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Interviewer: The highest risk factor for becoming hospitalized and suffering the worst effects of COVID-19 is being 65 and older. We're with gerontologist Dr. Mark Supiano, who is the Dhief of the Division of Geriatrics at U of U Health. Let's start out with the question, why is that?

Dr. Supiano: We do know that there are underlying changes in the immune system in an older person that puts them more at risk of getting an infection. They cannot mount the same immune defenses to fight it off. So that's first. Secondly, there are other physiologic changes in the lungs and the heart, in other responses to an infection that put older people at risk for more complications. So they don't have the functional reserves to compensate for the devastating effects of the COVID infection itself.

Interviewer: In addition to the immune system changes, which apparently starts at 65, is that what you're saying or ish?

Dr. Supiano: Yes. It's not a hard and fast number, but the older you are, the more likely those changes will be present.

Interviewer: Got you. So it's a linear kind of a decline.

Dr. Supiano: Yeah.

Interviewer: All right. In addition to that, are there other reasons why individuals over 65 are more likely to get COVID-19 and suffer the worst effects from it?

Dr. Supiano: I think related to that, and particularly as you go up in years above the age of 65, so it's a very heterogeneous group, but for 75 and older, or particularly 85 and older, the likelihood that you have multiple chronic conditions that are also associated with higher risk of COVID, such as high blood pressure, diabetes, obesity, renal disease, those other risk factors can accumulate. And the more risk factors you have the higher your risk would be.

Interviewer: So it sounds like if I have a mother or a grandfather that has some of those conditions and they're over 65, I might want to take additional precautions than perhaps if my parent was healthy?

Dr. Supiano: Exactly.

Interviewer: But still over 65, that in and of itself.

Dr. Supiano: Even without those underlying conditions, the current information suggests that just age 65 and higher, again, the higher, the more risk, but that age alone would be a significant high-risk factor.

Interviewer: How about the symptoms for people that are 65 and older for COVID-19? Are they the typical symptoms that we see in other people?

Dr. Supiano: So they can be. So the most common symptoms would include fever, cough, fatigue, or loss of energy, sometimes diarrhea. Those are the most common symptoms that have been reported. But as is true with many other infections in older populations, there's more often unusual presentations of that infection. So, for example, there may not be a fever. So older people may not mount a fever in response to the infection. So the absence of a fever should not make you think that the COVID is not a possibility.

Another possibility is that someone who presents with confusion or an acute change in their mental status, that in fact could be a presenting symptom of COVID. There's also evidence to suggest that an unusual symptom of losing taste or smell could be the first presenting symptom of COVID. So we need to have a heightened level of awareness for unusual ways that COVID might present in an older adult.

Interviewer: But the trick there to me is how do you differentiate that from just part of the normal aging process? If I understand correctly, loss of taste and smell, kind of common when you start getting older. Confusion can start developing when you get older. How do you determine if it's COVID or not?

Dr. Supiano: So it's really separating out what we would think about as being usual aging from a potential infection, and the general rule of thumb that I use and I teach our trainees is that age alone is almost never the answer, right? If someone's coming with some new concern or complaint, we need to think it's our job to find out what's going on, and in this case, have a very low threshold to think, is this possibly related to COVID?

Interviewer: If somebody in your life who is 65 or older then develops one of these COVID symptoms, whether normal or not quite as normal, what should you do at that point? Should you get to the hospital immediately? I suppose a test probably would be the first thing.

Dr. Supiano: So I think the first . . . exactly, Scot. And fortunately, with our health system now is very well-equipped to evaluate people with potential COVID-related illness in an environment actually outside of the hospital. We really don't want you bringing that patient into our clinic or directly into the emergency room. They should be evaluated at one of the testing centers where there's the outdoor testing facility. You don't have to leave your car, get the tests done. Then if further evaluation needs to be done, certainly going to urgent care or an emergency room that's equipped to appropriately isolate and manage someone as a potential COVID infection and has the appropriate personal protective equipment and so forth to also protect the other staff and other patients.

Interviewer: Of course, if you have severe symptoms, difficulty breathing, any of that sort of stuff, then . . .

Dr. Supiano: Do not pass go.

Interviewer: Yes.

Dr. Supiano: Yes, go straight to the emergency room.

Interviewer: All right. You're the expert. I always love to ask this last question when I've got an expert here behind the microphone. What's the one thing, when we're done talking, that you would want someone to take away from our conversation?

Dr. Supiano: Wash your hands. No, seriously, I think the main point is that people 65 and older are considered high-risk, and high-risk individuals need to be extremely vigilant about maintaining these precautions, hand washing being one of them, but maintaining physical distance, wearing a mask, minimizing your exposure. All of the things that are on that list, we need to not let down our guard and not be complacent. We need to keep up with those protective measures if we're going to get through this.

Interviewer: And as a loved one, also do those same things to protect those that I love.

Dr. Supiano: Exactly.

Interviewer: Three things that kill young, healthy people. That's coming up next on The Scope.

Announcer: This is "From the Front Lines" with emergency room physician, Dr. Troy Madsen on The Scope.

Interviewer: Today we're going to talk about from his perspective in the ER, three things that can kill young healthy people. Because generally young healthy people aren't prone necessarily to dying, but there's some kind of usual suspects that you see come up time and time again. So let's start with number one. What is that?

Dr. Madsen: So number one, the one thing I see that it's just devastating to see this, but this kills young healthy people is a pulmonary embolism. This is a blood clot in the lungs. Some people are prone to these because they may have a genetic disorder that makes their blood more likely to clot. But what will happen with the clot, it often forms in the legs, somewhere else in the body, breaks through, goes to the lung. And if it's large enough, can just cause just a massive collapse of your cardiovascular system where your heart is just not squeezing the blood out like it should, and that can kill people. It's a devastating thing. We do see it occasionally, and these are very often people who are otherwise healthy.

Interviewer: Now we're talking 30, 40 otherwise athletic. A lot of times it can affect them.

Dr. Madsen: Exactly. For a lot of these people, it's their first time in the ER. They may not even see a doctor. They may have zero health conditions, no meds and this can happen out of the blue.

Interviewer: Are there any warning signs for a pulmonary embolism that they could have been aware of that might have prevented it?

Dr. Madsen: So sometimes these people may have had a small pulmonary embolism before the big one hit, and they may have had some chest pain, shortness of breath. Classically the chest pain is worse when you take a deep breath. A lot of times they describe that they just can't do their usual activities. They feel shorter breath while they're trying to walk upstairs or run or things they would typically do. These are all things to watch for and try and get some medical attention if you're having these symptoms.

