Healthy Rounds With Dr. Anthony Alessi

The idea of using cells from your own tumor to develop a personalized vaccine that guides your immune system to fight your cancer goes back several decades. Today, we are on the verge of using messenger RNA to bring this concept to a new level, one that could change how we treat melanoma and other cancers. Dr. Margaret Callahan, chief of UConn Health’s Division of Hematology and Oncology and medical director of the clinical trials office, explains how immunotherapy works and why it holds so much promise.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Margaret Callahan:https://www.uconnhealth.org/providers/profiles/Callahan-Margaret
UConn Health Division of Hematology/Oncology:https://health.uconn.edu/medicine/divisions/hematology-oncology/
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information provided by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. I’m your host, Dr. Anthony Alessi, and it’s important for me to mention that this podcast is not an indication of what you should be doing in regard to your personal health. It is only there for information, and any personal health decisions should be provided between you and your personal physician.
I’m very happy to have as my guest today, Dr. Margaret Callahan. Dr. Callahan is a professor of immunology and medicine here at UConn Health. In addition, she’s chief of the division of hematology and oncology. Maggie, welcome to the show.
Dr. Callahan: Thanks so much for having me, Tony. Delighted to be here.
Dr. Alessi: One of the things that prompted us to do this show today has been a lot of new information for the treatment of melanoma. But before we get into that, let’s backtrack a little bit, and if you could, tell our listeners a little bit more about skin cancer and melanoma. When I think of those topics, I think, when I was young, we didn’t have SPF, right? People used to go to the beach to get tanned. Some still do. I remember people using baby oil and iodine combinations, right? And now, I mean, we have so many levels of SPF, and we are more alert to the fact of skin cancer. When did that shift change?
Dr. Callahan: Well, I’d say in the past couple decades, and if we bring it to today, where I slather my kids up with, I think it’s SPF 70 now, multiple hours at the pool, some of that just comes from knowledge of the biology of skin cancers.
Skin cancer is the most common cancer we see in humans, and there are two big families. There are keratinocyte skin cancers, which are basal and squamous skin cancers, and these are usually very treatable, but they are related to sun exposure, so you can save yourself some trouble by avoiding or safely interacting with the sun.
The more dangerous cancer that we’re talking about today, melanoma, starts with the pigment-producing cells in the skin. Those same skin cells that give you a great tan, they produce that pigment, and the tan we’re looking for can also go awry and become melanoma. And the reason we get scared about melanoma is because if it’s not caught early, it can spread to other organs and become a bigger problem.
Dr. Alessi: Maggie, are we becoming more aware of it also? Has it become more dangerous? Now, I’m talking about in the last 40 or, 40 or 50 years. Has the sun become a more potent enemy?
Dr. Callahan: Oh boy, this is a little outside of my area of expertise as a medical oncologist, but I do think the evidence out there is that changes in the environment and environmental exposures are exposing us to a little bit more UV, and maybe also changes in patterns of behavior.
But I do think part of the reason that we are seeing more melanoma comes from a couple of good problems we have. First, we’re living longer, and skin cancer and other cancers are often a disease of accumulated exposure over lifetimes. So the longer you live, the more exposure you’ve had. That’s a good problem to have.
Dr. Alessi: Oh, absolutely.
Dr. Callahan: And second, we’re looking harder, and we have better tools to find skin cancer, and so we’re finding more. And that’s also, in a way, a good problem to have. On a positive note, and to circle back to this idea that sun avoidance or safe sun exposure is a good strategy, according to the American Cancer Society, even though skin cancer rates are rising in people 50 and above, for people 50 and under, those folks who maybe were exposed to this high SPF environment, skin cancer rates are actually stable or slightly down. And so it does appear that maybe there are some modifiable risk factors that we can control our risk.
Dr. Alessi: Well, that’s interesting because, I’m encouraged, because it sounds like we’re having some benefit from all these new fabrics we’ve designed and people are wearing, and you see so many, especially children, in the pool wearing long sleeves and, and covering up.
Dr. Callahan: Hats. I’m a big fan of hats.
Dr. Alessi: You know, hats are key, especially with a big brim.
Dr. Callahan: Yeah.
Dr. Alessi: Because I’ve seen, and have had friends, where they get it right on the top of their ears with that exposure. But can we talk a little bit about what is messenger RNA? We all have come to know this term from COVID. How has that helped us design vaccines, and how is that helping us with designing a, a treatment for cancer?
I have to say, and I appreciate you sending me over some articles because I never heard the term “neoantigen” before, despite my years in medicine, so I’ve learned a lot, and that’s the advantage of doing this show.
But can you talk a little bit about messenger RNA and what role that is playing in what I consider almost a revolutionary change in medicine?
Dr. Callahan: Yeah. Messenger RNA, in part because of the success with the COVID vaccine as a strategy, has gotten a lot of press, and it’s a tool, and I’m going to try to explain how this tool works.
So if we think of DNA, our genetic material, DNA, as kind of a master cookbook, has all the recipes we need to do whatever our cells need to do, a messenger RNA is like a photocopy of that recipe, like, a single little recipe from the whole cookbook, and you can deliver it, bring it to the kitchen and say, “Hey, can you make, I don’t know, a donut?” And the cell reads that recipe, makes the donut, and throws it away. The messenger RNA vaccine is simply taking that little snippet, that little recipe of messenger RNA, putting it in a little fat bubble to protect it, and delivering it to the cell, and then the cell carries out that recipe, but it doesn’t change your DNA. It’s a temporary instruction. The mRNA degrades, and it’s gone.
Dr. Alessi: OK. And I hope we really get that out there because I think there’s this fear of messenger RNA even from the people who determine our funding, right? I think right now, NIH and the federal government no longer provides funding for messenger RNA studies.
Dr. Callahan: Gosh, it’s hard to keep track, and I wouldn’t purport to be an expert in what’s approved and not approved right now from a federal funding level. But certainly there’s been a lot of concern, and I think some concern along the lines that, that maybe just fundamentally show some misunderstandings or some mistaken understandings.
Like I said before, this does not change your genetic material, it’s a temporary message, and so maybe not as scary as some people have led us to think about it as. And then from a scientific standpoint, the real advantage, the reason this is being embraced as a technology is it is fast and flexible, meaning we can invent this recipe, deliver this recipe, as you saw with the COVID vaccine, in a matter of months, expediting the delivery of new therapies in a way that’s almost inconceivable, and manufacture it, get it to patients, and really help them out very quickly.
Dr. Alessi: Well, clearly the pharmaceutical companies have not turned their back on messenger RNA since I think that’s where most of the research, whenever we hear of research coming out, it’s coming out from Biogen and companies such as that. But if we’re to move on, how have we used messenger RNA to treat melanoma?
Dr. Callahan: Well, up until now, we haven’t, meaning messenger RNA platforms up until now have mostly been applied to vaccines in a more classic setting in infectious diseases, COVID being a good example of that. And so what’s really novel here is marrying the technology of messenger RNA, which is novel and cool in and of itself to a second really cool idea, and that’s the idea you alluded to before, which is neoantigens.
Dr. Alessi: Right.
Dr. Callahan: So infection-oriented vaccines are going to give you a little taste of whatever infection we want to prevent in advance of you being exposed to the infection and try to get your immune system geared up and ready to fight off that infection if it comes along.
But this is a very different challenge we have in cancer We’re not preventing cancer with these vaccines yet, not in this setting. What we’re doing is taking patients who have had melanoma, where we can cut them out, cut out the melanoma with a surgery, but we know there’s a risk that the melanoma will come back, and we’re using the vaccines in this setting to try to redirect the immune system to pay attention, eradicate residual melanoma cells, and protect the patient from the melanoma coming back. And the strategy we’re using here is a little different than the preventive vaccines we use for infection.
Dr. Alessi: So one of the things, this all falls into the idea of personalized medicine, right? So when we create a specific vaccine versus a tumor, that’s a vaccine that could only be used by that individual. Am I correct?
Dr. Callahan: That’s right. In this platform, this particular platform is a personalized vaccine. And so to go through it a little bit slowly, but, when a tumor grows, it accumulates mutations. Part of the reason we have tumors is because of this accumulation of mutations, and some of the mutations are necessary for the tumor to grow, but some of the mutations are just passenger mutations that accumulate over time.
These mutations can actually be seen by the immune system because they’re different. They’re different than your normal cells, and that’s what the immune system likes to see. So every patient’s tumor has a unique set of mutations. My neoantigens are different than your neoantigens, and so this vaccine is genuinely made to order.
Dr. Alessi: Now, I understand UConn and UConn Health are not new to this, and you have mentioned Dr. Srivastava, who did some of the original work on that. Can you talk a little bit about the origins of this work and UConn being involved in that?
Dr. Callahan: Sure. So the idea of a vaccine against cancer is not a new one. It is something the field has been working on for, gosh, decades and decades and maybe even a century, depending on when you, when you measure, measure this. And Dr. [Pramod] Srivastava, who’s our cancer center director here at UConn Health, led some pioneering studies in the 1980s and 1990s that demonstrated the potency of neoantigens as a cancer-fighting tool, really identified that the immune system is attracted to differences between normal tissue and cancers, which are explained by these mutations.
And he had a paper in 1993 where he specifically introduced the idea that each tumor’s unique mutations could generate individual, distinct tumor-specific antigens that can drive an immune response and can be used for therapy. And this concept really paved the way conceptually for this modern era of neoantigen vaccines.
What’s happened in the interim since that was a concept in the 1980s and 1990s, is that the technology we have, mRNA vaccines, for example, high-throughput sequencing, bioinformatics, has caught up in such an amazing way to make what was a cool idea something that we can actually do.
Dr. Alessi: Your career is kind of interesting, just being a professor of immunology and hematology oncology. Did you foresee this when you created your specialty or when you started your work? Did you foresee that immunology and cancer treatment may be coming together in the future?
Dr. Callahan: Boy, I wish I could take credit for that. No, I was simply really an interested, curious MD Ph.D. student, and I came across Dr. Srivastava’s work on neoantigens, and I thought it was the coolest thing I’d ever heard. I just thought, “This is such a cool idea, and I want to be part of the research, understanding how the immune system can fight cancer.” At that time, the field honestly had a pretty dismal track record, lots of failures, lots of advice from people saying, “This is never going to work. We’ve been trying forever and failing.” But I was really governed by where my interest led me.
Dr. Alessi: It’s like a baseball player going to play for a losing team, right? You’re thinking, “Listen, I can only help at this point.” Which has turned out to be phenomenal. How big a deal is this, what we’re reading about in terms of, in my mind, I keep thinking it’s a major step forward. Am I kind of pie in the sky and too optimistic, or is this a major breakthrough for the future?
Dr. Callahan: Oh, I think it’s definitely a major breakthrough. And I think immunotherapy has already transformed cancer care. So if we look in my disease, the disease I treat, melanoma, 20 years ago, a diagnosis of stage four melanoma was a death sentence, with a median survival of six months.
Checkpoint inhibitors, which now have been around for a decade and are widely used immunotherapies, have had an enormous impact. They have changed the death rates, the, the survival benefit for patients with melanoma such that half my patients are alive five and 10 years later. But the checkpoint blocking antibodies do one thing. They are like a gas pedal. They accelerate an immune response that’s already there, and they sort of pump up the immune system.
Dr. Alessi: Are those drugs like... is that why in this study they use Keytruda? Is that one of those checkpoint  inhibitors?
Dr. Callahan: That’s right. So Keytruda is one of those checkpoint inhibitors. So is Opdivo. There are a number that are in clinic now.
Dr. Alessi: So we see those ads on TV. So we might as well u- we can use brand names here.
Dr. Callahan: Oh. Got it. Yes. These are all FDA approved, and I’m not endorsing one or the other, but just giving a couple of examples and telling you how commonly they are out there. And they’ve been a big game changer. Survival rates for melanoma are better today than they ever have been because of these drugs. But If we think of checkpoint inhibitors as the gas for the immune system, these vaccines are like the steering wheel. They’re going to direct the immune system towards the right target, towards the cancer, and, I think we’ll all agree, your car works better with both a gas pedal and a steering wheel. And so I think there’s a tremendous amount of promise that combining these two modalities really sort of helps us capture a better portion of the potential of the immune system to fight cancer.
Dr. Alessi: All right. So what’s next? I’m going to ask you to take out your crystal ball and tell me what’s next. Are we going on, are we taking this technology to lung cancer, ovarian cancer, brain cancer? Where are we going with this?
Dr. Callahan: Well, I think that’s one of the really exciting things about immunotherapy, and something we learned from immune checkpoint blockade, which is these therapies, they don’t work directly on the cancers. They work on your immune system, and let your immune system do the job. And so they tend to be somewhat cancer agnostic, meaning they can be applied to lots of other cancer situations, and we’ve seen that with checkpoint blockade. I think 100% we’re going to see that with vaccines as well.
I think the other thing I’m really excited about is as the technology and our capability to understand the immune system evolves, we’re going to get so much better at understanding how individual patient’s immune system works, and therefore which of these levers, which of these tools are going to be most helpful in shaping their immune system and getting it to fight their cancer, and that’s work that I do in my own research.
