WEBVTT 00:13.250 --> 00:15.252 [SPEAKER_02]: Hello and welcome back to ACRAC. 00:15.613 --> 00:19.056 [SPEAKER_02]: I'm Jet Wolfaw and I'm thrilled we have a fabulous show for you today. 00:19.497 --> 00:27.946 [SPEAKER_02]: We had an amazing Grand Rounds talk at our place several months ago and I immediately said we have to have this amazing physician on. 00:28.446 --> 00:34.729 [SPEAKER_02]: Akrak and I'm so glad that she agreed to come on and so today we're going to talk about post-doc Delirium with Dr. Michelle Humeiden. 00:35.169 --> 00:38.911 [SPEAKER_02]: She's professor of anesthesiology at the Ohio State University Wexner Medical Center. 00:39.271 --> 00:42.252 [SPEAKER_02]: She's a clinician scientist and a practicing neuro anesthesiologist. 00:42.572 --> 00:55.338 [SPEAKER_02]: Her research focuses on preclinical and clinical studies of central nervous system aging with the overall goal of optimizing parioperative management of older patients to facilitate the best possible functional recovery after surgery for these patients. 00:55.818 --> 01:13.372 [SPEAKER_02]: She serves as the medical director for the multidisciplinary enhanced surgical recovery program at OSU, and she is the site PI for the multi-center scope trial, sleep cognition, and pain versus ERS cardiac for post-op delirium funded by the patient-centered outcomes research institute, also note as PCORI, thrilled to have her here. 01:13.572 --> 01:14.413 [SPEAKER_02]: Michelle, welcome to the show. 01:15.434 --> 01:16.715 [SPEAKER_01]: Thank you so much. 01:16.835 --> 01:19.697 [SPEAKER_01]: I'm really looking forward to the opportunity to speak with you. 01:20.158 --> 01:20.418 [SPEAKER_02]: Awesome. 01:20.538 --> 01:25.122 [SPEAKER_02]: Well, tell me a little bit about how you got interested in post-op delirium in the first place. 01:26.430 --> 01:37.982 [SPEAKER_01]: So I really got interested in this as a medical student toward the end of my, you know, clerkship time, which I did at the MDPHD program at the University of Kentucky. 01:38.022 --> 01:42.968 [SPEAKER_01]: So that was an eight-year, you know, run that was the traditional two years of, 01:43.629 --> 01:54.401 [SPEAKER_01]: kind of classroom based, and then I went to the lab for four years, and then the last years I was back, you know, doing my clerkships, and I did my PhD in neuroscience. 01:54.461 --> 01:58.606 [SPEAKER_01]: I already had that kind of lens that I brought back to the clinical time, but 02:00.428 --> 02:03.129 [SPEAKER_01]: I just got so in, first of all, I loved anesthesia. 02:03.209 --> 02:10.890 [SPEAKER_01]: I mean, as soon as I got the chance to try it, I was just totally enamored with everything about the OR and just all of the dynamics of it. 02:11.531 --> 02:19.132 [SPEAKER_01]: And what really got me interested in delirium was all the focus on optimization that was being taught to me. 02:19.252 --> 02:25.774 [SPEAKER_01]: And I was hearing about as a student observing the anesthesiologists, but they never talked about the brain. 02:26.234 --> 02:28.615 [SPEAKER_01]: It was always about the other organ systems. 02:30.615 --> 02:32.196 [SPEAKER_01]: just by the odd. 02:32.216 --> 02:34.137 [SPEAKER_01]: I didn't know what to make of that. 02:34.938 --> 02:46.944 [SPEAKER_01]: And at the time, you know, it really seemed like the general vibe around Lerian was like, well, you know, of course, we're going to have some confusion after, you know, grandma has a big surgery. 02:48.185 --> 02:53.088 [SPEAKER_01]: And while that has like really changed over over time, and now we recognize that, you know, that's. 02:53.546 --> 03:08.869 [SPEAKER_01]: Not something that we should just, you know, accept or, you know, we shouldn't try to intervene on and do much better for, but yeah, that that just disconnect really struck me when I was a student and I got so interested in that and have carried it on on since then. 03:09.476 --> 03:28.257 [SPEAKER_02]: very cool and that is you know as you're saying that i'm thinking of myself wow in many ways it's still that way we think really hard about the cardiac preopted optimization and you know what what's their what's their carton function did they have an echo how can we optimize that how can we avoid problems with the you know blood pressure we think a lot about cardiac pulmonary 03:28.757 --> 03:40.426 [SPEAKER_02]: But interestingly, even now, I think we don't do a whole lot of talking about the brain and how we can prevent decline and how we can prevent damage to the brain, other than thinking about blood pressure and perfusing the brain. 03:40.466 --> 03:45.950 [SPEAKER_02]: So it's, I think, really great that you're doing this work because I think there's still a lot of work to do. 03:47.331 --> 03:49.012 [SPEAKER_02]: Let's talk about post-op delirium. 03:49.072 --> 03:56.538 [SPEAKER_02]: How prevalent is it, why, I mean, obviously goes with that thing, but let's just say, why do we care, why do we want to prevent it? 03:58.139 --> 04:06.326 [SPEAKER_01]: Well, it's starting to be referred to as the most common complication after surgery and in older patients. 04:06.646 --> 04:11.610 [SPEAKER_01]: And I think that that's a pretty appropriate way to describe it because it is really common. 04:12.851 --> 04:23.360 [SPEAKER_01]: Certainly more common than other things that we've focused on in the consent, like mortality or airway injury, things like that, antiflaxis, it's way more common. 04:24.181 --> 04:35.637 [SPEAKER_01]: than all of those things, but it really depends on a lot of factors what someone's risk would be predicted to actually be for post-op delirium, you know, in general. 04:36.250 --> 04:58.464 [SPEAKER_01]: I think somewhere around 20 to 25% of all older adults presenting for a elective surgery are at risk and then if it's major, very invasive surgeries that risk goes up, if it's emergency surgery, no matter what variety that risk goes up as well, and then there's definitely patient factors that affect that too. 04:58.624 --> 05:00.365 [SPEAKER_01]: So in general, 05:01.310 --> 05:16.172 [SPEAKER_01]: you'll see somewhere between five to ten percent and really straightforward routine things without a lot of, you know, case or patient associated factors that could increase risk all the way up to 50 or 60 percent in cardiac or vascular surgery. 05:17.362 --> 05:19.644 [SPEAKER_01]: and high numbers like that, like I said for emergency. 05:19.724 --> 05:22.886 [SPEAKER_01]: So it's really variable, but it's certainly common, yeah. 05:23.287 --> 05:28.931 [SPEAKER_02]: And, you know, again, it seems like sounds bad, but why do we not want people to have this, right? 