Interviewer: And not be confused for maybe some other things like maybe thinking you've got asthma all of a sudden.

Dr. Madsen: Exactly. You know, usually people who have asthma have probably had asthma before. It would be unusual for that just to come on out of the blue. So if you have new chest pain, new shortness of breath, especially if that pain is worse if you take a deep breath, if you're passing out, if your heart is going really fast, all reasons to get checked out.

Interviewer: All right, go to the ER for that.

Dr. Madsen: I would go to the ER absolutely.

Interviewer: Three things that kill young healthy people. What's number two?

Dr. Madsen: So number two is an aneurysm in the brain or what we call a subarachnoid hemorrhage. This is when an aneurysm bursts. There's bleeding in the brain. This is a devastating thing, and I can think of cases I've seen of people who have come in, young, otherwise healthy people and classically they describe a severe sudden onset headache. They describe it as a thunderclap headache. It just comes on like that sound of thunder. Just out of the blue, out of nowhere, severe sudden onset, maximal intensity, very quickly and they have bleeding in their brain and that bleeding can expand very rapidly.

Interviewer: Is that caused by trauma or something like that? Or does it just come on you even if you're just sitting and not doing anything?

Dr. Madsen: So trauma can absolutely cause this sort of thing. We definitely see lots of cases of trauma, but the cases I'm thinking of are people who have not had any trauma and who just say, "Wow, I got a headache out of the blue. I don't normally get headaches. This is a 10 out of 10 headache. This hurts like crazy. My head just feels awful." Maybe they're confused. Maybe they're having nausea and vomiting. This can be a very devastating thing and, like I said, can go south very quickly if this bleeding expands.

Interviewer: So if you're a young, healthy person and you're having those symptoms, again, go to the ER immediately.

Dr. Madsen: Absolutely. I mean anyone of any age. But this is one of these things in young, healthy people that is just, again, people who may have no other medical issues, no indication of anything wrong get a sudden severe headache, get medical attention, get checked out.

Interviewer: All right. Three things that kill young healthy people from an ER doc's perspective, number three.

Dr. Madsen: So number three is trauma. And this is often one of the most devastating things we see. You know, young, healthy people sometimes are more likely to take risk, whether it be on, you know, motor vehicles, motorcycles, outdoor activities, that kind of thing. You hate to see people who are severely injured by trauma, but it's a devastating thing to see. We see lots of trauma, and a lot of those traumas are again in people who are young, healthy, otherwise have never had issues, never been to a doctor, and suffer severe trauma. Sometimes no fault of their own or sometimes maybe because they are taking some risk.

Interviewer: So I think the takeaway for me anyway, and you can help verify this, it sounds like if you're having any sort of symptoms of a pulmonary embolism or a brain aneurism, that either shortness of breath that we talked about where normally you wouldn't have that or that thunderclap headache, you should immediately go to the ER even if you're healthy because these are some pretty serious signs, and as far as trauma's concerned, just be aware that that's a danger for us young, healthy people.

Dr. Madsen: That's exactly right, yes. Pulmonary embolism, subarachnoid hemorrhage, like you said, watch out for chest pain, shortness of breath, sudden severe headaches, trauma.

Interviewer: Take it seriously.

Dr. Madsen: Take it seriously. Take the necessary precautions. Stuff's always going to happen. There's always risk in any activity, but take the necessary precautions. Wear a helmet, wear your seat belt, make sure you're safe in any kind of activity.

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Interviewer: Why is pneumonia so dangerous? That's next on The Scope.

Announcer: This is "From The Frontlines," with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: It's a little shocking, but when you look at the top 10 causes of death, pneumonia comes in at number eight. Doesn't seem like something that should be that deadly, but it is. Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Why is pneumonia so dangerous? Why is it so deadly?

Dr. Madsen: Well, pneumonia's deadly because, you think about the ABCs, we talk about that, and that's exactly what pneumonia hits. The airway and the breathing. So the first two things, number one and two priority. When you've got something like pneumonia and it settles in, it could take a person pretty quickly, and I think it makes it on the top 10 list because really the people it affects are old people. Pneumonia has been called in the past "The Old Man's Friend", you may have heard that term. I don't know what a great friend it is, but...

Interviewer: Yeah, it doesn't sound too good to me.

Dr. Madsen: But the idea is that it's one of these things that historically has taken an older person and essentially gradually ended their life. It often eases them into death. It's often not a struggle or a horribly painful death, historically. I think that's why it got that term. But it is something, when we talk about deaths, we're talking primarily about older people who get pneumonia.

A lot of times, in those older people, you may not recognize pneumonia until it's really progressed just because older people are less likely to have fevers, they are less likely to maybe even report they have pneumonia. Maybe they don't have a good cough reflex, they've been aspirating, or breathing food or water into their lungs. So gradually, it's been building up in there. And then when you realize they have pneumonia, it's progressed quite a bit.

So these are the individuals who then come in the ER and we see them and they just have a very severe pneumonia. Maybe no one's been checking on them too much, maybe they're already a little confused all the time, and then they just seem just a little more confused and that may be the only sign of it. So pneumonia, that's who it hits, and that's who it hits pretty hard. That's really why pneumonia is one of the big killers.

Interviewer: And what exactly is going on with pneumonia? You catch it like you'd catch anything? It's a virus, a bacteria?

Dr. Madsen: Pneumonias can be caused by viruses, but typically when we're talking about pneumonias that kill people, we're talking about bacteria. The pneumonia gets in their lungs, works its way down in there, the bacteria get in there either through something they were exposed to that gets down in their lungs, or they have what's called aspiration pneumonia where they're breathing something into their lungs, and then that sets them up for a bacterial infection to settle in there.

Maybe they had a virus, maybe even the flu. The flu can cause inflammation in the lungs, weaken it, make it more likely for bacteria to settle in there. Whatever it is, typically the serious pneumonias are caused by a bacteria that get in the lungs, maybe just one side of the lungs, maybe it's both sides, maybe it's the upper part, the lower part. Different bacteria tend to attack different places in the lungs.

But the bottom line is that bacteria get in there, causes an infection that just continues to grow. That then causes them to have more difficulty breathing. They're not moving air into their lungs as well, not getting oxygen in their body. And then that infection, like an infection anywhere, can then affect the entire body, where it just causes the blood pressure to drop, causes the heart rate to go up. The blood pressure just can't sustain itself and that whole cycle is what eventually leads to death.

