Podcasts about case conference

Understanding the implications of the 2024 Federal Budget and its proposed changes to capital gains taxation is crucial for individuals and corporations alike. In today's episode, we take a deep dive into the Canadian federal budget for 2024 and its impact on capital gains taxation. In our conversation, we discuss the technical details of capital gains taxation and its historical context and offer practical advice for navigating the proposed changes in the 2024 federal budget. We discuss the increase in the capital gains inclusion rate and how these changes will affect individual investors and corporations. Discover the mechanics of capital gains tax in Canada, essential tax planning strategies, the importance of diversified tax exposure, and the concept of capital gains harvesting. Gain insights into the impact of the changes on the retirement plans of incorporated business owners and professionals, the role of optimal compensation in realizing capital gains, and approaches for navigating the proposed changes. Join us as we delve into the complexity of tax planning for incorporated business owners and the importance of long-term projections, personalized advice, and strategic decision-making for realizing a capital gain. Tune in now! Key Points From This Episode: (0:00:00) Overview of the changes and their relevance for Canadian investors.  (0:07:59) How capital gains tax works in Canada and its impact on taxable income.  (0:13:34) Reasons for the variation of capital gains inclusion rates.  (0:18:18) The differences in tax treatment for individuals versus corporations.  (0:22:41) Capital gains in a CCPC, how it works, and the role of a shareholder.  (0:29:36) Implications of the changes on Alternative Minimum Tax (AMT) in Canada.  (0:37:58) Learn about the ‘breakeven horizon' and essential capital gain considerations.  (0:46:35) Capital gain harvesting and how optimal compensation ties into it.  (0:58:17) Explore the trade-offs of realizing a large capital gain and tax-reducing strategies.  (1:12:30) Hear case studies that illustrate the application of various tax-reducing strategies.  (1:29:56) Impact of capital gains inclusion rates on retirement planning for CCPCs.  (1:37:36) Final takeaways and tax planning recommendations.    Links From Today's Episode: Meet with PWL Capital: https://calendly.com/d/3vm-t2j-h3p Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://x.com/LoonieDoctor Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://x.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/ Episode 10 & 11: Case Conference — https://moneyscope.ca/2024/04/12/ep-10-11-case-conference-corporate-investing-puzzle-pieces/ Episode 13: Optimal Compensation from a CCPC — https://moneyscope.ca/2024/04/26/episode-13-optimal-compensation-from-a-ccpc/ Rational Reminder: Episode 304 — https://rationalreminder.ca/podcast/304 The Loonie Doctor Calculators — https://www.looniedoctor.ca/canadian-financial-calculators/#tax Realize or Defer Capital Gains Calculator — https://research-tools.pwlcapital.com/research/realize-gain Conquest Planning — https://conquestplanning.com  

Today's Case Conference episode is a supplement to Episodes 10 and 11 and uses several case studies to examine key subjects such as corporate bloat, tax-efficient retirement planning for high-income earners, the importance of diversifying your asset allocation, and more. For our first case, we take a step-by-step look at the decision to retain earnings in your corporation, and examine why you need to consider using some of that money for things like your personal RRSP and TFSA accounts. Our second case includes a number of examples. Using multiple simulations, we unpack how you could potentially sabotage the benefits of a corporation by letting its passive assets get too big. To wrap things up, we discuss another common temptation: the urge to transform your corporation into a tax-efficient, eligible dividend-generating powerhouse. We cover a lot in today's episode, so be sure to tune in for a deep dive on everything from addressing corporate bloat to diversifying asset allocation! Key Points From This Episode: (0:02:16) Our first case study concerning corporations, RRSPs, and TFSAs. (0:08:32) When to use a TFSA and why it will depend on your unique circumstances. (0:11:30) Our second case study on corporate bloat and optimal compensation for tax efficiency.  (0:16:38) Simulations of different combinations of earning and spending using Mark's optimal corporate compensation algorithm.  (0:19:50) Breaking down tax-efficient retirement planning for high-income earners.  (0:29:06) An example detailing a high earner and their spending, passive income limits, corporate bloat, and tax implications.  (0:35:12) Why it's so important to be able to measure progress towards your financial goals.  (0:38:12) Strategies for dealing with corporate bloat, tax optimization, and more.  (0:41:41) Our third case study where we examine what happens when you're overly focused on Canadian dividends and capital gains.  (0:43:43) Why it's so important to diversify your asset allocation.  (0:50:51) Negotiating fees and how this could be affected by upcoming regulations in 2024.    Links From Today's Episode: Meet with PWL Capital — https://calendly.com/d/3vm-t2j-h3p Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://twitter.com/LoonieDoctor Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://twitter.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/  

The overarching theme of today's conversation revolves around prudent financial decision-making, including tax-efficient investing, risk assessment, and leveraging home equity for investment purposes. This acts as supplementary material for the main episode, where we take a deep dive into the nuances of tax. Join us as we look at taxation and income through the lens of common scenarios that often lead people to make poor decisions with their investments. We uncover the importance of structuring investment portfolios with tax implications in mind and venture into the realm of corporate-class bond ETFs, assessing their potential benefits and complexities. You'll gain insight into the free dividends fallacy and the benefits of high dividend yield stocks. We also unravel the strategy of leveraging home equity to defer tax and share our personal experiences and insights, along with essential criteria to determine your risk profile.  Tune in as we turn dollars into sense and pave the road to a prosperous financial future!   Key Points From This Episode: (0:01:32) Optimizing investment portfolio structure without relying on dividends. (0:03:33) Essential aspects of taxes on capital gains and dividends.  (0:06:41) The risks of dividend-chasing strategies.  (0:09:56) A case study comparing premium with discount bond tax efficiency.  (0:12:26) Practical examples and steps for leveraging discount bonds effectively.  (0:19:11) Income after tax between discount and premium bonds.  (0:22:52) Using corporate class bond ETFs for tax deferral.  (0:25:07) Another case study that demonstrates leveraging home equity to invest.  (0:28:15) Risks and complexities of leverage investing.  (0:33:32) The value of a clear plan and reasonable expectations regarding your risk profile.  (0:36:31) Mark's experience of leverage investing.  (0:40:06) How he used leverage investing to reach his financial goals.  (0:47:39) Final thoughts and key takeaways.    Links From Today's Episode: Rational Reminder Podcast: Professor Samuel Hartzmark — https://rationalreminder.ca/podcast/273 BlackRock — https://www.blackrock.com/ca Horizons ETFs — https://horizonsetfs.com/ Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://twitter.com/LoonieDoctor Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://twitter.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/

