and to give things a tincture of time as we call it and a lot of things do tend to get better on the run with time.

[SPEAKER_00]: So instead of all these already solved published cases on which it could have been trained with no uncertainty with no healthy patients in the mix, that differs a ton from actual real life practice.

[SPEAKER_00]: The other thing is that the physicians in the study who were actually trying to solve these cases, they were not allowed to use the internet to search.

[SPEAKER_00]: They were not allowed to consult colleagues or consult specialists.

[SPEAKER_00]: They were not able to use up to date or like medical reference, you know, resources, things like that, which is also completely unrealistic.

[SPEAKER_00]: like just because I've gone through school and training and have a fair amount of postgraduate experience at this point in my own practice, I still am using those kind of medical reference resources most days in practice because that is the reality of what needs to happen, right?

[SPEAKER_00]: So I can't have the entirety of medical knowledge in my brain, now that might be feasible for an AI, but at the same time there are other things that I have that an AI doesn't and vice versa, right?

[SPEAKER_00]: The other aspect is, you know, you mentioned this difference in like a kind of cost effectiveness.

[SPEAKER_00]: And it was just using like one relatively limited measure of cost effectiveness, like just like the dollar cost of the test for example, but there's a lot of other costs and downsides to recommending more and more and more and more testing patients that we have talked about before.

[SPEAKER_00]: And when you know that there is an answer at the end of the road, [SPEAKER_00]: You will probably keep doing more and more and more testing to get there, whereas again, in real life, where there may not always be an answer at some point, you have to say, well, it's actually not, there's not ongoing benefit to keep doing more testing, maybe we've ruled out all the bad things, maybe we give this a little bit of time, some amount of time, some days, some weeks, some months, something like that and see if it gets better on its own and again, a lot of things do.

[SPEAKER_00]: I remember I often quote this line in one of my lectures on this topic.

[SPEAKER_00]: It was from an analyst of internal medicine paper where it said something to the effect of the vast majority of symptoms defied definitive biomedical diagnosis.

[SPEAKER_00]: And a lot of them have a favorable natural history.

[SPEAKER_00]: That is not the type of case that was being done here.

[SPEAKER_00]: I think that at the risk of sounding a little bit like a complainer, I think that this test was rigged against the physicians.

[SPEAKER_00]: And yes, exactly.

[SPEAKER_00]: He's using that word here, but then in favor of the AI.

[SPEAKER_00]: In other words, it was set up for the AI to have a strong of a chance as possible.

[SPEAKER_00]: And the physicians to have as weak of a chance as possible.

[SPEAKER_00]: Physicians isolated only what's in their brain, no resources, no consultation, no specialist, no conversation.

[SPEAKER_00]: So not reflective of real-world practice.

[SPEAKER_00]: And for the AI, cases that had [SPEAKER_00]: definitive proven diagnoses, no healthy patients, no counseling involved to say, yeah, let's, you know, take a pause and come back and follow up and things like that.

[SPEAKER_00]: So, I mean, I think that this technology has obviously improved really dramatically.

[SPEAKER_00]: It's not surprising to me that by collating all of this expert knowledge that's contained in those New England general cases among other places, that it can perform phenomenally well here.

[SPEAKER_00]: But there are additional layers to this to be more reflective of real or practice.

[SPEAKER_00]: So it's going to need to get trained and tested on like real [SPEAKER_00]: patient populations that include a lot of healthy people, right?

[SPEAKER_00]: Well, people who do not have a definitive underlying, you know, embryo, rabdo, myosarkoma or something like that, but people instead have like some not specific abdominal pain that gets better and doesn't actually really pass the virus, right?

[SPEAKER_00]: Yeah.

[SPEAKER_00]: And then I think if you're going to be assessing cost effectiveness, you also need to be assessing harms and risks of overdiagnosis.

[SPEAKER_00]: and making your comparison more realistic with actual physicians who are in real world practice who have the access to resources that they are already using and specialist consultation and things like that that is how the real system works.

[SPEAKER_00]: So those are my thoughts.

[SPEAKER_00]: I think that it's definitely something that's gonna continue to progress and may well end up overtaking a lot of us in some way, particularly non-procedural specialties.

[SPEAKER_00]: But those are some of the issues that jumped out at me and I saw discussed around this as it related to [SPEAKER_00]: you know, whether we are in fact cooked or not.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: I mean, I suspect that, you know, the combination of a trained clinician and AI together, like the, whether it's this model, this, or another would be superior to, to, to, you know, that has been tested.

[SPEAKER_00]: And it's been tested and it did not work out that way.

[SPEAKER_00]: Correct.

[SPEAKER_00]: Yes.

[SPEAKER_01]: And so again, I do think though like how you would implement this in clinical practice and ultimately how you're testing the outcomes, ultimately determines like how that, you know, what side, what side the results fall on.

[SPEAKER_01]: But yeah, it if, if and when probably more when than if AI is further refined to a point where we can reliably use this for either, whether it's picking tests, diagnostics, workup, et cetera.

