Podcasts about grade b

This episode opens with a gold trophy sitting in for the absent Ian, and somehow that sets the perfect tone. What follows is a deeply unserious, often morbidly hilarious conversation between the core group of Alex, John, Nick, and the spectral presence of Ian. Their stream-of-consciousness banter drifts through topics like grave aesthetics, cremation preferences, echolocation envy, and the mechanics of turning a man into a walrus—each one given equal (lack of) reverence.There are highlights. Nick's cemetery rant veers between poignant and absurd, revealing an unexpectedly human thread amid the nonsense. The group's fabricated scandal about Ian eating his dog is pure chaos, toeing the line between farce and bad taste—so, classic Selleck. Also worth noting is the segment on Serbian-Mexican cultural overlap, which is both strangely informative and a reminder that these guys occasionally stumble into sociological gold between fart jokes.That said, this episode is not for the easily offended or the structurally inclined. There's no narrative, no theme—just a freefall of degenerately funny bits. Do I recommend it? Only to someone who understands the phrase “Gold Dust is part of the Bic lore” without needing further explanation.Grade: B+. Best enjoyed with a low bar and a dark sense of humor.

Can the Cincinnati Bearcats basketball team make waves in the Big 12 Conference? With a strong non-conference performance, the Bearcats are poised for an exciting season. Key players like Simas Lukosius and Aziz Bandaogo have been instrumental, showcasing impressive skills that could lead to a standout conference run. Join hosts Nick Niehaus and Eric Lilly as they break down the Bearcats' journey, analyzing victories over Xavier and Dayton, and previewing the crucial matchup against Kansas State. They also tackle mailbag questions about potential coaching changes in UC football. Will the Bearcats capitalize on their momentum and make a statement in the Big 12? Tune in for expert analysis and insights that you won't want to miss! Subscribe to Chatterbox Bearcats on YouTube and follow us on Instagram for nonstop Bearcats content.

Episode 175: Alcohol Use Disorder Basics   Future Dr. Sangha explains the clinical presentation, diagnosis, and fundamentals of the treatment of alcohol use disorder (AUD). Dr. Arreaza offers insights about the human aspect of the treatment of AUD.    Written by Darshpreet Sangha, MS4, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is Alcohol Use Disorder?AUD is characterized as the inability to stop or control alcohol use despite adverse physical, social and occupational consequences. According to DSM-5, it is a pattern of alcohol use that, over 12 months, results in at least two of the following symptoms, indicating clinically substantial impairment or distress: Alcohol is frequently used in higher quantities or for longer periods than planned.There is a persistent desire or unsuccessful attempt to reduce or manage alcohol use.Activities that are required to get alcohol, consume alcohol, or recuperate from its effects take up a lot of time.A strong need or desire to consume alcohol—a craving.A pattern of drinking alcohol that prevents one from carrying out important responsibilities at work, school, or home.Sustained alcohol consumption despite ongoing or recurring interpersonal or social issues brought on by or made worse by alcohol's effects.Alcohol usage results in the reduction or cessation of important social, professional, or leisure activities.Frequent consumption of alcohol under risky physical circumstances.Continuing to drink even when one is aware of a chronic or recurrent health or psychological issue that may have been brought on by or made worse by alcoholTolerance: requiring significantly higher alcohol intake to produce the same intended effect. Withdrawal: Characterized by the typical withdrawal symptoms or a noticing relief after taking alcohol or a closely related substance, such as benzodiazepine.How can we determine the severity of AUD? Mild: 2–3 symptomsModerate: 4–5 symptomsSevere: >/= 6 symptomsWho is at risk for AUD?Note: Ancestry offers a DNA analysis to find out about your heritage. You can also send that DNA to a third party to learn about your risks for diseases and conditions (for example, Prometheus.) Anyone can find out about their risk for alcoholism by doing a DNA test. The risk factors for AUD are: Male genderAges 18-29Native American and White ethnicitiesHaving Significant disabilityHaving other substance use disorderMood disorder (MDD, Bipolar)Personality disorder (borderline, antisocial personality)What is heavy drinking?According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), heavy alcohol use is characterized as: Males who drink > 4 drinks daily or > 14 drinks per week Females who drink > 3 drinks on any given day or > 7 drinks per weekPathophysiology of AUD.The pathogenesis of AUD is not well understood, but factors that may play a role are genetics, environmental influences, personality traits, and cognitive functioning. Also, genetic factors may decrease the risk of AUD, i.e., the flushing reaction, seen in individuals who are homozygous for the gene that encodes for aldehyde dehydrogenase, which breaks down acetaldehyde. Who should be screened?A person with AUD may not be easy to diagnose in a simple office visit, but some clues may point you in that direction. First of all, patients with AUD may present to you during their sober state, that´s why ALL adults (including pregnant patients) must be screened for AUD in primary care )Grade B recommendation). The frequency has not been determined but as a general rule, at least in Clinica Sierra Vista, we screen once a year. The USPSTF has concluded that there is insufficient evidence to recommend screening adolescents between 12-17 years old. What are the clinical manifestations of AUD?Some symptoms may be subtle, including sleep disturbance, GERD, HTN, but some may be obvious, such as signs of advanced liver disease (ascites, jaundice, bleeding disorders, etc.)If you draw routine labs, you may find abnormal LFTs (AST:ALT ratio >2:1), macrocytic anemia (MCV >100 fL), and elevated Gamma-glutamyl transferase (GGT). All these findings are highly suggestive of AUD. Patients with AUD may present in either an intoxication or withdrawal state. Signs and symptoms of acute intoxication may include “slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, hypotension, tachycardia, memory impairment, stupor, or coma.” Signs and symptoms of withdrawal range from tremulousness to hallucinations, seizures, and death. They are seen between 4 and 72 hours after the last drink, peaking at 48 hours, and can last up to 5 days. Alcohol withdrawal is one of the few fatal withdrawal syndromes that we know in medicine, and the symptoms can be assessed using a CIWA assessment. Treatment of AUD.There are factors to consider before starting treatment: Evaluating the severity of AUD Establishing clear treatment goals is associated with better treatment outcomesAssessing readiness to change: It can be done by motivational interviewing and using the stages of change model, which are, Pre-contemplation, contemplation, preparation, action, maintenance, and relapse.Discussing treatment of withdrawal.Treatment may be done as outpatient or it may require hospitalization. Dr. Beare sent an email with this information: “The approach to treating patients with AUD can be broken into two parts - the first is withdrawal management and the second is the long-term maintenance part. You MUST have a good plan for withdrawal treatment as it can be fatal if it's not addressed properly.” “Patients with any history of seizures due to withdrawal or a history of delirium tremens need inpatient management. If their withdrawal symptoms are typically mild (agitation, tremors, sleeplessness, anxiety) then outpatient management may be appropriate, typically with a long-acting benzodiazepine such as Librium or Ativan.”According to Dr. Beare, “the human aspect isa key element in treating alcohol use disorder. These patients arrive with tremendous amounts of suffering, shame, guilt, and fear. The relationship between the patient and provider needs to be built with compassion and understanding that this disease is horrible from the patient's perspective and using an algorithmic and calculated approach can cause significant harm to the rapport-building process, leading to lower success rates.”Treatment requires a lot of motivation and willpower. Hopefully, we can use some tools to assist our patients to be successful.-For mild disorder, Psychosocial interventions like motivational interviewing and mutual help groups like AA meetings may be enough to help our patient quit drinking.-For moderate or severe disorder: 1st line treatment is Meditation and structured, evidence-based psychosocial interventions (CBT, 12-step facilitation); which leads to better outcomesFor patients who lack motivation, motivational interviewing can be a useful initial interventionFor motivated patients: medical management, combined behavioral intervention, or a combination of both can be utilizedFor patients with limited cognitive abilities, 12-step facilitation, or contingency management can be helpful For patients who have an involved partner: Behavioral couples therapy can be utilizedMedications for AUD.The first-line pharmacological treatment is Naltrexone. It is given as a daily single dose and can be started while the patient is still actively drinking. There is a monthly dose of long-acting injectable naltrexone as well. Naltrexone is contraindicated in individuals taking opioids, and patients with acute hepatitis or hepatic failure. Alternative 1st line treatment is Acamprosate which can be used in people with contraindications to Naltrexone.AUD is a chronic problem and requires a close follow-up to evaluate response to treatment and complications. Medications need to be used along with psychotherapy and support, and medications may need to be changed or adjusted depending on the patient. It is an individualized therapy that requires full engagement of the doctor, the patient, and their families or social support. In conclusion, I would just like to add that, be compassionate because AUD is not a choice. AUD is a chronic problem like diabetes and HTN and may require a long road to recovery. Treatment includes psychotherapy, medications, and regular follow-up.Thank you for listening!Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment, https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-clinical-features-adverse-consequences-screening-and-assessment, accessed on August 18, 2024.Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, Accessed on August 18, 2024.Alcohol use disorder: Treatment overview, https://www.uptodate.com/contents/alcohol-use-disorder-treatment-overview, assessed on August 18, 2024. Royalty-free music used for this episode, Grande Hip-Hop by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 171: Postpartum Blues, Depression, and PsychosisFuture Dr. Nguyen defines and explains the difference between baby blues, depression, and psychosis. Dr. Arreaza added comments about screening and management of these conditions. Written by Vy Nguyen, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.Pregnancy is one of the most well-celebrated milestones in one's life. However, once the baby is born, the focus of the family and society quickly shifts to the new member. It is important to continue to care for our mothers and offer them support physically and mentally as they begin their transition into their role. Peripartum mood disorders affect both new and experienced mothers as they navigate through the challenges of motherhood. The challenges of motherhood are not easy to spot, and they include sleep deprivation, physical exhaustion, dealing with pain, social isolation, and financial pressures, among other challenges. Let's focus on 3 aspects of the postpartum period: Postpartum Blues (PPB), Post-partum Depression (PPD) and Post-partum Psychosis (PPP). By the way, we briefly touched on this topic in episode 20, a long time ago. Postpartum blues (PPB) present as transient and self-limiting low mood and mild depressive symptoms that affect more than 50% of women within two or three days of childbirth and resolve within two weeks of onset. Symptoms vary from crying, exhaustion, irritability, anxiety, appetite changes, and decreased sleep or concentration to mood lability. Women are at risk for PPB.Several factors are thought to contribute to the increased risk of postpartum blues including a history of menstrual cycle-related mood changes, mood changes associated with pregnancy, history of major depression, number of lifetime pregnancies, or family history of postpartum depression. Pathogenesis of PPB: While pathogenesis remains unknown, hormonal changes such as a dramatic decrease in estradiol, progesterone, and prolactin have been associated with the development of postpartum blues. In summary, PPB is equivalent to a brief, transient “sad feeling” after the delivery. Peripartum depression (PPD) occurs in 20% of women and is classified as depressive symptoms that appear within six weeks to 1 year after childbirth. Those with baby blues have an increased risk of developing postpartum depression. About 50% of “postpartum” major depressive episodes begin before delivery, thus the term has been updated from “postpartum” to “peripartum” depressive episodes. Some risk factors include adolescent patients, mothers who deliver premature infants, and women living in urban areas. Interestingly, African American and Hispanic mothers are reported to have onset of symptoms within two weeks of delivery instead of six like their Caucasian counterparts. Additional risks include psychological risks such as a personal history of depression, anxiety, premenstrual syndrome, and sexual abuse; obstetric risks such as emergency c-sections and hospitalizations, preterm or low birth infant, and low hemoglobin; social risks such as lack of social support, domestic violence in form of spousal physical/sexual/verbal abuse; lifestyle risks such as smoking, eating sleep patterns and physical activities. Peripartum depression can present with or without psychotic features, which may appear between 1 in 500 or 1 in 1,000 deliveries, more common in primiparous women. Pathogenesis of PPD: Much like postpartum blues, the pathogenesis of postpartum depression is unknown. However, it is known that hormones can interfere with the hypothalamic-pituitary-adrenal axis (HPA) and lactogenic hormones. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks postpartum. The body receptors in postpartum depression are susceptible to the drastic hormonal changes following childbirth which can trigger depressive symptoms. Low levels of oxytocin and prolactin also play a role in postpartum depression causing moms to have trouble with lactation around the onset of symptoms. The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. Edinburgh Postnatal Depression Scale (EPDS) can be used in postpartum and pregnant persons (Grade B recommendation).Postpartum psychosis (PPP) is a psychiatric emergency that often presents with confusion, paranoia, delusions, disorganized thoughts, and hallucinations. Around 1-2 out of 1,000 new moms experience postpartum psychosis with the onset of symptoms as quickly as several days and as late as six weeks after childbirth. Given the high risk of suicide and harm, individuals with postpartum psychosis require immediate evaluation and treatment. Postpartum psychosis is considered multifactorial, and the single most important risk factor is first pregnancy with family or personal history of bipolar 1 disorder. Other risk factors include a prior history of postpartum psychosis, family history of psychosis, history of schizoaffective disorder or schizophrenia, or discontinuation of psychiatric medications. Studies show that patients with a history of decreased sleep due to manic episodes are twice as likely to have postpartum psychosis at some point in their lives. However, approximately 50% of mothers who experience psychosis for the first time do not have a history of psychiatric disorder or hospitalization. Evaluation.Symptoms of postpartum blues should not meet the criteria for a major depressive episode and should resolve in 2 weeks. The Edinburg Postpartum Depression Scale which is a useful tool for assessing new moms with depressive symptoms. Postpartum depression is diagnosed when the patient presents with at least five depressive symptoms for at least 2 weeks. According to the DSM5, postpartum depression is defined as a major depressive episode with peripartum onset of mood symptoms during pregnancy or in the 4 weeks following delivery. Symptoms for diagnosis include changes in sleep, interest, energy, concentration, appetite, psychomotor retardation or agitation, feeling of guilt or worthlessness, and suicidal ideation or attempt. These symptoms are not associated with a manic or hypomanic episode and can often lead to significant impediments in daily activities. Peripartum-onset mood episodes can present with or without psychotic features. The depression can be so severe that the mother commits infanticide. Infanticide can happen, for example, with command hallucinations or delusions that the infant is possessed.While there are no standard screening criteria in place of postpartum psychosis, questionnaires mentioned earlier such as the Edinburg Postpartum Depression Scale can assess a patient's mood and identify signs of depression and mania. It is important after a thorough history and physical examination to order labs to rule out other medical conditions that can cause depressive and psychotic symptoms. Disorders like electrolyte imbalance, hepatic encephalopathy, thyroid storm, uremia, substance use, infections, and even stroke can mimic a psychiatric disorder. So, How can we treat patients who are diagnosed with a peripartum mood disorder?Management.On the spectrum of peripartum mood disorders, postpartum blues are the least severe and should be self-limiting by week 2. However, patients should be screened for suicidal ideation, paranoia, and homicidal ideation towards the newborn. Physicians should provide validation, education, and resources especially support with sleep and cognitive therapy and/or pharmacotherapy can be recommended if insomnia persists. Regarding postpartum depression, the first-line treatment includes psychotherapy and antidepressants. For those with mild to moderate depression or hesitant to start on medications, psychosocial and psychotherapy alone should be sufficient. However, for those with moderate to severe symptoms, a combination of therapy and antidepressants, such as selective serotonin reuptake inhibitors, is recommended. Once an effective dose is reached, patients should be treated for an additional 6 to 12 months to prevent relapse. In severe cases, patients may need to be hospitalized to treat their symptoms and prevent complications such as self-harm or infanticide.Most SSRIs can be detected in breast milk, but only 10 percent of the maternal level. Thus, they are considered safe during breastfeeding of healthy, full-term infants. So, you mentioned SSRIs, but also SNRIs, bupropion, and mirtazapine are reasonable options for treatment. In patients who have never been treated with antidepressants, zuranolone (a neuroactive steroid) is recommended. Zuranolone is easy to take, works fast, and is well tolerated. Treatment with zuranolone is consistent with practice guidelines from the American College of Obstetricians and Gynecologists.While there are no current guidelines to manage postpartum psychosis, immediate hospitalization is necessary in severe cases. Patients can be started on mood stabilizers such as lithium, valproate, and lamotrigine, and atypical antipsychotics such as quetiapine, and olanzapine, to name a few. Medications like lithium can be eliminated through breast milk and can expose infants to toxicity.The use of medications such as SSRIs, carbamazepine, valproate, and short-acting benzodiazepines are relatively safe and can be considered in those with plans to breastfeed. Ultimately, it is a decision that the patient can make after carefully discussing and weighing the pros and cons of the available medical management. While the prognosis of peripartum mood disorders is relatively good with many patients responding well to treatments, these disorders can have various negative consequences. Individuals with a history of postpartum blues are at increased risk of developing postpartum depression. Similarly, those with a history of postpartum psychosis are at risk of experiencing another episode of psychosis in future pregnancies. Additionally, postpartum depression can have a detrimental effect on mother-infant bonding and affect the growth and development of the infant. These children may have difficulties with social interactions, cognitive development, and depression. In summary, following the birth of a baby can pose new challenges and often is a stressful time for not only the mother but also other family members. Validation and reassurance from primary care physicians in an empathetic and understanding manner may offer support that many mothers may not have in their close social circle. As the first contact, primary care physicians can identify cues and offer support promptly that will not only improve the mental well-being of mothers but also that of the growing children.___________________________Conclusion: Now we conclude episode number 171, “Postpartum blues, depression, and psychosis.” These conditions may be more common than you think. So, be alert during your prenatal and postpartum visits and start management as needed. Psychotherapy and psychosocial therapy alone may be effective but do not hesitate to start antidepressants or antipsychotics when necessary. Make sure you involve the family and the patient in the decision-making process to implement an effective treatment.This week we thank Hector Arreaza and Vy Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Raza, Sehar K. and Raza, Syed. Postpartum Psychosis. National Library of Medicine. Last updated Jun 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK544304/Balaram, Kripa and Marwaha, Raman. Postpartum Blues. National Library of Medicine. Last updated Mar 6, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554546/Mughal, Saba, Azhar, Yusra, Siddiqui, Waquar. Postpartum Depression. National Library of Medicine. Last updated Oct 7, 2022. https://www.ncbi.nlm.nih.gov/books/NBK519070/Royalty-free music used for this episode: Good Vibes by Simon Pettersson, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music/.

Patreon Producers: **Simi Sensei, @DadNeedsToTalk TMoneyFingerz, Phrozen Paradise, Dre G, JayLeeTrey, KedDaPro, ExplicitLi, Monique, Nochi, Saafir Catching up with the Hosts Episode of the week: Frieren, 100 Girlfriends Episodes just meh: Berserk of Gluttony, MF Ghost Nichijou - My ordinary Life (On Crunchyroll) Myriad colors phantom world (On Crunchyroll/Funimation) Invincible Season 2 (Amazon Prime) Fall Midterms • Opening thoughts on Fall Season • Supporters Season Grade • Telle's Grade: B+. Polow's Grade: B. Break Frieren Ep 10 Our Dating Story Ep 6 Ragna Crimson Ep 7

Former New Jersey Gov. Chris Christie is getting a lot of media — way out of proportion to the impact he has made as a candidate, measured by his low standing in the polls and the very modest amount of money he has raised. The explanation for this seems clear. The media loves his sharp and aggressive animosity to and criticism of former President Donald Trump. But the American people are looking for a leader. Could Chris Christie be that man? If Christie wants to be that man, he is going to have to do a better job showing how...Article Link

Are you frustrated, exasperated, or furious with the San Diego Padres? This is your chance to vent. Lee Hacksaw Hamilton offers up mid-season grades on the entire organization as well as his opinion why the team is performing so poorly. Wanna sound off? Here's what Lee Hamilton thinks on Monday, June 26, 2023. These are Hacksaw's Headlines:   1)...PADRES....GET TO MIDSEASON...WHAT TYPE OF LETTER GRADE PADRES LETTER GRADE "C" STARTERS "A" RELIEVERS "A" DEFENSE "A" OFFENSE "D" 2)...EVALUATE AJ PRELLER "GRADE "C"   3)...EVALUATE BOB MELVIN "GRADE C"   4)...EVALUATE PETER SEIDLER "GRADE B"   5)...PADRES SCORECARD (37-41) RECORD (5-13) 1 RUN (0-6) XTRA INN (8) SHUTOUTS (18-22) PETCO PARK   6)....PADRES STACK UP IN MLB RANKINGS "BAD METRICS" (232) BA (204) RISCP (315) RUNS (#25) HITS (#5) STRIKEOUTS (#1) WALKS (#11) HRS   7)...PADRES RUMORS-WHO'S FAULT? "MACHADO/BOGAERTS/CRONENWORTH - CHECK MY BASEBALL CARD"   =============================       #mlb #padres #mannymachado #xanderbogaerts #haseongkim #jakecronenworth #fernandotatisjr #trentgrisham #juansoto #austinnola #garysanchez #luiscampusano #joemusgrove #yudarvish #blakesnell #michaelwacha #sethlugo #nickmartinez #robertsuarez #timhill #stevenwilson #joshhader #bobmelvin #skipschumaker #mikeshildt #mattwilliams #ajpreller #peterseidler #dodgers #diamondbacks #giants #angels #pirates #nationals #reds   Be sure to share this episode with a friend!   ☆☆    STAY CONNECTED    ☆☆ For more of Hacksaw's Headlines, The Best 15 Minutes, One Man's Opinion, and Hacksaw's Pro Football Notebook: http://www.leehacksawhamilton.com/   SUBSCRIBE on YouTube for more reactions, upcoming shows and more! ► https://www.youtube.com/c/leehacksawhamiltonsports   FACEBOOK ➡ https://www.facebook.com/leehacksaw.hamilton.9   TWITTER ➡ https://twitter.com/hacksaw1090   TIKTOK ➡ https://www.tiktok.com/@leehacksawhamilton   INSTAGRAM ➡ https://www.instagram.com/leehacksawhamiltonsports/  

Listen to a soundcast of the May 19, 2023, FDA approval of Epkinly (epcoritamab-bysp) for relapsed or refractory diffuse large B-cell lymphoma and high-grade B-cell lymphoma.

Listen to a soundcast of the April 19, 2023, FDA approval of Polivy (polatuzumab vedotin-piiq) for previously untreated diffuse large B-cell lymphoma, not otherwise specified, and high-grade B-cell lymphoma.

We spoke with Mixæl Laufer of Four Thieves Vinegar Collective. Check it out! Follow Mixæl on Twitter and visit Four Thieves Vinegar Collective's website! Check out our previous episodes with Mixæl, too: Episode 14, 21, and 171. Support Coffee with Comrades on Patreon, follow us on Twitter and Instagram, and visit our website. Pick up a Coffee with Comrades t-shirt or coffee mug at our official merch store. Coffee with Comrades is a proud member of the Channel Zero Network. Coffee with Comrades is an affiliate of the Firestorm Books & Café. Check out our reading recommendations! Our logo was designed by Nathanael Whale.

