Welcome to the Behind the Shield podcast. As
always, my name is James Geering, and this week
it is my absolute honor to welcome on the show,
Doctor of Radiology and the Medical Director
of Primary Care Radiology at Pronuvo, Dr. Josef
Czodekowicz. Now, in this conversation, we discuss
a host of topics from his journey into the world
of medicine, the scope of practice within radiology,
innovations in modern day MRI, medical applications
of ultrasound, the safety and efficacy of full
-body preventative MRI scans, the application
for the first responder professions, spine health,
cancer detection, warning signs of potential
aneurysms, and so much more. Now, as a side note,
Pranuvo is offering you, the audience of the
Behind the Shield podcast, 20 % off any scan
through their Warrior program. And I will put
the link to that on the show notes. Now, before
we get to this incredibly powerful and important
conversation, as I say every week, please just
take a moment. Go to whichever app you listen
to this on, subscribe to the show, leave feedback
and leave a rating. Every single five -star rating
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I ask in return is that you help share these
incredible men and women's stories so I can get
them to every single person on planet Earth who
needs to hear them. So with that being said,
I introduce to you Dr. Yosef. Tredekowitz. Enjoy.
Well, Dr. Sefi, I want to start by saying thank
you so much for taking the time and coming on
the Behind the Shield podcast today. Thanks,
James. Thanks for having me. Glad to be here.
So where on planet Earth are we finding you this
afternoon? Well, I'm actually in California,
in Palo Alto, which I can't complain about because
I know most of the country now is under some
severe weather. So I hope everyone is keeping
as warm as possible and staying safe. Are you
getting any edge of the band? We're going to
get some cold weather starting tomorrow. For
Florida, it's going to be quite cold. But what
about California? This weekend was beautiful,
actually, in my area, in Palo Alto, sunny skies.
It wasn't particularly warm, but it wasn't particularly
cold either. It just was out and about with family
and kids, parks and birthday parties and things
like that. Absolutely. All right. Well, then
I would love to start at the very beginning of
your timeline. So tell me where you were born
and tell me a little bit about your family dynamic,
what your parents did, how many siblings. So
I was actually born in Los Angeles, California.
And, you know, I would say an interesting multicultural
household. So my father is Mexican. My mom is
Cuban. My family household is Jewish. And I went
to a Jewish school my whole life. And actually,
my father is a neurosurgeon. So I have sort of
medicine in sort of. I was always sort of around
it, like medicine in the household. There was
the idea that I would become a doctor early on,
but I actually didn't end up going that pathway.
I sort of wanted to carve out my own pathway.
And in college, I studied philosophy, actually,
and was not a pre -med student. And it was only
sort of later on in life when I stopped getting
parental advice on what to do with my life. I
said, oh, you know, on second thought, I think
I should go into medicine. So I learned a little
bit of a lesson from that. Whatever I want my
kids to go into, I will not tell them to do that.
I'll let them figure it out on their own, and
they'll probably come to it sooner than later.
What kind of perspective did you get? Neurosurgeon
is such an elite kind of sliver of the medical
world. So what were some of the stories that
you heard from your father of how his day at
work was? Yeah, so it's interesting. I think
my father being a neurosurgeon, had a big influence
probably on a lot of my interests actually. And
probably apple doesn't fall far from the tree.
So even though I didn't pursue medicine directly
right away, we had a similar shared interest
in sort of kind of a philosophical approach to
the body and biology. And in this case, the mind,
the brain, et cetera. So he had a unique specialty
where he would do functional neurosurgery and
would basically implant deep brain stimulators,
these electrical devices that would be able to
rewire the circuitry of the brain and help people
improve their function with movement disorders
or disorders of pain, et cetera. And I was very
fascinated by that aspect of medicine, more so
than I was about the simple biology of medicine.
And that's probably what led me towards the path
of philosophy, actually. And even after, when
I went back into medicine, I actually was gravitating
towards the kind of the neurosciences, the brain
sciences, the brain medicine fields. And I was
debating going into neurosurgery myself or something
with imaging. I ended up going into radiology.
At one point, I was going to go into neuroradiology
before I ended up going into body MRI and now
whole body MRI. So the technology he was working
with, would that be one of those examples we've
seen the videos of? I believe it's people with
pretty extreme Parkinson's and they've got the
implants. And when they turn it on, they're able
to kind of regain control of their body. That's
right. That's one very well -known indication
and application of that technology. So it's funny
if you take a bigger historical view, bird's
eye view. That technique with these brain stimulators
was something that was developed probably in
the early 90s, became much more mainstream in
the late 90s and 2000s. But if you go back in
time, they were doing different kinds of procedures
for the same concept without the implantable
electrical device, but with focal lesioning,
often a technique called thalamotomy, where they
basically cause a little micro lesion at a targeted
region of the brain. that would rewire the circuits
in a similar fashion. And the electrical stimulators
would basically create like these pseudo lesions
imitating that approach. Now, that was always
something I was interested in. And when I was
in medical school, there was another application
that came out, which was called MRI guided focus
ultrasound, which is essentially an imaging energy
-based modality where you went back in time and
did lesions with... ultrasound energy the same
way they used to do with an open craniotomy and
stick a probe in there and and kind of target
that area of the brain that was misfiring we
could now do that with radiologic based approaches
under mri guidance watching in real time and
then targeting ultrasonic energy to that same
region of the brain and burning a small little
hole with no incisions it's like magic magical
incisionless brain surgery so that was an area
that i wanted to go into through radiology and
kind of came full circle towards um kind of like
what I grew up hearing all about all the time,
this kind of rewiring of the brain, philosophical
neurosurgery in a way, and I was interested in
doing that through radiology. So I actually went
into a fellowship after residency to learn that,
and I ended up going to Stanford University.
The body MRI program had a big division in what's
called minimally invasive MRI -guided interventional
care. MIMRIC for short. And this was one of the
leading centers that was basically driving this
practice through radiology. Other centers were
doing it through subspecialists like neurosurgery
in the brain or in other areas like in the prostate
through urology, et cetera. But here at Stanford,
we were doing it all through radiology, including
we were doing these thalamotomies in the brain
with MRI guided focus ultrasound. Now, while
I was in that fellowship, body MRI was also exposed
to the whole body MRI. um as a as a screening
exam for cancer screening and we were doing that
in um not the same sort of patient population
that we're doing a prenuva which is more broad
for the general population but we were doing
it there more limited to individuals with certain
cancer predisposition syndromes that were at
high risk for developing cancer so that was an
area where i was exposed to whole body mri and
found that extremely fascinating with a lot of
kind of forward -looking applications um in the
field of medicine because historically imaging
is more relegated towards diagnosing a problem
the cause of a problem once it's clinically pronounced
itself you know patient goes to the doctor doc
it hurts me here or doctor does a physical exam
and palpates like there's a mass on examination
i feel something in the abdomen i'm not normally
feeling or there's an abnormal lab out and then
they'll send it to the radiologist the patient
of the radiology like figure out like what's
the cause of that abnormality? Is this something
that needs to be worked on or is this something
that can be sort of watched and waited, et cetera?
And as imaging had progressed and now we could
do this whole body MRI, it was like a no -brainer
that why don't we transform this modality towards
the forefront of the patient encounter, the first
point as part of a physical exam, essentially,
and then we can rather than wait for the clinical
symptoms to present themselves, get ahead of
that curve and try to... be informative to the
patient in an earlier state of kind of health
status before disease progresses to a point where
it's harder to treat and manage. So that was
like the thinking that I had at that time. And
then sort of I came to where I am now, Pernuvo,
sort of, you know, by coincidence, we were, the
company was just kind of emerging in The first
clinic was in Canada, in Vancouver, and they
were just opening their first clinic in the States,
in California. And that's when I started getting
involved with them at a very early stage. Basically,
right after fellowship, these ideas were all
kind of clicking together for me. So long story
short, what I'm doing here now is, you know,
a little bit forward looking in radiology, forward
thinking. And I think of it more as like a new
subspecialty in radiology, kind of like primary
care radiology or another way of thinking about
it, sort of. Radiology Enhanced Preventive Care.
