Podcasts about eliquis

This week we will discuss possible treatment methods for AFIB.   Atrial fibrillation (AFib) is a common type of irregular heart rhythm (arrhythmia) that occurs when the upper chambers of the heart (atria) beat chaotically and out of sync with the lower chambers (ventricles). This can lead to a variety of symptoms, including: Palpitations (a feeling of a racing or irregular heartbeat) Fatigue Shortness of breath Dizziness or lightheadedness Chest discomfort ​ AFib can increase the risk of blood clots, stroke, heart failure, and other heart-related complications. ​ Treatment Options for AFib Management of AFib focuses on controlling the heart rate and rhythm, preventing blood clots, and addressing underlying conditions contributing to the arrhythmia. The choice of treatment depends on the individual's symptoms, overall health, and risk factors. 1. Medications Medications are often the first line of treatment for AFib. These include: Rate-Control Medications Aim to slow the heart rate to a normal range. Common drugs: Beta-blockers (e.g., metoprolol), calcium channel blockers (e.g., diltiazem, verapamil), and digoxin. Rhythm-Control Medications Help restore and maintain a normal heart rhythm. Common drugs: Antiarrhythmics like amiodarone, flecainide, or sotalol. Anticoagulants (Blood Thinners) Reduce the risk of stroke by preventing blood clots. Examples: Warfarin, direct oral anticoagulants (DOACs) like apixaban (Eliquis) or rivaroxaban (Xarelto). 2. Ablation Therapy Ablation is a minimally invasive procedure aimed at correcting the electrical signals causing AFib. It is typically recommended for individuals who: Do not respond to or cannot tolerate medications. Have recurrent or persistent AFib that significantly impacts quality of life. Types of ablation: Catheter Ablation Uses thin tubes (catheters) inserted into blood vessels to deliver energy (radiofrequency or cryotherapy) to destroy small areas of heart tissue causing abnormal electrical signals. Surgical Ablation (Maze Procedure) Often performed during open-heart surgery for other conditions, creating scar tissue to block abnormal signals. Both options have high success rates, but catheter ablation is more commonly performed due to its minimally invasive nature. Choosing the Right Treatment Deciding between medications or ablation depends on factors such as: The severity and frequency of symptoms. The presence of other medical conditions. Patient preference and lifestyle. Consultation with a cardiologist or electrophysiologist is crucial to tailor treatment to the individual's needs.

Are you still a little confused about the redesign of Part D of this AEP?  There are some changes you need to understand.  There is also a solution to help your clients get their prescription drugs.  It's the Canadian Medstore.  In this episode of The Broker Link, The Brokerage Inc. Executive Vice President, Josh Slattery talks with Bill Hepscher about the top drugs offered by The Candian Medstore you can offer your clients for only $50 a month. Those drugs include:  Eliquis (5 mg) Xarelto (20 mg) Farxiga (10 mg) Pradaxa (150 mg) Breo Ellipta (200 mcg) Ventolin HFA (100 mcg) Spiriva (18 mcg) Janumet (50/1000 mg) Januvia (100 mg) Symbicort (200/6 mcg) You can find a direct link to the Canadian Medstore on our website, www.thebrokerageinc.com.  You can also sign up on the Sunfire customer intake form.  You can find that information on our website too.      

Understanding Medicare Part D and the Inflation Reduction Act Kathe Kline is joined by Andrew Saul, Sales Director at Physicians Mutual, to delve into the complexities surrounding Medicare Part D and the changes ushered in by the Inflation Reduction Act. Key points of discussion included the new $2,000 out-of-pocket cap and its impact on seniors, along with price negotiation for prescription drugs. One of the major hurdles discussed was the inability of Medicare to negotiate drug prices, which has historically driven up costs for seniors. Andrew Saul illustrated this disparity with the example of Eliquis, a popular blood thinner. Non-Medicare recipients might pay $10 a month, while those on Medicare face costs upwards of $500 monthly without manufacturer coupons. Kathe shared her firsthand experience with prescription costs during her recent COVID-19 quarantine. The difficulty in navigating prescriptions, particularly the high cost and obstacles to obtaining Paxlovid, highlighted a larger issue within the system. She emphasized the restrictions Medicare beneficiaries face with manufacturer coupons, which can drastically reduce prescription costs for others. Andrew and Kathe explored the balancing act between allowing pharmaceutical companies to profit while ensuring fair drug pricing. Even with laws like the Insulin Savers Act capping prices, the lack of generic options keeps costs high. Andrew noted that new regulations will enable Medicare to negotiate prices for 10 high-cost drugs starting in 2026, but the scale of change is limited. The Inflation Reduction Act, passed in August 2022, is poised to bring changes such as Medicare's newfound ability to negotiate drug prices. Despite this advancement, critics argue for a more comprehensive and expedited implementation. Kathe contrasted the U.S. healthcare system with Europe's, noting Europe's more effective cost management due to direct government negotiations with drug manufacturers. Andrew offered insights into upcoming changes and the importance of well-informed agents in guiding clients through Medicare's intricacies. He emphasized that periodic drug plan reviews are crucial for cost savings. As we await further changes prompted by the Inflation Reduction Act, staying informed and proactive remains essential for Medicare beneficiaries and advisors alike. This episode is sponsored by CertifiedMedicareAgents.com

Taxpayers are expected to save billions after the Biden administration inked deals with pharmaceutical companies to knock down the list prices for 10 of Medicare's costliest drugs. But how much older Americans can expect to save when they fill a prescription at their local pharmacy remains unclear, since the list cost isn't the final price people pay. After months of negotiations with manufacturers, list prices will be reduced by hundreds—in some cases, thousands—of dollars for 30-day supplies of popular drugs used by millions of people on Medicare, including blood thinners, diabetes drugs and blood cancer medications. The reductions, which range between 38% and 79%, take effect in 2026. Taxpayers spend more than $50 billion yearly on the 10 drugs, which include popular blood thinners Xarelto and Eliquis, and diabetes drugs Jardiance and Januvia. With the new prices, the administration says savings are expected to total $6 billion for taxpayers and $1.5 billion overall for some of the 67 million people who rely on Medicare. Details on those calculations, however, have not been released. And the White House said it could not provide an average cost-savings for individual Medicare enrollees who use the drugs. That's because there are a number of factors—from discounts to the coinsurance or copays for the person's Medicare drug plan—that determine the final price a person pays when they pick up their drugs at a pharmacy. The new drug prices are likely to most benefit people who use one of the negotiated drugs and are enrolled in a Medicare plan with coinsurance that leaves enrollees to pay a percentage of a drug's cost after they've met the deductible, said Tricia Neuman, an executive director at the health policy research nonprofit KFF. “It is hard to say, exactly, what any enrollee will save because it depends on their particular plan and their coinsurance,” Neuman said. “But for the many people who are in the plans that charge coinsurance, the lower negotiated price should translate directly to lower out-of-pocket costs.” This article was provided by The Associated Press.

Good morning from Pharma and Biotech daily: the podcast that gives you only what's important to hear in Pharma e Biotech world.Medicare has revealed the results of drug price negotiations, showing $6 billion in savings for taxpayers from talks involving drugs like Eliquis and Xarelto. Lilly has opened an R&D hub in Boston, while Ovid and Lexicon are facing layoffs. A journal has retracted papers on MDMA-assisted therapy, and Evotec is cutting jobs and exiting gene therapy. Galderma has received FDA approval for a skin condition treatment, and trends in cell therapy research and market strategies of pharma giants are being explored. The impact of AI technology on clinical trials, patient-centric commercialization strategies, and upcoming events in the biopharma industry are also discussed.Texas is suing the Biden administration over a nursing home staffing mandate requiring at least 3.48 hours of care per resident each day. A report accuses HCA of driving away doctors and downgrading care at Mission Hospital after acquiring it. Medicare drug price cuts may have limited early impact but could have bigger future implications for drug research. Nurses may need their own AI documentation tools due to complex work and shifting tasks. Additionally, Medicaid has overtaken Medicare Advantage as a concern for health insurers in the second quarter. The text also includes information on updating healthcare sales approaches and using data to improve patient outcomes.Pfizer and BioNTech's COVID-flu shot candidate faced setbacks in Phase III trials, potentially giving Moderna an advantage with its superior vaccine. Medicare negotiated drug prices touted by the Biden-Harris administration are criticized as hollow victories. Other news includes Lycos slashing its workforce, Bavarian Nordic's potential windfall with an emergency vaccine, and AstraZeneca's Imfinzi scoring FDA approvals. Layoff announcements in the biopharma industry are also highlighted. The role of Quality Assurance and Regulatory Affairs (QARA) professionals in market access is explored.Walmart's ad unit has experienced significant growth, with ad sales from marketplace sellers increasing by nearly 50% in fiscal Q2. The digital economy is expected to expand, particularly in online retail and online travel. Marketers are increasingly turning to first-party data strategies and behavioral data to enhance their marketing efforts. Industry Dive provides insights and news for marketing leaders, covering topics such as brand strategy, social media, video marketing, and more. Companies can post press releases on Marketing Dive to share announcements with a wide audience.

Audio roundup of selected biopharma industry content from Scrip over the business week ended 2 August 2024. In this episode: Pfizer bullish on its oral GLP-1; BMS's rising confidence about Medicare pricing of Eliquis; more long term data for Leqembi; NewAmsterdam's CETP inhibitor shows promise; and a look at Mankind's Bharat Serums buy. https://scrip.citeline.com/SC150698/Quick-Listen-Scrips-Five-MustKnow-Things Playlist: soundcloud.com/citelinesounds/sets/scrips-five-must-know-things

Send us a Text Message.When my daughter Hope graced the podcast with her presence, her story wasn't just a chronicle of living with a single ventricle heart at 29—it was a profound testament to her strength amid her gender transition. Our conversation unveils the seamless integration of her heart health with her journey of self-discovery, all while providing tangible advice for those who feel the pull of the pen and the thrill of authorship. Hope's insights on her upcoming book light the way for aspiring writers, proving that even with life's hurdles, one's voice and story are paramount.Flipping through the pages of Hope's past, we're reminded of the days when storytelling was a fledgling passion, cultivated through pen pals and children's magazines. The revelation of a bucket list in college sparked a monumental shift from engineering to writing, a decision that charted the course for my current literary adventures. Sharing these moments isn't just about nostalgia—it's about tracing the delicate threads that weave together to form a writer's identity, culminating in the excitement of discussing her latest book.For anyone out there who's ever doubted the path of a writer, let this episode serve as a beacon. We'll journey through the landscape of crafting narratives, the role of supportive writing communities, and the reality of financial expectations in the writing world. The serendipity of connecting with a publisher keen on LGBT+ stories is a reminder that sometimes, the stars align in unexpected ways, providing the chance to see one's work in the hands of eager readers. Join us for a heart-to-heart that celebrates the written word and the unwavering spirit of those who dare to write it.Hope's previous Heart to Heart with Anna Appearances:Congenital Heart Defects and Gender Identity: https://www.buzzsprout.com/62761/11506572Celebrating 300 Episodes of “Heart to Heart with Anna"https://www.buzzsprout.com/62761/8240177Sports and Extra-Curricular Activities for CHD Survivorshttps://www.buzzsprout.com/62761/398939Surviving a Long Hospital Stayhttps://www.buzzsprout.com/62761/398934Writer's League of Texas Agents and Editor's Conference (2024)https://writersleague.org/calendar/2024-agents-editors-conference/Armadillocon (2024)https://armadillocon.org/d46/Rattling Good Yarnshttps://rattlinggoodyarns.com/Slug Tribehttp://www.slugtribe.org/We appreciate it when people support Hearts Unite the Globe podcasts. Thank you to our newest supporters -- Annie Ulchak (Patreon) and Judy Miller (Buzzsprout)!Support the Show.Anna's Buzzsprout Affiliate LinkBaby Blue Sound CollectiveSocial Media Pages:Apple PodcastsFacebookInstagramMeWeTwitterYouTubeWebsite

Bristol-Myers Squibb started the year on a strong note, demonstrating their presence in the pharmaceutical industry. Their top-line growth in the first quarter was in line with internal forecasts, with products such as Eliquis, Opdivo, Reblozyl, Yervoy, and Breyanzi contributing to performance. The ability to sustain this momentum was a point of emphasis on the call.Alongside sound financials, Bristol-Myers Squibb has seen sales growth for its major brands. They have recorded key wins in their pipeline development, including cell therapy approvals and the launch of new trials. The acquisitions of Mirati Therapeutics, Karuna Therapeutics, RayzeBio, and SystImmune have enlarged the company's scope for growth, indicating planning beyond financial fortitude.Consumer trend analysis from the earnings call points towards an increased demand for products like Opdivo, Camzyos, and Sotyktu. Despite inventorial and gross-to-net impacts, products such as Eliquis, Opdivo, Reblozyl, and Breyanzi witnessed sales growth. The company plans to increase Sotyktu's commercial volume this year, in response to demonstrated consumer demand.Bristol-Myers Squibb's future strategy focuses on optimizing decision-making processes, refining its portfolio, and directing attention to high return on investment initiatives. The company projects significant cost savings by 2025, planning to reallocate these savings into growth brands and research and development. This signals an investment in fostering innovation and driving pragmatic growth. Future plans include the launch of KarXT for schizophrenia, and ramping up clinical programs for Krazati, RayzeBio's radioligand platform, and SystImmune's bispecific ADC.As the CEO mentioned in the earnings call, Bristol-Myers Squibb is relying on Opdivo as an important cog in the growth wheel of the company's future. This reliance on Opdivo is part of the larger growth strategy, indicating Bristol-Myers Squibb's focus on introducing innovative treatments in the field of life sciences. However, as with all business strategies, the outcomes will depend heavily on execution and market response. This brings forth the uncertainty associated with the future in spite of clear strategic direction and strong past performances. As much as Bristol-Myers Squibb has set its compass for a promising future, the path remains fraught with the challenges typical to the pharmaceutical industry. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.theprompt.email

Contributor: Travis Barlock MD Educational Pearls: Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes Use of anticoagulants with INR > 1.7 or  PT >15 Warfarin will reliably increase the INR Current use of Direct thrombin inhibitor or Factor Xa inhibitor  aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)  Intracranial or intraspinal surgery in the last 3 months Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding Current intracranial or subarachnoid hemorrhage History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK Recent (within 21 days) or active gastrointestinal bleed Hypertension BP >185 systolic or >110 diastolic Administer labetalol before thrombolytics to lower blood pressure Timing of symptoms Onset > 4.5 hours contraindicates tPA Platelet count < 100,000 BGL < 50 Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics References 1. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532 2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211 Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

Dr. Mindy answers questions about Joey's medical study, never trusting a fart, Heather's overwhelming amount of pee, weight loss surgery in Mexico, gout, Eliquis, Cervical Pre-Cancer, high liver enzymes, the virus tri-fecta, back pain, diverticulitis, Healthline.com, Moonesta, showing early during pregnancy, active babies, your 2nd brain, the HPV vaccine and Move Free Ultra.See omnystudio.com/listener for privacy information.

Good morning from Pharma and Biotech Daily, the podcast that gives you only what's important to hear in the Pharma and Biotech world. In our first news, Bayer shares fell by 20% after a study monitors halted a planned 18,000-person trial of its experimental blood thinner drug due to "inferior efficacy" compared to Eliquis. Bristol Myers is also facing a delay from the FDA on a decision regarding its cancer cell therapy. Astrazeneca has created a digital health unit called Evinova to tap into the growing market for digital health solutions. And fewer biotech companies are going public, but Carmot Therapeutics has filed plans to go public in hopes of capitalizing on investor interest in obesity medicines. Janet Woodcock, a top FDA official, will retire early next year after 37 years with the agency.Moving on to our second news, the Federal Trade Commission has filed a lawsuit to block John Muir Health's acquisition of Tenet Hospital, claiming it would reduce competition and increase prices. Mass General Brigham is being sued after potential exposure to HIV and hepatitis at Salem Hospital. Nurses and medical professionals are planning a five-day strike at HCA facilities in southern California. On the other hand, Novant Health plans to buy three Tenet hospitals in South Carolina for $2.4 billion. Telehealth is also highlighted as a growing trend for routine and mental healthcare.Next up, Bayer's investigational factor XIA inhibitor was found to be inferior to Pfizer and BMS' blood thinner Eliquis in a Phase III study. The UK's National Health Service has reached a new deal with pharmaceutical companies that doubles the annual allowed growth in sales of branded medicines. Carmot Therapeutics is planning to make its debut on the NASDAQ stock exchange. Servier is considering filing for FDA approval for its glioma candidate vorasidenib.Lastly, Biohaven aims to develop a novel drug called taldefgrobep alfa that can treat spinal muscular atrophy (SMA) as well as trim fat and build lean muscle mass in obese individuals. Clinical trial diversity has decreased, prompting companies to refine their diversity, equity, and inclusion strategies. The development of new drugs that can address multiple health issues simultaneously shows promise for improving patient outcomes and expanding treatment options.These developments highlight the challenges faced by pharmaceutical companies in developing new drugs and the importance of partnerships between healthcare systems and industry players to advance research and improve patient outcomes.That's all for today's episode of Pharma and Biotech Daily. Stay tuned for more updates.