We're one full week into the new year, and we got Steve Greenfield of Automotive Ventures joining the show to talk about the predictions he made for 2022 and how things actually turned out. Then, we'll look ahead to 2023 with 10 bold predictions for the coming year.Re-watch the Year End Extravaganza here: https://www.asotu.com/yeeThe Automotive Ventures Intel Report for January was released last week, and Steve Greenfield graded his predictions for 2022.#1: Lithia Becomes Largest Dealer In the US; Changes Name to Drive Driveway.com Grade: B-#2: 2022 will be the Year of The Connected Car Grade: A#3: Widespread Commercial Autonomy on the Street Grade: F#4: More Scrutiny of China Grade: A#5: 2022 will be the Year of EV Charging Infrastructure Grade: A#6: Compliance Coming Grade: B#7: Dealers Awarded Points for Vertical Take Off and Landing (VTOL) Grade: F#8: 2022 will be the Year of Corporate Divestitures Grade B#9: Usage-Based Insurance (UBI) Gains Traction Grade B#10: Test for Build-To-Order Grade BThe Intel Report also included predictions for 2023#1: Reynolds and Reynolds is Acquired#2: Tekion Acquired by Salesforce.com#3: Carvana Acquired by Amazon#4: AutoTech Valuations Reset#5: Dealership Valuations Drop#6: Dealerships Focus on Cost Reduction#7: Artificial Intelligence (AI) Goes Mainstream#8: Next Wave of AutoTech: Process Automation#9: Consolidation of Mobility Companies#10: Private Equity (PE) Acquires Public CompaniesGet the Daily Push Back email at https://www.asotu.com/ JOIN the conversation on LinkedIn at: https://www.linkedin.com/company/asotu/ Read our most recent email at: https://www.asotu.com/media/push-back-email Share your positive dealer stories: https://www.asotu.com/positivity ASOTU Instagram: https://www.instagram.com/automotivestateoftheunion

Welcome to December 17, 2022 on the National Day Calendar. Today we celebrate being sappy and fueling our dreams.  If you've ever wondered how maple syrup got its grades, here's a tip, it's all a matter of taste. In the past, Grade A syrup indicated an earlier harvest, hence a lighter color and milder taste. Grade C was harvested later and was best used as a substitute for molasses. Grade B was often overlooked, because folks thought it was somehow inferior. That's why the International Maple Syrup Institute dropped the grading system in 2015 and correctly labeled syrup by its color from golden to amber to dark and very dark. If you want to get fancy, check out the single forest Escuminac, Extra Rare syrup from Canada. That one will make you feel at the head of your class. On National Maple Syrup Day celebrate your sappy smarts with an extra pile of pancakes. From a young age Orville and Wilbur Wright were fascinated by flight. It all started in 1878 when their father brought home a rubber band helicopter. When the toy sailed across the room the boys were hooked. On December 17, 1903, their famous attempt to keep a mechanically propelled airplane aloft lasted only 12 seconds, but it carved a path that others would follow. While their dad was proud he was also nervous, and never allowed his sons to fly together. Seven years later, at the age of 82, he took a turn himself, and apparently enjoyed it. He reportedly yelled, “Higher, Orville, higher!" On Wright Brothers Day, we celebrate those who never lose sight of their dreams. I'm Anna Devere and I'm Marlo Anderson. Thanks for joining us as we Celebrate Every Day. Learn more about your ad choices. Visit megaphone.fm/adchoices

Episode 112: Statins in Primary CareDr. Tiwana explains the use of statins for the primary prevention of cardiovascular disease.Written by Ripandeep Tiwana, MD (Post-Doctoral Research Fellow at Cedar Sinai Medical Center – Heart Institute). Edition of text and comments by Hector Arreaza, MD.____________________________________________You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition.Statins commonly referred to as lipid-lowering medications, are important in primary care as they serve multiple long-term benefits than just lipid lowering alone. They are HMG-CoA reductase inhibitors. As a refresher, this is the rate-controlling enzyme of the metabolic pathway that produces cholesterol. This enzyme is more active at night, so statins are recommended to be taken at bedtime instead of during the day. Statins are most effective at lowering LDL cholesterol. However, they also help lower triglycerides and raise HDL cholesterol.Statins are not limited to just patients with hyperlipidemia. They reduce illness and mortality in those who have diabetes, have a history of cardiovascular disease (including heart attack, stroke, peripheral arterial disease), or are simply at high risk for cardiovascular disease. Statins are used for primary and secondary prevention.Types of statins.How do we determine which statin our patients need?First, we need to know that not all statins are created equal. They vary by intensity and potency thus, and they are categorized as either low, moderate, or high intensity.Several statins are available for use in the United States. They include Atorvastatin (Lipitor), Fluvastatin (Lescol XL), Lovastatin (Altoprev), Pitavastatin (Livalo, Zypitamag), Pravastatin (Pravachol), Rosuvastatin (Crestor, Ezallor), Simvastatin (Zocor)Commonly used in clinics: Simvastatin, Atorvastatin, and Rosuvastatin.Statin Dosing and ACC/AHA Classification of Intensity                                  Low-intensity                                   Moderate-intensity                                     High-intensityAtorvastatin              NA 1                                                          10 to 20 mg                                                   40 to 80 mgFluvastatin                20 to 40 mg                                          40 mg 2×/day; XL 80 mg                                NALovastatin                 20 mg                                                       40 mg                                                                         NAPitavastatin               1 mg                                                          2 to 4 mg                                                                   NARosuvastatin             NA                                                            5 to 10 mg                                                          20 to 40 mgSimvastatin                10 mg                                                      20 to 40 mg                                                             NAOf note, atorvastatin and rosuvastatin are only for moderate or high-intensity use, and do not use simvastatin 80 mg.Identifying patients at risk.How do we determine who needs statin therapy?Once we become familiar with the different statins, we must figure out which intensity is advised for our patient. Recommendations for statin therapy are based on guidelines from The U.S. Preventive Services Task Force (USPSTF), American Diabetes Association (ADA), and the American College of Cardiology/American Heart Association (ACC/AHA) which recommend utilizing the ASCVD risk calculator in those patients who do not already have established cardiovascular disease.ASCVD stands for atherosclerotic cardiovascular disease, defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease presumed to be of atherosclerotic origin. ASCVD remains a leading cause of morbidity and mortality in the United States, especially in individuals with diabetes.The ASCVD risk score determines a patient's 10-year risk of cardiovascular complications, such as a myocardial infarction or stroke. This risk estimate considers age, sex, race, cholesterol levels, use of blood pressure medication, diabetic status, and smoking status. Regarding age, this calculator only applies to the age range of 40-79 as there is insufficient data to predict risk outside this age group.There are several online and mobile applications available to calculate this score. Once calculated it gives a recommendation for which intensity statin to use. However, as this is a recommendation, it is essential to use your own clinical judgment to decide what is best for your individual patient. Please refer to the above table as a reference for which statin and dose you may consider using.Keeping the above calculator in mind, additional statin guidelines are recommended by the ACC:Patients ages 20-75 years and LDL-C ≥190 mg/dl use high-intensity statin without risk assessment. (You do not need the calculator.)People with type 2 diabetes and aged 40-75 years use moderate-intensity statins, and risk estimate to consider high-intensity statins. (It means moderate for all diabetics older than 40, high for some.)Age >75 years, clinical assessment, and risk discussion. Age 40-75 years and LDL-C ≥70 mg/dl and 10%. Grade B recommendation: prescribe a statin for the primary prevention of CVD.Grade C – 40-75 years with >= 1 cardiovascular risk factor AND estimated 10-year ASCVD risk 7.5-10%. Grade C recommendation: selectively offer a statin for the primary prevention of CVD. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater.Grade I - The USPSTF found insufficient evidence to recommend for or against initiating a statin for the primary prevention of CVD events and mortality in adults 76 years or older.The USPSTF is also very clear regarding the intensity of statin therapy. They explained that there is limited data directly comparing the effects of different statin intensities on health outcomes. Most of the trials they reviewed used moderate-intensity statin therapy. They conclude that moderate-intensity statin therapy seems reasonable for most persons' primary prevention of CVD.The USPSTF has a broader recommendation, whereas the ACC guidelines are more detailed and individualized and provide guidance on the recommended intensity of statin therapy.Labs needed.Establish baseline labs for serum creatinine, LFTs, and CK only if there is a myopathy risk. Routine monitoring of LFTs, serum creatinine, and CK is unnecessary; only check if clinically indicated.A lipid panel should be checked in 6-8 weeks, and the patient should monitor themselves for any side effects, including myalgias. If LDL-C reduction is adequate (≥30% reduction with intermediate statins and 50% with high-intensity statins), regular interval monitoring of risk factors and compliance with statin therapy is necessary to sustain long-term benefit.Side effects and contraindications.Some common side effects include URI-like symptoms, headache, UTI, and diarrhea. Some patients are very hesitant to take any medications. Warning about side effects may decrease compliance. Major  contraindications for statin therapy include active liver disease, muscle disorders, pregnancy, and breastfeeding.Special considerations.Chronic kidney disease: The preferred statins for CKD with severe renal impairment are atorvastatin and fluvastatin because they do not require dose adjustment. Pravastatin would be a second choice.Chronic liver disease: Statins are contraindicated in patients with decompensated cirrhosis or acute liver failure. Abstinence from alcohol is critical in patients with chronic liver disease who are taking statins. Pravastatin and rosuvastatin are the preferred agents. Check lipid levels to determine if LDL-C reduction is accomplished with no changes in aminotransferases. You may consider stopping, increasing dose, or changing statin as you discuss the risks vs. benefits with your patient.Conclusion: Simply put, if a patient has an LDL of greater than 190, is a diabetic, has an established history of cardiovascular disease, or is at risk for it, then the patient should ideally be taking a statin unless there is a contraindication, allergy, or other special circumstance that limits him/her from doing so. If you have patients that apply to any of the above scenarios and are not already on a statin, determine their risk, and consider starting them on a statin “stat” to reduce morbidity and mortality. On the other hand, be mindful of overprescribing. Do not prescribe statins to patients who do not meet the above criteria.________________________________________Now we conclude our episode number 113, “Statins in Primary Care.” Statins are powerful medications for the prevention of cardiovascular disease. Do not forget to recommend non-pharmacologic measures such as healthy eating and physical activity, but let's also consider adding a statin to patients who are at moderate to high risk for cardiovascular disease.This week we thank Hector Arreaza and Ripandeep Tiwana. Audio by Adrianne Silva.Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you; send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!______________________________________References:1. Statins, U.S. Food & Drug Administration, 2014, December 16, fda.gov, https://www.fda.gov/drugs/information-drug-class/statins, accessed September 14, 2022.2. Chou R, Cantor A, Dana T, et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Aug. (Evidence Synthesis, No. 219.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK583661/3. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; March 17. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention. 4. ASCVD Risk Estimator Plus, published by the American College of Cardiology, https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/, accessed September 14, 2022.5. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication, U.S. Preventive Services Task Force, Final Recommendation Statement, 2022, August 23. https://uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication6.  Videvo. “Distinction.” Https://Www.videvo.net/Royalty-Free-Music-Track/Distinction/227882/, Https://Www.videvo.net/, https://www.videvo.net/royalty-free-music-track/distinction/227882/. Accessed 26 Sept. 2022.

Synopsis Today marks the birthday of American composer David Raksin, born in 1912 in Philadelphia. He studied composition with Arnold Schoenberg, was friends with Igor Stravinsky, and has written a wide range of concert music. Yet Raksin is best known for one haunting tune – the theme he wrote for a classic 1944 film noir entitled "Laura." David Raksin said the true story behind this music sounds like something out of a Grade-B movie. The very weekend he faced a deadline and simply had to come up with a theme for "Laura," Raksin says he received a "Dear John" letter from his wife stating she was leaving him. Unwilling to believe she was serious (she was); he stuck the letter in his pocket and tried to lose himself in his work. "By Sunday night," recalled Raksin, "I realized I had a very painful case of writer's block. From the time I was a boy, when the music wouldn't flow, I would prop a book or a poem on the piano and improvise. The idea was to divert my mind from conscious awareness of music-making… I took the letter out of my pocket, put it up on the piano and began to play… and then, without willing it – I was playing the first phrases of what you now know as the 'Laura' theme." Music Played in Today's Program David Raksin (1912-2004) –Theme from “Laura” (New Philharmonia; David Raksin, cond.) BMG/RCA 1490