Dr. Alessi: Maggie, thank you.
Dr. Callahan: You’re very welcome.
Dr. Alessi: Thank you for your time today, and really an enlightening talk, and really thank you for all you do for our patients here at UConn Health.
If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu. Jennifer Walker is executive producer of the Healthy Rounds Podcast. Chris DeFrancesco is the studio producer of the Healthy Rounds Podcast. Until next time, this is Dr. Anthony Alessi. Please stay healthy.

As we get ready for football season, Dr. Alessi brings on a fellow expert in sports neurology, Dr. Stephanie Aless-LaRosa, program director of the UConn Health Sports Neurology Fellowship. They discuss not only concussions (which is more than just a football issue) but also other conditions they see in the sports context, how more folks seem be active for longer, the perspective of a team physician on the sideline, ways to possibly reduce injury risk, and other specialties involved in sports neurology, 
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health Sports Neurology Fellowship:https://health.uconn.edu/graduate-medical-education/sports-neurology/fellowship-program-contacts/
NeuroSport at UConn Health:https://www.uconnhealth.org/orthopedics-sports-medicine/services-specialties/neurosport
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery, and a grant from Coverys. It is not designed to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have today as my guest, Dr. Stephanie Alessi-LaRosa, who some of you may know is also my daughter, of whom I’m very proud of her accomplishments as assistant professor of neurology here at UConn Health, and also team consultant for UConn Sports. Steph, welcome to the show.
Dr. Alessi-LaRosa: Thanks for having me.
Dr. Alessi: Let’s talk a little bit. You’re a sports neurologist. Can you explain to our listeners your training and what a sports neurologist does?
Dr. Alessi-LaRosa: Absolutely. So I am a board-certified neurologist, and I completed a residency in neurology here at UConn, and I did a fellowship, an additional training year, in sports neurology at the Kutcher Clinic for Sports Neurology in Michigan, and now I’m a practicing sports neurologist here in Connecticut.
Dr. Alessi: What are some of the conditions that you run across? I think right away when people think sports neurologist, they think concussion, but it’s obviously a lot more. So can you talk about some of the conditions people come to you with?
Dr. Alessi-LaRosa: Yes. Concussion is certainly the number one thing, I think, again, like you said, most people think of, but we treat most commonly headaches or migraines. Those are the number one thing we treat outside of that. But really anything neurologic that occurs in active people is really our patient population. That could be patients who have dizziness or neurologic symptoms that we will then determine what’s the source of it, how to get them back playing and participating in their life the way that they want.
Dr. Alessi: What do you find are some of the typical sports the laypeople — We know you see a lot of football players and high-level athletes, but — during the course of your day when you say active people, what are people doing now? Because it seems like people who are older and older are becoming more active in sports. What are some of the sports you see people participating in now that you may not have seen previously?
Dr. Alessi-LaRosa: I think there’s all levels of participation. I do think that overall the population, especially in the aging population, has recognized that activity is very important for longevity of their life. So I do think that I see older folks even doing hockey leagues, and so there’s just quite a spectrum. Some folks do yoga and more gentle sort of exercises, but really being active does seem to be carrying people through their life in a healthy way.
Dr. Alessi: Well, we’re coming up on football season, so let’s talk a little bit about football itself. Obviously, the thing we fear most and people fear most are injuries to the brain and spine, as a result of a high-velocity collision sport like football. When we’re on the sideline working, can you share with our listeners a little bit about what we’re doing on the sideline, and what is our job, our role standing on the sideline?
Dr. Alessi-LaRosa: Yes. Really, we have to be paying attention to every play, because if we miss the hit, that’s really our first examination, how players are getting up from each play. So our observation is extremely important, especially because a lot of the players want to continue to play and act like nothing happened, and they may have even lost consciousness and not be aware of what happened. So if we don’t see it, then that does put us at a disadvantage, and we really want to keep the athletes as safe as possible, so our awareness is key. But also, we’re available to evaluate anybody for potential concussions, or other even peripheral nerve injuries, or, like you mentioned, spinal cord injuries, anything that may have occurred during the play.
And sometimes we use the tent that’s on the sideline at UConn or even taking athletes into the locker room and assessing them to try and limit the distractions.
Dr. Alessi: Since we’re chatting about the sideline, when I started out in this field, we didn’t have a lot of video. But now, how important is having video available instantaneously on the sideline for you to make a decision?
Dr. Alessi-LaRosa: I find it’s extremely helpful. I think that’s one of the benefits of having a spotter that they put high up, someone else who can actually watch just the plays and look at all the monitors that are happening above, and then getting us that information on the sideline, because our view is not great, to be honest, where we’re standing.
So it makes it hard in a lot of ways, but at the same time, we need to be there. So it’s difficult, but I find that the videos help a lot because you can see different angles, you could slow it down, you can see what happened after the hit, how long it took the person to get up, what initial post-impact signs there were.
Dr. Alessi: Well, now we have the tent, which we’ve had in the last few years, where we bring a player in and do an assessment. Can you share with the audience what we’re doing in the tent to help make a decision?
Dr. Alessi-LaRosa: Well, certainly we take the, especially in football, we take the athlete’s helmet off. Someone has to hold the helmet so that they don’t try to run back out on the field too quickly.
Dr. Alessi: Good, good point.
Dr. Alessi-LaRosa: Yes, that’s number one. But really we’re asking a couple of questions, really just doing our assessment. Neurologically, we would be asking some questions about what happened, what they recall, what quarter we’re in, who they played last week, things like that. And then going into our assessment, checking their eyes, checking their coordination, checking their eye movements, balance, some things like that, to get to a decision that everyone’s comfortable with. And there’s very few people usually in the tent, because it is a small space. So it’s usually just the necessary folks there.
Dr. Alessi: A lot of people are curious about baseline testing. Baseline testing has become kind of a buzzword, with, I think it was back in the early 2000s, maybe even the 1990s, when impact became available, and they started doing impact testing, which is still done today. And then there’s sway testing and, C3 Logic. How important do you find baseline testing in your work?
Dr. Alessi-LaRosa: I think it’s, it has a role. In some ways, it’s very important to understand what somebody looked like before if you have that information available. But in the most recent consensus statement that came out, it really does not emphasize too much of that.
You can actually use normative data of what we would expect in people that age. So you don’t have to have baseline testing, but I do find that clinical over computerized baseline testing is the most beneficial because you can really put any findings into a clinical context, whereas with a computer, it’s leaving that part out.
So impact or sway or some of these other computerized testing, they do have their limitations, but really the clinical evaluation and baseline testing from like a SCAT type of evaluation, which an athletic trainer typically can do preseason, is usually higher quality there.
Dr. Alessi: Now, your research has actually looked at doing clinical examinations as baselines in athletes before they would have an injury, meaning an actual clinical examination. Can you tell us a little bit about, um, how... what you found by, by looking at that in high school athletes?
Dr. Alessi-LaRosa: Sure. We have a small study being done, and over time of a high school career, so over the four years of a high school career, we haven’t found any significant changes in the athlete’s neurologic examination, their eye movements. We do a depression screening before each season starts with their first contact practice, and we have not seen dramatic changes. So over the course of a high school career, I think that’s important information, that there is maybe more benefits than risks at that level.
Dr. Alessi: So it sounds like the brain is a fairly resilient organ if you treat it right.
Dr. Alessi-LaRosa: Absolutely. Yes.
Dr. Alessi: Let’s move on to injury prevention. Everybody wants to know, how do I prevent a concussion? And people are always coming up with new designs for helmets. Do I buy a more expensive helmet? Is that the best helmet? But there are other ways, so can you talk a little bit about some of the other ways that we’re able to prevent concussions from happening in young athletes?
Dr. Alessi-LaRosa: Yes, I think there’s a few that certainly the helmets and mouth guards, those get a lot of the focus. People think that wearing something better would be helpful. But what we’re finding actually clinically is having a stronger neck, the neck musculature, having stronger muscles there, more balanced out musculature can actually prevent the biomechanical force that’s imparted to the brain, and that would be preventive.
So that’s something we talk a lot about as well. But really exposures to hits, so reducing the exposures is a way of preventing concussion, meaning less contact practices for football, as an example, and just reducing the potential for further hits. Those are some of the other ways that we focus on. And certainly in the youth level, where their neck musculature just really is not developed yet, heading the ball in soccer is something that we really don’t like to see in young, young kids because of this issue.
Dr. Alessi: One of the things you and I have talked about is the importance now of integrating other people into sports neurology and treating patients neurologically, like physical therapy, like kinesiology, from that standpoint. And I bring this up because UConn is fairly unique here at UConn Health, we have all of the necessary elements. If you were to design the single best program for addressing the neurologic needs of athletes, what would be the elements, the integration in a program like that?
Dr. Alessi-LaRosa: I mean, there’s certainly a lot of disciplines, so a multidisciplinary sort of program would be, like you mentioned, physical therapy, athletic training, neurologists, sports neurologists obviously. Neurosurgeons can be part of that team at times. I even often use sports cardiologists. That can be helpful. But neuropsychologists, psychologists, they’re an important piece of the team as well. So I think those are just to name a few. There are some centers in our country that have these components, maybe not all of them, but you can really tailor it to your population in a way which I think is really the goal.
Dr. Alessi: Steph, in closing, what are the things that parents need to know now that their children are going to be going out there to play, whether it be at the Pop Warner level or high school level? First of all, what should parents know before letting their children play a high-velocity collision sport, whether it be football, soccer or something of that nature?
Dr. Alessi-LaRosa: Yeah, in the under-14 age group, in terms of football, tackling is dangerous, but I think there’s some ways that if your child really expresses that they’ve got to do this and play tackle football, that the safest way to go about that and the best way for parents to help, with that process is to meet with the coach, get to know them, make sure they have some concussion training as is required in the state of Connecticut of coaches. But to really understand their philosophy. Are they big on hitting in practice? Are they big on maybe they hit, they use sleds or some other objects to hit rather than each other in practices. And having an athletic trainer available is really key in the safety of all sports, I feel, and especially at this level, but unfortunately at the youth level, there really are not many athletic trainers that are part of that picture, and so having some medical training in the coaches and especially the parents and the kids themselves, some understanding of concussion signs, symptoms, recognition is very important for best outcomes and the safest participation.
Dr. Alessi: One of the things we like to chat about here at the Healthy Rounds Podcast are unique programs and unique things that we can develop here at UConn Health. Steph, certainly a program in sports neurology complementing, all the sports specialists in the Department of Orthopedic Surgery has been one of those.
Thank you for your time today, and thank you for all that you do for patients in our community.
Dr. Alessi-LaRosa: Thanks for having me.
Dr. Alessi: Your mom and I are very proud.
Dr. Alessi-LaRosa: Thank you.
Dr. Alessi: If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu. Jennifer Walker is executive producer for the Healthy Rounds Podcast. Chris DeFrancesco is our studio producer.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.

The term “Western sports” refers to events like roping, steer wrestling, bareback riding, saddle bronc riding, and bull riding — some of the most dangerous forms of competition. Applying his expertise in neurology and sports medicine to care for these athletes over the last several years, Dr. Anthony Alessi has developed a unique perspective on this world. Professional bull riders have been flying in from other parts of the Americas to see him at UConn Health since 2018, when the first two arrived, concerned they’d leave with doctor’s orders to stop competing. In this solo episode, he shares his insight on the dynamic of the Western sports culture, why many of them lie to him, and what became of those first two bull riders who came in for neurological evaluations.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
NeuroSport at UConn Healthhttps://www.uconnhealth.org/orthopedics-sports-medicine/services-specialties/neurosport
Western Sports Foundationhttps://wsf.org
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health. with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to be with you as always on this podcast. Today’s going to be a little bit different. I’m going to be talking about a program that I’m involved with here at the University of Connecticut, and it involves Western sports. Now, Western sports present a unique challenge for sports medicine physicians, and we’re going to talk about that and my work with this outstanding group of athletes.
In the podcast, we’re going to define what Western sports are, talk a little bit about the historical background and the rules of Western sports, my involvement, as well as the involvement of UConn Health. So let’s get started.
When we talk about Western sports, we’re talking about two different types of events. There are timed events, such as tie-down roping, team roping, steer wrestling. So basically, your success is based on the amount of time it takes you to do something. Then there’s what we call “rough stock” events. Now, the rough stock events are events that focus on riding and breaking animals, and basically we’re talking about bareback riding, saddle bronc riding, and bull riding. And we spend, most of our discussion today will be centered around bull riding.
A little bit about the history: The Western sports really came to light in about the 16th century as a contest back in what was old Mexico, and it was a variant of bullfighting. So when we think of bull riding, it was a variant of bullfighting, and basically the idea was to stay on the back of the bull. It was modeled after the matadors and bullfighting itself.