A look at the history of antiplatelet, anticoagulation medications over their history and how we use them and reverse them today! All the medications that can make you bleed. Aspirin, plavix, coumadin, Xarelto, Effient, Eliquis, and many more. https://dralo.net/links

The federal government announced it has selected the first 10 drugs it will negotiate for lower prices with pharmaceutical firms. The Centers for Medicare and Medicaid Services selected the drugs, all of which are covered under Medicare Part D. The 10 drugs — Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara and Fiasp/NovoLog — accounted for .5 billion of total costs for Medicare's Part D program from June 2022 to May 2023. Medicare plans to use the cost savings to place a ,000 limit on enrollees' of out-of-pocket expenditures for drugs starting in 2026. But it could delay innovation...Article Link

Mark Twain once said, “Never put off till tomorrow, what you can do the day after tomorrow.” As an antidote to that Ralph welcomes Professor Piers Steel, author of “The Procrastination Equation: How to Stop Putting Things Off and Start Getting Stuff Done.” Plus, Ralph urges listeners to sign up for The Capitol Hill Citizen Association, another way to organize citizens to put pressure on the branch of our government where things must get done, the United States Congress.  Dr. Piers Steel is one of the world's leading researchers and speakers on the science of motivation and procrastination. Dr. Steel is a professor in the Organizational Behaviour and Human Resources area at the University of Calgary, and is the Brookfield Research Chair at the Haskayne School of Business. He is the author of The Procrastination Equation: How to Stop Putting Things Off and Start Getting Stuff Done.The root of procrastination is impulsiveness. Impulsiveness is valuing the now more than the later… We're designed to value the now. And this was really adaptive for a long time. It's not a bad trait. It's just that we've designed a world to take advantage of every little flaw that we have in our decision-making system.Dr. Piers SteelYou have to deal with yourself as an imperfect, flawed creature and deal with the reality of that. We're not robotic angels of perfection. We have limitations. And when I actually act within my limitations, I get stuff done.Dr. Piers SteelWe're superstars of self-control in the animal kingdom. We're able to hunt and kill most anything because we're willing to actually put in the delay of gratification. That's really what makes us great. But we're still not ready for things that are happening even a year off, much less five or ten.Dr. Piers SteelMore people will listen to what we just said about becoming part of the Capitol Hill Citizen Association and say to themselves, “I'm going to get around to doing that,” than the actual number of people who do it in a prompt period of time. So it would be very good to listen to Professor Steel's suggestions and read his book, because we cannot afford procrastinatory citizens. We have a procrastinatory Congress, and the citizens have got to get them to anticipate, to foresee, to forestall so many of the omnicidal urgencies that are coming at our country and other countries around the world.Ralph NaderTo become a member of the Capitol Hill Citizen Association, click here.In Case You Haven't Heard with Francesco DeSantis1. On August 28th, 20 groups – ranging from Left-wing anti-war organizations like Veterans for Peace to Right-leaning government transparency groups like R Street Institute – sent a letter to the Chairs and Ranking Members of the House and Senate Armed Services Committees demanding they maintain Rep. Jamaal Bowman's Cost of War amendment in the final National Defense Authorization Act. This provision “requires public disclosure about the cost of the U.S.' overseas military footprint and gives the American people greater transparency on military spending.” Hopefully, the left-right consensus on this issue is enough to maintain this amendment.2. In other Pentagon news, the Intercept reports that Rep. Matt Gaetz, Republican of Florida, has introduced an amendment demanding the Pentagon “collect information on trainees who overthrow their governments,” following the recent spate of coups in Africa. Gaetz told the Intercept “The Department of Defense, up until this point, has not kept data regarding the people they train who participate in coups to overthrow democratically elected — or any — governments.” This could become a flashpoint as Congress prepares to consider the 2024 NDAA when it returns from recess in September.3. As expected, tensions are running high in Guatemala following the upset victory of anti-corruption crusader Bernardo Arevalo. Opponents of Arevalo had urged the country's electoral tribunal to suspend his Semilla party on dubious legal grounds, which the tribunal resisted hewing to the letter of the law which dictated such actions could not be taken during the electoral process. After the election however, the party was officially suspended. Now, Reuters reports that suspension has been revoked, following a mass mobilization of Arevalo supporters in Guatemala City. It seems unlikely however that Arevalo's political opponents will accept his victory without a fight.4. In a dangerous, anti-free speech move, the Attorney General of Georgia has filed RICO indictments against 42 individuals involved with the Stop Cop City protest movement, the Atlanta Community Press Collective reports. This is the latest in a long line of attempts to quash opposition to the project, which has so far included trumped up domestic terrorism charges and arrests for handing out flyers.  5. Bloomberg reports that President Biden and Brazilian President Lula will jointly call for new worker protections at the upcoming General Assembly of the United Nations. While the article notes the two leaders have been “at odds” over China and Russia, they align on the topic of labor unionization. The two presidents have found common ground before, such as on the issue of climate change.6. Visual Effects workers at Disney have filed for unionization, per the Hollywood Reporter. Approximately 80% of VFX staff have already signed union cards, demanding an NLRB election and representation by the International Alliance of Theatrical Stage Employees or IATSE. This comes on the heels of a similar announcement by VFX workers at Marvel, a Disney subsidiary. In recent years. studios have increasingly relied on VFX workers in a rather blatant attempt to cut costs, as VFX workers have generally been non-union.7. At long last, the Department of Health and Human Services has announced the first ten drugs that will be subject to Mecicare negotiations to bring down prices. These are: Eliquis, Jardiance, Xarelto, Januvia Farxiga, Entresto, Enbrel, Imbruvica, Stelara and – crucially – several brands of insulin. HHS noted that “These selected drugs accounted for $50.5 billion in total [Medicare] Part D gross covered prescription drug costs, or about 20%, of total Part D gross between June 1, 2022 and May 31, 2023.”8. The Washington Post reports Acting Labor Secretary Julie Su has proposed new overtime rules intended to “extend overtime pay to an additional 3.6 million salaried white-collar workers in the United States.” According to current rules, workers are exempt from overtime if they make over $35,568 per year; the new rules would extend to workers making under $55,000 annually. If implemented, this would mean a whole new class of workers would be eligible for time-and-a-half pay if they work more than 40 hours per week.9. Per Republic Report: “The U.S. Department of Education announced…that it is cancelling $72 million in student loan obligations for more than 2,300 former students who attended for-profit Ashford University between 2009 and 2020.” Yet, even now the shady operators behind Ashford may still be able to squeeze money out of the taxpayers via a convoluted buyout by the University of Arizona Global Campus. Still, this marks a significant victory in a legal battle that has raged for over a decade, with Senator Tom Harkin of Iowa calling Ashford a “complete scam” all the way back in 2011.10. Finally, in more debt related news, the Philadelphia Inquirer has published a piece detailing how the nonprofit RIP Medical Debt was able to purchase – and forgive – over $1.6 million in medical debt. As the piece explains “When hospitals or physician groups have delinquent debts they have little chance of collecting on, they'll typically go to what's called the secondary market and sell their portfolios for pennies on the dollar.” It was on this secondary market that RIP Medical Debt was able to buy $1.6 million worth of debt for just $17,000. In celebration, “30 proud, self-described gutter-pagan, mostly queer dirtbags in their early 30s,” gathered for a ritual burning of an oversized medical bill. Someone chanted “debt is hell” and the crowd responded “let it burn.” Get full access to Ralph Nader Radio Hour at www.ralphnaderradiohour.com/subscribe

Politisches Risiko und hoch im Kurs Wer meine Podcasts Börsenminute und GELDMEISTERIN schon länger verfolgt, weiß, dass ich Pharmaaktien für mein Langfristportfolio als eine wichtige Säule favorisiere und das tue ich auch weiterhin. Nur: durch die letzten starken Anstiege vor allem beim skandinavischen Shootingstar Novo Nordisk (Stichwort Diabetesmedikamente, die als Abnehmpille Furore machen) bin ich dabei, mein Pharma-Portfolio zu Rebalancieren, sprich einen Teil der Kursraketen zu verkaufen, um den Gesundheitstitel-Anteil und so mein Klumpenrisiko wieder zu reduzieren. Oder mir maximal die jüngsten Rohrkrepierer wie Roche zumindest genauer anzuschauen. Denn Risiko-behaftet sind Gesundheitstitel in jedem Fall und da denke ich nicht einmal an etwaige Nebenwirkungen, die in der Vergangenheit schon des Öfteren zu sündteuren Klagen geführt haben. Nein, es sind die Bewertungen, die ich teilweise nicht mehr gesund finde. Eli Lilly zum Beispiel hat in den letzten fünf Jahren um 430 Prozent zugelegt. Das Kurs-Gewinn-Verhältnis liegt bei knapp 56. Soll heißen, ich muss - aus heutiger Sicht wohlgemerkt - 56 Jahre warten, bis ich den Preis für die Aktie hereinverdient habe. Das dauert mir zu lange, auch wenn ich ihnen viel Gewinnsteigerungspotenzial noch zutraue. Man sollte keinesfalls das politische Risiko der Branche unterschätzen. Joe Biden hat gerade zehn Medikamente auf seiner Watchlist, die seinen „Inflation Reduction Act“ konterkarieren. Hier wird gerade mit Bristol-Myers, Johnson & Johnsohn, Merck, Novo Nordisk, Boehringer Ingelheim, Novartis, Amgen & Co gefeilscht, welche Preise das staatliche Gesundheitssystem künftig nur noch für die Arznei bereit ist zu bezahlen und das ist nicht unerheblich. Zum einen, schreibt die Financial Times, droht ihnen eine Besteuerung von 65 bis 95 Prozent, zum anderen ein Ausschluss aus dem Gesundheitsprogramm Medicare, was tragisch wäre, da es teilweise zu 50 Prozent ihre Umsätze in den USA sichert. Die konkreten Medikamente, deren Preise für Biden´s Geschmack zu hoch sind, findet ihr hier im Beipackzettel zu dieser Börsenminute: • Eliquis von Bristol-Myers Squibb (NYSE:BMY); • Jardiance von Boehringer Ingelheim; • Xarelto von Johnson & Johnson (NYSE:JNJ); • Januvia von Merck (NYSE:MRK); • Farxiga von AstraZeneca (NASDAQ:AZN); • Entresto von Novartis (NYSE:NVS); • Enbrel von Amgen (NASDAQ:AMGN); • Imbruvica von AbbVie (NYSE:ABBV); • Stelara von Janssen (im Besitz von JNJ); • Fiasp, Fiasp FlexTouch, Fiasp PenFill, NovoLog, NovoLog FlexPen, NovoLog PenFill von Novo Nordisk (NYSE:NVO). Rechtshinweis: Dies ist die Meinunung der Autorin und keine Anlageempfehlung. Was ihr daraus macht ist Eure Sache, Julia Kistner übernimmt hierfür keine Haftung. #Börse #investment #Pharmatitel #Inflationreductionact #Aktien #podcast Foto: Unsplash

  Unpacking the first Medicare drug price negotiation list, the NAIFA, FSP, and Life Happens merger, Apple's Wonderlust Event and more!    Follow Us on Social! Ritter on Facebook, https://www.facebook.com/RitterIM Instagram, https://www.instagram.com/ritter.insurance.marketing/ LinkedIn, https://www.linkedin.com/company/ritter-insurance-marketing TikTok, https://www.tiktok.com/@ritterim Twitter, https://twitter.com/RitterIM and Youtube, https://www.youtube.com/user/RitterInsurance Sarah on LinkedIn, https://www.linkedin.com/in/sjrueppel/ Instagram, https://www.instagram.com/thesarahjrueppel/ and Threads, https://www.threads.net/@thesarahjrueppel  Tina on LinkedIn, https://www.linkedin.com/in/tina-lamoreux-6384b7199/   Resources: 4 Effective Techniques for Closing Insurance Sales: https://agentsurvivalguide.podbean.com/e/4-effective-techniques-for-closing-insurance-sales/ Best Practices for Conducting an Interview featuring Dylan Cook: https://agentsurvivalguide.podbean.com/e/best-practices-for-conducting-an-interview-featuring-dylan-cook/ CMS Announces First 10 Drugs for Medicare Drug Price Negotiation: https://www.ritterim.com/blog/cms-announces-first-10-drugs-for-medicare-drug-price-negotiation/ How to Overcome Common Insurance Sales Objections ft. Dan Ford: https://agentsurvivalguide.podbean.com/e/how-to-overcome-common-insurance-sales-objections-ft-dan-ford/ Understanding the C-SNP Product & Opportunity ft. Ben Miller (Zing Health): https://agentsurvivalguide.podbean.com/e/understanding-the-c-snp-product-opportunity-ft-ben-miller-zing-health/   References: 5 actual clues in Apple's iPhone 15 Wonderlust event invite: https://www.macworld.com/article/2046187/wonderlust-event-invite-clues-colors-apple-watch-iphone-15-airpods.html Apple announces the iPhone 15 launch event: https://www.theverge.com/2023/8/29/23819494/apple-september-event-iphone-15-pro-watch-ultra-date Apple Events: https://www.apple.com/apple-events/ Blood thinners, diabetes meds among first 10 drugs for US price negotiations: https://www.reuters.com/business/healthcare-pharmaceuticals/us-name-first-10-drugs-medicare-price-negotiation-2023-08-29/ Eliquis, Jardiance, Xarelto headline CMS' price negotiation list: https://www.fiercehealthcare.com/payers/eliquis-jardiance-xarelto-headline-cms-price-negotiated-drug-list Factsheet: Medicare Drug Price Negotiation Program: https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf HHS Selects the First Drugs for Medicare Drug Price Negotiation: https://www.hhs.gov/about/news/2023/08/29/hhs-selects-the-first-drugs-for-medicare-drug-price-negotiation.html Medicare Price Negotiation: Ten Drugs That Made the List, and Ten That Should Have: https://prospect.org/health/2023-08-30-medicare-price-negotiation-first-ten-drugs/ NAIFA, FSP and Life Happens announce plan to unite: https://insurancenewsnet.com/innarticle/naifa-fsp-and-life-happens-announce-plan-to-unite Strike Force Five: https://open.spotify.com/show/3YnUJC2alA6I1F2V7CdDa2?si=781e5bb1354e4406 The Late-Night Dudes Are Doing a Daytime Pod: https://www.vulture.com/article/late-night-hosts-podcast-strike-force-five.html