Interviewer: Wow. It's a little scary that you say that a lot of times people don't realize that Gram or Grandpa have it. How do I know? Is the breathing a noticeable symptom? Difficulty breathing is pretty noticeable?

Dr. Madsen: It is. It is. Difficulty breathing and, often, the signs are very subtle. Maybe your grandparent or your parent or friend, maybe they're just not acting quite right. They just seem a little different, little more confused. Maybe a little bit more of a cough. Something where in a younger person, you might think, "Ah, they just got a little something in their throat, maybe a little bit of a cold." Just even a little bit more of a cough can be a sign of something really serious in an older person.

Interviewer: So those minor coughs in an older person is something you really should pay attention to? Gotcha.

Dr. Madsen: Exactly. If someone comes in with a minor cough, absolutely. That's something where you definitely want to get a chest x-ray on them to see if they do have something down in their lungs.

Interviewer: All right. If somebody gets to you in time, is it reversible?

Dr. Madsen: It is, yeah. Most cases, we can treat with antibiotics, maybe we can treat them at home, just depending how they're breathing, how their vital signs look, looking at their blood work. Maybe they require hospitalization. But it's those severe cases where they're just really having a hard time breathing, those are the tough ones. And often, those cases, when someone comes in we have to intubate them, put a tube down their throat to breathe for them. Those are the really tough ones for them to come back from, just because it's so advanced.

Interviewer: What's the advice that you would have for somebody that has an older parent or grandparent? The takeaway that I'm taking, and maybe this isn't right, is if you're noticing the confusion and maybe just a cough that you might normally blow off for yourself, but it's an older person, take it seriously.

Dr. Madsen: That's exactly right. Don't expect them to have the same symptoms you're going to have. Don't expect them to just look absolutely miserable and have really high fevers and just be coughing incessantly. Can be a subtle cough, maybe just a little bit of a fever, something that's not even quite a fever. Or just they're a little bit more confused. Those are all signs that they probably need to get checked out.

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Interviewer: Getting a better understanding of the long-term effects of poor air quality in Utah. That's next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Heidi Hanson is a researcher that studies poor air quality and its adverse health effects. Heidi, when you look outside on one of our inversion type days, knowing what you know, what goes through your mind? Because I'd imagine it's a little different than what goes through my mind because of what you do know.

Heidi: Yeah, so I know that it's not great to be out there and it concerns me for a lot of the populations, especially the long-term effects of it. If a child's being exposed in utero, what are the long-term effects of this bad air quality? I'm thinking a lot further down the road. We also want to think about, obviously, our young children are a sensitive population and then older individuals as well.

Interviewer: Why young children? Is it because they're still developing?

Heidi: Yeah, yeah. So they're sensitive at the time of the exposure, but they're also sensitive for other reasons as well. So they're going through a period of development and so any environmental exposure to them may have long-term adverse effects. Because they're still developing, they're still growing their . . . environmental shock may really affect them in a long term and what we call that is a critical or sensitive period. When a child in utero, or is a fetus, they're going through a lot of rapid development at that time and any sort of environmental shock or exposure can change the way that they're developing.

And what we call that is scarring. Basically what that is, is that's a change to them that cannot be reversed. And for childhood, we usually we call it a sensitive period. So it's not quite as a critical growth period, but it's sensitive to environmental exposures, a lot more sensitive than an adolescent or an adult.

Women are another population that may be affected more than men by the poor air quality. And so that's something that's very interesting to look at the sex differences and really understanding if women are, what are those mechanisms? Then, another population that I've been working on with Dr. Anne Kirchhoff and Dr. Judy Ou at the Huntsman Cancer Institute is looking at cancer survivors. So trying to think through how cancer survivors are affected by bad air quality as well.

Interviewer: I guess I'm fairly fortunate the fact that I'm a male and I'm an adult and I don't have respiratory issues so, quite honestly, a lot of times I go out and I can smell the air, and I can see the air and I don't like the air, but I don't know that it affects me, really. Is that accurate or is it, "Oh, yes, it affects you, Scott"? What's your answer to that?

Heidi: I think it probably affects you a little bit more than you realize. So yeah, you may not have an asthma event or an asthma attack, but it's really . . . I don't know if you've noticed your nose running a little bit more or your body reacting because there are foreign materials going into your body that it's not expecting to deal wit. And your body does have to deal with them in some form. Even though you're not having an event that's taking you to the hospital, it's still affecting your health in some way.

Interviewer: Yeah, that would make sense. You look out and you look at that air and you go, "That can't be healthy," and the research shows that that's indeed the case?

Heidi: Absolutely. There is so much research on this topic and I really think it's pretty hard to refute that there are adverse health effects that are associated with air quality just because of the volume of research that's pointing to this. Not only is it just epidemiological research, but we're looking at animal models and you're seeing the same kinds of things. We're seeing there are definite effects to their quality. Even things you wouldn't necessarily think of, like your fertility. We're seeing there are studies out there showing that bad air quality may affect semen quality in men or bad air quality may affect fecundity for women. It's not just like your normal things, asthma, cardiovascular disease, but it may be affecting a lot more than just that.

Interviewer: And other stuff that we don't even realize.

Heidi: Right.

Interviewer: I know when you're doing research, when you're dealing with anything environmental, it can be very difficult because there are a lot of things in the environment. When you're looking at the effects of air pollution on the populations you're looking at, how do you know that it's air pollution that's causing it? How do you figure all that out?

Heidi: Yeah, so that's extremely difficult. A lot of what we are doing is with some of the methods we can do so you're comparing an individual to theirself in the statistical methods that we're using. And so what that does is that pretty much makes it so that anything we're not able to observe is kind of taken out of the equation. Basically, we're looking at the only things that are changing for that person on that day is their exposure to the air quality.

Air pollution is this amazing thing in Utah so we have this natural laboratory for doing this type of work where we have very clean air days and we have terrible air days. It leads to a kind of a perfect set up for this kind of research where there are strong environmental exposures that are well documented to have. There are biological mechanisms that are plausible that make us think this really may go on to have later life effects.

Interviewer: How do we get to a point where more people care? How do we get to a point where somebody . . . do you feel that we get to a point where somebody like me goes outside and I go, "This is terrible. We've got to do some about this," and then goes on with their day to day? Versus the people that are passionate about it are trying to make change. How we get more people like that?

