Bariatric Surgery: The Risks And Benefits
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. Over the past several years, doctors who performed weight loss surgery noticed an unexpected benefit: Many patients no longer needed to take their medication for their diabetes.
Now two studies published in the New England Journal of Medicine not only confirm that link, but found that what's known as bariatic surgery is much more effective against type 2 diabetes than conventional treatment. Since the start, critics protested that the risks of weight loss surgery - there can be complications. Many patients regain some or even all of the weight. But both obesity and diabetes are epidemic.
Doctors already perform some 200,000 of these procedures every year here in the U.S., and these new studies may well lead to more. If you've had bariatric surgery, what's been your experience? If you have diabetes, how do you balance the risk and benefits of this operation? Give us a call, 800-989-8255. Email firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, NPR's Ofeibea Quist-Arcton joins us from Bamako with the latest on the coup and rebellion in Mali. But first diabetes and weight loss surgery. Valerie Winestock participated in one of these studies. She received bariatric surgery last October and joins us now from her office in Berkeley Heights, New Jersey. Nice to have you with us today.
VALERIE WINESTOCK: Thank you.
CONAN: And after five months or so, how's it going ?
WINESTOCK: It's going very well.
CONAN: How's the diabetes?
WINESTOCK: Much reduced in my medications. I went into the surgery with taking insulin and three different oral medications. I am down to just one oral medication, and hopefully will be able to reduce that, as well.
CONAN: And have you lost a lot of weight?
WINESTOCK: Yes, I have.
CONAN: Can you give us an idea of how much?
WINESTOCK: About 50 pounds.
CONAN: That's a lot of weight. Is it still going down?
WINESTOCK: Yes, it is.
CONAN: And were there any complications?
WINESTOCK: During the surgery - I had a few complications during the surgery itself. I had an unexpected hernia, as well as some scar tissue that had to be removed before the bypass could be done.
CONAN: And that was the type of bariatric surgery you had, the gastric bypass?
WINESTOCK: Yes, I did.
CONAN: And as you anticipated this operation, I wonder, what were your concerns?
WINESTOCK: Well, I did it for the purpose of - to reduce the amount of drugs I was on for diabetes, as well as high cholesterol - which is usually accompanying diabetics. I was concerned that it wouldn't work. That was my biggest concern. And so far, that has proven untrue, and it is working very well, even as far as my cholesterol medication goes.
CONAN: And so you're taking much less diabetes medication, taking less cholesterol medication. Those are all, you know - diabetes and high cholesterol - those are major health problems.
WINESTOCK: Yes, they are.
CONAN: And as you look ahead, at least where you are now, was it worth it?
CONAN: How has it changed your life?
WINESTOCK: I'm not as reliant on the drugs and my eating. I don't eat as much, obviously, but my - what I eat I'm extremely careful with, because I don't want to have to go back to taking drugs or gaining the weight. And I'm very comfortable with my lifestyle.
CONAN: And as you know, there have been some patients who do gain at least some of the weight back.
WINESTOCK: That is what I've heard.
CONAN: And some will regain all the weight back.
CONAN: Are you worried about that?
WINESTOCK: No, because if I've gone through this surgery and underwent this procedure, I'm certainly going to stick to all the rules that they have put forth and the guidelines.
CONAN: Valerie Winestock, good luck to you, congratulations.
WINESTOCK: Thank you very much.
CONAN: Valerie Winestock received bariatric surgery in October 2011. She joined us from her office in Berkeley Heights in New Jersey. Here with us in Studio 3A is Rob Stein, science correspondent, senior editor here at NPR. He reported on the two studies that appeared in the New England Journal of Medicine. Nice to have you back on the program.
ROB STEIN, BYLINE: Hi, Neal, nice to be here.
CONAN: And based on the studies, is Valerie's story common?
STEIN: Yeah, that's pretty much the kind of story that I've heard from other patients who have gone through this surgery, and that's pretty much what these two studies that were published last week showed: that for patients who are obese, very overweight and have diabetes, that the results of the surgery can be pretty dramatic, both in terms of helping them lose weight and reversing their diabetes.
CONAN: And it's interesting, reading some of these stories, the benefit for diabetics - and obviously obesity is a contributing factor to type 2 diabetes - but - is almost immediate. It can be within hours or days afterwards. It doesn't seem to be connected, necessarily, to the weight loss.