05:28.971 --> 05:36.356 [SPEAKER_02]: Is it, you know, we also don't want people to, you know, I don't know, wake up wild and yelling, but if they do find, right, like, okay, we'll deal with it. 05:36.396 --> 05:38.638 [SPEAKER_02]: So why is this something we really want to try to prevent? 05:39.690 --> 05:42.952 [SPEAKER_01]: This is something we want to prevent for a lot of reasons. 05:43.052 --> 05:52.699 [SPEAKER_01]: I mean, just on its baseline level, it's distressing, not only to the patient and their family, but also the care team that's providing for them. 05:52.759 --> 05:54.861 [SPEAKER_01]: So it's just stressing all the way around. 05:55.581 --> 05:57.783 [SPEAKER_01]: It's associated with worse outcomes for sure. 05:58.063 --> 06:05.028 [SPEAKER_01]: So the risk of having, those are kind of acute complications and longer term things too. 06:05.813 --> 06:09.758 [SPEAKER_01]: You know, in the acute setting, a delirious patient is going to be in the hospital longer. 06:10.359 --> 06:14.485 [SPEAKER_01]: There is a great, by the way, I'll do a plug real quick for the ASA monitor in June. 06:14.545 --> 06:18.450 [SPEAKER_01]: It has some excellent articles in it that are all about this type of stuff. 06:18.971 --> 06:23.337 [SPEAKER_01]: We have some surgeon colleagues that contributed an article to and they have some cool data. 06:24.137 --> 06:30.559 [SPEAKER_01]: on emergency versus non-emergency risk for delirium in different types of surgeries that's worth checking out. 06:30.659 --> 06:39.963 [SPEAKER_01]: So I'm thinking about that as we're talking today but you know we we should definitely care because if they have delirium their risk of being in the hospitals longer. 06:40.942 --> 06:53.409 [SPEAKER_01]: Um, they have a higher likelihood of going to some other type of facility besides home and discharge the home is, you know, definitely something we really want to prioritize for folks when that's available and appropriate. 06:54.550 --> 07:05.796 [SPEAKER_01]: And then, you know, longitudinally the risk of having cognitive issues, you know, onset, new onset or ear even kind of a more steeper trajectory of decline. 07:06.597 --> 07:09.940 [SPEAKER_01]: you'll see that as a risk that's associated with postoperative delirium. 07:10.000 --> 07:17.208 [SPEAKER_01]: I mean those studies aren't perfect, but they're definitely seems to be some risk that's in the acute setting and longitudinal risk. 07:17.228 --> 07:20.172 [SPEAKER_01]: So we should care for all those reasons, definitely. 07:20.593 --> 07:21.974 [SPEAKER_02]: Yeah, that sounds right to me. 07:22.174 --> 07:39.607 [SPEAKER_02]: And it seems like the people who get post-Octolarium, tell me if I'm right here, most, but not all, will recover from a kind of get back to baseline where they were from a mental performance standpoint, but not all, right? 07:39.687 --> 07:41.268 [SPEAKER_02]: Some will never get back. 07:41.488 --> 07:47.593 [SPEAKER_02]: And do we know how common that is that people who get post-Octolarium don't ever fully recover back to where they were pre-surgery? 07:48.886 --> 07:52.069 [SPEAKER_01]: You know, I actually tried to find some information on that. 07:52.109 --> 07:53.610 [SPEAKER_01]: I kind of struck out a little bit. 07:54.751 --> 07:58.694 [SPEAKER_01]: I don't have a lot of good numbers that can say like this is the exact risk. 07:58.714 --> 08:04.558 [SPEAKER_01]: We know the risk goes up, but I don't have like an exact, you know, kind of conversion for sure to offer. 08:04.578 --> 08:06.360 [SPEAKER_01]: I think that, um, 08:08.237 --> 08:31.527 [SPEAKER_01]: You know, in general, the overall concern is present because we don't have the best way of predicting who has that lower risk, you know, they get delirium and like you said I totally agree like most of the time they recover might delay it's definitely going to delay their time in the hospital and it's going to increase costs and stuff that, you know, they recover and the long long term issues are not there. 08:31.647 --> 08:37.990 [SPEAKER_01]: That's the case most of the time, but what's the difference, you know, how do we know those folks from the ones that you go on to have 08:38.498 --> 08:44.440 [SPEAKER_01]: You know, significant challenges long term, um, that's that's that's something we don't have a good handle on as far as I know. 08:44.760 --> 08:45.541 [SPEAKER_02]: Yeah, interesting. 08:46.041 --> 08:50.482 [SPEAKER_02]: It seems like this is something we don't really know exactly what causes it. 08:50.522 --> 08:53.724 [SPEAKER_02]: You mentioned the cardiac surgery is much higher risk. 08:53.844 --> 08:59.686 [SPEAKER_02]: And so you might think duration of surgery, you might think invasive risk of surgery, duration of anesthesia. 08:59.966 --> 09:04.908 [SPEAKER_02]: But do we know is it the anesthesia is it the surgery is it how long you have those things for or do we not know? 09:05.653 --> 09:08.415 [SPEAKER_01]: I think the short answer is all of the above. 09:08.435 --> 09:24.008 [SPEAKER_01]: I think that it's definitely multi-factor oil, and that's a little bit frustrating in the sense of, it doesn't bring a lot of clarity to what we can do to prevent it or intervene on it, but it's definitely multi-factor oil. 09:24.589 --> 09:33.857 [SPEAKER_01]: To be the type of delirium that we're talking about postoperatively, you really do need to rule out some of the physiologic things that could be causing that rangements, 09:34.918 --> 09:40.922 [SPEAKER_01]: you know, their laboratory values or different aspects of, you know, their medications that might be contributing to things. 09:40.942 --> 09:49.047 [SPEAKER_01]: This kind of all those things set aside, the features of Delirium still being present is kind of the type that we're talking about. 09:49.148 --> 09:58.514 [SPEAKER_01]: So sometimes Delirium can be caused by these post-operative fluctuations in, you know, their labs and their medicines and all of that. 09:58.574 --> 10:01.916 [SPEAKER_01]: But those things resolved the Delirium 10:03.757 --> 10:05.838 [SPEAKER_01]: really hard to know where it comes from. 10:06.878 --> 10:22.982 [SPEAKER_01]: There's definitely like you said a surgical association, so it's pretty, you know, I don't know my area of expertise is not the inflammatory aspect of post-op delirium, but that is certainly something that is becoming more and more clear is 10:27.642 --> 10:43.333 [SPEAKER_01]: You know, inflammatory response kind of in the brain, but also out in the body, and that certainly goes with invasiveness of surgery and the type of arrangements that come along with very invasive surgeries in the inflammatory kind of pathways and characteristics that they set into a motion. 