Florida Gov and GOP 2024 also-ran Ron DeSantis looks to lead in wake of violence and major hurricane | Former SC Gov and UN Ambassador under President Trump, Nikki Haley is having a moment, kind of | President Biden names first 10 drugs subject to negotations with Medicare | 60th anniversary of the March on WashingtonSong playsIntro by hostWelcome to Heartland Pod Wednesday!Support this show and all the work in the Heartland POD universe by going to heartlandpod.com and clicking the link for Patreon, or go to Patreon.com/HeartlandPod to sign up. Membership starts at $1/month, with even more extra shows and special access at the higher levels. No matter the level you choose, your membership helps us create these independent shows as we work together to change the conversation.Alright! Let's get into it: Hurricane in Florida / Shooting in FloridaPOLITICO: DeSantis knows how to handle a hurricane. The racist shooting poses a bigger dilemma.A racially-motivated Jacksonville tragedy, couple with a looming storm, pose big tests for the governor.Florida Gov. Ron DeSantis, center and his wife Casey, right, bow their heads during a prayer.Florida Gov. Ron DeSantis (center) and his wife Casey bow their heads during a prayer at a vigil for the victims of Saturday's mass shooting on Sunday, Aug. 27, 2023, in Jacksonville. | John Raoux/AP PhotoBy KIMBERLY LEONARD08/28/2023 04:14 PM EDTUpdated: 08/28/2023 05:12 PM EDTMIAMI — Florida Gov. Ron DeSantis' handling of back-to-back crises — a racist mass shooting and a potentially catastrophic hurricane — could help burnish his image as a can-do, effective governor or further damage his standing with Black Americans who have grown livid over his policies.Already, DeSantis' attempts to show leadership in the immediate aftermath of the Saturday shooting were poorly received by some Black lawmakers, Democrats and residents in Florida. In the hours after a 21-year-old white man killed three Black Floridians near a historically Black college in Jacksonville, several state Democrats blamed DeSantis, who is running for president, for creating an environment, through policies such as loosening gun laws and ending diversity programs, that helped hate fester.DeSantis has condemned the shooting and said “targeting people due to their race has no place in this state of Florida.” But attending a Sunday night vigil in Jacksonville, he was jeered and booed by people who had come out to remember the victims. At one point, a Jacksonville Democratic councilmember stepped in to calm the crowd, urging people to “put parties aside.” Later during the event, a pastor took issue with DeSantis describing the gunman as a “scumbag,” and said he should have used the word “racist” instead.The vigil stood in contrast to press conferences in Tallahassee on Sunday and Monday, when DeSantis appeared visibly tired but spoke authoritatively about preparations overseeing Tropical Storm Idalia, which is forecast to become a major hurricane. He canceled campaign appearances and fundraisers, and told Floridians Sunday they could “rest assured” because “I am here” and would “get the job done.”DeSantis says politics won't interfere with storm response“He needs to be in Florida for as long as it takes,” said Adam Hollingsworth, the former chief of staff to Sen. Rick Scott (R-Fla.), who served as governor before DeSantis. “His presidential ambitions could be a distraction, but first Gov. DeSantis has to dance with the one who brought him. Right now, that's the people of Florida.”Though the shooting and looming storm are taking DeSantis away from campaigning for president following a high-profile debate, they'll also allow voters and donors to see the governor at work leading the hurricane response, letting the public assess how he balances multiple priorities, displays empathy and projects leadership in moments of tragedy. At the same time, the shooting has shined a spotlight on DeSantis' record and vulnerabilities on race, one of the areas for which he has faced the most criticism and controversy as governor.In times of tragedy, opponents are “looking for a misstep,” acknowledged Craig Fugate, who led Florida's emergency division under Gov. Jeb Bush and oversaw FEMA during the Obama administration.“They're looking for something to go wrong — particularly for the opponents; they're looking for something to capitalize on,” Fugate said.DeSantis began his Monday morning hurricane preparedness press conference by first addressing the mass shooting. He pledged $1 million in security funding to Edward Waters University, a historically Black university that the gunman is believed to have initially targeted, as well as $100,000 toward a charity for the families of the victims. He also deployed state law enforcement officials to evaluate the campus' security and make additional recommendations, pledging to continue to assist in the “days and weeks ahead.”But many Democrats in the state panned his response. They pointed to laws he enacted in Florida to carve up representation in a Black-majority district that eventually led a Black Democratic congressman, Rep. Al Lawson, to lose his seat. They also pointed to his policies, approved by the GOP-led Legislature, banning what he calls “critical race theory” in schools, as well as his defense of a public school curriculum on Black history that required middle-school teachers to instruct that enslaved people “developed skills which, in some instances, could be applied for their personal benefit.”Florida Minority House Leader Fentrice Driskell, a Black Democrat of Tampa, said it was “absolutely” the right decision for DeSantis to attend the vigil but added that she didn't want to give him a pass.“The reality is, a number of wrongheaded decisions about the state of Florida, and who we are as a people, I think contributed to this charged political climate that resulted in the violence that we saw,” Driskell said in an interview.The accused gunman, identified as Ryan Palmeter, had a racist manifesto and drew swastikas on his weapons. He also had a history of mental illness, having been involuntarily institutionalized for emergency mental health services as a teenager, police said.During DeSantis' vigil remarks Sunday, Democratic state Rep. Angela Nixon, who represents the district where the shooting took place, could be seen glaring at the governor in videos and photos widely shared on social media.“We feel the same,” the NAACP wrote on X, the social media platform formerly known as Twitter.AXIOS: Biden set to name first 10 drugs subject to Medicare negotiations.The blood-thinners Eliquis and Xarelto are among the 10 prescription medicines the Biden administration will seek lower Medicare prices for as part of a new program allowing the government to negotiate drug prices for America's seniors.Why it matters: The administration's landmark announcement Tuesday detailed the first-ever set of drugs subject to Medicare price negotiations, a longtime Democratic priority included in last year's Inflation Reduction Act over drug companies' fervent objections.Other drugs up for negotiation include:Jardiance, a diabetes drug.Januvia, also for diabetes.Farxiga, another diabetes drug.Entresto, for heart failure.Enbrel, for arthritis and psoriasis.Imbruvica, a blood cancer drug.Stelara, used on psoriasis, Crohn's disease and other illnesses.Fiasp, also used for diabetes.Of note: Insulin is already subject to a $35 monthly co-pay cap for Medicare prescription drug plan enrollees under a different provision of the IRA.State of play: The drugs' manufacturers will have just over a month to decide whether to participate in negotiations — which the industry is battling in court — or sit out the process, at the risk of significant financial penalty.Drugmakers who refuse to negotiate with Medicare face an excise tax of up to 95% of their U.S. sales, or they can withdraw their drugs from Medicare and Medicaid coverage, shutting them out of huge markets.What they're saying: "The cancer moonshot will not succeed if this administration continues to dismantle the innovation rocket we need to get there," Stephen Ubl, CEO of industry trade group PhRMA, said in a statement following the release of the list.Zoom out: The medicines up for negotiation were chosen from a list of the 50 products with the highest spending in Medicare's prescription drug program, Part D.The selected drugs accounted for 20% of Part D prescription costs between June 1, 2022 and May 31, 2023, according to the Health and Human Services Department.Some of the highest-cost Medicare drugs were not eligible for this round of negotiations, either because they still have market exclusivity, they're the only option for a rare disease or another factor.The prices won't take effect before the 2024 elections, but Democrats are expected to tout the negotiations, along with other drug cost reforms in the IRA, as part of their campaign messaging.What's next: The Centers for Medicare and Medicaid Services will submit price offers to the drug companies by Feb. 1, with negotiations continuing until next August.CMS will publish the drugs' final maximum fair prices by Sept. 1, 2024, and prices will go into effect in 2026.What we're watching: Ongoing legal challenges could draw out or halt the negotiation process.Drugmakers and allied groups have already filed eight lawsuits against the Medicare drug negotiation process, and more lawsuits could follow Tuesday's announcement.President Biden and his health officials committed this morning to fighting industry lawsuits."Let me be clear: I am not backing down. There is no reason why Americans should be forced to pay more than any developed nation for life-saving prescriptions just to pad Big Pharma's pockets," Biden said in a statement.Nikki HaleyDAILY BEAST: Is it time for Republicans to take Nikki Haley seriously?According to a new Emerson College Polling survey, “Haley saw the largest increase in support among Republican candidates, jumping 5 points from 2 percent to 7 percent” following last week's debate.“Nikki Haley's support increased from about 2 percent to 9 percent among voters over 50 [years of age],” said Spencer Kimball, executive director of Emerson College Polling, “while Trump's support dropped within this age group from about 56 percent to 49 percent after the debate.”Republican Debaters Agreed on One Thing: They Hate Vivek RamaswamyThis jump is modest, inasmuch as it still leaves Haley in the single digits. But it's also no outlier. According to a poll conducted by The Washington Post, FiveThirtyEight, and Ipsos released last Thursday, voters were persuaded to at least give her a second look. “Pre-debate, 29 percent of GOP primary voters who watched the debate said they were considering voting for her,” according to the survey, “and that increased to 46 percent after the debate.”So how did she do it? Haley caught our attention by being first to hit Trump (from the right), when she criticized him for “adding eight trillion to our debt.” This surprised everyone, demonstrated courage, and put to rest the notion that she is merely running to be Trump's vice president.Haley also staked out a strong position on abortion. While stressing her pro-life beliefs, she made the pragmatic case that a federal abortion ban would require 60 votes. Instead, Haley urged Republicans to focus on consensus issues, like banning late-term abortions, making sure contraception is widely available, and supporting adoption as an alternative.Trump's former veep, Mike Pence, who supports a 15-week federal ban on abortion, took umbrage with this. “Nikki, you're my friend, but consensus is the opposite of leadership,” Pence scolded. (As the Never Trump conservative writer Jonah Goldberg has pointed out on his podcast, building consensus is often a key attribute of leadership.)The Republican Debate Was a Futile Pudding Wrestling MatchThis exchange, like others during that same debate, made it clear that in a general election Nikki Haley would likely be Joe Biden's most challenging opponent.Having served as governor of South Carolina and ambassador to the United Nations, she has the experience needed for the office. She also has sharp elbows. (“You have no foreign policy experience and it shows,” she told Vivek Ramaswamy.)At 51, Haley would present a stark contrast in terms of generational change, assuming that Joe Biden was still the Democratic nominee. And (unlike others) she is not staking out an abortion position that might render her effectively unelectable, should she become the Republican nominee.Haley (who frequently cites Margaret Thatcher's line, “If you want something said, ask a man. If you want something done, ask a woman”) was the only woman on that stage. Her identity, temperament, and policy positions could help chip away at the gender gap that has only grown in recent years.The obvious caveat here is that all of these things would make Haley a great candidate to beat Joe Biden if she somehow wins the Republican nomination. But that's an awfully big “if.”Kareem Abdul-Jabbar: GOP Debate Showed How Not to Pick a PresidentHaley's answer to this is to make the electability argument: “We have to face the fact that Trump is the most disliked politician in America,” she—and she, alone—averred during last week's debate.But will that dog hunt?Right now, the electability argument isn't persuading Republicans to jump off the Trump bandwagon, even though that argument is likely the only one that could ever work. At some point (perhaps after Donald Trump goes on trial and it's too late), Republicans might be convinced that, as entertaining as Trump is, he simply can't win.Based on all of this, you might expect me to suggest that it's time to clear the field—to rally every freedom conservative, Reagan Republican, and Never Trump conservative to coalesce around Haley as the GOP's last, best hope.Some of my colleagues are already there. The New York Times columnist David Brooks, for example, declared last week that “Wednesday's debate persuaded me that the best Trump alternative is not [Tim] Scott, it's Nikki Haley.”But here's my problem. Haley has been all over the map for years now. One day she's courageous and impressive, and the next day she's a pathetic Trump toady.Haley is a political chameleon, which makes me reluctant to ever trust her again.Trump and Ramaswamy Show Us How the Worst Get to the TopOn the other hand, anyone looking for purity (as it pertains to Trump) can also dismiss Pence and Chris Christie—both of whom supported Trump until Jan. 6—and a vast swath of today's leading Never Trumpers. As the Good Book says, “Who then can be saved?”Nikki Haley's got a long way to go before she clears the not-Trump lane of candidates, much less taking on the final boss himself. And though nothing has yet made a dent in Trump's domination of the GOP voter base, he's never run as a candidate on trial before. But the whole 91-felony indictment thing might just do the trick.If Haley can prove herself by stringing together two or three of these kinds of courageous performances—in which she not only characterizes Trump as the guy who already lost to Biden, but also that she's as real a conservative as any of the other contenders—there is a path to success.It's hardly guaranteed, and as I've noted, courage comes and goes with Haley. But in the “Matt Lewis primary,” you can count me among the 46 percent who are now considering voting for her.Read more at The Daily Beast.SEMAFOR: Nikki Haley's abortion message could catch on in the GOPMorgan Chalfant and Kadia GobaRepublicans worried about Democrats leveraging abortion (again) to make gains in 2024 want GOP candidates to take a page out of Nikki Haley's debate prep playbook.Haley dismissed the idea that a 15-week national abortion ban could pass through Congress. Instead, she argued the focus should be on finding “consensus” around banning “late-term abortions,” sustaining access to contraception, allowing doctors who don't support abortion refuse to perform them, and preventing women who get abortions from being penalized.Defeated Michigan gubernatorial candidate Tudor Dixon bluntly said on Fox News that Republicans would lose the messaging war in 2024 unless they followed Haley's “perfect response” in the debate.“No one really understood how important abortion would be in 2022 because no one had run in a post-Roe world, so we suddenly got attacked, viciously attacked, by the Democrats, and it is a winning message for them,” she said. Gov. Gretchen Whitmer highlighted Dixon's opposition to rape exceptions in abortion bans in their contest, which took place alongide a ballot initiative guaranteeing abortion rights that passed by a wide margin.“The only candidate on the stage that talked about how we should protect women and not demonize them was Nikki Haley,” Rep. Nancy Mace, R-S.C. said Sunday on CBS of the first GOP presidential debate. “And that is a message that we have to carry through. We have to be pro-woman and pro-life. You cannot go after women and attack them because they make a choice that you don't like or don't agree with.”And Rep. George Santos, R-N.Y., who represents a district President Biden won in 2020, told Semafor at a watch party last week: “She had probably the best-packaged message on abortion that I've heard, I want to say, in my entire adult life.”Haley might have won herself some fans, but her position wasn't a favorite within the anti-abortion movement, which has rallied around a 15-week federal ban as a minimum ask for candidates.

