Healthy Rounds With Dr. Anthony Alessi

An advanced treatment for certain types of cancers is now available in central Connecticut, led by Dr. Kapil Meleveedu, director of UConn Health’s Blood and Marrow Transplant and Cellular Therapy Program. He joins Dr. Alessi to explain how this form of immunotherapy, known as CAR-T, essentially retrains the body’s T-cells to recognize and fight the cancer. Some studies have shown significant promise in improved life expectancy and even potential cure in some specific blood cancers. Hear why Dr. Meleveedu says talking about it “almost feels like science fiction.”
Submit questions for the Healthy Rounds Podcast:healthyrounds@uchc.edu
Dr. Kapil Meleveedu:https://www.uconnhealth.org/providers/profiles/meleveedu-kapil
Blood and Marrow Transplant and Cellular Therapy Program at UConn Healthhttps://www.uconnhealth.org/cancer-blood-disorders/services-specialties/blood-marrow-transplant-cellular-therapy
Carole and Ray Neag Comprehensive Cancer Center at UConn Health:https://www.uconnhealth.org/cancer-blood-disorders
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 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 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. Kapil Meleveedu. Dr. Meleveedu is an assistant professor of medicine here at UConn Health, where he serves as director of the Blood and Marrow Transplantation program, as well as director of the Cellular Therapy program. Kapil, welcome to the show. 
Dr. Meleveedu: Thank you so much. It’s a pleasure to be here.  
Dr. Alessi: So the last time we checked, and I looked at my notes, was almost exactly two years ago. We talked about marrow transplantation. We talked about cellular transplantation and stem cells. Now they’ve added onto your title. So since we last spoke they added Director of Cellular Therapy program.  
Dr. Meleveedu: Yeah.  
Dr. Alessi: Can you tell us what that means?  
Dr. Meleveedu: Yeah. I’m glad that you kind of led me with that. I think it really ties into what we’re going to talk later throughout the show. So cellular therapy, by definition, means you’re using human body cells as treatments. 
Usually, we are used to thinking drugs, pills, radiation, chemo, when we talk about treatment options. The broader context of cell therapy means you’re actually utilizing the power of your cells, usually your immune cells, to eradicate or treat or control the cancers. So that’s cellular therapy. 
There’s another nuance to it. Sometimes people call it adoptive cellular therapy, so it’s a broader umbrella of treatment option.  
Dr. Alessi: So it sounds like personalized medicine if you’re using your own cells. Does that fit into that broad category now?  
Dr. Meleveedu: It does, and it doesn’t. Why I say that is you could define stem cell transplant as well as a form of cell therapy because there what you’re doing is using another person’s stem cells, infusing it into a patient. 
So the oldest form of cell therapy has been transplant, which one could say it is personalized, but I think the definition of personalized has kind of evolved more recently into selecting what is uniquely specific for a patient. So I would say somewhat in the evolution of the definition in cell therapy. 
In the topic that we might kind of cover about CAR-T, one could argue, yeah, you are utilizing a person’s own cells to derive it, the treatment that you could use. So it is a form of personalized therapy, but it does encompass all kind of cells- That you might use otherwise to treat cancer.  
Dr. Alessi: Right, and when we talk about personalized medicine or personalized therapy, correct me if I’m wrong, but we’re talking about creating a therapy that’s only purpose is for that individual patient. 
In other words, it’s not going to work broadly. The same concoction, for lack of a highly medical term- Yeah, it’s not going to work for everyone because it’s their own cells being used.  
Dr. Meleveedu: Correct. I think it’s, again, you know, partly correct in the correct definition why I say that the current FDA-approved cell therapy is very individualized and personalized. 
But where the field is growing it’s to be able to use cells from the shelf, we call it off the shelf, so that it’s already pre-prepared, and then be able to use in multiple different patients. So there is that concept, not even a concept, there are clinical trials that’s ongoing for off-the-shelf cell therapy. 
So I would say, you know, yes and no again to that answer because both kind of models exist,  
Dr. Alessi: So you know, usually it’s the end of this program where I ask for something new that actually blows my mind. But you started right from the beginning with the idea that you could take cells off the shelf and be able to use that in any patient or in a group of patients to fight cancer.  
Dr. Meleveedu: Yeah.  
Dr. Alessi: And that’s phenomenal. I mean overall, because again, let’s talk about the types of cancer you’re treating?  
