The second installment of our Making the Rounds series, Dr. John D'Orazio talks about how he likes to spend his vacations, his favorite foods and more.

Dr. John D’Orazio takes us back to his first day of medical school

The second installment of Making the Rounds features Dr. John D’Orazio, a clinician and researcher at the DanceBlue Kentucky Children’s Hospital Hematology/Oncology Clinic. Making the Rounds is a Q&A series where you’ll get to know the providers at UK HealthCare and what they’re like outside the lab and clinic.

Making the RoundsDr. D’Orazio received his medical degree from University of Miami, School of Medicine, Miami, Fla. He then completed a Pediatrics residency at the Massachusetts General Hospital, Boston, and a Pediatric Hematology/Oncology fellowship at Boston Children’s Hospital and the Dana-Farber Cancer Institute, Boston. D’Orazio is of Italian descent, and he enjoys eating and cooking Italian food.

Dr. John D'Orazio

Dr. John D’Orazio

Where could someone find the most authentic Italian food in Lexington?

In Lexington? You’d have to come over to my house!

What do you like to cook yourself?

Well, the other night I made a good risotto. I make fresh pasta, and I make a sauce to go with it… Pizza – I do pizza a lot. The more toppings you can put on it and the less crust, the better for me!

Describe your ideal vacation.

So [my family and I] like nature. We like outdoors, we like hiking. I like photography. We’ve been three times up to the Yellowstone glacier. We’ve been a couple of times to Costa Rica – love it down there.

It would be a place like that, where you can just get away, you know. We like to rent a house for a week and just have a low-key time – go hiking, go fishing kind of a thing.

How would your friends describe you?

Optimistic, funny, kind.

Do you recall your first day of med school?

Yes. So I’m an MD, PhD – I’m a physician scientist. I did a kind of blended thing. But yes [I remember]. Just the great honor of sitting there and realizing that this is the beginning of a journey I followed my heart to.

You know, I’m the first person in my family to ever go to college, not even to mention med school. It was just a great honor, and I soaked it up like a sponge.


Watch this video to hear Dr. D’Orazio explain why making a connection with his patients is so important to him.


Next Steps

Dr. Carmel Wallace

UK Pediatrics chief honored by Ronald McDonald House Charities of the Bluegrass

The Ronald McDonald House Charities of the Bluegrass (RMHC) recently honored Dr. Carmel Wallace, chair of the UK Department of Pediatrics and physician-in-chief of Kentucky Children’s Hospital, with the 2016 Elizabeth Carey Nahra Legacy of Love Award.

The award recognizes an organization or individual whose exceptional contributions or projects have enabled the Ronald McDonald House of the Bluegrass to assist families of children hospitalized at Kentucky Children’s Hospital. Wallace founded the Helping Hands Fund, which supplements family donations to cover the charity’s operational costs through scholarships. The fund contributes $20,000 annually to the RMHC.

“Many of our Kentucky Children’s Hospital families reside in Eastern Kentucky and travel long distances to receive the best care possible for their child,” Wallace said. “The Ronald McDonald House Charities have provided support so parents can stay close to their children and have a place to lay their head at night. Covering the operational cost to stay at RMHC was an opportunity for us to make life a bit easier for these families.”

A native of Eastern Kentucky, Wallace has worked to ensure Eastern Kentucky families receive access to advanced pediatric care available at Kentucky Children’s Hospital. Through Wallace’s leadership, Kentucky Children’s Hospital has extended its presence in Eastern Kentucky by providing specialists and clinical services in rural communities.

Wallace accepted the award during the charity’s annual McDazzle Gala on Sept. 10. Recipients of the award are selected by the family of Elizabeth Carey Nahra, an advocate and former director of the Ronald McDonald House who passed away in 2015. Past recipients include Kentucky Children’s Hospital, Children’s Charity Fund of the Bluegrass and UK neonatologist Dr. Nirmala Desai.


Next steps:

  • When your child is sick or hurt, you want the best care possible, close to home. That’s exactly what you get at Kentucky Children’s Hospital. Learn more about our services.
  • KCH patients and their families share their stories. Read them here.
A mother using a fine-toothed comb to get rid of her daughter's head lice.