Florida Gov and GOP 2024 also-ran Ron DeSantis looks to lead in wake of violence and major hurricane | Former SC Gov and UN Ambassador under President Trump, Nikki Haley is having a moment, kind of | President Biden names first 10 drugs subject to negotations with Medicare | 60th anniversary of the March on WashingtonSong playsIntro by hostWelcome to Heartland Pod Wednesday!Support this show and all the work in the Heartland POD universe by going to heartlandpod.com and clicking the link for Patreon, or go to Patreon.com/HeartlandPod to sign up. Membership starts at $1/month, with even more extra shows and special access at the higher levels. No matter the level you choose, your membership helps us create these independent shows as we work together to change the conversation.Alright! Let's get into it: Hurricane in Florida / Shooting in FloridaPOLITICO: DeSantis knows how to handle a hurricane. The racist shooting poses a bigger dilemma.A racially-motivated Jacksonville tragedy, couple with a looming storm, pose big tests for the governor.Florida Gov. Ron DeSantis, center and his wife Casey, right, bow their heads during a prayer.Florida Gov. Ron DeSantis (center) and his wife Casey bow their heads during a prayer at a vigil for the victims of Saturday's mass shooting on Sunday, Aug. 27, 2023, in Jacksonville. | John Raoux/AP PhotoBy KIMBERLY LEONARD08/28/2023 04:14 PM EDTUpdated: 08/28/2023 05:12 PM EDTMIAMI — Florida Gov. Ron DeSantis' handling of back-to-back crises — a racist mass shooting and a potentially catastrophic hurricane — could help burnish his image as a can-do, effective governor or further damage his standing with Black Americans who have grown livid over his policies.Already, DeSantis' attempts to show leadership in the immediate aftermath of the Saturday shooting were poorly received by some Black lawmakers, Democrats and residents in Florida. In the hours after a 21-year-old white man killed three Black Floridians near a historically Black college in Jacksonville, several state Democrats blamed DeSantis, who is running for president, for creating an environment, through policies such as loosening gun laws and ending diversity programs, that helped hate fester.DeSantis has condemned the shooting and said “targeting people due to their race has no place in this state of Florida.” But attending a Sunday night vigil in Jacksonville, he was jeered and booed by people who had come out to remember the victims. At one point, a Jacksonville Democratic councilmember stepped in to calm the crowd, urging people to “put parties aside.” Later during the event, a pastor took issue with DeSantis describing the gunman as a “scumbag,” and said he should have used the word “racist” instead.The vigil stood in contrast to press conferences in Tallahassee on Sunday and Monday, when DeSantis appeared visibly tired but spoke authoritatively about preparations overseeing Tropical Storm Idalia, which is forecast to become a major hurricane. He canceled campaign appearances and fundraisers, and told Floridians Sunday they could “rest assured” because “I am here” and would “get the job done.”DeSantis says politics won't interfere with storm response“He needs to be in Florida for as long as it takes,” said Adam Hollingsworth, the former chief of staff to Sen. Rick Scott (R-Fla.), who served as governor before DeSantis. “His presidential ambitions could be a distraction, but first Gov. DeSantis has to dance with the one who brought him. Right now, that's the people of Florida.”Though the shooting and looming storm are taking DeSantis away from campaigning for president following a high-profile debate, they'll also allow voters and donors to see the governor at work leading the hurricane response, letting the public assess how he balances multiple priorities, displays empathy and projects leadership in moments of tragedy. At the same time, the shooting has shined a spotlight on DeSantis' record and vulnerabilities on race, one of the areas for which he has faced the most criticism and controversy as governor.In times of tragedy, opponents are “looking for a misstep,” acknowledged Craig Fugate, who led Florida's emergency division under Gov. Jeb Bush and oversaw FEMA during the Obama administration.“They're looking for something to go wrong — particularly for the opponents; they're looking for something to capitalize on,” Fugate said.DeSantis began his Monday morning hurricane preparedness press conference by first addressing the mass shooting. He pledged $1 million in security funding to Edward Waters University, a historically Black university that the gunman is believed to have initially targeted, as well as $100,000 toward a charity for the families of the victims. He also deployed state law enforcement officials to evaluate the campus' security and make additional recommendations, pledging to continue to assist in the “days and weeks ahead.”But many Democrats in the state panned his response. They pointed to laws he enacted in Florida to carve up representation in a Black-majority district that eventually led a Black Democratic congressman, Rep. Al Lawson, to lose his seat. They also pointed to his policies, approved by the GOP-led Legislature, banning what he calls “critical race theory” in schools, as well as his defense of a public school curriculum on Black history that required middle-school teachers to instruct that enslaved people “developed skills which, in some instances, could be applied for their personal benefit.”Florida Minority House Leader Fentrice Driskell, a Black Democrat of Tampa, said it was “absolutely” the right decision for DeSantis to attend the vigil but added that she didn't want to give him a pass.“The reality is, a number of wrongheaded decisions about the state of Florida, and who we are as a people, I think contributed to this charged political climate that resulted in the violence that we saw,” Driskell said in an interview.The accused gunman, identified as Ryan Palmeter, had a racist manifesto and drew swastikas on his weapons. He also had a history of mental illness, having been involuntarily institutionalized for emergency mental health services as a teenager, police said.During DeSantis' vigil remarks Sunday, Democratic state Rep. Angela Nixon, who represents the district where the shooting took place, could be seen glaring at the governor in videos and photos widely shared on social media.“We feel the same,” the NAACP wrote on X, the social media platform formerly known as Twitter.AXIOS: Biden set to name first 10 drugs subject to Medicare negotiations.The blood-thinners Eliquis and Xarelto are among the 10 prescription medicines the Biden administration will seek lower Medicare prices for as part of a new program allowing the government to negotiate drug prices for America's seniors.Why it matters: The administration's landmark announcement Tuesday detailed the first-ever set of drugs subject to Medicare price negotiations, a longtime Democratic priority included in last year's Inflation Reduction Act over drug companies' fervent objections.Other drugs up for negotiation include:Jardiance, a diabetes drug.Januvia, also for diabetes.Farxiga, another diabetes drug.Entresto, for heart failure.Enbrel, for arthritis and psoriasis.Imbruvica, a blood cancer drug.Stelara, used on psoriasis, Crohn's disease and other illnesses.Fiasp, also used for diabetes.Of note: Insulin is already subject to a $35 monthly co-pay cap for Medicare prescription drug plan enrollees under a different provision of the IRA.State of play: The drugs' manufacturers will have just over a month to decide whether to participate in negotiations — which the industry is battling in court — or sit out the process, at the risk of significant financial penalty.Drugmakers who refuse to negotiate with Medicare face an excise tax of up to 95% of their U.S. sales, or they can withdraw their drugs from Medicare and Medicaid coverage, shutting them out of huge markets.What they're saying: "The cancer moonshot will not succeed if this administration continues to dismantle the innovation rocket we need to get there," Stephen Ubl, CEO of industry trade group PhRMA, said in a statement following the release of the list.Zoom out: The medicines up for negotiation were chosen from a list of the 50 products with the highest spending in Medicare's prescription drug program, Part D.The selected drugs accounted for 20% of Part D prescription costs between June 1, 2022 and May 31, 2023, according to the Health and Human Services Department.Some of the highest-cost Medicare drugs were not eligible for this round of negotiations, either because they still have market exclusivity, they're the only option for a rare disease or another factor.The prices won't take effect before the 2024 elections, but Democrats are expected to tout the negotiations, along with other drug cost reforms in the IRA, as part of their campaign messaging.What's next: The Centers for Medicare and Medicaid Services will submit price offers to the drug companies by Feb. 1, with negotiations continuing until next August.CMS will publish the drugs' final maximum fair prices by Sept. 1, 2024, and prices will go into effect in 2026.What we're watching: Ongoing legal challenges could draw out or halt the negotiation process.Drugmakers and allied groups have already filed eight lawsuits against the Medicare drug negotiation process, and more lawsuits could follow Tuesday's announcement.President Biden and his health officials committed this morning to fighting industry lawsuits."Let me be clear: I am not backing down. There is no reason why Americans should be forced to pay more than any developed nation for life-saving prescriptions just to pad Big Pharma's pockets," Biden said in a statement.Nikki HaleyDAILY BEAST: Is it time for Republicans to take Nikki Haley seriously?According to a new Emerson College Polling survey, “Haley saw the largest increase in support among Republican candidates, jumping 5 points from 2 percent to 7 percent” following last week's debate.“Nikki Haley's support increased from about 2 percent to 9 percent among voters over 50 [years of age],” said Spencer Kimball, executive director of Emerson College Polling, “while Trump's support dropped within this age group from about 56 percent to 49 percent after the debate.”Republican Debaters Agreed on One Thing: They Hate Vivek RamaswamyThis jump is modest, inasmuch as it still leaves Haley in the single digits. But it's also no outlier. According to a poll conducted by The Washington Post, FiveThirtyEight, and Ipsos released last Thursday, voters were persuaded to at least give her a second look. “Pre-debate, 29 percent of GOP primary voters who watched the debate said they were considering voting for her,” according to the survey, “and that increased to 46 percent after the debate.”So how did she do it? Haley caught our attention by being first to hit Trump (from the right), when she criticized him for “adding eight trillion to our debt.” This surprised everyone, demonstrated courage, and put to rest the notion that she is merely running to be Trump's vice president.Haley also staked out a strong position on abortion. While stressing her pro-life beliefs, she made the pragmatic case that a federal abortion ban would require 60 votes. Instead, Haley urged Republicans to focus on consensus issues, like banning late-term abortions, making sure contraception is widely available, and supporting adoption as an alternative.Trump's former veep, Mike Pence, who supports a 15-week federal ban on abortion, took umbrage with this. “Nikki, you're my friend, but consensus is the opposite of leadership,” Pence scolded. (As the Never Trump conservative writer Jonah Goldberg has pointed out on his podcast, building consensus is often a key attribute of leadership.)The Republican Debate Was a Futile Pudding Wrestling MatchThis exchange, like others during that same debate, made it clear that in a general election Nikki Haley would likely be Joe Biden's most challenging opponent.Having served as governor of South Carolina and ambassador to the United Nations, she has the experience needed for the office. She also has sharp elbows. (“You have no foreign policy experience and it shows,” she told Vivek Ramaswamy.)At 51, Haley would present a stark contrast in terms of generational change, assuming that Joe Biden was still the Democratic nominee. And (unlike others) she is not staking out an abortion position that might render her effectively unelectable, should she become the Republican nominee.Haley (who frequently cites Margaret Thatcher's line, “If you want something said, ask a man. If you want something done, ask a woman”) was the only woman on that stage. Her identity, temperament, and policy positions could help chip away at the gender gap that has only grown in recent years.The obvious caveat here is that all of these things would make Haley a great candidate to beat Joe Biden if she somehow wins the Republican nomination. But that's an awfully big “if.”Kareem Abdul-Jabbar: GOP Debate Showed How Not to Pick a PresidentHaley's answer to this is to make the electability argument: “We have to face the fact that Trump is the most disliked politician in America,” she—and she, alone—averred during last week's debate.But will that dog hunt?Right now, the electability argument isn't persuading Republicans to jump off the Trump bandwagon, even though that argument is likely the only one that could ever work. At some point (perhaps after Donald Trump goes on trial and it's too late), Republicans might be convinced that, as entertaining as Trump is, he simply can't win.Based on all of this, you might expect me to suggest that it's time to clear the field—to rally every freedom conservative, Reagan Republican, and Never Trump conservative to coalesce around Haley as the GOP's last, best hope.Some of my colleagues are already there. The New York Times columnist David Brooks, for example, declared last week that “Wednesday's debate persuaded me that the best Trump alternative is not [Tim] Scott, it's Nikki Haley.”But here's my problem. Haley has been all over the map for years now. One day she's courageous and impressive, and the next day she's a pathetic Trump toady.Haley is a political chameleon, which makes me reluctant to ever trust her again.Trump and Ramaswamy Show Us How the Worst Get to the TopOn the other hand, anyone looking for purity (as it pertains to Trump) can also dismiss Pence and Chris Christie—both of whom supported Trump until Jan. 6—and a vast swath of today's leading Never Trumpers. As the Good Book says, “Who then can be saved?”Nikki Haley's got a long way to go before she clears the not-Trump lane of candidates, much less taking on the final boss himself. And though nothing has yet made a dent in Trump's domination of the GOP voter base, he's never run as a candidate on trial before. But the whole 91-felony indictment thing might just do the trick.If Haley can prove herself by stringing together two or three of these kinds of courageous performances—in which she not only characterizes Trump as the guy who already lost to Biden, but also that she's as real a conservative as any of the other contenders—there is a path to success.It's hardly guaranteed, and as I've noted, courage comes and goes with Haley. But in the “Matt Lewis primary,” you can count me among the 46 percent who are now considering voting for her.Read more at The Daily Beast.SEMAFOR: Nikki Haley's abortion message could catch on in the GOPMorgan Chalfant and Kadia GobaRepublicans worried about Democrats leveraging abortion (again) to make gains in 2024 want GOP candidates to take a page out of Nikki Haley's debate prep playbook.Haley dismissed the idea that a 15-week national abortion ban could pass through Congress. Instead, she argued the focus should be on finding “consensus” around banning “late-term abortions,” sustaining access to contraception, allowing doctors who don't support abortion refuse to perform them, and preventing women who get abortions from being penalized.Defeated Michigan gubernatorial candidate Tudor Dixon bluntly said on Fox News that Republicans would lose the messaging war in 2024 unless they followed Haley's “perfect response” in the debate.“No one really understood how important abortion would be in 2022 because no one had run in a post-Roe world, so we suddenly got attacked, viciously attacked, by the Democrats, and it is a winning message for them,” she said. Gov. Gretchen Whitmer highlighted Dixon's opposition to rape exceptions in abortion bans in their contest, which took place alongide a ballot initiative guaranteeing abortion rights that passed by a wide margin.“The only candidate on the stage that talked about how we should protect women and not demonize them was Nikki Haley,” Rep. Nancy Mace, R-S.C. said Sunday on CBS of the first GOP presidential debate. “And that is a message that we have to carry through. We have to be pro-woman and pro-life. You cannot go after women and attack them because they make a choice that you don't like or don't agree with.”And Rep. George Santos, R-N.Y., who represents a district President Biden won in 2020, told Semafor at a watch party last week: “She had probably the best-packaged message on abortion that I've heard, I want to say, in my entire adult life.”Haley might have won herself some fans, but her position wasn't a favorite within the anti-abortion movement, which has rallied around a 15-week federal ban as a minimum ask for candidates.

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Find links to all the following stories as well as other law and legal-adjacent stories at esq.social Links. On this day in history August 29, 1957, the Civil Rights Act of 1957 was passed by congress – the first piece of federal legislation aimed at civil rights since reconstruction.Prompted by the Supreme Court's landmark 1954 ruling in Brown v. Board of Education, which ignited public debate on school desegregation, the act aimed to address the widespread disenfranchisement of African Americans in the Southern United States. President Dwight D. Eisenhower initially proposed the bill to bolster federal protection for African American voting rights, a pressing issue given that only about 20% of black people were registered to vote by 1957.However, the act faced considerable opposition in Congress, particularly from Southern Democrats who were engaged in a campaign of "massive resistance" against desegregation and civil rights reforms. Amendments like the Anderson–Aiken and O'Mahoney jury trial amendments were successful in diluting the act's potency. Senator Strom Thurmond notably conducted the longest one-person filibuster in Senate history in an attempt to block the legislation.Despite these setbacks, the act did pass, albeit in a watered-down form orchestrated by Senate Majority Leader Lyndon B. Johnson. While the act had a limited immediate impact on African American voter participation due to the removal of stringent voting protection clauses, it laid important groundwork for future civil rights legislation. It established the United States Commission on Civil Rights and the United States Department of Justice Civil Rights Division, both of which would play crucial roles in the enforcement of civil rights laws.The act also set the stage for more robust civil rights legislation in the 1960s, including the Civil Rights Act of 1960, the Civil Rights Act of 1964, the Voting Rights Act of 1965, and the Civil Rights Act of 1968. These later acts would build upon the foundation laid by the 1957 act, offering more comprehensive protections against discrimination and disenfranchisement. Overall, the Civil Rights Act of 1957 was a pivotal, if imperfect, step in the long journey toward civil rights and equality in America.The Biden administration has targeted 10 prescription drugs for price negotiations under Medicare, aiming to cut their costs by half on average by 2026. This move is part of Biden's Inflation Reduction Act, which was signed into law a year ago to address the high cost of medicines in the U.S. Among the drugs targeted are Eliquis, a blood thinner by Bristol-Myers Squibb and Pfizer, and AstraZeneca's Farxiga, which treats diabetes and heart failure. These drugs alone accounted for significant spending, with Eliquis costing Medicare $16 billion in the year through May 2023.Previously, the U.S. government was prohibited from negotiating drug prices due to a 2003 law that created Medicare's Part D program. However, the Inflation Reduction Act has mandated these negotiations. The drugs selected for this round of negotiations account for nearly $51 billion, or about 20% of Part D's prescription drug costs. Around 9 million people on Medicare took these drugs and paid $3.4 billion out-of-pocket last year.Pharmaceutical companies have criticized the move, arguing that it threatens innovation and intellectual property rights. Johnson & Johnson, which has two drugs on the list, stated that the policies put an "artificial deadline on innovation." The Pharmaceutical Research and Manufacturers of America (PhRMA) also warned that giving the government the power to set prices could have "significant negative consequences."The drug industry is currently suing to block these negotiations, and companies like Merck, Bristol, J&J, and AstraZeneca have each filed lawsuits. The U.S. Chamber of Commerce is also seeking an injunction to halt the negotiations. Analysts project a manageable impact on industry revenue, estimating as much as a 5% hit. However, the government expects that the price negotiations will save Medicare $100 billion through 2031.Bristol, Lilly Blockbusters Targeted for Medicare Price Cuts (1)US names first 10 drugs for Medicare price negotiation | ReutersU.S. states are increasingly focusing on "opportunity transparency" to address pay gaps, requiring companies to be more transparent about promotion opportunities. Illinois and Colorado have enacted laws that will take effect in 2025 and next year, respectively, mandating employers to disclose information about promotions. New Jersey also has pending legislation on this issue. These efforts build on pay disclosure laws initiated in Colorado in 2021 and later adopted by states like Washington, New York, California, and Hawaii. These laws primarily aim to address pay disparities affecting women and people of color.The new rules are designed to counter the "shoulder tap" practice, where employees are quietly selected for promotions, often without the knowledge of their co-workers. This lack of transparency disproportionately affects women and minorities. A 2022 study by McKinsey & Co. and LeanIn found that for every 100 men promoted from entry-level to manager positions, only 87 women and 82 women of color are promoted. This contributes to men holding nearly two-thirds of managerial roles despite making up only half of the workforce.Colorado's law imposes fines of up to $10,000 per violation and mandates changes in business practices. It requires companies to notify all employees of job openings and promotions in writing, giving them sufficient time to apply. Amendments to the law will further require businesses to notify employees about all job openings, not just promotions.The Illinois law, effective in 2025, will require companies to announce all potential promotions to their current employees within 14 days of posting a position externally. It will also require the disclosure of salary ranges and a summary of benefits in job ads. These laws aim to have a "cascading impact" on pay equity, complementing other policy efforts like banning employers from asking about applicants' prior salary history.States Put New Spin on Pay Gap Laws With Promotion TransparencyThe American Bar Association (ABA) is forming a new task force to explore the impact of artificial intelligence (AI) on the legal profession. This move comes as law firms increasingly experiment with AI tools like ChatGPT, while also confronting ethical and practical challenges posed by the technology. The ABA Task Force on Law and Artificial Intelligence will be chaired by Lucy Thomson, a lawyer and cybersecurity engineer based in Washington, D.C. The group will include seven special advisors, such as former U.S. Homeland Security Secretary Michael Chertoff and former U.S. Solicitor General Seth Waxman.The task force aims to assess how AI will affect the practice of law, probe ethical questions, and focus on issues like risk management, AI governance, and AI in legal education. ABA President Mary Smith emphasized the need to address both the "promise and the peril" of emerging technologies like AI. The initiative reflects a broader trend of growing interest in AI tools among legal professionals, including law schools considering the use of AI in applications and classrooms.By way of brief biographical background, Lucy Thomson, the group's chair, is the principal at a firm in Washington D.C., Livingston PLLC, that focuses on issues related to cyber security.Michael Chertoff was the co-author of the PATRIOT act, and former Secretary of Homeland Security under George W. Bush. Seth Waxman was Solicitor General of the United States from 1997 through 2001 and is frequently before the Supreme Court. The average age among the team is about 70, they're all lawyers, and none of them have any evident technical expertise.ABA taps prominent lawyers to tackle AI risks, opportunities | ReutersA U.S. District Judge, James Donato, is set to decertify a class-action lawsuit against Google involving 21 million consumers who claimed the tech giant violated federal antitrust laws through its Google Play app store. The decision could significantly reduce any damages that Google might owe for its distribution of Android mobile applications. The judge stated that his previous class certification order from November 2022 should be thrown out, as he decided not to allow an economist to testify as an expert witness for the consumers. This move eliminated an "essential element" of the consumers' argument for class certification. The class action had included consumers from 12 U.S. states and five territories, separate from a similar case brought by state attorneys general against Google.US judge set to decertify Google Play class action | Reuters Get full access to Minimum Competence - Daily Legal News Podcast at www.minimumcomp.com/subscribe

In this episode, Mindy, Ryan, and Jen discuss recent newsworthy items, including legal challenges to the Medicare Drug Price Negotiation Program established by the Inflation Reduction Act.Podcast Tags: healthcare, healthcare news, life sciences, health policy, public health, CMS, HHS, Medicare, drug pricesSource Links: Merck sues to block Medicare negotiation of drug prices Bristol Myers follows Merck's lead with its own ⁠lawsuit blasting IRA's Medicare negotiations PhRMA joins legal battle over Inflation Reduction Act's 'price-setting' measures Explaining the Prescription Drug Provisions in the Inflation Reduction Act Pfizer, BMS' Eliquis tops list of drugs destined for Medicare price negotiations in 2026: Moody's For additional discussion, please contact us at TrendingHealth.com or share a voicemail at  1-888-VYNAMIC.Mindy McGrath, Healthcare Industry Advisor and Head of Public Health Sector Mindy.McGrath@vynamic.comRyan Hummel, Executive and Head of Provider Sector Ryan.Hummel@vynamic.comJen Burke, Director Jen.Burke@vynamic.com

This episode covers the basics of the oral anticoagulant Eliquis. The episode covers the indications, mechanism of action, common dosing, reversal, and a comparison to Coumadin. 