Today's Case Conference accompanies an episode in which we provide a detailed breakdown of the registered account types available to Canadian investors and how to utilize them. Despite their numerous potential advantages, however, there are still many people who avoid them, primarily because optimizing these can seem too complicated and overwhelming. Our hope is that today's episode will provide you with the confidence and knowledge you need to feel empowered to take the next steps in your investment journey. Tuning in, you'll hear several case studies that address common concerns, like how to avoid having a Retirement Savings Plan (RRSP) that's too big and how to navigate your RRSP and tax-free savings account (TFSA) as a high-income earner. We also get into Registered Education Savings Plans (RESPs), why group RESPs can be so predatory, how to plan your exit from a group RESP if you're already in one, and more. For relatable examples of how to use these accounts, plus the many benefits of diversifying them, listen in today!   Key Points From This Episode: (0:00:58) Our first case study concerning a technology company employee with restricted share limits (RSUs) as part of their expected compensation.  (0:02:02) Relevance for high-income earners and how to make decisions about RRSPs and TFSAs.  (0:05:35) A case study on two physicians with a young child who want to shift their investment plan from a group RESP to an individual RESP.  (0:06:59) The complexity of group RESPs, why they're predatory, and how to plan your exit.  (0:12:56) Case study three: common fears of a too-big RRSP, especially for those who are incorporated.  (0:15:54) How to optimally use your RRSP or Registered Retirement Income Fund (RRIF) when it comes to tax deferral, tax sheltering, and taking dividends out of your corporation.  (0:17:45) Controlling the income from a corporation, paying yourself dividends, and how to ensure you aren't penalizing yourself.  (0:19:09) Rational Reminder Episode 70 and key takeaways on how to avoid a too-big RRSP.  (0:21:10) A rundown of the many benefits of diversifying your accounts.    Links From Today's Episode: Money Scope Episode 8 — https://moneyscope.ca/episode-8-canadian-investment-accounts Rational Reminder: Episode 70 — https://rationalreminder.ca/podcast/70 Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://twitter.com/LoonieDoctor Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://twitter.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/  

In this episode, we follow the stories of two distinct investors facing unique challenges. First, meet a plastic surgeon in the high-flying tech-driven world of 1997. With a high-risk tolerance and a flourishing practice, this surgeon believes they can conquer the market. However, as the dot-com bubble looms, they must navigate the fine line between risk and reward, teaching us vital lessons about diversification, leverage, and the challenges of the market. Next, explore the journey of a savvy business owner who sold their company at just the right time, amassing substantial cash. Cautious due to past stock market losses, this investor seeks to protect their newfound wealth. We discuss the delicate balance of risk tolerance, financial independence, and how to construct a portfolio that aligns with individual objectives. Throughout these stories, listeners will gain insights into asset allocation, the psychology of risk, and the importance of rebalancing during market turbulence. To discover principles that will help you make informed investment decisions and steer your financial future toward success, tune in today!   Key Points From This Episode: Case study one: a plastic surgeon with high-risk tolerance and a successful practice. (0:01:21) Why they should diversify investments and avoid excessive amounts of risk. (0:02:12) How human bias plays into decision-making in our first case study. (0:05:10) An essential lesson from our first case: know your risk tolerance. (0:07:31) Case study two: an entrepreneur who sold their business and has a significant amount of cash on hand. (0:11:28) How they should structure their portfolio to safeguard their financial health. (0:12:13) Benefits of rebalancing and why it is vital, even during a volatile market. (0:15:55) Closing comments and key takeaways. (0:17:59)   Links From Today's Episode: Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://twitter.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/ Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://twitter.com/LoonieDoctor    

After our detailed examination of the basics of investment strategy, we are now delving into some common case studies that you may encounter on your investing journey. Our studies take us through the looming recession and why it should not be a major concern for investors, the economic activity of America's response to a recession, and deciding on how much, with whom, and when you should invest your money. We also critically assess what you need to be aware of before seeking a lower-cost investment model, how to save while making donations, value versus growth, and what Ben and Mark have to say about a particular hot investment idea.    Key Points From This Episode: Why the looming recession has many people worried about investing. (0:00:49) How a recession affects market prices, and why this isn't a major concern.  (0:01:45) America's economic behaviours in and around a recession. (0:02:58) Talking through a rationally optimal approach and an emotionally optimal approach. (0:07:13) Whether to invest it all at once or gradually enter the market. (0:09:08) Everything you need to consider if you're looking for a lower-cost model. (0:11:05) Capital gains and other tax implications to note when altering a retirement portfolio. (0:23:28) A quick look at a smarter way of making charitable donations. (0:28:52) Debunking the hot investment idea. (0:30:06) Value versus growth. (0:34:09)   Links From Today's Episode: Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://twitter.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/ PWL Capital — https://www.pwlcapital.com/  Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://twitter.com/LoonieDoctor

Today's show features our first case conference supplemental episode. We've built several cases, complete with figures, to expand upon our primary episode's discussions on debt, saving, and investing. These scenarios reflect common queries and challenges we frequently encounter from our audience. While we hope you can draw parallels to your own circumstances from these cases, it's crucial to understand that this isn't personalized advice. We aren't offering specific recommendations. However, our goal is for you to find elements in these cases that resonate and assist you in navigating your own financial journey, whether independently or with a consultant. Our first case study is one that many people will be able to relate to. We focus on a recent graduate, with a substantial amount of debt, with no investments or savings, and break down how they should go about navigating their financial wealth journey. Tuning in you'll hear a breakdown of the numbers for this case study, how to build competence and a financial plan, how your tolerance for debt will influence your financial decisions, plus a whole lot more. Join us for our first in-depth case study as a supplement to our main episode!   Links From Today's Episode: Benjamin Felix — https://www.pwlcapital.com/author/benjamin-felix/  Benjamin on X — https://twitter.com/benjaminwfelix Benjamin on LinkedIn — https://www.linkedin.com/in/benjaminwfelix/ Dr. Mark Soth (The Loonie Doctor) — https://www.looniedoctor.ca/ Dr. Mark on X — https://twitter.com/LoonieDoctor Money Scope Episode 5 — https://moneyscope.ca/2024/01/12/episode-5-debt-saving-investing/ Rational Reminder Episode 226: Colonel Chris Hadfield — https://rationalreminder.ca/podcast/226 Medical Student Debt Repayment in Early Practice — https://www.looniedoctor.ca/2022/12/30/medical-student-debt-repayment-2/      

12/21/2023 | December 2023 Case Conference

CME credits: 4.75 Valid until: 30-11-2024 Claim your CME credit at https://reachmd.com/programs/cme/panel-discussion-simulated-cteph-case-conference/16510/ The Midwest Regional Pulmonary Hypertension Summit occurred on October 14, 2023, in Chicago, IL. The event highlighted the management of PH with other coexisting comorbidities. Leading experts discussed the appropriate risk stratification, management of PH, updates on ERS/ERC guidelines, and optimal patient care practice.

11/16/2023 | Pancreas Case Conference

10/19/2023 | October 2023 Case Conference

09/21/2023 | September 2023 Case Conference

08/17/2023 | August 2023 Case Conference

07/20/2023 | Case Conference

06/15/2023 | Case Conference

05/19/2023 | May 2023 Case Conference

04/20/2023 | April 2023 Case Conference

03/16/2023 | March 2023 Case Conference

02/16/2023 | February Case Conference

01/19/2023 | January Case Conference

12/15/2022 | December Case Conference

11/17/2022 | November Case Conference

10/20/2022 | October Case Conference

09/22/2022 | September Case Conference

We're on the path to 100 episodes! Thanks for continuing to listen, and for contributing to the larger Divorced & Done community. The case about enforcing an EICC agreement was discussed in our May 7 episode, "When you've reached a deal and your ex tries to back out. New case from Alberta: make the deal and be done." Find the case on CanLII with the citation, 2022 ABQB 318. Find us online at DivorcedAndDone.com and our podcast email LawyersTalkingAboutDivorce@gmail.com, send voicemails to SpeakPipe.com/DivorcedAndDone We're a TOP 10 podcast as ranked by Feedspot, we recently ranked in the top 10 of the Best 25 Divorce Podcasts. Check it out https://blog.feedspot.com/divorce_podcasts/ We're also on TikTok: @familylaw_darrenschmidt and @robert_woodward Everything we talk about on this podcast is for your information, but it is not legal opinion or legal advice.

