Higher Cancer Rates (8.16.2024) Save
Dr. Jack Cush reviews the news and journal reports from the past week on RheumNow.com, noting his concerns about diet, cancer, ILD, death and dosing challenges.
Transcription
It's 08/16/2024. This is a RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor with rheumnow.com. This week on the podcast, a bunch of happy things, anti inflammatory diets, cancer, interstitial lung disease, death, dosing.
Oh my goodness. Put on your seat belt. Let's get started. A study of patients with PSA and psoriasis, mostly PSA patients, over four hundred patients. They looked at the associations of any out, I guess the outcomes, if you will, of exercise and diet in these people.
And what they found was kind of interesting. Number one, that PSA patients had more comorbidity than PSO patients. I don't know that I've ever seen that, forty three percent versus twenty six percent, that when they graded the exercise level in this large cohort, the majority had really low levels of exercise. And then they went to look further at what happened in those who did exercise more than a low level. And people who were exercising more had significantly lower and better scores at DAPSA, a measure of remission, and skin activity, tender joints, swollen joints, sed rates, and psoriasis extent or PASI scores.
When I looked at diet, those who are adherent to a high Mediterranean, meaning anti inflammatory diet, they were more likely to have bigger drops in their ESR and in PASI. But the only thing that panned out was high Mediterranean diet related to better enthesitis control. I found that kind of surprising, and that was significant. But, you know, kinda reinforces some of the things we've seen before, but there is clearly a big comorbidity burden. There's clearly a need for exercise.
There clearly needs to be a dietary approach to psoriatic disease. Another study on anti inflammatory diets comes from the US Biobank study, a large cohort that looked at patients who had cardiometabolic disease, diabetes, heart disease, stroke, etcetera, that when they showed those who were on an anti inflammatory diet, they found that there was a significant decreased risk for dementia. And that was when you compare an anti inflammatory diet to those that were taking sort of a Western, if not American, pro inflammatory diet. You know, diet as a preventative measure in dementia, I think it's the one thing none of us want to deal with going forward because it is devastating to those affected and the families. I like this data, about breast cancer that I published this week.
This was a study that gathered data from commercial claims data, Optum insurance claims data, and what was called the SEER Medicare database, and found that amongst all the patients that they had who had breast cancer, roughly seventeen percent of them had received the TNF inhibitor. So the question is, you know, are you happy to use a TNF inhibitor in people with breast cancer? Do you worry about that? Well, clearly seventeen percent of people didn't. And when you looked at the overall survival of people on a TNF inhibitor versus not on TNF inhibitor and having a diagnosis of breast cancer, no different.
In fact, it trended towards being a little bit lower, either twenty three percent or sixteen percent lower but that was not significant right so nonetheless patients with breast cancer did have better survival on a TNF inhibitor, and that was actually thirty no, seventy two percent lower or seventy two percent better versus those that were on a conventional DMARR like methotrexate. So, again, I won't put this up to dispel a lot of the myths we have, concerns we have about being aggressive in treating patients who have cancer. You know, last week, we had a download on RheumNow that you a slide download from the recent UR recommendations on how to treat patients with a diagnosis of cancer and how to treat their their their inflammatory disorder. You can download that and see that the UR points to consider, not really guidelines, but sort of eminence based, expert based opinions based on the data, really are kind of supportive of just what I said here, that you it's okay to use a TNF inhibitor with breast cancer. Speaking of cancer, how many of your patients are at higher risk?
You know, certainly dermatomyositis, we know rheumatoid, we know PSA, probably lupus. And I found a report this week on scleroderma. And this comes from the clinical practice research database. From that cohort, they found over fifteen hundred patients with systemic sclerosis. From that group, two hundred and six developed a cancer down the line.
The most common cancers were mucocutaneous, so skin, and I guess oral, lung, and breast cancer were the three most common ones. What they did find was that the scleroderma patients had a significantly increased risk with an adjusted hazard ratio of one point four, roughly about a forty percent increased risk. Question is, should you then be screening your patients with scleroderma for cancer much like many of you do with dermatomyositis? I must say I'm not too, carried away with cancer screening with dermatomyositis. I've always been reared with the data that it was more common with dermatomyositis and in men and 50 and that good health screening measures were appropriate.