Head lice: How to spot them and what to do

Elementary schools are notorious for spreading lice – tiny insects that live in human hair. Lice spread primarily through hair-to-hair contact but can move through shared items like hats and combs, too. While they aren’t dangerous, they are contagious and irritating. If you have young children in school, you should know the signs of head lice and how to treat them.

The signs of head lice

If your child displays one or more of these signs, seek treatment quickly.

  • Adult lice or nymphs. Nymphs, or baby lice, become adults one to two weeks after they hatch. An adult louse (the singular of lice) is pale to dark brown.
  • Nits. Lice eggs, called nits, are small dots that resemble dandruff usually found at the base of the hair shaft.
  • Itching. Lice and their nits cause scalp irritation, which leads to head scratching.
  • Red bumps or sores. Too much scratching can lead to a painful rash or even bacterial infection.

How to treat head lice

Should lice wind up in your child’s hair, there are a number of treatment options available.

  • Shampoo, cream rinse or lotion. These may be available either over-the-counter or by prescription. Your doctor can recommend one that’s right for your child.
  • Oral medication. For lice that are resistant to some treatments, your doctor may prescribe an oral medication to take care of them.
  • Fine-toothed combs. If your child is 2 months or younger and has lice, do not use medication. Instead, wet and condition your child’s hair, and use a fine-toothed comb to get rid of the insects.
  • Wash hats and personal items. Remember to wash any hats, scarves or hair accessories your child uses. You should clean their pillow cases and bedding, too.

Next Steps

Better quality of sleep has obvious health benefits, like improved attention and memory. So how much sleep should your child be getting? It varies by age.

For children, how much sleep is enough?

Better quality of sleep has obvious health benefits, like improved attention and memory, but this is particularly important for children. So how much sleep should your child be getting? Doctors agree that the right amount of sleep for children varies by age:

  • Infants. Babies that are 4 to 12 months old should be sleeping for 12 to 16 hours a day, including naps.
  • Young children. If your child is around 1 to 2 years old, they need 11 to 14 hours of sleep each day, plus naps.
  • Toddlers. 3- to 5-year-olds require 10 to 13 hours of sleep each day including naps.
  • Older children. Children between 6 and 12 should aim to sleep between nine and 12 hours a day.
  • Teenagers. Teens – age 13 to 18 – should get eight to 10 hours of sleep per day.

Getting the right amount of sleep is as important for children as nutrition and exercise. Sufficient sleep not only improves mood, it can lower your child’s chances of becoming overweight, of developing diabetes and of having attention or learning problems.


Next Steps

Make sure to dispose of expired medications

Written by Dr. Amy Meadows, assistant professor of pediatrics and psychiatry in UK’s College of Medicine.

Dr. Amy Meadows

Dr. Amy Meadows

When was the last time you cleaned out your medicine cabinet? Unlike a messy refrigerator, there’s nothing in your medicine cabinet to send a scented reminder that you need to throw out old bottles of ibuprofen and pain killers from your oral surgery two years ago.

Not only is this unsafe because medications should not be consumed past their expiration date, but they also have the potential for abuse. According to the 2014 National Survey on Drug Use and Health, the most commonly abused medications are opiates and other pain relievers, which is consistent with information from other sources.

Many medications have the potential to be misused, which includes both prescribed and over-the-counter medications. There are multiple ways drugs can be used incorrectly, or in some cases, illegally: they can be misused (used in ways other than recommended), abused (used for nonmedical reasons) or diverted (given/sold/bartered to people other than the intended patients).

When taken as directed and in the recommended amounts, over-the-counter medicines are generally very safe. However, those same medications can present a significant danger in overdose. Even over-the-counter analgesics like acetaminophen (Tylenol) or ibuprofen (Motrin) can cause organ damage or even death in some situations. It’s incredibly important that medications are taken as directed on labels or by a physician.

Children are especially at risk for abusing medications, either because they do not recognize medication as a danger or because of the impulsivity and risk-taking common in adolescents. It is recommended that medications be stored out of reach, such as in a medication lock box, to reduce to risk of misuse.

Medications should not, under any circumstance, be saved and used for future issues or ailments. This can be especially dangerous for antibiotics, which should be taken as directed until the full course of medication is completed. Other medications can become ineffective or potentially dangerous after their expiration. It is far safer to be evaluated by a medical professional to diagnose and treat a newly occurring issue rather than relying on old or expired medications.