Hey everyone!  We are totally not kidding - we ARE going to be spoiling some movies for you today.  If you're someone who gets easily pissed off at stuff like this, you can scroll down to the bottom and see the list of films we cover so you can watch them before listening to the show.  Or not.  But don't say we didn't warn you.   My buddy Doug Ferguson is back again for this episode and I'll tell you right now that Doug is going to be a regular.  He and I share the same brain and I'm so totally stoked to explore more Top Five lists with him as we continue to develop this show. Simply put - what is a spoiler alert?  A spoiler alert takes place when a warning that important detail of the plot development is about to be revealed.  And in this case, there are some amazing surprise endings that we're going to talk about - but it's because these surprise endings are so iconic that we can't help but dive right into them.   A couple of these films are a little bit "off the beaten path," so Doug and I are hoping that we give you some new entertainment to pursue AND that you'll shoot us an email about our lists (hello@thetopfivepodcast.com). And just in case you, too, happen to be a Higher Education Professional in the advancement and development area, we hope that you'll come to hang out with me and Doug at the CASE Conference for Community Colleges in Anaheim this coming October 26-28.  Doug and I fully intend to do a LIVE episode during cocktail hour.  Come hang out with us! P.S. Here are some of the movies we discuss in this episode:  Unbreakable, No Way Out, The Usual Suspects, Psycho, Frailty, Primal Fear, Halloween, The Crying Game, and a few others.  