So that's what I do. I do health screening measures especially in people with dermatomyositis, and especially as they get older. And then I follow the symptomatology or the quizzical things in their history like a cough or irregular bowel movements, and you would know what to do there. Another study of cancer this week comes from the VA administration, where they looked at a match cohort study and the numbers were really large. Wanna say it was like seventy three thousand RA patients were matched against non RA over six hundred thousand people.
These were older males, 63 years of age. They found seventeen thousand incident lung cancers between both groups. RA patients have, as you probably know and expect, an increased risk of lung cancer. You know, many studies show this. So RA patients are increased risk of skin cancer, lung cancer, lymphoma, right?
Those are the main ones, right? The increased cancer risk for lung cancer has as I said, hazard ratio of one point five eight or fifty eight percent increased risk, which still persisted in people who were not smokers ever, it was a sixty five percent increased risk, and was also found in just incident RA patients that were looked at about the same numbers. What they did also show was from that RA cohort, there were seven hundred and fifty seven who had RA ILD, and guess what? Their risk of cancer and lung cancer was threefold higher. So that's a little scary.
So we already know that bad things happen to RA ILD patients, higher mortality, higher risk of serious infectious events and hospitalizations. And now we can add to that list a higher risk of lung cancer. Again, a population we need to take note of, worry about, start developing some preventative measures for. A study from the Mass General Brigham looked at one hundred and seventy two patients with RAILD followed them a mean of six point five years. From the one hundred seventy two cohort, four percent ended up with lung transplant, forty four percent, I'm sorry, twenty six percent had an ILD related death.
When they took that one hundred and seventy nine, they either and they then grouped them by trajectory of their lung disease based on FVC. And they followed them again almost seven years and there were those who had no change or improvement in their FVC. The biggest group was over fifty percent that were a slow decline in their FVC. I want to say that the ones that actually, had a real decline, a rapid decline, fourteen percent, those are ones at higher risk. In those people, there was a nineteen fold increased risk of needing lung transplant and there was a what's the number?
Almost threefold risk of an ILD related death. So again, that's sort of surprising and worrisome. The patients with a slow decline was fifty four percent, no decline, thirty two percent. But again, their rates for lung transplants were much, much lower. Another study looked at what happens in ILD and myositis, specifically those with the antisynthetase syndrome.
And this systematic literature review found basically there is no conclusive study or evidence that anything works at improving ILD outcomes. So this is a study of five fourteen patients, two thirds were women. They did high res CTs in the vast majority, more than half of them or about half of them had NSIP patterns, half of them had JO-one antibodies, twenty eight percent with anti RO-fifty two, and again nothing worked really at improving the ILD. They had low level improvements with rituximab in twelve percent with cyclophosphamide in seventeen percent but again the story is not good if you've got ILD even with myositis due to the antisynthetase syndrome. The Journal of Rheumatology did a nice little review of anti coup myositis.
I must say I'm not someone who when I get a myositis patients, I don't I used to never do auto myositis antibody testing, you know, maybe occasionally a joe one. Many of you will do the whole panel and my point to that was well what are you going to do with the information? Know MI2 and CU and you know there's a PL7 and 12 and all you know again there's a lot to know there but the question is does it gonna change your therapy or are you gonna treat what they have? Well, this anti coup myositis study looked at, I can't remember the size of the cohort, but it was a fairly good gathering, ninety two percent female, average age 56 years, very high levels of CK, thirty one percent, almost a third of them had an overlap between myositis and scleroderma, and those that did, half of them had ILD. So that's maybe one reason to do anti coup testing that is potentially a risk factor for a scleroderma overlap which would make things worse would it not and add in the risk of, ILD.
The path is pretty distinctive, myofibro necrosis, endomycin inflammation, class one class two MAC positivity on staining. So I don't know that I'm fully you know buying into myositis specific autoantibodies on a large scale basis, but I thought this was interesting. Like looking at, you know, NXP2 and MDA5, I think that those have prognostic significance to me that's worth testing for. You know, sometimes we get patients who have these autoimmune diseases, whether it be lupus or Sjogren's or vasculitis and the question is what happens to them when they get pregnant and what's the data going to show? It was often not a lot of data.
I published this week, the results of a vasculitis pregnancy registry which is a sort of open label cumulative enrollment they reported on one hundred and forty seven women one hundred and forty nine pregnancies they have data on all complete data on seventy eight of them so about half thirty six percent had active vasculitis during pregnancy. That's a little scary. Fourteen of them were hospitalized, four because of vasculitis. The rest were for medical and pregnancy reasons. Seventy four percent took a vasculitis medication during the pregnancy.