[SPEAKER_01]: It's just going to move the responsibilities with a clinician to a different point, which is fine.

[SPEAKER_01]: I'm okay with that.

[SPEAKER_01]: I don't know where that point is and what the responsibilities of the clinician end up being, but it'll be different and I'm excited to see what it is.

[SPEAKER_00]: Yeah, yeah, uh, for sure.

[SPEAKER_00]: I think that there's still obviously going to be some human element in clinical medicine.

[SPEAKER_00]: I think people want that in general.

[SPEAKER_00]: I think that, you know, the worst case I'm imagining is from I don't know if you've remember seeing the movie Idiocracy when he sees the doctor and the patient just ends up going through this like robot machine with a bunch of probes that he has stuck in him and then it just like spits out a diagnosis and, you know, obviously it's a satirical kind of kind of take on it, but [SPEAKER_00]: You know, the aspects of my job that I imagine might be a little bit more difficult to replace until we get some hyper realistic humanoid robots that people deemed indistinguishable.

[SPEAKER_00]: So like we're living in Westworld that can do a hospice meeting and end of life conversation guiding people through the dying process like those are things that I do day to day that are not just like wrote memory of [SPEAKER_00]: Oh, I recognize this set of symptoms and it suggests this diagnosis.

[SPEAKER_00]: Yes, diagnosis confirmed.

[SPEAKER_00]: Here's your treatment and you're good to go.

[SPEAKER_00]: There's a lot more to clinical practice than that.

[SPEAKER_00]: So, you know, one day, but hopefully I'll be on the outs from my career by the time that's the case.

[SPEAKER_00]: Retired.

[SPEAKER_01]: All right.

[SPEAKER_01]: Last thing a little update here.

[SPEAKER_01]: Do you watch into the US open for golf?

[SPEAKER_00]: Very little, but [SPEAKER_00]: You kept me up to date on on some of the happenings, but yeah, what's up?

[SPEAKER_00]: We're our predictions were.

[SPEAKER_00]: Yeah, well, yeah.

[SPEAKER_01]: So I had picked Bryson to Shambo to win, just because I'm like, look, he hits the ball very far.

[SPEAKER_01]: It tends to be a good putter, particularly on Wixie's playing well.

[SPEAKER_01]: This course sets up nicely for him.

[SPEAKER_01]: He's on fire.

[SPEAKER_01]: Well, he didn't even make the cut.

[SPEAKER_01]: He did not even make the weekend.

[SPEAKER_01]: So that that money that I had placed on him down the drain.

[SPEAKER_01]: You pick Scotty Schuffler.

[SPEAKER_01]: He finished a distant seventh.

[SPEAKER_01]: I believe he was like six shots back or five shots back.

[SPEAKER_01]: JJ spawn.

[SPEAKER_01]: First time major champion end up winning this in dramatic fashion.

[SPEAKER_01]: Um, if you're not a golf fan, this would have been a tournament to watch because he has had all the drama.

[SPEAKER_01]: And, uh, yeah, I think as far as spectator sports go golf might be one of the worst.

[SPEAKER_01]: Like, like, uh, and it just reminded me when you said, oh, the pitch, there's a pitch clock.

[SPEAKER_01]: And baseball.

[SPEAKER_01]: And they're theoretically supposed to be like, uh, you know, you have this amount of time to play your shot and golf.

[SPEAKER_01]: Good God.

[SPEAKER_01]: They do not enforce this hardly ever and it is painstakingly slow to watch.

[SPEAKER_01]: I'll especially at the end of a tournament.

[SPEAKER_01]: Now, I don't know if that's because there's only like a handful of groups left on the course, you know, there's like three holes left and so you got what three or four groups left and so you're seeing like a handful of shots an hour and you're like, can we just can we just go?

[SPEAKER_01]: But anyway, yeah, it was really, really interesting tournament.

[SPEAKER_01]: There's one more major left.

[SPEAKER_01]: It's the British Open, actually called the Open.

[SPEAKER_01]: And we'll cover that on the next episode of the rundown.

[SPEAKER_01]: But let us know what you guys think.

[SPEAKER_01]: These are kind of like topical conversations.

[SPEAKER_01]: Thought this would be an interesting addition to our normal podcast episodes where we talk about one specific thing.

[SPEAKER_01]: We do mystery cases.

[SPEAKER_01]: We do Q&As, all sorts of stuff.

[SPEAKER_01]: But yeah, if you guys like this, let us know.

[SPEAKER_01]: Leave a comment wherever you can and take that into consideration.

[SPEAKER_01]: But before you guys going to wear a please of some five-star rating and a review, it really helps drive traffic to our podcast so we can keep bringing you all the latest nuance and health and fitness.

[SPEAKER_01]: Remember when here at Barbell Medicine, I'm Dr.

Jordan Vigam Mom.

[SPEAKER_01]: We'll get you next week and every week right here on the Barbell Medicine podcast.