08/18/2022 | August Case Conference

07/21/2022 | July Case Conference

In this episode, we chat with Kate Cole, a determined parent who managed to secure NDIS funding for her child living with dyslexia. Kate tells us exactly how she did it!   In this episode, we chat with Kate Cole, who tells her NDIS funding story. Kate tells us why she applied and how she navigated multiple rejections to ultimately have her funding approved. It's a story we hope you will find encouraging, useful and enlightening, as we did. So, if you live in Australia and know or support somebody living with a specific learning difficulty, this episode may be a game changer. What is the NDIS? The National Disability Insurance Scheme (NDIS) is for people in Australia under 65, living with permanent and significant disability. Permanent means the disability will not go away. Significant means the disability affects how you live every day. Both of these criteria can apply to people living with specific learning difficulties.   NDIS and Dyslexia – Kate's story in her own words Our daughter is a bright, happy, funny girl who is just a joy to be around. We began to have concerns about her literacy skills when was quite young. While her peers were able to recognise letters of the alphabet, she struggled to recall common letters, including those in her name from a young age. This was in contrast to the skills she displayed when performing other tasks as part of daily life – which she really excelled at! Our daughter settled well into school but struggled with basic literacy tasks from the beginning. By the end of Year 1 we requested her school to allow her to repeat Year 1 again. We were told that repeating her would only be allowed upon completion of a psychometric assessment, an assessment by an independent speech pathologist, an assessment by an occupational therapist. We arranged the necessary tests. Through Year 1 and 2, her school provided some support – Reading Recovery and MiniLit. In addition, we organised speech pathology & tutoring to help her. But by the end of Term 3, Year 2 it was evident that the support available within her school was insufficient to enable her to continue learning in that environment. We had had our daughter “tested” for countless things based on recommendations from the school – ADHD, eyesight problems, intellectual delays etc. None were really helpful. Our daughter is very well behaved, is a gun at ball sports and excels at mathematics. It was as though her school really did not understand her strengths at all. We made the decision to enrol our daughter in a different school commencing in Year 3. From the start, her new teacher contacted us to discuss concerns with her literacy. She was great. A further assessment by a speech pathologist was recommended, as was a referral to a Neuropsychologist. We were blown away with his findings. Essentially it showed she had a Specific Learning Disorder that impacted reading and writing only (dyslexia). It was also very clear that this was not related to an intellectual disability and that there were certain interventions were never going to work given her condition. The Neuropsychologist also provided very specific and clear recommendations for both school and for at home which were very useful. From that point onwards, her new school helped by providing in-class support, free access to evidence-based literacy interventions, MaqLit, assistive technology (e.g. “C-pen”), and access to learning support and a scribe. We supplemented this with regular speech pathology every week. This is all amazing while our daughter is at school. But what I think some fail to realise is that children also need to access texts and write things down when they are not at school – supports are still needed outside of an educational setting. This is why we applied to the NDIS. Here is our Timeline: May 2019 We applied for access to the NDIS for our daughter's primary impairment of a Severe Specific Learning Disorder with impairment with reading and written expression. We explained that our daughter had received evidence-based treatment from speech pathologist(s) since the age of 4 targeting literacy development, all with minimal improvement. She had also participated in multiple literacy interventions at school. I sought access to the NDIS for continued targeted evidence-based literacy programs to lift basic literacy proficiency as much as is possible within the context of her SLD. In the context of functional impairments, I sought access to the use of assistive technology for her learning. July 2019 We were informed that our NDIS Access Request was not successful. Specifically, the requirements that were stated not to be met were: Section 24(1)(c) relating to an impairment” that results in substantially reduced functional capacity; and Section 25 relating to whether the early intervention supports are most appropriately funded by the NDIS. Those familiar with NDIS may know that in order to meet the Access Criteria, you have to satisfy the NDIS on many criteria. Our application was targeted at Section 21(1) which includes: 21(1)(a) age requirements (Section 22); and 21(1)(b) residence requirements (Section 23); and 21(1)(c)(i) disability requirements (Section 24); OR 21(1)(c)(ii) early intervention requirements (Section 25). The first 2 items above (Section 22 & 23) were easy for us. It's Section 24 or 25 that presented the challenge. August 2019 I applied to the NDIS for a review of the outcome of our Access Request. In response to the items noted above, I wrote the following: “In contrast to what has been stated, (Name's) SLD significantly impedes her functional capacity to both learn and communicate in society. This is a lifelong disorder which negatively affects her ability to read and write. The ability to do so is a skill that we need to function in life and society. Her disorder has demonstrated impacts on educational and occupational attainment, as well as limiting participation and productivity. (Name) needs ongoing help and assistance, and we want to be able to help her to function in society. (Name) requires assistive technology aids to allow her to access written texts and express herself in written format. In addition, she requires speech pathology intervention to limit the detrimental impacts of her Specific Learning Disorder. Without such, (Name's) ability to communicate is severely compromised, and she will be unable to fully participate in society. As such, I request a review of the access decision for (Name) “ October 2019 I received a phone call from the NDIS seeking more information. Nothing specific was requested, just an overview of her daily life which I provided. The NDIS also contacted my daughter's Neuropsychologist. A few weeks later, I received a letter informing me that the earlier decision to reject our request was upheld and that we were not successful. What was great about this rejection letter was that the NDIS went into much more detail on each of the Access sub-criteria on what had not been met. For example, we were informed that she did not meet the following criteria: 21(1)(c)(i) disability requirements (Section 24) Criteria (c) which means that the impairment must result in substantially reduced functional capacity in one or more areas; Criteria (e) which whether the condition is likely to require lifetime support of the NDIS. 21(1)(c)(ii) early intervention requirements (Section 25) Criteria 25(3) that the NDIS is the most appropriate support system. Therefore, based on this knowledge, I applied to the Administrative Appeals Tribunal (AAT), requesting a further external review of the decision. December 2019 Our first case conference with the Administrative Appeals Tribunal (AAT) was scheduled, and in preparation, I was sent a “Respondent's Statement of Issues” (SOI), which summarised the decision under review. My daughter's Neuropsychologist attended the Case Conference by phone, which was a huge help. I used the Case Conference as my first opportunity to directly ask the NDIS what it was that they wanted or expected to be provided as evidence to satisfy the 3 areas that were deemed to be unacceptable. I explained what her daily life is like, and I was told I needed to provide a Statement of Lived Experience on what her life is like now and what it would be like if she was granted access