Dr. Meleveedu: So I am a hematologist mostly at this point in my career. I have kind of narrowed down my expertise to treating blood cancer specifically. Within our own department, we are highly becoming sub-specialized, which is usually the natural route. 
So I have kind of started focusing more on acute leukemias, all blood cancers, myelodysplastic syndrome, AML. There is a condition called chronic mono- myelomonocytic leukemia, CMML. And then also I do handle lymphomas at this point, all kind of aggressive lymphomas, non-Hodgkin’s lymphomas, indolent lymphomas. 
So mostly leukemias and lymphomas are where I’m kind of currently focused on. My colleague does multiple myeloma, which is another form of blood cancer, which is going to be relevant for the discussion that we’re going to have today.  
Dr. Alessi: Let get right to it because over the last couple of years from our last discussion, we were just starting to hear about CAR-T therapy, and CAR being these chimeric antigen receptors. Can you explain it to us? 
Dr. Meleveedu: Yeah. 
Dr. Alessi: In fairly simple terms what are these chimeric antigen receptors, and how do they play into treating these cancers?  
Dr. Meleveedu: It’s almost feels like science fiction when I talk about CAR-T every time, and in some sense it is. I’m hoping that I can convey that excitement when I talk about it. 
 
Dr. Alessi: I’m excited already  
Dr. Meleveedu: Yeah. 
Dr. Alessi: Go right ahead.  
Dr. Meleveedu: So the idea is using a person’s most powerful immune cell, which is a T cell. So you’re collecting a T cell, which is circulating in the bloodstream, and you’re taking it out of the body, and you’re using genetic engineering to have the T cells sprout a new receptor. 
And the reason we call it chimeric antigen receptor, I’ll come to that, but you’re specifically generating a new receptor which has been now trained to attach to a specific protein on the cancer cell. Once that’s prepared outside the body, you’re retrieving it back and infusing into the bloodstream back, where now these T cells have been powered to seek the specific cancer that it’s supposed to go after, find it, kill it. 
Dr. Alessi: And those T cells can only be used for that person’s cancer?  
Dr. Meleveedu: Correct. There’s only very specific kind of blood cancers that currently this procedure has been approved for. Because you have to have those specific target proteins.  I think the success has been in what we call as B-cell lymphomas or B-cell malignancies, so blood cancers. 
For example, acute lymphoblastic leukemia, non-Hodgkin’s lymphoma, which is of many different types, diffuse large B-cell lymphoma, follicular lymphoma, marginal zone lymphoma. So there’s multiple types of B-cell non-Hodgkin’s lymphomas and as well as multiple myeloma. So these are the cancers currently where this kind of therapy has been groundbreaking, has made a substantial difference in the outcomes as well. 
Dr. Alessi: When you describe the process, you talked about how we send the blood out to be genetically engineered.  
Dr. Meleveedu: Yep.  
Dr. Alessi: Where does it go? I mean, you know, do you run it down to the mall, to the genetic engineering store? How long does it take?  
Dr. Meleveedu: Yeah, very valid questions. 
So the genetic engineering is currently preparatory for the companies that have been FDA approved to offer this. There are some academic centers in the country which they are preparing these CARs independently, but not, you know, universal. So they’re collected, and then they are being manufactured in those pharmaceutical factories or companies, which is where they introduce a genetic vector and train the T cells to sprout this antigen, chimeric antigen receptor. 
And to your point, how long does it take, has been a critical point of discussion at this point in 10 years down the road from CAR-T’s, it can take anywhere up to 20 to 30 days for that process to take before you receive it back. And most of it is because of very strict quality control that has been set by FDA, which is very important for safety. 
Dr. Alessi: How did we figure this out? How did somebody come up with this idea? I mean where did this come from?  
Dr. Meleveedu: It’s been something that’s been studied 30-plus years, believe it or not. It’s, you know, the earlier idea of where you could utilize a person’s T cells against cancer has always been there. 
But the challenge has been manufacturing it to the point that these T cells can come back alive and stay alive in the bloodstream and do what it’s supposed to do. So it took 30-plus years for this field to evolve. The earliest CAR-T structure, we call it, or the currently FDA-approved CAR-T construct, believe it or not, has been actually discovered or developed, uh, in 2002 to 2005. 