In 1992, 20 professional bull riders got together and formed what’s now known as PBR; it’s basically a professional bull riders tour. Bull riding was always the last event in a rodeo, and it was one that people felt was the single most exciting event. So they decided to start their own system, their own company. And because bull riding is really among the single most dangerous sporting activities in the modern era — and that’s been documented throughout the literature; it’s really an extreme sport — and people especially now are drawn to these extreme sports.
So in bull riding, the rules are that the rider has to stay on the bull for a period of eight seconds. Doesn’t sound like it’s very long, but you’d be surprised when you actually watch an event. It begins when the bull’s shoulders or their hind parts break the plane of the chute. That’s when the clock starts, and it ends when the rider either falls off, or his hand comes loose from the bull, or he touches the bull with what we call his free arm, the arm that’s not strapped onto the bull itself. And the rider then gets assigned points. The points are based on a 100-point scale. Fifty points are attributed to the bull’s performance and 50 points to the rider’s performance.
There’s always been a lot of talk about cruelty to the bulls, and I can tell you from personal experience that the bulls are treated like VIPs. The reason is, stock contractors make their money from the bulls. The bulls are highly paid, or at least the contractors are paid. So it really would be a mess for them from a financial standpoint to harm or be cruel to the bulls. So these bulls are bred and treated quite well.
A lot of the bull riders now are international, mainly from Brazil. So I’d say about half of the bull riders are from Brazil, many from Western Canada, and we’ve had the pleasure of working with all of them over the years. The number of participants now, there are about 1,200 professional bull riders. The typical bull rider is an average age of 20 years old, average height of 5 feet, 7 inches, and weight of 139 pounds. So physically, they are smaller and lighter athletes. And again, I use the term “athlete.”
Let me digress a little bit. For many years, they were treated much like performers, that they are, like all athletes, but they were not treated like athletes. So the traditions that we extend to other athletes in organized sports were not really extended to Western sports athletes. In fact, it’s only the PBR tour that has their own athletic trainers and physician at every event, and really only at the highest level. There are physicians at many other events, especially with the PRCA, but not to the degree of PBR. Riders usually start riding steers at age 7, so they start very young. Before age 7, they’re riding calves and sheep.
And it’s also important to note that professional bull riders and Western sports athletes fit into the category of “self-employed athletes.” The difference being, when we think of baseball, football, basketball, these are employed athletes, right? They come under the employment of a team. They have benefits. If they’re injured, they still get paid. Self-employed athletes are somewhat different. When we think of those athletes, we think of boxers and MMA athletes, combat sports athletes, Western sports athletes, golfers, same thing. They’re self-employed. Bowlers, again, self-employed athletes. I often say that employed athletes lie to me half the time to tell me that they’re ready to go back to the event. But self-employed athletes clearly lie to me all the time because they’re in a situation where it’s no play, no pay. So it’s important to keep that in mind as a physician treating these folks.
Now, the program at the University of Connecticut started in 2018, and it was done in conjunction with a group called the Western Sports Foundation. This is a foundation set up to provide assistance to these self-employed athletes when they are injured to help them with whatever, car payments, house payments, and whatever that can be done in a charitable way. The people who support it are an interesting group. These are people who believe strongly in trying to preserve the Western culture, and it’s a different culture. As I’ve gotten to know people involved in this, it is a totally different culture. And for someone like myself, born and raised in the Bronx, it is a very different culture than I’m used to. And over the years, I’ve come to really appreciate these people and their dedication to this Western culture. So we started this program in 2018, and it was following the death of a professional bull rider named Ty Pozzebon.
To briefly summarize, I saw Ty Pozzebon in 2015 as a patient and advised him not to ride in professional bull riding anymore because of damage to his brain. Unfortunately, he persisted and rode at other levels other than PBR for a period of time. Two years later, at the young age of 25, he sadly took his own life, and he was subsequently found to have CTE As a result, PBR felt that they were somewhat responsible for the health of their athletes. And by this time, the original 20 athletes who started it had sold this to Endeavor at the time, which is a big sports management company. So they felt it was necessary to have a way of evaluating athletes before they get on a bull and to make sure their brains were healthy. And that’s where I came in, in working with them and developed this program at UConn Health.
Over the years, we’ve seen about 35 professional athletes who are involved in PBR, and some even at the amateur level. What was interesting was, the first two participants that came to us in 2018 came with the idea that they were being sent, and as a neurologist, I was going to end their career. What we found with the testing we did was one of them really had a learning disability that needed to be treated, and the other had migraine headaches. So they had conditions that had nothing to do with getting hit in the head or their performance. What was more interesting was that when we corrected their problem and treated them, they both rose to being among the top 10 bull riders in the world. So it was interesting because suddenly our program developed into a program about brain health and how we can help athletes improve their performance in Western sports, and that has led to what has been a great relationship.
Our process is basically doing a detailed neurologic examination, MRIs of the brain, neuropsychometric testing, and in many cases, having them consult with a physical therapist. We do this over a period of three days, so they are flown out here thanks to Western Sports Foundation, and all their expenses are paid for, including our fees at UConn Health. And what it has developed into is kind of an international program for these athletes, including not just bull riders, but ropers, bareback riders, barrel racers. And what our goal has been is to determine whether it’s safe for the athlete to continue riding or treat their problem as we did with these first two athletes in terms of whether it be with physical therapy, medication, hooking them up with counseling, since many have developed various mental disorders and depression, especially after retiring from the sport. We also talk a lot about vocational endeavors after they’re done bull riding. So it’s become a very individualized program based on the goals.
In closing, this program has become one of the unique programs that really distinguish UConn Health nationally. And surprisingly, one of the purposes of this podcast is, and will be, to raise awareness in the community and with our colleagues about unique programs that we have developed here at UConn Health in order to assist not just athletes, but all of our citizens on a national level and a local level to better health.
With that, as always, I thank you for your time today. Many thanks to our executive producer, Jennifer Walker. Chris DeFrancesco is the studio producer who put this together.
If you have any questions about future programs, you can reach out to me at healthyrounds@uchc.edu. As always, it’s been great chatting with you and doing this podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy

Neurosurgery is a relatively young discipline in medicine, one that began with a focus on survival. Today the focus goes beyond survival to restoring personalities, memories, limb function, even the ability to walk. Dr. Ketan Bulsara, chair of UConn Health’s Department of Neurosurgery, joins Dr. Alessi to discuss restorative neurosurgery, as well as UConn Health’s elite position when it comes to identifying and treating complex brain tumors, and how UConn is now attracting, training, and producing the next generation of talented neurosurgeons.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Ketan Bulsara:https://health.uconn.edu/neurosurgery/message-from-the-chair
UConn Health Department of Neurosurgery:https://health.uconn.edu/neurosurgery
UConn Today: ‘1 of 4 in the US for Advanced Brain, Spine Tumor Diagnostics’https://today.uconn.edu/2026/02/1-of-3-in-the-us-for-advanced-brain-spine-tumor-diagnostics/
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not inclined to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today Dr. Ketan Bulsara. Dr. Bulsara is professor and chairman of the Department of Neurosurgery here at UConn Health. Ketan, welcome to the show.
Dr. Bulsara: Tony, thank you for having me on the show.
Dr. Alessi: You know, it’s always a pleasure to chat with you because it always opens new horizons for me, and one of the things I said in the teaser for this program is that people often describe the brain as the new frontier, and I’ve always felt that it’s neurosurgeons who are the new explorers, or even the old explorers, when it comes to the brain. But I really would like to ask you a little bit about your background. You know, we became familiar with each other back when you were at Yale, but if you could, talk a little bit about your training and what it took to get where you are today.
Dr. Bulsara: Well, Tony, thanks a lot. I love the concept of being an explorer, and there’s nothing more exciting than being, on sort of the final frontier in terms of trying to understand the essence of what makes us who we are. And certainly, the brain and spinal cord certainly are integral to that. You know, in terms of my training, I went to medical school at Duke and then stayed there for residency. And when I was at Duke, there was this very pioneering Japanese neurosurgeon who really got me very interested in brain and spine surgery and all the technical nuances.
Interestingly, the man that was named the neurosurgeon of the century had moved from Zurich to Little Rock, Arkansas, and I got to go work with him and some of the other pioneers there. When I finished there and I initially started my practice, I realized that the world was changing very rapidly, and I was at this point where I felt very, very skilled at performing micro-neurosurgery, but the world was changing, and endovascular neurosurgery was really kicking in. So after about a year in practice, a year and a half in practice, I decided to go back and do a fellowship and learn how to do endovascular neurosurgery.
And the plan was always to stay, stay down South, but then, you know, I was attracted to Connecticut because I was given in New Haven the opportunity to build something that would be a legacy, and that sort of has continued in Connecticut with my move to the University of Connecticut about eight years ago.
Dr. Alessi: Now, you’ve talked about interesting how in a field such as neurosurgery and even neurology, things change a great deal. I was with a cardiothoracic surgeon earlier this week chatting, and we talked about how his field has changed dramatically. What are some of the changes we’re starting to see in neurosurgery now? I know you have so much experience with skull base surgery, which is a big part of neurosurgery. What are the hot topics? We just had Chris Connor on the show talking a little bit about stereotactic and functional neurosurgery. Where do you think things are going now?
Dr. Bulsara: Yeah, I think the beauty of neurosurgery in terms of brain and spine is that it’s a profession, that is, an organized profession that is only about 100 years old. And where initially we were focused on survival, we’ve really moved into an age where we’re focused on restorative neurosurgery, restorative for the brain, restorative for the spine. And what that entails is that, whereas before we were measuring our outcomes in terms of survival, we’re now measuring outcomes and our ability to make the person whole again like they were prior to the pathology that afflicted them.
And again, as this has happened, it’s really, really exciting because you have functional neurosurgery like you mentioned, you have vascular neurosurgery, you have endovascular neurosurgery, you have complex spine surgery. You have all these different arenas that are harnessing the advantages of AI, of robotics, and just sort of continuing to push the frontier forward. So I think it’s very exciting. I think for me, what’s most exciting is, is as we’re expanding our department and as we’re recruiting to bring in folks that focus on sort of integrating all of this together, such as in brain-computer interfaces, and that’s an area that’s very, very exciting for me and an area that I think the department is going to start venturing into.
Dr. Alessi: Let’s talk a little bit about being a department chairman. Actually, I didn’t know you weren’t a department when, when I came here, so I’m finding out that it, it recently became a department, but let’s talk a little bit about it. What’s the biggest challenge right now in chairing a department such as neurosurgery here at UConn Health?
Dr. Bulsara: Well, Tony, I was really fortunate that when I started here, Dr. McFadden, my chair of surgery, had always helped me chart out this plan where we would become an independent department, and he gave me the liberty, in many ways, to function as a department, so I’m always grateful to him.
In terms of the challenges, my challenges as a department chair are probably no different than any of the other department chairs. We’re in an era now where our resources across the board, across the country, are limited, and yet we have all these technological advances. And so you’re faced with the situation where you have these limited resources, all these technological advances. You want to have the technological advances ’cause you want to make sure that you provide care to your patients that’s second to none, and you’re shaping the future of care, but it becomes a struggle sometimes in terms of navigating that.
I think the other thing as a department chair is it’s very, very exciting to grow a program, to grow a department, and I think what’s really, really important, especially for neurosurgery as we’re continuing to grow, is that, sort of the, the main ingredient of our success has been the culture that we’ve cultivated within the department, within the context of the institution. And I think maintaining that as we continue to grow is something that I’m, I’m really, really focused on.
Dr. Alessi: What’s recruitment like? I mean, obviously you’re competing for a very limited pool of gifted neurosurgeons. I mean, for example, we have a residency here now in neurosurgery. How many residents do you train in neurosurgery?
Dr. Bulsara: We accept one resident a year. The number of graduates is, as you point out, is very, very small. I think it’s probably about 220 or 230 a year, if I recall correctly.
Dr. Alessi: Nationally?
Dr. Bulsara: Nationally. So the number of graduates, it’s a small number of graduates, but you know, something absolutely amazing has happened at our institution. I remember when I first came here and I was recruiting, we were getting people that were applying for jobs and things to that extent, but now during our recruitment process, maybe it’s because, I know for a fact it’s because of, sort of the reputation that all of us have contributed to for UConn Health and the University of Connecticut, we have had a tremendous number of applications for our open positions.
And so now the onus is to try to screen through those and, try to make sure that the individuals that we bring in will fit into the culture, not only of the department, but also the culture of our university.
Dr. Alessi: One of our challenges in medicine here in the state of Connecticut has been retaining our trainees, right, to go into practice and either stay at our institution or, or another institution in Connecticut rather than go south or go west. Are you seeing a change in that from the neurosurgical standpoint?
Dr. Bulsara: You know, we haven’t had a, neurosurgery, since it’s a seven-year training program, a new residency program, we haven’t seen a graduate yet. However, my general sense is UConn Health and University of Connecticut has become a very desirable place to work, at least that’s the sense that I’m getting. And, and what sort of reinforces that for me is the vast number of applications we’re getting for neurosurgery positions. And I have tremendous trainees right now, and would be happy if all of them or any of them decided to stay with us.