to the NDIS. When it came to the discussion around how significant her disability affects her life, her Neuropsychologist was amazing at articulating the research available that demonstrates the need for early intervention for this SLD and the positive impacts on day-to-day life it brings. He explained the long-term outcomes of people who have a history of reading disorders or learning disabilities and how the literature shows that children and adults with reading difficulties have established poorer functional outcomes across a range of domains, and as such, need support to be able to participate in society. He was asked to provide a summary of that research. He also provided context to the need for supports around the use of assistive technology and the use of evidence-based literacy support. I went through what the education system provides and asked specifically what the NDIS expected “mainstream services” to provide to support her. I explained that I had already consulted with our GP on this and had access to all mainstream services available, including through a GP management plan and such were insufficient. I was asked to provide written evidence of this. The grounds on which I argued included that her SLD does have functional impacts and such is beyond mere educational needs in the classroom. While it is true that it is the role of education to support for her in the classroom, education is not responsible for providing her assistance when she is not in class. For example, her school is not responsible to provide a C-Pen for her when she is reading at home, to assist with reading a bus or train timetable, or provide talk-to-text at home. She requires tools to navigate the written world long term. I was specifically asked what support she needed for her daily life outside of school. Here is an extract of what I provided: “Every-day activities that rely on reading or writing restrict her ability to participate, unless she is provided with someone to read or scribe for her or if she has access to the use of assistive technology. As parents, we have tried to support her independence by providing a C-Pen Reader for use outside of school. The C-Pen Reader enables her to scan a line of words so that they can be read back to her. While the C-Pen Reader enables her to understand some written texts, it is limited in its support when the words she needs to read are on a noticeboard (behind glass), if they are on signage (such as for pedestrian access), if they are on the TV (such as words to a song, or a warning sign etc.), or on packaging where the colours behind the words change. The latter is a good example of the challenges presented if she tries to “shop” for something, as labels on products are typically written over multi-coloured backgrounds. Some examples of day-to-day things that she requires support for that she is unable to perform independently include: Unable to read the ingredients and the methods to follow in a cookbook; Unable to read cereal boxes, so if the packaging changes to unfamiliar colours, she cannot ascertain what is inside; Unable to decipher from shampoo, conditioner, or any other product such as body wash (or other products in the bathroom) unless she has become familiar with the coloured branding on the packaging over time; Unable to read packaged items from grocery shopping that she is not familiar with; If we go out for dinner, she is unable to read from the menu; Unable to participate in after-school extra-curricular activities such as drama or speech, as participating relies on creating texts and reading lines; Unable to decipher or create text messages or emails; Unable to read the bus or train timetable; Unable to read Christmas cards, birthday cards, or letters from family members; Unable to read notes that she brings home from school or permission slips; Unable to read sign-ups for community days at the local shopping centre; Unable to read road/pedestrian signs.” I was also asked to approximate the level of support (in dollars) that we were after. I sought support for participation in evidence-based literacy interventions to build her literacy skills; and provision of assistive technology for reading and writing. Such should include technology that enables her to read from text, but also read words encountered in everyday life. Examples include a C-Pen Reader and technology that enables words to be read in any format, such as the OrCam MyReader. Based on these items, I estimated then to amount to approximately $10,000, consisting of ongoing weekly speech pathology ($3,500) and assistive technologies such as the Orcam MyReader ($5,695). We were given until February to compile all requested information. The respondent (NDIS) was given around 2 weeks to respond afterwards, and another case conference was scheduled for March 2020. February 2020 I sent the following info to the ATT:  Statement of Lived Experience Medical report from our GP (who was fabulous). Her letter explained the support available through mainstream services for children with dyslexia through Medicare consisted of 5 x subsidised Speech Therapy or Occupational Therapy sessions per year – and that such was totally inadequate to deal with the complex issues involved. Summary report from our Neuropsychologist Progress reports from my daughter's school. We were contacted in late Feb from the lawyers representing the NDIS to ask us if they could have more time to review our documentation. I refused. I figured I have 3 kids and work full time – why am I giving lawyers who are paid to do this more time? Soon after, we received an email stating that the NDIS agreed that our daughter now met the access criteria under Section 21(1)(a); 21(1)(b) and 21(1)(c)(i) disability requirements (Section 24). The key things that helped me throughout this process that I think made the most difference: 1. An amazing Neuropsychologist who specialises in this area and could be called upon to provide independent information to the NDIS at any time. 2. Keeping very detailed records of every phone call with the NDIS, taking the time to read the Operational Guideline behind the NDIS (Becoming a Participant) Rules…and not giving up. I had countless conversations where I was told that it's a good idea to “get a lawyer” to help me because Disability law can be complicated. The idea of paying for legal advice on top of everything else was a really big deterrent. But I did all of this without any of it. Yes, it took time, but I actually think it probably took less time (definitely less money) than if I had to explain it to someone else all the time and review everything they wanted to send out. This way I felt (marginally) in control. 3. Knowing that if the situation was different, and it was actually me that was dyslexic, that it would have been very unlikely that my parents could have afforded the sheer amount of therapy, assessments, intervention, and private school fees that we have spent to help our daughter with her condition…and that my adult life would be very different. I feel very lucky that I was able to go to University. It infuriates me that help for dyslexia mainly relies on parents that can afford it. Every child deserves support for dyslexia – and such should be supported through the NDIS. I really hope this post helps someone else access the NDIS for their child, or for themselves. From: https://www.facebook.com/groups/220307061381034/search/?q=ndis Since then This is just a follow-up to my post on April 16, where I went through the process we took to get our daughter on the NDIS (which was recently accepted). I had lots of questions on what was included in her plan, and I couldn't answer them because it hadn't been approved yet. I'm very happy to say that her plan has now been approved and is made up of the following: CORE/Consumables budget= $200 – For the purchase of low-cost Assistive technology to assist with her communication support needs Capacity Building- Improved Daily Living – $8,373.36 – Access to Speech therapy support + parent training. I can't tell you how much of a difference this makes to us – the ability to have funded speech pathology is absolutely amazing. I hope this post further inspires others to seek funding through the NDIS for themselves or their children, and please don't give up. I'm happy to help anyone on their journey.