You mentioned using ultrasound in a kind of surgical
way. It's funny because it's not funny at all.
My dad just got diagnosed with a very horrendous
cancer and it's not looking good. And the only
surgical option is the Whipple, which is to fillet
a human being, take everything out and kind of
hope that you can stitch them back together again.
But he's been looking at a technology, I think
it was Hippotripsy. where they're using it on
the liver to target, I think it's the solid organs
that it's working with. What is the potential
of that kind of technology when it comes to tumors
and other parts of the body? Yeah, I mean, that's
an area of, you know, very fascinating emerging
field, basically this area of histotripsy is
one effect that this focus ultrasound technique
can have. So you might think of, ultrasound of
this it's this mechanical um wave -based energy
that can have all kinds of effects and we use
an imaging all the time where we're not trying
to affect the tissues we're trying to do it in
a very low energy way and in order to get just
images of the tissue but if you can concentrate
ultrasound in a way where all that energy comes
to a point you might have an analogy too if you've
ever taken a magnifying glass and tried to kind
of focus a beam from the sun onto a piece of
paper and burn a little hole on the paper that's
what you can do with ultrasound as well focus
these beams create high energy and in one way
you could do um thermal ablation which is what
we were doing in the brain for thelamin but you
can also do histotripsy which is where you're
basically um creating such extreme vibrations
that the tissue the cells themselves basically
and they die in another way, not from heat, but
from sort of just high energy vibrations. There
is a lot of applications about those in the whole
body, the liver being one of them. I was familiar
with a trial that was being done for liver metastases
using histotripsy to ablate those in a more minimally
invasive fashion. That's a different... way of
controlling those ultrasound beams than we were
doing with a thermal ablation. And, you know,
there's debates on like what the best way to
do it is, but there's really a wide open field
for really interventional radiology using ultrasound
energy. In the brain, beyond like burning tissue,
you can also use it to open up the blood brain
barrier. And that has a lot of interesting applications
to deliver drugs to the brain and target all
kinds of disease that were kind of behind this
wall where so in the brain is is it's a it's
a unique organ where like a lot of the um uh
molecules that circulate in our blood they don't
have a way to get into the brain there's a special
physiologic structure called the blood brain
barrier which prevents things from going in and
that's you know by evolution to protect the brain
in a way but on the other hand it's an obstacle
in medicine where A lot of the drugs you might
want to use to treat, let's say, cancer, chemotherapies
or whatnot, and they might go all over the body
elsewhere. If there's a tumor in the brain, those
same drugs can't get to the brain because the
blood -brain barrier doesn't let them in. So
with the same kind of idea with focused ultrasound,
you can manipulate it in such a way where you
basically massage open the structures that create
the blood -brain barrier and it can create...
make them to be leaky and then the drugs can
leak in there. So all kinds of applications,
whether it's in the liver or in the prostate,
burning tumors or in the brain, doing functional
neurosurgery or burning tumors or blood brain
barrier opening, this is like a really This is
different from prenuvo. This is nothing that
we do at prenuvo, but that's a whole other area
of medicine that, yeah, interesting that you
have a similar, you know, you're aware of that
and interested in it. That's an area that I trained
in and was very fascinated in for a long time.
Absolutely. Well, my dad was a veterinary surgeon,
so he's a full -on, you know, science. Nerd is
the wrong term, but he's obsessed with it. And
so that's how he first came across it, was researching
treatment options for himself. So immunotherapy
is obviously another very exciting area, but
it's not applicable in this particular cancer,
sadly. When you talk about medical school, at
the front door, it's very interesting because
you went more recently than maybe some of the
people who have been on here. With the whole
cancer conversation, you've got some of these
innovations in the treatment side, but obviously
the other side of the conversation is, well,
the prevention side. What are some of these things
that are even creating more cancers in modern
society? In the medical route that you went,
how prevalent was training on nutrition, sleep,
exercise, some of the kind of preventative holistic
elements of medicine? I mean, that's not something
I really focused on in my residency in radiology
because we were usually focused on, obviously,
in the imaging diagnosis. And a lot of that preventive
management is something that would be sort of
a different area of preventive care training.
That being said, in medical school, I would say
that the educational Those who determine what
should be focused on in medical education at
the time, the kind of curriculum planners, were
starting to become aware of this. So we definitely
had in medical school several lectures kind of
peppered throughout training about nutrition
and how to optimize. you know, preventive disease
practices, as opposed to just treating the disease.
It was still at that time, not yet as I think
big, a mainstream focus as it is now. And that
was, I was in medical school, you know, about
10 years ago. And, or sorry, 10, 15 years ago,
and like the five years of four years of medical
school, I did research here for an extra year
there. So it was just kind of beginning to get
more an area of interest. I bet now if you go
to medical schools, it's probably a much bigger
focus. But yeah, at my time in medical school,
it was starting to become an area where we were
aware of this and it was important. We were having
dedicated lectures about nutrition, preventive
health, the metabolic effects on things like
cancer development related to diabetes and whatnot.
So yeah, this is not something new, but something
that is becoming more and more an area of awareness
and focus and investment in. these days brilliant
well walk me through kind of the overview of
the radiology track then as opposed to you know
someone who might be a gp at the end of their
their uh journey so uh you know radiology is
um a field in medicine and i'm going to focus
on diagnostic radiology first but basically it's
the field of medicine that that leverages the
kind of magic the magical abilities of you know,
various different energy forms in physics to
give you images of inside the body so you don't
have to cut open the body to look at it. Historically,
you might think that, not you might think historically
to look, they used to do things like exploratory
laparotomies, which, you know, may once in a
while happen these days, but is not something
that we normally do. So usually now if somebody's
you know, has an abdominal, acute abdominal pain,
they'll go to the emergency room or their outpatient
doctor will order an imaging exam to give them
the diagnosis. Is this appendicitis? Is this
cholecystitis? Is this diverticulitis? It does
not require having an open surgery to diagnose
the problem in advance. So that's sort of a magic
of radiology that's emerged from the beginning
of time when they, not beginning of time, from
the beginning of like the 1900s when they had
the first x -ray acquired. And then you move
forward into more advanced imaging, cross -sectional
imaging like CT scans and MRI scans, which started
emerging like the 1970s where you could actually
get like a textbook picture, a slice of anatomy.
Imagine like you look at a textbook of anatomy,
you see like slices of the body. We could do
that kind of imaging with those kind of new modalities.
So that's what radiology kind of emerged of.
Diagnostic radiology is, you know, give the diagnosis
to avoid having a... a very invasive procedure
medical procedure to get the diagnosis so that
you can treat it and and um and that's what we
basically you know we get trained on all the
different modalities there's x -rays and there's
live x -rays which is called fluoroscopy where
you're dynamically imaging the patient in real
time with giving let's say a contrast agent that
you can see how it flows through the body Then
there's ultrasound, there's MRI, there's CT scan.
There's another field called nuclear medicine
where we give a radio tracer that allows us to
image physiologic properties of the body from
the inside out. Now, a key feature of a lot of
those modalities is while they're more benign
in a sense than doing surgery to diagnose a problem,
they involve usually some ionizing radiation,
which is not a totally free lunch. in that if
you give too much ionizing radiation to an individual
at one time point, or those are not the doses
we deal with in radiology, but let's say the
small doses that we deal with, but you do that
frequently over time, that can lead to long -term
harm. So that radiation can actually cause mutations
in DNA and lead to actually developing cancer
in the long run, which is something we don't
want to do in a preventive health context. Those
are like historical modalities, the x -ray based
modalities or the nuclear medicine based modalities
that involve radiation. But there's a couple
modalities, ultrasound being one of them and
MRI being another one of them, which are unique
in that they don't involve any ionizing radiation.