10:43.353 --> 10:47.076 [SPEAKER_01]: I mean, those things are becoming more and more tied to delirium for sure. 10:47.096 --> 10:52.320 [SPEAKER_01]: And, you know, as far as other things that cause it, um, 10:53.078 --> 11:18.602 [SPEAKER_01]: Really what we're left with is what the patient comes to the gate with, you know, and how much, I, I mean, I really believe in this is going to kind of get over into my, to my research bias, but I really believe that all of those insults, you know, the information, the invasiveness of the surgery, the medications, the physiologic derangements, the what patients come to surgery with can help them whether that storm and whether they, 11:19.737 --> 11:46.157 [SPEAKER_01]: what kind of reserve that they have we're really determined I think they're they're overall outcome whether they get delirious how severe it is and if there's long-term sick while away from it so yeah that's that's a long answer for what causes it but it really is it's complex yeah yeah absolutely now is it fair to say that we can't really say that general anesthesia as opposed to let's say regional anesthesia 11:47.078 --> 11:47.939 [SPEAKER_02]: put you at higher risk. 11:48.019 --> 11:51.461 [SPEAKER_02]: I mean, I'm thinking about the regain trial and, you know, do you agree with that? 11:51.481 --> 11:57.924 [SPEAKER_02]: Do you think that it's likely that while it may, and a season might play a role, it's not clear that it's like one type of an a season versus another? 11:59.205 --> 12:09.671 [SPEAKER_01]: Yeah, there's definitely been so much good literature and expert consensus and recommendations come out in the past several years to kind of help guide us. 12:09.731 --> 12:11.632 [SPEAKER_01]: So it's really a great time 12:17.154 --> 12:26.557 [SPEAKER_01]: You know, it gets caught out a lot is that we don't have clear evidence that one particular type of anesthetic approach is clearly better than another. 12:26.637 --> 12:34.619 [SPEAKER_01]: And that goes for general versus a regional that also goes for a volatile based anesthetic versus a Tiva, right? 12:34.659 --> 12:39.401 [SPEAKER_01]: We really don't have evidence to say that there's clear benefit to one of those approaches. 12:39.461 --> 12:42.742 [SPEAKER_01]: So that's population based, right? 12:47.524 --> 12:58.413 [SPEAKER_01]: And so I think, in general, people do make those decisions based on the overall assessment of the patient and their situation, and I think in general less is more. 12:58.573 --> 13:14.947 [SPEAKER_01]: So if you approach an older patient with a less is more approach, you want to have really good pain control, you know, really good hemodynamic management, I think, and outside of that, how you achieve those things, there's no evidence that 13:15.835 --> 13:17.256 [SPEAKER_01]: the one way is better than the other. 13:17.296 --> 13:18.817 [SPEAKER_01]: You got to kind of approach each patient. 13:19.117 --> 13:19.898 [SPEAKER_02]: Yeah, okay. 13:20.238 --> 13:21.338 [SPEAKER_02]: Let's talk about risk factors. 13:21.359 --> 13:30.044 [SPEAKER_02]: I mean, the ones we've already discussed are age, obviously, pre-existing cognitive impairment, duration, slash kind of intensity of surgery on some level. 13:31.485 --> 13:35.007 [SPEAKER_02]: What about frailty in the kind of divorce from age? 13:35.027 --> 13:40.911 [SPEAKER_02]: In other words, does a 40 year old extremely frail patient have a higher risk than a 40 year old 13:45.627 --> 14:09.968 [SPEAKER_01]: Yeah, frailty is definitely an independent risk factor for post-op delirium and one of the things that I think's really interesting about the post-op delirium story is the frailty aspect of it because they're kind of developing together, right, this frailty, you know, really looking out for these high-risk patients before surgery, these high-risk frail patients because of all the, 14:10.753 --> 14:30.087 [SPEAKER_01]: you know issues that we know them to be at risk for it's it's kind of the same story with post-op delivering there's similar but also a little bit separated still but frailty definitely contributes to delirium risk and I I like you know I always I always give you know I always enjoy reading any of Dan McKice's stuff he's just such a great writer and he 14:30.527 --> 14:44.523 [SPEAKER_01]: He's a frailty expert and I like he kind of calls out that, you know, in resource limited environments or in a place where you're trying to start change, you know, that's really different from maybe what the current practice is. 14:44.985 --> 14:50.288 [SPEAKER_01]: frail patients are a good place to start because of that extra risk that they bring to the table. 14:50.408 --> 15:00.532 [SPEAKER_01]: And so if you're really going to get the most bang for your buck, that population is a really good place to start the process or the investment in and then you can kind of grow from there. 15:00.652 --> 15:01.413 [SPEAKER_01]: So yeah. 15:01.873 --> 15:02.753 [SPEAKER_02]: about anemia. 15:02.813 --> 15:10.276 [SPEAKER_02]: Do we know the S. for that does anemia on its own lead to a higher risk of developing post-opdolary? 15:10.536 --> 15:19.500 [SPEAKER_02]: And I ask that because I think there's more more data coming out about anemia as an kind of additive or synergistic risk factor with so many other things. 15:19.520 --> 15:24.762 [SPEAKER_02]: So people who are anemic and have diabetes do worse than people who just have diabetes but are not a need of right. 15:24.782 --> 15:24.842 [SPEAKER_02]: So 15:25.162 --> 15:34.346 [SPEAKER_02]: Is it true that people who are, have everything else the same and are anemic, have a higher risk of post-op delirium that people who have the same other risk factors, but are not anemic or do we not know the answer to it? 15:35.147 --> 15:37.088 [SPEAKER_01]: You know, I don't know the answer to that. 15:37.208 --> 15:51.895 [SPEAKER_01]: It might be out there, but I just haven't come across it, but I'll tell you, I mean, just to me, it would make sense because, you know, that oxygen carrying capacity piece of the equation is so important, I mean, 15:53.262 --> 16:13.283 [SPEAKER_01]: and aspects other than this, when I'm in my clinical hat because we do all of this work to support the blood pressure and to give volume and resuscitate people, but if you're not delivering oxygen, it's really, yeah, so I do think that anemia is probably an important contributor. 16:14.800 --> 16:21.506 [SPEAKER_01]: And we know that when that gets addressed before surgery, it definitely makes other outcomes better. 