06/16/2022 | June Case Conference

05/19/2022 | May Case Conference

04/21/2022 | April Case Conference

03/17/2022 | March Case Conference

02/24/2022 | February Case Conference

01/20/2022 | January Case Conference

Ys IX: Monstrum Nox is the latest title featuring Falcom's legendary red-haired swordsman, Adol Christin. Is his latest adventure, set in the prison city of Balduq and starring a monstrous-looking version of our hero, worth your post-call time? Listen in and find out! Welcome to Post Call Gaming's GRAND ROUNDS! This is our regular podcast where we talk about some of the latest news coming out of the video game industry and give it our own personal differential diagnosis. *

In this Live Friday CME Series recap, Dr. Todd Holcomb, an Internist and hospitalist with Lakeview Clinic and Ridgeview Medical Center, presents an interesting Internal Medicine case that is sure to scratch some heads, and remind us of the need to go back to the beginning, if it's not making sense after several attempts. Dr. Holcomb is accompanied by cardiologist Dr. Joshua Buckler, with Minneapolis Heart Institute, Dr. Jonathan Larson, family physician at Lakeview Clinic, Dr. Carl Dean, nephrologist with Kidney Specialists of Minnesota, and Dr. David Gross, radiologist with Consulting Radiologists.  So put on your thinking caps, listen closely and ask yourself what you would do as Dr. Holcomb guides us through this interesting case. Enjoy the podcast! OBJECTIVES:    Upon completion of this podcast, participants should be able to: Identify secondary causes of hypertension. Identify when further testing is warranted. Discuss newer treatments available for cholesterol related conditions. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.   CLICK ON THE FOLLOWING LINK FOR YOUR CME CREDIT: CME Evaluation: "2019 Internal Medicine Case Conference" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.   FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: PART 1: Alright, let's break down the first portion of this case discussion. This is a 60 yo male with chest pain for over a year. Intermittent aching and burning in right anterior chest, worse with activity and lately has worsened overall with a stressful job and strong family hx of heart disease. General exam ins unremarkable. ECG normal. HDL is 60 and LDL slightly up at 137. PFTs and CXR are normal.  Stress echo is normal.  Cardiology referral results in a low Ca++ score but some plaque in the LAD. Dr. Buckler, the cardiologist, feels this is ischemic heart disease until proven otherwise. Therefore, a coronary angiogram is necessary. Imaging has its limitations, as do stress tests. When the history still doesn't point in another explicable direction, we must follow the logic and most likely etiology, which is till coronary artery disease and ACS. One of the problems with stress tests in general, is there are limitations inherent. It's hard to miss the big stuff, but the more minor findings can be missed. With a high pretest probability, he could have perhaps gone straight to angio. In this case, though, he was started on a statin and aspirin. Per Dr. Buckler, Imdur could also have been given. Two year later, he comes in with headaches in the same area of the head since his wife recently passed away. He takes Advil for this. BP has been elevated at home. Dr. Jonathan Larson, family physician, questions the type of headache, it's location and possible etiologies. Is the Advil causing rebound headaches or contributing to the headaches? The elevated home blood pressures also need further investigation. His kidney function is temporarily normal. NSAIDs are d/c'd and Lisinopril is started. A month later, the headaches have improved. BP improved, but not tremendously. In addition, his chest pain has gone away. A new antihypertensive, a combo HCTZ/Lisinopril regimen is started. Although Amlodipine would have been a reasonable choice. A year later, he returns with the same chest pain on exertion. Normal ECG. Normal renal function too. He now goes back to a CT angiogram showing multi-vessel disease. Per Dr. Buckler, one of the reasons he has worsened on a statin is that we may have limited understanding of his pathology, or potentially the CTA was not accurate the first time. Virtual FFT now can show the flow and how significant the lesion is, which is an advancement in this technology. Unfortunately, despite aggressive lipid therapy, sometimes people progress. A few days after the CTA, his Creatinine goes up a bit and GFR goes to 43. This is also after years of Lisinopril. Dr. Carl Dean comments on this alteration in renal function. He feels this is not entirely unexpected, but the data doesn't really reflect CIN (contrast induced nephropathy). Yet intuitively and experientially, we sometimes see this. The amount of contrast used is significantly more on a CTA than on an invasive angio. At this point, the ACE inhibitor is held and Amlodipine is started. Renal function now has improved. The angiogram demonstrates significant 3 vessel disease, with good downstream targets. The SYNTAX surgical risk score directs the cardiologist toward CABG instead of PCI. Post angio, he develops some lower extremity edema, and he is discontinues on Amlodipine, resumed on the HCTZ, Lisinopril. The creatinine is now 2.4. Did he receive enough fluids for the angiogram? Or was the few hundred cc's he obtained during the angio okay? Again, hindsight is 20/20, but the data doesn't support a causality for AKI due to CIN, nor is there a true preventable measure, including n-acetylcysteine or bicarbonate. Perhaps, in this case, CIN as a possibility in the past as discussed, that many would not argue with overhydrating. Ultimately it was felt the ACE and contrast contributed to his creatinine elevation. The ACE combo is now stopped and he is started on Hydralazine and Metoprolol. Creatinine improves, and he goes into CABG surgery. He is discharged and he continues on aspirin and Plavix for 3 months, and Carvedilol and Hydralazine. Atorvastatin is increased to 80 mg daily, a more aggressive dose. EF is normal on echo.  Do statins affect kidney function positively or negatively? According to Dr. Dean, there is no trial that supports either. His BP starts to increase, and Lisinopril is once again added, along with an increase of creatinine, and the ACE is again d/c'd. HCTZ was added. Then spironolactone for ongoing HTN. He's still running high though. Labetalol is replacing carvedilol now. And the pressure is still running high. What is happening here? What to do next? Do we try Lisinopril again? It is attempted, and he once again fails the creatinine test. It goes up again. PART 2: What we do now for this patient? It seems he can only improve on Lisinopril for blood pressure, but his creatinine continues to go up. According to Dr. Dean, in this patient, Lisinopril may not be a great option going forward, not only due to creatinine increase, but it will not help him in terms of mortality outcome. renal artery stenosis is a concern in this case. Dr. Tara McMichael interjects the question, could a loop diuretic have been tried? With a creatinine of 2.3, a loop diuretic could have been an option, since volume and sodium retention could be contributing to the hypertension. Isosorbide with hydralazine is also an option if more meds were to be added. Per Dr. Buckler, however, a four drug regimen that is poorly controlling blood pressure doesn't necessarily indicate adding a fifth drug. We need to know if there is a secondary cause of HTN. Sometimes, even in the setting of renal artery stenosis, patients still require significant anti-HTN drug regimens. Also, per Dr. Dean, the pretest probability in this type of patient for renal artery disease is high. And will an intervention be desirable if it is found? The ASTRAL trial demonstrated no improvement in outcomes. The CORAL trial was also done and considered to be a negative trial. One of the trial criticisms though was that it didn't include patients with severe enough disease. According to Dr. Dean, refractory hypertension should cause screening for this and an intervention should be done if it is seen.  Our patient has a renal u/s that shows bilateral RAS. Dr. David Gross, radiologist discussed the results of the MRA. The aorta, SMA and celiac trunk show atherosclerosis. The renal arteries are paired bilaterally. They have moderate to high grade narrowing of the arteries. Dr. Buckler asks the question of the safety of gadolinium in renal disease. In the setting of low GFR, in other words, less than 30, the risk for nephrogenic systemic fibrosis exists, although very rare. This is usually fatal, though. Basically, he has 4 out of 4 arteries occluded. Dr. Dean feels referral to a center of excellence for this unique issue is best for the patient. He undergoes transaortic endarterectomy, as his creatinine is rapidly going up. A significant plaque is resected from the aorta which was extending into the renal arteries. Post-procedure, he is placed on metoprolol, requiring nothing further. Rosuvastatin, Zetia and baby aspirin is started. Basically, unclogging the pipes resulted in a cure. And a while later, he's no longer on any antihypertensives. Blood pressures are great now. LDL now 57 on the new cholesterol meds. Zetia has limited data, but the PcsK9 inhibitor and his LDL is now 1. Dr. Buckler states there is a lot of unknowns about the LDL levels and whether there is a point of diminishing returns, but the science is not there yet. In this case, Dr. Buckler feels that stopping the Zetia and continuing the pcksk9 inhibitor makes sense. PART 3: Renovascular HTN is more commonly found in the setting of acute, severe, refractory, very high blood pressure. Work-up is needed when there is a strong possibility of secondary cause, and in the absence of another secondary cause, like pheochromocytoma or hyperaldosteronism. Also in an acute rise in BP, a young age, elevated Cr after starting an ace inhibitor, etc. Renal asymmetry on imaging and flash pulmonary edema are other clues. If Cr and BP are stable in the setting of stenosis, no intervention is indicated. Testing can potentially worsen function, as can the interventions performed to treat the disease. Who benefits most? People with short term hx of HTN, people who fail optimal medical therapy, not tolerating medical therapy and progressive renal failure. Ultrasound and CTA or MRA are the options for work-up. US is cheaper, but time consuming and operator dependent, with modest sensitivity/specificity. CTA is accurate for atherosclerosis. Highly sensitive and better if GFR below 30. MRA is highly sens/spec. Gadolinium complications can ensue in low GFR situations. Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9) will lower LDL up to 60%. 50% decease in stroke and MI risk. The PCSK9 enzyme binds to liver LDL receptors and thereby increases plasma LDL levels. so inhibiting this enzyme leads to a lower LDL level. These inhibitors also can decrease triglycerides, increase HDL somewhat and decrease the volume of atheroma. Low adverse effects are noted with the med as well. Regarding renovascular HTN, Dr. Dean also reminds us that someone who is significantly older with chronic renal ischemia in the setting of this disease, may not have improvement in renal function even after intervention. Therefore, some of these patients who suddenly reperfuse a chronically ischemic kidney may actually worsen. Renal artery stenosis is also not an absolute contraindication for ACE. Such as in low EF heart failure. If the creatinine markedly rises, it can be discontinued again. Fibromuscular dysplasia patients, unlike atherosclerosis patients, should all receive an intervention. This is more commonly found in younger patients. Dr. Buckler addresses the ease of use and cost of the PCSK9 inhibitors. It turns out the cost is high at this point, up to $14k/year. But coverage has shown promise in FH and refractory high LDL. As it was alluded to by Dr. Holcomb, the patient really doesn't exercise and has a very stressful job, as it turns out. His dies wasn't discussed. Was he managing his risk factors very well? What does that mean nowadays? We have potent medications and skillful intervention options for reacting to this sort of pathology nowadays, but where are we at with prevention? Hopefully a conversation for another day.