And so this became an area of interest in terms
of how can we apply those other modalities towards
preventive health screening so that we can get
sort of our cake and eat it too. How can we get
sort of the power of radiology to diagnose disease
in a setting where, in a symptomatic setting,
you know, the pros of diagnosis usually outweigh
the risks. You go one -time CT scan when you
have an acute abdomen. It's not going to harm
you while getting the benefit to treat a potentially
high -risk condition will be benefited by getting
that diagnosis early on. But you kind of lose
that equation when you're like screening healthy
people that are not symptomatic. use a modality
that doesn't have ionizing radiation you kind
of have a different you lose that that trade
-off basically so for many years you couldn't
effectively do that with with mri because it
was a very very very very challenging complex
modality it would take a long time to scan a
patient for a small body part let alone for like
screening the whole body It was extremely expensive.
The exams would be intolerant to the patient.
They have to lie there for many hours. But as
technology progressed and it became more practically
feasible, so that's where we started sort of
thinking and sort of the prenuvo mindset of can
we put this in the kind of routine, the routine
apparatus, the toolbox of outpatient medicine.
And that's kind of where we are today. The technology
has accelerated to a level that you can do an
effective whole body exam with high quality imaging,
get a lot of information. It doesn't come at
much. There's no ionizing radiation, so there's
no sort of physiologic toxicity to the patient,
but it's also tolerable from a comfort perspective.
They can lie there for, you know, slightly under
an hour on the table. In our case, we set it
up with, you know, a way to be distracted. I'm
not going to say it's like going. On vacation,
it's not the most pleasurable experience. You're
still lying on an MRI board for an hour, but
they're relatively more comfortable than the
older, more tighter MRIs. They're a little bit
roomier. And the patients can watch a Netflix
movie and be distracted during the time while
they're in the scanner. So it becomes a degree
much more convenient and comfortable. So putting
all those things together, no radiation. No injections.
We don't give a dye, any contrast agent and kind
of the time. And then the expense keeps coming
down. All these things are allowing us to put
it sort of in this preventive healthcare context.
So that is kind of taking this like historical
view of what radiology was, this diagnostic,
this diagnostic, especially based on getting
images when there's already an established problem,
but avoiding. an invasive diagnostic procedure,
but doing that non -invasively, now we can do
that same non -invasive magic, but, you know,
go before the symptoms develop. Sort of a little
bit of a historical course there and then toward
the subspecialty that we do now. Yeah, I think
it's important just to understand the background
and, you know, the whys behind it. Total random
question. What is it about the technology that
makes it so loud, even with, you know, modern
day science? So loud, I mean, for... Like literally
when you're in the machine, the kind of grinding
noise. Yeah, that's due to the physics of the
machine itself and kind of the rapidly changing
parameters. There's no way yet that I'm aware
of to get rid of that noise factor. So even now,
like, you know, you're watching in the Pernuba
Clinic, let's say watching a movie and you're
listening to the movie, you know, you'll still
hear the noise to the headphones, but... We'd
give people earplugs to start trying to dampen
out the noise and then the headphones on top
of those so they can hear a movie. That will
help a little, but they'll still be pretty loud.
You can't get away from that, unfortunately.
Brilliant. What about where we are today? As
we had this conversation in 2026 versus, as you
mentioned, hours just to get a little sliver
of the body a couple of decades ago. What can
you see now with this head to toe scan that people
will be hearing about? We can see a lot and we
can get a sense basically of someone's general
state of health by what we see on the MRI. It's
not going to give us all the information. There's
going to be a role for things like labs, you
know, history, risk factors, et cetera. And that
will put sort of a lot of our imaging observations
in context as well as. fill in voids where we
can't give complete information from the imaging
alone. But all that put together allows us to
get sort of an integrated approach to giving
personalized sense of that patient's health and
give them guidance to what they should plan for
the next year, five years, 10 years, et cetera.
Low -hanging fruit, I would say, is kind of the
tumor screening. Obviously, that's an area of
main interest for a lot of our patients and referring
doctors. If you look at the current state of
kind of recommended cancer screening, there's
only about four specific cancers that are actively
screened for in a targeted fashion. And it's
limited to certain patients fit a demographic
profile above a certain age with certain risk
factors, which leaves a lot of people that maybe
don't fit that demographic or that may be at
risk for another cancer that's not one of those
four cancers sort of. at some degree of risk
for having a tumor develop that will go below
the radar until it's kind of like later on in
the stage of that tumor. Now, these might not
be necessarily the most common tumors and they
might not be individually very high risk, but
when you take them as a kind of totality, they
actually make up most of the cancers that are
diagnosed. So actually only 14 % of cancers are
diagnosed through screening in today's day and
age. So this is sort of a... unmet need still,
this sort of multi -cancer detection strategy.
And so you can think of what one important void
that something like the PNUVA scan fills is an
imaging -based multi -cancer detection tool in
a sense. It allows me as a radiologist to examine
the body head to toe through images and anything
that's basically forming a structural lesion,
a mass -like lesion. Essentially, that could
be a tumor that can further characterize this
as an aggressive looking tumor. Is this something
that looks benign? Maybe not even like something
to worry about. I can characterize these into
buckets of concern. Don't worry about it. This
isn't intermediate. follow this up a little bit
more actively and watch watchful waiting maybe
see you again in six months maybe see you again
in a year or maybe this is something that needs
immediate you know attention and intervention
prophylactically now so we can bucket these types
of observations and that may be tumors into these
different levels of concern and go do it you
know head to toe so whereas you know traditionally
there's only breast cancer that's green colon
cancer that's screened um um cervical cancer
that's screened in smokers that are of elevated
risk beyond a certain age. We do low -dose chest
CT screening. And even prostate screening has
itself some controversy. It's usually done with
PSA, a lab test. Some societies are for it. Some
societies think it's a little bit diminishing
returns. Those are the limited really cancers
that are actively screened for. But for everything
else, we're really sort of in the dark about
when we should be informed of a diagnosis. And
what you do about it is kind of tailored to a
patient -specific context. So not everything
needs an active emergency type alarm to it. A
lot of findings that we encounter can be watched
and waited. So that's important to realize as
well. It's sort of a risk stratifying practice.
That's from the tumor screening perspective,
but separate from tumor screening, this is really
not limited to tumor screening because we're
doing the radiology, the cross -sectional imaging.
So we get a lot more information beyond sort
of a a cancer risk score in a way. So we include
pretty high quality, high resolution imaging
of the brain. And if there's concerns for things
like demyelinating disorder, like multiple sclerosis,
we can find patterns that would be concerning
for that and then trigger appropriate follow
-up for that kind of condition. We screen for,
we do special sequences in the brain where we
look at the brain arteries, actually, the flowing
blood going into the brains. And this is done
just by tweaking the parameters on MRI, no dye
or anything like that. One of the magic things
you could do with MRI that you can't really do
with CT. And we use that very commonly to screen
for aneurysms, so brain aneurysms. So we do see
a good amount of aneurysms, actually. They're
often small, low -risk aneurysms for which we
don't recommend that every person needs to go.
get that treated. But we like to follow them
to see which are the aneurysms that are starting
off small, which one is going to stay around
stable and not going to grow and pose any risk
to somebody versus ones that are progressively
dilating. Those ones will trigger a prophylactic
consultation probably with endovascular neurosurgical
specialists or something like that. And many
of those will probably get treated because we
want to avoid a catastrophic event like a ruptured
brain aneurysm, which is can be basically a sudden
death type episode or if you survive that you
know can cause significant morbidity and cost
over over someone's life lifetime so brain aneurysms
that's another sort of high yield area that we
screen for um brain neurological disorders in
general and then in the body all kinds of metabolic
disorders we focus a lot on the liver um things
like fatty liver or hepatic steatosis, something
that a lot of people in America these days are
walking around with and don't even know about
it. It can be related to diet, can be related
to genetics. And we can see that very well with
MRI and quantify it and say, this is a mild level,
this is a moderate level, this is a severe level.