Episode Notes Episode summary Guest info and links The host Margaret Killjoy can be found on twitter @magpiekilljoy or instagram at @margaretkilljoy. This show is published by Strangers in A Tangled Wilderness. We can be found at Tangled Wilderness You can support the show on Patreon. Referenced Texts: > Fitzpatrick's Dermatology, 9e > Taylor and Kelly's Dermatology for Skin of Color, 2e > Sanford Guide To Anti-Microbials > UpToDate: > UpToDate – Evidence-based Clinical Decision Support | Wolters Kluwer > Where there is no Doctor:Books and Resources - Hesperian Health GuidesHesperian Health Guides > CDC > American Academy of Orthopedic Surgeons > Transcript Max on Taking Care of Medical Needs Margaret 00:15 Hello, and welcome to Live Like The Wold Is Dying, your podcast for what feels like the end times. I'm your host Margaret killjoy. I use she or they pronouns. And this week I'm talking to another medical practitioner. I'm talking to a nurse practitioner named Max, who is going to talk about how to access medical care when medical care doesn't want to give you access to medical care. And we'll be talking about the different ways that people source medications, and we'll be talking about the different diagnostic tools and kind of talk about what you can do to learn how to be your own doctor. Yeah, I hope you enjoy it. This podcast as a proud member of the Channel Zero network of anarchists podcasts. And here's a jingle from another show on the network. Ba-da-da-dah-dah-da. Channel Zero Jingle Margaret 02:18 Okay, so if you could introduce yourself with your name, your pronouns, and then I guess a little bit of your background as relates to the kind of stuff we're going to be talking about today. Max 02:27 Sure, my name is Max, I use he/him pronouns. I'm a medical provider, technically, I'm a nurse practitioner with a degree in family health care. I've been working in health care for about 15 years on the, on the East Coast, first doing primary care and working with LGBTQ+ folks, and now mostly doing HIV care in an infectious diseases environment. Margaret 02:56 Okay, so the reason I wanted to have you on the show is I wanted to talk about, I guess you could say like DIY allopathic health care, or maybe rather like accessing allopathic medical care without access to the allopathic medical system. And, I was wondering if you could kind of give a brief introduction to that, and also explain what allopathy is, for anyone who's listening who's not familiar with that term? Max 03:21 Sure. Allopathic is the word I think I'm going to use to describe the medical world I work in, I think about it, like how people talk about Western medicine. But I feel like there are so many different contributions to what we think of as Western medicine, from all over the world historically, and currently that it seems kind of like a dumb term. And I sort of reached out to some friends of mine who are in other kinds of health care, outside of this sort of what we think of as like this health care model and was like, "What's the best terminology?" and they're like, "Oh, "allopathic", that's what you should use," you know, and so I think, "all right, that's what I'm going to use for this." And for me, I think a lot about expertise, right? Like someone could learn to work on a bicycle outside of ever having to learn necessarily in a shop or in a school. And they could learn to work on their bicycle super super well, and they could learn to start working on other people's bicycles. And they could go on the internet and they could diagnose problems with bicycles and they could you know, become the person who lives next door who's really really good at fixing everybody's bicycles. And ultimately with experience that person can be an expert in bicycles right? That's that's something we allow people and there's something about allopathic medicine that just doesn't allow for that expertise outside of really rigid model, outside of schooling outside...it it police's its borders. So like, if you want to go and look something up about your own health care on the internet, the things that you find are are terrible, even the things that are supposed to be reliable, like something like Medscape or something like that, you know, it's like every, "Oh, you have a sore throat," you look up sore throat, and it gives you every possible thing that could ever possibly have ever caused a sore throat, including some kind of cancer, right Margaret 05:16 Yeah like if you look up, yeah. Max 05:17 Yeah. And if you...but if you look up how to fix a flat, there's not disclaimers about "Oh, you might cut off your tongue while fixing a flat, or run yourself over, or wear a helmet." You know, it's this...it's like, matter of fact, you're allowed to access the information. And I think that there's...it's a big problem when it comes to health care. And... Margaret 05:29 Well everyone has bicycles, but only some people have bodies. Max 05:42 No, no one has bodies. No one... Margaret 05:44 Yeah. But everyone has a bicycle. So it makes sense. Max 05:47 Everyone has a bicycle. Yeah. Margaret 05:49 Yeah. Sorry, I cut you off. Please continue. Max 05:51 No, it's fine. Makes total sense. I, I, I also think too, about a lot of the, you know, I think one of the things I think about in your show is that idea of like, you know, the prepper, and the fallout shelter, or like the little green anarchists like how that's not necessarily like a sustainable model in the, in the tradition, like, because we need each other, right. And I think one of the things that we need about each other is that we need all of each other. And I think this idea of being able to just go and live on the mountaintop and survive on your own is deeply ablest and assumes a lot about bodies and what bodies need and what people need to keep their bodies healthy. Margaret 06:29 Yeah, and it doesn't take into account that like even able-bodied people aren't always perpetually able-bodied, you know, like, speaking as someone who currently lives alone on a mountaintop...you know, I think about it a lot, right? Like, I'm like, if I fall on the ice, my dog isn't going for help. You know, and like, I could probably only do what I do with access to a cell phone. You know, like, realistically, I mean, sure people successfully live alone for long periods of time, without access to any of that, but people also unsuccessfully live alone without access to other people, too. So I agree with you. I am....Yeah, we do need each other even even, even when you choose to be mostly isolated, which actually come any kind of crisis. I'm not making this about me, I just got really self conscious thinking about the mountain top thing. You know, come any kind of crisis, I immediately don't want to be alone anymore. Like, be...living alone only make sense in the context of the entire, like, social infrastructure that we have set up, you know? Max 07:34 Oh, for sure. Oh, for sure. And it's like, as soon as you get a little bit hurt, and you're laying on the ground, and you're like, "Why did I do that thing that I just did that got me a little bit hurt?" you're like, "Will I be hurt forever. Will anybody findfind my corpse. Margaret 07:51 Okay, so, so and then. So, you're someone who does have access to a lot of the, you know, traditional allopathic medical world, right. And and what you're saying is that it's something that people can become more competent as individuals, whether they're, like specializing, or whether they're just like Jack-of-all-trades-ing their, you know, their health care. What does that...what does that look like? What are good places to start, either in the current context, or in a, you know, a crisis context in which we might be detached from social infrastructure? Like, what what should people learn? Max 08:28 I'm definitely not in the working in any kind of realm of right now, like, emergency, right? So this definitely isn't the like, 'how to, you know, stop somebody from bleeding and excessively' or... Margaret 08:41 We have that episode, actually, so. Max 08:43 Exactly, yeah. No, I've listened to it. And it was great. Um, but it's sort of more like, how do we access these things, so that so that people can become experts outside of a traditional model, right? And so I think about things like, like, sort of big three big things as like reliable sources, right? Where can you look up information and actually get information without being told that you're gonna, that you have cancer when you just have a sore throat, right. And, and then you have access to diagnostic tools, and things that help make diagnostics, and things that help sort of lay it out. And then because that's something that you...we use all the time. And then the final thing I think about is, and also in in that realm of tools, is medications, right? Like how do we get medicine? You know, like this, like medicine in pill form, medicine in injectable form, like how do we get those things outside of a doctor model? And then the final thing is just like, what makes someone an expert is experience. But so the big things I'm going to talk about, like are like what I'd like to talk about, I guess is sources, and tools. Tools, and in the sense of tools I think, you know, diagnostics, manuals and things like that, but diagnostic tools and, and medicines. Okay, so Margaret 10:09 This is exciting, I want to know these things, and then I'm going to ask you about fish antibiotics afterwards. Max 10:13 And then in the very most fundamental level, I think that everyone in the whole world who...should have a little index card that they keep on their person that says, you know, their name and emergency contact, what they're allergic to, if they have any medical conditions, if they take any medications, you know. It...or make, you know, or make that if you live with someone who's older, if you live with someone who's house bound, if you live with someone who's particularly vulnerable, help them do that, make them for that for them, and just have that on hand. Because that just simplifies every process. Margaret 10:50 I, I really liked that idea. And then like maybe people who have access to whoever in your neighborhood has a lamination machine, you know, make laminated cards for everyone. No, that makes sense. It's one of the questions I get the most, you know, because the traditional, as you kind of mentioned, the traditional prepper space is very ableist, and very focused on people who are not marginalized by society. And, and so a lot of people are like, well, you know, "I need a thyroid pill every day, or I'll die," or, you know, or "I don't want to go off antidepressants, I'd rather die," or, you know, whatever these things are. And I don't usually have good solid answers. So that was actually why when you reached out, I was so excited to talk to you. So I guess, do you want to start with sources? What are good sources, obviously, WebMD and Wikipedia, but... Max 11:41 I have a ton as they do about ways of sort of amassing medication, so we'll get to that. Margaret 11:46 Okay, cool. Yeah, yeah. Max 11:47 So, sources was like the first thing. If you can get health insurance right now. And I mean that in like...there are sometimes ways to get it. Like if you can access a lower income clinic, or you know, someone who's a social worker, or does case management, they can help you often get, like state assistance health insurance. And like if you're super sick, and you have a complex issue that would might involve...like, if you have a broken bone, or you worried that you might have legit pneumonia, you can absolutely always give fake information at an emergency room. Just be savvy about it... Margaret 12:24 Right, and obviously only do this.... Max 12:25 And if you have to get hospitalised... Margaret 12:27 Oh no, obviously, we're talking about fiction in this particular context, as we would never advocate for you to break the law, but yeah. Max 12:31 Yeah, absolutely fiction. Yeah, absolutely fiction and in... Margaret 12:33 In a post apocalyptic society that looks exactly like our current society. This is what you could tell. Max 12:37 Yeah, that's what we're, that's what we're talking about. And the only way to talk, you know, and in said society too, if you end up in a in a hospitalized situation, and you're what they consider to be indigent. They know they can't get blood from a stone. So they'll often sort of retroactively sign people up for medical coverage to cover that. This is all of course, assuming that someone is documented so I don't want to, I don't want to assume that. So that's on the baseline. But, so things that you could do diagnostic wise, right, we can learn and people can learn how to do physical exams. But I'm a big fan of, of, of some sources that people can access, there's this book called "Where There Is No Doctor", and everyone and their mother should ownthis book. You can get free PDFs of it, and tons and tons of languages, tons and tons and tons and tons of languages. And it is an incredibly useful thing. People should just get it for each other for like birthday presents, you know, and it pretty much shows you how to like diagnose and treat a wide variety of illnesses, even with explicit medication instruction. And it's just, it's just a really, really, really, really useful tool. There's also this thing, this online thing that most healthcare people have access to called "Up To Date." And if you know anyone in healthcare, and you know, in an in an in an alternate reality, where people can share things like you know, logins and things like that, you know, someone who might be willing to share that, you can use Up To Date to diagnose and treat everything. And what it is, is it's, it's, it's staffed by medical people who create, you know, pages about different illnesses, about different things that you might encounter, and gives you all the most quote unquote, "up to date" well referenced literature about whatever it is, you know, and they kind of grade like, "Okay, we give this a Grade A, we give this a Grade B" in terms of like, okay, this is a good intervention or not. And you it's, it's, I look at it all day long, and I've been doing healthcare for a long time. Another possible thing that one could do if one was in like a collective of people was you could all go in on it have an Up To Date. Margaret 15:06 How much does it cost? Or do you need to provide like medical license? Or? Max 15:09 I've not had to, to sign up for it? I mean, and I think it's, I think it's very worth it. But I think it's also like one of those kinds of things like, you know, a lot of subscription services where somebody's got login. And there's no way to sort of misuse it, you know. Margaret 15:29 it just, it drives me crazy how like, this exists, and that we can't access it. Like, I mean, obviously, some people can. And that's, that's wonderful. And I'm sure there's reasons or whatever, but it's just, it's very frustrating the idea that, like, we're all stuck with WebMD, you know, whereas like, actual doctors are able to like...it's not that they just magically know, all this information, you know, I mean, I've been going to a friend of mine for years as like my primary medical provider, basically. As soon as he started going to med school, you know, he just started answering everyone's medical questions for the community that he was in. And, you know, yeah, he spends all of his day like reading and stuff like that, and keeping up to date...it is a very clever name...about all this stuff. And it's amazing how much it changes. I don't know. I don't know, I sorry, I just got really frustrated, think about how that that exists, and I can't immediately access it, and I'm stuck, like, using things telling me I'll die of cancer. Max 16:30 And it's, it's...that's kind of one of the things I mean, like what else? What else? Where else? Is it so difficult maybe to to access, actual legitimate, you know, resources, if you have a friend, like who's in health care, and they're associated with a university or like a major hospital system, there are also sometimes these biomedical libraries online? Well, of course, there are there are biomedical libraries online, sorry. And, you know, you can look up to the very most current research on things papers wise, you know, and that's a fantastic, fantastic resource. If you know anybody with a login, who's...or is...who is a medical student, or even just a student period, most of them have an online acc... online access to really, really good current research. And ways of guiding care. And so that's another great tool. So you can actually be doing, you know, very, very current, you know, well documented smart health care for people, because they're these things exist. These these documents, these research papers, exist, we just, it's the access, right? It's, it's the access like 100%. Let's see.... Margaret 17:56 I mean, it's, it's ivory tower shit, it's like, it's the same as like, whenever I'm trying to research history. There's all kinds of papers written by historians, and they're all locked up behind these academic paywalls. And I basically have to like bug my friends in the academy being like, "Hey, can you pull this paper?" Or like, write the author's directly and be like, "Hey, you're the only person who's written about the blue spectacles worn by the nihilists in 1860s. Russia, can you tell me why they were blue? Can you just give me the paper?" You know, and I don't know. Sorry, as an aside, it just irritates me. I don't like this ivory tower thing. Max 18:28 It's ridiculous. It's so ridiculous. And you know, but it really, I think, probably a lot of people are only probably a couple of degrees, like, away from someone who might have one of these log-ons...logins. So I think we should just pressure the hell out of our friends and colleagues, and make sure that they you know, distribute... Margaret 18:48 Yeah. Max 18:49 equitably, equitably. The...one of the things I really use a lot is like dermatology guides. So if you have a bunch of friends and you want to go in on a little like Biomedical Library, you know, you know if you know someone who ever went to nursing school or anything like that, ask them if they have, you know, things like anatomy books and things like that. But if you can get Derm books, they're great. There's one called "Fitzpatrick's Dermatology". And it's just like the tome, and has, it has tons of color pictures, if you get an outdated one, just know that some of the recommendations in terms of things like antibiotics might be outdated, but...but what the rash is, and what it what it is, you know, is not...it hasn't changed. That book, though, has...centers I think white skin considerably. There's a book called "Taylor And Kelly's Dermatology For Skin Of Color" that's much much better in terms of, obviously, skin of color. It's very, very good book as well. The problem with both of these books is that they're not cheap. So it's totally worth finding old copies. But then again, just remembering that, you know, the "how to treat things" might have changed. Margaret 20:11 Okay, so the diagnostics are good, but the treatment... Max 20:15 Yeah, but the "what to do" has changed. Margaret 20:17 But once you diagnose it, then you can reference Up To Date or whatever to figure out a better.... Max 20:23 Absolutely. And just in terms of rashes, you know, rashes kind of can all look like each other, too. So that's that problem with rashes. Margaret 20:30 I mean, to be honest, like to just admit to everyone the main thing I've been going to medical care provider for many years, I, you know, i was a squatter, and I live in a van, I live in a cabin was was like, "Hey, what's this rash?" Max 20:43 What's this rash! Margaret 20:44 And usually the answer is shower more, and... Max 20:48 Dirt rash. Margaret 20:50 Yeah, and like, I think, ended up having to put anti-dandruff shampoo on various parts of my body at various points, and like leave it there for 10 minutes. Anyway, now that you all know more about me, then you need to...dermatology that that makes sense. Max 21:09 I love getting to tell patients to shower less that sometimes happens with eczema, Margaret 21:13 Oh, interesting. I haven't had that problem. I'm looking forward to having that problem. Max 21:24 So there's a thing called the "Sanford Guide To Anti-Microbials". They're little bitty books, if you can get a very, very up to date one, or like, like, current one. Sorry. That's a really useful thing. They're teeny. The CDC website is really, really useful when it comes to all manner of things like travel exposures, bacterial and viral illnesses, their STD stuff is great, their PrEP stuff, which is like a pre-exposure prophylaxis for HIV, their PrEP guidelines are great and super, super accessible. And that's just free and available, and you just look it up. But just instead of looking at the...look at the "For Providers", you know, always just click on "For Providers." And then I really like the American Academy of Orthopedic Surgeon website when it comes to like certain exercises for bones and joints. And then let's see, a lot of schools and universities will just have like"best practice guidelines, which are just the best ways to...like algorithms for diagnosing things. And then there's some, like online videos, there's this place I used to work....They... I used to refer a lot of my patients at this one practice to this place called Excel PT, Physical Therapy, and I love them because they have tons and tons and tons of free physical therapy videos on their website that are really really good. Like they're legitimate physical therapy exercises that people can go through and be put through. And I just really liked them because I feel like, I don't know it's not just a printout. It's...they're actually putting someone's body through the motions. They have them right up there and there's not like 50,000 disclaimers, like you're gonna...I don't know, I really I think they're super, super valuable. And I use them a lot with patients of mine who are uninsured who can't go to physical therapy. So, that's some of my...those are like my manuals, I love manuals anyways, in all manner of things. Margaret 23:37 Yeah, that's like the...sometimes people come over my house are sort of disappointed because I'm a fiction writer, and most of my shelves are just like...if I see a manual for how to do something at a used bookstore, I'll buy it. Max 23:47 Oh my gosh, totally. Every time. Margaret 23:51 I really don't see the world where I'm trapping small game. I just don't see it happening. I've been vegan for 20 some years, but... Max 23:59 I got this really good. It's like a guide. It's exactly that. I have to remember the name. I'll have to tell you later. We can cut this out of there. Margaret 24:07 Naw, we should leave that part in. Max 24:10 It's like a hunter-trapper manual. It's so good. Margaret 24:14 Good. Will we be able to put in the show notes all of the... wil you be able to send me the list and I could put this in top of the show note, so you don't have to dig through the trans, transcription to find these again. Anyone who's listening they'll be in the top of the show notes. Max 24:27 Absolutely. I will send you all of my, all of my bits and bobs. And then, I guess after after that comes to me like, diagnostic tools in terms of like physical things in like, you know everybody if you you know [have a] blood pressure cuff, pulse oximeter and stethoscope. Right. But you can use...if you get a microscope and you have slides...like a decent student microscope, you can actually diagnose a fair number of things. You know, if you can, you can learn how to Gram stain so you can figure out, you know a lot about bacteria. Margaret 25:08 What kind of stuff can you successfully diagnose yourself with this kind of thing. Max 25:12 Like with a microscope, for instance? Margaret 25:14 Yeah. Margaret 25:16 You can diagnose like a yeast infection or a fungal infection. If you have a microscope and something called potassium hydroxide, you can like...Trichomoniasis is like an STD. You can absolutely see Tric, like swim on a microscope slide. Um, you can, you know, if you look at a slide and there's like loss of white blood cells, and then also like little 'cock-eyes' , sometimes you can diagnose certain kinds of STDs. And then yeah, with a microscope slide and some some pH paper, you can diagnose bacterial vaginosis, yeast infections and Trichomoniasis for sure. For sure. Margaret 26:08 That's cool. Max 26:09 And then, yeah, it's really cool actually. It's fantastic. And it's old school and, you know, people miss things. And sometimes things don't look like how they should but there's tons of information about that online Margaret 26:22 There's a question and probably, you probably can't,but a friend of mine in med school saw his own chromosomes. And I assume that's more than a microscope. Max 26:33 Yeah, no. But, you know, a student microscope is going to be kind of more like bigger, bigger cells, things swimming across, you know, little fungal things that are growing. That kind of stuff. Margaret 26:46 Okay. Max 26:48 And then if you can get access to urine dipsticks, so which you can actually buy, I think just, I mean, I even I think I looked them up on Amazon, which I shouldn't have. But I did, just to see how easy they were to get, because there are in medical offices. They just have to be kept like in the little...they have to be kept in their little container that they're in because they have to be kept dark. But, those can be used to diagnose, you know, a urinary tract infection. And if there's sort of three things, or if there's little two major things going on on them, you know, if you see something like an increase in the white blood cells that are on the little strip, and you see something called leuk leukocyte, esterase, or leuk esterase, or nitrites on there, those things pretty much are indicative of of a UTI. So if someone has recurrent UTIs, they can actually like pee on a strip and be like, you know, this is this is legit, this just this isn't just me feeling like dehydrated or having coffee, too much coffee bladder or something like that. So it's kind of really useful. Also, if someone just has a ton of glucose on there, that you know, that's like a diabetes diagnosis. So that can be really useful. Having a glucometer is really useful, which tests their blood sugar levels because it can test to see if someone, you know if someone in somebody's community is diabetic, and they get too low or too high, or just in general, if you have someone that's not faring super hot, you can check their their blood glucose levels. The problem with glucometers is they're maddeningly proprietary. So you get them and like there's strips and there's the little finger stick things and they all go with the one has the ones and so it's really obnoxious because it's not like you can super easy cobble together a little glucometer setup. Margaret 28:44 That's basically to rip off diabetic people. Max 28:47 Oh, completely. It's just all...it's the dum dum dum dum, dum dum. You know, pregnancy tests. There's home HIV tests. Now we've got COVID test. Apparently, mine's coming from the government. I just finished and I just got it back a negative rapid covid just like two seconds before this. I was feeling kind of rundown. Yeah, I was feeling kind of rundown. So I was like, I should do this before I see my kiddo tomorrow. Yeah. And then now more and more, you can just order lab work for yourself. And I think it's really useful to know what you're going into before doing something like that. And all these things I'm talking about, you know, it should be for really big like, "I think I might have an STD," you know, or like, I think, you know, there's something, something isn't right with this very specific thing. But a lot of these sort of like LabCorp and Quest Diagnostics and things you can actually just go on and order your own tests. It's not cheap, but... Margaret 29:52 I went and got a bunch from Let's Get Checked. And I'm a little bit squeamish around blood and it was like, "Oh, it's a finger prick and I can handle a finger prick." What they don't tell you is that it's a finger prick and then milk the blood out of your finger. Max 30:05 Oh, I hate that, the word milking. Margaret 30:08 Yeah, and I literally couldn't do it. I like, tried. And then I was like making someone help me. And then they were like getting really stressed out because I was kind of freaking out of them. And I couldn't do it. So I have like, a fair amount of expensive tests sitting and waiting for me to figure out how to, and then, you know, I like I talked to them, and they're like, "Oh, you just got to make sure you take a shower first, and that you're all warmed up so that you can like..." and I'm like, "I will not milk blood from my finger." So I have...my squeamishness prevents me from accessing certain amongst these tests. Max 30:48 Well, some of them, you can order yourself and actually just bring to the lab. And they'll actually do a blood draw for you. So I learned that from... Margaret 30:57 Okay, okay. Max 30:58 Yeah. But they're not always, you know, I think the cost is always kind of an issue at the end of the day with some of these things. Margaret 31:08 Yeah, I like the idea that someone in like, someone in your crew can have a microscope and at least tell you if you have Tric. Max 31:15 Yeah, for sure. For sure. Especially if you know, the symptoms, and the and the test match up. Yeah, possibly all labs may be able to be ordered. But the thing is, I'm a big fan of like, not going looking for things unless there's an actual... I don't know, unless someone's having a problem in that they feel like it means that something has changed from their baseline to such a degree that it's causing them...like, things aren't going well. Margaret 31:48 Yeah. Max 31:48 You know? And if something I always tell people, if something's been there on your body for a long time, and it's unchanged, it's probably not anything. You know, like, it's probably just a... it's probably just your variation on a theme, or it's some kind of weird little cyst that's just always gonna be there. And if if it's causing sort of psychological distress, distress, or something, that's totally fine. Like, we can deal with it. But if it's not changing or getting worse or anything, it's probably nothing. That...nothing worrisome. It might be something but it's not going to be something worrisome. Margaret 32:23 Yeah. Max 32:24 Yeah. Margaret 32:25 You mentioned also in diagnostic tools, like physical exams, like, what are the kinds of physical exams that we should be learning how to administer on ourselves and our friends? Max 32:35 Well, I think just sort of knowing what your body is like, like know, from the get-go, like not to be totally "to our bodies, ourselves," but I think there's something really good about knowing what's there. You know, and, like self exams are good in terms of people think about, like, you know, chest self exams, testicular self exams, those kinds of things. I think if someone really wants to pursue be... you know, knowing about other people's bodies, you know, knowing knowing what, what to listen for, would you listen at someone's heart and things like that are important things, you know, to know. But I think just having kind of a sense of oneself and like, "Oh, something isn't right. Something really isn't right," is is kind of the most important part when it comes to physical exams. Margaret 33:25 So just knowing your baseline basically, and knowing... Max 33:27 Knowing your baseline and knowing when something wildly deviates from your baseline. Margaret 33:33 Okay. Which of course always says the fun, like aging thing where you're like, Oh, that's a new spot. Max 33:38 Oh, yeah, totally. Or that hurts so much. Margaret 33:41 Oh, actually, okay here's a diagnostic question: What should I look for? What should 'one' look for when they look at moles? To try and figure out whether or not they're worrisome? Max 33:52 Is it? Is it new? Is it irregular? Like very irregular. Not like a nice little round, nice, like continuous border, but does it look raggedy? Right? Is it, is it kind of just like a different pigmentation from your skin color? Or is it like, like really black? Or is it like, going to bleed easy? Is it kind of bumpity all over as opposed to kind of a continuous smooth thing? In my experience, things that are worrisome that turn out to be cancer, things look worrisome. They look really different. Usually. Not always, but usually, you know, you see something and you're like, "What is that?" That's not something that's been on your body before. And again, if it's something that's unchanged, really, mostly it's been there for a long time. It's not doing anything. It's just chillin with you. Margaret 34:55 So, one of the things I want to ask about, that you talked about briefly before we before we started recording is, is access to medications. Obviously, medications are something that it's, you know, there's there's probably two types of answers to this question or almost two questions. And one of them would be like, "What can you gain access to in a situation where law is no longer a thing?" Versus "What can you gain access to within the existing society?" Like, how can you gain access to different things? And those are maybe related questions, and maybe not, but I'm curious. Max 35:31 I think they're related. I think I need to preface it, okay. Something that's really important to me is anti-microbial stewardship. And it's, it's up there with, you know, all kinds of stewardship, right, like Earth stewardship, meaning like, we have access to drugs that treat microbes. We have overuse to them as a society, right. And now we have these things called multi-drug-resistant organisms. And the way we prevent more of that is not is by not taking medicine that we don't need. Okay. And by taking medicine, that makes sense for the organism. So that's my only little caveat that I'm putting out there. Margaret 36:18 No, that's interesting. The way of phrasing it as like, part of stewardship makes a lot of sense. Like, so what's involved in...I mean, like, you know, I remember, was a kid, we'd all be like, "Oh, don't use antimicrobial soap, or you'll make everything worse," you know, and I don't know, that was us being like, proud about being dirty, or whether that was legitimate and, like, like, so what else is involved? I mean, there's also the like, you know, always complete your round of antibiotics, so that you like, actually destroy it versus like, you know, almost killing it having come back worse, but like, what are... Max 36:53 That's kind of changed a little, they've actually shortend a lot of courses. Margaret 36:55 Oh, interesting. Max 36:56 Yeah. You know, it used to be these sort of like long drawn out courses. We just want to make sure that someone's using the right, right drug for the right critter, right. And that we're not just taking medicine because we don't feel good. Because, there's a lot of things that may make people not feel good, that doesn't even have anti whatever's towards it, like anti-microbials. Because it might not be bacterial it might be viral, there might not be anything to do for it. You know, like the vast majority of of those, those two, three weeks, sort of sinusitis, doom, "I'm so sick, and I'm never going to be a well person." That's all viral illnesses, you know, there's not anything we can really do for them. If it's multi-symptom, like that, like runny nose, and yucky eyes, and a cough, and chest, and I mean pre-COVID virus, right? Viruses present a lot similarly to each other. Right. And viral illnesses make us kind of have viral illnesses, which are usually multi-symptom. And a lot of viruses, we just kind of have to suck it up and do the soup and neti pot and be miserable for a while. Margaret 38:15 Okay. Max 38:16 But so that, you know, we can target anti-microbials like anti-biotics like specifically to certain to certain things, because we can diagnose them pretty specifically with certain tools, or, you know, we kind of really know that these symptoms always kind of equal "this" or whatever. But it's just something good to keep in mind going into things. I mean, everybody does dumb things. And everybody...sometimes I have definitely...many times I've written prescriptions for things that I wasn't 100% sure of, because I want to make someone well, and we don't have access to all the diagnostics and... Margaret 38:56 Right. So it's just your best guess or whatever. Max 38:59 Yeah. But, not everybody should be taking azithromycin if they feel bad, ya know? But so I think that's my only thing going into things. It's just, you know, we should be we should be conscientious of these things. Um, because we only, you know, we have the potential to create total havoc when it comes to critters, right. I mean, yeah. I guess I think about accessing medications or anything. So, where do you get medications in the world, right, if you don't have like a provider or prescriber? So, most medicines, if they're like a tablet form, do not readily expire. So most medication... Margaret 39:50 I've heard the efficacy drops a little bit. Max 39:53 Maybe, maybe a little, but it takes a lot for the efficacy to drop, drop, drop. I mean, I guess Have you opened up an old thing of meds and it just looked very, very strange? Maybe...but if it's still there, most of the time, most medications, they just don't have the money to keep studying them out and out and out and out and out expiration wise and they get to the point where they're like, "It's probably not expired..." Certain...like tetracycline, maybe it causes a dangerous situation. So, stay away from old tetracycline and Ranitidine. Margaret 40:32 And that's an anti-biotic? Max 40:34 Oh, yeah, so tetracycline is the antibiotic. And that, that could be dangerous if, if it's old, theoretically, but it's not prescribed, like all that anymore. And Ranitidine, which is like a stomach med that's been taken off the market, it's an antacid style medication, it has some cancer causing compounds that could have occurred, that most things like if they're a tablet, they don't expire. Like it's completely reasonable to hoard medication. Margaret 41:05 Okay, is there a way to get the doctor to give you like, longer prescriptions? Like I've heard that like, sometimes people struggle to be like, I want my ADHD meds more, you know, and people are like, nervous to give larger best perscriptions or whatever. Max 41:21 That's tricky because they're control...sometimes they're controlled. And I think with controlled meds, providers are super squeamish. Margaret 41:28 Okay. Okay. Max 41:29 Which sucks. But, some meds just keeping them you know, just if you have them in your house, and, you know, maybe you didn't take them, as long as it's not liquid medicine or emergency medicine. So, if it's like an epi pen, or insulin, you want those things to stay, obviously, like, you don't want them to be expired. Margaret 41:52 Okay. Max 41:53 But you know, but inhalers seem to be okay. And I always just say, if you have like old meds, antibiotics, et cetera, keep them. Someone may need them. Right? Do you have a relative that's passed from this mortal coil or whatever, and you know, you're cleaning out their space? Maybe there's something that they might have that someone needs? Max 42:18 You know, I shouldn't I mean, this is like that...my pharmacist friend is going to roll over in her not grave, but like, but we're always told not to tell people this, but we're talking about, you know, access, if someone doesn't have access to medicine that they need, you know, how do we get them access to medication. So this is sort of talking about, like, you know, worst case scenario, but, and then I always think about, you know, if someone, if you got a prescription of something, say, and you took it, and it gave you a rash all over, and the doctor said, "Don't take it anymore, you're allergic to it," or you're like, "Oh, I threw up and I never took that, again," save it, because that's almost a full course of the medicine. It's probably the you know...which is fantastic. You know, if you if you were taking something for something like, like for HIV, and you were on anti-retrovirals, and you switched regimens, because you were cured... like wanted to take something new, save your old meds. So, because as long as you're not resistant to your old meds, your previous med regimen still works. And you could go back to it, and you could save yourself, like a couple months of heartache if something went down. Margaret 42:18 Yeah. Margaret 43:34 Okay. So theoretically. This is okay...Wait, no, I don't want to give terrible medical advice on this show. Nevermind. Max 43:44 I'm not trying to either. That's, why I'm like..."ahhhh!" Margaret 43:48 Because I'm like, well, how could someone get a backstock of you know, someone who's HIV positive and wants to have access to their medication, despite disruptions in supply chains, and whatever. I dunno people can figure that out themselves. Max 43:59 You know, I think about this all the time, I think about this all the time, do you have a friend that would be willing to get meds prescribed for them? Even if they you know, do you have a friend with insurance that would be willing to, to say that they had X, Y and Z in the low stakes way? I mean, it starts to become high stakes if controlled substances are involved. Right? That's when things become dangerous for everyone involved. And you know, could be... Max 44:02 And that would be stuff like painkillers, Ritalin. I forget the name of the larger...SSRIs. Max 44:39 Not SSRIs. Margaret 44:41 Oh really, okay. Max 44:42 But benzodiazepines... Margaret 44:45 Oh, that's what I was thinking of, benzos. I dont' take medication. Max 44:48 Yeah, I think that you know, you have to you have to go and and, you know, get special scripts for and things. Those are the things that they... Margaret 44:56 The stuff with street value, basically. The stuff that's fun to take. Max 44:58 Exactly. Those are the things sprays thick eyebrows. Yeah, yeah. And, and, you know, and there's a lot of surveillance of, you know, but if if if you're someone who needs thyroid medication to live, you know, and you have someone, you know, if you have access to other ways of getting your same medication, you know, that's not a medicine that's necessarily going to raise eyebrows or some of the medications can be very expensive. Sometimes, you know, people can ask their providers to give them 90 day supplies of things. I...you know, I think we try to do that all the time. And I think a lot of people who do have chronic health conditions are very savvy about pre planning. Margaret 45:47 Okay. Max 45:47 When it comes to medications, otherwise, you can't go anywhere. Margaret 45:50 Yeah. So so what else? How else does one access medications? Max 45:56 I think I talked about partners like if you if you have a partner or a friend who has health insurance, and you don't. And then if you know, anyone who's traveling to countries with pharmacies that don't require prescriptions. So there's a you know, handfuls of countries where one can just go into a pharmacy and just purchase medication. Margaret 46:15 And is this something that's like, like, what's the legality of taking like, let's not let's, let's pretend like we're not taking other controlled substances, let's talk thyroid pills or whatever, right? If I, if I go to a country where I can just get thyroid pills over the counter, I actually don't know whether you can get thyroid pills over the counter or whether they require Medicare? Is this a good example? Max 46:34 It's a great example. Okay, let's talk about levothyroxine. Can you go in to a pharmacy in some countries and just buy it? Yes. Do you have someone in your life that needs it desperately? Maybe? Go and get it. Margaret 46:46 What? What's the law about bringing it back into the country, something that requires a medication [perscription] in another country, and in this country? Max 46:54 So I can't speak specifically to any law, but it's not something that I've ever heard of penalized. Margaret 46:59 Okay. Max 47:00 Because again, it's not, it does...There's not a control piece there. Max 47:04 Okay. And again, we're not telling anyone to break any laws, and people should make their own decisions. And if it turns out that this stuff is illegal, that would also map to being morally wrong, because obviously, the laws of our society are just and worth valuing. Margaret 47:04 Right. Max 47:04 It's not a scam. It's not a, you know, I think if you set up like a capitalist, Super Buyers Club kind of concept thing where, you know, you're bringing levothyroxine back into the United States and selling it for I don't know, I would be like, you're pretty savvy, but you know, that I don't think it would be...I mean, otherwise, I think if you're just bringing back amounts, that makes sense for like, a person, a single person to use, I don't think there would be any surveillance of that at all. Max 47:50 Especially when it comes to people's health. Margaret 47:52 Yeah, totally. Max 47:54 And you know, some countries, some countries have it more restrictive than we do like, right, like so in Ireland, like, if you go to Ireland bring birth control to Ireland. People can't get birth control, you know, i was staying in the, I was staying in the Netherlands with some friends years ago, and they had a kid who had pretty severe allergies, like, you know, and you can't buy over-the-counter Benadryl in in the Netherlands at least when I was visiting. So we would just always bring Benadryl to the Netherlands, especially children's Benadryl. Margaret 48:29 Yeah. Yeah, that's funny. Cuz that's like, what I mean, people give that for anxiety when they don't want to give benzos you know, I don't know about Benadryl, specifically, but things in that catergory. Max 48:45 Like hydroxyine and things. Yeah, for sure. It's just wild, though, what is and isn't sort of acceptable, over the counter and not over the counter and all that in, in different places that you visit and, and we should just, you know, be be trucking things around, because these aren't things that are they're not, they're not controlled medications. They're not, you know, medications that are necessarily going to get someone in trouble, Margaret 48:48 Right. So what about um, it's funny because like, the classic example in a prepper mindset is that preppers are very concerned about the health of their fish. And they're very concerned about their fish getting diseases. And since they're so worried about their fish, they stockpile fish anti-biotics for their fish. And with the possible use, if absolutely worse, came to worse of taking them as humans, because theoretically like veterinary medicine isn't as controlled. But obviously this then gets into like current horse medicine craze with ivermectin, Max 49:10 Oh, ivermectin. Margaret 49:16 Or even ketamine. I mean, you know, we're talking about like, the Right takes ivermectin and the Left takes ketamine where everyone wants horse drugs. Like, how useful is like, how useful are things like fish antibiotics, or even like other veterinary medicines for cross species application in an apocalypse? And that's not why you bought them. It just happens to be the apocalypse and you happen to have them? Max 50:21 Well, I mean, so ivermectin has its uses, right? Like we use it in people to treat like, I don't know, like, Strongyloidiasis. Like it's an anti parasitic, so it has its uses. I think it's sometimes about the preparation of things. Like is something, if you're giving it to your fish? Like, what how would you make it? I think it would be about figuring out how to make it so that it was in people. People form. In terms of dosage. Margaret 50:57 Right. Max 50:58 Right, and figuring out that kind of thing. And I think it depends on the antibiotic. Margaret 51:03 Okay. Max 51:04 Yeah. Margaret 51:04 So some of them will actually only be applicable to fish, whereas some of them might actually be applicable across species? Max 51:10 I think most of them should be applicable cross species, if it's something that is a drug that both species use. Margaret 51:18 Okay. Max 51:19 Like, so if I don't know what fish antibiotics are available? I wish I did. Because it I could say, "Oh, this, this amoxicillin could absolutely be used for fish and people. You know, I mean, I think it's more just about like, how do you figure out... because, you know, it's probably with the fish, it's probably like some kind of, like, drops that you put in the water? Or? Because, it can't imagine how you would give your fish their antibiotics. Margaret 51:44 I'm a bad prepper I should know this stuff. But I don't actually know a ton about bunkers, or fish antibiotics, or buying gold. Margaret 51:47 Is it flakes? Is it in flakes? Yeah. Max 51:54 But I mean, I think yeah, I mean, I think at the end of the day, we're going to have to find ways to access these things. You know, I think the big deal is going to be like, how are we going to eventually manufacture things that we... because we are going to need antibiotics, we are going to need anti-parasitics, and all these sorts of things. Margaret 52:15 Well, my general mindset around that, you know, people have asked me this a long time, people might ask it more about like, "How in an anarchist society, would you X, Y and Z," right? Like people will be like, well, "I need..." I'm just gonna use thyroid medication forever as my example just because like years ago, like 10 years ago, a friend of mine asked me this question directly, you know, and they were like, "Well, I need a thyroid pill every day. Or I'll die? How would an anarchist society make it?" And my answer has always been, or I don't know, however, we do it now, right? Because like, people and physical infrastructure will likely still exist in various ways through various types of crises. And the things that are more disrupted are the, the mechanisms of control and the organizational mechanisms that, you know, distribute these things, or even pay the people to make them, right, that kind of stuff could be disrupted. But by and large, you're still going to have people who know how to make antibiotics, and you're still gonna have, you know, the...the supply chain might get disrupted, which is a problem, right? But then even then, it's like, you know, well, there's people who know how to grow grain in the West and Midwest. And there's people who know how to load it onto trains, there's people who know how to drive those trains to the coasts to feed people, and we probably won't lose that. But we might lose the system that tells everyone to do those things. And I don't know whether it's a cheap out, but... Max 53:40 it's obviously like anarchists and BioPharm. Like, it's not like we're like in this universe, like where it's just, you know...there's all kinds of folks. I just sort of think about it, like, in terms of times of times have like interim times times of like crisis. How do we make sure that people have access to things? Which I think were gonna have to work on. Margaret 54:02 Yeah, no, that makes sense. Because, it's like, there is a difference between talking about disaster and talking about like an anarchist society or whatever. Max 54:09 Yeah. Margaret 54:10 Okay. So one of the things that you mentioned, kind of related to this, but in an actual like, apocalypse scenario, right every...I'm no longer being euphemistic. Although, of course, I was never been euphemistic. But, I'll be euphemistic if i includes zombies in this in this disaster, but whenever you watch a zombie movie, they like raid the pharmacy, right? Max 54:29 Which is such a good idea. Margaret 54:31 Yeah. So what would you raid like if you're in the apocalypse and like you are trying to set up your I guess, like clinic or you're trying to take care of people, while there's like nuclear fallout and zombies and, I don't know, roving militias, but different than the current roving militias, what are you looking for? Max 54:52 When a...you know in an apocalypse situation? I think about this so much I've had so many fun conversations with my peers. It's actually wonderful to work in an infectious diseases practice and ask everybody what they would bring, because it was one of the biggest, like conversations, like arguments that came up about anti-microbials, antibiotics that was just amazing. I don't think I would be thinking in terms of setting up a clinic, I think it would be very much in terms of like, "What can't I get?" and I would try to get broad spectrum antibiotics. So if I had to name them, I would get doxycycline, and levofloxacin, and or ciprofloxacin, and or a medication called amoxicillin. amoxicillin, amoxicillin clavulanate, because I can't talk today, I would get albuterol. And mostly, that's for selfish reasons, because I'm a little asthmatic. And also, because asthma. I would try to get prednisone, epinephrine, like epi pens, and some...anything for like pain and fever. Those would be like, really, really high up there on my list. But I would, if I had to have pick a single antibiotic, I would choose doxycycline, all the way, which is part of my big arguments with all my coworkers. But you know, everybody has their things. Margaret 56:26 They're not big doxy, they're not big doxy-fans? Max 56:29 All of them. Everyone is. They would all have it on their list, but everybody had it on different sections of their list. Margaret 56:36 Yeah, it was an interesting conversation. And then I think if, if things were a little more mellow, and had a little more time in there, I would start to grab stuff that was like, sort of more meaningful for just long term existence. Right? And I think about this in terms of my, my friends and my people and stuff, but um, you know, like queer folks and, and, and PAW's [Post Acute Withdrawl] folks and stuff, but, so I think, alright, I would, you know, maybe grab...let me see, do I have my list up even? Margaret 56:36 Okay. Margaret 57:13 In your bug-out bag is the like...you keep a laminated, like if you hit the store, this is what you get list. Max 57:23 Yeah, exactly...if you have 10 more minutes in the store you know... Margaret 57:27 If you brought the large bag put in.... Max 57:30 So like insulin, you know, requires refrigeration. But if you could get any kind of grab 70/30 cause you can keep the largest number of people, probably. I would grab testosterone and estradiol. Probably morphine, because it's really useful in a lot of different situations, and in cardiac situations. And then if I had to choose like two HIV meds, I would choose Biktarvy and Prezista, or probably Biktarvy and Prezcobix, cause that combination of medicine covers for a huge number of resistant HIV strains. And also, it's just, I would just have it and be like, "Here, let's keep people around for longer." Margaret 58:16 Yeah. Max 58:17 I don't know. Those are sort of, that's sort of my short list. I...honestly, if I was if I was raiding, a pharmacy, and...I would just grab everything that I could get my hand on. Seriously, because it all would come in handy at some point, you know, especially if it was antibiotic. Margaret 58:36 Yeah. Max 58:37 Or like something for giardiasis , that would also be something I would probably get on there. Margaret 58:42 I had giardia once, it was not my favorite thing that's ever happened to me. Max 58:45 It's not the...it's...I had it too. It's not fun. Margaret 58:48 Yeah. Which is why I'm such a big like filter water person. Because I definitely got it from unfiltered water at a big gathering once. Max 58:56 I got it from swimming in, from swimming in the river by my old house. Margaret 59:02 See, that's better because that's like a reasonable thing to do. Whereas, I should have known better, you know? Max 59:07 It wasn't...it was not that reasonable. Believe me it's a filthy river. Margaret 59:11 I'm Sorry. Max 59:13 It's okay, it was a blast, but i was like "Ooooh," Margaret 59:18 No pun intended? Max 59:20 Yeah, that's true, too. Margaret 59:24 Okay, but what...it seems like okay, you raid the pharmacy, it would just set up shop in the pharmacy. Just get like, you know, all your friends with rifles, defend the pharmacy and become a pharmacist. Max 59:35 That's true. I would be a terrible pharmacist. I have no precision in anything I do. Margaret 59:41 Yeah, okay. Max 59:42 I would bring in my pharmacist friends. Margaret 59:45 Okay. So you'd be the doctor at the pharmacy? Max 59:48 No, I don't know what I would do. If I didn't...I don't know, healthcare is like it's a job. But I like doing it also. I don't know, I'm sort of thinking about your friend who, who we're talking to, in the interview about working during COVID.... Margaret 1:00:11 Are you having feels about the working during COVID? Max 1:00:15 Big time. It's been a wild thing. Everyone's sad. Margaret 1:00:22 Yeah, Max 1:00:23 Yeah. But no, it's just more just sort of like, would I do health care if it wasn't my job? And I think I would, but I think I would do it in a totally different capacity. Margaret 1:00:37 How would you do differently if in a, in an anti-work environment where you didn't have to? Max 1:00:43 I would walk in the woods with people and talk about their health in a totally different way. Margaret 1:00:48 Yeah. Max 1:00:49 Yeah. You know, and, or visit them in their homes. And I would have a ton of time. And I would like get to know what they were doing in their lives in a way that I can't in like tiny little weird rooms, with a limited amount of time and that kind of thing. Margaret 1:01:12 I even just think about one time someone was doing some alternative healing with me, actually helped. I used have a chronic injury in my chest. And it's, it certainly wasn't the thing that cured it, but it helped. But as they're doing this thing, they're like, playing soft ambient music and like, you know, like, talking softly to me, and like, the lights are dim, and it's a very calm environment. And I'm like, "Why can't the dentist be this way?" You know? Like, why do you gotta go to the dentist, and it's not like, I don't know, like, someone's rubbing your feet and like telling you, everything's gonna be fine. You know? Max 1:01:55 I can't go to the dentist until...unless I'm like, high out of my mind on some kind of benzodiazepine. Like I can't, I have to literally kind of create like a, like a non remembering experience every time I go to the dentist. So like, I go to the dentist, and I'm like, "Do whatever you want." And then three years later, I go back and have the same experience. Margaret 1:02:24 Yeah. Max 1:02:25 Which is probably a self fulfilling prophecy of dentistry. Margaret 1:02:28 Yeah. Max 1:02:29 Yeah, but then it's always like a tooth removal. Margaret 1:02:32 With what you're talking about, about, you know, all the medical care providers being so tired. And obviously, this thing that I'm talking about doesn't solve like, COVID, right? But what you're talking about about wanting to help people become...gain expertise and control over their own bodies, it seems like that would help, you know, because it's like, like with the bike repair example, right? Like, I don't know, when I wrote a bike all the time, like I could, I could swap out the handlebars, I could tighten the brakes, I could patch a tire. Or I could patch a tube. But, I couldn't. But, I couldn't align the spokes. I could have learned to align the spokes, but like I, I didn't, you know, and I certainly wasn't building bikes. And every time I look at the derailleur, my head would break. And like, and so there's, there's always going to be a role for bike shops, even if everyone's good at bikes. And... Max 1:03:31 Right. Margaret 1:03:32 And so having, you know, crews of people who are specialized in allopathy, as the thing they do, the thing that they're most interested in, will always make sense. But like, just having more people able to do more of it on our own seems like it really just helps everyone. It doesn't help the people who want to make a ton of money off of things, or have a ton of control over how people live and what they do, you know. Max 1:04:01 Yeah, I think that's totally real. I think it will also alleviate things on patients. I think that when people know themselves and can come to their provider, with a sense of what's going on with their bodies and navigate the system in a way that feels a little bit more, I hate to be corny, but like empowered. Like, I think that's super legitimate. I think that one of the ways that healthcare just screws people over constantly, is that no one knows how to deal with it. They don't know what to ask for. They just they are in a little room and all of a sudden someone comes in tells them a bunch of stuff they're supposed to do gives them some papers and shews them out. Margaret 1:04:42 Yeah. Max 1:04:43 And it's there's nothing in there that that creates a relationship. There's nothing in there that creates...I don't know. I don't know. I think that people being in charge of their own bodies is is awesome. Margaret 1:05:00 Yeah, and it's, it's something that like, I had this realization about school, as well as like doctors or whatever. Like, at some point, especially with like higher education, if you go to college, it doesn't make any sense to me that the teachers like, are in charge of you. Because they're, they're literally people that you're hiring to teach you. Like, you're giving them money, and they're teaching you and that's cool. That's great. But they, they act like, "Oh, well, if you miss class, then you're in trouble." It's like, what trouble? Like, why? Why would this institution have any leverage over you?And Margaret 1:05:39 And that's kind of how I feel about the medical world is that like, it always helps me, and I'm actually almost lucky in that I've been, well, now I have regular insurance, but I was sort of underinsured for most of my adult life. And so I relied heavily on public health and clinics. And I actually found that people on public health they are way more tired, but they're also working there because they like care. And so they're like frazzled and annoyed, but they also like, fundamentally care more often, I also am more likely to end up at like LGBTQ clinics and things like that. And that also helps me. But it...the main thing that helps me is that I kind of remember I'm like, in there, and I'm like, the doctor is not in charge of me. Like, either I'm paying or the state is paying or whatever for service. It's like, it's like going to the bike repair shop, you know, like, you're like, if I go into the bike repair shop, and they just yell at me about how I'm riding my bike. I'm like, I mean, you could tell me that if I ride this bike this way, it's gonna get destroyed. And that makes sense. But you can't tell me I can't ride my bike that way. Like, I don't know. Max 1:05:39 Always true Max 1:06:46 Yeah. But like going on that metaphor, right, like, same thing, like, how many times have people gone to the bike shop and been treated shitty, and then left out feeling like, super demoralized? And like, they can't ride their bike? Margaret 1:07:02 Yeah, totally. Max 1:07:03 And Like I think about that too, like, there's so much of that. I don't know, it's that it's that it's the realm of expertise. And like, you know, it's like, once, once someone is like, in this certain space, they get to have all the power and authority. And I always tell people, like, if you're the doctor, and you don't like what's going on, just leave. Margaret 1:07:25 Yeah. Max 1:07:26 Just leave, like, unless you like, are in a bad way and are really, really, really sick. Like, if you're there to get get access to things or something and you're not being treated well just get out of there if things are not going well. Margaret 1:07:41 Yeah. Max 1:07:42 Because that's going to end up being a squirrely relationship. And there's some really bad doctors, there's some really bad nurse practitioners, there's some really bad everybody, but like, there's, you know, there's people that are unkind and not not good, and are just going to tell you what they think, is the matter with you before they've even met you. Margaret 1:08:01 Yeah, and, and, just like this, like sense of that, people thinking that they have power over you, because we have these institutions that sort of claim it, but it's like, you're, you're in charge of yourself. Like, I mean, there's, there's institutions that exist to try and stop you from being in charge of yourself, you know, like, there's a certain things that we could do that would then have other people throw us in prison or whatever, right? But like, that doesn't mean we're not in charge of ourselves. It just...Well, it does, but, you know, on th