16:21.606 --> 16:31.234 [SPEAKER_01]: So I would think that it would help with delirium, but I don't know that particular literature, so I'll have to investigate, because I think it probably makes sense for sure. 16:31.254 --> 16:31.995 [SPEAKER_02]: Yeah, great. 16:32.095 --> 16:36.839 [SPEAKER_02]: Okay, let's talk about preoperative cognitive impairment, because I know that's such a strong risk factor. 16:37.339 --> 16:37.580 [SPEAKER_02]: So, 16:38.571 --> 16:42.513 [SPEAKER_02]: We know the people who have pre-operative cognitive impairment are at high risk for developing post-opulare. 16:43.394 --> 16:47.516 [SPEAKER_02]: How can we identify patients who have pre-operative cognitive impairment? 16:47.976 --> 16:51.939 [SPEAKER_02]: And I'm more thinking in the short time, we might have in, like, the pre-op area. 16:52.339 --> 16:57.222 [SPEAKER_02]: Unless, I mean, you could also talk about in pre-op clinic where you have a lot more time and it might be weeks. 16:57.862 --> 17:08.657 [SPEAKER_02]: before surgery, but, you know, what if you're just seeing the patient, the morning of surgery, is A's, I guess, is it worth trying to identify if pre-operative cognitive impairment, and if so, how can you do it in a short amount of time? 17:09.733 --> 17:14.194 [SPEAKER_02]: Pay for us, I just want to take a second to shout out our Rockstar Returning Sponsor True Learn Smart Banks. 17:14.675 --> 17:18.516 [SPEAKER_02]: I've used True Learn for my resins for years, and it has hands down the best smart bank out there. 17:18.836 --> 17:23.737 [SPEAKER_02]: The questions are excellent, and the answers have clear explanations that break down why each choice is correct or incorrect. 17:24.098 --> 17:28.959 [SPEAKER_02]: And now you can create flashcards, which are a key tool for high quality studying and maximizing test performance. 17:29.319 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prep, and I recommend you do the same www.truelearn.com and use code ACRAC. 18:10.769 --> 18:29.158 [SPEAKER_01]: that is a great question and I will say yes it is worth trying to do you know there's a lot there's there's also a lot of really cool literature coming about over the last few years and even recently about this and how we don't do a good job with this and it's multi-factual one is you know like 18:29.842 --> 18:44.770 [SPEAKER_01]: You know, sometimes we are capturing people right before we're heading back to the OR and how practical is that and what do we do with that information and is that the right time to start addressing these types of risks for the first time that should really be done earlier on in the process. 18:44.830 --> 18:50.273 [SPEAKER_01]: And then also documenting the screening test like in the medical records so that it can be helpful. 18:50.373 --> 18:56.837 [SPEAKER_01]: But those things set aside it, I think it is worth doing, you know, they've shown that 18:57.813 --> 19:12.745 [SPEAKER_01]: You know, if you do like something very simple like a mini cog, which takes just a couple of minutes, and there's some great resources that will teach you how to do that and kind of show you how to interact integrate that into your your practice with patients on the brain health initiative for free at the ASA. 19:26.095 --> 19:30.157 [SPEAKER_01]: screeners available, some take 10 minutes, some take just a couple of minutes. 19:30.197 --> 19:33.118 [SPEAKER_01]: It depends on the situation that you're trying to apply it to. 19:33.898 --> 19:45.743 [SPEAKER_01]: But the benefit of doing it is that if the patient screen's positive, it definitely is a good starting point to kind of start redirecting some resources toward them as high risk. 19:45.763 --> 19:54.006 [SPEAKER_01]: So even if it's just as simple as the anesthesia team and the surgical team being aware, and maybe they adjust a few of the medications that they 19:56.626 --> 19:59.130 [SPEAKER_01]: You know, they change maybe what bed the patient goes to. 19:59.150 --> 20:01.092 [SPEAKER_01]: They try to get a room with a window. 20:01.573 --> 20:13.729 [SPEAKER_01]: You know, those types of things are a lot of hospitals now have kind of geriatric order sets or protocols in place that can make sure, you know, it can just make sure is the check that that is in place for someone that screens positive. 20:14.289 --> 20:37.887 [SPEAKER_01]: Things can happen and people really believe if we do some of this basic stuff that we can impact the delirium risk pretty significantly, but it's tough because identifying that risk like right before going back to the OR, when it could have, it's usually short term consequences, but it could have very serious long term consequences. 20:38.407 --> 20:39.808 [SPEAKER_01]: That's the part that I think we're 20:44.157 --> 21:13.644 [SPEAKER_01]: And that's going to take a team effort between our surgeon colleagues and us and our pre-operative clinic folks as well because that conversation really should be had earlier on when it's, you know, if you're in some emergency surgery obviously, that's tougher, but yeah, I, I think that's what I'm reading and seeing and that's the direction our profession's going to push it out further, but even right beforehand it can, it can help change some key things that could have real impact. 21:14.324 --> 21:14.564 [SPEAKER_02]: Great. 21:14.624 --> 21:27.531 [SPEAKER_02]: Yeah, I think I had mentioned to you when we were talking before that we did this whole project when I was a resident years ago incorporating the animal fluency test into our pre-operative charting. 21:27.792 --> 21:39.138 [SPEAKER_02]: So we would have the patients in pre-op tried to name as many animals as they could in 60 seconds and then I don't remember the cutoffs but this is a published test and it's probably not the best one out there but it was easy to do. 21:39.758 --> 22:02.674 [SPEAKER_02]: And then what we did was if the patient screened positive, which meant they were at higher risk for having, they may have some pre-op cognitive impairments, so they are higher risk for post-op telegram, we would do things like avoid benzos, recommend that the surgical team put them in a high visibility bed, you know, double check and make sure they had their hearing aids in their classes and things like that. 22:02.714 --> 22:05.957 [SPEAKER_02]: All the things they've kind of both pharmacologic and non-pharmalologic that we can do, 22:06.537 --> 22:07.758 [SPEAKER_02]: So what can we do? 22:07.798 --> 22:11.380 [SPEAKER_02]: I mean, you mentioned some of the things, but let's talk about, like, in the OR. 22:11.441 --> 22:12.882 [SPEAKER_02]: So or in pre-op in the OR. 22:13.722 --> 22:20.267 [SPEAKER_02]: I guess one question is, does it make sense to not give the kind of standard one or two of her said to these patients? 