Dr. Alessi: Oh, that would be great.
Dr. Bulsara: So I think it would be tremendous.
Dr. Alessi: Let’s move on. We chatted a little bit about middle meningeal artery occlusions, correct, for chronic subdural hematoma. And it took me a little bit by surprise, ’cause whenever I think of the middle meningeal artery, I think of an epidural hemorrhage and someone dying pretty quickly. So can you talk a little bit about what a chronic subdural hematoma is, and how occluding the middle meningeal artery can help that?
Dr. Bulsara:This is an area of considerable controversy. At least it started off as an area of considerable controversy.
Dr. Alessi: All these things start as controversy, believe me, and that’s why we’re on this podcast, because that’s what we like here. So let’s go with it.
Dr. Bulsara: There you go. So what is a chronic subdural? Well, usually when patients, suffer some form of trauma, they may have an accumulation of blood along the brain, inside the membrane of the brain, and usually it’s not initially causing any significant pressure or anything of significance. Now, there are some subdurals that require emergent evacuation, like the acute subdurals, but what we’re talking about is a chronic subdural.
What happens over time is the body realizes that there’s blood there and it needs to get rid of the blood, and it starts this inflammatory-type response to try to get the blood away, break down the blood products, and things to that extent. It works, probably works more often than not, but in the situations that it doesn’t work, what ends up happening is that very small amount of fluid that you had, as it’s undergoing its changes, increases in volume, and as it increases in volume, it starts to put more pressure on the brain. And as it puts more pressure on the brain, and as the body’s still trying to sort of fight it off, it forms membranes around it. And so the current state of middle meningeal artery embolization is such that if you have a patient who has a subdural hematoma, chronic subdural hematoma, they undergo surgery for it, then if you embolize the middle meningeal artery, embolize meaning you close off the middle meningeal artery, the chance of them recurring is much, much lower.
And the, the etiology behind that is because the membrane is supplied by branches in the middle meningeal artery. So if you shut that down, then you get less of the exudate and things to that extent that contribute to the expansion of the subdural fluid.
So that’s the only sort of group that we have definitive data on. In terms of using middle meningeal artery embolization without surgery, there are ongoing randomized studies to try to determine if there’s a role for that. And I think in very, very, very select patients, you may choose to do that, patients who may have to go on anticoagulation or patients, uh, who may have other sort of issues that may preclude them from being surgical candidates.
We recently published the guidelines from the Society of Neurointerventional Surgeons, and clearly the strongest evidence right now is for patients who have a chronic subdural hematoma have surgery, and following that, they undergo middle meningeal artery embolization, the chance of recurrence of that subdural is much smaller.
Dr. Alessi: So when you mentioned doing the procedure, the embolization, in lieu of surgery, so for example, if you find a chronic subdural and the person is not a surgical candidate, you would go ahead and embolize just to avoid it from getting any larger?
Dr. Bulsara: That is certainly one of the gray areas right now. It’s a gray area because we don’t have any strong randomized evidence to suggest that it works for this patient population. We don’t know for a fact if it’s better than the natural history.
Dr. Alessi: Gotcha.
Dr. Bulsara: And, as you know, if you have a procedure that can be applied relatively easily, the chance is it may be overused if you don’t have strong sort of guidelines in terms of when it should be used. So again, a lot of these patients would benefit just from observation, most likely.
Dr. Alessi: You know, one of our past discussions has been, and it’s probably a whole show in talking about neuro-oncology and talking about brain tumors. Where are we with the status of brain tumors? Have we made progress with the treatment of glioblastoma and glioblastoma multiforme? I mean, it’s just, that’s always been a, a huge issue.
Dr. Bulsara: Glioblastoma multiforme is such a heterogeneous tumor type that we’ve really had trouble identifying specific initiators of the disease process. I’m really excited to say though that we have been on the forefront of the diagnosis and leading to subsequent treatment of glioblastomas, and also all other tumor types in the brain and spine. In collaboration with Dr. Wu from pathology, and Dr. Becker, who’s in my department, who’s a neuro-oncologist, we’ve been able to work with Jackson Labs and become one of four centers in the country that is capable of real-time clinical methylation profiling, which allows for very, very precise diagnoses.
Dr. Alessi: He and I, Dr. Becker and I, recently shared a patient, and it was an eye-opener for me as to what’s available.
In wrapping things up, what’s the next big thing we’re going to hear about in neurosurgery? What do you think?
Dr. Bulsara: Again, I think it focuses on this theme of restorative neurosurgery. It’s absolutely amazing that we’re at a stage, it’s such an exciting time to be involved in the neurosciences, that we can return people’s sort of personalities, we can return their memories, we can do all these sorts of things. We’re at a stage where we can now start thinking about realistically making people who couldn’t walk, walk again, or move their arms, move their arms again. And that’s what I think is the most exciting aspect of the neurosciences in general right now, this restorative neurosurgery.
Dr. Alessi: That’s so great to hear. Ketan, thank you. Thank you for your time today, and more importantly, thanks for everything you do for our community, and being such an essential part of UConn Health. Thank you.
Dr. Bulsara: Tony, thanks a lot. Thanks for the opportunity.
Dr. Alessi: If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer for the Healthy Rounds Podcast, and Chris DeFrancesco is our studio producer here at the podcast. Until next time, this is Dr. Anthony Alessi. Please stay healthy.

You don’t have to be an athlete to benefit from the expertise of sports medicine physicians. While Dr. Allison Schafer and Dr. Katherine Coyner are team physicians for UConn athletics, they also run the Women’s Center for Motion and Performance at UConn Health, a collection of coordinated services to keep women of all ages active and healthy, athlete or not. They join Dr. Alessi to discuss the advantages of this care model, how their individual specialties with sports medicine fit into it, and how women tend to be more susceptible to certain orthopedic injuries.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Women’s Center for Motion and Performance at UConn Healthhttps://www.uconnhealth.org/orthopedics-sports-medicine/womens-center-motion-performance 
Dr. Allison Schaferhttps://health.uconn.edu/find-a-provider/physician/Schafer-Allison 
Dr. Katherine Coynerhttps://health.uconn.edu/find-a-provider/physician/Coyner-Katherine 
Women's Center for Motion and Performance nurse navigator:860-679-6330

Already on the leading edge of electronic stimulation for new applications like stroke recovery, UConn Health's Dr. Christopher Conner, who specializes in stereotactic and functional neurosurgery, is on the verge of another one! He joins Dr. Anthony Alessi to explain how Vivistim has been opening new doors to regaining function after stroke, who the best candidates are, and how a similar concept for autoimmune disorders may not be far behind.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Christopher Conner:https://www.uconnhealth.org/providers/profiles/conner-christopher
UConn Health Department of Neurosurgery:https://www.uconnhealth.org/neurosurgery
The Brain and Spine Institute at UConn Health:https://www.uconnhealth.org/brain-spine
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
“UConn Health Neuromodulation Center of Excellence for Veterans” (UConn Today, June 17, 2025):https://today.uconn.edu/2025/06/uconn-health-neuromodulation-center-of-excellence-for-veterans/
“Grateful Stroke Survivor Shares How New Technology Is Transforming His Recovery” (UConn Today, Nov. 25, 2024):https://today.uconn.edu/2024/11/grateful-stroke-survivor-shares-how-new-technology-is-transforming-his-recovery/
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today Dr. Christopher Conner. Dr. Conner is an assistant professor in the Department of Neurosurgery, and he specializes in stereotactic and functional neurosurgery. Chris, welcome to the show.
Dr. Conner: It’s fantastic being here, Dr. Alessi.
Dr. Alessi: Let’s talk. Can you explain to our listeners what is stereotactic and functional neurosurgery?
Dr. Conner: The simple answer is that I get paid money to put wires and batteries into people’s bodies, which is a really weird thing to do with your day-to-day work, but it is what it is. What it really means, though, is that a majority of what I’m doing is trying to improve people’s day-to-day lives.
That’s kind of the functional aspect of it, and that can encompass a lot of things. It can encompass chronic pain. It can encompass stroke recovery. It can also involve Parkinson’s disease or movement disorders, and even epilepsy. And so these are some diseases that you might sometimes think of as not something that surgery can, can treat, but this is kind of where someone like myself comes into play.
Dr. Alessi: That’s great. Now, let’s go back a little bit. I want to talk, you brought up several different topics, and I know we covered this about two years ago when you were on my radio show. So I want to touch base. Let’s go to Parkinson’s disease, doing deep brain stimulation. You were just starting that at the time here at UConn Health. Where are we with that program?
Dr. Conner: The program has really gotten its feet underneath it. We’ve done upwards of, I think, about 25 or 30 patients with deep brain stimulation, primarily for Parkinson’s disease, although we also treat patients with essential tremor and some other disorders with that here at UConn Health.
But at this point in time, we have a, a really full-fledged program. My movement disorder neurologists, like Dr. [Sarah] Mancone, Dr. [Bernardo] Rodrigues, Dr. [Chindhuri] Selvadurai, and I, we’re really proud of what we can accomplish here, and we can offer kind of a full-stack treatment for people who have advanced Parkinson’s disease. And again, that deep brain stimulation, when I use that term, stimulation, it generally means applying electricity somewhere in the body, and it’s been really gratifying seeing a lot of our patients now that are coming back in a year or two years who are having life-changing, remarkable improvements in their symptoms.
And so we’re finally kind of at that point where we’re getting to our long-term patient outcomes, and I’m really happy to report that we’re doing as well or really much better than what kind of the typical program’s able to achieve.
Dr. Alessi: Let me get back to the idea of putting batteries and wires in people How does that work? In other words, when you’re doing deep brain stimulation or, for years we talked about vagal nerve stimulation, right? People were, and still are, obsessed with the vagus nerve. But when you’re doing that, is it the depolarization? Is it the stim? What is actually taking effect when you’re doing something like that?
Dr. Conner: So every one of these applications we have works in a different way, and the uncomfortable but honest answer that I have for you is that a vast majority of the time, we don’t understand how the electricity is really working on a pretty fundamental level. And that’s true of deep brain stimulation, of vagus nerve stimulation, of spinal cord stimulation. Every one of those is a different kind of wire. Every one of those is a different kind of thing we’re stimulating, and a lot of the time we don’t completely understand it. We might have a good idea about it, but it’s still more than a little bit of a mystery.
Dr. Alessi: And I want to clarify, because I was talking to a patient about it today, and they said, “Oh, is that like ECT?” And this is very different from electroconvulsive therapy which we know how that works.
Dr. Conner: Yeah. We have a better idea, kind of generally, of how electroconvulsive therapy works. The difference is that electroconvulsive therapy is, I think it’s fair to say that it’s a less targeted therapy. So when we’re talking about these wires, we’re talking about trying to deliver electricity to something that’s the, you know, maybe two or three millimeters in size.
That’s a really small area. It’s really targeted that we’re trying to deliver therapy to. Electroconvulsive therapy is more of a whole-brain kind of style of therapy. And so the difference really is magnitude and targeting when we’re talking about the difference between those different approaches.
Dr. Alessi: Let’s go to the vagus nerve, vagal nerve stimulation, I remember, I mean, we’ve been doing this for decades for epilepsy. How effective is it for epilepsy?
Dr. Conner: Yeah. So it’s been around and FDA approved for several decades for both epilepsy and then also for depression. Epilepsy is a seizure disorder. Once you’ve had several seizures, you have a diagnosis of epilepsy, and in some people, we can’t really figure out exactly what area of the brain it’s coming from. It’s called generalized epilepsy. And in those patients, sometimes medications work, and in a shockingly large chunk of people, medications don’t work.
And then, kind of one of the best therapies we had for a long time was stimulating the vagus nerve, which is a nerve in the neck, and the general kind of way I counsel patients is that in 50% of patients it’ll drop your seizures by 50%. So it’s kind of a 50/50 rule, which, in some people, that’s enough to have them be happy with the outcome and to think that the surgery was worthwhile. But it still wasn’t maybe the best that we could do. Fortunately, now there are some deep brain stimulation, wires inside of the brain, there are some ways that we can do that in order to treat epilepsy as well now.
Dr. Alessi: I’ve seen several people using or purchasing these external vagal nerve stimulators. Do they work? Is it garbage? What is it?
Dr. Conner: I mean, that’s a really great question. To my knowledge, no one’s ever really validated whether or not external vagus nerve stimulation works. The vagus nerve is not right at the surface. There’s a big muscle in your neck. If you turn your head, there’s a big muscle coming from the back of your skull all the way down to your collar or clavicle, and that muscle, it’s called the sternocleidomastoid, it’s a big, thick muscle, and it’s sitting right over the vagus nerve.
I just don’t—it’s tough for me to see how electrical stimulations can get through that muscle and into the nerve and not cause that muscle to painfully contract. So I don’t know if it works or not. I think there’s a lot of people out there selling it to you, and it’s up to them to really tell you whether or not it’s effective and do that study. I don’t think it’s been done, though.