The good news is that ninety seven percent had live births, twenty one percent were preterm births, which is kind of favorable outcomes given the picture I painted for you here, which is that they may continue to have active vasculitis and require active treatment for vasculitis, but the outcomes were favorable. Again, I think the challenge here is that when you have an autoimmune disorder and a patient gets pregnancy has pregnancy, number one, consult the ACR reproductive guidelines on what you might find and what about what to do. Secondly, you know, do a literature search and find what the data is on outcome so that you can be knowledgeable and then help guide the patient and the maternal fetal health person or the OBGYN in managing that patient over time. A recent study was published that showed obese patients have a significantly greater odds of developing gout. The odds were basically, you know, seventy to eighty five percent higher than if you didn't weren't obese.
And that's really was very significant. There's a study of six hundred gout patients and almost 10,000 controls. And it was looking at diabetics, and then they measured obesity in four different ways, waist circumference, BMI, visceral fat area, waist to hip ratio, things that and the bottom line is, I guess, it's really diabetes and obesity significantly increases the risk of gout. Maybe that's not surprising to you, but such data isn't plentiful and that's why I published it. Death rates were reported for The United States in this past week by the CDC in their MMWR report that they and this is a death rates in The United States from 2023 where the death rates are down six percent and that's kind of encouraging.
You know, the last several years we've had a significant lowering almost every year of the average life expectancy in The United States. Initially, was due to the opioid epidemic and then it was due to COVID. But this, death rate is even down further, and the rate of COVID deaths, you know, dropped from two hundred and forty five thousand in 2022, which was less than 2021 and 2020, to in 2023 only seventy six thousand, meaning it dropped by seventy six percent and that probably accounts for a lot of the improvement in the mortality rate in The United States. The overall mortality rate was lowest in non Hispanic mixed race people about I think was like three hundred per hundred thousand, and then was highest in non Hispanic blacks and African Americans where it was like almost threefold higher. Speaking of death, an important study about the protective benefits of GLP-one agonists in patients with immune mediated inflammatory diseases and diabetes.
So this is published in PLOS-one, a population study from British Columbia looked at over almost eleven thousand patients with diabetes and an image disorder like RA, IBD, and closing spondylitis, PSA, etcetera. And they found, they compared patients with their diabetes were treated with GLP-one receptor agonist versus the DPP-4I, the dipeptidyl peptidase drugs. And GLP-1s had a significantly lower all cause mortality that was fifty two percent better than the DPP drugs. And they all had a significantly lower rate of MACE thirty four percent lower, and both of those were highly significant. Again, the use of these GLP-one drugs for diabetes is going to extend to obesity, is going to extend to improvement of cardiovascular mortality in diseases like RA, lupus, gout, and maybe more going forward.
I'm gonna end with the a sleep study. That's the ASLEAP study, l e a p, that tested the potential benefit of dose increasing secukinumab in people who were not responding to the usual dose. So secukinumab use in ankylosing spondylitis, the usual dose is a hundred and fifty milligrams sub q given weekly for four weeks and then every month. In this study, 322 is a phase four trial, by the way. Three twenty two patients with AS were started on secukinumab and then at sixteen weeks, if they were non responders, their doses were escalated or not.
So at that sixteen weeks, 64 were not yet responders. They did a one to one randomization and at the end of, I think it was fifty two weeks, there was, what was the number, really low People that actually achieved improvement, which was defined as an ASDAS less than 1.3. So number one, no difference between those who escalated to 300 and those who stayed at one fifty. Very sobering. Second, that the number of people that did improve in either group was incredibly low, less than nine percent, eight point eight versus six point seven not being significant.
Adverse events, this is a now concern, now an issue if you have an AS patient not responding. Whatever dose you're using, are you gonna switch drugs? Are you gonna switch classes? Are you gonna use another IL seventeen? That wasn't studied here.
And switching to another class like a JAK inhibitor or a, you know, a TNF inhibitor is not that wasn't studied here either. But I think this data says not much hope for sticking with a secukinumab after they haven't respond to your initial dosing. So kind of, not a lot of happy stuff this week, but still nonetheless informative. And I had you on the edge of your seat. I'm sure most of you who are driving had to pull over and listen to this because of the earth shattering news, such as the podcast.