Everyone can and should periodically dispose of old, unused and expired medications. In Lexington there are several options for safe disposal, including units at the Lexington Police Department and Fayette County Sheriff’s Office or on medication take-back days. Some pharmacies are also able to offer safe disposal of unused medication. Alternatively, if people are unable to access medication take-back programs, it is recommended that medications be placed in a sealable container or bag and mixed with kitty litter, dirt or coffee grounds before being thrown away.


Next steps:

JC and Max Middleton.

Family confronts diabetes with help from UK

A natural instinct for a mother is to protect her children by keeping them healthy and safe. But what do you do when your spouse and not just one, but both of your children are diagnosed with a chronic illness like diabetes, all within a relatively short amount of time? That’s the challenge Lisa Middleton, her husband and two young children faced.

With the help of the University of Kentucky’s Barnstable Brown Diabetes and Obesity Center, the Middletons are confronting diabetes, ready to meet that challenge head-on, all day, every day.

The first diagnosis

James and Lisa Middleton look like the couple next door. Lisa, an energetic and personable young woman, received her doctorate degree in pharmaceutical sciences from the University of Kentucky College of Pharmacy and later was a research assistant professor in the College of Medicine. She is currently a lecturer at Eastern Kentucky University.

James “JC” Middleton is an avid long-distance cyclist and a software engineer at Valvoline. It was quite a shock when, 12 years ago at age 29, he was diagnosed with diabetes. JC suddenly dropped 20 pounds from his already slim physique. He was constantly tired, stayed thirsty and drank more than usual. That caused him to use the bathroom more frequently, even throughout the night. Weight loss, excessive thirst and frequent urination are common symptoms of diabetes.

Lisa was puzzled by her husband’s initial diagnosis of Type 2 diabetes sometimes referred to as adult-onset or non-insulin dependent diabetes because he didn’t completely fit the profile. Type 2 diabetes typically occurs in older adults and can be aggravated by unhealthy eating habits, inactivity and obesity. None of these traits describe JC. Following a visit to the endocrinologist, JC’s diagnosis was changed to Type 1, and that day he began insulin therapy.

Lisa describes her husband as “independent and incredibly smart.” He was immediately able to learn carbohydrate counting and quickly did the math to calculate his insulin doses. Although the diagnosis presented a huge change in JC’s life, she said “he just handled it.”

Barnstable Brown supports the family

The Middletons have two children, Kara, a lively and self-confident 7-year-old who loves horses and wants to be a famous singer, and Max, an active and strong-willed 2-year-old who likes to run, jump and climb.

About a year ago, the Middletons noticed something unusual about baby Max. He stopped gaining weight and produced a lot more wet diapers. Late one evening while JC was testing his blood glucose level, he decided to test Max’s glucose level on a whim. He couldn’t believe his eyes.

“It was off the charts; it simply registered high,” JC said.

The next day, Max’s pediatrician strongly suspected that at age 20 months, the Middletons’ youngest child had Type 1 diabetes, and their world seemingly turned upside down.

“It crushes you,” JC said. “We were all but on the floor crying.”

Their pediatrician immediately directed the Middletons to UK’s Kentucky Children’s Hospital where Max was hospitalized. The first night, as Max was sleeping, Lisa took out her smart phone and read everything she could on diabetes, including the latest on clinical trials and advances in research.

Today, Max wears an insulin pump connected to a strap around his waist that delivers constant short-acting insulin through a catheter placed under the skin. The pump offers freedom from multiple injections and can be programmed based on what Max eats throughout the day and his activity level. A continuous glucose monitor, called a Dexcom, is attached to Max’s upper arm. This allows JC and Lisa to continuously monitor his glucose levels every five minutes, 24 hours a day. If his glucose level reads too low or too high, the Dexcom will send an alarm to JC’s and Lisa’s smart phones to warn them, which is especially important throughout the night.

“He handles his diabetes like a rockstar,” Lisa said. “Once you see your 2-year-old handling their diabetes better than you are, you have to get over it and move forward.”

About six weeks ago, while on a family vacation in Lisa’s home state of Michigan, Lisa noticed Kara had wet the bed during the night and thought she had a possible urinary tract infection.

“I think it was always in the back of my mind that diabetes could also happen to Kara, but honestly, I thought we were in the clear with her. We had one child with diabetes, surely we wouldn’t have another,” Lisa said. “My mom had some urine test strips and I tested Kara. Her urine was full of sugar.”