STEIN: That's right, that's right. That's what got doctors kind of intrigued about this to begin with, is that they would see patients come in, and they would - their diabetes would start to improve and sometimes reverse, as you said, within hours or days of the operation, way before they started to lose any of the weight from the surgery.
CONAN: And do they know why?
STEIN: You know, they don't really know why. They have some theories, and there's some evidence suggesting what might be going on here. And one of them is that the surgery, their sort of rearranging the plumbing and the digestive system, may affect some key hormones that are produced by the gut, by the digestive system that play a role in regulating metabolism. And that could reduce blood sugar levels, it could have an effect on the pancreas and insulin levels and help improve the diabetes.
CONAN: So whatever it is, it's really positive, but it's only been a couple of years after these studies began. Do we know how long it lasts?
STEIN: Yeah, that's a key question. I mean, this is relatively new, and even the patients in these studies that came out recently were only followed for about a year. And so we really have to be cautious at the moment, until we see some long-term results about both the benefits and the potential risks, long-term.
CONAN: And there are risks. Any surgery has risks. As I understand, relatively little risk of death, less than one percent in these procedures, but you can get infections, you can have bone - all kinds of stuff.
STEIN: That's right, that's right, any kind of surgery involves some risks. So far, this seems like a fairly safe procedure for most people, but there can be complications, the kind of complications you'd experience with any surgery. And the concern is also about the long-term risks. I mean, patients who go through the surgery do face some potential long-term complications, including nutritional deficiencies and - from the blocking the uptake of nutrients in the digestive system, that sort of thing.
CONAN: And that can contribute to bone loss for some people.
STEIN: That's right, that's right, osteoporosis can develop in some patients and some other nutritional deficits.
CONAN: And how common is it, we mentioned with Valerie Winestock, some people do gain some weight back, some people gain all the weight back. How common is that?
STEIN: Yeah, it really varies from patient to patient. Almost everybody gains at least some weight back, and some patients gain almost all of it back. But in other patients, they can keep it off long-term, and that can have long-term health benefits, both for their diabetes but also for other things like their blood pressure and their cholesterol levels.
CONAN: And do we have any information on long-term, does bariatric surgery improve your prospects for the rest of your life? Outside of these studies with diabetes, but bariatric surgery has been conducted for quite some time now.
STEIN: Yeah, but it is relatively new still. It hasn't been that long. So it's been several years that they've become really popular, and so far, again, they seem safe in the long term for the few years or several years after the surgeries, and they do seem to help a lot of patients keep the weight off. But the very - you know, you really have to follow patients for many years to really see what the long-term consequences might be.
CONAN: And I guess the controversy now is that some feel this is so effective that we ought to consider starting it much earlier and maybe with people who are less obese than the people in this study.
STEIN: Right, there's a big debate going on right now about really how - what we should do with this information, whether patients should start getting it on a more routine basis, whether they should be getting it earlier in their diagnosis with diabetes, and whether some patients who aren't even obese or maybe even just overweight or maybe just are diabetic should get the operations.
There are actually doctors in this country and elsewhere who are using it as a diabetes treatment, not as a weight loss treatment, but that's extremely controversial, and that's really not recommended by most leading medical groups at this point.
CONAN: Is there more research under way?
STEIN: There is, there is. There's a group in New York that was involved in one of these studies that is now doing a study right now looking at patients who are less overweight or aren't really severely obese to see how it affects those people.
CONAN: We should point out that there are many different kinds of bariatric surgery. One of the more popular ones is called lap band. None of these - no lap band patients were involved in these studies.
STEIN: Right, right, these studies did not involve that procedure, it involved other procedures. There are several different procedures, and the gastric bypass, though, was looked at in these papers, and that is one of the more common procedures that's used right now.
CONAN: Let's see if we can get some callers in on the conversation, 800-989-8255. We want to hear from those of you who have had bariatric surgery about what your experience has been. If you've got diabetes, how do you weigh the costs, the risks and benefits of this kind of an operation? We'll start with Tom, Tom with us from Cincinnati.
TOM: Hello, it's great to be on with you.
CONAN: Thanks, Tom.
TOM: I had Roux-en-Y gastric bypass surgery in March of 2009. I've lost about - oh, it's varied up and down a little bit, but between 135 to 150 pounds and kept it off for three years now.