22:20.587 --> 22:23.249 [SPEAKER_02]: Do we know, I mean, I'm an ICU doc, believe me. 22:23.349 --> 22:25.410 [SPEAKER_02]: I know that in the ICU, benzos are bad. 22:25.430 --> 22:28.893 [SPEAKER_02]: They lead to a high, much higher risk for delirium in the ICU. 22:29.253 --> 22:43.747 [SPEAKER_02]: but does the pre-op dose of versed cause or increase the risk of post-op delirium in anyone and especially in high risk patients stay with us will be right back all right and we're back 22:44.797 --> 22:55.340 [SPEAKER_01]: Um, so this has been something that's been kind of back and forth, you know, to completely avoid, um, to kind of where it's at, you know, from one where it was like at Adlib, right? 22:55.380 --> 23:06.764 [SPEAKER_01]: We didn't change anything about how we cared for an older patient to complete avoidance at all costs to where it's it's settling now, which is I think that, you know, low doses, one or two milligrams. 23:07.722 --> 23:16.605 [SPEAKER_01]: of Medazlam if you feel like that there's benefit for a patient is probably not going to put them at a significantly increased risk. 23:16.646 --> 23:32.652 [SPEAKER_01]: That's kind of the latest from the patient's safety foundation and you know, these best practice, I don't think those are mentioned the best practice specifically, but just some of the more current research is kind of said these lower doses, you know, maybe aren't as bad as we might have thought. 23:33.392 --> 23:42.719 [SPEAKER_01]: But that said again, you know, there's some caveats to that, you know, like when it's given, you know, is giving a milligram of birthset as part of your induction. 23:43.119 --> 23:51.206 [SPEAKER_01]: The same is giving a milligram of birthset in pre-opolding, taking their hearing aids, and then transporting them in a strange environment to the OR. 23:51.366 --> 23:55.849 [SPEAKER_01]: I don't know, you know, I don't know that we have that answer from our current, you know, studies. 23:55.929 --> 24:01.714 [SPEAKER_01]: So those are the kind of things that I think might actually have real impact that we don't 24:02.515 --> 24:04.556 [SPEAKER_01]: You know, necessarily have a good way to study. 24:04.656 --> 24:21.844 [SPEAKER_01]: So I think it's totally reasonable to give it if it feels like the right thing for a patient, you know, based on the current situation and what we know about the risk, like you said a nice, huge different thing, but definitely long acting, then it asapines, I think are a definite no, like we can, we can, 24:22.184 --> 24:27.245 [SPEAKER_01]: say that anything like that unless that's like a whole medication or something, we can avoid that periodically. 24:27.685 --> 24:31.506 [SPEAKER_01]: First, that's probably okay in low doses, but it's a case-by-case basis. 24:31.666 --> 24:32.726 [SPEAKER_01]: I tend to avoid it. 24:34.166 --> 24:49.510 [SPEAKER_01]: I'll spend a little more time talking to older patients instead of going with the antibiotics if I can to try to help whatever it is that they're stressed about, but if they need it, I think that people should be reassured that it's probably not causing 24:51.310 --> 24:51.550 [SPEAKER_02]: Great. 24:51.891 --> 25:13.254 [SPEAKER_02]: There's some literature in the ICU that suggests that using dexmeditomiting can maybe delay or prevent the onset of ICU delirium and maybe shorten its course if it happens, do you think there's a role in high risk patients for using specifically for this purpose using dexmeditomiting in the OR? 25:14.575 --> 25:19.158 [SPEAKER_01]: that is coming out is something that people can definitely consider that might mitigate risk. 25:19.558 --> 25:22.519 [SPEAKER_01]: Um, you know, again, it's like every case has its ups and downs. 25:22.579 --> 25:27.882 [SPEAKER_01]: If you're, if you're having a lot of break to cardiac and hypotension from it, you know, then it might not be worth it. 25:27.922 --> 25:34.086 [SPEAKER_01]: But, um, but it, there's definitely some, some evidence to support that Dex Mediterranean in the OR could be a benefit. 25:34.166 --> 25:36.667 [SPEAKER_01]: So I think that, that's worth considering for sure. 25:37.267 --> 25:37.528 [SPEAKER_02]: Okay. 25:37.628 --> 25:43.571 [SPEAKER_02]: Anything else you recommend people do if they screen someone as high risk, uh, because they're, they have free offer to cognitive impairment. 25:44.832 --> 26:08.007 [SPEAKER_01]: As far as, you know, kind of immediate in the OR and post-stop stuff, I think in general, if you really are thoughtful about the medications that you use for nausea prevention, for example, or pack you management, you know, I get a call every once in a while from a pair of dean and someone that's older and that's like an absolute no, that's a really good opportunity. 26:08.027 --> 26:08.668 [SPEAKER_01]: He's dexented. 26:13.651 --> 26:20.634 [SPEAKER_01]: You know, that's, there's just, you know, especially, you know, some of her more central actuate acting anti-naugest medicines and stuff. 26:20.674 --> 26:27.817 [SPEAKER_01]: It's guppalamine is another one to really be, I think, careful about, you know, who you're selecting to use that for. 26:28.137 --> 26:33.779 [SPEAKER_01]: Those types of things can really be helpful, I think, in managing these older patients in our pretty practical, 26:34.833 --> 26:58.175 [SPEAKER_01]: If it's appropriate and they're a good candidate for any type of original to not necessarily to avoid a general, but just to supplement the pain management plan, I'm always supportive of that too because, you know, pain is pain that's not well controlled can cause delirium and too many opiates or too many, you know, too much other adjuncts on. 26:58.875 --> 27:01.036 [SPEAKER_01]: that could be sedating can also cause delirium. 27:01.076 --> 27:11.660 [SPEAKER_01]: So you want to kind of strike that balance where their their pain is well controlled, but you're not having side effects from, you know, your approach and I think incorporating regional or near axles are really great way to do that. 27:13.257 --> 27:35.352 [SPEAKER_01]: And, you know, like you said, there's other practical things, getting them their sensory aids, their teeth, the student is possible, getting them, you know, the type of setting that can help them stay oriented and, you know, there's other kind of rest practices can continue out of the OR and to the for and, and that's really, if we do those things consistently, it is very beneficial. 