Kara was taken to a hospital in Michigan and was diagnosed with Type 1 diabetes. She began treatment that day. The Middletons then contacted UK to consult with Max’s pediatric endocrinology team about Kara’s treatments. The team includes Dr. Alba Morales, associate professor of pediatric endocrinology and Barnstable Brown faculty member and diabetes educator Angela Hepner.

“They were incredibly helpful, supportive and confirmed treatments,” Lisa said. “As soon as we returned home to Kentucky, Kara was seen at Barnstable Brown immediately.”

Kara is currently taking four to six shots every day and checking her blood sugar by herself six to 10 times per day. She also will be starting on an insulin pump and Dexcom next week thanks to the quick work of the staff and doctors at Barnstable Brown.

Dealing with diabetes

According to the American Diabetes Association, there is a 3-5 percent chance siblings will develop diabetes. Hepner said UK is seeing more sibling sets with diabetes as well as several families where one parent has Type 1.

“Our team is committed to making families like the Middletons have as positive an experience with diabetes as possible,” Hepner said. “For our younger children, we focus our educational efforts toward the parents, and also emphasize to the kids that diabetes should never stop them from doing what they love.”

Morales says it is a huge challenge to manage children with diabetes because they are changing and growing on a daily basis and their management has to evolve with them.

“The mother has been wonderful in the way she manages her children’s diabetes on a daily basis. It is more difficult than anyone can imagine,” Morales said. “She is really good at keeping us informed here so that we can all work as a team.”

While the Middletons say they are fortunate because both their children were diagnosed early before they got extremely sick, their biggest challenge is managing their worry.

“Like all parents, we want the best for our children and want them to lead as normal a life as possible, and a diagnosis of diabetes is just a detour in the road,” JC said. “I try not to blame myself for my kids’ diabetes because in all likelihood, I passed it on to them. There are so many potential things that may cause diabetes, you can’t blame it all on genetics.”

Morales says that the reason there is no cure for diabetes yet is because the disease’s causes are still unknown.

“It’s a combination of factors and genetics is only one. We believe there are undiscovered environmental factors as well,” she said. “Diabetes is impossible to predict in children, even if both parents have diabetes.”

Lisa said JC knows the seriousness of the disease and is involved in every aspect of their children’s care, but as the mother and the only non-diabetic in the family, she worries about them all.

“I worry whose blood sugar is up and whose is down. I have to keep track of checking glucose levels and who ate what and when, and if they got their insulin. Now that Kara is in the mix, it’s even more worrisome. I have to work every day to keep my family alive,” she said. “Worrying can consume all of the energy I have that I could be putting somewhere else; so I have to push nervousness to the back of my mind and focus.

“Diabetes is an invisible disease. My kids are not obviously diabetic. They are normal and active. We can easily hide the monitors and pumps with clothes but the seriousness of the disease is always present.”

JC adds, “there is light at the end of the tunnel. You can live a normal healthy life with diabetes. Hopefully our children will see a cure for Type 1 diabetes in their lifetime.”

Dr. John Fowlkes, director of the Barnstable Brown Diabetes and Obesity Center, said the clinical team is about much more than just seeing patients and prescribing treatment.

“Diabetes doesn’t just impact the individual, it can potentially impact the entire family whether there is one diabetic or several,” he said. “We strive to educate our patients on how to live a full and healthy life with diabetes, and serve as a medical home that addresses all their needs.”

5 benefits of breastfeeding

5 benefits of breastfeeding

Breastfeeding is a natural way for mothers to bond with their new baby and provide the vital nutrition the baby needs.

Celebrate World Breastfeeding Week this week by learning more about breastfeeding’s benefits.

