(instrumental music) <v ->With questions, thoughts, some comments for all of us.</v> We have about 10 minutes for some interactive discussion. Katie, if you don't mind. I wanna go back to the issue of less treatment. Women are not offered treatment to the same rate as men for this condition which is quite remarkable, 'cause when you've seen other literature suggested, women are a lot more likely to seek physicians they're more likely to take advice, follow up. Any thoughts on why that is the case? <v ->Yeah, obviously this is really complicated</v> and I think that with PAD specifically, especially with claudication, there's a lot of shared decision making that then show on to asymptomatic carotid patients for instance, and whether or not to get intervention. And depending how risk adverse women happen to be compared to men, or depending how they're presented different treatment options. Or if they're being told, which is the truth, that supervised exercise therapy is the gold line standard. Maybe they're more likely to try that first and less likely to pursue treatment as a first line intervention for PAD. That certainly does not explain the difference in aneurysms, right? Because I mean that's just the size of the aneurysm and you get an EVAR. So I mean there's some kind of implicit bias as to the underlying medical sexism going on, I'm sure in addition. But for PAD at least, that's my theory. <v ->Katharine, thank you very much for your talk,</v> we've learned a lot. <v ->Yeah, its the less likely to ask, sorry.</v> <v ->I feel feelings didn't work with (indistinct) makes sense.</v> But interestingly enough, as you mentioned, women are undertreated and the likelihood is because they're underdiagnosed. Should we be adding adjunctive diagnostic tools other than screening with ABI, such as exercise ABI, to improve the diagnosis of PAD, particularly in women? <v ->Maybe, I think that a lot of the really important reasons</v> to diagnose asymptomatic PAD is to get people on multi-modal medical therapy to prevent a heart attack. And so, I think we don't have a really clear understanding of the actual cardiac risk in asymptomatic PAD. And so, since we don't know what the risk is, then it's hard to understand the value of a heart-at-rest screening program. My bias of course is that, yes, we should screen and treat or screen and identify, and then medically treat more everybody with PAD, I think it's really undertreated. But exactly what the risk benefit is and at what value, we don't have enough data yet. <v ->I have a point about screening,</v> which is, in my experience a lot of PAD is missed. A lot of tibial PAD is missed by a regular ABI and a lot of centers don't have the pressure to do TS. So then what happens is, in this scenario that you presented so well in our clinic of the women presenting at end stage with more CLTI with fewer options for treatment because they never had the harbinger of claudication at the outset. And that could be the case for our diabetics who are, they don't have important femoropopliteal disease or aortoiliac disease, it's all sciatic-tibial disease, until it's absolutely not. You know? So obviously if we are not checking TBIs and home records because they might be complicated to get in certain centers we probably, what we really need is a really good tibial screening test that we don't have. <v ->Yes, that is so true.</v> And I think, and I'm still high in the sky thinking about this and this is far from fruition, but inspired by continuous glucose monitors. I think that you could probably use it in a technology that's maybe there's just like lactate or something, but you can stick little tapes on people's feet, for instance, in a primary care clinic and have them wear it for 24 hours or whatever the right period of time is and then turn them back in and they can measure whatever biomarkers are relevant. Lactate is just an example that I think might work. And so yeah, I mean I think that there's plenty of ways that we can either make standard ABIs and TBIs more easily obtainable. It's a little bit mind boggling to me that maybe it's your blood pressure cuffs or such a magical thing that is already at primary care offices. But like that way one easy solution or one very complicated data technology solution. (laughs) These patches, I know folks who are working on that in one of our bio technology labs. <v ->And I add even cheaper than a TBI blood pressure</v> or a remote lab tape measure would be even a really good physical exam for auscultation of the doppler signals because it's the doppler signals are triphasic in a PUPD. I feel pretty good about my tibials, I think. <v ->Yeah, that's true.</v> Yeah, I mean the question is like who can actually differentiate between the venous signal and a monophasic arterial signal? But if you're getting into that, then of course you can like just make the referral, right? <v ->Yes, come please, come to the mic if you don't mind.</v> <v ->And I think it's our responsibility as a company</v> for future trials to involve more women. And when anyone is involved in a clinical trial they need to say, hey, instead of having a 70/30%, 30% women, in the clinical trial. We need to make sure we have a better representation of women. And also, taking in some of the information that Doctor McGingle just said about how do we treat them differently? Medication, post procedure or what have you. But we as a industry, we have to be more responsible. <v ->Absolutely agree.</v> I mean, I think in design of some of these clinical studies there should be minimum percentages fifty-fifty you know, why not? I think it's definitely achievable and we should all be responsible for getting us there. I do wanna come back to your comment about increased bleeding. Which we actually have seen in clinical cardiology as well and struggle to understand the higher rates of bleeding in women. It's very consistent. Any insights as to why this happens? Is it just poor technique? Is it we need to use alternative access like radials or pedals? Any insights into how we can reduce bleeding? Perhaps it's over medication. <v ->Yeah, I think it's probably multifactorial</v> as with everything of course. The, I mean now that ultrasound has become so much more ubiquitous and more and more people are doing ultrasound guided access, I think in general, access complications should be going down. I mean, presumably for the access complications especially in the groin, women are maybe chubbier in that area so it's a little bit harder access or a weirder angle if you push the pubis up. They have smaller targets. Maybe they can't accommodate a certain size sheath without being at higher risk of dissection. You know, I mean there's a lot of things that just having absolutely pristine access that need is important no matter who you're intervening on. And then actually during the procedure when you're heparinizing patients, there's been one study done and this was done in patients getting leg amputation. And so people who were not even heparinized for the operation but women are more likely to have hematomas after leg amputations not related to the medical therapy which maybe has something to do with spontaneous retroperitoneal bleeding and puncture site bleeding related to some vascular biology that's yet to be elucidated. And then also, literally all of our drug studies are done in male animals and in male humans, done in all of the Epstein safety trials are done. And so there's, we don't really know what the regulars are and only a few drugs have actually gone back and studied this from the beginning, moving forward. The herpes vaccine is one EBV is another one. but certain cardiovascular methods are used routinely. (instrumental music)

women's health

treatment disparities

peripheral artery disease

shared decision making

implicit bias