It’s already a 20 year old product that is currently having to go through the clinical trials and human trials to get it approved. We are standing on the shoulders of many scientists and brilliant minds who thought this could work and they were right. 
Dr. Alessi: Okay, there has to be a downside.  
Dr. Meleveedu: Yeah.  
Dr. Alessi: Okay? Let’s start with how often does it work?  
Dr. Meleveedu: In the cancers that are currently being approved for, historically has been the patients or the diseases where all kinds of chemotherapy that we used to have were ineffective. The outcomes were unfortunately very much limited. 
What I’m talking about is less than six months to one year, because of any chemo that we used to have, including transplants that we had talked about in the previous show, none of that modality was actually helping control the cancer. So that’s the space this CAR-T was studied in to begin with, because now you’re moving away from the traditional concept of chemo, you’re unleashing the power of immune system against cancer. 
And if you think about that logic and the clinical trial that showed, is the most long-term follow-up is for relapse refractory diffuse large B-cell lymphoma, is what I’m kind of using as an example, and we just had a 10-year long-term follow-up data which showed that more than 50% of those people are alive without disease. More than six years to 10 years out and potentially cured. And that’s a heavy word sometimes that we worry about using, but we’re seeing the curve that is plateauing. So, it does work, not in everyone, I would say, but if it were to work in the first two years, and then it works forever. Technically, that’s the literature that we’re seeing, that the early responses translate to long-term potential cure. 
Dr. Alessi: What are the side effects?  
Dr. Meleveedu: One has to be very careful of course. We are meddling with a person’s immune system here. The most important side effect or couple of side effects that I can think about is you have now invoked almost what I would like to say a beast in yourself, which was always there. 
T cells usually don’t get activated by themselves. It almost always requires a middleman to show itself to the cancer, and then T cells are activated. Now, what you’re doing with the CAR-T, the receptor design that I talked about, is you are trying to develop that receptor where you can bypass the need for the middleman, so the T cells now can directly find the cancer. 
What it brings in itself is now the possibility the T cells can proliferate uncontrolled. We call it cytokine release syndrome when a complication happens. What happens is that the T cells now have started this highly strong immune response, which looks like you’re having the worst flu of your life. It could be fevers, body aches, low blood pressure sometimes, and low oxygen levels. 
So that has to be very carefully monitored. You should have in the hospital monitoring system, expertise on your side. But it’s common. You could see a grade one or two toxicity; we call it, in almost eighty percent of the time. So manageable, treatable, requires some strict attention, but treatable. 
So that’s the most common one, cytokine release. The second one is what we call as a neurological syndrome, where again, these excess protein activations sometimes causes a person to behave as though they are having almost like a stroke. It’s not exactly like a stroke, but they could have confusion. 
They could have word-finding issues. We call it ICANS or neurotoxicity. These are the most common toxicities one needs to be careful about.  
Dr. Alessi: If someone is treated with it, has a response, and then their cancer returns, can you use it again?  
Dr. Meleveedu: Excellent question. So that brings us to the idea, how does a cancer return after a CAR-T? 
And that is where current research is kind of looking into. The cancer relapses expressing a different protein that the CAR-T was targeting. So normally, nowadays, all the FDA-approved CAR-Ts target two proteins on the cancer cells. One is called a CD19, the other one is B-cell maturation antigen, or BCMA. 
When cancer relapses, we have certainly seen this where the cancer now has not expressing CD19, instead expressing another receptor, CD22 or CD20, on the surface. There are currently clinical trials which are looking at using a different CAR-T to target those new cancer relapses target antigens, and then see if that works, but not currently approved. 
Currently, the only approved ones are the CD19 and the BCMA-targeted approaches.  
Dr. Alessi: And we’re the only program around?  
Dr. Meleveedu: Around in this area, for certain. In Connecticut, Yale has been doing this kind of therapy probably for a few years already, but we’re the second, and the only one in the central Connecticut area. 
Dr. Alessi: Wow.  
Dr. Meleveedu: Yeah.  
Dr. Alessi: Wow. Well, Kapil, you never cease to amaze me and, blow me away on things being done, not only in your field, but here at UConn Health. Thank you for your time today. Thank you for everything you do for our patients.  
Dr. Meleveedu: No this is very exciting. Thank you for having me, because, you know, this is a need for the other. 