27:35.532 --> 27:35.772 [SPEAKER_01]: Yeah. 27:36.872 --> 27:42.337 [SPEAKER_02]: Now, I know your work has shown that cognitive pre-habilitation may actually be helpful in protective. 27:42.377 --> 27:47.022 [SPEAKER_02]: So tell me a little about that because when you talked about this and when you give our grand rounds, it was fascinating. 27:47.042 --> 27:54.409 [SPEAKER_02]: So, I mean, you took talk for many hours about it, but what are the highlights of how this you're looking, how you're looking at this and how it could help. 27:55.168 --> 28:12.978 [SPEAKER_01]: Yeah, so same time that I got really fascinated with delirium as a medical student, I got fascinated with the idea of cognitive reserve and trying to pre-ability somebody because I came from a department that was very strong and dementia research. 28:12.998 --> 28:17.260 [SPEAKER_01]: And there was all this great literature that an active mind is a protected mind, right? 28:17.320 --> 28:20.362 [SPEAKER_01]: So the more active that you keep yourself and the better 28:21.343 --> 28:47.486 [SPEAKER_01]: You know, you'll age from a cognitive standpoint and I just thought that that was so interesting and and you know It was always talked as a longitudinal kind of construct, but I thought around surgery I mean, you know, as I didn't think it was crazy to believe that maybe we could do some things that would Bring some benefit even even though that usually takes a lifetime, right to build up or would a way cognitive reserve I thought in a cute intervention could help so 28:47.953 --> 28:58.181 [SPEAKER_01]: So that's really where the idea came from, and I did a clinical trial, a randomized trial with it, and what I love most about it is it's it's really low risk. 28:58.382 --> 29:00.864 [SPEAKER_01]: I mean, this is not a pharmacologic intervention. 29:01.794 --> 29:05.157 [SPEAKER_01]: Um, you know, it's, it's, it's, it's one of the few things. 29:05.237 --> 29:22.912 [SPEAKER_01]: I mean, all the stuff we've talked about so far is stuff we do stuff we do in the OR stuff we do after surgery there's not a lot that we can offer patients that they are empowered to go home and do and that's one of the things I really like about it too is it gives them a chance to have some agency and their risk, you know, management. 29:23.152 --> 29:27.676 [SPEAKER_01]: Um, if they choose to and, um, you know, it's an active area of study right now. 29:27.916 --> 29:29.618 [SPEAKER_01]: I mean, my clinical trial showed 29:30.424 --> 29:34.442 [SPEAKER_01]: a decent reduction in the patients that actually played the games we had. 29:35.470 --> 29:46.977 [SPEAKER_01]: a couple of patients in our intention to treat analysis that were in our intervention group that didn't play and they had to have those four had delirium, so it affected our overall statistics. 29:47.537 --> 29:58.724 [SPEAKER_01]: But if you just look at the people that played, they hit about five hours in the ten days or so before surgery and yeah, the delirium rate went from about 23% down to 13%. 29:58.804 --> 30:03.847 [SPEAKER_01]: So for a behavioral study that was pragmatic, it was pretty, pretty great. 30:04.907 --> 30:08.010 [SPEAKER_01]: I definitely, you know, don't think I was just one study, right? 30:08.130 --> 30:28.384 [SPEAKER_01]: So, but I think based on that and just the risk profile of it, it's definitely exciting that it's been studied more and by other folks, and they've also shown benefit in other settings and have another trial right now that's looking at it and proposing more trials to try to continue to study this. 30:32.422 --> 30:56.238 [SPEAKER_01]: when the brain has an insult happening, which we talked about right all that inflammation, all those medications, all the physiologic changes that come with being in surgery and immediately after, the more the brain has to be able to function, despite that insult, the more redundancy, the more pathways, so whatever you want to look at it. 30:56.909 --> 31:01.573 [SPEAKER_01]: Um, the, the lower the chance that someone's actual function will be compromised. 31:01.653 --> 31:14.082 [SPEAKER_01]: And so, um, I don't, you know, it's, it's kind of wild to study something that I don't have a perfect mechanism for, I can't tell you that there's more synapses when they play brain games or anything like that at this point. 31:14.182 --> 31:17.325 [SPEAKER_01]: But I'm trying to, to figure out ways to study that. 31:17.845 --> 31:28.594 [SPEAKER_01]: to measure the reserve because it certainly seems like the ones that play have some sort of benefit and it's very low risk and I think that's that it gives them an opportunity to do something within their controls. 31:28.654 --> 31:30.635 [SPEAKER_01]: So yeah, that's a helpful story. 31:30.655 --> 31:43.045 [SPEAKER_02]: And these games are things like memory games, is it, you know, think to like just crossword puzzles count like what accounts and what doesn't count for something that you're looking at. 31:44.353 --> 31:47.695 [SPEAKER_01]: So what I've studied are dynamic computer games. 31:47.836 --> 31:50.537 [SPEAKER_01]: So I use an app called the Mossity. 31:50.597 --> 31:52.479 [SPEAKER_01]: There's other ones that are similar. 31:53.480 --> 31:58.003 [SPEAKER_01]: But what's special about what I've been using is that it is dynamic. 31:58.063 --> 32:03.787 [SPEAKER_01]: So the more challenges the person, it's not like a static interaction. 32:04.317 --> 32:13.326 [SPEAKER_01]: So that's important, I think, to kind of find ways to be challenged to have a novel, you know, kind of exercise as part of it. 32:13.967 --> 32:19.393 [SPEAKER_01]: I think, you know, originally I wanted to study crosswords and like Sudoku and things like that. 32:19.853 --> 32:28.536 [SPEAKER_01]: But practically speaking, it was very difficult to be sure what the patients had actually done or not done as part of the intervention. 32:29.116 --> 32:36.878 [SPEAKER_01]: So I geared myself more towards something that I could measure and actually prove and be sure that they were getting challenged. 32:37.218 --> 32:42.840 [SPEAKER_01]: And that it wasn't too difficult or too easy because it also adjust if people aren't performing well. 32:42.860 --> 32:43.320 [SPEAKER_01]: It'll kind of... 32:43.820 --> 32:47.722 [SPEAKER_01]: back it down in intensity so that they'll keep, you know, keep engaging with the game. 32:47.822 --> 32:57.925 [SPEAKER_01]: So, they cover different areas of cognition, so there's speed, attention, flexibility, memory, there's some language and math in there too. 32:58.986 --> 33:04.968 [SPEAKER_01]: But the ones I think that are probably the most interesting or most helpful are kind of the attention speed flexibility. 