The Jon Chuckery Show -   JC reflects on the Falcons draft and says that overall he was satisfied and give them a letter grade of a B

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Intrahepatic Cholestasis of Pregnancy (ICP).Amel and Dr Wonderly discuss the signs, symptoms, and management of ICP. A reminder for alcohol use disorder screening.Introduction: Screening for alcohol use disorder. Written by Hector Arreaza, MD. Reviewed by Jacqueline Uy, MD. Today is December 3, 2021.Substance misuse occurs in about 20% of patients seen in primary care settings. For example, alcohol-related disorders are present in up to 26% of general clinic patients, “a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes”[1]. The USPSTF recommends screening for unhealthy alcohol use in adults 18 years or older, including pregnant women, and provide those engaged in risky drinking with brief behavioral counseling to reduce alcohol use (this is a Grade B recommendation). This brief introduction is to encourage everyone to screen adults for alcohol use disorder. Let's start with the basics.  It is important to know the size of a standard drink so you can counsel your patients appropriately. According to the CDC, a standard drink is equal to 14 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in:12 ounces of beer (5% alcohol content).8 ounces of malt liquor (7% alcohol content).5 ounces of wine (12% alcohol content).1.5 ounces or a “shot” of 80-proof (40% alcohol content) distilled spirits or liquor (such as gin, rum, vodka, whiskey).Moderate alcohol drinking means 2 drinks or less in a day for men and 1 drink or less in a day for women. Binge drinking means drinking enough to bring your blood alcohol concentration (BAC) level to 0.08% or more. This may be different in each patient, as humans metabolize alcohol differently, but usually it corresponds to 5 or more drinks on a single occasion for men or 4 or more drinks on a single occasion for women, generally within about 2 hours[2]. A good approach to screen for alcohol use disorder is by asking: “Do you sometimes drink alcoholic beverages?”, and then the single screening question, “How many times in the past year have you had 5 or more drinks (men) OR 4 or more drinks (women) in a day?”[3]  The screening is considered positive if the patient answers one or more times a year. If positive, then you may continue your assessment with another tool such as AUDIT. This can be a topic for a whole episode.  For now, we just want to remind you to screen your patients for alcohol use because the prevalence is very high and we as primary care physicians can make a big difference in the prevention and treatment of alcohol misuse in our communities.  This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Intrahepatic Cholestasis of Pregnancy (ICP). Written by Amel Tabet, MS3, American university of the Caribbean. Discussion with Sally Wonderly, MD; and Hector Arreaza, MD.What is Intrahepatic Cholestasis of Pregnancy and why does it matter?As its name implies, Intrahepatic Cholestasis of Pregnancy (ICP) is a multifactorial liver dysfunction in some pregnant women that occurs during their either second or third trimester of pregnancy and resolves spontaneously after parturition. It is defined by the presence of pruritus -- previously called pruritus gravidarum or recurrent jaundice of pregnancy-- and abnormally elevated serum bile acid levels and mildly increased hepatic aminotransferase levels, in the absence of diseases that may yield similar laboratory findings and symptoms. Key symptoms are pruritus, high bile acid and high transaminases. How common is ICP?In the US incidence ranges from 0.32 percent to 5.6 percent, depending on the area. The Los Angeles area has a high incidence compared to other areas in the US. The highest rates in Europe are in Scandinavia. It is very frequent in Chile (South America). The indigenous people known as Araucanos have the highest incidence worldwide at 27.6 percent.PathogenesisThe pathogenesis of ICP remains unclear. It is mainly attributed to changes in various sex steroid levels but more recent research points towards an etiology that relates to various mutations in the many genes involved in the control of the hepatocellular transport systems such as the ABCB4 gene, which encodes multidrug resistance protein 3 (MDR3) linked to progressive familial intrahepatic cholestasis, errors of the ABCB11 gene that encodes for the bile salt export pump, and more recently on FXR/NR1H4 and PXR/NR1I2 genes that encode for proteins that critically regulate bile acid synthesis and transport, and the transcription of ABCB11 in humans and the role of epigenetics influence by means of methylation of these genes. Dangers for mother: Beside the discomfort of pruritus, ICP is transient and of little maternal risk generally. The mother may be uncomfortable but it's not fatal. Danger to fetus: The elevated bile acids enter the fetal circulation because it crosses the placenta. Bile acids cause major fetal and neonatal complications, such as abnormal intrapartum fetal heart rate and meconium-stained amniotic fluid that can lead to fetal distress and prematurity or intrauterine demise and to neonatal respiratory distress syndrome associated with bile acids entering the lungs. Who is at risk for ICP?Multifetal pregnancies.Genetics: There is also a significant genetic influence that leads to variability of incidence by population. In North America, cholestasis is infrequent with an overall incidence approximating 1 case in 500 to 1000 pregnancies. Whereas its rate is high in indigenous women from Chile and Bolivia and nears 5.6 % among Hispanic women in Los Angeles. In other countries, for example Sweden, China, and Israel, the incidence varies from 0.25 to 1.5 %.Diet and environment can also have an influence. Research has shown an association of ICP with environmental and dietary factors such as seasonal changes of mineral dietary components and with gut-derived endotoxins subsequent to increased gastrointestinal permeability. This complex nature-nurture interaction suggests that ICP is strongly modulated by epigenetic mechanisms.Liver disease: Women with preexisting liver disease are at risk. Other risks include in vitro fertilization, cholelithiasis, advanced maternal age, and Hepatitis C and fatty liver disease.  History of ICP is an important risk, because it also recurs during subsequent pregnancies in 60 to 70 % of patients. Signs and symptoms:The main clinical presentation is an often-generalized pruritus in late second or third trimester, that usually starts and predominates on the palms and soles and is worse at night. It could range from mild to intolerable pruritus that may precede laboratory findings by several weeks and evidenced by possible presence of scratch marks and excoriations on physical examination. Jaundice arises in 14 to 25 % of patients and it typically develops 1 to 4 weeks after the onset of itching. Other accompanying symptoms may also occur such as nausea, RUQ pain, steatorrhea, poor appetite and sleep deprivation. Other signs include dark urine, pale stools. Diagnosis:To establish a diagnosis, careful history taking, physical examination, and laboratory evaluation are performed. Thus, in the absence of any other liver disease, ICP is diagnosed by the presence of pruritus that is associated with elevated total serum bile acid levels, elevated aminotransferases (seldom exceed 250 U/L), hyperbilirubinemia (4 to 5 mg/dL) and elevated alkaline phosphatase. In severe cases that account for 20%, cholestasis manifests as bile acids levels > 40 micromol/L.Differential diagnosis include: Preeclamptic liver disease, which is ruled out if blood pressure elevation or proteinuria are absent and cholelithiasis and biliary obstruction are excluded by sonography. Moreover, because of mild transaminitis in case of ICP, acute viral hepatitis is an improbable diagnosis. Liver biopsy is generally not needed. Even though not necessary for diagnosis, liver biopsy for research purposes, showed occurrence of changes with presence of cholestasis with bile plugs in the hepatocytes and canaliculi of the centrilobular regions, without inflammation or necrosis. These changes were found to fade after delivery with recurrence in successive pregnancies or with estrogen-containing contraceptives.Management:Management focuses mainly on reducing maternal discomfort due to pruritus and prevention of more serious fetal outcomes and reduce the risks of prenatal morbidity and mortality. For patients that have persistent clinical findings consistent with ICP without any biochemical evidence of ICP, we only treat with antihistamines and topical emollients such as calamine lotion and we perform a weekly evaluation of maternal total serum bile acid (TSBA) level.  In symptomatic patients with positive biochemical evidence of ICP we treat with ursodeoxycholic acid (UDCA) 300 mg BID or TID until delivery. UDCA was found in clinical trials to relieve pruritus, lower bile acid and serum enzyme levels, and to reduce preterm birth, fetal distress, respiratory distress syndrome, and neonatal intensive care unit admission. Along with treatment, we continue the weekly evaluation of the TSBA level with a warranted earlier delivery if TSBA ≥100 micromol/L and the related high risk of stillbirth.  Thus, delivery management is mainly based on the highest TSBA level at any time during pregnancy. If TSBA level is