And if that goes sort of undetected and unmanaged,
it can lead to things like liver disease, inflammation
in the liver, even in the long run, fibrosis
and cirrhosis. So getting ahead of that in advance,
you can manage that with lifestyle changes, improve
your diet. And we can see again, how's the fatty
liver changing? If there's elevated liver enzymes,
you might need to go for, you know, more targeted
attention to like a hepatologist that might want
to treat the inflammation associated with, with,
you know, fatty liver. Are there sort of liver
toxins that you're ingesting or, you know, change
your drinking habits and things like that. kind
of impetus to a patient that may not be thinking
about these in advance to like want to act on
it. So in a way, a picture speaks also a thousand
words. And we've seen this anecdotally in our
practice, like patients will know that they need
to kind of improve their diet or kind of cut
back on their drinking, but they've not done
it. And then we show them like, look, this is
your liver and this looks really fat. This is
going to keep getting worse. And they'll use
that as, oh, wow, now I really am motivated to
improve that because I can see that myself. So
tumors, aneurysms, as I mentioned, metabolic
disorders like fatty liver, these are sort of
examples of the wide spectrum of conditions that
we can assess for on a whole body MRI examination.
And it's really a risk stratifying approach.
It's information that we can provide that can
then be put in context and inform next steps
on how to optimize health in the short term or
long term. So you guys were kind enough to allow
me to come and do an MRI myself. And I was incredibly
impressed by the depth of the family history
questionnaire prior and my own personal history.
Very, very impressed. And for everyone listening,
I haven't been paid to say any of this stuff
by the actual. clinic itself, the place where,
you know, where we did the MRI, um, really, really
great experience, very thorough. Like you said,
it's the most encapsulating MRI I've ever done.
And I've had MRIs on my back on my knees after
injuries. Um, and then after, you know, the consultation,
so you get, you know, the results and it was
very, very quickly as well, but it was, I think
we talked for an hour in the end and went head
to toe, all the different, you know, um, systems
and organs and, you know, the, the musculoskeletal
system. And it was so incredibly thorough. And
when I think the application of the fire service
or the first responders listening, it in itself
is incredibly powerful. But if you have a baseline,
whether it's the first day firefighter, cop,
whoever it is, or whether it's now someone's
25 years into the fire service, which is their
first one, the ability to scan and detect, God
forbid, abnormality in a blood vessel or some
sort of tumor. in itself is incredibly powerful
because as you said normally we're not going
to hone in on it unless um really unless there's
symptoms because most departments don't have
thorough blood work either they're very kind
of surface level but where i see the superpower
of this is you've had your baseline and in medicine
obviously trending is is the biggest thing is
the second scan There's a couple of places where
I had a blood vessel and it's probably just thickening
genetically, but it's something that I'm going
to look. And when I get it done a year or two
later, now I'm going to be able to compare 2026
and 2028. And I think that's where there's incredible
value because now, as you said, you can see,
was this a benign genetic non -abnormality? It's
just I'm abnormal in my anatomy. Or is this a
growth or a weakening of an artery that I need
to be worried about? Yeah, that's a really important
point. So the idea, the highest value for an
individual will come from using something like
the whole body MRI as a longitudinal surveillance
tool. And it allows the individual then to basically
serve as their own reference control. You get
the baseline in hopefully a healthy state. Hopefully
on the first scan, we don't find anything that...
it's particularly radiologically concerning.
Like we'll see a lot of benign, nobody has a
completely normal whole body MRI. That really
doesn't, that's sort of like a paradox in a way
that doesn't exist. Like everybody has dots all
over the body. You might think of it as an analogy
to like, look at everyone's skin. Like everyone
has freckles somewhere. You don't go to the dermatologist
and they biopsy every freckle for possible melanoma,
but they can recognize the ones that maybe are
more concerned that need watchful waiting or
the ones that need a biopsy on the spot. So you
now, go deeper into the body and everyone will
have things like, you know, little dots and little
cysts and, you know, say the kidneys or the liver,
things like that. Those are sort of leave alone,
but we can document that the baseline. And then
serving as someone's own control, what is normal
for them is basically what are the expected age
appropriate changes that that person might develop
within a year or two. There are things that from
seeing so many healthy whole body MRIs, we can
have a sense of, This is within the spectrum
of normal versus this is outside the spectrum
of normal. And this requires some tailoring,
targeted attention in that specific patient.
It's not all just about tumors and aneurysms.
It could be, you mentioned, you know, spine imaging
could even be something about spine health. So,
you know, there's a lot of wear and tear that
we all get on our spine. No one's going to escape.
You know, the radiology term we use is degenerative
change of the spine. That really means, you know,
wear and tear. Now, you can be somebody in their
50s who has the spine of a 50 -year -old. That's
maybe age appropriate. You can be someone in
their 20s and has the spine of a 50 -year -old.
And you might not have any back pain issues right
now, but you might want to be alerted to that
so you can practice good spine health, good posture.
If you work at a desk, maybe get ergonomic type
desk setup, standing desk, good chair, et cetera.
Do appropriate exercise and manage your weight
to avoid the accelerated deterioration of the
spine so that when you're in middle age, you
don't have the spine of somebody who's like in
advanced age. And maybe when we all get to advanced
age, maybe on the other hand, we have, if we
can be mindful enough of our physical mechanics
better. We might be in our 70s and have the spine
of a 50 -year -old. So that is sort of the idea.
Getting this imaging information is a motivating
factor towards optimizing long -term health.
Now, tumors, obviously, those are important because
we will often see a smaller, locally, like a
local tumor that will never have pronounced itself
until... diagnosed for another reason once it's
much bigger and harder to treat. But when you
see with imaging at the earliest stages, where
it's just a small, it's a nodule in an organ,
and it's new from, let's say, last year, and
it doesn't look like the benign picture of a
cyst or some other typical benign thing like
a hemangioma that we often see in different organs,
then this is basically an alert to early action.
And many times those... don't need to be aggressively
treated with a major surgery, let's say, but
we have the tools to observe them minimally invasively,
either with more imaging or to even intervene
on them without having the morbidity and risk
associated with big open surgery. So an organ
that I'm particularly excited by in my case is
kidneys. Kidneys, we actually see a good number
of early renal cell carcinomas. And there's probably
some controversy about those. Like maybe we're
detecting a lot more renal cell carcinomas that
really would never have hurt the patients had
they not been like detected with imaging. Maybe
they'd be slow growing, relatively indolent,
and a patient might die from some other cause
in like 10 years and better they didn't know
about it, but rather than know about it. However,
that's sort of based on, I think, incomplete
assumptions because not every small tumor needs
to have a major surgery and take out the whole
kidney. So nowadays we can minimally invasively
with imaging, you know, put a needle into that
tumor and ablate that like we were talking about
earlier with focused ultrasound in the brain.
Similarly, you could do, whether it's with not
so much these days with an ultrasound, but maybe
in the future with something like histotripsy
or another ultrasound too. But these days we
usually do it with like a needle -based ablation
with radiofrequency or microwave ablation. And
you could leave the whole kidney intact. You
just burn. the tumor, and that's just the disease
tissue is removed. And the benefits are that
you kind of get the benefit of early detection
without the cost or the trade -off of the unintended
consequences of the high risk and highly costly
treatments that would go along with that. So
the technologies are kind of emerging in parallel,
medicine from the interventional side, as well
as medicine from the... diagnostic as well as
medicine from the pre -diagnostic but early detection
side. So the baseline really enables you to use
your own self, your own data as that control.