Thank you for tuning in. Go to the website to check out these citations and more. We'll talk again next week. Take good care of yourselves.
Oh my goodness. Put on your seat belt. Let's get started. A study of patients with PSA and psoriasis, mostly PSA patients, over four hundred patients. They looked at the associations of any out, I guess the outcomes, if you will, of exercise and diet in these people.
And what they found was kind of interesting. Number one, that PSA patients had more comorbidity than PSO patients. I don't know that I've ever seen that, forty three percent versus twenty six percent, that when they graded the exercise level in this large cohort, the majority had really low levels of exercise. And then they went to look further at what happened in those who did exercise more than a low level. And people who were exercising more had significantly lower and better scores at DAPSA, a measure of remission, and skin activity, tender joints, swollen joints, sed rates, and psoriasis extent or PASI scores.
When I looked at diet, those who are adherent to a high Mediterranean, meaning anti inflammatory diet, they were more likely to have bigger drops in their ESR and in PASI. But the only thing that panned out was high Mediterranean diet related to better enthesitis control. I found that kind of surprising, and that was significant. But, you know, kinda reinforces some of the things we've seen before, but there is clearly a big comorbidity burden. There's clearly a need for exercise.
There clearly needs to be a dietary approach to psoriatic disease. Another study on anti inflammatory diets comes from the US Biobank study, a large cohort that looked at patients who had cardiometabolic disease, diabetes, heart disease, stroke, etcetera, that when they showed those who were on an anti inflammatory diet, they found that there was a significant decreased risk for dementia. And that was when you compare an anti inflammatory diet to those that were taking sort of a Western, if not American, pro inflammatory diet. You know, diet as a preventative measure in dementia, I think it's the one thing none of us want to deal with going forward because it is devastating to those affected and the families. I like this data, about breast cancer that I published this week.
This was a study that gathered data from commercial claims data, Optum insurance claims data, and what was called the SEER Medicare database, and found that amongst all the patients that they had who had breast cancer, roughly seventeen percent of them had received the TNF inhibitor. So the question is, you know, are you happy to use a TNF inhibitor in people with breast cancer? Do you worry about that? Well, clearly seventeen percent of people didn't. And when you looked at the overall survival of people on a TNF inhibitor versus not on TNF inhibitor and having a diagnosis of breast cancer, no different.
In fact, it trended towards being a little bit lower, either twenty three percent or sixteen percent lower but that was not significant right so nonetheless patients with breast cancer did have better survival on a TNF inhibitor, and that was actually thirty no, seventy two percent lower or seventy two percent better versus those that were on a conventional DMARR like methotrexate. So, again, I won't put this up to dispel a lot of the myths we have, concerns we have about being aggressive in treating patients who have cancer. You know, last week, we had a download on RheumNow that you a slide download from the recent UR recommendations on how to treat patients with a diagnosis of cancer and how to treat their their their inflammatory disorder. You can download that and see that the UR points to consider, not really guidelines, but sort of eminence based, expert based opinions based on the data, really are kind of supportive of just what I said here, that you it's okay to use a TNF inhibitor with breast cancer. Speaking of cancer, how many of your patients are at higher risk?
You know, certainly dermatomyositis, we know rheumatoid, we know PSA, probably lupus. And I found a report this week on scleroderma. And this comes from the clinical practice research database. From that cohort, they found over fifteen hundred patients with systemic sclerosis. From that group, two hundred and six developed a cancer down the line.
The most common cancers were mucocutaneous, so skin, and I guess oral, lung, and breast cancer were the three most common ones. What they did find was that the scleroderma patients had a significantly increased risk with an adjusted hazard ratio of one point four, roughly about a forty percent increased risk. Question is, should you then be screening your patients with scleroderma for cancer much like many of you do with dermatomyositis? I must say I'm not too, carried away with cancer screening with dermatomyositis. I've always been reared with the data that it was more common with dermatomyositis and in men and 50 and that good health screening measures were appropriate.
So that's what I do. I do health screening measures especially in people with dermatomyositis, and especially as they get older. And then I follow the symptomatology or the quizzical things in their history like a cough or irregular bowel movements, and you would know what to do there. Another study of cancer this week comes from the VA administration, where they looked at a match cohort study and the numbers were really large. Wanna say it was like seventy three thousand RA patients were matched against non RA over six hundred thousand people.