Download Meredith's 20 Pallet Vendor list (Use the code FREE1 to get your free copy!) : https://meredithandbiz.gumroad.com/l/GjcMwyFollow her on Instagram here: https://www.instagram.com/meredith.the.entrepreneur/Rob: We are so excited to have Meredith The Entrepreneur here to talk to us about pallet flipping. Melissa: It's a really cool topic. Rob: It is! We're super excited to have her here. She's given some time up and now super excited and appreciative for her to jump on here and answer these questions. Melissa: So thanks, Meredith for being with us.Meredith: Thank you guys for having me. Melissa: So tell us a little bit about your backstory, how did you get into, flipping pallets? [00:01:00] And we're going to dive into a whole bunch of questions that I'm sure everybody has about how, how this whole thing works. Meredith: Well, initially I got started due to the pandemic and having a baby and not being able to go back to work.So I came across Ashley Jane on Instagram who has a pallet flipping course, I took her course. And from there I kind of took off with it. I learned how to pallet flip, where to pallet flip, and that's how I created my liquidation pallet vendors list and I'd never gone into it at that point, I had never gone into a warehouse to purchase a pallet.I ordered online and the pallets came right to me within three or four days. I sold my products on eBay, Facebook, and OfferUp, and I made thousands of dollars within weeks just taking products [00:02:00] from the pallets and reselling them. Rob: Wow. I love it. I love it. So many great questions spark in this. So we've never done pallet flipping.It's very exciting. Melissa: We get asked that question a lot. So it's definitely, it's a cool niche to get into. Rob: So Meredith, let's break down a couple of questions for you. Definitely and we'll walk through some of these, exactly the key questions to anybody who might be interested in getting started in pallet flipping, where to start, all that kind of stuff.Melissa: So, what exactly is it that you're doing with flipping pallets, like what are we doing with this? Meredith: So what pallets are, maybe people think that it's the products that come on the pallet, that's the pallet. The only thing that's a pallet is the wood that everything sits on. So, what pallet flipping is, is taking products that a customer returns from big brand stores, like Walmart, Home Depot, Target, they get customer returns [00:03:00] or they get items that are overstocked on shelves and they can't sell them quickly enough because they're getting more in and not enough is going out. So they put these items on pallets and sell them to warehouses for literally nothing. So what those warehouses do is then resell to the public, which is us, for dirt cheap prices.So you can get thousands of dollars worth of items that you only pay $300 or $400 for thousands of dollars worth of items. So that's basically what a pallet is, what pallet flipping is. Taking those customer returns and those overstocked items and then reselling them for profit. Rob: Awesome. Awesome. So, okay. So if I am a customer and I take something back to Walmart, and some people maybe have never even thought about this is where it comes from, but now if I take it back to Walmart, if it's broken, whether it's just, I don't need it anymore. [00:04:00] Those are the things that are going onto the pallets. Are you dealing with broken items? Are you dealing with items that are perfectly okay? What kind of items are coming on these pallets? Meredith: So you can get new items. You can get items that may be broken. You can get items that may be missing a cord or may be missing a remote, or, they may even be missing the packaging, the box.So, because they can't put those items back on the shelves they resell them on pallets for a cheaper price. A way to tell whether you have broken items or whether you're buying a pallet that has items that are not brand new, there is something called a manifest. The manifest will tell you what grade those items are in.So for example, if you had a Grade A pallet, those are all new items. They have all of the packaging. All of the cords, all of the remotes, anything that comes with the packaging, that's all there. [00:05:00] Then it goes from Grade B to Grade C and Grade D whereas if you get to Grade D and E that means there's something missing.Either something doesn't work or something is missing from there, and I tell people all the time, Read the descriptions and read the manifest, know what you're purchasing before you purchase it. Melissa: That's really good. Cause I was wondering the same thing. Like you just like, do you know what you're getting? But if you read it, then you should know that you can have an expectation. These are not, need work or whatever, whatever, better items Rob: That sparks another question to me. So are you going in, are, are these like if I went to a store, are you paying, they have a certain price for this pallet? Or are you bidding like an auction? How does it work in correlating with a Grade A, Grade B, Grade C, whatever the different grades are. What are the prices? How does that vary on that? Meredith: Well the higher the grade, Grade A, Grade B, the higher the amount of the pallet will be the [00:06:00] better the products are. A way to kind of determine that would say is, like I mentioned before to read everything, don't purchase anything without reading it.I'm trying to see most places when I purchased pallets personally. They will try not to give a description, which you don't want to purchase from anyone who won't give you a description of what's on the pallet. If you're purchasing Grade A or Grade B items, you should expect to have new or close to brand new items, with you purchasing Grade C or Grade D, you know going into it that either something is not working on the pallet or something is missing from it, but they should itemize each package that's on the pallet and should have an itemized description of its condition.Melissa: Okay. Do you know on the [00:07:00] pallet I'm like I'm getting 20 vacuums or I'm getting like a D, is that in the description or no, you don't really know that? Meredith: Yes. You will know that as well. Some places as well have barcodes on each box, or you can use your phone to scan the barcode. Then it'll tell you where where the item came from. If it came from Amazon, if it came from Home Depot and it'll tell you the MSRP price, the price that it should be sold for. Melissa: Wow. Okay. That's good to know. Rob: Yeah. So much great information. So much more. I want to know. So if I go to one of these warehouses or I try and buy this, am I going to bid on this pallet? Or is it going to be listed for, this is a Grade A that we want $300 for this pallet. How does that whole process work?Meredith: Okay. Now some places do offer bidding and they do offer, outright purchasing. I personally try not to bid because you have to be extremely, extremely consistent and on it to bid on the the great [00:08:00] products, and they go very quickly.And with bidding, sometimes you won't win. You know what I'm saying? A lot of people we wanna win. We wanna win that. Some places do offer only auctions and some places do offer outright buying. Some places offer both. There are websites that are on my list that offer both as well. But with auctioning you have to really, really be consistent and constantly checking the prices.But with auctioning, it is, I would say a cheaper route. If you do choose to auction over purchasing it outright.Rob: Cool. Awesome!Melissa: So what's an average cost that you can expect to pay for the different grades? Meredith: I would say for Grade A to grade B? You're looking at, I would say about over $800 for a pallet. Rob: And even further into that, I [00:09:00] was going to say that you said MSRP, what it actually retails for. If you're paying $800,what are you expecting to MSRP? I mean, you've done this quite a bit, so you probably have a good idea. Meredith: So if I'm purchasing a pallet for $800, I'm expecting to make at least $2,500 or more from the $800 pallet. They have pallets where you're getting all brand new TVs, but you're paying $11,000 just for that pallet. But you can make $50,000 to $60,000 once you sell all of the items on that pallet. So I would say Grade A, Grade B items, you can expect the MSRP of $2,500 or more, off of that pallet.Rob: Awesome. Cool. Now my wheels are still spinning, so I might've missed this. And you did say this, I think you did. Can I just go to a warehouse and like, are there warehouses that just sell the pallet? I can walk in. I can look at the manifest. I can check on my iPhone or whatever. I can do [00:10:00] that. And then they'll have a price that I can just go. I can pay that price. They'll put it in the back of my truck and I go away with it. Is it that easy to do a pallet sometimes? Meredith: Yes, most warehouses, especially on where it goes to physical locations that have a set price, where if you spend $450, you can choose any one of these pallets that you like. You know, they have certain deals where they don't want you to auction.They have a set price that you can pay or a price that you can negotiate, it just really depends on the warehouse that you're going to.Rob: That's so exciting. You got me sucked in, so I'm excited. We've never done pallets before, but I love finding deals and that's kinda what it is. You're jumping into these things. You might find a sweet deal inside of one of the pallets, and you have a great chance for markups on it. You can make your money back easily and then make, you know, double, triple, quadruple your money, your investment. So that'sexciting. Melissa: So, where are you? You talked about the warehouses, but, do those stores actually do these too, or do they always have a warehouse that takes care of all [00:11:00] this, like to get rid of their stuff?Meredith: There are sites where you can specifically go to, there is a site called direct liquidation. Where you can go to this site and they have direct links to Walmart, direct links to Target, direct links to Home Depot, Amazon, or you can purchase pallets from them, but not necessarily going to amazon.com and purchasing a full pallet.Melissa: Yeah. Oh, that's cool. So where do you sell a lot of your items?Meredith: I sell the majority of my items locally. I'm using Offer Up or Facebook marketplace. If I am selling online, I do so, via Poshmark or E-bay or Amazon. Rob: Awesome. Cool. Now, when you're doing this, are you buying like some of these places and maybe, did say this too. I can just buy one pallet. I don't have to go and buy 15 pallets or 10 pallets. I can go and just buy one pallet. If I want to get started in this to see if I really like it, I can go pay the price. You're asking me to put it in the back of your truck. You can go and try and sell all that stuff. Then if [00:12:00] you make good money on it, you can come back and buy multiple pallets or whatever you want to do. Is that correct? Meredith: Yes, you only, you can only purchase one. If you only want to purchase one, you don't have to buy a truckload of pallets if you don't want to. But, if you want to go even smaller than a pallet, you can get on what they call a big box. And a big box is smaller items like headphones or books or something like that.It's smaller items that can be put into a big box and they sell those boxes for people who don't necessarily want to get started with having boxes all over their house or boxes all over their apartment, you can start with the big box of smaller items. Rob: Okay. And maybe I missed it, or if I misunderstood it, you can buy one pallet. Can you buy multiple pallets as well? Or you have to go from one to a truck. Okay. So you can Meredith: buy as many as you like.Melissa: Yeah. The boxes too, because some people are probably thinking, oh, I need a truck and trailer to go do this. And you [00:13:00] don't really. Meredith: Yeah, no, off with my Ford Taurus and loading boxes in the trunk, backseat, everywhere that I can fit a box. We loaded our car up. Sometimes we made multiple trips when we had bigger pallets or more than one pallet, but I used a Ford Taurus starting out to get my pallets. Rob: I love it! That is great. Great information to know, because that's what we get asked a lot with what we do. Hey, do I have to have a truck? Do I have to have a trailer? And you're thinking of pallets, you got to have a truck in the trailer, but you don't, you can start where ever you're at. So that's very, very exciting for a lot of people because people don't want to go out and, buy that truck. And we always recommend people don't go out and buy a truck and a trailer.Start where you are at. If you enjoy it and you start making some money, that's where you guys can upgrade and go into, you know, a truck and a trailer and that kind of stuff. So thank you, Meredith. That's definitely a great clarification that we can start anywhere, wherever we're at right now. We can start buying one pallet, one big box, [00:14:00] to get the entry-level into this pallet flipping.Melissa: Yeah, that's really cool. What would you say somebody could expect if they're getting into this, that they could make a month doing. Like on average. I mean, I get it all depends how much time and what they get and all that stuff. Meredith: Well, for me, from personal experience, being dedicated and consistent with doing it constantly, I made, over $4,000 my first month with flipping pallets and that was just purchasing the one pallet.Reselling my items consistently, constantly, checking the websites and constantly checking the warehouses for the best pallets. I made personally $4,000 my first month, but I feel like it's always whoever is selling. You have to be very consistent. It's not a get rich quick scheme that you can just pick up [00:15:00] and, you know, you'll be successful at it.You really have to put in some form of work and dedication into reposting and selling these items. And a lot of people say, well, I don't want a million things around my house. Well the point is to sell those things and not to keep them in your home. You know what I mean? So, I would say if you're consistent, you can make over $2,000 a month flipping pallets.Rob: Yeah, I love it. That's awesome. And thank you for clarifying that because that people need that clarification. This is not a get rich quick guys. We work, we work as flippers, whether you're a big item, small item whatever you got, whatever you do in this industry, nobody comes in knowing this. Pay a little bit of money and you get rich quick. That's not how it works. We worked and it worked for what we do, but we love it. Meredith: Exactly. Rob: It's so much fun. I'm one for the hunt. And so I totally get that. We are, you know, we're right next to you on that. So, I had another question [00:16:00] about the pallets, my mind, is spinning like crazy.If I do want to go and buy one of these pallets, do they designate in. Are they going to put a vacuum with a blower? Is it like items in there that are just maybe related? Electronics and then yard equipment, do they designate different types of pallets? If I go and pick one, I can say, I really love electronics. I love DVD players. You know, I love MP3 players. I love all this kind of stuff. Do they do that in certain pallets or is it all mixed together and you just have to check the manifests. Meredith: That's a really great, question. They categorize each pallet. So, going into it you'll know, well, this is an electronics pallet, or this is a home goods pallet that has,blenders and microwaves, or this is a clothing pallet that has majority clothing, or you have a shoe pallet that has all shoes, but they tend to categorize each pallet. So, you will know what you're getting and what category [00:17:00] you're getting.Rob: Awesome. That's exciting because we recommend people doing stuff that they love. If you don't love doing shoes, don't go buy a shoe pallet. And if you love electronics toys, kid's toys, stuff like that. If they are designated in different, categories. That's awesome. That's very exciting as well. So, one other question, like I said, my mind's running a million miles a minute. One other question is, when you go into these warehouses, you probably have some warehouses that you are enjoying buying from more. Do you create relationships with those people that are in there that might benefit you to where, you buy a couple of pallets from them?Exactly. Like, do you go in and you're like, Hey Bob, how you doing today? Yeah, I'm looking for this. Do you have relationships like that? Or it doesn't work that way with pallets. Meredith: Yes, you definitely build relationships when you're going to physical locations. And they're used to seeing you and used to you purchasing from them.They tend to give you discounts. They tend to want to help you more. If you need help unloading. First, starting out you know, you [00:18:00] look around and it's like, who's going to help me. Who's going help me put this pallet up here. But the more you go, the more they're like, okay, she's consistent.She's purchased from me every week. They tend to have better relationships with people like that. They know me now by name, just going in there. Hey Meredith, what are you buying today? What category can we show you today? So it's great to go to physical locations. Build relationships with the owners. Rob: That's really cool. That's awesome.Melissa: Go ahead. I thought of one question too earlier, when you were talking about, you know, an obstacle people have is, having things all over their house, like you said, on the object is to sell it. Like, that's what you want to do.But also if you think about it, you start where you're at. If you have an extra bedroom in your apartment, maybe that's where you start. And then you get to a point where maybe you do get a storage unit and it makes sense, and you're making the money, you're making more money. So it makes sense to maybe have a storage unit. So then that's your business right there, but you can always start where you're at. We started with just putting stuff in our [00:19:00] closets. We had extra, like an extra closet, and then we got a shed in the backyard and then it started where we were. Rob: And one thing that you did say that I want to touch on, was consistency guys. We're the same way we build relationships with people with the flea market. It's one of those things that when you're consistently in front of people and consistently running this business, that's when stuff pays off. Meredith just said, when people start to know you and start to see you week after week, it's hard not to build a communication or relationship with somebody that you're dealing with weekend and week to week out. And I know you, so that's really, really cool to build relationships and create that consistency in your business. So that's awesome. Any other key points or any other key things you want to touch on about pallet flipping or anything like that? Before we jump off?Meredith: I would say, there will be wins, big wins, and there will be losses when it comes to, flipping pallets.Don't let the losses steer you away from picking it back up going in there, getting another pallet and trying it again. I would [00:20:00] say, educating yourself on the matter and knowing that, knowing what you're doing when you're going into it, but I will say start, that's the first thing. Just start, even if you're nervous, even if you're scared, just start.And I promise you once you start, whether than this is anything, not just pallet flipping once you just start, you'll get it. You'll consistent, you will start and be consistent. It'll come to you just don't quit. Rob: I love it. Two great points out of that is the starting, no matter what gets started. The other one was, don't let any failures or any losses get you down. I was going with that... It's the growth you guys grow in those losses, there's losses in every business. There's, things that you don't like about every business, but grow from those, learn those mistakes. Like Meredith is saying, I'm sure buying a pallet, you know, you might get something you're expecting a bigger return on it than you got...But you're able to liquidate it and you just learn, you learn for next time around. Okay. Well, I can't do the,I'm not going to make as much [00:21:00] money on this or, you know, I, got a bad pallet, I tried a low grade pallet and it didn't work out for me. You guys got to experiment, you have to do it. And you have to learn from those losses.So, great, great points for sure. Meredith and you also, wanted to end with this too. You put together a list of vendors or pallets. A warehouse vendors list? Meredith: Yes. Liquidation pallets Melissa: Awesome! We'll link to that. And then also, if you do have the Reseller Pro Power Pack, she has a list of 170 in there.But for everybody here, that's watching, we do have the 20. Rob: Awesome! to get you started and then that's when you go to the next level. So, that's awesome. Meredith, thank you so much. You provided so much value to us today. I've never done this before. I'm excited about it. I'm super excited about it. So thank you for bringing the energy and getting me excited about this and all the great, great information that you actually provided for everybody who's here watching this. So thank you. Thank you. Thank you. Meredith: Thank you guys for having me. Thank you for asking me to be a part of the [00:22:00] summit. This is my first time to be a part of anything, so I really appreciate it. And, I look forward to you guys getting all the information that you guys need from watching everybody on the summit.Rob: Awesome. Sweet, have a great day. We'll see you guys soon. Thank you. Bye guys.

On this week's episode of Fast Facts - Perio Edition, Katrina Sanders, RDH discusses the current AAP current grading parameters and how we identify Grade B for a patient.   Quotes:    “We should start by placing all patients into grade B, and if there are modifiers that move the patient into grade A because of direct evidence, indirect evidence, risk factors, or systemic burden for example, then we move the patient down into a grade A or we move the patient up into a grade C in some instances.”   “I want to be very clear with these patients, you are going to take whichever identifier or modifier would move the patient into the higher grade, and that is going to be the weight that you will use to identify the patient's grade.”     Resources:   DentistRX: https://www.dentistrx.com  More Fast Facts: https://www.ataleoftwohygienists.com/fast-facts/    Katrina Sanders Website: https://www.katrinasanders.com  Katrina Sanders Instagram: https://www.instagram.com/thedentalwinegenist/    Sources:   Papapanou, P. N., Sanz, M., Buduneli, N., Dietrich, T., Feres, M., Fine, D. H., ... & Tonetti, M. S. (2018). Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. Journal of periodontology, 89, S173-S182.  

On this week's episode of Fast Facts - Perio Edition, Katrina Sanders, RDH discusses the current AAP current grading parameters and how we identify Grade B for a patient.   Quotes:    “We should start by placing all patients into grade B, and if there are modifiers that move the patient into grade A because of direct evidence, indirect evidence, risk factors, or systemic burden for example, then we move the patient down into a grade A or we move the patient up into a grade C in some instances.”   “I want to be very clear with these patients, you are going to take whichever identifier or modifier would move the patient into the higher grade, and that is going to be the weight that you will use to identify the patient's grade.”     Resources:   DentistRX: https://www.dentistrx.com  More Fast Facts: https://www.ataleoftwohygienists.com/fast-facts/    Katrina Sanders Website: https://www.katrinasanders.com  Katrina Sanders Instagram: https://www.instagram.com/thedentalwinegenist/    Sources:   Papapanou, P. N., Sanz, M., Buduneli, N., Dietrich, T., Feres, M., Fine, D. H., ... & Tonetti, M. S. (2018). Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. Journal of periodontology, 89, S173-S182.  

Eavesdrop on the chats Brian and his guests have right before the show starts. Episode 18-26 Compilation. New episode next Monday!