Because if I see a new lesion, small, maybe looks
low risk at the first baseline without the prior
baseline, I might not be able to tell you, oh,
this is more concerning because I want to see
another time point. But if I already had an earlier
time point, where I can see it wasn't there and
now there's a new tumor there. That means I can
give you a trajectory of like sort of this is
number one new. What's the growth rate? What's
the doubling time? This has more concerning for
something more progressive versus something stable.
Now, if I see it for the first time and I see
you again in three months or six months and I
can demonstrate, well, look, it hasn't grown
actually. It's stable. We don't have to really
worry too much about it so we can afford to watch
and wait it. So those longitudinal data points
are more additional information that people forget
about. Like that value is really in that longitudinal
follow -up goes beyond just the baseline alone.
And the ability to do that without ionizing radiation
means that we don't have to worry about the concept
of overdosing people with the trade -offs that
we would get in other radiology contexts that
would also, you know, In theory, be able to do
the same thing, but come at that radiation cost.
I had a guest on for a second time, Josh Clemente,
who's the man behind Levels. And he made a really
powerful kind of point. He said, and he was obviously
generalizing, but he said doctors were never
meant to be treating chronic disease. He said
doctors were originally created for trauma and,
you know. childbirth and some of these other
areas where you need this medical professional
with this medical expertise. And with this AI
and with the much better blood work now and technology
like preventative MRIs, his point was we're putting
the power back in the hands of the patient. Now
we're asking medical professionals to interpret
this data for us. But now you can say, okay,
I'm starting to get slightly fatty liver disease.
Before I ever would have walked in, because now
I'm bright yellow and asking my doctor what's
wrong, now I'm so far ahead of it that I can
look at all these things and say, as James Gearing,
as my own advocate, what am I going to do to
get ahead of this? And we don't really have that
in a lot of modern medicine. People go when they're
already feeling bad or they're already hurt.
And I'll give you a good example. When I had
my MRI, and I wish I could remember your colleague's
name that was the one that was walking me through
it. But she was saying how good my spine looked.
And what was interesting is I had a near career
ending back injury about 10 years ago. And even
though I was told to take meds and probably go
down the surgical route, I refused and did chiropractic
and specific movement practice that is amazing
for back health. And my back looks great, even
like the actual disc, the bulging of the discs.
gone down and i hadn't really had an mri on my
back since i originally heard it which at that
point there was multiple protruding discs and
one of my vertebrae was turning the wrong way
so again it goes to show that now you have this
kind of imaging proof, like, okay, you're not
going to go back to having an 18 year old back.
But yeah, in that particular case, movement practice
helped my back without any surgery. You know,
you reverse some areas in the body by changing
your exercise routine and your sleep routine
and your nutrition. So what I love about this
is not only obviously the screening itself, but
it's putting the power of the patient, you know,
back in their own hands, which is the whole point.
They're the only person really, apart from their
family, that's affected by this health. So the
more we can empower them with this modern technology,
the more they can understand this whole issue,
the more empowered they are to make their own
decisions. And then most importantly, that proactive
preventative health becomes a lot more powerful
now. Totally. So in a way, it democratizes the
medical data and makes it accessible to the...
the patient direct, and it's not limited to,
you know, the whole body MRI and prenuvo scan
alone. Like nowadays patients have access to
their own medical records relatively generally.
Right. The challenge is a patient may also be
overwhelmed with all that data without sort of
kind of, like you said, like originally medicine
emerged as sort of a way to treat acute disease,
but at the same time, even outside the acute
setting you kind of need an expert coach to kind
of make sense of all this data for you that's
often can be very technical or maybe you might
be you know well versed and so one area of it
but you don't understand how it inter integrates
with another area of like how does imaging relate
to labs etc and so kind of having a medical expertise
to holistically integrate this and counsel you
so counseling i think is going to be very important
nonetheless i don't think i don't think it will
be any one individual can be assumed to um it
would be sort of irresponsible i think of doctors
to sort of say here's your data and go figure
it out but it is our job to educate counsel and
provide guidance on on um on how to use that
information but the patient then once they have
that that framing is then armed to take care
of their own health in a way that is not behind
sort of the gates of medicine. You don't have
to go to any one center or doctor who's sort
of controlling all the data and then having them,
the doctors talk to the other doctor to share
the opinions of the day. They can all be centralized
in really the patient as the concentrating point
for their own. their own data and healthcare.
And that's something that we've done at Prenuva
specifically. We had that in mind. And so every
patient through like the Prenuva app will get
the full set of, you know, the whole, the radiology
report for sure. They'll also get sort of direct
embedded links to sort of educational materials
for any one of those conditions that we may be
observing, whether it's the fatty liver or the
liver cysts or hemangiomas, et cetera. be able
to put that in their own context in addition
to having the medical consultation that you experienced,
but then also have the images themselves downloadable
through the app that they can then share directly
with the specialist that they go to. So they
can go to, let's say, the liver doctor, and the
liver doctor can download the images and look
at them directly themselves and then have...
the maximal exposure to the pure data and it
not having to be filtered through, you know,
multiple kind of plain telephone in a way. And
the patient takes ownership of their own care
because they could choose their provider. They
can connect the data directly to the provider.
And I think that's been very well received and
very, very useful. Nobody is more of an advocate
for their own health than themselves. Having
been in the medical environment as a patient
myself and for my wife when she was delivering
our kids, everybody needs to be able to advocate
for themselves. And the more knowledge that you
have and information you have at your disposal,
the more it arms you to do so. Especially as
the system gets bigger and bigger and bigger
and it's hard to sort of, we lose a lot of that
personalization that is... important to the tradition
of medicine, that patient -doctor relationship.
I think this new development of democratizing
medical data and making it directly available
to patients and arming them with that information
is important, especially as we just keep making
it more accessible to the larger masses. People
need to be able to advocate for themselves and
have that direct touch on their information.
Another application that I'm thinking of in my
mind, just as you're talking, even at my level,
at the bachelor's level in the paramedic school,
when we're taught medicine, it's organ system
by organ system. Okay, this chapter is a renal.
And then I would imagine as you go through medical
school, if you have a residency and a specialty,
and now you become a renal specialist, there's
a danger of becoming myopic in that one area.
When you have the ability to then have all these
images, though, from a full body MRI and you
think this issue is coming from the kidneys,
but you're like, well, I wonder if it's coming
from this other area. Now you're able to look
at the whole body and say, well, was there an
issue with the liver? Or was there some cardiovascular
issues in the lower legs? Whatever it is that
you're looking for. And I can tell I'm just making
that part up because I'm not a doctor. But getting
that macro perspective of the whole person again,
I could see there was value. um when trying to
even diagnose something when you have gone to
that specialist yeah and um even in radiology
it's it takes some wrapping your head around
because in radiology usually we would outside
the whole body screening context usually you'd
get like a brain mri or a prostate mri you know
these are totally separate organs they don't
like interact with each other. They're not diagnostically
related, but it's not really true because they're
all part of the organism, the whole body entity.
And a lot of these conditions and pathologies
and organisms, they interrelate with each other.
So obviously, when we talk about the heart, the
kidneys, the lungs, the liver, these are all...
physiologically related with each other. And
you can have fluid dynamics and physiology that
affects all those organs or systemic conditions
like inflammation or even cancer that you might
have a tumor in a certain organ. Then you have
metastases spread elsewhere. Until you take the
whole body approach, number one, you can sort
of characterize distinct processes that are separated
in anatomic space in a way. But a lot of times
they do interrelate. So when you see somebody
with, let's say, a picture of metabolic syndrome,
you know, they have enlarged visceral fat. So
when I talk about visceral fat, I mean, there's
like two general categories of fat. There's like
subcutaneous fat, the fat below the skin, which
is, you know, maybe aesthetically not, you know,
the type of fat that we want to have. But from
a metabolic perspective, it's not like the bad
metabolically. you know, dysfunctional type of
fat as much as visceral fat. Visceral fat is
like the deep fat, usually within the abdomen,
but also can be, you know, in the chest, the
thoracic, pericardiac fat. But these are the
kinds of fat that will go along with things like
sugar, dysregulation, diabetes, and things like
that. They'll often be part of a manifestation
of a metabolic syndrome and fatty liver, and
can also relate to all kinds of chronic vascular
disorders. So, you know, diabetes can cause,
you know, small vessel disease. So in the brain,
we might see small vessel ischemia, a little,
you know, what we call non -specific white spots,
but it's often a kind of small vessel ischemia
from long -term sort of narrowing of those end
small blood vessels. And you can grade it in
terms of mild, moderate, severe. And as you can
see, get a more general whole body picture of
not just This organ is diseased, but how does
this organ manifest in a sort of whole body system
with integrated systems and get a sense of this?