CONAN: How difficult has that been?
TOM: That's not been nearly as difficult as getting through the initial process and somewhat unexpected consequences. But the great news is I had six major diagnoses - diabetes, which was one - all of which are either gone now or are in remission.
I did have a significant post-operative infection and had to be hospitalized for a month after my surgery and was ill for quite some time after that, but did get through that. I also had a subsequent bowel obstruction and hernia repair, and they created an emergency surgery for me nine months after the original surgery.
So it's not been a walk in the park. On the other hand, I feel - I'm 63, and I feel younger than I did when I was 45.
CONAN: So that's a tremendous improvement in your life.
TOM: It really is. The other dynamic I've dealt with is I developed what they're referring to as cross-addiction, and I had to go through alcoholism treatment, and had a really difficult time getting through that process but have done that now and am thrilled with the prospects of the remainder of my life.
CONAN: Let me ask you a question that sometimes we skip over: Did your insurance cover this? Or how did you pay for it?
TOM: Fortunately, I had excellent insurance which did pay for it, yes.
CONAN: And Rob Stein, that's not always the case.
STEIN: That's right. At the moment, insurance companies are really only paying for this - not all insurance companies pay for it, and when they do, it's only for patients who meet these strict criteria, which is patients who are usually extremely obese or are just obese and have some other major medical problem that makes them eligible for the procedure.
CONAN: And the procedure runs, I saw in a newspaper account, 11,500 up to $26,000.
STEIN: Yeah, it can be up to about 25, $26,000. So it's not a cheap procedure. But more and more insurance companies have been starting to pay for it as the evidence has been building of the effectiveness, especially for weight loss.
CONAN: Tom, any regrets?
TOM: No regrets, and by the way, on the insurance question, a unique dynamic is my wife is employed by one of the very largest health insurance companies. They cover it for their employees because they know of its cost benefit.
CONAN: Tom, thanks very much for the call, and good luck to you.
TOM: Take care, thank you.
CONAN: When we come back, we'll hear from one of the surgeons behind the studies in these - New England Journal of Medicine. If you've had bariatric surgery, how are things going? If you have type 2 diabetes, how do you weigh the risks and benefits of this kind of an operation? Give us a call, 800-989-8255. It's the TALK OF THE NATION from NPR News.
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CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan in Washington. Bariatric surgery's serious business. In gastric bypass operations, one of the most common types, surgeons divide the patient's stomach into a small pouch and a larger one, then reconnect the small intestine.
It reduces the capacity of the patient's stomach and typically leads to significant weight loss. But the surgery carries significant risks, too, from ones typically associated with any operation to specific complications like nausea, hernias and worse.
But type 2 diabetes is tough on the body, too. It's long been considered a chronic disease. After years of living with it, diabetics can become blind, lose limbs to infection, have heart attacks and strokes. Now, two major studies found bariatric surgery can actually reverse type 2 diabetes. So we want to know if you've had bariatric surgery, what's life been post-surgery? And if you've got diabetes, how do you consider the pros and cons of the operation?
800-989-8255. Email email@example.com. You can also join the conversation on our website. Go to npr.org. Click on TALK OF THE NATION. Science correspondent and senior editor Rob Stein has been reporting this story for NPR. He's with us here in the studio. Joining us now, Dr. Phillip Schauer, a surgeon, director of the Bariatric and Metabolic Institute at the Cleveland Institute. He led one of the studies that appeared in the New England Journal of Medicine and joins us now from studios at the Cleveland Clinic. Nice to have you with us today.
DR. PHILLIP SCHAUER: Hi, Neal, good to be here.
CONAN: And you've been performing these surgeries for years. Were you surprised by these findings?
SCHAUER: Well, not really, Neal. I think as Rob pointed out earlier in the program, these operations have been around for a while. Gastric bypass goes back 25, 30 years, and these observations that these operations can have a dramatic effect on blood sugar and diabetes has been known for a while.
But I think what's new and what these two studies point out are two, you know, very rigorous scientific studies that compare surgery head-to-head with medical treatment for diabetes. And the studies show that surgery was much more effective than standard medical therapy.
CONAN: The study that was published regarding the surgeries conducted in Rome seemingly had much more success than the studies you did, though I should say your studies were still three to four times more effective than conventional treatment.