Please Subscribe and Review: Apple Podcasts | RSS Submit your questions for the podcast here News Topic: Mike Rowe The Way I Heard It, episode 294: The Ballad of Tom Odom   Show Notes: Muscular exercise can cause highly pathological liver function tests in healthy men Muscle Protein Synthesis Laura says: Hi Robby and Nicki I'm a 45 year old female and have been listening to lots of things protein related recently. It seems like "experts" from many backgrounds seem to agree on the importance of protein, especially as one ages. Meeting a leucine threshold in a meal seems to be a common consensus as well. I love meat and hit that target with no issue 3x per day. However, what I've never heard any of these protein experts talk about is a "stimulus" threshold for MPS. They all talk about weight lifting being a MPS signal but I've never heard of a minimum required dose. I was wondering if in your reading/learning you've heard anyone talk about the minimum "strength workout" needed to initiate MPS. Or is it relative? Like my doing 2 sets of max rep pull ups gets a little MPS going but an hour long leg workout with leg press, deadlifts, RDLs, split squats triggers more? Any insights here would be appreciated! Thanks :)   Early onset Parkinsons and a different approach Amy says: First I want to say I love you guys. I'm always trying to obtain more knowledge in the health and wellness field as a Firefighter/Paramedic and Fitness Coach as a part time. Your show is easy and fast knowledge. Plus I love LMNT. The chocolate medley is my favorite. Now my question. Recently my husband had a hand tremor experience. Early in the morning in bed where it woke me up. He didn't mention it for a couple days but when he did I realized it concerned him as well. He is your typical male that doesn't want to seek medical advice and had to be dragged to the doctor years ago when I suspected a DVT. We found out he had the largest his physician had seen from his ankle to his hip and 3 PEs. ( Pre covid, no he is not vaccinated) we found out it was a genetic disorder. Since the tremor, in my own research I feel like he has a lot of early signs for Parkinsons which I may be me jumping ( but so was the DVT at the time) but this is so concerning. We take a more functional approach to our health and I was wondering your thoughts on that for Parkinsons. I have a previous client where we found weight training really helped his tremors but also any emotional response could make it worse. My husband is healthy, 45, weight trains multiple times a week and does a lot of zone 2 training. Only medical history is the clotting disorder for which he takes Eliquis. Sorry for the long question. Thanks in advance.   Kidney function and protein with age Dawn says: Hello Robb and Nicki, A friend of mine in her late 40's is following a mostly paleo diet and has been increasing animal proteins and working on resistance training to increase muscle mass the last few years to help with healthy aging, glucose control, maintaining function etc. She has recently started including creatine supplementation to help with brain and muscle function as per all sorts of recommendations from various ppl in the healthy aging and menopause space. She has relatively low body fat (visible abs and shoulder muscles) and has only a couple drinks a week. She uses LMNT daily. She just received blood work results showing higher than normal creatinine and ALT levels and is wondering whether to stop creatine supplements. Also, she will be booking in to see a renal doc to discuss further but is worried because all conventional advise for kidney disease Appears to be: go on a low protein diet, eat vegetable oils, “healthy” whole grains etc….which completely flies in the face of her experience of better health and body comp for years on a more ancestral style diet with increasing protein over time. She has experienced several UTIs in the last year which could be due to estrogen dropping post hysterectomy (therefore she is menopausal) and recently had covid…so there is a history now of urinary infection AND it seems that some people experience renal issues post virus. Any suggestions on protein and creatine? Resources we can research so she can make informed choices? It's scary that the conventional dietary changes are totally opposite what someone needs to do to retain good muscle mass as one ages, and they seem to promote higher glucose levels over time which we know will lead to diabetes. Thanks so much for any light you can shed. It can be difficult when you are trying to buck the normal trend of decline with middle age by doing seemingly the opposite of what the doctors tell us to do. Sponsor: The Healthy Rebellion Radio is sponsored by our electrolyte company, LMNT. Proper hydration is more than just drinking water. You need electrolytes too! Check out The Healthy Rebellion Radio sponsor LMNT for grab-and-go electrolyte packets to keep you at your peak! They give you all the electrolytes want, none of the stuff you don't. Click here to get your LMNT electrolytes

Dr. Naomi Wolf brings up Pfizer's Eliquis that is being made available for reducing blood clots. Those side effects in that package insert though…would make you concerned.

Apple Watch detection of atrial fibrillation; Atrial fibrillation and psychological stress; Eliquis wins in new Afib study; Population screening for atrial fibrillation

Paul Strikwerda is a voice over artist. You may have heard is voice in commercials and other projects. Now, he is also a stroke survivor. The stroke he suffered in his voice over booth engaged multiple primal fears (except for spiders) and is one of the more terrifying I've heard.  I'll save the details for the interview itself. The genesis of this episode is that I wanted an answer to the question, "Is voiceover a good career choice for a stroke survivor contending with disabilities?" I was referred to Paul, by Anne Ganguzza of the VO Boss podcast (another great resource for the VO field), and in this episode Paul and I discuss that question and so much more. If you don't see the audio player below, visit http://Strokecast.com/MSN/VoiceOver to listen to the conversation. Click here for a machine-generated transcript Who is Paul Strikwerda? Paul Strikwerda was born and grew up in the Netherlands. He studied music in college and began a career in radio after graduation. Life eventually took him to the United States and an unexpected series of events led him down the path of a voice over artist. Paul wanted to do more than read scripts for clients. He wanted to help other artists in the VO field. He would go on to write "Making Money In Your PJs: Freelancing for Voice-Overs and Other Solopreneurs"* and expand his blog on NetherVoice. He offers an unvarnished view of what life in the VO field is like and what newcomers need to watch out for. For those who want to grow their skills as voice over artists and voice over business people (you have to be both to succeed) Paul offers coaching programs. As he says on https://www.nethervoice.com/coaching/: It's not enough to be outstanding. You need to stand out. Voice overs are the invisibles of the entertainment industry. Competition is increasing, and clients aren't going to book you if they don't know you exist. You need a plan to put you on the map, so clients can find you, hear you, and hire you. Let me be your visibility coach, and help you attract the jobs you're dreaming of doing. What is the Voice Over field? The Voice Over industry is one most people don't think about, but it is one that we've encountered throughout our lives. Every time we hear a narrator on TV or listen to an audio book or hear a corporate voice mail system or listen to the introduction to this show (Thanks, Tim!) or complete eLearning with a person speaking, or learn about pancakes, we are listening to a voice over artist at work. https://youtu.be/FEelYk8y_O4 The breadth of the field is fascinating. The industry itself is facing some growing pains with technology and the increase in computer generated voices. There are some growing pains there. Technology has also led to a democratization of the field in some respects. Microphones and computers for editing have gotten cheaper and more widely available. Home studios are within reach of more people. Some of the same technology trends that drive podcasts drive voice over work Lots  of people toy with the idea of becoming voiceover artists so, especially at the entry level, there is a ton of competition. As Paul explains, though, it takes a lot more to be successful than the ability to speak into a microphone. A voice over artist needs to be a business person. The need to sell their services. The need to audition well. They need to write contracts and collect from clients. They need to have a handle on the assortment of ways they can license their voice. And they still need to act and edit and produce. If you are thinking about a career in voice over, and you're will to do all the stuff that goes along with it,  Paul's coaching services might be a good fit How does AFib cause stroke? The heart is made up of four chambers. Blood normally flows from the upper right to the lower right to the lungs to the upper left to the lower left and then on to the rest of the body. Moving it efficiently from one place to the next requires a precise rhythm -- the lub-dub of the human heart beat. When someone has AFib, or atrial fibrillation, it means the rhythm isn't quite right sometimes. Maybe different parts of the heart are out of sync, or part vibrates too fast or the heart rhythm itself fluctuates in an odd way. When this happens, blood doesn't always leave the chamber it's in when it's supposed to. And when blood pools or collects in the heart when it shouldn't, it can start to coagulate. It forms clots. Then when the heart beats one of those clots that formed due to AFib can shoot off to another part of the body. If that clot makes it to the brain and gets stuck in a blood vessel, you have an ischemic stroke. So how do you treat it? Well, first you have to find it. Since it is irregular, that's not always easy. Some people will get a surgically installed monitor that will track their heart rhythm for a couple years. Others (like me) will have to wear a device like a Zio patch for two weeks to look for abnormalities. Bill wearing a Zio patch to check for irregular heart rhythm. If doctors find or strongly suspect AFib affects a patient, they have a few treatment options. Blood thinners, or anticoagulants are one option. These medicals like Eliquis and Xarelto are more aggressive at stopping clots than antiplatelet medication like aspirin or Plavix (Clopidogrel). They require additional blood tests and monitoring and put the patient at greater risk of bleeding because that's exactly what their supposed to do. Paul had an ablation therapy. Doctors either freeze or burn some small amount of heart tissue. This disrupts the way electricity flows through the heart, which helps normalize the heartbeat. It's a fascinating technique and eliminated the problem for Paul. You can read more about the procedure from Johns Hopkins or from the Mayo clinic. Some people, if their unusual rhythm is too slow, may need a surgically implanted pacemaker to keep the heart moving enough blood quickly enough. As more people become aware of AFib and research continues, the future of treatment may change dramatically. In defense of social media A lot of people claim to hate social media. The conversation is even louder in December 2022 with Elon Musk's takeover of Twitter. Hate speech, privacy concerns, online bullying, the growth of influencer culture, and more have all made it fashionable to hate on social media. And there are a lot of problems with it. By allowing folks with fringe and extremist views to connect and validate one another's views, it has likely allowed those views to become more common. I'm not defending that. That same mechanism, though, has allowed people with disabilities to find other like-minded folks. Stroke and other disabling conditions are isolating. Appearances of disabled people in media are still rare. After stroke, many folks leave their jobs, removing another vector for social experience. Friends and family members may pull back from stroke survivors either because the survivor is no longer able to participate in the same activities or because they are uncomfortable around a person with disabilities. Or because the survivor is a living reminder that they could find themselves in the same situation. And disabilities themselves make social connection hard. Aphasia impacts conversation. Mobility challenges make it harder to go someplace to meet someone. Vision or equilibrium challenges may make it unsafe to drive. That's to say nothing of the assortment of cognitive, sensory processing, emotional, and fatigue related challenges a survivor may live with. And then we can look beyond the stroke world to our neuro cousins in the MS and TBI communities, and beyond that into the broader world of people with disability. Despite the billion+ disabled people in the world, it's easy to feel the despair of feeling alone. Social media changes that. Or at least helps with it. People with disabilities are able to connect with one another across the street and around the world. There is power in the shared experience -- of finding someone going through a similar experience. There's power and hope in being able to support each other -- to build on the success of others to drive our own recovery and that of others in the community. To be able to raise a voice and say, "This is my hidden reality!" To be able to see that the way someone else treats us may not be right and to have that reinforced by people all over the country. There's power in giving everyone a literal or metaphorical voice. To demonstrate to the world that we're here and we're not going anywhere. Whether it's on Facebook, Instagram, Tik Tok, IRC, MUDDs, Discord, YouTube, or whatever, we can leverage those platforms to empower us to live our best lives. Or to share a simple message of support. Look for communities that resonate with you in a supportive fashion. Follow hashtags like these to start and try others to build your community: #Stroke #StrokeAwareness #StrokeRecovery #BrainInjury #LifeAfterStroke #Aphasia #Mindset #CripTheVote #Disability Social media allows us to connect and that connection is so important to getting more out of life. BEFAST & AHORA Raising voices in social media isn't just about supporting our own lives; it's about saving others. And you can help save other's lives by sharing the stroke warning signs far and wide. We know time is essential. We also know that over the past 20 years or so there have been tremendous changes in stroke treatment - new ways to save lives and reduce the severity of disability. That, of course, assumes treatment begins as soon as possible. And to make that happen, people need to recognize that a stroke is happening and contact emergency services immediately. So share the stroke warning signs in English and Spanish far and wide -- BE FAST and AHORA. And if you have the warning signs to share in another language, share those, too. June Hawkins writing workshop June Hawkins is a stroke survivor in Canada helps stroke survivors connect (or reconnect) with their creativity through the power of writing. Her program is called, "With a Stroke of my Pen" and with her cofacilitator, writing prompts, and exercises she helps other survivors explore their world in writing. The next cohort starts soon. To learn more, visit http://www.withastrokeofmypen.ca/ Hack of the Week There are two things that Paul found critical to going through recovery and living with disability. The first is to have a dedicated partner who can advocate for you. It's not easy to navigate the healthcare industry with sudden, unexpected brain damage, and a supportive partner makes a huge difference. Finding the right person to be your partner in life, of course, is not always the easiest task. The other element which may be easier to cultivate is to develop a "stubborn positivity." The right action-oriented attitude is what gets us developing the right mindset for recovery. It helps us expect to get better and it drives us to do the work -- the exercises, the metal health care, the repetitions, etc. -- that will ultimately help us drive the neuroplastic change in the brain that empowers recovery. Links Where do we go from here? Check out Paul's blog and website at http://NetherVoice.com Share this episode with someone you know by giving them the link http://Strokecast.com/VoiceOver Check out June's writing course at http://www.withastrokeofmypen.ca/ Don't get best…get better More thoughts from Paul

This week on Pharm5: Eliquis v. Xarelto for AFib Improve M&M by quickly titrating HFrEF treatments National Adderall shortage Novavax ok'd as booster Student loan forgiveness application Connect with us! Listen to our podcast: Pharm5 Follow us on Twitter: @LizHearnPharmD References: Dawwas GK, Cuker A, Barnes GD, Lewis JD, Hennessy S. Apixaban versus rivaroxaban in patients with atrial fibrillation and valvular heart disease. Annals of Internal Medicine. October 2022. doi:10.7326/m22-0318 Strong-HF study in patients admitted for acute heart failure (HF) terminated early for superior efficacy. STRONG-HF study in patients admitted for acute heart failure (HF) terminated early for superior efficacy. https://prn.to/3sbDrMv. Published October 13, 2022. Accessed October 14, 2022. Safety, tolerability, and efficacy of rapid optimization, helped by NT-probnp testing, of heart failure therapies - full text view. Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies - Full Text View - ClinicalTrials.gov. https://bit.ly/3MQktVd. Accessed October 14, 2022. Brooks M. FDA confirms nationwide Adderall shortage. Medscape. https://wb.md/3DfXS0O. Published October 14, 2022. Accessed October 14, 2022. FDA drug shortages. FDA. https://bit.ly/3yZiAzG. Accessed October 14, 2022. CDC allows Novavax monovalent COVID-19 boosters for adults ages 18 and older. Centers for Disease Control and Prevention. https://bit.ly/3VM10J9. Published October 19, 2022. Accessed October 20, 2022. Center for Biologics Evaluation and Research. Novavax COVID-19 vaccine. U.S. Food and Drug Administration. https://bit.ly/3eMcbkC. Accessed October 20, 2022. Federal Student Aid. https://bit.ly/3ToNLwC. Accessed October 20, 2022. Duster C. How to qualify for Biden's new student loan forgiveness plan. CNN Politics. https://cnn.it/3ALjKjF. Published Wednesday August 24, 2022. Accessed August 24, 2022. Occupational Employment and Wages, May 2021 - Pharmacists. U.S. Bureau of Labor Statistics. https://bit.ly/3PObHXm. Published March 31, 2022. Accessed August 24, 2022. Smoot C. What is the average pharmacy school debt in 2022? SuperMoney. https://bit.ly/3PHqZNK. Published April 26, 2022. Accessed August 24, 2022.

Apixaban (Eliquis) and rivaroxaban (Xarelto) are commonly used in patients with atrial fibrillation and valvular heart disease, but comparative data is limited. New study compares the risks of stroke, systemic embolism and bleeding events.