33:05.659 --> 33:10.481 [SPEAKER_01]: Um, you know, I'll derail for just a second and go back to where we were talking about the mini-cog. 33:10.841 --> 33:15.703 [SPEAKER_01]: Um, you know, it's, it's widespread as that is and is useful as it is. 33:15.723 --> 33:21.926 [SPEAKER_01]: I mean, because we know if people screen positive on the mini-cog, their, their risk is, is increased and that's very helpful. 33:22.486 --> 33:30.790 [SPEAKER_01]: But I, I, I really think that we're missing even still when, if we're screening people with that, I still think we're missing some folks that have some, 33:31.370 --> 33:35.614 [SPEAKER_01]: cognitive vulnerability that is clinically significant, but we just aren't capturing. 33:35.674 --> 33:48.584 [SPEAKER_01]: And so, you know, some of the things I'm interested with with the brain games is maybe teasing some of that out too, so it being a little bit of a prognostic and also a therapeutic, which I think is cool because it's all together. 33:48.604 --> 33:50.145 [SPEAKER_01]: And one thing. 33:50.586 --> 33:55.009 [SPEAKER_01]: But yeah, I think an act of mind is great. 33:56.363 --> 34:01.289 [SPEAKER_01]: You know, patients might not have access to things like tablets and computer games. 34:01.369 --> 34:02.550 [SPEAKER_01]: I really think that's okay. 34:03.131 --> 34:11.200 [SPEAKER_01]: You know, crosswords reading the newspapers, social interactions, listening to music, writing emails even. 34:11.281 --> 34:14.985 [SPEAKER_01]: These are all versions of things that have been shown to have benefit. 34:15.917 --> 34:27.482 [SPEAKER_01]: If you do them regularly, and so I think it's just, again, staying active, and it just so happens that this particular construct has performed well in research settings too. 34:27.502 --> 34:28.662 [SPEAKER_02]: Yeah, very cool. 34:29.082 --> 34:30.723 [SPEAKER_02]: What is the scope trial looking at? 34:31.927 --> 34:38.151 [SPEAKER_01]: This scope trial is an kind of an expansion of the original neurobics trial that I did. 34:38.671 --> 34:47.177 [SPEAKER_01]: And it's a collaborative effort with me and Beth is real deaconess and Massachusetts general and then also Columbia. 34:47.197 --> 34:54.822 [SPEAKER_01]: The two PIs, Dr. Bala Supermonium and Lake Al, they're the PIs on the study. 34:55.062 --> 34:59.465 [SPEAKER_01]: And then I'm the site PI at Ohio State and then we have the Vet Moitra Columbia. 35:00.025 --> 35:14.114 [SPEAKER_01]: The study is taking the brain exercises and adding sleep hygiene, coaching, and patient education and kind of in the pre-operative setting to further add cognitive reserve and pre-habilitation. 35:15.094 --> 35:19.697 [SPEAKER_01]: That package is being done before surgery with the tablet, again, brain exercises. 35:19.777 --> 35:23.819 [SPEAKER_01]: And then after surgery, there is some opiate-sparing pain management aspects of the study. 35:28.765 --> 35:48.935 [SPEAKER_01]: But that population is very high risk, so we really wanted to take the slayer to approach in that really high risk population, because it's a lot of elements, but again, it's kind of a lot of things that are low risk, which I think is ideal in this population or any population always. 35:49.996 --> 35:58.006 [SPEAKER_01]: To be able to have these things layered on and they're all pretty low risk things hopefully we'll see a great benefit And it'll actually be something that could be implemented. 35:58.066 --> 35:59.187 [SPEAKER_01]: So that's this goat trial. 35:59.248 --> 36:00.109 [SPEAKER_02]: Yeah, very cool. 36:00.129 --> 36:05.496 [SPEAKER_02]: Well, we'll be exciting to see the results and I mentioned it'll be few years before we have that 36:06.603 --> 36:07.584 [SPEAKER_01]: It'll be a couple of years. 36:07.644 --> 36:09.545 [SPEAKER_01]: We're in the middle of enrollment right now. 36:10.366 --> 36:13.568 [SPEAKER_01]: That trial will have 406 patients at the end. 36:13.628 --> 36:17.231 [SPEAKER_01]: We're about maybe about 30% of the way through. 36:17.291 --> 36:20.874 [SPEAKER_01]: So we're we're well into it, but we've got a ways to go still. 36:20.954 --> 36:22.115 [SPEAKER_01]: So another couple years. 36:22.355 --> 36:22.936 [SPEAKER_02]: very exciting. 36:23.416 --> 36:25.718 [SPEAKER_02]: Well, we've talked about some of the kind of things to come. 36:25.758 --> 36:36.009 [SPEAKER_02]: I mean, the scope trial obviously, you've mentioned the idea of maybe using some games as a diagnostic intervention to try to figure out someone if they had pre-operative cognitive impairment based on how they do on a game. 36:37.610 --> 36:57.451 [SPEAKER_02]: You, I know when we talked before after your grand rounds, there's also the thought of, could you figure out specifically which games or which type of skills are the most protective if you get good at them, so all that's really interesting and exciting are there other things that you think are coming down the road in this area of research and in terms of just cognitive protection and general that they're exciting, which you keep our eyes out for? 36:58.664 --> 37:16.332 [SPEAKER_01]: Yeah, I think, you know, it definitely think that using dynamic, you know, kind of like self-administered brain exercises is really interesting thing for the future because like you said, the ability for the patients to to play some games and that would be our way of screening them. 37:16.512 --> 37:18.733 [SPEAKER_01]: It could integrate right into our medical record, right? 37:18.753 --> 37:22.195 [SPEAKER_01]: It would kind of solve some of these logistical issues, I think that of 37:23.515 --> 37:30.077 [SPEAKER_01]: kind of stymied our ability to do this on a bigger scale, and I think that's super exciting. 37:31.317 --> 37:49.321 [SPEAKER_01]: I also, you know, I think sleep and kind of the anti-inflammatory standpoint, I mean, there's just a lot of good pieces coming together, and I think the most exciting thing for the future is that we might have a way to really tailor certain things depending on what 37:52.029 --> 37:58.092 [SPEAKER_01]: It might be a combination of things before or in the OR or more at, you know, with after surgery. 37:58.772 --> 38:10.177 [SPEAKER_01]: And it's just, it's so, because there's so many different things that contribute to delirium, I think the future is really exciting because it's going to continue to kind of chip away at each of those things. 