Dr. Alessi: Well, it’s interesting because I had a patient who had a concussion, and he was a professional athlete, so he had unlimited means. And someone told him to buy one of these vagal stimulators.
Now, professional athletes don’t buy anything, so he had somebody buy it for him, OK? I’m sure that they wanted an endorsement. He used it once and said it was so uncomfortable and painful, he would never touch it again. So I think that’s the idea of trying to get the stim through the sternocleidomastoid and probably made it very uncomfortable. And I’ve not known it to work at all for a concussion.
Let’s move on, when we talk about the vagus nerve, and I really wanted to get to Vivistim. Because Vivistim is something we talked about back in February of 2024 when you were on my radio program, and you were really just starting that program. Can you tell people really what is Vivistim, and what are you using it for?
Dr. Conner: Awesome question, something I love talking about. So Vivistim is the commercial name for a vagus nerve stimulator. It’s a totally new one, even though it’s very similar to the old one that we had. Again, it’s a small wire that wraps around a nerve in your neck, and it runs electricity into that nerve. We are using it right now for stroke recovery.
A lot of people who have strokes, they don’t get back to where they want to be at in terms of their functional ability, that’s the word functional again, and they kind of plateau between six and twelve months after the stroke. What we have found is that if you stimulate that nerve in a certain way, you can actually boost someone’s recovery quite significantly, even years after they’ve had their stroke.
Now, the vagus nerve doesn’t control your arms or legs, so we don’t know how it works. But what we do find is that if we stimulate it while you’re getting occupational therapy, while you’re trying to use whatever arm or leg is affected — and technically only the arm’s FDA approved — your therapy is much more effective at getting you back to where you want to be.
Now, at this point in time, I’m really happy to let everyone know we’ve done over 25 patients. We’ve just had our first paper on our first 20 patients accepted, and I can report that in our first 21 patients, everyone saw a functional gain with this vagus nerve stimulation, and our results were about 2X, about twice what they saw in the initial trial.
And so it does work. And I see patients back in my clinic all the time who’ve had this done, and it’s incredibly gratifying to see how much benefit they can get from it. It’s been remarkable. And I have physicians text me, physiatrists, I have neurologists text me, or come and find me to talk to me, like, “I’ve never seen this kind of recovery in stroke before,” and it’s really changing how we’re treating things.
Dr. Alessi: So I guess I have to ask you, why only 25 patients in two years? So how do you select your patients? Is it just people who had a hemorrhagic stroke? Is it just ischemic stroke? Is it lacunar stroke? I mean, how are you picking it? Because obviously there’ve been a lot more patients here for stroke.
Dr. Conner: I think... Well, to get to the primary question, which is how do we, what is patient selection? Right now the only strokes that are on label are what are called ischemic strokes. You have to be several months out from the stroke, so we’re usually saying six to 12 months out from the stroke. You still have to have a deficit, i.e., weakness or some kind of functional issue with one of your arms. But there’s a Goldilocks zone for that. If you have a stroke and you get no recovery at all, you can’t move your arm at all, Vivistim’s not going to work for you. If you have a stroke and you get all the way back to where you were before the stroke, you have a complete recovery, we wouldn’t do surgery, OK?
So there’s a Goldilocks zone in there, and that’s measured by an occupational therapist, and that window can sometimes be a little bit tricky because it seems pretty wide, but sometimes patients don’t quite qualify on that. I’d say that’s the most common reason that patients don’t qualify.
And then we’re doing a lot of work trying to get the message out. This is one of the reasons that I’m here today, that I’m really excited to talk about Vivistim because I do think that we need to do a better job kind of advertising this and kind of talking to people about this as an option. So I spend a lot of time doing that, going out and talking to occupational therapists, physiatrists, patient support groups. We’re doing a lot of outreach, and I think outreach is kind of one of the ways that we’re going to get more in.
Twenty-five, though, for a program of our size, in our state is... I’m really proud of that. We actually have had a faster adoption than just about anywhere else, and the company’s told me that. I did three of them on Monday. So we’re picking up a lot of speed. We have money from the Connecticut legislature to do a whole program just focusing on veterans. So we really are kind of like ramping this up, but this is where I need people like Dr. Tony Alessi to help out.
Dr. Alessi: Do you you expect that Goldilocks range to increase to some degree? I mean, well, let me go back. What are the risks of the surgery?
Dr. Conner: So I mean, every surgery has a risk of bleeding, infection, all that kind of stuff. The main risks of this surgery, when we’re putting one of these implants in, the infection risk is 3%. It’s kind of generally what’s accepted. So it’s not trivial. You can damage any structure that we’re operating around. We talked about the muscle that it’s underneath, but there’s a big artery in your neck you can feel, your carotid artery. That big pumping artery is actually how I find the nerve. Now, knock on wood, I’ve never actually injured that during a surgery, but that’s there.
There are other small nerves there, the jugular veins, so there’s a lot of things there. So the risks are low, though. The main one is infection, and I’ve seen... I generally quote people there’s a 1% to 3% risk of having a major complication. It’s pretty safe. It’s outpatient. You go home the same day.
Dr. Alessi: Why does it not work if you have complete paralysis of the limb?
Dr. Conner: So your brain needs to have some connection to the arm. Some information needs to be getting through. And we have to have something to kind of build on. If that hasn’t happened at all, my thought is that it’s telling us that the stroke was too extensive for us to really build on it. So something has to be getting through. Some activity or activation has to be making it through, and if that’s not occurring by six to 12 months, I think it’s unlikely for that to occur.
Dr. Alessi: Is that why the six-to-12-month period to see how much recovery was going to occur on its own?
Dr. Conner: That’s just how they designed the study. Should we be doing it earlier and super charging—
Dr. Alessi: Yeah! Well, I’m thinking of myself, OK? If it was my stroke, I’d want to get on this deal.
Dr. Conner: I have no problem with that. My hands are... I’m a little bit handcuffed by like the guidelines and all that kind of stuff. It’s hard for me to even begin to tell you how much work it takes to get a patient into my clinic all the way through insurance authorization. I have a meeting every month with my whole team to talk about, “Where are all of our patients at?” We have a list of everyone. Where’s everyone at in insurance authorization?
If you guys and your listeners think insurance is a pain for them, on the physician side, it’s just as annoying because I see people who I know qualify, and then I have people who it takes over a year, and I have to go and talk with judges and make write letters all the time, and it’s a huge outlay, but I believe in it, and it works, so I’m willing to do it.
But I would love to do it earlier. Maybe we should do it at three months. Why not?
Dr. Alessi: What’s it cost?
Dr. Conner: That’s always a tricky question. Probably, I think all in, it’s, I don’t know, the device costs, I think 20, 25-thousand bucks. I’m pretty cheap. I’m a pretty cheap date, actually, timewise.
Dr. Alessi: Well, it’s UConn.
Dr. Conner: It’s UConn, right? We’re a state institution. We’re trying to have deals for people. So it’s not, it’s really not bad, and if someone wanted to pay out of pocket, we’d find a way to do that, but that would be what we’d have to do in order to do the surgery earlier.
Dr. Alessi: Let me move on a little bit, and since we’re coming to the end of the podcast, I always find it exciting to talk to you, and I certainly did the last time. What’s the next big step? I mean, what are we looking for in functional neurosurgery?
Dr. Conner: OK, so I’m, we’re going to stay on the topic of vagus nerve stimulation because we’re already there. So we are this close — and I’m holding my pinky and thumb really close together, or my index finger really close together — really close to launching a program and another stimulator called SetPoint. SetPoint — this is where things get totally weird. You can put a stimulator on the vagus nerve, and you can stimulate it to help people with autoimmune disorders get significant relief from their autoimmune disorders.
Now, number one on that list is rheumatoid arthritis, and this is a brand-new device. They are just launching it. We’re going to be one of the first centers anywhere to get it. I just talked with one of the reps today, like our lawyers are finishing up the agreement, but set point’s the next thing, and we’re going to do it for rheumatoid arthritis, but I know they’re looking into other indications for it as well.
And how does the vagus nerve affect your autoimmune system? The argument is that there’s an organ in your abdomen called the spleen. It’s really involved in your immune system, and there is some innervation, that’s nerves, from the vagus nerve going to the spleen, and that’s the thought.
Dr. Alessi: And it’s a different device.
Dr. Conner: It’s a totally different stimulator.
Dr. Alessi: So it’s not like one of those things where you put it in somebody who had a stroke, and they also had rheumatoid arthritis, and their arthritis got better.
Dr. Conner: I do have someone who’s had a stroke who has RA, and I was like, “Man, should we actually, like, follow and see what happens here?” Here’s the thing: They stimulate in different ways to get the electricity to do something different. So it’s actually a very different device, but that’s the thing I’m really excited about. We’re going to have that soon. We’re going to be the only place in Connecticut, to my knowledge, that’s going to have it. We’re really excited about it because those patients can be really disabled. And the reports, the literature, what it says out there is pretty remarkable.
Dr. Alessi: You know, I thought you were getting to the point where you were going to say, “And we’re this close, and this new device is going to result in weight loss.”
Dr. Conner: Ugh. There was a guy, his name is Casey Halpern. He’s now in Pennsylvania. He’d done a tremendous amount of work on deep brain stimulation for weight loss. Unbelievable science.
Dr. Alessi: Did he really?
Dr. Conner: Unbelievable. It was really, I mean, he was really doing it right. And then Ozempic came out, and I haven’t heard him talk about weight loss ais much. It was a little depressing ’cause it’s like, man, he did all the basic science. He did everything, and he had—
Dr. Alessi: He got it all.
Dr. Conner: and he got his lunch eaten.
Dr. Alessi: Chris, thank you. Thank you for your time today. Thank you for everything you do for our patients here at UConn Health.
Dr. Conner: Absolutely.
Dr. Alessi: If you have any questions or ideas for future programs, you could reach out to me at healthyrounds@uchc.edu. Jennifer Walker is executive producer for the Healthy Rounds Podcast. Chris DeFrancesco is our studio producer. Until next time, this is Dr. Anthony Alessi. Please stay healthy.

In 1974, a 31-year-old pitcher for the Los Angeles Dodgers underwent a new procedure to repair the ulnar collateral ligament (UCL) in his left elbow. His name was Tommy John, and so would become the name of the surgery. Today, it’s not unheard of for baseball players to get Tommy John surgery before they turn 20. One factor is, it’s become the norm for many child athletes to specialize, for example, playing baseball not just during Little League season, but throughout the year. With that has come an upward trend in upper extremity injuries, and elbow and shoulder surgeries as adolescents.
Dr. Cory Edgar, UConn Health orthopedic surgeon and co-director of the UConn Institute for Sports Medicine, joins Dr. Alessi to discuss youth sports injuries, the risks of playing a sport year-round with no downtime, the importance of pitch counts, and what parents might consider when it comes to their children’s participation in youth sports.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Cory Edgar:https://www.uconnhealth.org/providers/profiles/edgar-cory
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
UConn Institute for Sports Medicine:https://sports.institute.uconn.edu 
“The Story Behind ‘Tommy John Surgery’” (UConn Health Blog, Oct. 22, 2018)https://health.uconn.edu/health-blog/2018/10/22/the-story-behind-tommy-john-surgery 
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date, timely medical information provided by national and international experts in their field. This podcast is brought to you by UConn Health with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to in any way direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today Dr. Cory Edgar. Dr. Edgar is an MD, Ph.D. He is associate professor of orthopedic surgery here at UConn Health, where he also serves as co-director for the UConn Institute for Sports Medicine. He’s also a team physician. Cory, welcome to the show.
Dr. Edgar: Thank you, Tony. Always a pleasure to talk to you and be on the show.
Dr. Alessi: Let’s talk a little bit about Little League sports. And something we’re always hearing about is throwing injuries in athletes who are younger and younger, and I know that you treat a lot of these in athletes — We talk about Little League, but in all throwing sports. So I really want to emphasize today on upper extremity injuries. My first question is, are we seeing an upward trend in these injuries in general, and especially in a younger population?
Dr. Edgar: Yeah, great question. So overall, we have been seeing a trend in injuries, specifically around the elbow, and also the shoulder, with an uptick in people that need surgical intervention.
Interestingly, some of the newer data that’s come out suggests that this is trending surgery towards a younger throwing athlete, such that up to 60% of all the UCL reconstructions or Tommy John surgeries that we do on the young throwing elbow is now in the age bracket of age less than 20. So we’re seeing an uptick in injuries to the elbow and the shoulder in younger athletes for a variety of reasons.
Dr. Alessi: Let’s talk a little bit about the reasons. Is it because, I mean, it used to be, people played Little League, children played Little League, and that was it, the end of the season, some playoff, everybody got a trophy. But now we’re hearing a lot about travel, and you and I have talked about this at ringside and on the sideline over the years. I mean, it’s now Little League, sectionals, championship, travel, things like that. And in addition to increased expense for parents, it’s also been increased wear and tear on these arms. Is that one of the reasons that we’re facing this problem now?