Heidi: I think people really need to understand that this not just an acute effect. It's not something I'm only dealing with today and then tomorrow it's gone and it's okay. But if people really start to realize that what they're being exposed to may affect them now. It has potential to affect them long-term, especially when they start to get older. But not only that, it really has the potential to affect multiple generations.

If people are concerned about the health of their children and their grandchildren, they should be concerned about the air quality right now. There are studies that are just starting to come out showing there may be epigenetic changes related to air pollution. Basically, what they're saying is that air pollution may affect you, but it also may affect your sperm, which may go on to affect your children, or your grandchildren, or that exposure in utero may lead to epigenetic changes that go on to affect that child and also that child's child.

This is all newer research and so that has to be considered when you're thinking about this. But there is potential that this goes on to affect generations and it's not just that the only person that's affected it's you on the day of bad air quality.

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Interviewer: Research that gives us a new understanding of common yet relatively unknown birth defect, congenital diaphragmatic hernia.
Examining the latest research and telling you about the latest breakthroughs, The Science and Research show is on The Scope.
I'm talking with Dr. Gabrielle Kardon, Associate Professor in Human Genetics at the University of Utah. She's just published research in the journal Nature Genetics that gives us a new perspective into the causes of congenital diaphragmatic hernia or CDH. Dr. Kardon, I had not heard of CDH before can explain what that is?

Dr. Kardon: Most people are familiar with hernias as inguinal hernias and so in an inguinal hernia, you have a weakness in your abdominal wall and your guts basically protrude through your abdomen. And what you can think of CDH as an inguinal hernia in reverse. So instead of your guts going downwards they go upwards through to weakened diaphragm and up into the thoracic cavity and the big problem is if you have your liver and your guts into thoracic cavity, they will basically interfere with the growth of the lungs.

Interviewer: Before your research what did we know about how this birth defect happens?

Dr. Kardon: So I would say the majority of the information about CDH actually comes from human geneticist. They take blood samples from CDH patients and they look at the genetics and they look and see whether there are mutations in their genes or the regions of their chromosomes that are deleted. And so basically what we know is a whole lot of genes and quite a few chromosomal regions that are strongly correlated with the incidents of CDH. And the real problem has been that we have no idea how these mutations lead to CDH. And I think that's the problem that we were interested in addressing. How do we go from a mutation to developing a weakness in the diaphragm?

Interviewer: And that's part of why your research is so insightful because you came at it from a totally different approach than what's been done before?

Dr. Kardon: Right. So we just started by looking at how the diaphragm normally form and basically we looked at a lot of different kinds of mice where we could genetically label different components of the developing embryo to track where did the muscle cells come from, where does the connective tissue come from, where does the tendon come from and how they get linked up.

Interviewer: And that's part of your research too is understanding what happens normally and then understanding what happens in the context of CDH.

Dr. Kardon: Right.

Interviewer: So what do we know now about what happens normally and then what goes wrong?

Dr. Kardon: Basically the diaphragm you can think of as a ring of muscle cells and that inside the center of that ring the muscle cells are hooked up to tendons and surrounding each one of those muscle cells is a bunch of connective tissues or collagen. And that collagen is linking the muscle to the tendon and also the muscle to the bone.
And so normally we think of the connective tissue as basically providing structural support and holding the thing together, but basically playing a pretty passive role. And then the surprising thing that we found in development is that the connective tissue was the driving force for diaphragm development. It basically told all the other cells what to do.
And so we basically took our cue from the human genetics studies and we looked at basically one of the most prominent genes that has been identified as playing a role in CDH and this was a gene that's called GATA4. And what we used was some fancy tricks so we could knock out GATA4 and its function in particular cells.
And what we found that was really surprising is that GATA4 was essential in the connective tissue. Now when you got rid of GATA4 in the connective tissue you always got hernias and the hernias looked just like the patient hernias. And so we had weaknesses in the diaphragm. We had the liver herniating through the diaphragm and the mice had small lungs and just like the human patients most of those mice died at birth.

Interviewer: One thing that was amazing to me is that you got these hernias every time you did that experiment, which doesn't happen very often in science.

Dr. Kardon: Right. We have now looked at hundreds of these mice and every single time we knock out the gene in the connective tissue and I should point out not in the muscle. So in the connective tissue we have these hernias.

Interviewer: The way these hernias develop is actually little bit counterintuitive.

Dr. Kardon: Right, so there's just decades of data on hernias in patients and from that data, doctors had always suggested that hernias were holes in the diaphragm and that through these holes, the liver and the guts can herniate through. And what we found is that in the mice, where we can observe the formation of hernias from the very beginning, what we found is that there hernias are not initially holes in fact what they are, are regions of connective tissue but that have no muscle in them. And so they are not actually holes.
So the holes may form later as the liver keeps protruding through this region which is really weak and has no muscle but initially it doesn't start out as a hole. So that's completely counter with the dogma that is from the physicians and pediatric surgeons.

Interviewer: Now that you have all this basic information what can you do with that?

Dr. Kardon: So we know that the connective tissue is the problem and the other thing that was really surprisingly learned is that the defect is really early. So typically in humans a mother learns that her baby has CDH by an ultrasound at roughly 20 weeks. And this is quite late and in the mice, where they have a much shorter gestation time, we see herniation about two thirds of the way through gestation but when we look earlier we see that the defect is much, much, much earlier. In fact the defect would correspond to roughly between 40 and 60 days in utero in a human so it's much earlier.
But the idea is that we could actually go and test some potential therapies in our mouse embryos and see if we could rescue these mice, that we know will get hernias if we allow them to develop. And can we somehow intervene? So obviously clinical trials is a big deal and especially when you're talking about doing something potentially in utero. So you need to be able to try to test things in something other than a human. And the trick has been that we've never had basically a very good mouse model of CDH and so I think it's an excellent starting point that we haven't had before.

Interviewer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: If you have chronic shortness of breath while exerting yourself or exercising, it could be a condition called dyspnea. Dr. John Ryan is the director of the new dyspnea clinic here at the University of Utah Division of Cardiology. It's one of the first clinics of its kind and currently the only one here in the Mountain West region. Tell me, dyspnea; what causes it?

Dr. Ryan: Dyspnea is, as you described, a shortness of breath on exertion. It can be driven by a lot of things. A lot of the time it's due to stiff hearts or diastolic dysfunction. Other times it's due to chronic lung disease; asthma, emphysema, bronchitis, etc. Obesity in particular can also contribute to it. Then sometimes, of course, it can be due to deconditioning.

