 I would like to thank Texas Heart Institute and Dr. Stephanie Coulter for this kind invitation. The title of my talk is Intersectionality and Patients with Treat with regards to cardiac and aortic disease. And I would like to applaud the entire planning committee for this great program. This is my disclosures. So why intersectionality is important? With intersectionality we consider all factors attribute to a patient in combination rather than considering its factor in isolation. And is important in healthcare, has been applied in health system research. And the aim is to understand and respond to health inequalities. The main benefits are support equity analysis. Importantly draw attention to the drivers of inequality and also leads to more focus interventions and policies. This is from Center, UCL Center for Gender and Global Health in London. And we can see the relationship between gender and health and well-being. And we do know that the gender can interact with other social determinants of inequality such as poverty, occupation, geography and participation as well as education. When there is gender inequality this can have direct negative effects on health and well-being. So this talk is going to concentrate on intersectionality in clinical medicine and specifically in workforce of vascular surgery and cardiothoracic surgery and how this can affect the patient care. We can see here regarding the workforce in vascular surgery a recent report where women and black trainees were underrepresented in vascular surgery as compared with their representation in medical school. And also furthermore in cardiothoracic surgery this is led by Jackie Olive one of our studies where we are examining the landscape of cardiothoracic surgeon and residents of the United States. And we can see as others also have shown or to make it and other colleagues that women and racial and ethnic minorities are underrepresented among trainees and faculty in academic cardiothoracic surgery compared with surgery and medicine overall. Now of course the question is can this intersectionality in the workforce can affect our patients or the way that we treat our patients. And even though we do treat diverse patient population there is a little focus on ensuring that therapies are developed and tested in both men and women. Men and women manifest diseases differently, metabolize, drugs differently and have different outcomes following medical and surgical therapies. This is from our recent work led by and very well conducted by one of our students who is currently a surgical resident in Miami Andre Cristinelli's where we look into clinical trials.gov. This is a public website where we look over 20 year period cardiovascular clinical trials pertinent to coronary artery bypass, heart valve disease, aneurysms ventricular assist devices and heart transplantation in over 230,000 patients. And we wanted to analyze the female patients and racial and ethnic minorities representation in these trials. So this is what we found. This is a sex distribution by disease or procedure. We can see a male over a presentation across all the diseases coronary artery bypass, transplant, valve heart disease as well as aneurysm. The same over a presentation exist when we see the sex distribution by funding source with the blue bin the male patients participated in the cardiovascular clinical trials for coronary artery bypass as well as for transplant and mechanical ventricular assist devices. This slide here is a little concerning and the reason is because it shows that even though there is a persistent male representation by time period both for coronary artery bypass and transplant and ventricular assist device, there is a continuous under a presentation for female patients and this participation haven't really changed or in certain instances became worse. And this is the sex distribution by time period for the valve heart disease and maybe this is the only time where the distribution was similar between both sexes. When we look the racial and ethnic distribution we also saw the same similar ethnic health care disparities and distribution for both transplant and assist devices as well as coronary artery bypass. This is another study led by Dr. Jessica Mayer. He was one of our trainees and this is currently a vascular training university of Pittsburgh and with Dr. Chong and where they look common vascular disease and women participation in trials. This study looked was shorter was over a 12 year period but what we found was that participation of women in the US trials for common vascular diseases remain low and has not improved over time since 2008. Now after we look the patients and how the patients participated in clinical trials and why this is important is important because clinical trials are where the devices are getting tested and also clinical trials are the ones where the guidelines are based on. We wanted to see what is a gender representation among principal investigators among the pay among the physicians who lead these trials and we concentrate it in a subset on the cardiac surgery trials. And what we found was we looked around 128 institutions, more than a thousand adult cardiac surgeons and we found with no surprise that all that was a persistent of a representation of male cardiothoracic surgeons for trials funded by industry and no NIH funded trials had any female cardiothoracic surgeon as principal investigator. In addition we compare female and male cardiothoracic surgeons being at the same level of seniority meaning associate professors and professors both male and female cardiothoracic surgeons and we found this proportionally more men than women to be principal investigators in these trials. Why this is important because you can see that in a way this is a reflection to how we have the same male over a presentation as patients in various trials and how when these trials getting funding we see the same results. It's very important to ensure that therapies are developed and tested in both men and women and understanding sex related differences in patients with cardiovascular disease could have important implications for preoperative assessment, cancelling and outcomes. You can see here a recent study where they look at large coronary artery bypass trials among 13,000 patients is important to see that only 2700 were females. Females had worse outcomes than males in the first five years after coronary artery bypass not related to technique. And also in another study even though the results were getting better still there is some considerable burden of postoperative morbidity which was high among women. Regarding the aortic disease we look in our own patients, patients who had thoracic abdominal aortic aneurysm repair and we wanted to see if the outcomes were any different and even though we found similar outcomes the important message was that were specific preoperative factors and predictors of poor outcome. The same we look at the sex differences in the proximal aorta in a propensity match comparison. And what also we found was that even though long term the survival was similar were certain preoperative characteristics and presentation which were different between men and women and led to poor outcomes. This is why precision medicine is important because there is a focus intervention and we have a patient directed cancelling, assessment and guidance which can be extremely important. So in conclusion intersectionality is a useful framework to make the cardiovascular medicine environment more attentive to the complex identities of patients and clinicians. It provides a useful starting point to address some of the challenges that arise in clinical context and importantly it acknowledges how these differences shape the patient-physician interaction and forces a reframing that can lead to improve outcomes. I would like to thank you for this kind invitation. It is a great privilege to present this important work and again I would like to applaud the entire faculty as well as Dr. Calder for this excellent symposium. Thank you.