We believe in this cause. We are a public university. We have a need. Access has been a big problem in CAR-T. You know, this is groundbreaking, nice to talk about, but if you can’t get the treatment into a patient’s arm, I mean, it’s futile. We’re very happy to be part of that solution, at least offering for the patients in the area to bring such groundbreaking therapies closer to home. 
Dr. Alessi: Kapil, thanks again.  
Dr. Meleveedu: Thank you very much, guys. Thank you for having me, Dr. Anthony.  
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, and Tessa Rickart is in charge of social media for our podcast. 
Until next time, this is Dr. Anthony Alessi. Please stay healthy. 

How much of a factor is genetics when it comes to breast cancer, and how does that inform the best treatment approach? As Dr. Daniel Morgenstern, who specializes in breast cancer and genetics at UConn Health, explains, there's quite a spectrum when it comes to types of breast cancer, and immunotherapy, while promising, is not effective with a majority of them. Dr. Morgenstern also discusses the evolution of breast cancer awareness, today's recommendations on mammograms, and how personalized medicine figures into the future of breast cancer treatment.
Submit questions for the Healthy Rounds Podcast:healthyrounds@uchc.edu
Dr. Daniel Morganstern:https://www.uconnhealth.org/providers/profiles/morganstern-daniel
Breast cancer diagnosis and treatment at UConn Health:https://www.uconnhealth.org/cancer-blood-disorders/services-specialties/breast-cancer
Breast cancer screening at UConn Health:https://www.uconnhealth.org/cancer-blood-disorders/prevention-screening/breast-cancer-screening
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, 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 Orthopedic Surgery and a grant from Coverys. This podcast 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. Daniel Morgenstern. Dr. Morgenstern is an associate professor of medicine here at the University of Connecticut, and working at UConn Health in the Carole and Ray Neag Comprehensive Cancer Center. His specialty is breast cancer and genetics. 
Dan, welcome to the show.  
Dr. Morganstern: It’s great to be here.  
Dr. Alessi: Let’s chat a little bit. As we all know, this is Breast Cancer Awareness Month. Nowhere in our history have we seen a more successful campaign than Breast Cancer Awareness Month, right? National Football League players are wearing pink. Baseball players are wearing pink. 
Everything merges at one time. And yet, I guess my real question is, in this period of time where we’ve raised awareness of breast cancer, what has been the result? Are we making headway?  
Dr. Morganstern: Absolutely. I mean, I think if you go back to the 1970s and think about Betty Ford, when we all remember her diagnosed, you know, one of the original problems was that this was a disease in the shadows, and there was all kinds of embarrassment and shame associated with that. 
And as you mentioned, this has sort of been flipped, the script’s been flipped, and, really no one has shame anymore. People are comfortable talking about the experiences they’ve had, peer support among survivors, and again, it’s sort of out of the cloaks of embarrassment and so forth, and really something that everyone feels comfortable addressing with their primary care provider, screening, and so forth. 
So it really has become something that I think has worked to improve screening and outcomes.  
Dr. Alessi: You know, one of the things that’s impressed me most about breast cancer care is the development of a multidisciplinary team that approaches breast cancer. Can you tell our listeners what they should be looking for in a team? 
Because it’s not just a surgical approach, as it has been in the past. Can you talk a little bit about the team here at UConn Health and the approach to breast cancer?  
Dr. Morganstern: So yes, it is a multidisciplinary disease, and our patients will be the first one to tell you that, both in a positive and negative ways. 
In a positive way, they have a group of physicians. You might say the triad is between a medical oncologist, a radiation oncologist, and a surgeon. So they have three people who independently but collaboratively are thinking about their case, and all cases are reviewed at our multidisciplinary tumor board, and this results in sort of a optimized outcome and a tailored outcome for each patient. 
I say there’s a flip side of it, which is I always say that the most multidisciplinary person of all is the patient because they’re subject to both the benefits and also the toxicities of all therapies. So sometimes those are sort of mitigated. For example, we have data that shows that in some patients, if they take an endocrine therapy, they can safely defer radiation therapy. 
So not only do we work together, sometimes we decide who can step aside and patients who can defer various modalities.  
Dr. Alessi: I just want to talk a little bit about probably a somewhat controversial topic that shouldn’t be controversial, and that is mammography, right? When a woman should get mammograms, right? 
We’ve had the Professional Services Task Force, the Federal Task Force come out with their recommendations. And in many cases, that’s been in conflict with the professional societies. Can we clear up for our listeners, when should women begin to go and get a mammogram?  