So we might say, oh, well, you might want to
get more aggressive management of your cardiovascular
risk factors because, look, you're on the verge
of showing signs of metabolic syndrome. You have
increased liver fat. You have increased visceral
fat. You have end organ, ischemic change in the
brain, et cetera. You're in your 40s. Let's think
about this so that when you're in your 60s, you
don't have. increased risk for cardiovascular
acute events or even brain health like vascular
dementia, which can lead to over time of one
kind of dementia from just brain small vessel
ischemia that just goes unchecked and keeps progressing.
Now, it's not going to be a magic bullet. These
are informational findings that will... Give
a patient sort of impetus and maybe give them
a benchmark from which they can compare future
changes over time. And as long as things are
improving without getting worse, that's probably
in many cases the best that we can hope for.
But there are targets like the liver fat that
we can actually, we can see, you know, you're
taking fat off the liver or visceral fat. The
visceral fat is decreasing. And so your general
trajectory might be improving. So, in another
sense, another kind of interesting application
to make it easy is from a tumor screening perspective,
cancer screening is often like binary tests.
Is there cancer? Is there not cancer? And it
might be in an organ -limited fashion, like with
the PSA, we're looking for prostate cancer, or
in breast, another imaging modality. targeted
just for breast is mammography which on a side
note i just want to clarify you know when we
talk about these multi -cancer detection technologies
these usually are not intended to replace any
one single cancer screening approach because
those are evidence -based to be high ceo for
patients of certain risk factors for that kind
of cancer they complement each other but that
being said usually they'll be focused for is
there concern for cancer in that one organ binary
and then a patient will have to go undergo other
examinations to, let's say, cancer is proven,
what's the sort of burden of disease? How big
is the tumor? Where is the tumor located? Is
it, you know, which organ of origin is it from?
Is it on the right side? Is it on the left side?
Is there evidence of local invasion or distant
metastatic disease? So those sort of staging
evaluations are often, you know, additional exams
after the fact. We'll have a role still, no doubt,
after, let's say, screening detection with whole
body MRI. But you can imagine we will also get
at the time of screening, the same encounter,
the detection, but also an estimation of disease
burden because we're getting that whole body
view. So I might be able to say, oh, there's
a prostate lesion. But by the way, there's, and
that's very concerning for prostate cancer. It
looks like. you know, you know, we grade it on
sort of, you know, MRI features and say, this
looks like cancer to proven otherwise needs a
biopsy. But by the way, there's also all these
bone lesions and those look like prostate metastases.
This might be considered high, you know, late
stage cancer to proven otherwise, which changes
sort of maybe the aggressiveness with which you
work it up and treat it or the treatment options
or sort of the goals of care. And you can get
that at the same time point of screening that
you wouldn't get with other kind of non -holistic
approaches to the whole body. Almost all diseases
that we are concerned about will progress towards
sort of systemic manifestations. But our goal
with early detection is to detect them at a local
stage. But if there is evidence of systemic manifestations,
be able to... get a sense of that as well. So
it's kind of like a lot of bang for your buck
in the early detection space because we get that
systemic view at the same time as a byproduct
really of the early targeted detection. What
about the skeleton? You're able to see bone density
or potential fractures, et cetera? So that's
an interesting area. I would say that's... Talking
about bone density, not something today that
we are doing. I wouldn't hang my hat on that.
But there is research that MRI, at some point,
should be able to get developed and become clinically
mainstream enough to be able to do some form
of bone mineral density assessment. Now, that's
not where we are today. So you come to Pernuvo,
you would not get sort of an osteoporosis screening.
But there are... So individuals, researchers
looking into being able to do that sort of opportunistic
sort of detection with MRI as well. So it would
put kind of bone mineral density aside. If someone,
let's say, usually females over a certain age
that are at risk for osteoporosis, they should
probably still go for this usual DEXA -based
screening, which allows to measure the bone density
relative to age -matched controls and see if
they're more at risk for getting a fracture.
So we definitely don't want someone to replace
that practice with anything we're doing with
whole body MRI today, but there would be potentially
some applications in the future. So put that
aside, the bone mineral density for now, but
talking about, let's say, fractures, if someone
had a trauma, they fell something or they have
an unexplained pain in a bone or joint, I don't
want them to come to Prenuascan to diagnose that
because it'll be a... A more directed diagnostic
modality in that setting. But if somebody has
a history of a fracture and they didn't even
know about it, it's chronic at this point. Let's
say in the spine, they previously had trauma
and they know about it or they don't know about
it and there was compression fractures or they
have osteoporosis and there's compression fractures
and maybe they didn't know about it. We can see
manifestations of... what looks like chronic
compression fractures, we might say that there's
no evidence for acute findings. There's no, you
know, there's no edema. There's no spinal canal
stenosis or cord compression or anything like
that. But usually these would be chronic, but
we can give a sense of they are there present.
So that would be something we could comment on,
but I wouldn't recommend that that's something
to come to Prenuva for because usually those
are things that would be diagnosed routinely
in more acute settings. or with a bone mineral
density in sort of the standard screening context.
I want to go to some of the success stories that
you heard, but just before we do, my profession
is known, sadly, cancer is a big thing in our
profession. We have carcinogens in the fires
we respond to and a lot of the other hazards.
We have carcinogens in our gear, like PFAS. It's
actually in there because of the manufacturer.
We also know that sleep deprivation is carcinogenic,
which is a more recent revelation, let's put
it that way. We have the heart disease, and again,
from the stress to the body composition. But
one of the ones that's been alarming recently
is a lot of young firefighters getting strokes,
and a lot of them are hemorrhagic strokes. With
obviously your father and then now yourself,
what, if any, have you... seen read about as
far as a correlation between shift work chronic
sleep deprivation and that kind of disease process
in younger men so i want to not over say what
i'm not an expert on um so i'm not necessarily
specifically informed on the firefighter specific
risk factors for developing stroke and young
men for developing stroke. That being said, all
the things that you mentioned, these are known
risk factors for all kinds of significant disease,
including cardiovascular disease and stroke risk.
So I'm not surprised that firefighters as a group
would be at elevated risk for developing things
like stroke, in addition to their risk for developing
all kinds of tumors that are... at higher risk
than the standard population. But as a matter
of, can I say, do I know more about like, this
causes them to be at more risk, this particular
practice or this material that they're exposed
to, or, you know, in their gear, that is not
an area that I'm particularly informed on. But
I will say that I have a good amount of experience
doing whole body MRI in firefighters. We see
a lot of firefighters at Pernuba, a lot of departments
are actually referring their their members to
us for advanced screening. Oftentimes, the first
thing that I'm aware of that they're interested
in is the cancer screening. I actually was less
aware about the cardiovascular concerns. That
being said, we can provide a lot of information
that would inform risk assessments towards that.