Dr. Edgar: 100%, that’s the primary reason. I think we can talk about differences from region and weather-related and stuff like that, but the No. 1 reason is based on the amount that these kids are playing. There’s really no downtime for a lot of them. With travel baseball, and certainly in Little League and some of the more monitored associated programs, there are pitch count institutions that really help preserve the amount of exposure that these kids have. But when you get in the travel world, which, I have a kid that participates in travel baseball, you can go to a weekend tournament, the kids can play upwards of five, six, seven, eight games, play multiple positions in which they’re throwing regularly, not just pitching, but pitcher, now to catcher, now going to the outfield, and so there’s a lot of use to that arm. So overuse and tired forearms that now put stress across the elbow is what we’re seeing, and this is what we’re getting.
Dr. Alessi: So Cory, is there a difference when we see young athletes who play in the north where we have winter, and athletes who live in Florida and in the South, where it’s warm year-round and they’re playing baseball year-round?
Dr. Edgar: Yes, yes, there is. We often see Tommy John surgeries in the southern states over the life of an athlete go up. That said, in New England or areas in which there’s kind of extremes of weather changes where you can’t really play baseball regularly in the winter, we’re forced to go indoors, and it kind of forces a shutdown.
So there is this phenomenon that we and others are doing some research in, this start-stop phenomenon. So we see an uptick in the early parts of baseball season, so the Januaries, Februaries, and Marches, when the kids maybe get outside, they try to throw, it’s cold, and we see an uptick in the skeletally immature athlete or the little leaguer’s elbow.
So we’re trying to allow kids to play other sports and be diversified, but they still need to throw. Meaning throw the football, safe, have a catch one or two days a week, and it keeps mild stress across the elbow and strengthening to the flexor pronator mass so it protects them when they, quote unquote, “jump back into things” because they just go back into it really quickly.
And I’ll come up with a program where there’s kind of a throwing transition that happens, so that way there’s a much less risk of acute injury.
Dr. Alessi: Cory, I find that amazing, ’cause I thought you were going to talk the other way and tell us that you see more injuries in people who play year-round and in the South. So that’s fascinating, and I’m sure we look forward to the results of that research.
Alright, so when we’re looking at throwing injuries, are we talking about because they’re throwing harder? The old thought used to be that you didn’t want a young pitcher to throw curve balls and stuff ’cause they were stressing their elbow more, or is it purely just the number of pitches regardless of velocity and technique?
Dr. Edgar: A lot to unpack there. So yes, so I think there’s multiple things. Chasing velo is definitely becoming part of our culture, chasing velocity. And the kids, when we were kids, we were just competing against other kids. Now we’re competing against ourselves and just chasing numbers, with all the information that we’re given with TrackMans or just radar guns. These kids are into it early. So that’s one.
Two, the type of pitches that we throw probably doesn’t make as much as different as the technique by which we’re throwing them. So I think having a young kid that still doesn’t have the ability to grip the ball well and is can’t get through a fastball, and now you’re asking them to throw a curve ball, maybe it’s more a mechanics issue, but purely throwing a curve ball as a thrower in the age of skeletally immature 10 through 14, that’s not the danger. One pitch that we do see a higher risk is what we call a power change, when they actually pronate, or the palm goes down as they throw the baseball, ’cause that disengages the protective muscle or the flexor pronator mass, the big wad of tissue on the inside of your elbow that attaches to that bony prominence called the medial epicondyle.
Dr. Alessi: When we’re thinking about this, we’ve been talking about Little League and overhand throwing, but are you seeing this in softball as well with underhand pitching, or softball throwers as well?
Dr. Edgar: 100% from pitching, totally different mechanics, not an issue in softball pitchers. In fact, they’re much more liberal in the amount of restrictions that we put on softball pitchers for that reason. Now, when they go to overhead throwing, the softball catcher, the outfielder, they still play a lot of games, and we can see really particular shoulder conditions with softball players is more common.
Dr. Alessi: Why is that? I mean, when I watch fast pitch softball players, like here at UConn, I mean, it looks like a tremendous amount of stress on their shoulder more than anything. I’m kind of surprised that we’re not seeing more injuries mechanically on the shoulder from a pitcher.
Dr. Edgar: If you think about how the kinetic chain generates velocity into a ball that you’re hurling towards a catcher and a batter, two totally different mechanisms, and the body is designed well for the torque that’s put on them with the shoulder in the softball motion. They’re generating a lot of power, they’re stopping quickly, and then everything follows through in a range of motion. And their deceleration phase is just swinging the arm back over the top. So the things that decelerate the shoulder in a pitcher, a baseball pitcher, depending on their kinematics, but with most mechanics, they’re coming across, and so those powerful decelerators are your lat, your posterior shoulder muscles, and they have a lot of force that is trying to stop that arm from going forward and then coming across their body, so two totally different throwing mechanics.
Dr. Alessi: What about other injuries that parents need to be aware of in Little League, in terms of lower extremity injuries, are these an issue? I primarily see when they get hit with a comebacker, if they get hit in the head, but fortunately they do wear, pitchers do wear helmets at the younger levels. What other injuries should parents be aware of?
Dr. Edgar: Knock on wood, there’s the usual stuff, you know, the knee injury, the ankle injury. Baseball specific, I think the catastrophic ones, as you kind of mentioned, the comebackers. So getting hit in the chest, I think if anybody sees a kid get hit in the chest and goes down right away, you have to think that there’s an immediate cardiac issue because that can happen. The pitcher can have it. The batter can have it. Eyewear, you can get hit in the orbital, like, all those things are sort of specific dangers for baseball.
But overall, I think arm care, shoulder care is really what we’re dealing with these young kids because we’re trying to, to protect them with the amount that they’re playing, what we’re asking their bodies to take on.
Dr. Alessi: Alright, so here’s what we need to know. What do parents need to know in terms of, what should they do when their child is now doing this? Should they... First of all, I always believe in interviewing the coach and find out what their philosophy is, but what should parents know? What should they be doing? I know that many of us have advocated for playing different sports.
In other words, not just throwing year-round, like some people are, but what do you think parents should be doing?
Dr. Edgar: So two things that you brought up that I think is excellent. So obviously, myself included with my 12-year-old, we all think our kid’s going to have the ability to play in college. So we tend to migrate to that sport and what we call sports specialization becomes early. My kid’s a baseball player, that my kid’s going to play baseball year-round.
The data clearly says that, two things, one, Geno says it all the time, and the data backs him up, that people that are more athletic, meaning play multiple sports, the likelihood that they play a sport in college is, I think, three times greater than just the person that from a young age has focused on that one sport. Athleticism, strength is all key, and that also helps with the wear and tear on a body doing the same repetitive activities. Baseball is very different from a demand standpoint than football, than basketball, than soccer. Now, there’s overlap, but having that diversification gives a little bit of rest, gives the body time to stress another area where another area is recovering.
I personally think, and I’ve seen from experience, my own and with patients, understanding who your kid plays for is really important. I think little leagues, you know, they’re all the dads trying to do their best. That’s not really where we’re going to see it. We’re going to see it when you start to pay money for coaching, when you start to, like, one-on-one coaching, or you start to pay money for, in particular, travel baseball. Is this travel baseball program or coaching invested in our kids getting better, learning the basics, becoming better baseball players, recovery, nutrition, strengthening programs, or do they just want to go out there and play a bunch of games, win a bunch of games, get a bunch of awards so that that program looks better, but at the cost of your child?
So I think that’s huge ’cause you’re, you’re paying money to get your son better, or daughter, better, and more exposure, but you want to limit the risk associated with that
Dr. Alessi: What’s the future look like, in terms of Little League? Are we seeing somewhat of a trend where people are becoming more aware of these injuries and avoiding them, either from the rules standpoint with pitch counts or parents becoming more aware?
Dr. Edgar: I would like to say yes. I think from a regulatory standpoint, the pitch counts that have been instituted in Little League have made a huge difference, meaning that you’re only allowed to pitch 85 pitches for a 12-year-old. If you pitch a certain number, you have to have a certain number of days’ rest. So that’s pretty regimented and pretty clear and pretty accepted.
Not at all applicable for the travel programs. I think parents still don’t really understand. It’s not often, it’s not that uncommon, rather, that people come into my office that have elbow pain that probably could be treated conservatively, and the parent is right away like, “Well, why don’t we just do the surgery now so that way he doesn’t have to get it done later?” Because it’s more convenient to do it when he’s 13 than it is when he’s 17, which obviously from a medical standpoint doesn’t make much sense, and we certainly have that conversation about all the behind-the-scenes on that one.
Dr. Alessi: With that, Cory, I just want to take time to thank you, and thank you for your time today, and thank you for everything you do for Little League athletes here at UConn Health in the Department of Orthopaedics.
Many thanks to my guest today, Dr. Cory Edgar. If you have any questions or ideas for future programs, you could reach out to me at healthyrounds@uchc.edu. Jennifer Walker is the executive producer for the Healthy Rounds Podcast. Chris DeFrancesco is our studio producer who puts all this together.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.

An outbreak of an uncommon but not unheard-of illness is responsible for the deaths of at least three people who were on an international cruise ship. With the rest of the passengers and crew under observation in their home countries — including 18 Americans who went to a quarantine facility at the University of Nebraska — how worried do we need to be about hantavirus? Dr. David Banach, UConn Health infectious diseases physician and hospital epidemiologist, explains what we're dealing with, the public health implications, and how, unlike COVID, the medical community at least has some history with this virus.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. David Banach:https://www.uconnhealth.org/providers/profiles/banach-david
UConn Health Infectious Diseases Division:https://www.uconnhealth.org/infectious-diseases
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to direct your personal healthcare, and that should only be done with your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today Dr. David Banach. Dr. Banach is an infectious disease specialist and he is head of the infection prevention program here at UConn Health. David, welcome to the show.
Dr. Banach: All right. Thank you.
Dr. Alessi: Let’s talk. I mean, there’s a lot of information out there about the hantavirus and how this all came about. Let’s go back and really address how this infection developed. What does it mean to our listeners?
Dr. Banach: Sure. So, kind of taking it back to the basics, hantavirus is a virus that we’ve known about now for many years, even maybe upwards of decades, that exists in the rodent population. So it’s primarily circulating among rodents, particularly in certain geographic areas. And then on certain situations it does infect humans, typically humans who are in close contact with rodents or rodent excrement. It causes what we call a zoonotic infection, where a virus that typically is present in animals moves into a human host. And in most situations, those are one-offs. Someone will have some sort of environmental exposure, could be in any part of the world, could be here in Connecticut, getting sick from this particular virus, and not pass it on to anyone else. But occasionally we do see it occur in clusters, and that’s what’s happened with this most recent situation on the cruise ship that returned and several individuals on that ship became sick and were eventually diagnosed with hantavirus.
I think in terms of the big picture, again, this does seem to have caused a bit of an outbreak on that ship. What it means for the larger public, I think we’re still kind of keeping an eye on it right now. I think the general feeling is that the risk for the general population is low, but I think it’s something that we’ll have to keep a close eye on in the coming weeks.
Dr. Alessi: What’s interesting when we talk about hantavirus, I’d never heard the term until Gene Hackman died of it, right? In the, in the past year, right, Gene Hackman and his wife die of hantavirus, and now we hear about hantavirus again. What’s the difference? He wasn’t in South America. Can you talk a little bit about why he’s dead and now these other people are dead.
Dr. Banach: Sure. I think the illness that his wife, I believe, contracted was the hantavirus, and that, there’s different strains of hantavirus. This particular strain, on the cruise ship, is the Andes virus. That’s like a type of hantavirus, if you will, that causes a specific illness. But there’s also, as I mentioned earlier, hantavirus that’s present in rodents throughout the world, and I think the situation with Gene Hackman’s wife, I think, was linked to some sort of environmental exposure to rodents that she was in contact with.
So it’s same virus, but a little bit different in terms of the way that it’s showing, in terms of individual cases versus, like, a cluster of infections like we’re seeing with this cruise ship.
Dr. Alessi: Now, when we talk about viral outbreaks, right, everybody immediately thinks of COVID. And there’s that fear of, are we going to be dealing with another pandemic? And obviously, with the hantavirus, the mortality is much higher than COVID. So can you talk a little bit about the differences and why this should not be similar to COVID?
Dr. Banach: Sure. “Viruses” is such a broad term. We think about our seasonal influenza viruses. COVID, of course, got so much attention over the last five years in the light of the pandemic. But then there’s other viruses. You remember Ebola was a big viral outbreak from a few years prior to the COVID pandemic, and they cause a wide range of illnesses. Hantavirus can cause quite severe illness. It causes a very severe cardiopulmonary symptom that can often lead to people needing ICU care and even succumbing to the virus.
In contrast to COVID, where the virus tends to be sort of uniformly a respiratory virus, so a little bit different in terms of, like, the clinical illness that they cause. In terms of the way they spread, also different. So COVID was different in a lot of ways. It was a virus that, first of all, we had never seen circulating in human populations.