However, most of the time that we see is a combination. People have problems with their heart and problems with their lungs and then become deconditioned, and then their shortness of breath begets more shortness of breath and begets more dyspnea. The analogy we give when people come in is that if your work life isn't going well, your home life likely won't be going well either, because everything just has a knock-on effect. Therefore, in dyspnea when you have the chronic shortness of breath in the setting with exertion, there will be knock-on effects on your heart, on your lungs, on your waist, and also, incidentally actually, on your mood as well.

So all of these things tie together and we really wanted to break down the traditional barriers in medicine which are organ-based barriers, which are incredibly artificial and evolve into a more patient-centered approach in order to figure out what it is that's going on with you and what we can do to help you.

Interviewer: And what's causing your problem.

Dr. Ryan: And what's causing your problem, specific to you rather than saying, "It's not this organ, it's not that organ," but actually say, "Listen, this is what's going on."

Interviewer: So is dyspnea hard to diagnose for a regular physician? If I went in to my physician and said, "I exercise and I get really short of breath," are they going to miss that a lot of times, or no?

Dr. Ryan: Yeah. Dyspnea is more of a symptom. It's what people describe or what they complain of. Ironing it out is not difficult, but it just takes time or takes testing to figure out what the cause is.

Interviewer: It takes an expert that knows, because there are a lot of different things that can cause it, right?

Dr. Ryan: Yeah, and it really takes an involved program as well, and a protocol. We have a protocol in terms of when people come in, what testing we recommend.

Interviewer: Who are some of the common patients that come in? Are they people that are athletes or like to exercise? You mentioned some of these rural areas. I suppose you get a lot of farmer ranchers?

Dr. Ryan: The patients that we get really vary considerably. We get a lot of young ladies in their 20s who really are thin and have previously been quite active and find themselves getting fatigued very easily. Then we get a lot of folks in their 50s and 60s who, again, similar to the farmers that you described who are just becoming very, very fatigued and aren't able to do the full days of work or are just very tired by the end of the full days of work.

I think the main thing that we're trying to move away from is a 60-year-old person who isn't able to exercise as much as they used to and telling them, "It's just because you've gotten older." So I think that shouldn't happen and that's not exactly very rewarding, either.

Interviewer: You said you can't help everybody, but for the most part do you find that people live better lives after they come to you?

Dr. Ryan: I think so, and that's our goal, that their quality of life improves. A lot of the times we try and rule out the things that will shorten their length of life, so coronary artery disease, valvular disease, pulmonary hypertension, and then once we've ruled out the things that will shorten their length of life, then we re-focus on improving their quality of life so that they are able to do more.

Most people have realistic expectations. Even your 60-year-old farmer from Idaho knows that they're not going to be able to do as much as when they were 20 or 30. So most people's expectations are realistic, it's just they want a better quality of life. I think we're doing that.

Interviewer: Are you somebody that a patient can come directly to or do they have to go to their primary care physician first?

Dr. Ryan: Folks can come to us directly. Most of the time, 90% of our patients are coming through their primary care doctor probably because dyspnea is a medical term for shortness of breath and most folks, patients themselves, don't describe dyspnea but their doctors would. So the moniker of the clinic is kind of designed that way. We do have 10% of patients self-refer or come in through other patients who've been through our clinic and liked what we did.

Interviewer: Where can somebody go to get some more info on this condition and the clinic?

Dr. Ryan: Through the University of Utah Heart website, which is heart.uofuhealth.org, and then find our dyspnea clinic through there.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with out physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

updated: September 19, 2018
originally published: February 24, 2015

Interviewer: A new video game that teaches about air pollution in Utah. What does the creator hope to accomplish? We'll talk about that next on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: "Bad Air Day: Play It Like UCAIR" is a brand new web-based game that teaches why Utah's air pollution woes are local and frequently misunderstood, their words not mine. Actually, I want to ask a question about that because I found that misunderstood thing interesting. Kerry Kelly is in the Department of Chemical Engineering at the University of Utah and the game was originally her idea. So first of all, tell me about the game, what is it about? What is the objective?

Kerry: Okay, so you get to be the mayor of Salt Lake City, and you get to decide what kind of policies you're going to make to either help improve air quality or maybe you don't care about air quality and you'll make other decisions.

Interviewer: Sure.

Kerry: So you get to fly a paper airplane around the city, and it is your job to collect votes. If you make decisions that improve air quality, you'll have a nice clear day and you'll fly quickly around the city. If you choose to make air quality poor, you'll see a visible deterioration in air quality and it will also be much more difficult for you to fly around the city. In fact, if you make enough bad choices, you'll have trouble seeing.

Interviewer: Really?

Kerry: Yeah.

Interviewer: Okay. One of the other aspects of it that I thought was interesting is that you have what is called a "Wall of Public Anger".

Kerry: Yes!

Interviewer: How does that play into it?

Kerry: We were trying to figure out how to address the challenges when you're looking at public policies and strategies, and we developed this "Wall of Public Anger" as a way to address that some of these strategies might incite a lot of public anger. For example, if you forbid all driving, we believe that there would likely be a lot of Walls of Public Anger. In the game that means these walls go up and you can see shadows of angry people and you'll have to fly around the Wall of Public Anger if you wish to continue to collect your votes.

Interviewer: And it makes it a lot more difficult. I think that's an interesting juxtaposition that a lot of people don't think about is, sure, you'd have great clean air but you're also making people angry because it's really unrealistic to think everybody is going to stop driving.

Kerry: Exactly.

Interviewer: Or people are going to give up their wood-burning fireplaces.

Kerry: Yes, that's another very hot topic.

Interviewer: I bet it is. What are some of the other hot topics like that?

Kerry: Increased use of mass transit, so how aggressive you are with encouraging that. A shutting down of a variety of permutations of industry, so for example, shutting down the refineries or shutting down all large industry in the valley, so you get to see what that would do to air quality.
I guess one important aspect of the game that I wanted to mention, is that every single strategy that we've proposed in the game we are able to link to a quantifiable change in air quality. We had a lot of strategies that came up in our meetings with the stakeholders, and there are some really interesting strategies, but we weren't able to come up with a quantified change in air quality. So we stuck only with the strategies, I believe there are 20 or 30 of them, and how they will affect our air quality.

Interviewer: And you know exactly how that will affect the air quality, and you can actually watch that in the game so you can experiment and play around with the different choices.

Kerry: Yeah, in fact I think it's kind of fun to select poor air quality choices to see what happens.