Episode 68: Prevention - Aspirin, STIs, and Diabetes. Updates on aspirin use for preeclampsia prevention, updated STIs screening guidelines, and new age to start screening for diabetes.  Introduction:  COVID-19 Booster Shots.  Every week there is a lot of information to cover about COVID-19. I'm sure you are aware of some of this information, but here you have it again for historical purposes. Pfizer and BioNtech announced on September 20, 2021, that their COVID-19 vaccine is protective in pediatric patients between 5 and 11 years of age. Let's remember that this vaccine is being used for patients older than 12, but so far none of the vaccines have been authorized for younger patients. A submission to FDA has been sent, but no approval has been given yet.Recently, we mentioned to you that a booster shot for the mRNA COVID-19 vaccines were likely to be authorized by the FDA around September 20. Indeed, an authorization for a booster was given on September 22, 2021. This authorization was given to the Pfizer/BioNtech vaccine only, and it can be given at least 6 months after the completion of the primary series.The patients who are authorized to receive the booster shot are: Patients who are 65 years of age and older; patients between 18 and 64 years of age at high risk of severe COVID-19; and individuals 18 through 64 years of age with frequent occupational exposure to COVID-19.The Moderna vaccine has not been authorized for a booster shot.Let's remember that both Pfizer and Moderna have been authorized for a third dose in patients who are immunocompromised. The third dose can be given 4 weeks after completing he initial 2 doses of these vaccines. Patient who may receive a third dose are those who are receiving active cancer treatment, recipients of an organ transplant, or have a moderate or severe immunodeficiency. Stay tuned for more updates in the future.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Page BreakPrevention - Aspirin, STIs and DiabetesBy Hector Arreaza, MD, and Valerie Civelli, MDThe USPSTF has been very active lately. They have released several recommendations in the last few months. Aspirin and preeclampsia: On September 28, 2021, the USPSTF released their recommendation about the use of aspirin to prevent preeclampsia in pregnant persons at high risk. This recommendation is consistent with the previous recommendation given in 2014. New evidence has reinforced that aspirin is effective at reducing risk of perinatal mortality when used properly.The recommendation states: “The USPSTF recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.” This is a grade B recommendation. A grade B recommendation means the net benefit of this preventive intervention is moderate to substantial.Who is at risk for preeclampsia? You can classify the risk as High, Moderate, and Low.High: Preeclampsia during previous pregnancies (especially if you had an adverse outcome), multifetal gestation, chronic hypertension, type 1 or 2 diabetes before pregnancy, kidney disease, autoimmune disease, or a combination of multiple moderate-risk factors. Recommend aspirin if a woman has 1 or more of those high-risk factors. Moderate: Nulliparity, obesity, history of preeclampsia in mother or sister, black persons, low income, age 35 years or older, personal history factors (e.g. low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval, and in vitro conception. Recommend aspirin if patient has 2 or more of these moderate risk factors. You may recommend aspirin even to women with 1 of these risk factors. Low: Do not recommend aspirin to pregnant women who have low risk for preeclampsia. A patient is considered low risk if she had a previous uncomplicated term delivery and has none of the risk factors mentioned above.As a side note, given the current movement for diversity, equality and inclusion, the article also states that “black persons have higher rates of preeclampsia and are at increased risk for serious complications due to various societal and health inequities,” not due to biological propensities.When do you stop aspirin in pregnancy?The decision to continue aspirin in the presence of obstetric bleeding (or bleeding risk) should be considered on a case-by-case basis. You can decide to stop at 36 weeks or continue until delivery based on your clinical judgement or local protocol.Bottomline: Recommend low-dose aspirin to pregnant women who are at increased risk for preeclampsia after 12 weeks of gestation.Chlamydia and gonorrhea screening: On September 14, 2021, the USPSTF recommended screening women younger than 24 years old who are sexually active for BOTH chlamydia and gonorrhea infection. Also, screen all women 25 years and older who are at increased risk. Increased risk means: a previous or coexisting STI, history of incarceration, and any kind of sexual intercourse out of a mutually monogamous relationship (new partner, more than one partner, partner who has sex with other partners, partner with an STI, history of exchanging sex for money or drugs).  The screening for GC/Chlamydia in women is a grade B recommendation. In this recommendation, the term “women” refers to persons born with female genitalia and does not apply to persons who identify as women but have male genitalia.  This recommendation also includes pregnant persons and adolescents. The evidence is insufficient (Grade I) to assess the balance and benefits and harms of screening for chlamydia and gonorrhea in asymptomatic men. Remember, a grade I recommendation is not a recommendation for or against a preventive intervention. To make it easy to remember “I stands for I don't know, more research is needed”. Recommendations about the age to start screening or the frequency of screening is not given explicitly, but the population with the highest incidence is women between 15-24 years old. Use your clinical judgement to determine when to start and how often. Prediabetes and diabetes screening: On August 24, 2021, the USPSTF updated their recommendation for prediabetes and diabetes screening. The recommendations states: “The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity (BMI above 25). Clinicians should offer or refer patients with prediabetes to effective preventive interventions. This is a Grade B recommendation. The age to start screening is now 35 years old (instead of the previous recommended age of 40). This is an update from the recommendation given in 2015. We should consider screening at a younger age in:Persons from groups with high incidence and prevalence. These groups are American Indian/Alaska Native, Asian American, Black, Hispanic/Latino, or Native Hawaiian/Pacific Islander persons. Persons with family history of diabetes, history of gestational diabetes, or a history of polycystic ovarian syndrome.Screen Asian Americans with a BMI of 23 or greater after age 35.How to screen for prediabetes and diabetes? You have three options: Fasting glucose (normal below 100, prediabetes below 125, diabetes above 126)Hemoglobin A1C (normal Below 5.6, prediabetes below 6.4%, diabetes above 6.5%). Do not use point of care A1C for screening, use a venous sample instead.Oral glucose tolerance test in the morning (fasting); measure glucose 2 hours after ingesting 75 g of oral glucose (normal below 140, prediabetes below 200, diabetes above 200). The diagnosis of prediabetes or type 2 diabetes should be confirmed with repeat testing before starting intervention.Random glucose above 200 is highly suggestive of diabetes.      The diagnosis of diabetes should be confirmed before starting interventions.Summary: Aspirin for preeclampsia prevention, screen for gonorrhea and chlamydia all women younger than 24, and screen for diabetes everyone older than 35 with overweight or obesity.______________________HIV Series Part II: HIV TransmissibilityBy Robert Dunn, MS3, Ross University School of Medicine.People infected with HIV are often thought to be contagious even by touch; though the reality is transmission is primarily transmitted via sexual contact, bodily fluids, from mother to baby during pregnancy, shared needles, or accidental needle sticks in the medical workplace. And when it comes to sex, it is common that a person is afraid to engage in any sexual contact with a HIV positive person, even though the patient may have their infection controlled with medicine.Per the CDC, the most common ways of contracting HIV are through sex without protection, shared needles, and perinatal transmission from mother to child.Sexual transmission:With anal sex, the receptive partner, or bottom, is at higher risk of contracting HIV because the rectal mucosa is thin, more prone to micro-abrasions and create an opportunity to contract HIV. The insertive partner, or top is also at risk of infection via the opening of the urethra, the foreskin of an uncircumcised penis, or any cuts, scratches or open sores on the penis. With vaginal sex, the woman can be infected via the mucus membranes that line the vagina and cervix. And the man can become infected from the vaginal fluid or blood that may carry HIV. Needlesticks:Sharing needles is high risk for contracting HIV. If one person has HIV and uses a needle, the blood of that person is carried on the needle and can inject the virus directly into anyone else who uses that needle. This can occur if people are sharing injected drugs, medications, or even in a needle stick accident that may occur when treating patients in the hospital with HIV. Vertical transmission:Perinatal transmission occurs when the mother infected with HIV passes the infection to her newborn. It is now recommended to test every pregnant woman for HIV and treat as needed. This can occur while the fetus is in the womb or upon delivery. It is recommended that the mother be placed on HIV medication immediately to reduce the risk of infecting the baby. These are ways how HIV is NOT transmitted: kissing on the cheeks, hugging, holding hands, sharing silverware, talking to someone, mosquitos, or sharing toilet.___________________________Now we conclude our episode number 68 “Prevention – Aspirin, STIs, and Diabetes.” Dr Arreaza and Dr Civelli explained the most recent updates by the USPSTF regarding use of aspirin to prevent preeclampsia, screening for gonorrhea and chlamydia in women, and screening for diabetes in patients older than 35. Robert continued with his HIV series and explained how HIV is mostly transmitted, a good reminder for all of us that the most common way of transmission continues to be sexual transmission. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. 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. This week we thank Hector Arreaza, Hasaney Sin, Valerie Civelli and Robert Dunn. Audio edition: Suraj Amrutia. See you next week! _____________________References:Erman, Michael, Pfizer/BioNTech say data show COVID-19 vaccine safe and protective in kids, Reuters, reuters.com, September 20, 2021. https://www.reuters.com/business/healthcare-pharmaceuticals/pfizerbiontech-say-data-show-covid-19-vaccine-safe-protective-kids-2021-09-20/, accessed on September 29, 2021. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication, United States Preventive Services Taskforce, September 28, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication. Chlamydia and Gonorrhea: Screening, United States Preventive Services Taskforce, September 14, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening. Prediabetes and Type 2 Diabetes: Screening, United States Preventive Services Taskforce, August 24, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes Ways HIV can be Transmitted. CDC, April 21, 2021. https://www.cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html. Accessed on September 21, 2021.

Every year, more than 1 billion pounds of food is wasted in the United States. In this episode, I speak with Ashley Weingart, the founder of Perfectly Imperfect Produce, a Northeast Ohio company that is rescuing produce from a variety of sources and giving it a second life in the form of home delivery boxes. The company also makes substantial donations to the Hunger Network of Greater Cleveland. Call it what you want...ugly food, surplus or Grade B. It might look a little tired, or rough around the edges, but it is entirely edible. Order from Perfectly Imperfect Produce and might find yourself with unexpectedly perfect Ohio blueberries, amusing two-legged carrots or a batch of knobby potatoes. Or you could score the first whole pineapple you've ever cut into. Just like you can't judge a book by its cover or wine by its label (I might debate that point), you shouldn't judge your produce by the skin it's in.