As I mentioned, hantavirus is not new in that sense, so we’ve known about hantavirus, and we’ve seen individual infections. We’ve even seen clusters in the past. There was a large cluster around 2018, 2019 in South America that was well-studied and described. There’s actually a very notable New England Journal of Medicine publication on this hantavirus outbreak that came as COVID was starting to take off, so it went under the radar in that sense. But it was well-described, related to sort of a cluster of hantavirus infections, this particular type of hantavirus specifically. And so we understand a little bit more about how it’s transmitted. It doesn’t spread in the same way that COVID does in the sense that there’s no established sort of asymptomatic or pre-symptomatic spread.
Remember, that was a big challenge with COVID, that people could potentially be contagious before they showed signs of illness. But then on the other end of the spectrum, hantavirus does cause quite severe illness, and often has a much higher morbidity and mortality associated with it than COVID.
So, yeah, I think there’s differences. I think there’s some differences that make this less likely to spread in a larger fashion as COVID did. But I think it’s still early, that we have to kind of keep an eye on things, and what we’re going to be looking for in the coming weeks are any evidence of secondary transmission.
At this point, the people with infections have all been directly linked to the ship and the original cases of the two individuals who were first ill. But if we start to see additional spread, that would raise some concern that there may be a little bit more going on in terms of its ability to transmit to a the broader population.
Dr. Alessi: David, do antivirals help? I mean, these people who are being treated now who are symptomatic, and are they treating them with antivirals, or, what are they doing for these people?
Dr. Banach: Yeah, at this point, it’s really supportive care. As I mentioned, these patients can develop really severe cardiopulmonary illness, requiring pretty intense supportive care at times.
There’s a wide spectrum of illness. Some individuals may recover with sort of minimal support, but some do become quite sick. So it’s really supportive care at this point. We don’t have an established antiviral per se, and there’s no vaccine available for hantavirus at this point, and that’s largely because these infections, although we’ve known about them for many decades, are quite infrequent.
I think, and the CDC I think, they reported that there’ve been something like 800 cases described since 1990 of hantavirus in the US. So it’s been circulating, but very sporadically. So there hasn’t been kind of a need for sort of a wide-scale public health intervention. But, I think we’ll have to keep an eye on this particular outbreak and see how things unfold.
Dr. Alessi: Do we need to do anything here in Connecticut?
Dr. Banach: I think at this point, the most important thing for people here in Connecticut is to kind of listen to what’s happening. There doesn’t seem to be a direct risk to people here in Connecticut from this infection, but listen to what you’re hearing on the news. See what’s being reported by the public health authorities and, how the situation evolves.
My optimistic hope is that this will be very limited, and the outbreak will subside with now that the appropriate measures are being taken to try to quarantine people who are exposed and prevent spread, but we’ll have to keep an eye on things.
Dr. Alessi: When you say listen, that raises a flag because we don’t know who to listen to anymore, right? We’ve had some issues with scientists leaving the CDC. Do you listen to the WHO? I- if you go on the internet, we’re all going to be dying in the next week from hantavirus. So who do you listen to? I mean, who should, who do you consider the reliable source here for our listeners?
Dr. Banach: I think that is a real challenge for the public to really understand how to get accurate information. With this particular situation, the World Health Organization seems to be the most tied in. Remember, this is an outbreak that started outside the U.S. The initial cases were detected, and those patients are being taken care of in various countries, including, I think, countries in South Africa and other parts of the world. So the WHO is really leading this effort, and they’re keeping updated stats and updated reports on how things are unfolding.
So I think that they’re the most attuned to what’s going on, and I would have confidence in what they’re reporting out. But now the news is taking hold of this story, sometimes for better, sometimes for worse. And take the information that you’re getting as it’s coming to you, but, think about, I think the CDC has been reporting updates on the hantavirus situation based on information they’re getting from WHO and other international sources. But I think those are the kinds of voices that we can listen to at the moment and learn as much as we can.
Dr. Alessi: I want to talk to you a little bit about the incubation and the isolation period. In European countries, most notably Spain and France, people who were exposed on the ship are isolated for 42 days, and they feel that that’s the safest thing to do. Here in the United States, we’re kind of letting people decide for themselves how much they need to isolate, which always shakes me up a little bit. Can you talk about why we’ve taken this relaxed view of isolation as opposed to other countries?
Dr. Banach: I think it is varied in terms of the way that isolation is handled. So the incubation period, like you mentioned, is up to 40 days, so that means patients may not become sick for that period of time. And different approaches are taken to how patients are going to be monitored who were potentially exposed, and different countries are taking different approaches.
I think here in the U.S. we have a few different ways that we’ve handled it. I know there are, the highest risk individuals, I think, are being monitored very closely. I think several people, especially those who are showing any signs and symptoms, are being monitored in, like, a biocontainment unit in Nebraska, I believe.
But other lower-risk exposed individuals can be monitored by public health authorities in a less invasive kind of way. And we’ve seen this also with, thinking about individuals who returned from Africa after taking care of Ebola patients, they were still monitored by public health authorities. For instance, the state or local health department would be checking on them frequently after they returned. They weren’t necessarily confined to their homes. They were allowed sort of limited public exposure as long as they were checking in with the appropriate public health authorities. So I think we, we sort of triage exposed individuals, the highest-risk individuals being monitored the most intensely.
I mean, certainly anyone who has symptoms gets really the most intense monitoring. But we sort of triage based on the level of exposure and ensure that we have monitoring that’s appropriate. But I think the different countries are taking different approaches, and I think we have to rely on our public health authorities here in the United States to monitor exposed individuals appropriately.
Dr. Alessi: David, thank you. Thank you for your time today. Thank you for jumping on this on short notice. You’re always our trusted resource when we have questions around here. So thanks again.
Dr. Banach: Thanks, thanks for having me on, and happy to give any updates as needed.
Dr. Alessi: Thanks again. If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is the executive producer for the Healthy Rounds Podcast. Christ DeFrancesco is our studio producer. Until next time, this is Dr. Anthony Alessi. Please stay healthy.
 

Gone are the days of stroke having only two outcomes — death or disability — now that we have a window of time to treat what still is very much a medical emergency. For Stroke Awareness Month, Dr. Priya Narwal, medical director of UConn Health’s stroke program, joins to discuss how stroke care, recovery, and even prevention have evolved over the years, how the UConn Health Stroke Center harness that expertise, and why it remains critically important to “BE FAST.”
The UConn Health Stroke Center is certified as a Primary Stroke Center by the Joint Commission.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Priya Narwal:https://www.uconnhealth.org/providers/profiles/narwal-priya 
UConn Health Stroke Center:https://www.uconnhealth.org/neurology/stroke 
UConn Today: “First in Connecticut: Ischemic Stroke Survivors Have Renewed Hope with the Vagus Nerve Stimulation Device Now Available at UConn Health”https://today.uconn.edu/?p=214132
UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date and timely medical information provided by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. This podcast is not designed to direct your personal care in any way, but that should only be done in conjunction with your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today, Dr. Priya Narwal. Dr. Narwal is an Assistant Professor here at UConn Health in the Department of Neurology. She’s also director of the stroke program. This is especially timely because the month of May is stroke month where we raise awareness about stroke and the treatments for stroke.
And what better than to have an expert in that field with us. Priya, welcome to the show.
Dr. Narwal: Thanks, Tony.
Dr. Alessi: Let’s talk a little bit about your directorship of the stroke program. Again, that’s a fairly new term in terms of having a program in neurology to direct one specific entity. Can you talk about the stroke program here at the University of Connecticut?
Dr. Narwal: Sure. So when we say a stroke program, it means that the hospital is equipped to provide specialized stroke care and meet the needs of patients who have stroke or are experiencing stroke-like symptoms. So, what that entails is being able to identify stroke symptoms, realizing how urgent it is to address stroke symptoms, and also have a team in place, a team that consists of different specialties and departments such as emergency department, radiology, neurology, neuro intervention, ICU, to be able to provide expedited care to these patients.
Dr. Alessi: Let’s back up a little bit. Let’s define stroke because it’s an old term. We’ve been using this term for many, many decades, and yet it’s still so relevant. Can you share for our listeners a little bit about the specific types of stroke?
Dr. Narwal: Sure. So, a stroke is a medical emergency that is caused by interruption of blood flow to the brain. When we typically use the term stroke, in general, we are alluding to ischemic stroke or strokes caused by a blood clot interrupting the blood flow. However, strokes can be ischemic due to lack of blood flow or hemorrhagic or bleeding types of strokes that are caused due to rupture of blood vessels in the brain.
Dr. Alessi: So, when we talk a little bit about the history of stroke itself, I’m still old enough to know when it was an untreatable condition, right?
Where you brought someone to the hospital and you had them do some physical therapy, but there was nothing to do, right? And then we went to baby aspirin or using aspirin only, and now we’re using terms like “neuroplasticity” and “penumbra” and “antithrombin therapy”. Can you take us through that history of treating strokes a little bit?
Dr. Narwal: Right, so as you said, you know, earlier we did not have much to offer to our stroke patients in terms of acute treatment or minimizing the risk of disability going forward. The main focus was on secondary prevention, meaning you had a stroke, and what do we do to prevent it from happening again, which is where the aspirin came in.
However, in the late 90s, we had this incredible drug that was FDA approved, which was Alteplays or tPA or loosely called the clot buster, which if patients met certain criteria, we could give that medication and it had a positive impact on their long-term functional outcome. So that was a huge game changer when it came to acute stroke treatment, and that was the case for a long time, however, the treatment window was four and a half hours. So, if you were last known well within, you know, the previous four and a half hours, then we could treat you with the medication. But if you know, someone went to bed, woke up with stroke-like symptoms, there wasn’t much more to offer.
Also, if patients have a blood clot in the brain that is large, the clot buster may not work too effectively and those patients may not have as good of an outcome. So, in the past decade or so, we have this new intervention that we’re able to offer to patients, which is called “clot retrieval” or “mechanical thrombectomy”.
So again, if patients meet certain criteria based on what their exam findings look like, what their imaging findings look like, and they have a blood clot that we can go after, we will do that, and that has shown to have a positive impact as well.
Dr. Alessi: You know, it’s so interesting to me because as someone who doesn’t do that in the field of neurology, I think of it as literally they’re going in there and fishing out a clot from the brain.
Dr. Narwal: Right.  
Dr. Alessi: It’s something that we would never even think of. And then watching someone get their function back, I think, for of those of us who have used these clot busting drugs, watching someone get better before our eyes after the administration is, it’s a powerful experience.
Dr. Narwal: It’s pretty incredible, and I think one particular case that left a mark on me was a patient who came with a top of the basilar occlusion, which as you know can be catastrophic.
Dr. Alessi: Right. 
Dr. Narwal: And the patient came in, we were able to do a thrombectomy and he was discharged the next day from the ICU. That’s how good the outcome was.
The patient had practically no deficits.
Dr. Alessi: Alright, and can you describe a little bit, I think our listeners may not know what a "top of the basilar syndrome” is.
Dr. Narwal: Mm-hmm.
Dr. Alessi: Can you explain that severity to folks?
Dr. Narwal: Right, so the basilar artery is a big blood vessel in the back of the brain that supplies several critical areas that are essential to our basic function pretty much like being able to breathe and, you know, move our eyes and just be awake or conscious. So, when someone has an occlusion sitting at the very top of their basilar artery, this whole area of the brain that allows for wakefulness is disrupted and patients look comatose and have a really poor outcome.
Dr. Alessi: So that is phenomenal, really. Lately, we’ve used the "BE FAST" acronym. Can you talk a little bit about the acronym itself, and you know, has it been effective?
Dr. Narwal: I would like to think so. I do think it has helped a lot with community outreach. I do see patients in office who will tell me, you know, we called 911 because we saw this or read this somewhere.
I don’t know if we have a way to measure how effective it’s been, but the "BE FAST" acronym itself stands for “balance issues or dizziness”, “eye problems”, which could be double vision or blurry vision, or missing parts of your vision, “facial droop”, “arm or leg weakness”, “speech changes”, which could be slurred speech or word finding difficulties, and T stands for “time to call 911.”
Dr. Alessi: It’s kind of interesting because, you’re right, it’s probably hard to measure the success of it, but you know, I tend to think that anything that empowers a patient is important, whether it be breast exam, testicular exam cell, any self-examination, and certainly "BE FAST” lets somebody do their own self-examination. So, I’d have to think it’s effective.
Dr. Narwal: Yeah, I’d like to think that too. And also, you know, earlier it used to be "FAST” and then we added the "BE” because very commonly, again, symptoms affecting the back of the brain can be a little bit subtle, like patients may just feel dizzy or unsteady, and oftentimes they wouldn’t think much of it.
So that’s why having the "BE” in there has definitely made a positive impact as well.
Dr. Alessi: I want to talk a little bit about the role of rehabilitation. And, I go back to share a story. Back in the early 80’s, actually, I had just finished medical school, it was 1981, and my wife to be’s uncle had a stroke, and her mother would go to the rehab to see her brother-in-law and make him squeeze a ball so many times with this bad hand.
