Healthy Rounds With Dr. Anthony Alessi

Retraining the Brain With Advanced Neurosurgery

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 [HealthyRounds@uchc.edu] Dr. Christopher Conner: https://www.uconnhealth.org/providers/profiles/conner-christopher [https://www.uconnhealth.org/providers/profiles/conner-christopher] UConn Health Department of Neurosurgery: https://www.uconnhealth.org/neurosurgery [https://www.uconnhealth.org/neurosurgery] The Brain and Spine Institute at UConn Health: https://www.uconnhealth.org/brain-spine [https://www.uconnhealth.org/brain-spine] UConn Health Orthopedics and Sports Medicine: https://www.uconnhealth.org/orthopedics-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/ [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/ [https://today.uconn.edu/2024/11/grateful-stroke-survivor-shares-how-new-technology-is-transforming-his-recovery/] UConn Health: https://www.uconnhealth.org [https://www.uconnhealth.org/] Grant support from Coverys: www.coverys.com [http://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.

Kids on a Pitch Count

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 [HealthyRounds@uchc.edu] Dr. Cory Edgar: https://www.uconnhealth.org/providers/profiles/edgar-cory [https://www.uconnhealth.org/providers/profiles/edgar-cory] UConn Health Orthopedics and Sports Medicine: https://www.uconnhealth.org/orthopedics-sports-medicine [https://www.uconnhealth.org/orthopedics-sports-medicine] UConn Institute for Sports Medicine: https://sports.institute.uconn.edu [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 [https://health.uconn.edu/health-blog/2018/10/22/the-story-behind-tommy-john-surgery]  UConn Health: https://www.uconnhealth.org [https://www.uconnhealth.org/] Grant support from Coverys: www.coverys.com [http://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 [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.

Hantavirus: How Worried Should We Be?

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

Stroke Prevention, Treatment, and Recovery

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

Tony’s Take: Acetaminophen Myths, Messenger RNA

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