  1. Breastfeeding has preventive power. Research has shown that breastfeeding can help prevent allergies, asthma, diabetes, ear infections, childhood obesity, leukemia and even sudden infant death syndrome. Your first milk, colostrum, provides your baby with all your immunity to diseases.
  2. It creates a special bond. Breastfeeding allows you to have a special bond with your baby. Studies have shown that breastfeeding can improve your child’s neurodevelopment. And the hormones released during breastfeeding have been found to decrease maternal stress and increase bonding.
  3. Breast milk is easy on your baby’s tummy. Breast milk is easier to digest than formula, meaning your baby will have fewer stomach aches and develop fewer food allergies. Breast milk also changes to meet your growing baby’s needs
  4. Breastfeeding is good for you, too. Breastfeeding can decrease your risk of heart disease, diabetes, osteoporosis, postpartum depression and some forms of breast and ovarian cancer. The longer you breast feed, the greater your protection. Plus, you burn an extra 500 calories per day breastfeeding!
  5. Breastfeeding saves you money. Formula, bottles and supplies can cost about $3,000 annually, but breast milk is free. There’s no prep time for breast milk, and it’s always the right temperature.

The Birthing Center at UK HealthCare wants your breastfeeding experience to get off to the right start. Our nursing staff and physicians have received special training to help you begin breastfeeding. We also have lactation consultants who will see you during your hospitalization and the Mommy and Me Clinic, located at the Kentucky Clinic, for assistance after you are discharged.

For more information, visit our breastfeeding support services website or contact your physician or the Childbirth Education Coordinator at 859-323-2750.


Next steps:

  • UK HealthCare is a Baby-Friendly Hospital, which means we offer the highest-quality care for newborns and their mothers, emphasizing mother-baby bonding and successful breastfeeding. Learn more out what it means to be Baby-Friendly.
  • Are you expecting or thinking about having a child? Check out our UK Delivers blog, where our experts discuss topics related to pregnancy and childbirth.
Preventive exercises have been shown to reduce the risk of ACL injury, and they are becoming increasingly important for young athletes.

Preventive exercises can reduce ACL injuries

Written by Dr. Cale Jacobs, Assistant Professor in UK’s Department of Orthopaedics and Sports Medicine.

Dr. Cale Jacobs, Assistant Professor in UK’s Department of Orthopaedics and Sports Medicine.

Dr. Cale Jacobs

Unfortunately, each year, about 7 million sports-related injuries occur in the U.S. Approximately half occur in people between the ages of 5 and 24 years old. Injuries, especially to the knee, remove young athletes from the playing field and can have long-term repercussions that limit mobility and lead to more severe issues.

Tearing the anterior cruciate ligament (ACL), the tough band of tissue joining the thigh bone and shin bone at the knee joint, is not uncommon in “cutting” sports like soccer, volleyball, football and basketball. An ACL tear is a particularly damaging injury as it often leads to knee arthritis, and studies have reported that 50 percent of people who tear their ACL develop arthritis within 15 years of their injury. When you consider that most ACL injuries happen to those under the age of 25, this means that many patients are developing knee arthritis in their 30s or early 40s.

The ACL can be surgically reconstructed, which improves the stability of the knee. However, for young female athletes playing in cutting sports after ACL reconstruction, roughly one in three of these athletes will suffer a second ACL injury. Also, recovery after ACL reconstruction differs from patient to patient, with some taking longer to safely return to sports.

Because of the high rate of early knee arthritis and the risk of a second injury, preventing the first ACL injury is crucial. Preventive exercise programs have been shown to reduce the risk of ACL injury, and the free Get Set-Train Smarter app available on Android and iOS is a great resource for parents and athletes. This app, created by the International Olympic Committee, enables athletes to select an exercise program that is specific to the sports they play.

In addition, UK researchers are studying a number of ways to prevent a second ACL injury as well as prevent or delay the onset of knee arthritis for younger athletes that suffer an ACL injury. These include injections to lessen cartilage damage, improved surgical techniques for younger athletes and innovative rehabilitation protocols like one’s being used with injured NFL athletes. Current research has also identified that athletes still have sizeable muscle imbalances when they return to sports, suggesting that both improved rehabilitation protocols and better testing methods be used to safely return young athletes back to their sport.


Next Steps

Former UK nurse Kristin Ashford has dedicated her life to researching ways to prevent pre-term birth and promote healthy pregnancies.

UK nurse, researcher helps prevent pre-term birth

Working as a labor and delivery nurse for a decade, Kristin Ashford was surrounded by happy beginnings. She helped women and families welcome healthy babies into the world. But Ashford also helped mothers and their families deal with the stressful and heart-wrenching experience of pre-term birth.

As a first-hand witness of the negative outcomes associated with pre-term birth, Ashford was motivated to make a difference. She transitioned from nursing into a researcher, studying risk factors of pre-term birth and creating strategies to prevent them through pregnancy interventions.