Interviewer: Yeah, and how bad it really makes it.

Kerry: And this is from an air quality researcher, so . . .

Interviewer: Exactly. How do you hope that parents will help kids use this game as a learning experience? Because the target is teens, correct?

Kerry: Yes, but we're partnering with Breathe Utah so they have a big educational component to their organization and they're going to be testing this game with a variety of high school and even some middle school students, so we'll see how it plays with each of those two groups. And they're developing some lesson plans that will accompany the game.
One challenge we faced was how much information to put in the game versus how much to just inspire curiosity. I think we went more on the inspiring curiosity and left it up to the teachers and the experts in developing lesson plans, so that they could develop materials that would then tie to state core or whatever they needed it to. We just wanted to make sure that the air quality part of it was correct.

Interviewer: So after some teens, or anybody, plays the game, if they were to walk by you and you were to stop them and say, "Hey, what's your takeaway?", what would you hope their takeaways would be?

Kerry: Well, A, that it's a tough problem, first of all, and that they have a little bit of a feeling for the variety of strategies that we could take, and that it's going to take a combination of strategies to solve this problem, and that there will be some trade-offs. Some of the things we'll have to do will cause us some sacrifices. Whether or not it's paying a few cents a gallon more for gasoline, or not burning wood, we'll all have to make some choices.

Interviewer: Yeah, so kind of educate people on the basics of it, help them understand that there are trade-offs, help them understand that it is a complicated problem.

Kerry: Right, yeah.

Interviewer: So it sounds like there was probably a lot of thought put into this game, a lot of scientific fact, a lot of work and effort from a lot of different people.

Kerry: Exactly, and I wanted to thank the partners we had. In particular, I wanted to thank the students in Engineering Arts and Entertainment. They did the lion's share of the work, they made this all happen. I wanted to thank Breathe Utah. They helped with the educational side of the game, and they're currently out there play-testing the game.
I wanted to thank Utah Education Network, that's who is hosting the game. I wanted to thank the Utah Health Department and the Utah Division of Air Quality. They really helped as we developed strategies and vetted strategies and the Division of Air Quality was invaluable as we were trying to put numbers on each of those strategies we were considering.

Interviewer: In the description of the game it said, "Air pollution woes that are local and frequently misunderstood". Have we covered the misunderstood part of that?

Kerry: Yeah, I think so.

Interviewer: Okay, that's what you referred to there, all right. You can get the game at badairday.org. Kerry Kelly, good luck with your game and thanks for taking time.

Kerry: Oh, thank you very much.

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Dr. Jones: The number one cause of cancer deaths in women? Most women would say breast cancer, but its lung cancer, and although the rate of lung cancer in men is falling, lung cancer deaths in women is rising. This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care and November is Lung Cancer Awareness Month. Lung cancer in women, today on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Jones: The white ribbon. We see pink ribbons everywhere for breast cancer, teal ribbons for ovarian cancer, but where are the white ribbons for lung cancer? The CDC reports that more women die of lung cancer than breast, uterine, and ovarian cancers combined. Twenty-seven percent of all cancer deaths in the US are caused by lung cancer. The five year survival rate for those diagnosed with lung cancer is 16%, which makes it a particularly deadly cancer. Now, the lung cancer rate has fallen 21% among men, but for reasons that remain unclear, the rates have risen 116% among women. Of course, we all know that smoking is the major risk factor. Since 1960, the rate of smoking in men has gone down, but for women, not so much.

Lung cancer develops differently in women than men. Women who have never smoked have a greater risk of developing lung cancer than men who've never smoked. Go figure. Worldwide, 53% of women with lung cancer were never smokers. They could have been exposed to more indoor air pollution related to cooking and heating, and that may be the risk factor for women in Asia and in China and somewhat in the United States. Women tend to develop lung cancer at a younger age than men, too. The good news is women are more likely than men to be diagnosed in early stages of lung cancer, because women probably get more health care, and women tend to live longer than men after treatment for lung cancer. So, that's the good news.

Well, I'm thrilled to live in Utah where smoking is so uncommon, and where it's against the law to smoke in enclosed public places. However, a notable trend in the increase in lung cancer among healthy non-smokers is known primarily in women. If lung cancers in non-smokers were its own category, it would rank among the top 10 of fatal cancers in the US. Lung cancer can result from factors other than smoking. Genetic mutations, as well as exposure to radon gas, secondhand smoke, air pollution and asbestos, among some other things. In Utah, we have particular geographic risks related to radon and air pollution.

So, what to do for this largely preventable, common cancer? If you're a smoker, you should stop smoking. Ten years after quitting, your risk of lung cancer is half of what it would have been if you didn't quit. If you're a heavy smoker over 50, talk to your doctor about the pros and cons of low dose CT scans for screening. If you aren't a smoker, don't start. If you're an adolescent or the parents of one, starting smoking is especially bad, as you're more likely to be addicted to nicotine, and have your developing brain wired for risky behavior, like alcohol.

Lowering your risk of secondhand smoke. If someone in your family smokes, no smoking in the house or in the car. Check your home for radon. Now, radon is a naturally occurring radioactive gas that results from the breakdown of uranium and soil and rocks. It cannot be seen, tasted, or smelled, and according to the EPA, radon is the second leading cause of lung cancer in this country, and it's the leading cause among non-smokers. Outdoors, there's so little radon that it's not likely to be dangerous, but indoors, radon can be more concentrated. When it's breathed in, it enters the lungs and exposes them to radiation. Homes in some parts of the US, like Utah, which are built on soil with natural uranium deposits can have high indoor radon levels, especially in basements. My basement is ventilated and has a fan in it specifically for that reason, and I live here in Salt Lake City.

If you are concerned about radon exposure, you can use a radon detection kit. State and local offices of the EPA can give you the names of reliable companies who can test your home. So get it checked and get it fixed. Limit your time on the freeway and be an advocate for clean air. Eat your fruits and vegetables. Antioxidants in your diet is associated with lower risk of lung cancer. Vitamin pills won't do the trick. So, ladies and gentlemen, put on your white ribbons this month. Lung cancer is largely a preventable disease. Think about the air you breathe and what's in it. Protect yourself and the people around you. This is Dr. Kirtly Jones and thank you for joining us on The Scope.

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Interviewer: You may think that e-cigarettes are safer than conventional cigarettes, but did you know that in 2014, poison control centers in the United States received up to 215 calls per month about e-cigarette poisoning? That's next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier, healthier life. You're listening to The Scope.