These were older males, 63 years of age. They found seventeen thousand incident lung cancers between both groups. RA patients have, as you probably know and expect, an increased risk of lung cancer. You know, many studies show this. So RA patients are increased risk of skin cancer, lung cancer, lymphoma, right?
Those are the main ones, right? The increased cancer risk for lung cancer has as I said, hazard ratio of one point five eight or fifty eight percent increased risk, which still persisted in people who were not smokers ever, it was a sixty five percent increased risk, and was also found in just incident RA patients that were looked at about the same numbers. What they did also show was from that RA cohort, there were seven hundred and fifty seven who had RA ILD, and guess what? Their risk of cancer and lung cancer was threefold higher. So that's a little scary.
So we already know that bad things happen to RA ILD patients, higher mortality, higher risk of serious infectious events and hospitalizations. And now we can add to that list a higher risk of lung cancer. Again, a population we need to take note of, worry about, start developing some preventative measures for. A study from the Mass General Brigham looked at one hundred and seventy two patients with RAILD followed them a mean of six point five years. From the one hundred seventy two cohort, four percent ended up with lung transplant, forty four percent, I'm sorry, twenty six percent had an ILD related death.
When they took that one hundred and seventy nine, they either and they then grouped them by trajectory of their lung disease based on FVC. And they followed them again almost seven years and there were those who had no change or improvement in their FVC. The biggest group was over fifty percent that were a slow decline in their FVC. I want to say that the ones that actually, had a real decline, a rapid decline, fourteen percent, those are ones at higher risk. In those people, there was a nineteen fold increased risk of needing lung transplant and there was a what's the number?
Almost threefold risk of an ILD related death. So again, that's sort of surprising and worrisome. The patients with a slow decline was fifty four percent, no decline, thirty two percent. But again, their rates for lung transplants were much, much lower. Another study looked at what happens in ILD and myositis, specifically those with the antisynthetase syndrome.
And this systematic literature review found basically there is no conclusive study or evidence that anything works at improving ILD outcomes. So this is a study of five fourteen patients, two thirds were women. They did high res CTs in the vast majority, more than half of them or about half of them had NSIP patterns, half of them had JO-one antibodies, twenty eight percent with anti RO-fifty two, and again nothing worked really at improving the ILD. They had low level improvements with rituximab in twelve percent with cyclophosphamide in seventeen percent but again the story is not good if you've got ILD even with myositis due to the antisynthetase syndrome. The Journal of Rheumatology did a nice little review of anti coup myositis.
I must say I'm not someone who when I get a myositis patients, I don't I used to never do auto myositis antibody testing, you know, maybe occasionally a joe one. Many of you will do the whole panel and my point to that was well what are you going to do with the information? Know MI2 and CU and you know there's a PL7 and 12 and all you know again there's a lot to know there but the question is does it gonna change your therapy or are you gonna treat what they have? Well, this anti coup myositis study looked at, I can't remember the size of the cohort, but it was a fairly good gathering, ninety two percent female, average age 56 years, very high levels of CK, thirty one percent, almost a third of them had an overlap between myositis and scleroderma, and those that did, half of them had ILD. So that's maybe one reason to do anti coup testing that is potentially a risk factor for a scleroderma overlap which would make things worse would it not and add in the risk of, ILD.
The path is pretty distinctive, myofibro necrosis, endomycin inflammation, class one class two MAC positivity on staining. So I don't know that I'm fully you know buying into myositis specific autoantibodies on a large scale basis, but I thought this was interesting. Like looking at, you know, NXP2 and MDA5, I think that those have prognostic significance to me that's worth testing for. You know, sometimes we get patients who have these autoimmune diseases, whether it be lupus or Sjogren's or vasculitis and the question is what happens to them when they get pregnant and what's the data going to show? It was often not a lot of data.
I published this week, the results of a vasculitis pregnancy registry which is a sort of open label cumulative enrollment they reported on one hundred and forty seven women one hundred and forty nine pregnancies they have data on all complete data on seventy eight of them so about half thirty six percent had active vasculitis during pregnancy. That's a little scary. Fourteen of them were hospitalized, four because of vasculitis. The rest were for medical and pregnancy reasons. Seventy four percent took a vasculitis medication during the pregnancy.