There's a place where sports and data meet, and it's as powerful a collision as on any football field!  Jeff Sagarin has been a figurehead in the sports analytics realm for decades, and we're thrilled to have had the chance to have him on to talk about his data journey!  There's a fair mix of math AND sports geek out time in this episode.  And, did we mention that Dr. Wayne Winston is sitting in on this episode as well? References in this Episode: 2 Frictionless Colliding Boxes Video Scorigami Episode Transcript: Rob Collie (00:00:00): Hello, friends. Today's guest is Jeff Sagarin. Is that name familiar to you? It's very familiar to me. In my life, Jeff's work might very well be my first brush with the concept of using data for any sort of advantage. His Power Ranking Columns, first appeared in USA Today in 1985, when I was 11 years old. And what a fascinating concept that was. Rob Collie (00:00:29): It probably won't surprise you if I confess that 11-year-old me was not particularly good at sports, but I was still fascinated and captivated by them. 11-year-old kids in my neighborhood were especially prone to associating sports with their tribal identity. Everyone had their favorite teams, their favorite sports stars. And invariably, this led to arguments about which sports star was better than the other sports star, who was going to win this game coming up and who would win a tournament amongst all of these teams and things of that sort. Rob Collie (00:01:01): Now that I've explained it that way though, I guess being an adult sports fan isn't too terribly different, is it? Those arguments, of course, aren't the sorts of arguments where there's anything resembling a clear winner. But in practice, the person who won was usually the one with the loudest voice or the sickest burn that they could deliver to their friends. And then in 1985, the idea was planted in my head by Jeff Sagarin's column in USA Today, that there actually was a relatively objective way to evaluate teams that had never played against one another and likely never would. Rob Collie (00:01:33): I wasn't into computers at the time. I certainly wasn't into the concept of data. I didn't know what a database was. I didn't know what a spreadsheet was. And yet, this was still an incredibly captivating and powerful idea. So in my life, Jeff Sagarin is the first public figure that I encountered in the sports analytics industry long before it was cool. And because it was sports, a topic that was relevant to 11-year-old me, he's really also my first brush with analytics at all. Rob Collie (00:02:07): It's not surprising then, that to me, Jeff is absolutely a celebrity. As a guest, in insider podcasting lingo, Jeff is what we call a good get. We owe that pleasure, of course, to him being close friends with Wayne Winston, a former guest on the show, who also joined us today as co-guest. Rob Collie (00:02:28): Now, if none of that speaks to you, let's try this alternate description. He's probably also the world's most famous active FORTRAN programmer. I admit that I was so starstruck by this that I didn't even really push as hard as I normally would, in terms of getting into the techniques that he uses. I didn't want to run afoul of asking him for trade secrets. At times, this conversation did devolve into four dudes sitting around talking about sports. Rob Collie (00:02:59): But setting that aside, there are some really, really interesting and heartwarming things happening in this conversation as well. Again, the accidental path to where he is today, the intersection of persistence and good fortune that's required really for success in anything. Bottom line, this is the story of a national and highly influential figure at the intersection of the sports industry and the analytics industry for more than three decades. It's not every day you get to hear that story. So let's get into it. Announcer (00:03:34): Ladies and gentlemen, may I have your attention, please? Announcer (00:03:39): This is the Raw Data by P3 Adaptive podcast with your host, Rob Colley and your co-host, Thomas LaRock. Find out what the experts at P3 Adaptive can do for your business. Just go to p3adaptive.com. Raw Data by P3 Adaptive is data with the human element. Rob Collie (00:04:02): Welcome to the show, Jeff Sagarin. And welcome back to the show. Wayne Winston. So thrilled to have the two of you with us today. This is awesome. We've been looking forward to this for a long time. So thank you very much gentlemen, for being here. Jeff Sagarin (00:04:16): You're welcome. Rob Collie (00:04:18): Jeff, usually we kick these things off with, "Hey, tell us a little about yourself, your background, blah, blah, blah." Let's start off with me telling you about you. It's a story about you that you wouldn't know. I remember for a very long time being aware of you. Rob Collie (00:04:35): So I'm 47 years old, born in 1974. My father had participated for many years in this shady off-the-books college football pick'em pool that was run out of the high school in a small town in Florida. Like the sheets with everybody's entries would show up. They were run on ditto paper, like that blue ink. It was done in the school ditto room and he did this every year. This was like the most fascinating thing that happened in the entire year to me. Like these things showing up at our house, this packet of all these picks, believe it or not, they were handwritten. These grids were handwritten with everyone's picks. It was ridiculous. Rob Collie (00:05:17): He got eliminated every year. There were a couple of hundred entries every year and he just got his butt kicked every year. But then one year, he did his homework. He researched common opponents and things like that or that kind of stuff. I seem to recall this having something to do timing wise with you. So I looked it up. Your column first appeared in USA Today in 1985. Is that correct? Jeff Sagarin (00:05:40): Yeah. Tuesday, January 8th 1985. Rob Collie (00:05:44): I remember my dad winning this pool that year and using the funds to buy a telescope to look at Halley's Comet when it showed up. And so I looked up Halley's Comet. What do you know? '86. So it would have been like the January ballgames of 1986, where he won this pool. And in '85, were you power ranking college football teams or was that other sports? Jeff Sagarin (00:06:11): Yes. Rob Collie (00:06:12): Okay. So when my dad said that he did his research that year, what he really did was read your stuff. You bought my dad a telescope in 1986 so that we could go have one of the worst family vacations of all time. It was just awful. Thank you. Jeff Sagarin (00:06:31): You're very welcome. Rob Collie (00:06:39): I kind of think of you as the first publicly known figure in sports analytics. You probably weren't the first person to apply math and computers to sports analytics, but you're the first person I heard of. Jeff Sagarin (00:06:51): There is a guy that people don't even talk about very much. Now a guy named Earnshaw Cook, who first inspired me when I was a sophomore in high school in the '63-'64 school year, there was an article by Frank Deford in Sports Illustrated about Earnshaw Cook publishing a book called Percentage Baseball. So I convinced my mom to let me have $10 to order it by mail and I got it. I started playing around with his various ideas in it. He was the first guy I ever heard of and that was in March of 1964. Rob Collie (00:07:28): All right, so everyone's got an origin story. Jeff Sagarin (00:07:31): The Dunkel family started doing the Dunkel ratings back I believe in 1929. Then there was a professor, I think he was at Vanderbilt, named [Lipkin House 00:07:41], he was I think at Vanderbilt. And for years, he did the high school ratings in states like maybe Tennessee and Kentucky. I think he gave Kentucky that Louisville courier his methodology before he died. But I don't know if they continue his work or not. But there were people way before me. Rob Collie (00:08:03): But they weren't in USA Today. Jeff Sagarin (00:08:04): That's true. Rob Collie (00:08:06): They weren't nationally distributed, like on a very regular basis. I've been hearing your name longer than I've even been working with computers. That's pretty crazy. How did you even get hooked up with USA Today? Jeff Sagarin (00:08:23): People might say, "You got lucky." My answer, as you'll see as well, I'd worked for 12 years to be in a position to get lucky. I started getting paid for doing this in September of 1972 with an in-house publication of pro football weekly called Insider's Pro Football Newsletter. Jeff Sagarin (00:08:45): In the Spring of '72, I'd written letters to like 100 newspapers saying because I had started by hand doing my own rating system for pro football in the fall of 1971. Just by hand, every Sunday night, I'd get the scores and add in the Monday night. I did it as a hobby. I wasn't doing it for a living. I did it week by week and charted the teams. It was all done with some charts I'd made up with a normal distribution and a slide rule. So I sent out letters in the spring of '72 to about 100 papers saying, "Hey, would you be interested in running my stuff?" Jeff Sagarin (00:09:19): They either didn't answer me or all said, "No, not interested." But I got a call right before I left to go to California when an old college friend that spring. It was from William Wallace, who was a big time football correspondent for The New York Times. That anecdote may be in that article by Andy Glockner. He called me up, he was at the New York Times, but he said also, "I write articles for extra money for pro football weekly. I wanted to just kind of talk to you." Jeff Sagarin (00:09:49): He wrote an article that appeared in Pro Quarterback magazine in September of '72. But during the middle of that summer, I got a phone call from Pro Football weekly, the publisher, a guy named [inaudible 00:10:04] said, "Hey Jeff. Have you seen our ad in street and Smith's?" It didn't matter. It could have been their pro magazine or college. I said, "Yeah, I did." And he said, "Do you notice it said we've got a world famous handicapper to do our predictions for us?" I said, "Yeah, I did see that." He said, "How would you like to be that world famous handicapper? We don't have anybody." Jeff Sagarin (00:10:25): We just said that because he said William Wallace told us to call you. So I said, "Okay, I'll be your world famous handicapper." I didn't start off that well and they had this customer, it was a paid newsletter and there was a customer from Hawaii. He had a great name, Charles Fujiwara. He'd send letters every week saying, "Sagarin's terrible, but he's winning a fortune for me. I just reverse his picks every week." So finally, finally, my numbers turn the tide and I had this one great week, where I went 8-0. He sent another letter saying, "I'm bankrupt. The kid destroyed me." Because he was reversing all my picks. That's a true story. Rob Collie (00:11:07): At least he had a sense of humor. It sounds like a pretty interesting fellow on the other end of that letter. Jeff Sagarin (00:11:13): He sounds like he could have been like the guy, if you've ever seen reruns of the old show, '77 Sunset Strip. In it, there this guy who's kind of a racetrack trout gambler named Roscoe. He sounds like he could have been Roscoe. Rob Collie (00:11:26): We have to look that one up. Dr. Wayne Winston (00:11:27): It's before your time. Rob Collie (00:11:28): I don't think I saw that show. Jeff Sagarin (00:11:29): Yeah. Wayne's seen it though. Rob Collie (00:11:31): Yes. I love that. There are things that are both before my time and I have like old man knees. So I've heard this kind of thing before, by the way. It's called the 10-year overnight success. Jeff Sagarin (00:11:47): I forgot. How did I get with USA Today? I started with Pro Football weekly and continued with them. I was with them until actually why don't we say sometime in the fall of '82. I ended up in other newspapers, little by little: The Boston Globe, Louisville Courier Journal. And then in the spring of '81, I got into a conversation over the phone with Jim van Valkenburg, who is the stat guy at the NCAA. I happened to mention that going into the tournament, I had Indiana to win the tournament. They were rated like 10th in the conventional polls. Jeff Sagarin (00:12:23): And so he remembered that and he kept talking behind the scenes to people in the NCAA about that. And so years later, in 1988, they called me out to talk to them. But anyhow, I had developed a good reputation and I gave him as a reference. Wayne called me up excitedly in let's say, early September of 1984. He said, "Hey, Jeff. You've got to buy a copy of today's USA Today and turn to the end of the sports section. You're going to be sick." Jeff Sagarin (00:12:53): I said, "Really? Okay." So I opened to where he said and I was sick. They had computer ratings by some guy. He was a good guy named Thomas Jech, J-E-C-H. And I said, "Damn, that should be me. I've been doing this for all these years and I didn't even know they were looking for this." So I call up on the phone. Sometimes there's a lot of luck involved. I got to talk to a guy named Bob Barbara who I believe is retired now there. He had on the phone this gruff sounding voice out of like a Grade B movie from the film, The War. "What's going on Kitty?" It sounds like he had a cigar in his mouth. Jeff Sagarin (00:13:30): I said, "Well, I do these computer ratings." [inaudible 00:13:33] Said "Well, really? That's interesting. We've already got somebody." He said, "But how would you even send it to us?" I said, "Well, I dictate over the phone." He said, "Dictate? We don't take dictation at USA Today, kid. Have you ever heard of personal computers and a modem?" I said, "Well, I have but I just do it on a mainframe at IU and I dictate over the phone to the Louisville Courier and the local..." Jeff Sagarin (00:13:58): Well, the local paper here, I gave them a printout. He said, "Kid, you need to buy yourself a PC and learn how to use a modem." So I kind of was embarrassed. I said, "Well, I'll see." So about 10 days later, I called him up and said, "Hey, what's the phone number for your modem?" He said, "Crap. You again, kid? I thought I got rid of you." He says, "All right. I'll give you the phone number." So I sent him a sample printout. He says, "Yeah, yeah, we got it. Keep in touch. We're not going to change for football. But this other guy, he may not want to do basketball. So keep in touch. Who knows what will happen for basketball?" Jeff Sagarin (00:14:31): So every month I'd call up saying, "It's me again, keeping touch." He said, "I can't get rid of you. You're like a bad penny that keeps turning up." So finally he says look, after about five of these calls, spreading out until maybe late November, "Look kid, why don't you wait... Call me up the first Sunday of the new year," which would have been like Sunday, January 6 of 1985 I believe. So I waited. I called him up. Sure enough, he said, "You again?" I said, "You told me you wanted to do college basketball." Jeff Sagarin (00:15:04): He said, "Yeah, you're kind of right. The other guy doesn't want to do it." So he said, "Well, do you mind if we call it the USA Today computer ratings? We kind of like to put our own name on everything." I said, "Well, wait a minute. During the World Series, you had Pete Rose as your guest columnist, you want not only gave his name, but you had a picture of him." He said, "God damn it." He said, "I can't..." He said, "You win again kid. Give us a bio." Jeff Sagarin (00:15:32): An old friend of both me and Wayne was on a business trip. He lived in California, but one of the companies he did work for was Magnavox, which at the time had a presence in Fort Wayne. So he had stopped off in Bloomington so we could say hi. We hadn't seen each other for many years. So he wrote my bio for me, which is still used in the agate in the USA Today. So it's the same bio all these years. Jeff Sagarin (00:15:56): So they started printing me on Tuesday, January 8 of 1985. On the front page that day and I got my editor of a couple years ago, he found an old physical copy of that paper and sent it to me and I thought that's pretty cool. And on the front page, they said, "Well, this would be the 50th birthday of Elvis Presley." I get, they did not have a banner headline at the top, "Turn to the sports and see Jeff Sagarin's debut." That was not what they did. It was all about Elvis Presley. And so people will tell me, "Wow! You got really lucky." Jeff Sagarin (00:16:30): Yeah, but I was in a position. I'd worked for 12 years since the fall of '72 to get in position to then get lucky. They told me I had some good recommendations from people. Rob Collie (00:16:42): Well, even that persistence to keep calling in the face of relatively discouraging feedback. So that conversation took place, and then two days later, you're in the paper. Jeff Sagarin (00:16:54): Well, yeah. He said, "Send us the ratings." They might have needed a time lag. So if I sent the ratings in on a Sunday night or Monday morning, they'd print them on Tuesday. They're not as instant. Now, I update every day on their website. For the paper, they take whatever the most recent ones they can access off their website, depending on I've sent it in, which is I always send them in early in the morning like when I get up. So they print on a Tuesday there'll be taking the ratings that they would have had in their hands Monday, which would be through Sunday's games. Rob Collie (00:17:26): That Tuesday, was that just college basketball? Jeff Sagarin (00:17:28): Then it was. Then in the fall of 85. They began using me for college football, not that they thought I was better or worse one way or the other than Thomas Jech who was a smart guy, he was a math professor at the time at Penn State. He just got tired of doing it. He had more important things to do. Serious, I don't mean that sarcastically. That was just like a fun hobby for him from what I understand. Rob Collie (00:17:50): I was going to ask you if you hadn't already gone and answered the question ahead of time. I was going to ask you well, what happened to the other guy? Did you go like all Tonya Harding on him or whatever? Did you take out your rival? No, sounds like Nancy Kerrigan just went ahead and retired. Although I hate to make you Tonya Harding in this analogy and I just realized I just Hardinged you. Jeff Sagarin (00:18:10): He was just evidently a really good math professor. It was just something he did for fun to do the ratings. Rob Collie (00:18:17): Opportunity and preparation right where they intersect. That's "luck". Jeff Sagarin (00:18:22): It would be as if Wally Pipp had retired and Lou Gehrig got to replace him in the analogy, Lou Gehrig gets the first base job but actually Wally Pipp in real life did not retire. He had the bad luck to get a cold or something or an injury and he never got back in the starting lineup after that. Rob Collie (00:18:38): What about Drew Bledsoe? I think he did get hurt. Did we ever see him again? Thomas LaRock (00:18:43): The very next season, he was in Buffalo and then he went to Dallas. Rob Collie (00:18:46): I don't remember this at all. Thomas LaRock (00:18:47): And not only that, but when he went to Dallas, he got hurt again and Tony Romo came on to take over. Rob Collie (00:18:53): Oh my god! So Drew Bledsoe is Wally Pipp X2. Thomas LaRock (00:18:58): Yeah, X2. Rob Collie (00:19:02): I just need to go find wherever Drew Bledsoe is right now and go get in line behind him. Thomas LaRock (00:19:08): He's making wine in Walla Walla, Washington. I know exactly where he is. Rob Collie (00:19:12): I'm about to inherit a vineyard gentlemen. Okay, so Wayne's already factored into this story. Dr. Wayne Winston (00:19:23): A little bit. Rob Collie (00:19:23): A bit part but an important one. We would call you Mr. Narrative Hook in the movie. Like you'd be the guy that's like, "Jeff, you've got to get a copy of USA Today and turn to page 10. You're going to be sick." Jeff Sagarin (00:19:37): Well, I was I'm glad Wayne told me to do it. If I'd never known that, who knows what I'd be doing right now? Rob Collie (00:19:44): Yeah. So you guys are longtime friends, right? Dr. Wayne Winston (00:19:47): Yeah. Jeff, should take this. Jeff Sagarin (00:19:49): September 1967 in the TV room at Ashdown Graduate's House across from the dorm we lived, because the graduate students there had rigged up, we call it a full screen TV that was actually quite huge. It's simply projected from a regular TV onto a maybe a 10 foot by 10 foot old fashioned movie projector screen. We'd go there to watch ballgames. Okay, because better than watching on a 10 inch diagonal black and white TV in the dorm. And it turned out we both had a love for baseball and football games. Thomas LaRock (00:20:26): So just to be clear, though, this was no ordinary school. This is MIT. Because this is what people at MIT would do is take some weird tech thing and go, "We can make this even better, make a big screen TV." Jeff Sagarin (00:20:38): We didn't know how to do it, which leads into Wayne's favorite story about our joint science escapades at MIT. If Wayne wants to start it off, you might like this. I was a junior and Wayne was a sophomore at the time. I'll set Wayne up for it, there was a requirement that MIT no matter what your major, one of the sort of distribution courses you had to take was a laboratory class. Why don't we let Wayne take the ball for a while on this? Dr. Wayne Winston (00:21:05): I'm not very mechanically inclined. I got a D in wood shop and a D in metal shop. Jeff's not very mechanically inclined either. We took this lab class and we were trying to figure out identifying a coin based on the sound waves it would produce under the Scylla scope. And so the first week, we couldn't get the machine to work. And the professor said, "Turn it on." And so we figured that step out and the next week, the machine didn't work. He said, "Plug it in." Jeff can take it from there. Jeff Sagarin (00:21:46): It didn't really fit the mathematical narrative exactly of what metals we knew were in the coin. But then I noticed, nowadays we'd probably figure out this a reason. If we multiplied our answers by something like 100 pi, we got the right numbers. So they were correctly proportional. So we just multiplied our answers by 100 pi and said, "As you can see, it's perfectly deducible." Rob Collie (00:22:14): There's a YouTube video that we should probably link that is crazy. It shows that two boxes on a frictionless surface a simulation and the number of times that they collide, when you slide them towards a wall together, when they're like at 10X ratio of mass, the number of times that they impact each other starts to become the digits of pi. Jeff Sagarin (00:22:34): Wow. Rob Collie (00:22:35): Before they separate. Jeff Sagarin (00:22:36): That's interesting. Rob Collie (00:22:36): It's just bizarre. And then they go through explaining like why it is pi and you understand it while the video is playing. And then the video ends and you've completely lost it. Jeff Sagarin (00:22:49): I'm just asking now, are they saying if you do that experiment an infinite amount of times, the average number of times they collide will be pi? Rob Collie (00:22:57): That's a really good question. I think it's like the number of collisions as you increase the ratios of the weight or something like that start to become. It's like you'll get 314 collisions, for instance, in a certain weight ratio, because that's the only three digits of pi that I remember. It's 3.14. It's a fascinating little watch. So the 100 pi thing, you said that, I'm like, "Yeah, that just... Of course it's 100 pi." Even boxes colliding on a frictionless surface do pi things apparently. Jeff Sagarin (00:23:29): Maybe it's a universal constant in everything we do. Rob Collie (00:23:29): You just don't expect pi to surface itself. It has nothing to do with waves, no wavelength, no arcs of circles, nothing like that. But that sneaky video, they do show you that it actually has something to do with circles and angles and stuff. Jeff Sagarin (00:23:44): Mutual friend of me and Wayne, this guy named Robin. He loves Fibonacci. And so every time I see a particular game end by a certain score, I'll just say, "Hey, Robin. Research the score of..." I think it was blooming to North against some other team. And he did. It turned out Bloomington North had won 155-34, which are the two adjacent Fibonacci, the two particular adjacent Fibonacci. Robin loves that stuff. You'll find a lot of that actually. It's hard to double Fibonacci a team though. That would be like 89-34. Rob Collie (00:24:18): I know about the Fibonacci sequence. But I can't pick Fibonacci sequence numbers out of the wild. Are you familiar with Scorigami? Jeff Sagarin (00:24:26): Who? I'd never heard of it obviously. Rob Collie (00:24:29): I think a Scorigami is a score in the NFL that's never happened. Jeff Sagarin (00:24:32): There was one like that about 10 years ago, 11-10, I believe. Pittsburgh was involved in the game or 12-11, something like that. Rob Collie (00:24:40): I think there was a Scorigami in last season. With scoring going up, the chances of Scorigami is increasing. There's just more variance at the higher end of the spectrum of numbers, right? Jeff Sagarin (00:24:50): I've always thought about this. In Canada, Canadian football, they have this extra rule that I think is kind of cool because it would probably make more scores happen. If a punter kicks the ball into the end zone, it can't roll there. Like if he kicks it on the fly into the end zone and the other team can't run it out, it's called a rouge and the kicking team gets one point for it. That's kind of cool. Because once you add the concept of scoring one point, you make a lot more scores more probable of happening. Rob Collie (00:25:21): Oh, yeah, yeah, yeah, totally. You can win 1-0. Thomas LaRock (00:25:25): So the end zone is also... It's 20 yards deep. So the field's longer, it's 110 yards. But the end zone's deeper and part of it is that it's too far to kick for a field goal. But you know what? If I can punt it into the end zone and if I get a cover team down there, we can get one point out. I'm in favor of it. I think that'd be great. Jeff Sagarin (00:25:43): I think you have to kick out on the fly into the end zone. It's not like if it rolls into it. Thomas LaRock (00:25:47): No, no, no. It's like a pop flop. Jeff Sagarin (00:25:50): Yeah. Okay. Rob Collie (00:25:50): If you punt it out of the end zone, is it also a point? Thomas LaRock (00:25:52): It's a touch back. No, touch back. Jeff Sagarin (00:25:54): That'd be too easy of a way to get a point. Rob Collie (00:25:57): You've had a 20 yard deep target to land in. In Canadian fantasy football, if there was such a thing, maybe there is, punters, you actually could have punters as a position because they can score points. That would be a really sad and un-fun way to play. Rob Collie (00:26:14): But so we're amateur sports analytics people here on the show. We're not professionals. We're probably not even very good at it. But that doesn't mean that we aren't fascinated by it. We're business analytics people here for sure. Business and sports, they might share some techniques, but it's just very, very, very different, the things that are valuable in the two spaces. I mean, they're sort of spiritually linked but they're not really tools or methods that provide value. Rob Collie (00:26:39): Not that you would give them. But we're not looking for any of your secrets here today. But you're not just writing for USA Today, there's a number of places where your skills are used these days, right? Jeff Sagarin (00:26:51): Well, not as much as that. But I want to make a favorable analogy for Wayne. In the world of sports analytics, whatever the phrases are, I consider myself to be maybe an experimental applied physicist. Wayne is an advanced theoretical physicist. I do the grunt work of collecting data and doing stuff with it. But Wayne has a large over-viewing of things. He's like a theoretical physicist. Dr. Wayne Winston (00:27:17): Jeff is too modest because he's experimented for years on the best parameters for his models. Rob Collie (00:27:27): It's again that 10-year, 20-year overnight success type of thing. You've just got to keep grinding at it. Do the two of you collaborate at all? Jeff Sagarin (00:27:35): Well, we did on two things, the Hoops computer game and Win Val. I forgot. How could I forget? It was actually my favorite thing that we did even though we've made no money doing the randomization using Game Theory of play calling for football. And we based it actually and it turned out that I got great numerical results that jive with empirical stuff that Virgil Carter had gotten and our economist, named Romer, had gotten and we had more detailed results than them. Jeff Sagarin (00:28:06): But in the areas that we intersected, we had the same as them. We used a game called Pro Quarterback and we modeled it. We had actually, a fellow, I wasn't a professor but a fellow professor of Wayne's, a great guy, just a great guy named Vic Cabot, who wrote a particular routine to insert the FORTRAN program that solved that particular linear programming problem that would constantly reoccur or else we couldn't do it. That was the favorite thing and we got to show it once to Sam White, who we really liked. And White said, "I like this guy. I may have played this particular game," we told him what we based it on, "when I was a teenager." Jeff Sagarin (00:28:46): He said, "I know exactly what you want to do." You don't make the same call in the same situation all the time. You have a random, but there's an optimal mix Game Theory, as you probably know for both offense and defense. White said, "The problem is this is my first year here. It was the summer of '83." And he said, "I don't really have the security." Said, "Imagine it's third and one, we're on our own 15 yard line. And it's third and one. And the random number generator says, 'Throw the bomb on this play with a 10% chance of calling up but it'll still be in the mix. And it happens to come up.'" Jeff Sagarin (00:29:23): He said, "It was my eight year here. I used to play these games myself. I know exactly." But then he patted his hip. He said, "It's mine on the line this first year." He said, "It's kind of nerve wracking to do that when you're a rookie coach somewhere, to call the bomb when it's third and one on your own 15. If it's incomplete, you'll be booed out of the stadium." Rob Collie (00:29:46): Yeah, I mean, it's similar to there's the general reluctance in coaches for so long to go for it on fourth and one. When the analytics were very, very, very clear that this was a plus expected value, +EV, move to go for it on fourth and one. But the thing is, you've got to consider the bigger picture. Right? The incentives, the coaches number one goal is actually don't get fired. Jeff Sagarin (00:30:14): You were right. That's what White was telling us. Rob Collie (00:30:14): Yeah. Winning a Super Bowl is a great thing to do. Because it helps you not get fired. It's actually weird. Like, if your goal is to win as many games as possible, yes, go for it on fourth and one. But if your goal is to not get fired, maybe. So it takes a bit more courage even to follow the numbers. And for good reason, because the incentives aren't really aligned the way that we think they are when you first glance at a situation. Jeff Sagarin (00:30:41): Well, there's a human factor that there's no way unless you're making a guess how to take it into account. It may be demoralizing to your defense if you go for it on fourth and one and you're on your own 15. I've seen the numbers, we used to do this. It's a good mathematical move to go for it. Because you could say, "Well, if you're forced to punt, the other team is going to start on the 50. So what's so good about that? But psychologically, your defense may be kind of pissed off and demoralized when they have to come out on the field and defend from their own 15 after you've not made it and the numbers don't take that into account. Rob Collie (00:31:19): Again, it's that judgment thing. Like the coach hung out to dry. Dr. Wayne Winston (00:31:22): Can I say a word about Vic Cabot, that Jeff mentioned? Jeff Sagarin (00:31:26): Yeah, He's great. Dr. Wayne Winston (00:31:27): Yeah. So Vic was the greatest guy any of us in the business school ever knew. He was a fantastic person. He died of throat cancer in 1994, actually 27 years ago this week or last week. Jeff Sagarin (00:31:43): Last week. It was right around Labor Day. Dr. Wayne Winston (00:31:46): Right. But I want to mention, basically, when he died, his daughter was working in the NYU housing office. After he died, she wrote a little book called The Princess Diaries. She's worth how many millions of dollars now? But he never got to see it. Jeff Sagarin (00:32:06): He had a son, a big kid named Matt Cabot, who played at Bloomington South High School. I got a nice story about Matthew. I believe the last time I know of him, he was a state trooper in the state of Colorado. I used to tell him when I was still young enough and Spry enough, we'd play a little pickup or something. I'd say, "Matthew, forget about points. The most important thing, a real man gets rebounds." Jeff Sagarin (00:32:32): They played in the semi state is when it was just one class. In '88, me and Wayne and a couple of Wayne's professor buddies, we all... Of course, Vic would have been there but we didn't go in the same car. It was me, Wayne and maybe [inaudible 00:32:48] and somebody else, Wayne? Jeff Sagarin (00:32:49): They played against Chandler Thompson's great team from Muncie Central. In the first three minutes, Chris Lawson, who was the star of the team went up for his patented turn around jumper from six feet away in the lane and Chandler Thompson spiked it like a volleyball and on the run of Muncie Central player took it with no one near him and laid it in and the game essentially ended but Matt Cabot had the game of his life. Jeff Sagarin (00:33:21): I think he may have led the game of anyone, the most rebounds in the game. I compliment him. He was proud of that. And he's played, he said many a pickup game with Chandler Thompson, he said the greatest jumper he's ever been on the court within his entire life. You guys look up because I don't know if you know who Chandler Thompson. Is he played at Ball State. Look up on YouTube his put back dunk against UNLV in the 90 tournaments, the year UNLV won it at all. Look up Chandler Thompson's put back dunk. Rob Collie (00:33:52): Yeah, I was just getting into basketball then, I think. Like in the Loyola Marymount days. Yeah, Jerry Tarkanian. Does college basketball have the same amount of personalities it used to like in the coaching figures. I kind of doubt that it does. Rob Collie (00:34:06): With Tark gone, and of course, Bob Knight, it'll be hard to replace personalities like that. I don't know. I don't really watch college basketball anymore, so I wouldn't really know. But I get invited into those pick'em pools for the tournament March Madness every year and I never had the stamina to fill them out. And they offer those sheets where they'll fill it out for you. But why would I do that? Jeff Sagarin (00:34:28): I've got to tell you a story involving Wayne and I. Rob Collie (00:34:31): Okay. Jeff Sagarin (00:34:31): In the 80 tournament, I had gotten a program running that would to simulate the tournament if you fed in the power ratings. It understood who'd play who and you simulate it a zillion times, come up with the odds. So going into the tournament, we had Purdue maybe the true odds against him should have been let's say, I'll make it up seven to one. Purdue and Iowa, they had Ronnie Lester, I remember. Jeff Sagarin (00:34:57): The true odds against them should have been about 7-1. The bookmakers were giving odds of 40-1. So Wayne and I looked at each other and said, "That seems like a big edge." In theory, well, odds are still against them. Let's bet $25 apiece on both Purdue and Iowa. The two of them made the final four. Jeff Sagarin (00:35:20): In Indianapolis, I'll put it this way, their consolation game gave us no consolation. Rob Collie (00:35:30): Man. Jeff Sagarin (00:35:31): And then one of the games, Joe Barry Carroll of Purdue, they're down by one they UCLA. I'm sure he was being contested. I don't mean he was all by himself. It's always easy for the fan who can't play to mock the player. I don't mean... He was being fiercely contested by UCLA. The net result was he missed with fierce contesting one foot layup that would have won the game for Purdue, that would have put them into the championship game and Iowa could have beaten Louisville, except their best player, Ronnie Lester had to leave the game because he had aggravated a bad knee injury that he just couldn't play well on. Jeff Sagarin (00:36:11): But as I said, no consolation, right Wayne? Dr. Wayne Winston (00:36:14): Right. Jeff Sagarin (00:36:15): That was the next to the last year they ever had a consolation game. The last one was in '81 between LSU and Virginia. Rob Collie (00:36:23): Was it the '81 tournament that you said that you liked Indiana to win it? Jeff Sagarin (00:36:28): Wait, I'm going to show you how you get punished for hubris. I learned my lesson. The next year in '82, I had gotten a lot of notoriety, good kind of notoriety for having them to win in '81. People thought, "Wow! This is like the Oracle." So now as the tournament's about to begin in '82, I started getting a lot of calls, which I never used to do like from the media, "Who do you got Jeff?" I said confidently, "Oregon State." I had them number one, I think they'd only lost one game the whole year and they had a guy named Charlie Sitting, a 6'8 guy who was there all American forward. Jeff Sagarin (00:37:06): He was the star and I was pretty confident and to be honest, probably obnoxious when I'd be talking to the press. So they make the regional final against Georgetown and it was being held out west. I'm sort of confidently waiting for the game to be played and I'm sure there'll be advancing to the final four. And they were playing against freshmen, Patrick Ewing. Jeff Sagarin (00:37:29): In the first 10 seconds of the game, maybe you can find the video, there was a lob pass into Ewing, his back was to the basket, he's like three feet from the basket without even looking, he dunks backwards over his head over Charlie Sitton. And you should see the expression on Charlie Sitton's face. I said, "Oh my god! This game is over." The final score was 68-43 in Georgetown's favor. It was a massacre. It taught me the lesson, never be cocky, at least in public because you get slapped down, you get slapped down when you do that. Rob Collie (00:38:05): I don't want to get into this yet again on this show. But you should call up Nate Silver and maybe talk to him a little bit about the same sort of thing. Makes very big public calls that haven't been necessarily so great lately. Just for everyone's benefit, because even though I'd live in the state of Indiana, I didn't grow up here. Let's just be clear. Who won the NCAA tournament in 1981? Jeff Sagarin (00:38:29): Indiana. Rob Collie (00:38:30): Okay. All right, so there you go. Right. Jeff Sagarin (00:38:33): But who didn't win it in 1982? Oregon State. Rob Collie (00:38:38): Yeah. Did you see The Hunt for Red October where Jack Ryan's character, there's a point where he guesses. He says, "Ramy, as always, goes to port in the bottom half of the hour with his crazy Ivan maneuvers and he turns out to be right." And that's how he ends up getting the captain of the American sub to trust him as Jack Ryan knew this Captain so well, even knew which direction he would turn in the crazy Ivan. But it turns out he was just bluffing. He knew he needed a break and it was 50/50. Rob Collie (00:39:08): So it's a good thing that they were talking to you in the Indiana year, originally. Not the Oregon State year. That wouldn't be a good first impression. If you had to have it go one way or the other in those two years, the order in which it happened was the right order. Jeff Sagarin (00:39:22): Yeah, nobody would have listened to me. They would have said, "You got lucky." They said, "You still were terrible in the Oregon State year." Rob Collie (00:39:28): But you just pick the 10th rated team and be right. The chances of that being just luck are pretty low. I like it. That's a good story. So the two of you have never collaborated like on the Mark Cuban stuff? On the Mavs or any of that? Jeff Sagarin (00:39:43): We've done three things together. The Hoops computer game, which we did from '86-'95. And then we did the Game Theory thing for football, but we never got a client. But we did get White to kind of follow it. There's an interesting anecdote, I won't I mentioned the guy who kind of screwed it up. But he assigned a particular grad assistant to fill and we needed a matrix filled in each week with a bunch of numbers with regarding various things like turnovers. Jeff Sagarin (00:40:13): If play A is called against defense B, what would happen type of thing? The grad assistant hated doing it. And one week, he gave us numbers such that the computer came back with when Indiana had the ball, it should quick kick on first down every time it got the ball. We figured it out what was going on, the guy had given Indiana a 15% chance of a turnover, no matter what play they called in any situation against any defense. Jeff Sagarin (00:40:44): So the computer correctly surmised it were better to punt the ball. This is like playing Russian roulette with the ball. Let's just kick it away. So we ended up losing the game in real life 10-0. White told us then when we next saw him, we used to see him on Monday or Tuesday mornings, real early in the day, like seven o'clock, but that's when you could catch him. And he kind of looked at us and said, "You know what? We couldn't have done any worse said had we kicked [inaudible 00:41:14]." Rob Collie (00:41:13): That's nice. Jeff Sagarin (00:41:14): And then we did Mark Cuban. That was the last thing. We did that with Cuban from basically 2000-2011 with a couple of random projects in the summer for him, but really on a day to day basis during a season from 2000-2011. Rob Collie (00:41:30): And during that era is when I met Wayne at Microsoft. That was very much an active, ongoing project when Wayne was there in Redmond a couple of times that we crossed paths. Dr. Wayne Winston (00:41:43): And we worked for the Knicks one year, and they won 54 games. Jeff Sagarin (00:41:47): Here with Glen Grunwald. So they won more games than they'd ever won in a whole bunch of years. And like three weeks before the season starts or so in mid September, the next fire, Glen Grunwald. Let's put it this way, it didn't bother us that the Knicks never made the playoffs again until this past season. Rob Collie (00:42:10): That's great. You were doing, was it lineup optimization for those teams? Jeff Sagarin (00:42:15): Wayne knows more about this than I do. Because I would create the raw data, well, I call it output, but it needed refinement. That was Wayne's department. So you do all the talking now, Wayne. Dr. Wayne Winston (00:42:26): Yeah. Jeff wrote an amazing FORTRAN program. So basically, Jeff rated teams and we figured out we could rate players based on how the score of the game moved during the game. We could evaluate lineups and figure out head to head how certain players did against each other. Now, every team does this stuff and ESPN has Real Plus-Minus and Nate Silver has Raptor. But we started this. Jeff Sagarin (00:42:58): I mean, everybody years ago knew about Plus-Minus. Well, intuitively, let's say you're a gym rat, you first come to a gym, you don't know anyone there and you start getting in the crowd of guys that show up every afternoon to play pickup. You start sensing, you don't even have to know their names. Hey, when that guy is on the court, no matter who his teammates are, they seem to win. Jeff Sagarin (00:43:20): Or when this guy's on the court, they always seem to lose. Intuitively since it matters, who's on the court with you and who your opponents are. Like to make an example for Rob, let's say you happen to be in a pickup game. You've snuck into Pauley Pavilion during the summer and you end up with like four NBA current playing professionals on your team and let's say an aging Michael Jordan now shows up. He ends up with four guys who are graduate students in philosophy because they have to exercise. You're going to have a better plus-minus than Michael Jordan. But when you take into account who your teammates were and who's his were, if you knew enough about the players, he'd have a better rating than you, new Michael Jordan would. Jeff Sagarin (00:44:08): But you'd have a better raw plus-minus than he would. You have to know who the people on the court were. That was Wayne's insight. Tell them how it all started, how you met ran into Mark Cuban, Wayne, when you were in Dallas? Dr. Wayne Winston (00:44:20): Well, Mark was in my class in 1981, statistics class and I guess the year 1999, we went to a Pacers Maverick game in Dallas. Jeff Sagarin (00:44:31): March of 2000. Dr. Wayne Winston (00:44:33): March of 2000, because our son really liked the Pacers. Mark saw me in the stands. He said, "I remember you from class and I remember you for being on Jeopardy." He had just bought the team. And he said, "If you can do anything to help the Mavericks, let me know." And then I was swimming in the pool one day and I said, "If Jeff rates teams, we should rate players." And so we worked on this and Jeff wrote this amazing FORTRAN program, which I'm sure he could not rewrite today. Jeff Sagarin (00:45:04): Oh, God. Well, I was motivated then. Willingness to work hard for many hours at a time, for days at a time to get something to work when you could use the money that would result from it. I don't have that in me anymore. I'm amazed when I look at the source code. I say, "Man, I couldn't do that now." I like to think I could. Necessity is the mother of invention. Rob Collie (00:45:28): I've many, many, many times said and this is still true to this day, like a previous version of me that made something amazing like built a model or something like that, I look back and go, "Whoo, I was really smart back then." Well, at the same time I know I'm improving. I know that I'm more capable today than I was a year ago. Even just accrued wisdom makes a big difference. When you really get lasered in on something and are very, very focused on it, you're suddenly able to execute at just a higher level than what you're typically used to. Jeff Sagarin (00:46:01): As time went on, we realized what Cuban wanted and other teams like the next would want. Nobody really wanted to wade through the monster set of files that the FORTRAN would create. I call that the raw output that nobody wanted to read, but it was needed. Wayne wrote these amazing routines in Excel that became understandable and usable by the clients. Jeff Sagarin (00:46:26): The way Wayne wrote the Excel, they could basically say, "Tell us what happens when these three guys are in the lineup, but these two guys are not in the lineup." It was amazing the stuff that he wrote. Wayne doesn't give himself the credit that otherwise after a while, nobody would have wanted what we were doing because what I did was this sort of monstrous and to some extent boring. Dr. Wayne Winston (00:46:48): This is what Rob's company does basically. They try and distill data into understandable form that basically helps the company make decisions. Rob Collie (00:46:58): It is a heck of a discipline, right? Because if you have the technical and sort of mental skills to execute on something that's that complex, and it starts down in the weeds and just raw inputs, it's actually really, really, really easy to hand it off in a form that isn't yet quite actionable for the intended audience. It's really fascinating to you, the person that created it. Rob Collie (00:47:23): It's not digestible or actionable yet for the consumer crowd, whoever the target consumer is. I've been there. I've handed off a lot of things back in the day and said, "The professional equivalent of..." And it turned out to not be... It turned out to be, "Go back and actually make it useful, Rob." So I'm familiar with that. For sure. I think I've gotten better at that over the years. As a journey, you're never really complete with. Something I wanted to throw in here before I forget, which is, Jeff, you have an amazing command of certain dates. Dr. Wayne Winston (00:47:56): Oh, yeah. Jeff Sagarin (00:47:57): Give me some date that you know the answer about what day of the week it was, and I'll tell you, but I'll tell you how I did it. Rob Collie (00:48:04): Okay, how about June 6, 1974? Jeff Sagarin (00:48:08): That'd be a Thursday. Rob Collie (00:48:10): Holy cow. Okay. How do you do that? Jeff Sagarin (00:48:11): June 11th of 1974 would be a Tuesday, so five days earlier would be a Thursday. Rob Collie (00:48:19): How do you know June 11? Jeff Sagarin (00:48:19): I just do. Dr. Wayne Winston (00:48:23): It's his birthday. Rob Collie (00:48:24): No, it's not. He wasn't born in '74. Dr. Wayne Winston (00:48:27): No, but June 11th. Jeff Sagarin (00:48:29): I happen to know that June 11 was a Tuesday in 1974, that's all. Rob Collie (00:48:34): I'm still sitting here waiting what passes for an explanation. Is one coming? Jeff Sagarin (00:48:39): I'll tell you another way I could have done it, but I didn't. In 1963, John Kennedy gave his famous speech in Berlin, Ich bin ein Berliner, on Wednesday, June 26th. That means that three weeks earlier was June 5, the Wednesday. So Thursday would have been June 6th. You're going to say, "Well, why is that relevant?" Well, 1963 is congruent to 1974 days of the week was. Rob Collie (00:49:07): Okay. This is really, really impressive. Jeff, you seem so normal up until now. Thomas LaRock (00:49:16): You want throw him off? Just ask for any date before 1759? Jeff Sagarin (00:49:20): No, I can do that. It'll take me a little longer though. Thomas LaRock (00:49:22): Because once they switch from Gregorian- Jeff Sagarin (00:49:25): No, well, I'll give it a Gregorian style, all right. I'm assuming that it's a Gregorian date. The calendar totally, totally repeats every possible cycle every 400 years. For example, if you happen to say, "What was September 10, of 1621?" I would quickly say, "It's a Friday." Because 1621 is exactly the same as 2021 says. Rob Collie (00:49:52): Does this translate into other domains as well? Do you have sort of other things that you can sort of get this quick, intuitive mastery over or is it very, very specific to this date arithmetic? Jeff Sagarin (00:50:02): Probably specific. In other words, I think Wayne's a bit quicker than me. I'm certain does mental arithmetic stuff, but to put everybody in their place, I don't think you ever met him, Wayne. Remember the soccer player, John Swan? Dr. Wayne Winston (00:50:14): Yeah. Jeff Sagarin (00:50:15): He had a friend from high school, they went to Brownsburg High School. I forgot the kid's name. He was like a regular student at IU. He was not a well scholar, but he was a smart kid. I'd say he was slightly faster than me at most mental arithmetic things. So you should never get cocky and think that other people, "Oh, they don't have the pedigree." Some people are really good at stuff you don't expect them to be good at, really good. This kid was really good. Rob Collie (00:50:45): As humans, we need to hyper simplify things in order to have a mental model we can use to navigate a very, very complicated world. That's a bit of a strength. But it's also a weakness in many ways. We tend to try to reduce intelligence down to this single linear number line, when it's really like a vast multi dimensional coordinate space. There are so many dimensions of intelligence. Rob Collie (00:51:11): I grew up with the trope in my head that athletes weren't very bright. Until the first time that I had to try to run a pick and roll versus pick and pop. I discovered that my brain has a clock speed that's too slow to run the pick and roll versus pick and pop. It's not that I'm not smart enough to know if this, than that. I can't process it fast enough to react. You look at like an NFL receiver or an NFL linebacker or whatever, has to process on every single snap. Rob Collie (00:51:45): It's amazing how much information they have the processor. Set aside the physical skill that they have, which I also don't have and never did. On top of that, I don't have the brain at all to do these sorts of things. It's crazy. Jeff Sagarin (00:52:00): With the first few years, I was in Bloomington from, let's say, '77 to '81, I needed the money, so I tutored for the athletic department. They tutored math. And I remember once I was given an assignment, it was a defensive end, real nice kid. He was having trouble with the kind of math we would find really easy. But you could tell he had a mental block. These guys had had bad experiences and they just, "I can't do this. I can't do this." Jeff Sagarin (00:52:25): I asked this defensive end, "Tell me what happens when the ball snap, what do you have to do?" I said, "In real time, you're being physically pulverized, the other guy's putting a forearm or more right into your face. And your brain has to be checking about five different things going on in the backfield, other linemen." I said, "What you're doing with somebody else trying to hurt you physically is much more intellectually difficult, at least to my mind than this problem in the book in front of you and the book is not punching you in the face." Jeff Sagarin (00:52:57): He relaxed and he can do the problems in the room. I'd make sure. I picked not a problem that I had solved. I'd give him another one that I hadn't solved and he could do it. I realized, my God, what these guys they're doing takes actually very quick reacting brainpower and my own personal experience in elementary school, let's say in sixth grade after school, we'd be playing street football, just touch football. When I'd be quarterback, I'd start running towards the line of scrimmage. Jeff Sagarin (00:53:26): If the other team came after me, they'd leave a receiver wide open. I said, "This is easy." So I throw for touchdown. Well, in seventh grade, we go to junior high. We have squads in gym class, and on a particular day, I got to be quarterback. Now, instead of guys sort of leisurely counting one Mississippi, two Mississippi, they are pouring in. It's not that you're going to get hurt, but you're going to get tagged and the play would be over. It says touch football, and I'd be frantically looking for receivers to get open. Let's just say it was not a good experience. I realized there's a lot more to be in quarterback than playing in the street. It's so simple. Jeff Sagarin (00:54:08): They come after you and they leave the receivers wide open. That's what evidently sets apart. Let's say the Tom Brady's from the guys who don't even make it after one year in the NFL. If you gave them a contest throwing the ball, seeing who could throw it through a tire at 50 yards, maybe the young kid is better than Tom Brady but his brain can't process what's happening on the field fast enough. Thomas LaRock (00:54:32): As someone who likes to you know, test things thoroughly, that student of yours who was having trouble on the test, you said the book wasn't hitting him physically. Did you try possibly? Jeff Sagarin (00:54:45): I should have shoved it in his face. Thomas LaRock (00:54:49): Physically, just [crosstalk 00:54:50]. Rob Collie (00:54:50): Just throw things at him. Yeah. Thomas LaRock (00:54:52): Throw an eraser, a piece of chalk. Just something. Jeff Sagarin (00:54:56): I'll tell you now, I don't want to name him. He's a real nice guy. I'll tell you a funny anecdote about him. I had hurt my knuckle in a pickup basketball game. I had a cast on it and I was talking to my friend. And he had just missed making a pro football team the previous summer and he was on the last cut. He'd made it to the final four guys. Jeff Sagarin (00:55:18): He was trying to become a linebacker I think. They told him, "You're just not mean enough." That was in my mind. I thought, "Well, I don't know about that." He said, "Yeah, I had the same kind of fractured knuckle you got." I said, "How'd you get it?" "Pick up [inaudible 00:55:32]. Punching a guy in the face." But he wasn't mean enough for the NFL. And I heard a story from a friend of mine who I witnessed it, this guy was at one point working security at a local holiday inn that would have these dances. Jeff Sagarin (00:55:47): There was some guy who was like from the Hells Angels who was causing trouble. He's a big guy, 6'5, 300 whatever. And he actually got into an argument with my friend who was the security guy. Angel guy throws a punch at this guy who's not mean enough for the NFL. With one punch the Jeff Sagarin tutoree knocked the Hell's Angels guy flat unconscious. He was a comatose on the floor. But he wasn't mean enough for the NFL. Rob Collie (00:56:17): Tom if I told my plus minus story about my 1992 dream team on this show, I think maybe I have. I don't remember. Thomas LaRock (00:56:24): You might have but this seems like a perfect episode for that. Rob Collie (00:56:27): I think Jeff and Wayne, if I have told it before, it was probably with Wayne. Dr. Wayne Winston (00:56:31): I don't remember. Rob Collie (00:56:32): Perfect. It'll be new to everyone that matters. Tom remembers. So, in 1992, the Orlando Magic were a recent expansion team in the NBA. Sometime in that summer, the same summer where the 1992 Dream Team Olympic team went and dominated, there was a friend of our family who ran a like a luxury automotive accessories store downtown and he basically hit the jackpot. He'd been there forever. There was like right next to like the magic practice facility. Rob Collie (00:57:09): And so all the magic players started frequenting his shop. That was where they tricked out all their cars and added all the... So his business was just booming as a result of magic coming to town. I don't know this guy ever had ever been necessarily terribly athletic at any point in his life. He had this bright idea to assemble a YMCA team that would play in the local YMCA league in Orlando, the city league. Rob Collie (00:57:35): He had secured the commitment of multiple magic players to be on our team as well as like Jack Givens, who was the radio commentator for The Magic and had been a longtime NBA star with his loaded team. And then it was like, this guy, we'll call this guy Bill. It's not his real name. So it was Bill and the NBA players and me and my dad, a couple of younger guys that actually I didn't know, but were pretty good but they weren't even like college level players. Rob Collie (00:58:07): And so we signed up for the A league, the most competitive league that Orlando had to offer. And then none of the NBA players ever showed up. I said never, but they did show up one time. But we were getting blown out. Some of the people who were playing against us were clearly ex college players. We couldn't even get the ball across half court. Jeff Sagarin (00:58:33): Wayne, does this sound familiar to you? Dr. Wayne Winston (00:58:35): Yes, tell this story. Jeff Sagarin (00:58:38): Wayne, when he was a grad student at Yale, and I'm living in the White Irish neighborhood called Dorchester in Boston, I was young and spry. At that time, I would think I could play. Wayne as a grad student at Yale had entered a team with a really intimidating name of administration science in the New Haven City League, which was played I believe at Hill House high school at night. So Wayne said, "Hey Jeff, why don't you take a Greyhound bus down. We're going to play against this team called the New Haven All Stars. It ought to be interesting." Rob Collie (00:59:14): Wayne's voice in that story sound a little bit like the guy at USA Today for a moment. It was the same voice, the cigar chomping. Anyway, continue. Jeff Sagarin (00:59:25): They edged this out 75-31. I thought I was lined up against the guy... I thought it was Paul Silas who was may be sort of having a bus man's holiday playing for the New Haven all-stars. So a couple weeks later, Paul Silas was my favorite player on the Celtics. He could rebound, that's all I could do. I was pitiful at anything else. But I worked at that and I was pretty strong and I worked at jumping, etc. Jeff Sagarin (00:59:53): So a few weeks later, Wayne calls me up and says, "Hey Jeff, we're playing the New Haven All-Stars again. Why don't you come down again and we'll get revenge against them this time?" Let's just say it didn't work out that way. And I remember one time I had Paul Silas completely boxed out. It was perfect textbook and I could jump. If my hands were maybe at rim level and I could see a pair of pants a foot over mine from behind, he didn't tell me and he got the rebound and I'm at rim level. Jeff Sagarin (01:00:24): We were edged out by a score so monstrous, I won't repeat it here. I'm not a guard at all. But I ended up with the ball... They full court pressed the whole game. Rob Collie (01:00:34): Of course, once they figure out- Jeff Sagarin (01:00:36): That we can't play and I'm not even a guard. It was ludicrous. My four teammates left me in terror. They just said, "We're going down court." So I'm all alone, they have four guys on me and my computer like my thought, "Well, they've got four guys on me. That must mean my four teammates are being guarded by one guy down court. This should be easy." I look, I look. They didn't steal the ball out of my hands or nothing. I'm still holding on to it. They're pecking away but they didn't foul me. I give them credit for that. I was like, "Where the hell are my teammates?" Jeff Sagarin (01:01:08): They were in terror hiding in single file behind the one guy and I basically... I don't care if you bleeping or not, I said, "Fuck it." And I just threw the ball. Good two overhand pass, long pass. I had my four teammates down there and they had one guy and you can guess who got the ball. After the game I asked them, I said, "You guys seem fairly good. Are you anybody?" The guy said, "Yeah, we're the former Fairfield varsity we were in the NIT about two years ago." Jeff Sagarin (01:01:39): I looked it up once. Fairfield did make the NIT, I think in '72. And this took place in like February of '74. It taught me a lesson because I looked up what my computer rating for Fairfield would have been compared that to, let's say, UCLA and NC State and figured at a minimum, we'd be at least a 100-200 point underdog against them in a real game, but it would have been worse because we would never get the ball pass mid-court. Rob Collie (01:02:10): Yeah, I mean, those games that I'm talking about in that YMCA League, I mean, the scores were far worse. We were losing like 130-11. Jeff Sagarin (01:02:19): Hey, good that's worse than New Haven all-stars beat us but not quite that bad. Rob Collie (01:02:24): I remember one time actually managing to get the ball across half court and pulling up for a three-point shot off of the break. And then having the guy that had assembled the team, take me aside at the next time out and tell me that I needed to pass that. I'm just like, "No. You got us into this embarrassment. If I get to the point where like, there's actually a shot we can take like a shot, we could take a shot. I'm not going to dump it off to you." Thomas LaRock (01:02:57): Not just a shot, but the shot of gold. Rob Collie (01:03:00): The one time we did get those guys to show up, we were still kind of losing because those guys didn't want to get hurt. It didn't make any sense for them to be there. There was no upside for them to be in this game. I'm sure that they just sort of been guilted into showing up. But then this Christian Laettner lookalike on the other team. He was as big as Laettner. Rob Collie (01:03:25): This is the kind of teams we were playing against. There was a long rebound and that Laettner lookalike got that long rebound and basically launched from the free throw line and dunked over Terry Catledge, the power forward for the Magic at the time. And at that moment, Terry Catledge scored the next 45 points in the game himself. That was all it was. Rob Collie (01:03:50): He'd just be standing there waiting for me to inbound the ball to him, he would take it coast to coast and score. He'd backpedal on defense and he would somehow steal the ball and he'd go down and score again. He just sent a message. And if that guy hadn't dunked over Catledge, we would have never seen what Catledge was capable of. So remember, this is a team th