Interviewer: I'm talking with Dr. Zane Horowitz today. He's the Medical Director of the University of Utah Poison Control Center. Dr. Horowitz, I read something from the Center for Disease Control recently about the rise in poison control center calls regarding poisoning from e-cigarettes. What's that all about?

Dr. Horowitz: Well it's not so much the cigarettes themselves but the refillable cartridge where you put the liquid that you vape, in. Right now the amount of nicotine that's in that can vary dramatically. The flavors are tasty flavors that are attractive to kids, bubble gum, cherry, and all these fruity flavors. A few sips of that will deliver sometimes as much as anywhere from on the low side 10 milligrams of nicotine all the way up to 200 to 400 milligrams of nicotine. To put that in perspective, when we smoke a single cigarette, that delivers about 1 milligram of nicotine.

So a child who accidentally takes the top off this and smells it and it smells nice and fruity, and tastes it and it tastes really delicious, and takes a gulp or two, he's getting the equivalent of maybe 200 or more cigarettes delivered all at once. And he's going to get quite sick. The poison centers nationwide and here in Utah have been receiving increasing number of calls as these products have grown on the market. People are having these out on the kitchen table and the coffee table in the living room, so children just reach over. A sip later, and all of a sudden they're vomiting and they're sick and they have to go into the emergency room to be treated.

Interviewer: I guess maybe we need to go back and talk a little bit about e-cigarettes to begin with. Tell me what an e-cigarette is and how a person uses it.

Dr. Horowitz: The "e" stands for electronic. They're made to look a lot of times like cigarettes or cigars, although sometimes they're made to look like other objects. There's a long chamber where you can put a liquid, and the liquid contains mostly nicotine, but it could be flavored and there could be other things in it as well. There's a little heater that warms that up and creates a vapor. You inhale it just like a cigarette and you just get the vapor of nicotine without all that other smoke, all that burning tobacco leaves stuff that makes you smell like an ashtray. So it's reasonably odorless, although they tend to have a fruity odor about them. When that portion gets burned up, you take a refill out of your pocket or wherever you have it and you fill up that little chamber again so you can keep on vaping, is the term.

Interviewer: Recently the CDC put out a report that stated that back in 2010, poison control centers were getting about one call per month on e-cigarettes. In 2014, they're getting as many as 215 calls per month. That's a pretty astounding jump, don't you think?

Dr. Horowitz: Right. It's been rising almost every month, month to month, as more and more of these products are sold and they're in people's homes and they're where children are. Currently because there isn't any regulation one way or the other, how much is in these liquids is unknown. There's no safety cap as there would be with a medicine bottle or an automotive product. Other consumer products that we have around the house that we know can be dangerous to children often have some sort of cap that the child can't take off easily. And it's usually the exploratory 1 or 2 year old child who's learning how to manipulate things and pulls it off that and it smells delicious and they stick in their mouth and it tastes delicious and they drink a gulp. It doesn't take much with this. That's probably the key point. One gulp can be quite toxic to children.

Interviewer: And you're talking specifically about the flavored liquid that goes inside of these e-cigarettes.

Dr. Horowitz: Right.

Interviewer: What do the containers look like?

Dr. Horowitz: They look like a little eye dropper bottle. So far there aren't giant companies making these yet, so a lot of these are home grown little stores. They buy a little plastic bottle with a little screw top on it and you pour that little screw top or an eye dropper full into your chamber of your e-cigarette and put the cap back on. It doesn't take more than a quarter turn twist to get the cap back off, and that's easy for a child of 1 or 2 years old to manipulate and they have access to it.

Interviewer: The CDC Director, Tom Frieden, actually mentioned that these e-cigarette liquids are not required to be childproof.

Dr. Horowitz: Right now there isn't any regulation about that. That's being considered. I think we have to take a very rational common-sense approach to it. The simplest thing is obviously make these things childproof like we've made medicine bottles, automotive products, and some household cleaners that are toxic. That's the first big thing. Then I think the number of exposures will go down.

The second thing is just educating parents and uncles and aunts and whoever else is going to be visiting with little children, use some common sense. Don't put this out on the table and have your 2-year-old watch you pull it out and spill it in your little chamber of the e-cigarette and sit there vaping. They'll all look at it and go, "Wow. That looks like a cool little toy that I can play with now." Then you put it back on the counter or the table and they're going to take it apart and try to figure it out for themselves because that's what kids do.

Interviewer: If a child ingests this, what do some of the symptoms look like?

Dr. Horowitz: Usually they have nausea and vomiting. Sometimes they vomit over and over and over again. They can get pretty dehydrated pretty quickly for a small child. But in large amounts, like I said those concentrations sometimes can be equal to 200 cigarettes, this could potentially be fatal. A child could die if he takes those really concentrated liquids, and some stores are selling those, the high concentration, meant to be diluted down by the person who's going to be vaping. If a child gets into a few gulps of that, they can have seizures. They can have heart arrhythmias, where their heart beats very irregularly, and in severe cases, if they took enough of that, they could die.

Most of the things we're seeing are the lower concentrations, but there's no labeling. We don't know how much is in any product, and the size of these can vary from a tiny little dropper size to something that looks like a soda bottle size.

Interviewer: How long does it take for some of these symptoms to appear?

Dr. Horowitz: Usually pretty quickly, usually within minutes. Usually within five or ten minutes we're going to see something. The child is going to start vomiting and sweating and feeling pretty miserable.

Interviewer: Let's say they get a really heavy dose, one of these that could be fatal. How long does the child have to get treatment before they die?

Dr. Horowitz: Well if someone accidentally drank one of these with a high concentration, we would probably advise parents to call 911 and have an ambulance drive them to the hospital.

Interviewer: With a lower dose poisoning, do you still recommend that parents take their children into the emergency room, or what do you suggest to them?

Dr. Horowitz: Well I think if there's an accidental little taste or a lick, they certainly can call the poison center 24 hours a day. We have nurses and pharmacists with training, we've briefed everybody on this, and they can talk through the particulars of each individual occurrence. So if it's a small amount and the child's not having immediate nausea and vomiting, we may not have to send you to the hospital or the doctor. We'll just sort of call you back and see how you're doing.

Interviewer: Can you just tell us the number to the Poison Control Center for parents that might be interested to know that?