“It really got me interested in how to help these women more,” Ashford said of her nursing experience in labor and delivery. “Not only to reduce their risk, but also to help them emotionally cope with pre-term birth.”

Risk factors for pre-term birth

Pre-term birth is defined as delivery prior to 37 weeks gestation. Several risk factors, including smoking, substance abuse, poor socioeconomic conditions and obesity, increase a woman’s chance of experiencing pre-term birth. The consequences for the baby include respiratory illness, gastrointestinal disorders, immune deficiency, hearing and vision problems, and a prolonged hospital sta. There can also be longer-term motor, cognitive, visual, hearing, behavioral, social-emotional, health, and growth problems.

Now, as the assistant dean of research in the UK College of Nursing, Ashford oversees multiple research projects and interventions driven by the common goal of prolonging pregnancy.

“I think that any time that you can prolong a pregnancy, it is a rewarding experience,” she said. “If you can prevent the child from being sick, prevent that family’s stress and prevent life-long complications associated with that risk, that’s extremely rewarding.”

Research and interventions

Ashford’s research covers the issues relevant to pre-natal care, as there are many things that can be changed in order to prevent pre-term birth, like tobacco use. Her interventions aim to prevent tobacco and illicit drug use, manage chronic conditions such as diabetes and obesity, and reduce emotional distress in expectant mothers.

Ashford’s interventions are founded on the CenteringPregnancy model, which prepares women for pregnancy, labor and delivery, and motherhood through a peer support groups led by nursing and other health professionals. Ashford has designed CenteringPregnancy interventions to help pregnant women in high-risk categories like diabetes, tobacco use, substance abuse, or other socioeconomic or ethnic risk factors.

“Our UK program actually wants to put women together that have more in common with one another,” Ashford said. “So, in addition to being put in the group about the same time that they’re pregnant, they also are put in (a group) based on their most high-risk factor for pre-term birth.”

One intervention effort led by Ashford effort seeks to inform pregnant women about the dangers of using tobacco products while pregnant and give them resources to quit. Despite the known risks of using tobacco products during pregnancy, many pregnant women in Kentucky still smoke. Ashford is troubled by the rising popularity of e-cigarettes among women of childbearing age. Her research studies indicate that women are using both e-cigarettes and traditional tobacco products during pregnancy.

“Tobacco causes birth defects in pregnancy — that’s known,” Ashford said. “And so, it’s very clear that electronic cigarettes contain tobacco. Certainly, there’s risks associated with electronic cigarette use in pregnancy.”

Ashford is expanding CenteringPregnancy programs to areas in Eastern and Western Kentucky. She is working with local health departments to provide a Centering support network for pregnant women in high-risk groups.

She said her position in the UK College of Nursing allows her to research and circulate interventions, teach future nurses and nursing researchers, and serve communities by improving the quality of health care.

UK assistant professor has been awarded a $65,000 grant to support new UK research on coloboma, a leading cause of blindness in children.

UK researcher uses zebrafish to study eye disorder

UK Assistant Professor of Biology Jakub Famulski has been awarded a Career Starter Grant by the Knights Templar Eye Foundation, a charity sponsored by the Grand Encampment of Knights Templar. The $65,000 grant will support Famulski’s new UK research on coloboma, a leading cause of blindness in children. The eye abnormality occurs before birth and involves missing tissue in or around the eye.

Famulski and his collaborators recently discovered a new type of coloboma, superior coloboma, which occurs in the top of the eye. But the underlying cause of most coloboma cases remains unknown.

To better understand the disorder, Famulski and UK graduate students Kristyn Van Der Meulen and Nicholas Carrara will use zebrafish as a model to study how coloboma occurs in the eye’s early development. With zebrafish, the team can easily and efficiently observe, manage and change cells in the laboratory.

“For a junior faculty member like myself, this grant is not only great financial help, but also confirmation that scientists in the community value this work, which I hope will help patients suffering from this disorder,” Famulski said.

The Knights Templar Eye Foundation, incorporated in 1956, works to improve vision through research, education and supporting access to care. Since its beginning, the foundation has awarded more than $23 million in grants to pediatric ophthalmology research. Thanks to this most recent grant, new UK research can help Famulski make a difference through the power of advanced medicine.