Throwback Thanksgiving takes us to summer 2015 at the Issues Etc. making the Case Conference where I had the honor defending the worldview of Christianity against the tyranny of the postmodern movement and its rejection of hearth and altar lifestyles. Preorder my new book Without Flesh: https://amzn.to/34d2Ass --- Episode Artwork: https://www.pinterest.com/pin/406590672600190889/ Support me: www.patreon.com/revfisk Get Mad: https://www.subscribepage.com/l0w0j0 — Music: Courtesy the glorious DJ Quads  https://soundcloud.com/freemusicforvlogs/dj-quads-a-guide-to-life-free-music-for-vlogs and http://free-stock-music.com/dj-quads-copa.html Mad Music Samples: https://www.one-tab.com/page/i_garbrJRWaa9tRIaeW1dA MadPx Font: https://www.dafont.com/tfu-tfu.font?fpp=100&text=The+Mad+Christian — Find everything else at www.revfisk.com

This podcast presents an interesting internal medicine case of a patient who initially presented to themselves to the clinic with a chief complaint of a cough, and the chain of events that occurred with this particular case.  Joining Dr. John Peitersen, (Internal Medicine) in the case discussion today include: Dr. Barrett Larson, (Pulmonary Medicine), Dr. James Currie (Lakeview Clinic-Infectious Disease), Dr. Matthew Herold (Emergency Medicine), Dr. David Gross (Radiology), Dr. Susan Bowers (Pathology), Dr. Kevin White (Hospitalist), along with various other providers and Allied Health staff.  Enjoy the podcast. Objectives: Upon completion of this CME event, program participants should be able to: Perform a differential diagnosis on cases presented. Identify limitations of certain tests. Discuss the interpretation of lab results on the cases presented. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit:  CME Evaluation: 2019 Internal Medicine Case Conference (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.” FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.   Show Notes:      This is the case of a 44 year old woman who initially presents for a cough for about a week. She is obese and has OSA. She is on flonase. She had a low grade fever. Exam doesn’t reveal much besides a serous OM and some mild anterior cervical lymphadenopathy. Conservative care was advised, as well as follow-up in the next couple weeks if not improving. Dr. Peiterson now will tell us the chain of events in this peculiar case. Joining Dr. John Peitersen in the discussion today are: Dr. Barrett Larson from Ridgeview pulmonary medicine, Dr. James Currie, Lakeview Clinic infectious disease, Dr. Matthew Herold, Ridgeview emergency medicine, Dr. David Gross, Radiologist with Consulting Radiologists, Ltd, Dr. Susan Bowers, Pathology, Dr. Kevin White, Ridgeview hospitalist, and various others from the provider and allied health audience.      The initial small segment of this discussion had recording difficulty, so our conversation picks up immediately after the initial presentation of the patient.   CHAPTER 1 REVIEW:      So... let’s recap up to this point. So far we have heard input from Dr. Peiterson, Dr. Larson the pulmonologist, Dr. Gross the radiologist and Dr. Bowers the pathologist. So, initially she was seen for what sounds like a viral URI, and was told to f/u if not improving. Well, we all see this kind of case every day, right? She was then treated by phone with Azithromycin; seen by different providers; Reports “crackling in the lungs’, malaise and subjective fever. She has a Son who had strep 9-days ago. Ears look better today. Cryptic tonsils. VSS. Negative strep test. This was felt to be Viral bronchitis.  CXR offered, patient declined due to $.      Five months later, the patient sees a sleep doctor. Continued cough noted. Pulmonary function tests are likely now indicated. Is there mild asthma? PFTs are able to give us a lot of information. Is the FEV1-FVC ratio acceptable.  Yes, it’s above 80 -  in her case. Chance of asthma markedly low. However the diffusion capacity is low at 83. For some reason, she is not absorbing O2. Nothing really going on with her expiratory loop, or any other major issues with this test. Is the patient’s obesity contributing to her poor lung perfusion? Interestingly, her weight has decreased by 15 lbs since her last visit.       Pulmonary physician recommended a CXR, a 4 week post nasal drip protocol. Additionally is a metacholine challenge needed here? Often a pre- and post-neb peak flow will first be done first. Then the metacholine challenge is done if the clinical picture fits. Is it time to rule-in or out asthma and spare someone years of MDI use. Diffusion capacity should be normal in asthma.       Dr. Peitersen reflects on an often asked board question. When to get a chest xray for the complaint of persistent cough. Barring other obvious reasons such as new chest pain, high fever/shaking chills or focal exam findings, The American College of Chest Physicians recommends that if a cough is present for greater than 8 weeks, a CXR is indicated. This patient’s CXR reveals interstitial changes that bring up a broad list of possibilities on the differential. These include CHF, infection, autoimmune disease.      Chest CT non-contrast was now ordered and shows reticulonodular areas and some regions of consolidation that are almost mass like. Other patchy areas noted throughout. No endobronchial findings. Lymphadenopathy is also noted in various areas of the intra- and extra-thoracic regions. CT with contrast is important to see vascular issues, but also to see small hilar lymph nodes. Sometimes contrast can falsely increase the density of a nodule leading you to call it a granuloma. Hi Resolution chest CT is an older term, but current modern CT scans accomplish this . This involves 1 mm cuts vs. 3 mm cuts. Essentially thinner cuts to see nodules better.      The patient is now seeing a new pulmonologist and has normal vital signs, unremarkable lung exam, which is not totally unusual despite a very abnormal looking xray or CT. A PET CT scan is advised and will show hypermetabolic lesions. Essentially it will help find other areas of concerning activity that would be less risky to biopsy. Radiologist generally avoid biopsy of central lesions that are near important organs and structures. Insurance declines the PET CT, but a node was biopsied in the thigh. Dr. Bowers comments that this biopsy could be a low grade lymphoma, although at this point it would need further assessment, but this is a send-out, looking for B and T cell rearrangement. A hematopathologist would also be good to consult with in this case. For now, this is benign specimen.       Another lymph node specimen was obtained, now axillary. This one shows really no other concerning findings. Tiny granulomas are noted. A variety of staining procedures were performed and all were negative. For Dr. Bowers, Toxoplasmosis may need to be considered.   CHAPTER 2:      Toxoplasmosis seems unlikely because this patient is apparently not immunocompromised. The differential dx does include various other infectious etiologies, such as bartonella, brucellosis and Q-fever. Melioidosis as well. Therefore, a travel history such as to SE Asia should be obtained. So, what now? There are about 20 possible infectious etiologies for this presentation...we need to do more tests. But, the patient was lost to follup for some time.       Now it is 16-months later, and she returns to urgent care with cough, fever, increased respiratory rate, O2 sats are marginal and an abnormal lung exam. Mild leukocytosis noted, and anemia which is new. Dr. White interjects with the following questions: 1. Has she ever been treated with a steroid? 2. Did anyone perform laryngoscopy? In the setting of normal chest imaging, these things should be considered. But of course, since her last CT scan was abnormal, a pulmonary etiology is of highest concern. And indeed a repeat CXR shows worsening overall interstitial change along with increase in the density of the azygoesophageal fissure which was noted on previous CT. The UC provider feels this looks like pneumonia. She was treated for pneumonia and a potpourri of other remedies were tried. Unfortunately, she did not follow-up with her medical doctor. She did see her naturopathologist who resumed drops for bartonella and Lyme disease. As Dr. Currie said, though, Lyme Disease does not present with granulomatous lymph lesions.       She now presents to the Emergency department 18 months after the UC visit. She is SOB, coughing, and states she has “chronic lyme disease”. She is 85% on RA. She has SIRS. Leukocytosis, and a respiratory alkalosis is noted. Her CXR shows Left upper lobe infiltrate that is quite dense. This must be followed to ensure resolution. Lactate and influenza were normal. The commentary from Dr. Herold in the audience was that this patient is not quite meeting sepsis criteria, but quite ill all the same. The decision to initiate broad spectrum antibiotics was made. Further history demonstrates that she was diagnosed with Lyme disease at age 10 and has struggled with health issues ever since. The patient had ongoing frustrations about cost of care and so she continued to see her naturopathologist.       Regarding another good exchange between Dr. Gross and Dr. Herold, involved the discussion of using CT to differentiate this very abnormal CXR for infiltrate vs. empyema. Ultrasound can also be employed for thoracentesis if indeed it is empyema.       Dr. Currie also makes the point that "chronic lyme disease" is not a known condition, so that when patients present with this issue or concern, other underlying disease states must be considered.      While CAP is the leading dx, other considerations in the differential still exist. Dr. Curry also states that azithromycin/Ceftriaxone is a reasonable inpatient treatment regimen going forward. She is feeling better on hospital day 2, but her blood cx come back positive in all 4-bottles. Strep pneumonia is the culprit, and is the current, but certainly not chronic reason for her symptoms. TTE was recommended to rule out endocarditis, especially given her chronic issues. Echo showed high right sided pressures, and a CT PE study was done showing no PE. Dr. Gross discusses the CT reading and notes bilateral signifcant hilar and subcarinal lymphadenopathy. Dense alveolar consolidation around the bronchi and layering left sided pleural effusion. Also noted is a large spleen and some prominent retroperitoneal nodes. Hospital day 3 she has left sided chest pain and had an unchanged repeat chest CT.       Dr. Bowers, the pathologist, discussed the blood cell differential and comments that she is anemic and that is the primary issue. All other counts are normal. Mild rouleaux (stacking of cells) is noted on the morphology and prompts you to think about increased proteins, such as monoclonal and fibrinogen. On hospital day 3, the patient was to go home on levaquin. She is supposed to f/u with pulmonary, but then develops another fever and requires O2 once again. Fever after 40-hours of antibiotics is not entirely unexpected in this patient, especially due to her past history and the likelihood of some underlying etiology that has yet to be discovered.   CHAPTER 3:      Okay, so her immunoglobulins are low. What does that mean? Well, this looks like Chronic Variable Immunodefincy disorder. Does she need IVIG? Yes, it is worth a try per the immunologist. Especially since she is having fevers, rigors and need for increased oxygen. Repeat CXR shows some mild improvement in infiltrate, but a bit more of a CHF pattern, perhaps. ID is involved now and they feel that CVID made sense as a diagnosis. Her symptoms improved and no further IVIG is given. In terms of follow-up, the patient has done quite well. No further hospitalizations to date. There were some barriers in her care involving cost and insurance issues. A repeat CT in 2018 was reviewed by Dr. Gross and she still has some reticulonodular infiltrates. No further dense consolidation in the lung. Lymphadenopathy has improved in general. And the spleen is still enlarged. The patient apparently then was referred to another facility and had another node biopsy after she had yet another scan that showed once again some worsenening. IVIG is helpful for these patients and unfortunately is also very expensive. Many of these patients succomb to cancers of various types, as opposed to infection as they once did many years ago.       According to UpToDate, Common variable immunodeficiency is the most common form of severe antibody deficiency in adults and kids. It is somewhat complex, but in general is due to severe antibody deficiency due to impaired B cell differentiation with defective immunoglobulin production. Recurrent infections, chronic lung disease, GI disease and increased susceptibility to lymphoma are common. Besides having very low IgG, IgA and IgM levels, there is also a poor or absent response to vaccinations.      Feel free to comb through the literature on this one, and while it is not ultra common, it is not unreasonable to consider this in your patients who just can’t seem to avoid getting sick on a regular basis, or who happen to have significantly waned immunity to pathogens they were once immunized for.   Thanks to Dr. Peiterson for bringing this baffling diagnosis to our attention, and to everyone else involved in presenting this case.