So if I see examples of prior strokes that may
have been subclinical stroke we we can give that
information on the whole body scan if i see evidence
of risk factors like small vessel ischemia like
white matter disease and whatnot even if no like
large vessel occlusion or territorial vascular
territory stroke had occurred this is an one
data point that says this patient is a vasculopath
and probably should get into some a preventive
care program to minimize their ongoing risk,
not just for brain, but for cardiovascular events
as well. The two will go hand in hand. If I see
things in the brain, you mentioned hemorrhagic
stroke, that could be various different kinds
of stroke. If it's a hemorrhagic stroke, meaning
maybe one type being from a ruptured aneurysm,
we would see manifestations of aneurysms pretty
well, probably as good as one would hope for.
in a pre -acute scenario, which allows you an
opportunity. You want to do surveillance on that
or even prophylactically intervene on it if it's
beyond a certain size. You have risk factors,
familial concerns, et cetera. Those patients
might go for an early, hopefully relatively minimally
invasive intervention as well. Now, those would
be like subarachnoid hemorrhage from an aneurysm,
but there could be other types of hemorrhagic
stroke. It could be from hypertension or other
ideologies. I'm not going to be probably able
to predict a hypertensive stroke because that
is going to be acute and shown probably from
a history of hypertension. But again, those are
data points that will go together. If a patient
knows they have high blood pressure and maybe
that wasn't itself like something that motivated
them to get into a blood pressure control improvement
plan. but I show them all these other data points.
Oh, look, you also have small vessel ischemia.
That's also related to hypertension, plus minus
diabetes, or you have these metabolic disorders
with visceral fat and fatty liver, et cetera.
The picture is not looking like it's going in
the right direction. The picture speaks a thousand
words and has been very helpful for those patients.
We can also see if there's, I want to soften
this a little bit, sort of like significant atherosclerotic
disease in the intracranial arteries, if there's
like high -grade stenosis, usually this is not
the first line approach for kind of screening
for atherosclerosis. But if I see sort of irregularities
in the brain arteries, and this could be suggestive
of atherosclerosis and high risk for developing
future strokes, I might comment on that. But
usually that's not the first way we look at that.
So I don't want someone to think that they can
get a prenuvo scan. and have sort of no comment
on like atherosclerosis or narrowing of the brain
arteries and think that that means they're risk
-free. But we might comment on that opportunistically
if we see that. Similarly for like dissections,
which can be a cause of stroke as well. We see
sort of weakenings in the blood vessel wall where
it's now starting to... kind of tear off some
of the inner lining of the blood vessel often
from hypertension or from some let's say neck
manipulation we see that once in a while as well
we might say oh there's concern for dissection
we need to further evaluate this and see somebody
uh to evaluate if there's any risk for stroke
or symptoms and then treat the risk factors that
may go along with that so it it can heal basically
not have an acute event so these are things that
are like But the main thing that we screen for
kind of neurovascular wise would be brain aneurysms.
And one way we didn't really touch on was the
heart specifically. What are you able to see
with the heart? So in this kind of basic, the
current iteration of the printable scan, and
I emphasize current iteration because this is
always an improving exam, improving technique.
We will hopefully improve our heart evaluation
over time. But right now, because the heart is
a moving structure, it's beating, there's some
blurring of that organ relative to the static
organs that are not in motion. You might think,
obviously, if you're taking a picture of somebody
and they're running around, they might be blurred.
So the same kind of logic applies by analogy
in kind of medical imaging. So because the heart
is beating in motion and we didn't do any special
tricks on the prenuvo scan that you might have
in like a cardiac MRI where you're doing. kind
of cardiac gating where you're timing the imaging
to a certain point of the cardiac cycle where
you can control for that motion. It has the state
of contraction of the heart as well. We're not
doing that in our screening context right now.
So the heart will have some relative limitations.
So it's not going to be an exam that can really
tell you much about heart function or the kind
of coronary arteries or many of the relevant
important... structures that you'd want to know
about from a more complete evaluation from a
preventive mindset about heart health. That being
said, if there's a big abnormality like a mass
around the heart or a lot of fluid around the
heart or a gross enlargement of the heart, we
would comment on that. If I see related not to
the heart itself, but let's say to the vessels
coming out of the heart, the aorta, if I see
the aorta is dilated, I might comment on. dilation
of the aorta and risk for aneurysm. That goes
for the thoracic aorta in the chest, as well
as for the abdominal aorta in the abdomen. So
those major cardiovascular structures, we can
provide some comment on, but as much as like
a detailed evaluation of the heart, this will
not be the first line for that. So for let's
say coronary artery evaluation, there's better
techniques for that right now. And if someone
is interested in sort of heart function and looking
at the heart valves and looking at the ejection
fraction of the heart, how much it's pumping
out, then something like an echocardiogram is
going to be more standard and more informative
from that perspective than what we can currently
do with the Pernua scan today. So the chief of
Boynton Beach Fire Department, Hugh Bruder, not
only was part of the movement to move them to
a healthier work week in the fire service, 24
-72 we call it, which is a 42 -hour work week.
They also use you guys. I think it's every two
years they do a scan. And he was singing from
the rooftops about how incredible it was. And
he talked of several lives that were potentially
saved through this technology. we don't have
to talk about that particular department, but
in general, talk to me about some of the incredible
success stories you've had with this preventive
medicine. So hard to talk about specific individual
stories without risking sort of, you know, talking
about and violating kind of patient confidentiality.
But I can tell you like a big picture. We've
had a lot of positive feedback, similarly from
the firefighting community. We have a program,
we call it the Warriors program that, kind of
acknowledges sort of the additional risk and
appreciation. So the risk that firefighters and
other first responders and veterans kind of put
themselves at for the benefit of basically everyone
else in society and acknowledges that and appreciates,
wants to demonstrate that we want to deliver
this kind of service to those that... need it
most potentially and appreciate them for everything
that they sacrifice. So we have a program like
the Warriors program that allows it to make it
easier for firefighter communities to come and
get scanned with us. And we've had a lot of very
positive feedback, whether it's an early detection
of a tumor. whether like a bladder cancer or
a brain tumor. We've seen these examples, frequently
early detection of an aneurysm. We've seen these
stories come back to us with gratitude saying,
wow, if it wasn't for this, I would be at extreme
risk and put my team at risk. If I had a ruptured
brain aneurysm in the field or my family at risk,
et cetera. So this is something that I think
affects firefighters. at least as much as our
regular patients, even more so because of the
added responsibility that they carry and the
risks that they put themselves at. We're collaborating
in a, that's the warrior spring, but we're collaborating
in a firefighter cancer screening study as well.
So we're not the only ones interested in this,
but we have partners in the community that are
clinicians in this particular study based out
of kind of the Maryland area that they're running
a firefighter cancer screening study looking
at. can we offer actual benefit to firefighters
with early cancer detection going beyond sort
of like the n of one like we know we can affect
individualized but does this affect with benefits
sort of like the group level can we justify this
from a broader active screening perspective so
we have a very you know active uh program that
we're collaborating on over there out of the
maryland area with the innova health system uh
and that's ongoing so i don't have like results
that i can share about it but you know these
are Definitely, we start off with the anecdotal
stories, and then that gives us reason to want
to investigate things more robustly in a scientific
context. So that's where we're kind of moving
towards right now, establishing more scientific
methods to study the benefit to groups like firefighters,
especially. Well, going back to that one department,
you take your work week to a healthier work week.