The good news is that ninety seven percent had live births, twenty one percent were preterm births, which is kind of favorable outcomes given the picture I painted for you here, which is that they may continue to have active vasculitis and require active treatment for vasculitis, but the outcomes were favorable. Again, I think the challenge here is that when you have an autoimmune disorder and a patient gets pregnancy has pregnancy, number one, consult the ACR reproductive guidelines on what you might find and what about what to do. Secondly, you know, do a literature search and find what the data is on outcome so that you can be knowledgeable and then help guide the patient and the maternal fetal health person or the OBGYN in managing that patient over time. A recent study was published that showed obese patients have a significantly greater odds of developing gout. The odds were basically, you know, seventy to eighty five percent higher than if you didn't weren't obese.
And that's really was very significant. There's a study of six hundred gout patients and almost 10,000 controls. And it was looking at diabetics, and then they measured obesity in four different ways, waist circumference, BMI, visceral fat area, waist to hip ratio, things that and the bottom line is, I guess, it's really diabetes and obesity significantly increases the risk of gout. Maybe that's not surprising to you, but such data isn't plentiful and that's why I published it. Death rates were reported for The United States in this past week by the CDC in their MMWR report that they and this is a death rates in The United States from 2023 where the death rates are down six percent and that's kind of encouraging.
You know, the last several years we've had a significant lowering almost every year of the average life expectancy in The United States. Initially, was due to the opioid epidemic and then it was due to COVID. But this, death rate is even down further, and the rate of COVID deaths, you know, dropped from two hundred and forty five thousand in 2022, which was less than 2021 and 2020, to in 2023 only seventy six thousand, meaning it dropped by seventy six percent and that probably accounts for a lot of the improvement in the mortality rate in The United States. The overall mortality rate was lowest in non Hispanic mixed race people about I think was like three hundred per hundred thousand, and then was highest in non Hispanic blacks and African Americans where it was like almost threefold higher. Speaking of death, an important study about the protective benefits of GLP-one agonists in patients with immune mediated inflammatory diseases and diabetes.
So this is published in PLOS-one, a population study from British Columbia looked at over almost eleven thousand patients with diabetes and an image disorder like RA, IBD, and closing spondylitis, PSA, etcetera. And they found, they compared patients with their diabetes were treated with GLP-one receptor agonist versus the DPP-4I, the dipeptidyl peptidase drugs. And GLP-1s had a significantly lower all cause mortality that was fifty two percent better than the DPP drugs. And they all had a significantly lower rate of MACE thirty four percent lower, and both of those were highly significant. Again, the use of these GLP-one drugs for diabetes is going to extend to obesity, is going to extend to improvement of cardiovascular mortality in diseases like RA, lupus, gout, and maybe more going forward.
I'm gonna end with the a sleep study. That's the ASLEAP study, l e a p, that tested the potential benefit of dose increasing secukinumab in people who were not responding to the usual dose. So secukinumab use in ankylosing spondylitis, the usual dose is a hundred and fifty milligrams sub q given weekly for four weeks and then every month. In this study, 322 is a phase four trial, by the way. Three twenty two patients with AS were started on secukinumab and then at sixteen weeks, if they were non responders, their doses were escalated or not.
So at that sixteen weeks, 64 were not yet responders. They did a one to one randomization and at the end of, I think it was fifty two weeks, there was, what was the number, really low People that actually achieved improvement, which was defined as an ASDAS less than 1.3. So number one, no difference between those who escalated to 300 and those who stayed at one fifty. Very sobering. Second, that the number of people that did improve in either group was incredibly low, less than nine percent, eight point eight versus six point seven not being significant.
Adverse events, this is a now concern, now an issue if you have an AS patient not responding. Whatever dose you're using, are you gonna switch drugs? Are you gonna switch classes? Are you gonna use another IL seventeen? That wasn't studied here.
And switching to another class like a JAK inhibitor or a, you know, a TNF inhibitor is not that wasn't studied here either. But I think this data says not much hope for sticking with a secukinumab after they haven't respond to your initial dosing. So kind of, not a lot of happy stuff this week, but still nonetheless informative. And I had you on the edge of your seat. I'm sure most of you who are driving had to pull over and listen to this because of the earth shattering news, such as the podcast.
Thank you for tuning in. Go to the website to check out these citations and more. We'll talk again next week. Take good care of yourselves.
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