Dr. Morganstern: Okay. Correct. 
There are different recommendations. The American College of Radiology recommends annual screening for average-risk women beginning at age forty, with the U.S. Preventative Task Force prior to this administration, recommending a more liberal onset that considering once every other year mammography within the forties and not going annually until the fifties. 
I would break down two aspects of how you address this question. One is a public health question. Where is our money best spent in screening and so forth? And the other relates to how screening could harm if misapplied to the wrong population. And what I would say is that unquestionably there is some element of what we call over-diagnosis. 
We know that with the onset of mammography from the nineteen eighties to the two thousands, there was a skyrocketing incidence of early-stage breast cancer, but not a requisite decrease in later stages of breast cancer, and much of that was the DCIS or so-called pre-cancer, stage zero. But I think we’ve pretty much landed at an annual mammography for the average risk patient beginning at age forty. 
Now, very interestingly, Laura Esserman spearheaded a trial that was reported last year called the Wisdom Trial, which was an online phone app-based research which risk-stratified patients for either more intensive screening than annually or less intensive screening than annually based on risk factors like genetic testing, breast density, and so forth. They actually showed with that study that even when they had risk-adapted screening with many women having screening at lesser intervals, the outcomes were essentially the same in terms of the ability to identify early-stage disease and cure rate. 
So this was a very important contribution. There may be more evolution of our guidelines in the future where we can say to someone that based on your polygenic risk score and your risk factor estimates, maybe they can defer to every other year. And that is a growing emerging field that I have a lot of interest in. 
Dr. Alessi: Let’s talk a little bit about taking a step back, you mentioned risk factors, right? I’m assuming those include smoking and other things such as that. But what else? How big a role do genetics and family history play? And do you recommend that if there’s a family history, women begin getting mammograms earlier? 
Dr. Morganstern: So I’ll use our vocabulary a little bit carefully. We can talk about familial breast cancer where there seems to be some overabundance of breast cancer within a family tree, but no gene identified. And then we can talk about those cases where there’s sort of a smoking gun, if you will, BRCA1, BRCA2. 
The latest and most important gene second to those is PALB2. In those cases, we can say that probably about five to seven percent of breast cancers can be explained by a single gene mutation that predisposes the woman to develop breast cancer or man. Alternatively, we know there’s this other familial clustering that occurs in families that is independent of any single gene mutation, and this is the growing field of polygenic risk scores where they look at all throughout your genome, little subtle changes that by themselves don’t do anything very much. 
But if you have a number of these, it does elevate your risk. Again, this is a field that’s a hot field that I hope to be doing some research in terms of risk stratification as well.  
Dr. Alessi: Is it because of the genetics that some women advocate for bilateral mastectomies?  
Dr. Morganstern: So again, we have to talk carefully about which genes and so forth. 
So we call BRCA1, BRCA2, and PALB2 highly penetrant or highly to moderately penetrant genes where the cumulative lifetime risk of developing breast cancer and developing breast cancer at early age is quite high, over 50%. And in those patients, risk-reducing mastectomy and reconstruction has come a long way. 
Obviously, it’s an option for those patients, although there are many patients who choose to do surveillance with enhanced surveillance such as MRI as well, and this has been shown to save lives as well in that patient population. So, there is an alternative to risk-reducing surgery. When we have lesser penetrant genes such as CHEK2, ATM, which might be having a lifetime risk of breast cancer anywhere from like 15 to 30%, in those individuals, most do not opt for risk-reducing surgeries. 
Dr. Alessi: I’m going to shift gears a little bit and get into a field that’s somewhat confusing even for me, and that is receptors, right? Are receptors good? Are receptors bad? Are some good, some bad? Because we hear about these receptor-positive, receptor-negative tumors. Can you give us the Cliff Notes version of it? 
Dr. Morganstern: Absolutely. So the most important thing to take home is that most breast cancer is estrogen receptor or hormone receptor positive, 70% in fact. So when we think about that, we also think about that gains and improvements in care in that 70% majority make the most public health impact. About, depends on where you get your data from, but roughly 10 to 15% respectively of HER2 receptor-positive and triple-negative breast cancer, namely negative for the estrogen receptor and the HER2 receptor represent the remaining population. 