****DISCLAIMERS: THESE PRICE COMPARISONS ARE NOT PROMOTIONAL. THE MANUFACTURERS WERE NOT INVOLVED IN THE MAKING OF THIS PODCAST MINISERIES. THESE WERE REQUESTS FROM PODCAST LISTENERS ON DRUG PRICING EXAMPLES ONLY - TO BE USED FOR EDUCATIONAL PURPOSES ONLY AND NOT PROMOTIONAL IN NATURE. NOTE AS WELL THAT ANY OPINIONS EXPRESSED BELOW ARE BY PODCAST HOST AND PHARMACIST, DR. ERIN ALBERT, AND NOT NECESSARILY THOSE OF ANY OF HER EMPLOYERS OR AFFILIATIONS. PRICES AND OFFERS CAN CHANGE AT ANY TIME WITHOUT NOTICE.**** Eliquis (apixaban) is our drug to hunt for the best price today - you'll want to go over to our resource guide, request a copy and then look at the "Eliquis" pricing tab. Our resource guide tracker, which you can request access to here. --- Support this podcast: https://anchor.fm/theedutainer/support

A cry for help from a 70-year-old physician living in a wealthy country. Hi Bob, I wanted to tell you about my experiences with the bad effect of the Covid vaccine on me. 1. I was vaccinated twice with AstraZeneca as a result of pressure from family. I did not take a booster. 2. Despite having normal blood pressure, blood sugars (on Metformin), normal cholesterol (on statins) and on Eliquis (blood thinner), on February 9th, I woke up with severe chest pain around 7 AM. 3. Ambulance was in my bedroom within 10 minutes 4. Cardiogram showed ST-elevation heart attack (n.b. severe type that is frequently fatal)5. Rushed to the hospital and my cardiologist was already waiting for me6. Cardiac stents were used to open my coronary arteries within an hour 7. I saw the blood flow return immediately and the ST elevation and pain went away 8. Troponin (heart enzyme) was zero after 1 week9. Back to work after 1 week Also, my hearing had deteriorated dramatically since the vax. I now have trouble living without a hearing aid. My staff had to shout for me to hear them. RegardsSamDear Sam:Jeez, you knew the truth from my emails, and yet you bowed to idiots. You now know why I call it the clot shot. You got lucky.  The vax is a purpose-designed bioweapon that, like the virus, is being used for genocide. The criminality proven by the Pfizer data dump destroys any of the jab's credibility for treatment or prevention of disease. By the second month after its release, the company knew their injection was going to murder millions worldwide—by then, they had killed 1200 in the US alone—yet they proceeded anyway. Worse: the FDA approved it for babies. The evidence it is evil includes the VAERS database, military records, country comparisons, and insurance data that shows vastly increased population-wide fatalities. Deaths are up by a stunning 40 percent overall and far more in younger people. You damaged your immunity by getting jabbed. So now your chance of dying from COVID and other causes is higher. Vax damage involves multiple organ systems—heart, brain, circulatory system, and general inflammatory conditions that may continue years later. Lots of my friends have died and some had terrible strokes. Your experience is hardly unique. Well, I don't want to lose you. Ignore the advice of jackasses from now on. BestRobert See RobertYoho.substack.com for the complete essay. See RobertYohoAuthor.com to learn about my books, Butchered by “Healthcare” and Hormone Secrets. My essay with links to COVID treatment and more is HERE. “LEGAL” DISCLAIMER: Use this information at your own risk. It is general commentary and not medical advice. Robert Yoho is retired and no longer practices medicine. Make your healthcare decisions with the help of a physician or other licensed provider. Support the show

Looking for a motivation source? Many listeners ask me, how do you stay motivated to exercise?  Meaning, not me,  but for them. If you're asking the same, today's podcasts offers an unlikely motivation source. It's certainly not my usual answer.  00:00 I'd offer something like choosing an activity you love, starting with just 5 or 10 minutes, and pairing the exercise with something or someone you love. But today we dig a little deeper and look at why you might be lacking motivation in the first place.   So, if in fact, it's dopamine, then this.    In addition to motivation, this episode is all about answering questions from our previous episode's listeners.    My Guest: Ken Swartz, aka “Ken the Scientist,” is the Founder and Chief Science Officer of C60 Purple Power, a health and wellness company committed to delivering the highest quality C60 products available.   Ken is back for this second interview and the first interview where we really discuss C60 Purple Power is linked to here.   Ken earned a Master of Science degree from the University of Colorado at Denver and a Bachelor of Science in Economics from Arizona State University. He spent the early part of his career as a secondary school teacher and is passionate about helping and educating people.   Ken has run several research science laboratories over the course of his career and discovered C60 while developing the MOXY fusion reactor. During his research, he became aware of the powerful free radical neutralizing properties of C60.   He first began using C60 as a radiation protectant while leading a fusion reactor project. He noticed, after taking C60 for a couple of months, that not only was it protecting him from the radiation, but it was also improving his overall health. So, he continued taking it.   About 8 months after Ken started taking C60, he was at a routine visit with his optometrist and discovered that his dry Macular Degeneration was gone. The doctor was dumbfounded and told him that in all his years, he had never seen such a miraculous outcome. Due to this healing experience, he decided to dedicate himself to the research, study, and production of C60 Buckminsterfullerene products.   In 2016, he founded C60 Purple Power which offers C60 made with certified organic oils and 99.99% pure sublimated Carbon 60, never exposed to solvents, and sourced in the U.S.   Ken believes that “your health is your responsibility” and he is on a mission to help people feel empowered to take back control of their health.   Ken mentions in the show that one of the first noticeable changes for those trying C60 is motivation. It stems from the boost in dopamine. So, though libido and energy are big draws for many,  C60 is could also be a motivation source if you're seeking a boost.   Questions we answer on this podcast: 06:22 What are the first benefits people usually see when starting C60? 09:00 What I've noticed: enhanced libido, thicker hair/much less hair in the shower drain, recovery quickly (having started some high intensity/high impact interval training recently)  11:28 How long should one take C60 to see the full results? 13:12 If I stop taking C60, do results revert [slowly or quickly] back to original status, depending on lifestyle habits?  14:24 What is the most important instruction to follow when taking C60? 15:32 Does your C60 dosage determine how fast you see results? 17:48 I was wondering if I could get rid of half of my supplements if I start taking this? Would you do a show on supplements and how much you should really be taking?  19:30 How will this affect you if you are on HRT? 20:00 Debra I'd like to know what amount you are taking - you mentioned the cinnamon MTC in a coffee....teaspoon? Tablespoon? Thanks! Cindy   20:41 I take Eliquis, a blood thinner, due to a pacemaker, and am wondering if the C60 purple cream would cause my blood to become thinner, or does it only become thin if you take the liquid C60 purple product. 21:01 Are there any drug interactions?  I am on anastrozole after being treated for breast cancer.  Also any interaction with cholesterol-lowering medication or meds for blood pressure? Kendra 22:50 Is C60 safe to take for those who have had thyroid cancer, do not have a thyroid, and are keeping their TSH suppressed so not to stimulate any residual thyroid tissue? 23:37 Renee struggled a little with some details but her message: In a Google search P60 [I believe she meant C60] exposed to light is carcinogenic, and so processing and manufacturing wasn't discussed by Jen [I believe she meant Ken]. I did share that all the bottles are dark and glass and the wrap-around packaging shields additionally. Do you want to address this Google researcher?   Connect with Ken and Try C60 Yourself:  https://www.flippingfifty.com/c60 Coupon Code: Flipping50   My favorite ways to use:  The cinnamon-flavored coconut oil or straight-up coconut oil in (coffee which I've quit again) Coconut oil added to a smoothie Olive oil drizzled on salads at lunch   C60 Purple Power is Social: Instagram:https://www.instagram.com/c60purplepower/ Facebook: https://www.facebook.com/c60purplepowerproducts Youtube: https://www.youtube.com/c/C60PurplePower?sub_confirmation=1 Twitter: https://twitter.com/c60purplepower   Additional Resources:  Protein for a Stronger Second Half: https://www.flippingfifty.com/Smoothies Stronger: Tone & Define: https://www.flippingfifty.com/getstronger Other Episode with Ken:  Oxidative Stress: The Gatekeeper to Healthy Aging and Healthy Libido: https://www.flippingfifty.com/oxidative-stress/

In this episode, Professor Jan Beyer-Westendorf and Professor Rupert Bauersachs discuss the latest real-world evidence for the extended treatment of patients with venous thromboembolism (VTE). They focus on data published from the all-comer Dresden NOAC Registry, which provides important insights on the adherence patterns of patients with VTE on anticoagulation treatment beyond 12 months. Our experts also discuss the FIRST and SWIVTER registries, and how their findings highlight the importance of patient preference in maintaining patient persistence with extended treatment in order for patients to gain the full benefits of their treatment. The views and opinions expressed throughout this podcast are those of the speakers based on their expertise and do not necessarily reflect those of Bayer. • You can read the most up to date CHEST guidelines here: https://journal.chestnet.org/article/S0012-3692(21)01507-5/fulltext • The Dresden NOAC Registry showed high persistence of patients with VTE on rivaroxaban, these results can be viewed here: https://www.thrombosisresearch.com/article/S0049-3848(21)00515-6/fulltext • EINSTEIN CHOICE investigated the extended treatment of VTE patients with rivaroxaban versus aspirin, results from the trial can be found here: https://www.nejm.org/doi/full/10.1056/nejmoa1700518 • The FIRST registry is the largest real-world evidence registry for rivaroxaban to date, read about its findings on treatment adherence here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8606029/ • Read more about the insights from the SWIVTER registry here: https://www.thiemeconnect.com/products/ejournals/abstract/10.1160/TH16-03-0209 • The EINSTEIN EXTENSION study our experts discuss in this podcast can be found here: https://www.nejm.org/doi/full/10.1056/nejmoa1007903 Extended treatment VTE podcast-draft1 4 • The pooled results from the EINSTEIN PE and EINSTEIN DVT studies are available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3850944/ • For anticoagulant dosing information, see the European labels for apixaban (Eliquis) (http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_- _Product_Information/human/002148/WC500107728.pdf), dabigatran (Pradaxa) (http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_- _Product_Information/human/000829/WC500041059.pdf), edoxaban (Lixiana) (http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_- _Product_Information/human/002629/WC500189045.pdf), rivaroxaban (Xarelto) (https://www.ema.europa.eu/documents/product-information/xarelto-epar-productinformation_en.pdf) and warfarin (https://www.medicines.org.uk/emc/product/3064/smpc) Recording approval: PP-XAR-ALL-2638-1 Shownotes approval: PP-XAR-ALL-2639-1

Contributor: Aaron Lessen, MD  Educational Pearls: Direct Oral Anticoagulants (DOACs) have surpassed Warfarin and Lovenox® for anticoagulation as they do not require injection and allow for easier discharge. In the ED, they are commonly prescribed after PE or DVT diagnosis.  Common DOACs are Apixaban (Eliquis®) and Rivaroxaban (Xarelto®). There has not been a direct head to head study comparing outcomes.  2 large observational studies evaluated the recurrence of clots and bleeding risk in patients with newly prescribed Eliquis® or Xarelto® for DVT or PE. Both studies found that Eliquis® had superior outcomes.  Further data is required to determine the preferred DOAC. A randomized trial comparing the two DOACs is upcoming with enrollment ending in 2023.  References Dawwas GK, Leonard CE, Lewis JD, Cuker A. Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med. 2022;175(1):20-28. doi:10.7326/M21-0717 Aryal MR, Gosain R, Donato A, et al. Systematic review and meta-analysis of the efficacy and safety of apixaban compared to rivaroxaban in acute VTE in the real world. Blood Adv. 2019;3(15):2381-2387. doi:10.1182/bloodadvances.2019000572 Image from: Bristol-Myers Squibb Company. Eliquis 10 Million Patients and Counting. Sec.gov. https://www.sec.gov/Archives/edgar/data/14272/000114036119003478/s002621x16_425.htm. Accessed June 12, 2022.   Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

"Dagáll læknanemans" er hlaðvarp fyrir læknanema og annað áhugasamt fólk um hvaðeina sem viðkemur klínik og læknisfræði. Stjórnendur eru Sólveig Bjarnadóttir og Teitur Ari Theodórsson. Í þessum þætti er fjallað um blóðþynningu og viðmælendur eru Davíð O. Arnar sérfræðingur í hjartalyflækningum og Páll Torfi Önundarson sérfræðingur í blóðlækningum. Ræddir eru kostir og gallar blóðþynningar með nýju lyfjunum (DOAC) í samanburði við warfarín bæði með tilliti til virkni og aukaverkana. Þá deila viðmælendur þáttarins sinni framtíðarsýn og hvort nýju lyfin munu algerlega taka yfir eða hvort að warfarín muni áfram gegna mikilvægu hlutverki í blóðþynningarmeðferð sjúklinga.Þessi þáttur er annar í röðinni af þremur sem unnir eru í samstarfi við læknadeild. Munu þeir nýtast í kennslu í lyfjafræði á 3. ári við Háskóla Íslands. Magnús Karl Magnússon, prófessor í lyfjafræði og sérfræðingur í blóðlækningum, heldur utan um verkefnið og er jafnframt viðmælandi í þáttunum þremur.Dagáll læknanemans er sjálfstæð þáttasyrpa innan Hlaðvarps Landspítala. Þættirnir eru aðgengilegir á helstu samfélagsmiðlum Landspítala og einnig í streymisveitunum Spotify og Apple iTunes, ásamt hlaðvarpsveitum á borð við Simplecast, Pocket Casts og Podcast Addict.(Tónlist: "Garden Party" með Mezzoforte. Notað með leyfi frá hljómsveitinni.)SIMPLECAST:https://landspitalihladvarp.simplecast.com/episodes/dagall-20

Episode NotesFor more information, contact us at 859-721-1414 or myhealth@prevmedheartrisk.com. Also, check out the following resources:  ·PrevMed's website·PrevMed's YouTube channel·PrevMed's Facebook page

For more information, contact us at 859-721-1414 or myhealth@prevmedheartrisk.com. Also, check out the following resources:  ·PrevMed's website·PrevMed's YouTube channel·PrevMed's Facebook page

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Another fun one this week, friends... it's all bc of YOU and you're submissions through Facebook and Twitter. Have something on your mind? Send it my way! Connecting with you is the best. My continual thanks for your love and support. Keep fighting. - M  Check out our sponsor to see how you can make positive change possible with your patients! 

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Description: Viagra, Crestor, Eliquis, and many other brand-name medications come to mind when the discussion turns to expensive drugs. These drugs are pocket change in comparison to Zolgensma, a new(ish) gene therapy for Spinal Muscular Atrophy that costs as much as a private island. Tune in as our hosts discuss this incredible drug and some of the ramifications of its incredible price tag. This is NOT your physician's podcast. Hosts Shane Garrettson and Cal Vandergrift dive into the pharmacy world with fun, interesting, and downright weird topics! Tune in for NEW episodes, available on Spotify, Apple, Anchor, and more! Check out our Facebook, Twitter, and Instagram pages at Let's Pharmonize to view videos and images relevant to every episode! If you have any questions, comments, or even corrections, e-mail us at pharmonization@gmail.com. PLEASE READ: Shane and Cal are NOT medical professionals. DO NOT USE the information presented in this podcast to aid in your own personal health or medicinal benefit. This is a light-hearted podcast that should not be taken with the same seriousness as your own personal health, A special thanks to Kelly Kerr for creating the music used in the intro and outro. Additional music by FesliyanStudios See omnystudio.com/listener for privacy information. Learn more about your ad choices. Visit megaphone.fm/adchoices

Description: Viagra, Crestor, Eliquis, and many other brand-name medications come to mind when the discussion turns to expensive drugs. These drugs are pocket change in comparison to Zolgensma, a new(ish) gene therapy for Spinal Muscular Atrophy that costs as much as a private island. Tune in as our hosts discuss this incredible drug and some of the ramifications of its incredible price tag. This is NOT your physician's podcast. Hosts Shane Garrettson and Cal Vandergrift dive into the pharmacy world with fun, interesting, and downright weird topics! Tune in for NEW episodes, available on Spotify, Apple, Anchor, and more! Check out our Facebook, Twitter, and Instagram pages at Let's Pharmonize to view videos and images relevant to every episode! If you have any questions, comments, or even corrections, e-mail us at pharmonization@gmail.com. PLEASE READ: Shane and Cal are NOT medical professionals. DO NOT USE the information presented in this podcast to aid in your own personal health or medicinal benefit. This is a light-hearted podcast that should not be taken with the same seriousness as your own personal health, A special thanks to Kelly Kerr for creating the music used in the intro and outro. Additional music by FesliyanStudios See omnystudio.com/listener for privacy information.