So now your men and women are getting more rest
and recovery. ideally from day one, a baseline,
you know, full body MRI. And then, you know,
every year, two years, whatever it is, you're
putting that in as well. And you have comprehensive
blood work. And I know your colleague was talking
to me about the potential of even doing an ultrasound
as well as part of the overall test to hit some
of the areas that, you know, that. that they
are better at hitting than the MRI. And now you've
got the ability to get ahead of so many of these
issues way before they become acute, you know,
potentially. Of course, you know, there's always
those anomalies. But to me, this technology seems
like if it was interwoven into the fire service,
I mean, firstly, you'd save so much money catching
these before they became, God forbid, some, you
know, hundreds of thousands of dollars chemo
treatment or, you know, neurosurgery. But also,
more importantly, you're empowering the firefighter
to stay ahead. And then, as you mentioned, even
with body composition, you know, when you start
to see that fat is actually very visceral, you
can show the pictures to the firefighter and
then that will definitely help. hopefully motivate
them to start curbing the way they eat and exercising
more and that kind of thing. So I see so many
different applications from a prevention point
of view, rather than what we normally see, which
is reactive. Our whole profession, that's the
nature of the beast is someone calls 911 and
we react to whatever we go to. Well, the other
side of the equation is how do we stop people's
homes burning in the first place, people having
heart attacks in the first place. And this gives
us the potential to do that same thing to our
own health. Yeah, I'll add on to that. I think,
and it may not be surprising, but from what I've
seen, the firefighting community that I see at
Pernuvo, they seem to be a relatively, not relatively,
I think an objectively stoic bunch. I mean, you
guys are tough. And so a lot of times the kind
of observations that I see in firefighters, I'm
like, surprise, wow, how are they not complaining
of this? And being symptomatic, like whether
it's like a musculoskeletal injury, like a muscle
tear or a, you know, degenerative spine issue,
like very tough guys kind of suppressing a lot
of the physiologic symptoms of stress on the
body to get the job done. But it puts their own
well -being on the side because it's, you know.
hard to focus on that when you're running into
buildings and doing whatever you have to do to
lift somebody out of that state of danger. And
at the same time, you're overcoming the sensations
of pain or something in that body part that is
telling you, oh, don't lean on that knee or something
like that. You just ignore that. And then the
acute pains subsides. And then It goes back to
normal, but that doesn't mean the body has totally
healed. So we see this all the time in imaging.
And I talked to some of my referring colleagues
who tend to refer us to these firefighters. I'm
like, wow, these guys are stoic, right? I don't
understand how this is even in the screening
context a lot of the time. This is stuff that
if my body looked like that, I feel like I'd
be in the doctor complaining like a little baby
myself. So the view into the body, it gives.
kind of like the those of us that are tougher
than others from like our um our body is still
not foolproof even though we may be able to mentally
overcome the pain in the short term and it allows
you when you're not dealing with that emergency
situation and having to you know take someone
out of the burning building to like refocus on
yourself and say oh yeah i gotta really work
on that pt for that knee injury that i had or
you know my my my back that It does kind of ache
me a little bit, but, you know, I can like brush
it aside that then I point out, oh, no, look
at that big disc herniation over there. Maybe
you got to do some more active, you know, take
it easy. Don't don't do some physical therapy.
Let's let things go back to the way they're more
physiologic. So I think the imaging information
arms, especially people like probably firefighters
that have to suppress a lot of those internal
triggers. Those cues that there's something to,
you know, pain is good. It tells our body, like,
take it easy on that part of the body, allow
it to heal. And some of us aren't as in an environment
that allows us to do that routinely, while some
of us are. So I think firefighters are a unique
group that could benefit from this proactive
health information, body information that is
not really accountable in a routine preventive
health care context. In the mental health conversation,
it's been interesting because my mind has shifted
from nine, 10 years ago, which was, man, you
know, we keep taking our own lives. This is addiction
crisis. You know, we're air quotes broken. How
do we fix us? And then over the years, from the
resistance through the conversations to understanding
what. psychology looks like in high performers
you realize that really the conversation we should
be having is actually performance because if
you do the things that forge mental performance
you are simultaneously addressing the issues
that affect you know negative mental health and
i think this is the other part of this conversation
is if you if you have um first responders who
are proactively staying on top of their health
and the injury prevention and these other areas,
you will perform at a much higher level. As someone
who has nursed many injuries through my career
before they were addressed, you are operating
at a lower percentage. You cannot deny that.
So I think from a performance point of view,
where do we take the fire service? Where do we
take law enforcement ultimately? This kind of
proactive preventative screening allows you to
get ahead of all the things that are going to
hold you back, address them early so that you
can carry on performing at a high level. Yeah,
I know. I think that also makes a lot of sense.
It's not just for the firefighter, the individual
themselves, but the team, the society benefits
from maintaining the optimal health. performance
health of the individuals on the team. So it's
mutually important to value this perspective
of preventive health. The team is only as strong
as the individuals that make it up, right? So
if not everyone is performing at 100 % because
they're nursing an injury or they're struggling
with a mental health issue, this needs to be
addressed. sooner rather than later when they
are actually more addressable and you can change
the trajectory of the course of that limited
condition, but also that how it affects the individual
holistically and then by extension affects the
team. So it's really multifactorial, totally.
Absolutely. Well, for people listening, I'm sure
they would love to learn more, you know, just
be able to schedule a consultation, maybe even
approach you as far as getting screens for their
entire department. Where are the best places
online to do that? Oh, well, number one, they
could go to the Prenuva website. There's like
a direct platform there where they can. see what
the availability is at whatever clinic they are.
And we have like, I forget the number now, how
many clinics, 25 or so clinics across the US
and basically in the major cities in different
states. And they can directly book an opening.
They can see the calendar or they can call in
and have someone on our team going to assist
them to book an appointment. That's at the one,
you know, single person level. But if their department
has already sort of somewhat of a program where
they're referring out or even helping fund some
of these exams for their members. They might
want to reach out and see if that exists. And
then there's often like a special pathway that's
already pre -established for those kind of partner
departments already. And if their department
is interested in that, but hasn't yet established
that, that might be also something, a conversation
they could bring up and reach out to our teams
and see if a pathway could be established for
that. In the meantime, anyone is able on their
own to go to the website and book an appointment
or call in to our team. I don't have the number
offhand, but we can get that for you after the
call. Brilliant. And then 25 at the moment, what
is your goal to be in all 50 states? I think
so. It's not really the area that I'm actively
involved in, in the kind of like company planning.
But yeah, no, I think the goal is to make proactive
care informed by radiology or whole body MRI
at its foundational level accessible to everybody,
both in terms of location and also in terms of
cost as well. So we're always trying to. make
it faster, make it less expensive and make it
more widely available. So probably if it can
be in every state, that'd be the ideal in every
major city, the ideal to work towards. Right
now we're at 25. I don't know what the sort of
the timeline is to get towards the ideal state,
but that is sort of the goal we're working towards.
If you look back over the last few years, you
know, when I started at Adventure and Pernuvo
about five years ago. We had one clinic and then
we accelerated to now 25 clinics, most of them
open in the last, you know, I think one to two
years. So pretty good stage of growth right now.
And hopefully soon we'll be more accessible to
mostly everybody. Brilliant. Well, I want to
thank you so much. It's been such an amazing
conversation. I've genuinely, people know now
if they've listened to this podcast for nine
years, I will not stand behind anything I don't
believe in. The sponsors that come on the show
are all products that I've used in the past,
for example. But I was genuinely so impressed,
not just by the actual imaging itself, but the
medical history before, the consultation after.
And as someone who's been in the wellness space,
I'm no expert by any means, but I've got a pretty
good barometer on what I think is going to be
important for this profession. And this is hands
down one of them. So before I let you go, if
people want to reach out to you and learn more
about you, are there any other places online
to do that? Oh, yeah, I have a LinkedIn page,
which, you know, it's my name right here. I have
my Pernuvo email. I'm not always the best at
responding to direct emails to me. But if they
want, anybody wants to learn more about our firefighter
program or talk to me as a sort of one of the
radiologists and get more information, it's Yosef,
Y -O -S -E -F at Pernuvo .com. And at least maybe
I can point them in the right direction if I
can't answer the question directly. And otherwise.
Just call anyone in the company if there's a
special interest to reach out to me directly
about research projects, collaborations, radiology,
this idea of primary care radiology. They can
call the company or email me directly and I'm
happy to be connected with them. Beautiful. Well,
again, I want to thank you so much for being
not only so generous with your time, but also
just educating us on a bunch of areas that is
very, very new technology and coming on the Behind
the Shield podcast. So thank you so much. Thanks
for having me.