But a full 70% is by far the most common type of breast cancer, and the most curable type of breast cancer as well is estrogen receptor-positive.  
Dr. Alessi: So it’s good to have estrogen receptors?  
Dr. Morganstern: Right. It’s because estrogen-dependent tumors respond to an armamentarium of things that are lesser impact in terms of side effects and tolerability on patients such as estrogen blockers, tamoxifen, aromatase inhibitors, and soon to be approved is a new class of drugs called SERDs, or selective estrogen receptor, down-regulators or degraders. 
And one that appears to be on the cusp of FDA approval as a preventive, after a breast cancer diagnosis is a compound called juridestrant  
Dr. Alessi: So we know we’ve been hearing a lot about immunotherapy for cancer, right? Most notably, we had Dr. Callahan on recently, and we talked about melanoma and a new term for me, neoantigens, and she explained that. 
Where are we with that in breast cancer? Will we someday or are we on the verge of an immunotherapy, um, for breast cancer?  
Dr. Morganstern: Well, sort of circling back to that seventy percent, in that seventy percent of people, no. And there is a good reason which you mentioned, which relates to those neoantigens and, and effectively, estrogen receptor-positive breast cancer so closely resembles normal breast tissue that there are not these neoantigens present by and large. 
Okay. And we don’t see breast cancer developing amongst immunocompromised individuals. So there’s the sense that at least the most common type of breast cancer is not under immunosurveillance to start with, and hence why it’s not been a particular success, but continues to be sub-- explored in estrogen receptor-positive. 
Conversely, in estrogen receptor and HER2 receptor negative, aka triple-negative breast cancer, some of which is represented by carriers of the BRCA1 and BRCA2 mutation, there are these neoantigens. And, we’ve shown that an immunotherapy called pembrolizumab or brand name Keytruda, has shown improvements in survival both in early-stage breast cancer when given prior to surgery in combination with chemotherapy, and we’ve seen also improvements in how long women can live after a relapse of triple-negative breast cancer using that same drug integrated with chemotherapy. 
Dr. Alessi: That’s very interesting. In wrapping things up, what’s next? What are we going to hear about next in the field of breast cancer treatment?  
Dr. Morganstern: Well, I think the story continues to be one of what I would call divide and conquer. So we have our subtypes of breast cancer I just talked to you about, hormone receptor-positive, triple-negative, and HER2-positive. 
And we are gradually subdividing this broad array of estrogen receptor-positive into those that have mutation of the estrogen receptor, mutation of the PI3 kinase receptor. And as we drill down all these molecular differences, that’s where we’re going to see our advances. So there are going to be drugs developed for subpopulations within these larger groups, and they’re already being done with three novel agents approved actually within this year for estrogen receptor mutated and PIK3CA mutated estrogen receptor-positive breast cancer. 
So that process of subdividing and personalizing the treatment is the path forward.  
Dr. Alessi: Dan, thank you for your time today. We really appreciate it, you sharing your knowledge with everyone. Welcome to UConn Health, and we look forward to chatting again in the future.  
Dr. Morganstern: Thank you so much.  
Dr. Alessi: Many thanks to my guest today, Dr. Daniel Morgenstern. 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, and Tessa Rickart is in charge of social media. Until next time, this is Dr. Anthony Alessi. Please stay healthy. 

ALS (amyotrophic lateral sclerosis, commonly known as Lou Gehrig's disease) is a devastating motor neuron disease that effects movement, speech, swallowing, and breathing. Dr. Cristina Viguera, who practices neuromuscular medicine at UConn Health, joins Dr. Alessi to discuss some potentially promising research findings in ALS, as well as some progress in treating the genetic condition spinal muscular atrophy. 
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Cristina Viguera:https://www.uconnhealth.org/providers/profiles/viguera%20altolaguirre-cristina
Neuromuscular Medicine at UConn Health:https://www.uconnhealth.org/neurology/neuromuscular-medicine
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 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 direct your personal healthcare, which should only be done by your physician.
It gives me great pleasure to have as my guest today Dr. Cristina Viguera. Dr. Viguera.is assistant professor of neurology, and she is a specialist in neuromuscular diseases that affect the nervous system. Cristina, welcome to the program.
Dr. Viguera: Thank you so much for having me.
Dr. Alessi: Let’s chat a little bit. You’re relatively new here at UConn Health, so can we talk a little bit about, your background? What brought you to us?