In this podcast, Ashley Leland and Alex Ross, clinic pharmacists with Ridgeview, provide a discussion on medication therapy management, through a case study perspective.  Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Describe medication therapy management (MTM) and clinic pharmacists roles and responsibilities. Identify patients who may be candidates for a referral to a clinic pharmacist for medication therapy management (MTM) pharmacy services. Recognize the types of drug therapy problems (drug/ medication related) which a clinic pharmacist could help resolve. CME credit is only offered to Ridgeview Providers & Allied Health Staff 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 approximately 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: "Skills to Manage Your Pills: Medication Therapy Management" (**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.)  DISCLOSURE ANNOUNCEMENT  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; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's 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. Ridgeview's CME 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: CHAPTER 1: Medication Therapy Management can also be called CMM or Comprehensive Medical Management. For the sake of this episode, it will be referred to as MTM throughout. MTM is a pharmacy service for targeted disease states like - asthma, COPD, diabetes, and/or congestive heart failure, and also for patients with polypharmacy. Really, any patient with concerns about their medications, can utilize this service. The goal is to identify drug therapy problems: side effects, medication compliance, drug interactions, and overall management of symptoms, to improve outcomes, for example, reducing hospital readmissions. CHAPTER 2:  In chapter 2, a patient was seen with a complex medical history, including heart failure, diabetes, new a-fib, and a recent hypokalemic event. MTM services identified several drug therapy problems, including drug interactions between the patient's diltiazem and atorvastatin, and between turmeric and Eliquis. Also identified was the need for diabetic management, and that the patient's over-the-counter potassium supplements were not sufficient in maintaining normal levels. In follow-up, the patient was doing well, had started taking farxiga, stopped the turmeric, and switched from diltiazem to metoprolol. In this chapter, Ashley and Alex briefly discuss natural medications and the use of the Natural Medicines Database to evaluate over-the-counter supplements and herbals. It's noted that some patients want to take a more wholesome approach to their medications, they recommend doing the research for good manufacturing practices or USP verified supplements and herbals. A great resource is your local MTM pharmacist. Another important service MTM pharmacists is helping patients navigate the financial decisions regarding medication cost. Whether suggesting alternatives or navigating the patient to assistance programs for specific mediations. CHAPTER 3:  In chapter 3, a patient who recently changed countries, had several drug therapy problems like adjusting medications to what is available here in the US, adjusting dosages of his current medications, gaining access to a glucose monitor, and updating vaccines. It's a good example of the range of things a MTM pharmacy visit can manage. Common drug interactions were touched on briefly. Highlighting the importance of knowing not just what over-the-counter medications a patient is taking, but the quantity as well. Also important, knowing the supplements and herbals being taken and how they might interact with any prescribed medications. It's noted that the structure of an MTM visit, that hour long conversation just about medication management, helps break down barriers, and hone in on the issues that patients can have with their medications. It also brings up areas for opportunity elsewhere, where that medication discussion is happening in much shorter time periods. CHAPTER 4:  The last patient case touches on an important demographic for MTM pharmacists, mental health regimens. This patient presented with a new tremor and agitation. Her drug therapy problems included duplicate therapy, suspected serotonergic complications, stimulating compounds, and an emotional attachment to her medications. The results of her MTM visit included stopping her amitriptyline and her focus supplement. Tapering off her duplicate therapy escitalopram, and then returning for follow-up. The follow-up time frame for patients depends on the complexity of drug therapy problems identified. Ashley found that setting the follow-up appointment during the current appointment, increases the follow through for patients. MTM Pharmacy is located at 7-9 Ridgeview primary and specialty clinics. They can be directly consulted by the patient's primary care provider or patient's can reach out to any of the clinics they are located in. Patients that would specifically benefit from these services include those with polypharmacy, those who are not doing well with their current medication regimen, and those with chronic disease states. Other areas where MTM pharmacy is involved, but not mentioned in depth here include - immunizations, opioid prescribing and stewardship, anticoagulation, and non-surgical weight loss programs. Thank-you for listening.

Viagra, Crestor, Eliquis, and many other brand-name medications come to mind when the discussion turns to expensive drugs. These drugs are pocket change in comparison to Zolgensma, a new(ish) gene therapy for Spinal Muscular Atrophy that costs as much as a private island. Tune in as our hosts discuss this incredible drug and some of the ramifications of its incredible price tag. This is NOT your physician's podcast. Hosts Shane Garrettson and Cal Vandergrift dive into the pharmacy world with fun, interesting, and downright weird topics! Tune in for NEW episodes, available on Spotify, Apple, Anchor, and more! Check out our Facebook, Twitter, and Instagram pages at Let's Pharmonize to view videos and images relevant to every episode! If you have any questions, comments, or even corrections, e-mail us at pharmonization@gmail.com. PLEASE READ: Shane and Cal are NOT medical professionals. DO NOT USE the information presented in this podcast to aid in your own personal health or medicinal benefit. This is a light-hearted podcast that should not be taken with the same seriousness as your own personal health, A special thanks to Kelly Kerr for creating the music used in the intro and outro. Additional music by FesliyanStudios --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/calvin-vandergrift8/support

Prescription medications such as Eliquis, Jardiance, Spiriva, and Tradjenta have gone up 6%. Drugs such as Truvada, Chantix, Flovent, and Premarin have gone up between 3 to 5 percent.https://recoverypartnernetwork.com/drug/how-much-do-drugs-cost-the-steep-price-of-addiction

Episode 25: Autism [Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) The sun rises over the San Joaquin Valley, California, today is August 28, 2020. The Journal of the American Board of Family Medicine recently published the characteristics of primary care physicians (PCPs) associated with prescribing potentially inappropriate medication (PIM) for elderly patients. Medicare data from more than 100,000 PCPs was analyzed. The sample included specialists in family medicine, internal medicine, geriatrics and general practice. PCPs more likely to prescribe PIMs were on average older, male, DO, practicing in the South, and have a smaller Medicare patient panel. The study also found that PIM rates have been decreasing over time (1). So, don’t forget to review your Beers Criteria (2) when prescribing meds to your elderly patients. Cancer and VTE normally means low molecular weight heparin, LMWH aka Lovenox®, right? But direct oral anticoagulants (DOACs) are being used more frequently in patients with acute venous thromboembolism (VTE) and active cancer. Studies comparing their safety and efficacy with LMWH are limited. In a recent, randomized trial of 1170 patients with cancer and VTE, the DOAC apixaban resulted in similar rates of recurrent VTE when compared with the LMWH dalteparin (Fragmin®) (5.6 versus 7.9 percent) without any impact on major bleeding events. Apixaban is now considered a suitable alternative to LMWH for treatment of VTE in patients with active cancer (3). So, good point for Eliquis®.  [Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] ____________________________[MUSIC]“By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.” –Confucius Spanish refrains don’t make sense, but here I have one to see if it makes sense: “Nobody learns on someone else’s brain”. It means, you learn better by experience. Dear residents, how do you want to learn wisdom? By reflection, by imitation or by experience?  Question number 1: Who are you?  This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer. I am also a recent graduate from RBFM and have come back as faculty Tag line: I’m here to give you your weekly suppository of information. Relax and let it in.  Question number 2: What did you learn this week?  What I actually encountered was a need for follow up from podcast #9 vaccine hesitancy.  There were follow on questions for autisms and what we can be doing as primary care providers. I’m going to start with some basics of autism. Diagnostic Criteria The current DSM criteria states that a child must have persistent deficits in 3 areas of social communication/interaction and at least 2 of 4 types of restricted/repetitive behaviors.  It’s important to understand these criteria as not every child who has difficulty with eye contact falls on the spectrum. A: Areas of social communication and interactionDeficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).C: Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.E: These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.Hey. Hey you.  The poor resident and or medical student that just sat through a bunch of raw criteria.  I’m sorry. A real quick aside, we have already covered some of the basics of epidemiology in a prior podcast (that’s Podcast #9 which dealt with vaccine hesitancy) Let me expand that discussion a little bit, we know that boys are about 4x as likely as girls to have it, there does seem to be a genetic component as noted in twin studies.  As far as impact it falls somewhere around 1 in 40 and 1 in 500 people.  There may be environmental factors that act as a second hit, but again see our prior podcast- studies have shown time and again no significant correlation between vaccines and autism.    There are some things which have been shown to cause a greater relative risk such as older parents, chromosomal abnormalities (such as fragile X), and certain medications taken during the prenatal period (such as valproic acid)Symptoms can present prior to 18 months, but they are most typically fully noted at 18 to 24 months when symptoms exceed the capacities of the patient. Let’s talk about something that you might need to wake up for.  Wake up. Wake up. Wake up.  The role of Primary Care is not necessarily to make the diagnosis.  Comprehensive evaluation by appropriate tools is still best left to specialists who are well trained in the field.  Most commonly developmental pediatricians, pediatric psychologist/psychiatrists, or pediatric neurologist.  However, it is very important that we recognize the signs and symptoms of autism and that we perform appropriate screening.   So, what constitutes appropriate screening? For children who appear neurotypical in whom parents are not concerned, routine screening should be implemented at ages 18 and 24 months using any of the standardized tools. The M-CHAT R/ F is validated as a first tier screening.  It is available in multiple languages through their official website.  Importantly for the primary care provider it can be completed in under 5 minutes and at least for the initial questionnaire can be completed by the parent before the visit eg either in the waiting room if given while awaiting or if the appropriate underlying electronic health record / email service is in place, the questionnaire can be given online prior to the visit.  For F component of the M-CHAT R/F is a structured set of follow up questions that should be done prior to referral.  For example, the first question: “If you point at something across the room, does (your child) look at it?”    Prompts the question, what does your child typically do?  There is a list of 7 items that are typical examples.  A child might still pass for example if he were to point at the object.  A greater concern might be when the child ignores the parent or looks at the finger instead of the object. Please note that there are other standardized questionnaires for example the Autism Spectrum Screening Questionnaire.  Most still require additional studies or are potentially better at finding other issues (such as general intellectual disability)  Resources for parentsIf the child is less than 3 years old, the Early Childhood Technical Assistance Center may be of use (especially if I am talking to people outside of my local jurisdiction)  Their website located at ectacenter.org has a contact list for coordinators that may be connect parents with services.Locally, we have the Kern Regional Center    For those 3 and older, you can contact the local public school system even for those not currently enrolled in school.For those of us in California, the Lanterman Act is very important.  The Lanterman act is the California law that gives people with developmental disabilities the right to the services and supports they need to live a more independent and normal life.  In particular, your patient may be eligible for Medi-Cal even if they might otherwise not be eligible, and they may be entitled top additional services.  Furthermore, it allows them to access for additional services through the Regional Center.  As an example, their diagnosis may entitle the family to Respite services. Now that we have identified the patient with autism, what are some of the ways that we can improve their care in our primary care.First remember that these children still need routine primary care preventive services and screening.  Anticipatory guidance may need to adapted to include some additional safety recommendations for example discussing elopement  Those with autism may have some difficulty with change, and so unfamiliar settings eg things that are not done everyday and per routine, may be more difficult.  If the patient is already in ABA therapy they may already be getting social stories or a visual board to orient the child as to expectations.  Allow additional time if possible (or manipulate your schedule to have easier / shorter appointments adjacent to this visit) to give more time to allow the patient to adapt.     Question number 3: Why is that knowledge important for you and your patients?   Question number 4: How did you get that knowledge? (learning habits)  As a general rule, I refer to multiple online sources like UpToDate to read articles and get suggestions for primary source citation. eg check the bibliography from UTD to see there sources and see if you agree with their evidence for your evidence-based medicine and primary sources.   However, for this talk I wanted to get some additional sources to discuss.  My usual go to locations for additional broad information is to first start with important medical institutions including the Center for Disease Control, World Health Organization, and AAFP. Question number 5: Where did that knowledge come from? (cite source)  I used a variety of references.  Primarily I used  UpToDate, but I also used the DSM, as well as information from the Center for Disease Control and the World Health Organization Rights Under the Lanterman Act https://www.disabilityrightsca.org/publications/rula-rights-under-the-lanterman-act-complete-manual Date of access 8/18/2020 Caldwell, Nicole. Going to the Doctor http://www.positivelyautism.com/downloads/DoctorVisit_Story.pdf “Autism” Center for Disease Control, https://www.cdc.gov/ncbddd/autism/index.html  Date of access 8/18/2020American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.50World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. www.who.int/classifications/icd/en/bluebook.pdf (Accessed on March 28, 2018).Augustyn, Marilyn MD. “Autism spectrum disorder: Terminology, epidemiology, and pathogenesis” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-terminology-epidemiology-and-pathogenesis Date of access 8/18/2020Weissman, Laura MD “Autism spectrum disorder in children and adolescents: Pharmacologic interverventions” UpToDate https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-pharmacologic-interventions  Date of access 8/18/2020Augustyn, Marilyn MD and von Hahn, L Erik MD. “Autism spectrum disorder: Clinical Features” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-clinical-features   Date of access 8/18/2020Augustyn, Marilyn MD. “Autism spectrum disorder in children and adolescents: Overview of management” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-managementDate of access 8/18/2020 Handleman, J.S., Harris, S., eds. Preschool Education Programs for Children with Autism (2nd ed). Austin, TX: Pro-Ed. 2000.National Research Council. Educating Children with Autism. Washington, DC: National Academy Press, 2001.  ____________________________[Music] Speaking Medical: Anosognosia by Cameron Anderson, MS4When someone rejects a diagnosis of mental illness, it’s tempting to say that he's “in denial.” But someone with acute mental illness may not be thinking clearly enough to consciously choose denial. They may instead be experiencing “lack of insight” or “lack of awareness.” The formal medical term for this condition is anosognosia, from the Greek meaning “to not know a disease.”As humans, we are consistently updating our reality and perception. Think about it this way: when you get a sunburn because you spent your weekend at the beach you expect yourself to look red when you look in the mirror. You have updated your perception of what your reality is. You now expect to appear more red. This update requires a functioning frontal lobe of the brain. When that is not working properly you can lose your ability to update what is real. Everyone else can tell you received a sunburn but you are unable to recognize you have one. In essence, this is anosognosia.This lack of insight into the disease is fairly common in those with schizophrenia and bipolar disorder. When a person is in this state they become very difficult to treat because they believe their perceptions of reality are what we should be experiencing. These people frequently will stop taking their medications because in their mind there is no reason to continue them because there is no disease.People with anosognosia often fluctuate with how aware they are of their disease. This can also cause a strain on their support system and relationships with friends and families. Since our perceptions feel accurate, we conclude that our loved ones are lying or making a mistake. If family and friends insist they're right, the person with an illness may get frustrated or angry, or begin to avoid them. When maintaining a relationship with a person with anosognosia, it is important to realize that their perception of reality is as real to them as our reality is to us.  Remember the word anosognosia.____________________________[Music]  Espanish Por Favor: Cansancioby Dr Claudia CarranzaHi this is Dr Carranza on our section Espanish Por Favor. This week’s word is cansancio. Cansancio means tiredness or fatigue. The verb “cansar” comes from the Latin word “campsare” which means to deviate or bend from a path or trajectory. Interestingly, back in the day cansancio began to be used to describe taking a break from a trip, taking a break due to exhaustion, or to rest because you’re tired. Patients can come to you with the complaint: “Doctor, tengo cansancio” or “Doctor, estoy cansado” which means: “Doctor, I am tired” or “I feel tired”. Cansancio is a very common complaint in clinic but it’s not very specific. So, the question “¿Se siente cansado?” “Are you feeling tired?” normally is answered with a yes, more so if you are a resident. Feeling tired may be physiologic, but feeling tired continually, with no relief after rest, and with no identifiable cause can lead you to start an investigation. Ask if this cansancio is new or chronic, think of differentials such as thyroid disease, anemia, sleep apnea, acute viral illness and continue with your work up. Now you know the Spanish word of the week, cansancio. ___________________________[Music]For your Sanity: Medical Jokesby Dr RAVA[SURAJ, PLEASE EDIT]I used all my sick days, so I called in dead.Statistically, 9 out of 10 injections are in vein.PMS jokes aren't funny; period.He was wheeled into the operating room, and then had a change of heart.I don't find health-related puns funny anymore since I started suffering from an irony deficiency (5). [Music to end: Jeremy Blake - Stardrive - Rock | Bright ]Now we conclude our episode number 25 “Autism with Saito”. Dr Saito explained the key features of Autism Spectrum Disorder and reminded us to screen at 18 and 24 months by using M-CHAT. Health care of patients with ASD requires a multidisciplinary team, and you can be part of that team. For some reason, we decided to expand on the word anosognosia (explained in episode 14). Cameron explained that anosognosia (UH NO SO NOGSIA) may fluctuate in intensity causing difficulty in relationships with family and friends. Dr Carranza gave us a good explanation about cansancio, which means tiredness, a good word to describe how we feel after a busy shift like today. Tomorrow the sun will rise again over the San Joaquin Valley and we’ll continue to learn and grow.This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. _____________________Our podcast team is Hector Arreaza, Lisa Manzanares, Steven Saito, Roberto Velazquez, Audio edition: Suraj Amrutia. See you soon! _____________________References:Avanthi Jayaweera, Yoonkyung Chung and Yalda Jabbarpour, The Journal of the American Board of Family Medicine July 2020, 33 (4) 561-568; DOI: https://doi.org/10.3122/jabfm.2020.04.190310American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults By the 2019 American Geriatrics Society Beers Criteria, Update Expert Panel, https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdfAgnelli G, Becattini C, Meyer G, et al. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med 2020. 382:1599-1607. https://www.nejm.org/doi/full/10.1056/NEJMoa1915103Stokes, Andrew, PhD; Dielle J. Lundberg, MPH; Bethany Sheridan, PhD; et al, Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US, April 2, 2020, JAMA Netw Open. 2020;3(4):e202012. doi: 10.1001/jamanetworkopen.2020.2012, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763785https://aimseducation.edu/blog/medical-puns-jokes-and-one-liners

A typical case of severe intraparenchymal hemorrhage with resulting herniation. Takeaway lessons DOACs like apixaban (Eliquis), although not usually monitored using routine coagulation assays, tend to elevate the INR only slightly (e.g. 1.0–1.3 or so). A strikingly INR in warfarin-like ranges should raise suspicion for an additional occult cause of coagulopathy. Manage elevated ICPs using … Continue reading "Episode 13: Intracerebral hemorrhage and elevated ICP (part 1)"

US equity markets rallied, with both the Dow and S&P500 logging a fourth straight day of gains investors continued to eye developments in Congress around a fresh coronavirus aid package and digested the latest earnings releases - Dow rallied +373-points or +1.39%, it largest daily percentage increase since 14 July. The Walt Disney Co rallied +8.8% following the release of their fiscal third quarter result after the closing bell of the previous session. Johnson & Johnson rose +0.8% after the company said it will receive more than US$1B from the U.S. government to manufacture 100M doses of its investigational COVID-19 vaccine. Boeing Co gained +5.58%, with Chief Financial Officer Greg Smith saying that the company does not see the need to add to liquidity through additional debt offerings to manage the downturn in global aviation caused by the COVID-19 pandemic. The broader S&P500 gained +0.64% . Bristol-Myers Squibb Co gained +4.88% in the extended session after receiving a positive federal court judgement around a patent infringement for a blood thinner Eliquis. Costco Wholesale Corp rose +1.84% in after-hours trading that July sales rose +14% to US$13.04B, from US$11.43B in July 2019. Same-store sales rose 13.2%, including a 13.3% increase in U.S. same-store sales. E-commerce sales increased 75.3%, the company said. Airline stocks rose broadly after Senate Republicans said they supported an additional US$25B in federal aid for the industry. United Airlines Holdings closed +4.46% higher , Delta Air Lines Inc +3.12% and American Airlines Group Inc +9.5%. The NASDAQ gained +0.53% (to 10,998.40) and logging its 31st record closing high of 2020 and touching a fresh record intra-day peak of 11,002.11. Apple Inc rose +0.36%, shrugging off a downgrade by analysts at Bank of America. In merger and acquisition (M&A) news, Teladoc Health Inc (down -19.01%) and Livongo Health Inc (-11.4%) announced they have agreed to merge in a deal valued at $18.5 billion to create a company that can serve a spectrum of health needs, using virtual care.