SCHAUER: Yeah, some of the differences can be explained by the fact that there are different types of patients with diabetes. In our study in general, our patients had diabetes for a longer period of time, on average more than eight years, and their blood sugar was in much worse control than those in the Italian studies.
So those are big factors in terms of predicting the overall remission rate.
CONAN: Let's go to an email question, this from Martha(ph), who points out: There is a big difference between type 1 and type 2 diabetes, and I really think you need to specify which type we're talking about. We've been specifically mentioning type 2. She adds: Type 1 diabetics are not the subject of today's program.
SCHAUER: Yeah, that's correct. Type 2 represents the vast majority of patients with diabetes in our country. There's about 25 million type 2 diabetics. It's associated with adult onset and usually associated with obesity. Type 1 generally occurs in younger people, and the condition is not necessarily associated with obesity. And with type 1 diabetes, the pancreas makes no insulin at all.
CONAN: And as you continue down this road, what more research needs to be done?
SCHAUER: Well, I think as Rob pointed out earlier in the program, these studies need further follow-up. We need to determine how durable the effect is. It's unlikely that we're going to see this effect, you know, go away very rapidly because there's such a dramatic difference between the medical patients and the surgical patients in terms of the overall result.
There are other studies, however; they're not randomized controlled trials, but other studies have followed patients out for many years. For example, the Swedish obesity subject study has follow-up beyond 20 years with bariatric surgery, and it shows that the majority of patients have kept their weight off and that a majority have, you know, continued to enjoy the benefits of either diabetes control or improvement in these other medical conditions associated with obesity.
CONAN: Let's get another caller in, this is Joan, Joan with us from Nashville.
JOAN: Hi, how are you? Let me get you off the speaker here.
JOAN: OK, yes, I had my surgery in 2004, before the laparoscopic. So I had the big incision going down the middle of my body. And I have had relatively no complications. I had diabetes, gestational diabetes with both of my children with the use of insulin, so - and I was well on my way, at almost 300 pounds, to having diabetes full-out.
So I have had that disappear, as well as a lot of other things. My question is: Do you think that the diabetes would be in check for people by losing weight? Is it just the simple fact that you lost weight that's making the diabetes disappear?
CONAN: And Dr. Schauer, as you know, some people say wait a minute, diet and exercise, they can do the same thing.
SCHAUER: Absolutely, diet and exercise and even a mild degree of weight loss can improve diabetes. Unfortunately, folks who really struggle with their weight, 50, 60 pounds overweight, you know, oftentimes that weight loss is short-lived. And we do know that at least part of the effect of the bariatric surgery for improving diabetes is related to weight loss.
But we also know that, it was pointed out earlier that there's a very dramatic improvement even within hours or days of the operation, before there's much weight loss. So there's a secondary, probably a hormonal effect that's working, as well.
CONAN: Joan, thanks very much, and continued luck.
JOAN: Thank you, have a good day.
CONAN: Email from Elroy(ph) in Portland: Please remember that not all those with diabetes are overweight with bad dietary intake. A minority of diabetics can't lose weight to cure the disease. I'm a 51-year-old white male with type 2 diabetes who found out less than two years ago I'm diabetic. I have no family history, have never been overweight, have had no early onset warnings.
It's frustrating to hear about quote-unquote cures that have nothing for those of us who have the disease neither by our action or inaction. The road for us is test, exercise, control our diet and test again. Please remember us, too. And Dr. Schauer, he's not alone.
SCHAUER: Yeah, the caller is right. It's estimated about 80 percent of patients with type 2 diabetes are either overweight or obese. So 20 percent are in this normal-body-weight range. And so far, surgery has not been tested very well on folks with normal body weight.
Obviously, there would be no particular benefit from weight loss in those folks who are already normal body weight, but this hormonal improvement could potentially be used in that group with normal body weight. But that is a theory that would need to be investigated further.
CONAN: And Rob Stein, is that one of the controversies that's ongoing right now?
STEIN: Yes, it is, it's: At what point should somebody be recommended to get the surgery? And as I mentioned earlier, there are some doctors, it's a few at least in this country that I know of and more in other countries, that have been starting to do this operation on people who are not overweight at all but just have diabetes and are using it as a treatment for that. But that's considered a very controversial issue right now.