Dr. Viguera: So let’s see. It was a long journey to specialize in neuromuscular medicine. So I’m originally from Spain, and I came to the United States to do a degree in neuroscience at first, actually, and then I got really interested in neuromuscular medicine, had an early interest in ALS, decided that I wanted to not just do research, but I decided to pivot to clinical work. I was at Johns Hopkins for university, medical school, and then I went to Boston to do my residency in neurology and then neuromuscular medicine, and then I came over here to do just that.
Dr. Alessi: Let’s talk a little bit about neuromuscular medicine and various neuromuscular diseases. What are some of the conditions that you spend your time researching and treating?
Dr. Viguera: I like to tell people in neuromuscular medicine, within neurology, there’s so many different fields. You have stroke for things related to the brain, dementias. In neuromuscular medicine, it’s really about select type of neurons that go from the spinal cord to your muscle. So I joke if it’s anything that can affect your ability to move or feel, it probably is related to neuromuscular medicine. So commonly that’s going to be neuropathies are a common condition that we see, myasthenia gravis, so that’s on the more autoimmune side, and also a lot of genetic conditions like muscular dystrophies, spinal muscular atrophy. We see all of those.
Dr. Alessi: So when a patient comes to your clinic, what can they expect in terms of the amount of time they spend and what tests are typical that you might order?
Dr. Viguera: So oftentimes when a patient sees a neuromuscular doctor, they’ve probably seen a couple of doctors by then. So someone has probably evaluated that person and said, “Hmm, there’s something else going on here,” or, “This is not your typical neurological condition.” And they’re suspecting maybe one of these more rare disorders. And they might order some tests in advance, they might order some MRIs to make sure that there’s not something in the brain, an EMG, an electromyography study, where they test the function of the nerves and the muscles. And then they come to our clinic. We review all the information. We take a careful history and examination, and we come up with a plan.
And we order those tests as well if they haven’t been done, but it’s a very comprehensive evaluation, and we do many of those tests in-house. So usually we’re talking about a one-hour appointment for the first time.
Dr. Alessi: One of the things in neuromuscular medicine that I think distinguishes it from neurology is that it’s so multidisciplinary. Can you talk about some of the other disciplines that play an important role in seeing a patient in the neuromuscular clinic?
Dr. Viguera: For sure, yeah. So one of the things in neuromuscular medicine, to your point, I mean, a disease can affect so many parts of a patient’s life, right? So we’re talking about these conditions that affect people’s mobility, people’s day-to-day function, their speech. So a lot of what we do in neuromuscular medicine is that we’re bringing all these other fields, so the occupational therapists, physical therapists, respiratory therapists, and have this team-based approach so that we can treat people and try to improve their quality of life and their independence as long as possible.
Dr. Alessi: One of the most feared diagnoses we ever have to share with a patient is Lou Gehrig’s disease, amyotrophic lateral sclerosis, and it is one of the motor neuron diseases. Can you talk a little bit about, globally, what motor neuron diseases are, and maybe we’ll drill down a little bit on some of the other ones that are less familiar to our listeners?
Dr. Viguera: Yes, of course. So yeah, the nomenclature of motor neuron disease has changed quite a bit. It was coined by Lord Brain way back, and since then our understanding has changed a little bit. So amyotrophic lateral sclerosis is the more classic disorder, or Lou Gehrig’s disease, where it affects certain types of these motor neurons, the neurons that affect motion, movement, speech, and swallowing, and breathing.
Dr. Alessi: I’ve got to ask you a question. It just came to mind. Do they call it Lou Gehrig’s disease in other parts of the world? Like, I trained in Italy, and we didn’t really call it Lou Gehrig’s disease. Did they call it that in Spain?
Dr. Viguera: They did not.
Dr. Alessi: OK
Dr. Viguera: They did not.
Dr. Alessi: I’m just curious. I just struck me. I mean, I just wondered if Lou Gehrig reached international fame, but anyhow, sorry for the interruption. But it just struck me.
Dr. Viguera: No, no, no, it’s a good question. But I feel like it’s more known as Lou Gehrig’s here, ‘cause that’s how it was popularized. But right, so within motor neuron diseases, there’s, depending on which type of motor neuron, the final appearance of it in a person and on the testing that we do is a little bit different, and that’s kinda where some of the nomenclature changes. But at the end of the day, we think that the biology of it is actually quite similar.