Episode 3: James Horowitz interviews Rachel Rosovsky on DOACs. Dr. Rosovsky is the Director of Thrombosis Research in the Division of Hematology at Mass General Hospital. She is also an Assistant Professor at Harvard and a member of the Board of Directors of the PERT Consortium.  Dr. Horowitz is the Director of the CCU at NYU Langone Health and the Co-Chair of the Interdisciplinary Resuscitation Committee. He is also an Assistant Professor or Medicine and a member of the Board of Directors of the PERT Consortium. Directly acting oral anticoagulants.   FDA approved DOACS: Xarelto (rivaroxaban), Eliquis (apixaban), Savasya (edoxaban), Pradaxa (dabigatran). All DOACs have similar efficacy in terms of VTE occurrence and better safety profile compared compared to Coumadin. MOA: Dabigatran: directthrombin inhibitor.   Rest of the DOACs: factor X inhibitors. DOACS usually do not need monitoring. Most common interaction noted with drugs like ketoconazole (CYP3A4). Dosing: Dabigatran and Edoxaban: Overlap with parenteral enoxaparin for 5 to 10 days is needed. Apixaban and Rivoraxaban: Need loading dose. For apixaban it is 10 mg 2 times a day for 7 days followed by 5 mg 2 times a day.  Rivaroxaban: 15 mg 2 times a day for 21 days followed by 20 mg once a day. (Xarelto need to be taken with food) Only 55% of the patients with Coumadin remain in therapeutic range. Drug reversal agents for DOACs Dabigatran reversal: Idarucizumab Xarelto and Eliquis reversal: Andexenat Alpha. Factors in deciding candidacy for DOACs: DOACs in patients with Child-Pugh score B/C cirrhosis should not be used. Renal failure with CrCl 120 kg, based on ISTH guidelines. (higher the BMI may have increased risk of bleeding with better efficacy, potentially due to absorption issues-- levels can fluctuate) Drug monitoring for DOACs: No standardized methods. Not routinely done. It should be considered in patients with extremes of weight and patients who have gone gastric/bariatric surgeries, because all DOACs are absorbed get into upper GI tract. Pregnancy and Venous thromboembolism: No DOACs in pregnancy. Enoxaparin is the treatment of choice -1 mg/kg every 12 hours up to week 36 followed by changing them to unfractionated heparin. (subcutaneous calculated dose). Patients who had prior DVTs/PEs and become pregnant may need prophylactic dose of enoxaparin (40 mg subcutaneous once a day) Cancer and VTE: VTE is a second leading cause of death in cancer patients. Drug of choice was enoxaparin over warfarin. Edoxaban Vs Enoxaparin: Edoxaban with less recurrent VTE, but worse bleeding profile (most bleeds in gastric cancer patients) Rivaroxaban Vs Enoxaparin: Rivaroxaban with less recurrent VTE, but worse bleeding profile (most bleeds in gastric cancer) Cancer patients who may not be good candidate: a) GI cancer b) needing many procedures c) liver/renal failure d)brain mets.  Provoked vs Unprovoked and extended a/c: Unprovoked PE: Two-year risk of recurrence 25% or higher. Provoked by surgery [mainly orthopedic surgery, pregnancy, long hospital stay]: risk of recurrence 1% at one year, 3% at 5 years. Flying is a weak risk factor to be considered as provoked. Amplify-Ext trial: 70% decrease risk of recurrence with low dose apixaban without an increased risk of bleeding in unprovoked VTE. Einstein Choice trial: 70% decrease risk of recurrence with low dose rivaroxaban without an increased risk of bleeding. 60% of patients had provoked VTE with ongoing risk factors. (i.e. Obese patients, patients who are immobile, and are still immobile). Cancer screening following PE: 5-10% of patients with VTE would be diagnosed with malignancy in next 5 years. Recommendation is to do age appropriate cancer screening. Valves and DOACS: (increase risk of ischemic events)   Reference: Rali P, Gangemi A Moores A et al. Direct-Acting Oral Anticoagulants in Critically Ill Patients. Chest. 2019 Sep;156(3):604-618.

Welcome back to our weekend Cabral HouseCall shows! This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track! Check out today's questions:  Cara: Hi Dr. Cabral! Yesterday (August 31) about 45 minutes after a hard workout at 10:30am; dead lift holds, overhead holds, kettlebell swings, assault bike, I got home and I had wavy lights in my peripheral vision. It freaked me out and this had happened to me a couple of months ago and I remembered a nurse friend said it was likely low blood sugar. I ate some mango and about 20 minutes later it went away. I had a DNS smoothie with blueberries and avocado about an hour before my workout and by the time I was done working out, I had half a gallon of water. This has happened 3 times in the last 4 years, each time was after a work out. I'm super healthy, I don't drink alcohol. I do the Dr Cabral Foundation Level 1 plus cal/mag, 3,000mg of Alkalized vitamin c, lysine, Vitamin D, CBD. I eat wild salmon twice a week and sardines 3 times a week, so I only occasionally take EN fish oil. I started to google search this but stopped because things like mini-strokes came up. All of my recent bloodwork was all where it should be according to your podcast guidance and I just had an eye exam and other than my life long near-sightedness, my eye health is perfectly healthy. Does this sound like low blood sugar? If so, why would it be the case if I ate breakfast and worked out at 10:30, plus had 32 oz of water? I do not want to go to a doctor because it'll be at least an MRI ordered. Im in your IHP Level 2 right now. Thank you for ALL you do! Cara: Follow up: I received a reply from our Dr Cabral Support Group from an optometrist and she said that what I experienced could be a visual aura. She said most visual auras precede a migraine or headache but a good amount of people never get the headache and just experience the aura. I never had a headache or a migraine after any of these occurrences. Then my next question, why would I be getting these aura migraines? Gabriela: Hi Dr. Cabral First I love your podcasts, very informative. Now for my question do you believe women should fast differently than men, are you familiar whith Dr. Beth who is all about women's health. She believes women should have snacks during the fast because of our hormones. Would really love to hear what you have to say about this. Thank you! Luke: Hi Dr. Cabral. Would you be able to tell me what you typically feed your dog. As with humans, diet for pets seems to be a topic that has many differing opinions. What does your dog's diet look like (types of foods and amount), and do you give him any supplements? I know you would have done your research on this and I appreciate your response. Thank you. Richelle: Hi Dr, Cabral,I’ve done your 7 day detox and am currently using the deep sleep protocol. I love using the support group and Michelle advised me to ask you my specific question. I have Blepharitis and my doctor currently has me using tea tree oil wipes which has helped. She says it will never be cured but by doing this it will keep it under control. Because of this, I rarely wear any makeup. I also suspect that I have a parasite issue and plan on doing that protocol in October after my trip to Jamaica.I also have been diagnosed with Afib and aflutter and had open heart surgery as a baby back in 1960. I’m currently on a blood thinner,Eliquis, and take diltiazem for high blood pressure. I’m taking magnesium and only half the recommendation for the blood thinner. At my request, my doctor is gradually lowering my blood pressure medicine as I don’t want to be on any meds. I’ve lost 11 pounds recently, retired from teaching after 36 years and need to lose more weight as I know it will help lower blood pressure. Please give me your expert advice regarding my issues.Thanks for your time Natasha: Hi SC I was wondering if there was a way to stop or get rid of seborrheic keratosis other than freezing them off. As i get older I seem to be getting more and more and im becoming self conscious to wear a bikini in summer they are over my back and stomach and chest and dont look that great. Would appreciate any advice. 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Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month!

Contributor: Don Stader, MD Educational Pearls: Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke) Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE) Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA References: Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, Al Qasmi M, Bhatt DL. Clopidogrel and aspirin after ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis. 2019 Feb;47(2):233-247. doi: 10.1007/s11239-018-1786-z. PubMed PMID: 30511260. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Talk to a Dr. Berg Keto Consultant today and get the help you need on your journey (free consultation). Call 1-540-299-1557 with your questions about Keto, Intermittent Fasting, or the use of Dr. Berg products. Consultants are available Monday through Friday from 8:30 am to 9 pm EST. Saturday & Sunday 9 am to 5 pm EST. USA Only. Take Dr. Berg's Free Keto Mini-Course! Intermittent Fasting Basics: https://www.messenger.com/t/drericberg Acceptable Vegetables if on Warfarin(Coumadin): https://www.youtube.com/watch?v=kEc30... Dr. Berg talks about vitamin K1. It is a co-factor or a helper nutrient to make Prothrombin (clotting factor) and very important for making bone. There are also many different types of proteins like C and S in vitamin K1 which are anti-clotting. If you're in Coumadin, you can't take vitamin K1 because you have a blood thinner and couldn't consume a lot of leafy greens. He also discussed the other medication called Eliquis, which can allow you to consume leafy greens. Things That Block the Absorption of Vitamin K1 • Constipated • Liver Problem – Fatty Liver, Cirrhosis • Insulin Resistance • Gallbladder Problems • IBS - Damage within the Colon • Gastric Bypass Best Sources of Vitamin K1 • Leafy Greens • Spinach • Kale Dr. Eric Berg DC Bio: Dr. Berg, 51 years of age is a chiropractor who specializes in weight loss through nutritional & natural methods. His private practice is located in Alexandria, Virginia. His clients include senior officials in the U.S. government & the Justice Department, ambassadors, medical doctors, high-level executives of prominent corporations, scientists, engineers, professors, and other clients from all walks of life. He is the author of The 7 Principles of Fat Burning. ABOUT DR. BERG: https://bit.ly/2FwSQQT DR. BERG'S STORY: https://bit.ly/2RwY5GP DR. BERG'S SHOP: https://bit.ly/2RN11yv DR. BERG'S VIDEO BLOG: https://bit.ly/2AZYyHt DR. BERG'S HEALTH COACHING TRAINING: https://bit.ly/2SZlH3o Follow us on FACEBOOK: https://www.messenger.com/t/drericberg TWITTER: https://twitter.com/DrBergDC YOUTUBE: https://www.youtube.com/user/drericberg123 Send a Message to Dr. Berg and his team: https://www.messenger.com/t/drericberg

On this episode, I talk about apixaban (Eliquis) pharmacology. I also cover adverse effects like bleeding and what to monitor. Drug interactions are a concern with apixaban and I discuss a few items that you may want to look out for. It is important to remember that apixaban does require dose adjustments in certain situations as well. Check out our free giveaway for healthcare professionals and students.  It is a top 200 study guide of highly testable pearls! (Free 31 page PDF)

The popularity of NOACs has grown. Numerically, though they are safe, it’s likely that the Emergency Physician will see more and more bleeds, especially in a trauma situation. In early May, Portola Pharmaceuticals got FDA approval for the targeted reversal agent, Andexanet, as indicated for the reversal of Eliquis and Xarelto. Dr. Williams breaks down the research on this episode of ACEP’s Frontline. Support for this segment was provided in-part by Portola Pharmaceuticals.

I det här avsnittet av Läkemedelspodden träffar vi vinnarna av 2017 års pris för bästa patientinformation, BMS och Pfizer för sitt arbete med Eliquis. I avsnittet nämns ett par onlineresurser, kolla in dem på länkarna nedan www.blodproppsskolan.se www.eliquis.se www.eliquispatient.se

Lyrica, Cialis, Eliquis, Humira, Latuda, Celebrex, Chantix, you’ve seen the commercials, over 80 run every hour on American television. America is on DRUGS! Oh no, I do mean literally! 79 million Americans Take Psychiatric Drugs! Worse even, well intentioned parents feed the drugs to their kids - all compliments of a drug-induced bureaucratic system that has gone both wild and unchecked. The Eggs Image, you might recall was the famous ad - This Is Your Brain On Drugs. It should be resurrected for the Pharma Industry! TV ads for prescription drugs are illegal in most countries, yet legal in two - and yes you guessed it - America is one of the two. I'll tell you the other one during the show :). TV ads encourage the pharmaceutical industry to cast a wider net for its drugs and to develop drugs that even healthy people would want to take - it's called ADVERTISING folks. These drugs expose people to unnecessary risks and discourage alternative, nonpharmaceutical treatments. Advertising campaigns also shift the market toward newer drugs, which are more expensive and possibly more risky - but what the hell - they make BIG PHARMA RICH! And then there's this notion that - 45% of Americans are mentally ill? At least some doctors seem to think that's the case. Dr. Gary Kohls discusses that issue as well as the roots of psychiatric problems. “If you say a lie often enough, people start believing in its truth,” says Dr. Gary Kohls. People are buying the drugs. And the IMPACT they’re having on society is not good. Drugs like VIOXX for Arthritis instead of ibuprofen  - but the drug increased the risk of heart attack and stroke. Kaiser Permanente ended up having to pull the ad campaign. The ad exposure led to inappropriate prescribing it was found. People died, and yet the FDA continues to look the other way. Dr Gary Kohls is a retired family practitioner, who specialized in holistic (non-drug) and preventive mental health care for the last decade of his career. Dr Kohls worked with previously psychologically traumatized, usually malnourished, sometimes seriously neglected, and always over-drugged patients - many who were labeled “mentally ill” erroneously. Over the decade prior to his retirement, Dr Kohls treated over 1,200 patients and developed a unique treatment regimen that we will talk about today. Ask yourself the following questions: Why isn’t the psychiatric profession held accountable for having no science to support even one of their disorders? How can we as a society put blind trust in a profession that prescribes dangerous drugs especially to children based on subjective criteria instead of science?

Bloody Oral Anticoagulants – BCC talk 2014 The use of the New Oral Anticoagulant Drugs present unique challenges for the Intensive Care practitioner 1. The NOACs now have PBS approval for non-valvular AF, below knee DVT, DVT prophylaxis and low volume PE 2. There is no specific antidote for NOAC related bleeding but don’t despair there are some things that can help 3. Routine coagulation testing does not reflect drug levels or anticoagulation activity Global sales of Dabigatran topped $1billion in 2012.  This talk outlines the pharmacodynamics and pharmacokinetics of the NOACs. Limitations and cautions of use are outlined with a review of the extensive literature. Clinical cases involving the NOACs are presented. The timing of stopping the agents before minor or major surgery, the approach to a patient with intracranial haemorrhage taking oral anticoagulants and the challenges faced when patients have an Acute Kidney Injury whilst taking these

MM&M's Larry Dobrow talks to Michael Maher, president of ID Health, about the advertising for Eliquis. The DTC campaign launched last year.

In this episode, we discuss the new drug class of Novel Oral Anticoagulants (NOACs), which include dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis).

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Rod and Karen are joined by Basa from the Fiyastarter.com podcast to discuss long restaurant reviews, Karen's eating dance, buying lube, Bossip headline cyses, Miss Parker, Don Lemon revisited, divorce equality, Amazon drones, Gut for of GOAT, Eliquis, Anthony Mason, black kids arrested at bus stop, pedo using grocery store printing, robbing store for beer, a fight over cheese, a teacher goes dogging and sword ratchetness. Twitter: @rodimusprime @SayDatAgain @TBGWT @HotFiyaStarter Blog: www.theblackguywhotips.com Voice Mail: 704-557-0186 Guest Website: http://hotfiyastarter.tumblr.com/ Sponsors: www.adamandeve.com And they're on Twitter: @adamandeve Code: TBGWT

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