38:11.278 --> 38:15.820 [SPEAKER_01]: And hopefully, land is in a place where this is, this is not something that we're dealing with as much, so. 38:16.387 --> 38:22.896 [SPEAKER_02]: very cool looking forward to it all right well let's turn to the portion of our show where we make random recommendations what's something you would recommend the audience check out for fun 38:23.852 --> 38:25.433 [SPEAKER_01]: All right, totally for fun. 38:25.933 --> 38:29.315 [SPEAKER_01]: I came across this book several months ago. 38:29.415 --> 38:31.377 [SPEAKER_01]: I have no idea how I found it. 38:32.017 --> 38:33.538 [SPEAKER_01]: It's just random. 38:33.878 --> 38:35.039 [SPEAKER_01]: And it caught my attention. 38:35.079 --> 38:37.460 [SPEAKER_01]: It was in my audible, believe it or not. 38:37.600 --> 38:39.201 [SPEAKER_01]: I still have no idea how it landed there. 38:39.361 --> 38:42.243 [SPEAKER_01]: I must have thought it was interesting at some point and put it in my library. 38:42.263 --> 38:47.847 [SPEAKER_01]: And I was scrolling through it's called many lives, many masters, is that the name of it? 38:47.867 --> 38:48.107 [SPEAKER_01]: Yeah. 38:48.667 --> 38:58.470 [SPEAKER_01]: And it's about a psychiatrist and his kind of account of just this extraordinary patient encounter that he had in the 80s. 38:59.330 --> 39:00.671 [SPEAKER_01]: And it's fun to read. 39:00.791 --> 39:10.993 [SPEAKER_01]: It's definitely pushes the boundaries, I would say, of what we think of when we think of kind of typical medicine or practice and therapy, but it's fun. 39:11.174 --> 39:15.415 [SPEAKER_01]: It just is fun to think about, like, when you're a scientist or you're a clinician and 39:16.615 --> 39:35.720 [SPEAKER_01]: something come to you that just completely challenges your core system of how you put it process things like it's fun it's a really great story it's interesting to hear the stuff work through this this patient experience and kind of all the the wild things that she she told him and how he handed all that just fun it's an interesting read so 39:36.040 --> 39:36.520 [SPEAKER_02]: Very cool. 39:36.680 --> 39:36.981 [SPEAKER_02]: All right. 39:37.001 --> 39:37.641 [SPEAKER_02]: That sounds awesome. 39:38.041 --> 39:41.303 [SPEAKER_02]: I'm going to recommend a TV show called Justified. 39:41.323 --> 39:42.563 [SPEAKER_02]: And you can stream it on Hulu. 39:43.144 --> 39:44.985 [SPEAKER_02]: It's a lot of fun. 39:45.085 --> 39:48.406 [SPEAKER_02]: And I will say one of the interesting things about this is that I asked Claude. 39:49.107 --> 39:50.968 [SPEAKER_02]: I told Claude some of the other shows I had liked. 39:51.008 --> 39:52.969 [SPEAKER_02]: And I said, you know, I'm looking for another show to watch. 39:53.829 --> 39:53.969 [SPEAKER_02]: And 39:55.230 --> 39:56.331 [SPEAKER_02]: I'll tell you I was very impressed. 39:56.391 --> 40:17.533 [SPEAKER_02]: Claude told me, check out justified and Claude said the first season is a little on the slower side and not quite as good, but it's worth making it through because the second season is really much better and I was kind of almost done with the first season and thinking, I don't know, I might not stick with it and then I went back and read and I saw, oh yeah, Claude said, and sure enough, I got to the second season and it's really got me hooked now. 40:18.314 --> 40:22.136 [SPEAKER_02]: both a plug, I guess, for Claude, in terms of TV recommendations. 40:22.176 --> 40:22.977 [SPEAKER_00]: Well done, Claude. 40:23.157 --> 40:24.098 [SPEAKER_02]: Yeah, exactly. 40:24.158 --> 40:27.800 [SPEAKER_02]: And then justified, which I think is worth watching. 40:27.880 --> 40:30.922 [SPEAKER_02]: If you just get through the first season, it's not that you have to suffer through it. 40:30.942 --> 40:31.382 [SPEAKER_02]: It's fine. 40:31.422 --> 40:33.143 [SPEAKER_02]: But the second season is better. 40:34.524 --> 40:34.824 [SPEAKER_02]: Awesome. 40:35.365 --> 40:36.945 [SPEAKER_02]: Well Michelle, thanks so much for coming on the show. 40:37.926 --> 40:38.606 [SPEAKER_01]: I appreciate it. 40:38.647 --> 40:39.027 [SPEAKER_01]: Thank you. 40:39.845 --> 40:42.186 [SPEAKER_02]: All right, hopefully you got as much out of that as I did. 40:42.626 --> 40:43.727 [SPEAKER_02]: That was really fantastic. 40:43.987 --> 40:45.087 [SPEAKER_02]: Let us know what you thought. 40:45.327 --> 40:48.809 [SPEAKER_02]: Go to the website,acrack.com, where you can leave a comment. 40:49.209 --> 40:51.130 [SPEAKER_02]: Others can learn from what you have to say. 40:51.970 --> 40:54.951 [SPEAKER_02]: If you are a fan of the show, you can follow us. 40:55.272 --> 40:56.092 [SPEAKER_02]: We're on Twitter. 40:56.512 --> 40:57.773 [SPEAKER_02]: We are on Facebook. 40:58.233 --> 40:59.693 [SPEAKER_02]: We are on Reddit. 41:00.094 --> 41:01.174 [SPEAKER_02]: And we are on Instagram. 41:01.814 --> 41:03.375 [SPEAKER_02]: I'm at Jay Wolpa on Twitter. 41:03.435 --> 41:04.916 [SPEAKER_02]: And we're at Acrack Podcast. 41:05.196 --> 41:07.757 [SPEAKER_02]: And you can find us on all those other platforms as well. 41:08.177 --> 41:16.539 [SPEAKER_02]: If you are a fan of the show, please consider going to Apple Podcasts or wherever you get your podcasts and leaving a comment and a rating, it really helps others find the show. 41:16.979 --> 41:26.742 [SPEAKER_02]: If you'd like to support the making of the show, please consider going to patreon.com slash accurate, that's p-a-t-r-e-o-n.com slash ac-c-r-ac where you can become a patron of the show. 41:27.422 --> 41:30.923 [SPEAKER_02]: Even if it's just a dollar or two that you pledge, it makes a big difference and we really appreciate it. 41:31.323 --> 41:39.164 [SPEAKER_02]: You can also make donations anytime by going to paypal.me-slash-acrack or looking up J.Wallpa on Venmo. 41:39.484 --> 41:44.125 [SPEAKER_02]: Thank you so much to those who have already made donations and become patrons, we really appreciate it. 41:44.585 --> 41:47.486 [SPEAKER_02]: Thanks as always to our fantastic acrack crew. 41:48.066 --> 41:55.027 [SPEAKER_02]: So, niaminat is our tech lead, chitima ikanti, Rachel Furman, and Muhammad Selab are our production assistants and social media managers. 41:55.857 --> 41:57.217 [SPEAKER_02]: Thanks so much for all you do. 41:57.958 --> 42:00.698 [SPEAKER_02]: Our original ACRAG music is by Dr. Dennis Quow. 42:01.058 --> 42:04.079 [SPEAKER_02]: You can check out his website at studymusicproject.com. 42:04.940 --> 42:07.340 [SPEAKER_02]: All right, that is it for today. 42:07.760 --> 42:10.421 [SPEAKER_02]: For the ACRAG podcast, I'm Jed Wolpa. 42:10.921 --> 42:11.721 [SPEAKER_02]: Thanks for listening. 42:12.202 --> 42:17.363 [SPEAKER_02]: Remember what you're doing out there every day is really important and valued.