I mean, he would have to do it, so every day she would drive this home while he was in the rehab. And, you know, naturally I just graduated medical school, so I knew everything, right? So, I told my fiance at the time I say, “you know, I don’t know what she’s doing. That doesn’t do any good. OK? It’s a stroke, nothing’s going to get better.”
And sure enough, the guy regained the use of his hand, left the hospital, went back to enjoy his boating and whatever. So, I was proven wrong. Now we go forward another 40 years, right? And that’s all we do. We know to now use the bad hand to the point where sometimes, right, we immobilize the good hand...
Dr. Narwal: Right
Dr. Alessi: ...to get it going. So, I like to tell people that I learned the most about stroke rehabilitation from my now deceased mother-in-law more than any conference I ever went to. So can you talk a little bit about rehabilitation and the importance of early rehabilitation after a stroke.
Dr. Narwal: Absolutely.
Rehab, you know, is still the cornerstone of post-stroke recovery. Early rehab is what we really like to emphasize on, which is why when patients are admitted to the hospital, they will be evaluated by physical therapy, occupational therapy, speech therapy, to make sure we have an appropriate plan in place when they leave the hospital, whether that’s going to a rehab or outpatient services.
You know, rehab makes a huge amount of difference. There are times when I’ll see someone in the hospital and they come to see me in office and I don’t recognize them ’cause that’s how much better they’re doing, just with rehab alone. And there have been advances in rehab as well.
So, the new device that was FDA approved was Vivistim, which is a vagal nerve stimulation. It’s approved for patients with ischemic stroke who have upper extremity weakness. So Vivistim combined with rehab has shown to have a positive outcome in terms of functional recovery. So that’s been incredible, and we have a bunch of patients here.
We do offer Vivistim here at UConn as well.
Dr. Alessi: Is it an external stimulator or an internal stimulator? How is that done?
Dr. Narwal: Patient can do it themselves, but it’s an implant.
Dr. Alessi: Yeah.
Dr. Narwal: But the patient, so, either they do it during rehab with the therapist, or they can self-stimulate it as well.
Dr. Alessi: OK. Going back to my mother-in-law story, do we ever do enough rehab?
Right. Someone may go to a skilled facility, right, and they’ll get physical therapy once a day, right?
Dr. Narwal: Right.
Dr. Alessi: And even in the hospital, it’s not possible for the physical therapist to be there the whole time, right. And it impresses to me the importance of family involvement, right. And we see that in foreign countries, right.
Dr. Narwal: Right.
Dr. Alessi: I practiced in Italy before when I went to medical school, and you know, the family is always at the bedside, and, even in Haiti, we would instruct the family on how to do the therapy. Have we gotten to a point where we can increase that, but what’s the solution to that?
Dr. Narwal: So, I think a lot depends on how much the patient can participate.
I think that guides a lot of where they end up going. So, if someone is requiring a lot of support or cannot stand up without 2% assist, they cannot go to an acute rehab and undergo that intensive therapy, versus someone who was able to do that. So, I think how much therapy they end up getting also depends on how much they can tolerate.
And, you know, once they leave the nursing facility, there’s always the option of doing at home rehab. And a lot of my patients actually just like you said, do exercises on their own. Like they will ask the therapist what can they do on their own and they will just, you know, squeeze the ball or open and close their fist and do all of that stuff all by themselves.
Dr. Alessi: Priya and wrapping up, what’s the future? What are we looking at in the future of stroke care, and I know it’s such an exciting field, but when you go to meetings and talk to people, what could we expect?
Dr. Narwal: I think in terms of acute treatment, one of the big next steps is broadening the number of patients we can offer acute treatments to, right?
So like if someone has a large vessel occlusion and their scan doesn’t meet the current parameters that we look for, we’re trying to broaden those parameters. Like even if someone has a larger core infarct, can we still go in and perform thrombectomy? Will that have a positive outcome on them? So that’s absolutely the big next step.
And the other thing that’s of great interest is focusing on etiology. You know, a lot of times people say, oh, they had a stroke. All you can do is give aspirin and that’s it. But it’s not that straightforward. I think a lot of focus is now shifting on doing targeted therapy in the sense of really, you know, focusing on the stroke etiology, trying to identify that and then addressing that as opposed to like a blanket approach.
Dr. Alessi: Priya, thank you. Thank you for your time today, and really thank you for everything you do here at the University of Connecticut and for our patients.
Dr. Narwal: Thank you for having me, Tony.
Dr. Alessi: Many thanks to our guests today, Dr. Priya Narwal, who’s director of the stroke program here at the University of Connecticut.
If you have any questions. Or ideas for future programs or any specific question for Dr. Narwal, you could just reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer of the Healthy Rounds podcast.
Chris DeFrancesco is the studio producer of the Healthy Rounds Podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.

In between studio guests, Dr. Alessi brings new information to earlier conversations about messenger RNA and how it’s showing promise in treating pancreatic cancer, a study further debunking the Trump Administration’s assertions about the safety of Tylenol, and whether reasonable solutions to physician licensing challenges could improve access to care.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Jan. 27, 2026, with DPH Commissioner Manisha Juthani:https://healthyrounds.podbean.com/e/the-impact-of-public-health/ 
Jan. 13, 2026: with Dr. Andy Agwunobi, UConn Health CEO:https://healthyrounds.podbean.com/e/premiere-with-dr-andy-agwunobi-uconn-health-ceo/
Feb. 24, 2026: with DSS Commissioner Andrea Barton Reeves:https://healthyrounds.podbean.com/e/medicaid-myths-keeping-ct-families-healthy/
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date, timely medical information brought to you from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys.
It is not designed to direct your personal healthcare, which should only be done by your physician. I am your host, Dr. Anthony Alessi, and this week we’re going to chat a little bit about some topics that, some of which we’ve talked about in the past, but now we have new information on, and I think it’s information that we need to provide you, our listeners to provide best healthcare overall, and really pay attention to what’s going on that is publicized and how it affects all of you. And there are three specific topics I want to touch on.
The first is pancreatic cancer. I also want to talk a little bit about a exciting study that was just published in The Lancet on Tylenol use in pregnancy, and then we’re going to talk about physician licensing in the United States. So with that, let’s get started.
This week at the National Oncology meetings, they presented new data on the treatment of pancreatic cancer. Now, for those of you unfamiliar with pancreatic cancer, it is one of, if not the most deadliest cancer, and the reason being that typically by the time you find evidence for the tumor, it has already metastasized, it is already spread to vital organs. So with that, it’s very difficult to treat. In the studies published, one in particular I want to talk about, they use messenger RNA as the vehicle for treatment.
Now, I know I’ve talked about this before, but it bears repeating messenger. RNA is just that, it’s a messenger, and we chatted with Dr. Juthani about this. It does not alter your DNA in any way, shape or form. So the best analogy I could come up with was, it’s a messenger. So if you get a delivery, right, to your house, whether it be from Amazon or GrubHub, a messenger comes and delivers a package, then they leave. That’s exactly how messenger RNA works. So when the messenger comes to your house, they don’t go in your house and start rearranging your furniture, right? And I think that’s the misunderstanding here is they think the messenger RNA goes in the cell and starts mixing things up. That’s not the case.
But what it does do, it brings a message that trains your immune system to fight the cancer with your own body. Your own T cells are now redirected to fight the tumor. So in the case of pancreatic cancer, what they do is they go in, a surgeon goes in, removes the tumor. They take the tumor and use material from the tumor to create your own personal vaccine through messenger, RNA, which is injected by infusion. And the cases that were presented, it’s typically eight infusions.
And the results have been fairly astounding. Now it’s a small, early study and only 16 people were studied, but eight of those had a positive response. The first patient has actually lived six years beyond the diagnosis, which is astounding for pancreatic cancer. For two people, their tumors actually returned and they worsened, and the other six had no benefit. So it’s interesting to look at this, but we also have to bear in mind that the federal government has stopped all research on Messenger RNA, because the person in charge of Health and Human Services, Bobby Kennedy, he is against messenger, RNA, because it’s a vaccine. Even if it’s a vaccine to kill cancer, he’s against it. So the research being done is being privately funded.
Our government has walked away from this, what has become one of the greatest hopes we have in the treatment of cancer, and it just, it makes me personally upset. Because these cancers have affected my family, as many of you who listen to this podcast. So we need to stay on this and really follow this along, and it’s just so hopeful.
The next topic is one to revisit, and this is a recent article published in Lancet Obstetrics and Gynecology, where again, there has been misinformation out there regarding the use of acetaminophen, where they are out there saying that during pregnancy, if you use acetaminophen, it increases the risk for autism and other neurodevelopmental conditions.
So again, this comes directly from the president of the United States, who says, don’t take acetaminophenm and again, our esteemed director of Health and Human Services, who is a non-physician, non-scientist, Robert F. Kennedy Jr. And I wanna stress the “Junior” because he’s far from his father.
But with that, what we have is a situation where they looked at retrospective studies. And they look back at 43 studies, so talk about a waste of time, but here they are. They go back and do a meta-analysis of 43 studies. And once again, when they focused on these studies, they found that there is no evidence that acetaminophen in any way causes ADHD or causes children to be on the autism spectrum. So I’m hoping we could put this aside.
The next topic I wanted to touch on was licensure, physician licensure, and what happens is, in the United States, we don’t have national licensure for physicians. Every other country in the world, when you get a license, you could practice anywhere in that country. But in the United States, you have to have an individual license for every state, and it’s pretty costly. Here in Connecticut, I believe it’s now $575 a year we pay for a license. So in every state you, you pay a fee commensurate with that; some states, I know it’s 600, but you have to reapply.
And and the reason that this becomes a problem is because there’s a shortage of physicians in many rural areas. So a field of telemedicine has developed, especially for neurology and other specialties, where there aren’t enough people in these rural communities, they can be accessed by video and through telecommunication, something we talk about a lot on this program. So what has happened is that even to do telemedicine in another state, you need a license In that state. That wasn’t the case during COVID. That rule was waived, but now they’re back on it. And it’s really sad, from the standpoint that they are in any way inhibiting physicians who are duly licensed and have credentials that have been presented to a state, from practicing in other states.
But here’s what’s happened. So there’s been a push for national licensing, and what they’ve come up with is the Interstate Medical Licensing Compact, and this is the IMLC. This was just approved in March, and it’s basically a system where you can apply with all your credentials, and those credentials can then be shared with other states so that you can more easily get a license in another state.
The one thing these states did not give in on was paying those fees in that state. So again, we come up with the problem of greed versus care, and it’s something we talked about with Dr. Andy Agwunobi and the fact that if we’re going to revise our healthcare system in any way, shape, or form, we have to have everybody having their incentives aligned.
So the idea of a state saying, “Wait a second. I might be able to get more physicians, give the people of my state more access, should be something I want to do,” without trying to make a few hundred bucks off of a doctor who may only be called on to see one patient or two patients a year in that area in your state. But you want access to those doctors. So again, it’s something we really need to rethink.
Apropos to that, commissioner Andrea Barton Reeves and I had a conversation off-mic when she did the podcast with me a few months ago, and that was regarding retired physicians. Many physicians are retiring at a younger age. So when they retire, often they give up the license, they give up their medical license ’cause they don’t want to pay the $575 each year. But many also have the desire to volunteer their time. They’re willing to volunteer to just stay active in medicine without being reimbursed. It’s kind of like paying back the system that supported you all this time.
But clearly if you’re going to go volunteer, it’s not worth paying five or $600 so you can volunteer. So I introduced to her the idea that the state of Connecticut may want to consider that if a physician is willing to volunteer in a qualified health facility. And the one we used as an example was the Homeless Hospitality Center in New London, where homeless patients who are discharged from the hospital can come and get some extended care until they’re able to go live independently. So I know of several physicians who would be willing to volunteer and give their time. But again, there’s this hurdle, actually there are two hurdles: One, getting a license, and two, med malpractice insurance.
Now, fortunately, when you participate in a federally qualified health facility, you are indemnified by the federal government, so there isn’t a need for additional malpractice insurance, but I’m hoping Commissioner Barton Reeves does bring this to the governor and possibly something could be worked out so that physicians who retire and may want to spend some time volunteering and giving back can do so without the encumbrance of having to pay for a license in their state.
Many thanks to all you listeners for getting ideas into us about topics that we’re going to be talking about in some of these future sort of podcasts that we use in between having guests. This has been a lot of fun for me ’cause it’s a chance to really update everybody on topics we have been discussing over the past several months. So if you have questions or ideas for future programs, you can reach out to me at healthyorunds@uchc.edu.
Next week we’re going to resume having guests, and our guest is going to be Dr. Priya Narwal. Dr. Narwal is a neurologist, she’s the chief of the stroke service here at the University of Connecticut, and we’re going to be chatting with her in honor of stroke awareness.
Many thanks to Jennifer Walker, who is the executive producer for the Healthy Rounds Podcast. Chris DeFrancesco is our studio producer here, and Tessa Rickart is in charge of social media for the Healthy Rounds Podcast. Until next time, this is Dr. Anthony Alessi. Please stay healthy.