CONAN: Have they had any results that we can report?
STEIN: Not any kind of carefully controlled, well-designed studies like the ones that were just published. There have been a series of case reports reported around the - from around the world, and, you know, they have indicated that there is benefits, but until you do the kind of studies Dr. Schauer did, it's really hard to evaluate that kind of evidence.
SCHAUER: Right, and Neal, I'll just point out that in our study, we had patients who had a body mass index as low as 28, which is roughly 25 to 30 pounds overweight, and they seem to have enjoyed the same or at least similar benefit in improving their blood sugar as some of the heavier patients, who were, you know, close to 100 pounds overweight.
CONAN: What do you tell your patients about the risks?
SCHAUER: Well, it is surgery, and I think a good comparable comparison would be other operations of the abdomen: gall bladder surgery, hysterectomy, C-section. These are fairly - appendectomy. These are common operations that also carry risks. The risk of dying from surgery is extremely low, about 0.2 percent, two out of 1,000 patients, and that's usually someone who's very sick already.
The risk of a major complication is around four percent, four out of 100, and most of these can be, you know, corrected. So there are risks, but you have to look at, you know, again the risks of the diabetes and the risk of becoming blind or having kidney failure and heart attack or stroke. So it's that - that risk-benefit discussion is so important to have with the patient.
CONAN: Let's go next to Greg, and Greg's with us from Binghamton, New York.
GREG: Hi, I had my surgery two years ago. I used to weigh 385 pounds at 5'8". I'm pleased as heck that I lost 150 pounds. I lost my sleep apnea. I lost diabetes. I lost high cholesterol. But honestly, the medical thing wasn't as big a concern for me as the emotional and the mental. That's really where the rubber meets the road for anyone, I think, after bariatric surgery is that yeah, the surgery is going to take 100, 150 pounds off you for sure, but then the honeymoon period ends.
And you can feel that you have to be more careful about what you eat or you really can gain it back. So it's - basically I see it as a really big motivator to stay on a diet for the rest of my life, but I'm awfully glad I did it.
CONAN: And when you talk about the emotion - are you in therapy, or are you talking to somebody?
And when you talked about the emotion, are you in therapy? Are you talking to somebody?
GREG: Oh, absolutely. I go to my support group as often as I can, with my surgeon support group where we talk - those of us who've been through the surgery. And I'm in psychotherapy every week just to deal with the issues of body image and how I perceive myself and how people perceive me. It's different.
CONAN: It's - I bet it is. Congratulations, Greg.
GREG: Well, thanks.
CONAN: And, Dr. Schauer, is that common, that people have to deal with their emotions as well?
SCHAUER: Absolutely. And the larger a person is, you can imagine the more psychological challenges there could be. I have a patient on the schedule today who's 650 pounds and someone who's had that kind of weight for many decades is carrying around a lot of, if you will, excess psychologic, you know, challenges. And that's why it's really important for a person who's thinking about surgery to go to a center that has multidisciplinary support. In our program, we have phenomenal psychologists who evaluate our patients, you know, before surgery and also are there to help afterwards to help guide them - for those that need it - if they develop issues.
CONAN: Here's an email from Carl(ph) in California. I'm 320 pounds, and I have diabetes. In the past, I've lost massive amounts of weight - 70 to 130 pounds - quickly on Weight Watchers, but eventually, I go off the program and gain the weight back. I asked my doctor about bariatric surgery. He says since I can't keep the weight off, I'm not a good candidate. This seems counterintuitive to me. If people can keep their weight off on their own, why do they need the surgery? Isn't it the people who can't maintain a healthy weight on their own are the ones who would benefit the most from surgery? Is my doctor's point valid? And obviously, Dr. Schauer, you can't diagnose this patient on the radio, but just about his point in general.
SCHAUER: Yeah. Here's the problem, Neal. When a person becomes severely obese, say, 100 pounds, 150 pounds above their ideal body weight, it's very hard to lose weight and keep it off. A number of studies have tried very dramatic medical, exercise, psychologic strategies, and on average, patients with that amount of excess weight lose about 10, 15 pounds, and that's it. So it's extremely difficult to lose that amount of weight when you're that heavy. And right now, surgery is really the only therapy that can consistently, in a large percentage of patients, get a lot of weight off and keep it off for five years or more. And that's the bottom line.