Dr. Alessi: In terms of all -- So in other words, all motor neuron diseases share the same biology?
Dr. Viguera: Yes.
Dr. Alessi: OK
Dr. Viguera: Yes. So something happens at the level of the neuron that results in its degeneration. And then just the way that it looks in a given person can change depending on whether it starts in the lower motor neurons, in the upper motor neurons, in the hand, around the face, and that’s where a given person with Lou Gehrig’s disease can look very different from another person where maybe the site where the disease started looked a little bit different.
Dr. Alessi: One of the areas where we’ve had some success in treatment has been spinal muscular atrophy, which is one of the motor neuron diseases. Can you talk a little bit about spinal muscular atrophy and the success? And I know that you have a system here for treating these patients, which is fairly complex. So can you talk a little bit about that and the system you have in place here for treating patients?
Dr. Viguera: Of course. Yeah, spinal muscular atrophy, it is one of these disorders that affects the motor neurons. It is a genetic condition, so, it is now included in the newborn screen, so people know from birth if they have the condition, and it’s a treatable disorder. It’s one of the great examples that we have in neuromuscular medicine, but also in, in neurology, I would say, of really getting to the understanding of how the disease comes about, what’s the biology behind it, and then how can we do a targeted therapy to stop the disease.
And it’s been extremely successful, so we have multiple treatments now available for spinal muscular atrophy, and we do have a clinic dedicated towards that here as well. So these are treatments that are targeting, I mean, are going into the spinal fluid, some of them. Other ones are taken by mouth, and they stop the disease progression.
Dr. Alessi: That’s fascinating, right? Because, as someone who’s much older than you who’s trained in it, we often didn’t have anything to share with them. But let’s go to ALS and Lou Gehrig’s disease, and you mentioned about it affecting upper and lower motor neurons. Can you explain that distinction and how it affects the patient?
Dr. Viguera: Yes. So the way that it would most typically present is it starts with weakness. Usually will start in an arm, like a hand with a clumsy hand, dropping things, in the foot, so people will start tripping over things, or maybe their speech and they have trouble swallowing and with their speech, and it’ll progress from there. So it’ll start involving other parts, other neurons nearby. And so when we say the lower motor neurons, that’s going to be in the form of losing the muscle, getting twitching, things like that that we observe on examination. And then the upper motor neurons, those are the ones that go from the spinal cord above, and they will result more in the stiffness that people might experience, and it changes some of the symptomatic, the treatment options that we offer.
Dr. Alessi: So let’s talk about those. In terms of -- one of the things we like to do on this program is really look to the future. And from your standpoint, what’s the future of treatment of motor neuron disease in terms of Lou Gehrig’s disease specifically, since that evokes the greatest fear? Is it with stem cells? People always hear about, “Well, stem cells, I’ll go to Mexico and get stem cells,” OK? And I know you’re laughing, as am I, because that’s not been the case. But again, what treatments are out there, and where do you think our research is taking us in the field of ALS?
Dr. Viguera: I only laugh ‘cause it’d be great if it were that easy, right? Like, you just kind of inject, drink muscle milk, and you’ll be fine. But I think what’s been so rewarding has been seeing how much the field has already changed in terms of our understanding of the disease. So like we touched on earlier, just understanding the biology of it, the genes that are involved in a disease like ALS, and understanding that not everybody might have the same kind of initial cause for the disease, but at the end it looks very, very similar.
And that’s already been translating into different therapies that are more targeted to different types of ALS. So, for example, before we only had one medication available, so that’s, riluzole or Rilutek.
Dr. Alessi: Rilutek.
Dr. Viguera: Now there’s a genetic form of ALS, SOD1-mediated ALS, which is a very rare form of genetic or familial ALS. And through understanding the mechanism of it, we now have a treatment for that specific type of ALS that slows the disease. So it’s rare. It’s not for every case, but it’s something that we just never really had available before, and it’s giving us a lot of hope that we can find maybe other shared mechanisms that can apply to other patients as well, and that that will translate into something meaningful for our patients.
Dr. Alessi: Well, it sounds like we’re on the right track, and often it is genetics that leads us there. Cristina, I want to thank you. Thank you for your time today. Thank you for everything you do for our patients here at UConn Health, and welcome aboard.
Dr. Viguera: It’s my pleasure. Thank you so much.
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 the 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 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.