Dr. Horowitz: Yes. It's a universal 800 number. In whatever state you are in it will get you to your state's poison center. It's 1-800-222-1222. 24 hours a day that phone will be answered live by our poison information specialists and they're very happy to talk to you. No question's too small, whether it's e-cigarettes or any other product that your child might get into at home.

Interviewer: All right. Thank you.

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Interviewer: Tibetans thrive in the high mountains of the Tibetan Plateau, conditions that most others just can't survive in. My guest, Dr. Josef Prchal, a professor in internal medicine at the University of Utah, led a study; identifying an 8000-year-old variation in the DNA sequence of Tibetans that help explain their amazing adaptation.
Today, I'm also joined by first author of the study, Dr. Felipe Lorenzo, and Dr. Tsewang Tashi, who is also an author on the paper and a native Tibetan. Dr. Prchal, Tibetans and lowlanders like us adapt very differently to high altitude conditions, what are the differences that you're interested in?

Dr. Prchal: The obvious difference is that if lowlanders go to very high altitude, they may die, but if you stay there for a long time, there are some chronic consequences which are not suitable for reproduction and for thriving in this high altitude. There are many and some of them we will not fully understand, but one of them is, what we call, pulmonary hypertension; that the pressure on the lungs is so high that it interferes with the circulation and you get, eventually, heart failure.
The other well-known adaptation is the level of oxygen tightly controls how many red cells we make. It means if we don't have enough oxygen, we make more red cells. So if you go to high altitude where the oxygen pressure is lower we make too many red cells. That's called polycythemia. That means the blood gets too thick and it's not very suitable for them, but it has been known that most of the Tibetans have a normal level of hemoglobin in very high altitude and this is something which gave us tools to study this.
And we selected then the Tibetans who had high hemoglobin and low hemoglobin, and that allows us to look at the genetic differences in these two populations. And with a graduate student here from department of genetics, Tatum Simonson, we selected these two population, did, at that time, the state of our genetic studies and we were able to look at the fingerprint of the genes of interest. We selected about 300 genes and 10 of them had clearly selected, that means they achieve much higher frequence in Tibetans, in those who were adapted well to high altitude.
And these adaptation mutations then must have some beneficial effect and so that was the first lead. And at two of the genes, which are selected, had something to do with how the body responds to oxygen, so one of them, a gene called PHD2 is a negative regulator of master regulators of response to hypoxia which is called HIF.

Interviewer: And what does the gene do?

Dr. Prchal: It decreases the over-response to very low oxygen. So sometimes our physiological responses may be detrimental. And so by modulating the intensity of the response, I think that was one of the benefits.

Interviewer: Dr. Lorenzo, you've been on the trail of this gene for a long time. It must have been satisfying to find it at last.

Dr. Lorenzo: It's really a challenge actually. Sequencing that region of a gene we just recently reach took me like six to nine months of trial and error. Finally, when we get it, it was just like you win a lottery and it's something to move on.

Interviewer: So when you saw it, you knew that was the one.

Dr. Lorenzo: Yes, because it's reproducible, it's there, it's common in our sample, and not common in the controls, so there's a story to tell.

Interviewer: So if the variation was selected for it, it must be important.

Dr. Prchal: If a gene happens to be beneficial in a given environment, with each generation the prevalence of these genes will increase. And so, again, if the Dr. Lorenzo's mutation of variant is find of 85% of Tibetans, it must be beneficial.

Interviewer: Dr. Tashi, you're a native Tibetan, it sounds like you guys went through great lengths to gain acceptance by the Tibetan community.

Dr. Tashi: So I join here in 2012 in University of Utah and one day Dr. Prchal approached me while I was in clinic and he was very excited that I was a Tibetan and I was kind of surprised.

Interviewer: Who's this guy?

Dr. Tashi: Initially, it seemed to me that he just wanted some blood and I said, "Well, that's easy. I can get some friends and get some blood."

Interviewer: Were you one of the ones sequenced in this study?

Dr. Tashi: Oh, of course, yes.

Dr. Prchal: He is.

Dr. Lorenzo: One of the first ones.

Dr. Tashi: And later on as the study progressed, I realized the significance of the whole study and this is a new potential, a very groundbreaking discovery, in a sense, and the importance that it would have, not only for the science as a whole. But being a Tibetan and also something uniquely Tibetan that's potentially the result of this, then we decided, okay, we should go and get involved more Tibetan. Actually, we went there twice and they don't really like to give blood because when you hear blood, it's kind of "Wow."

Interviewer: Yeah. But once you were able to explain it to them, and probably the fact that you are a Tibetan yourself and you're willing to undergo this, that helped them to accept it?

Dr. Tashi: Yeah, that was one of the major helping point.

Dr. Lorenzo: This is why Tsewang is a key for the success of this study because Dr. Prchal and I went actually to the community. It took us six to nine months talking to them and we got two samples.

Dr. Tashi: It's really difficult.

Dr. Prchal: We were well received.

Dr. Tashi: When it came to collecting blood, they just backed out. So it's really a key to get them into the study, and it really did go well.

Interviewer: And in the end, how many took part, the Tibetans?

Dr. Tashi: For here, locally, we have 26 or 28 and then I brought it 60 plus.

Interviewer: Wow.

Dr. Prchal: Well, began probably more than 200 samples.

Dr. Lorenzo: More than 200 in China.

Dr. Prchal: Yeah, more than 200 samples.

Interviewer: It's important for you to get letters of support from high leaders in the Tibetan community, including the Dalai Lama.

Dr. Prchal: The Dalai Lama was contacted by a principle physician called Dr. Dorjee, who easily organized all these Tibetan health care in exile community and that only happen through Dr. Tashi. And Dr. Dorjee has contacted Dalai Lama, explained to him what we try to do, and Dalai Lama felt a better of the Tibetan adaptation would be helpful to Tibetan community, but also to humanity at large. And I think that Dalai Lama is very ethical man and when it comes to ethic issues, I think it's very important to him.

Interviewer: What are the implications of this work?

Dr. Prchal: There are many human disorders which are regulated by oxygen; not only the pulmonary or lung diseases, brain edema, but also cancer. So we think that delineation of this Tibetan adaptation and deeper understanding of this can eventually lead to better understanding of common human diseases.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on the Scope.

Host: Only 15% of patients with squamous cell lung cancer survive to five years past their diagnosis. It is a difficult cancer to treat. My guest, Dr. Trudy Oliver has developed a new tool for understanding the disease and developing targeted therapies.

Dr. Oliver, you've developed a mouse model for lung squamous cell carcinoma. Why is this important?