CONAN: Dr. Phillip Schauer, surgeon and director of the Bariatric and Metabolic Institute at the Cleveland Clinic and professor of surgery at the Lerner College of Medicine at Case Western Reserve. Also with us, NPR correspondent and senior editor Rob Stein. You're listening to TALK OF THE NATION from NPR News. And, Rob, I just want to go back to you for a moment to say - to ask, we're told obesity is epidemic. We're told type 2 diabetes - it used to be "adult onset"; it's happening a lot in kids now, too - that's epidemic, too. How large a problem is this, and how quickly is it growing?
STEIN: Oh, yeah. The numbers on diabetes have been rising very quickly, and it's become a major concern and as you said, especially among kids. I mean, as you said, type 2 diabetes, which is what we're talking about, used to be called adult-onset diabetes. That's because you never saw it in kids. It was only as people got older and they put on weight, and then they'd start to develop diabetes. But now, you're starting to see it in the younger kids. And we don't really know what that's going to do. We've never - they're going to have this disease now for decades. And, you know, we know what it can do to adults. We don't really know what these kids face for the rest of their lives, what kind of medical complications they may be facing.
CONAN: Let's go next to Laurie,(ph) and Laurie is on the line with us from Salt Lake City.
LAURIE: I had my surgery May of 2005, so I'm at that seven-year mark. And I was 384, and I got - the lowest I got down to and I tried my hardest with exercise and everything, was 235. But I haven't been able to maintain it. I'm close to 300 again now. And I'm feeling very depressed. It's been really hard because it seems like the surgery didn't do anything for the mental part of being fat. And then the other - and - but I still don't regret doing it, but it's such a strange thing. The medical complications I've had after the surgery is I'm, they say, one click away from full osteoporosis. And I also have developed pretty severe hypoglycemia.
CONAN: I wonder, Laurie, is there - this is sort of a last resort, as I understand it, for weight loss. Does it feel a little - you'll forgive me for saying this - but you've tried for that last brass ring and it didn't work.
LAURIE: Yeah. Well, I'm hoping that I don't gain any more, obviously. I'm still 84 less than when I started. And I was on high-blood pressure medicine and cholesterol medicine and I'm not, and I haven't developed those back again. But it just seems like if I'm going to get - keep the weight off, I have to really, really work hard on the exercise part of it, particularly, otherwise my metabolism seems to actually be slower than it was before the surgery, which to me makes sense because you're eating such a small amount of food for such a long time.
CONAN: Yeah. Dr. Schauer, is there any sort of appeal after bariatric surgery for somebody like Laurie, it doesn't seem to have been entirely successful?
SCHAUER: Oh, yeah, absolutely. A patient that gains weight back should be evaluated. Sometimes, there can be - identify some behavioral issues that can be modified and improved to return to the weight loss. Sometimes, it's a surgical problem. And that's why it's important to be evaluated by, you know, by a surgical team. That gastric pouch can sometimes dilate. Surgical complications such as a fistula can happen. That's a connection between the pouch and the old stomach, and that can cause weight gain.
Some patients just need a more powerful procedure. Somebody who's 450, 500 pounds needs a more powerful weapon than someone who is just 350 pounds. So there are about 5 or 10 percent of patients who have these operations may need a revisional sort of tune-up procedure.
CONAN: Has that been considered, Laurie?
LAURIE: Well, I did have an endoscopy last year, and they didn't say my pouch was - that I had a fistula or the pouch seemed that much extended. I mean, it's the anastomosis, as my understanding is, that actually extends or whatever.
LAURIE: But I don't know. I just, you know, it's a really tough thing for me to say because I really do believe in it, and I know it helped me feel a lot better. But it certainly hasn't cured me.
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LAURIE: I don't want people to think it cures you.
CONAN: Well, Laurie, good luck. Thank you very much for the call.
LAURIE: Thank you. Bye.
CONAN: And, Dr. Schauer, remarkable results. Thanks very much for being with us today.
SCHAUER: A pleasure. Thank you.
CONAN: Dr. Phillip Schauer at the Cleveland Clinic and also with us here in Studio 3A, Rob Stein, correspondent and senior editor for NPR's Science Desk. Rob, always nice to have you on the program today.
STEIN: Oh, nice to be here.
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