Pat and Pete are back with their picks for the last time before college bowl season begins.With Pat still leading by ten beers, Pete will need to get four of his five picks right to have a chance at the most epic comeback in podcast game-picking history.This week’s slate of games:SEC ChampionshipAlabama -13.5 vs. Georgia (3:30)Big 12 ChampionshipOklahoma -8 vs. Texas (8:00)Big Ten ChampionshipOhio State -14.5 vs. Northwestern (13:00)Pac-12 ChampionshipWashington -5.5 vs. Utah (17:00)ACC ChampionshipClemson -27.5 vs. Pittsburgh (23:00)And, as always, the guys give their Six Pack Picks for “lock of the week.” (30:00)Have a beer you'd like to recommend or a game you want them to pick in a future podcast? Leave either in a review and we'll try to get to as many as we can. Thanks for listening! See acast.com/privacy for privacy and opt-out information.

The purpose of this podcast is to describe the interdisciplinary assessment and management of a complex patient with advanced pulmonary disease and dementia, with a focus on the patient and family as the unit of care.

This podcast will describe the interdisciplinary assessment and management of a complex patient with advanced dementia and weight loss, who is facing a decision to withdraw or withdraw and restart artificial nutrition.

The purpose of this podcast is to describe the interdisciplinary approach to the assessment and management of chronic pain in a patient with an indolent cancer and a history of substance use disorder.

The purpose of this podcast is to describe both evidence-based practice and collaborative practice undertaken by a professional team--physician, nurse, and social worker--providing ongoing care for the patient with severe and progressive renal dysfunction.

(October 26, 2017) Dr J is once again Todd Wilkin's guest on Issues, Etc. They're discussing the current sexual abuse scandal surrounding Harvey Weinstein, California's new "non-binary" gender designation, and not-so-nefarious goings-on at the recent Values Voters Summit. We made mention of the articles Dr J penned on the subjects: The Toxic Ideas that Enabled Weinstein and Others and The Medical Risks of Homosexuality and the Values Voters Summit. Also: more information on Issues's annual Making the Case Conference.

Dr. Jeffery Holmes: Emergency Department Presentations of Gastric Bypass Complications   Reproduced with permission from https://www.downeastem.org/

Original Air Date: June 9, 2017 at the Issues, Etc. Making the Case Conference Details: Do you believe in a false christ? Pastor Richard's interview of his new book, "Will the Real Jesus Please Stand Up?" at the 'Issues, Etc. Making the Case Conference.'

Student philanthropy continues to be a hot topic in higher education. Just about every institution hosts some form of student philanthropic engagement. The goal is to engage students in causes that they are passionate about, help students thank current donors, and if we do it right, help students understand the importance of giving back as future alumni. Josh Harraman and Felicity Meu are experts with years of experience with successful student philanthropy programs. I’m proud to serve as faculty with them in the upcoming Engaging Students in Philanthropy Symposium, put together by CASE this coming August. I got Josh and Felicity on the line to talk about the state of student philanthropy, what we’re talking about this year, and what the future holds for this crucial higher education effort. Josh and Felicity offer great insights on how to engage students in philanthropy. We’re talking about a lifetime relationship with your alma mater here, and increasingly, institutions are working to start that deep philanthropic relationship before students graduate. Engaging students with the causes they care about, and inviting them to thank current donors can go a long way to making that happen. Join us at the 2017 Engaging Students in Philanthropy Symposium, August 3-5, as part of the CASE Conference for Student Advancement in Columbus. It’s the biggest event of the year for student philanthropy programs. And if you are hearing this podcast after the symposium, head over to CASE.org to find resources on accelerating your student philanthropy program, including the CASE ASAP network, the premier network for student philanthropy. Check out the Symposium program and registration at: http://www.case.org/CSA17/ESPS17_Home.html

Student philanthropy is a hot topic these days, with just about all higher education institutions organizing some student giving program.  Two experts on this topic are Collin Hennessy at Penn and Lori Hurvitz at University of Chicago. In advance of the upcoming CASE conference for student advancement, and the Engaging Students in Philanthropy Symposium, which they are helping put together, I got these two experts on the phone to talk about their take on student philanthropy, current research, and their suggestions for the best ways to engage students around giving while they are still on campus. CASE Conference for Student Advancement and Engaging Students in Philanthropy Symposium: http://www.case.org/CSA16/ESPS16_Home.html Episode Description: Colin D. Hennessy and Lori Hurvitz join the podcast to talk about the Conference for Student Advancement and the Engaging Students in Philanthropy Symposium that they're organizing together. Colin is the executive director for the Penn Fund at University of Pennsylvania and Lori is the senior director of Annual Giving at the University of Chicago. They both discuss the future of philanthropy, what institutions are doing right, and how behind-the-trend institutions can get up-to-speed with their student philanthropy. Key Takeaways: [1:25] How did Colin and Lori get involved with student philanthropy? [3:45] How are the best institutions engaging their students right now? They're starting philanthropy early. [6:15] Students are naturally very philanthropic. Millennials are engaged in causes. [6:35] What suggestions do Colin and Lori have for institutions who are just starting down this path? [7:50] Look at your own culture and see what's important to your students. [8:15] Colin and Lori talk about the Engaging Students in Philanthropy Symposium they're organizing. [10:45] Colin recently finished his dissertation and talks about his study on the influence of learning and annual giving. [11:45] There's a lack of understanding as to why philanthropy is important on college campuses. [12:05] Lori discusses her research and her dissertation on building a culture of student philanthropy. [13:25] What is the University of Chicago currently doing to engage students in philanthropy? [15:00] What is Colin's university doing right with philanthropy? [17:50] The conference will be held at the Omni Hotel at CNN Center in Atlanta on Aug 4th through Aug 6th. Quotes: "Student philanthropy is a great way to engage students and it gets students to connect with alumni and role models." "Student philanthropy gives us an opportunity to educate students early." "Students are, by their nature right now, very philanthropic. Students have causes these days."

As many as 98,000 people in America may die each year due to medical errors. Interprofessional education seeks to reduce medical error through increased communication and teamwork. UNE’s IPE Case Competition team presents their winning root cause analysis to demonstrate a 360-degree perspective on patient safety in today's health care system and how it might be improved

Through the lens of one veteran and family, raise your awareness of the benefits of interprofessional health practice; become better acquainted with the roles of other health professionals; develop knowledge related to person-centered care

Click here for audio of lecture.