Introduction about Wegovy as a new treatment for obesity. Dr Amodio discusses fall prevention in older adults. News: Semaglutide for the treatment of obesityBy Hector Arreaza, MD, and Daniela Amodio, MD. About 70% of Americans suffer from overweight or obesity. It has been 7 years since a medication was approved by FDA for chronic weight management. As a reminder, Saxenda® (liraglutide, daily SQ injection) was approved in 2014 for the treatment of obesity in adults (7 years ago), and remarkably, in December 2020, Saxenda® was also approved for the treatment of obesity in children older than 12 years old (good to know). Saxenda® is a GLP-1 receptor agonist.On June 4, 2021 (7 years later), Novo Nordisk® did it again and got approval for a new medication for the treatment of obesity (disclaimer, I do not receive any money from Novo Nordisk®)After extensive trials (drum rolls), Wegovy® (pronounced wee-GOH'-vee) has been approved by the FDA for chronic weight management. The component is semaglutide, yes, you heard me right, this is the same component of Ozempic®, an injected medication FDA-approved for diabetes treatment, and it is the same component in Rybelsus® (pronounced reb-EL-sus), which is the same semaglutide but in oral form. -Wegovy® is a synthetic version of a hormone called glucagon-like peptide 1 (GLP-1). GLP is an incretin, and as such, it reduces glucose levels by optimizing the secretion of insulin and decreasing the secretion of glucagon during digestion. Wegovy® exerts its action in areas of the brain to curb appetite and increase satiety. The use of Wegovy is approved in adults with a BMI above 30 kg/m2, or above 27 kg/m2 who have at least one weight-related condition. As with other medications for obesity, Wegovy is an adjunct therapy which can be added to intensive lifestyle modifications.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.  Page BreakElderly Falls.   By Daniela Amodio, MD, and Hector Arreaza, MD Patients who are older than 65 are normally called “older patients”, but sometimes it's confusing, older than who? What does it really mean? There are many euphemisms: seniors, older adults, elderly, “prolonged youth”, or old-timers.“Aging experts… have tried calling people young old (65 to 74), old old (75-84) and oldest old (85+). Age-based categories at this stage of life often aren't helpful because there is so much variability in how people age.” (Tracey Gendron, gerontologist at Virginia Commonwealth University)[2]Key points: 1. A fall is one of the most common events that may make older adults lose their independence.2. Complications from falls are the leading cause of death from injury in adults older than 65 years old.3. A multifactorial risk assessments should be done in older adults with >2 falls in the past 12 months.  Interventions that have shown to be effective in reducing falls: Medication reviewExercise programs for muscle strengthening and balance trainingVitamin D supplementation in vitamin D deficiency Use appropriate footwear Home hazardous assessment Comment: Deprescribing is an essential activity during your geriatric visits. Avoid unnecessary medications. Use the AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults to determine which medications you should either discontinue or change to minimize risk of falls. Some examples include: benzodiazepines, some antidepressants and dextromethorphan/quinidine. Prevalence and morbidity of falls in older adults:According to CDC, one out of three adults older than 65 years old reports falling in the previous year. The incidence of falls is higher with advanced age, which means one half of individuals older than 80 years old or those living in nursing homes will fall each year. Most falls result in soft tissue injury and 5-10% result in fracture or head trauma. Women and nursing facility residents are more prone to non-fatal injury than men. Death rate due to falls is more common in white men older than 85 years old. Risk factors: Multiple studies indicate that falls are multifactorial. Risk factors include: old age, cognitive impairment, female gender, history of falls, gait/balance problems, low vitamin D, pain, psychotropic medications, Parkinson's disease, stroke and arthritis. Physiologic changes expected with aging: With aging visual acuity is affected as well as inability for dark adaptation. Loss of sensitivity in the legs is expected as well as loss of balance. Also, there may be other changes in the CNS that affect postural control, including loss of neurons and dendrites and depletion of neurotransmitters such as dopamine in basal ganglia. There is inability to keep an upright posture due to decline in baroreflex sensitivity, resulting in hypotension.  Elderly patients are prone to dehydration due to decreased body water percentage and decreased renin and aldosterone levels, these factors can lead to orthostatic hypotension and falls.Prevention: The most modifiable risk factor is medication use. Of note, there is no difference in the risk of falling with the use of older antidepressant or antipsychotics compared with the newer SSRIs. Same thing applies with newer nonbenzodiazepine hypnotics to treat insomnia versus using benzodiazepine. So, the risk is the same.The risk of falls increases with older adults taking more than one psychotropic medication, and among adults taking >3 medications of any type. Other medications that affect the risk of falls are antihypertensive medications. Meta-analysis studies have shown an increase of risk in those elderly patients taking medications such as:  digoxin, diuretics, class Ia antiarrhythmics and NSAIDs. As a reminder, class Ia antiarrhythmics are sodium channel blockers. Drugs in this group include quinidine, procainamide, and disopyramide. They cause QT prolongation, that's why they are used, for example, in patients with short QT syndrome and recurrent ventricular arrhythmias (VA). Medications for dementia such as acetylcholinesterase inhibitors, have been associated with increased risk of syncope. Examples on this group: donepezil and memantine for Alzheimer's disease.Hypoglycemia is a risk factor for falls, so be cautious if you decide to use medications that cause hypoglycemia, including insulin. What do we do when we see a patient who reports frequent falls? Evaluation of the Elderly Patient Who Falls:The most important point in the history is asking if there has been a previous fall because this is a strong risk factor for future falls. For patients presenting with a fall, it is important to include the activity at the time of the fall, the occurrence of prodromal symptoms (lightheadedness, dizziness and imbalance) and the location and time of the fall. Medication history should focus on newly added medication or recent dosage changes as well as the use of medications mentioned before. We need to identify potential factors in the environment such as lighting, floor covering, railings, furniture.  Physical Exam/Screening tests:The most important part of the physical examination is evaluation of musculoskeletal function that can be accomplished by performing stability tests.  A useful test that evaluates strength and balance is the Up and Go test: patient stands up from a chair without using their arms to push against the chair, walks across the room (10 feet), turns around, walks back and sits down without using their arms. This test can evaluate muscle weakness, balance problems, gait abnormalities. Timed up and go test (TUG): An elderly patient who takes ≥12 seconds to complete this test is at risk for falling. This should be done routinely in geriatric visits. POMA test (performance-oriented Mobility assessment) It evaluates balancing gait through a number of items including ability to sit and stand from an armless chair, ability to maintain standing balance when pulled by an examiner and ability to walk normally, and maneuver obstacles. Treatment and Prevention:In 2011 the AGS and BGS updated clinical practice guidelines for prevention of falls in older adults. All older adults in the community at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. The interventions should be tailored to the individual's cognitive ability and language. The interventions considered to be effective are the following:1. Home environment assessment and intervention should be performed by a healthcare professional in older adults who have fallen or have risk factors for falling. 2. Discontinue or minimize psychoactive medications. Tapering medication is associated with a decreased rate of falls.3. A prescribing modification program for PCP that includes medication review checklist, education and feedback from pharmacists. 4. Manage foot problems: Clinicians should advise their patients to use walking shoes with high contact surface area. In elderly patients with disabling foot pain, falls may be reduced by intervention such as: customized insoles, foot/ankle exercise and falls prevention education. The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls (Grade B). The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older (Grade D).Fall is a common cause of morbidity, disability and mortality. Let's remember to screen and intervene to prevent falls.____________________________Conclusion: Now we conclude our episode number 56, “Elderly Falls.” Dr Amodio gave us a summary of effective strategies to prevent falls in elderly patients. She described how to perform the “Timed-Up-and-go” test, a useful tool to screen for fall risk. She explained that exercise, home safety inspection, and medication reconciliation are useful strategies to prevent falls. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. 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. This week we thank Hector Arreaza, Daniela Amodio, and Cecilia Covenas. Audio edition: Suraj Amrutia. See you next week! _____________________References:FDA Approves New Drug Treatment for Chronic Weight Management, First Since 2014, FDA (online), June 4, 2021. https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014 Burling Stacey, “If we can't call old people 'old,' what's the right word?” The Philadelphia Inquirer (online), July 20, 2017. https://www.inquirer.com/philly/health/health-news/if-its-rude-to-call-old-people-old-whats-the-right-word-20170723.html Berry, Sarah D and Douglas P Kiel, Chapter 34: Falls. Geriatrics Review Syllabus, 9th edition. Editors: Barbara Resnick, 2016. Reuben, David B. Falls Prevention and Falls. Geriatrics At Your Fingertips, 22nd edition. American Geriatrics Society, 2020.  

A1C is an easy way to diagnose and monitor diabetes, use and limitations of A1C are discussed with Dr Rodriguez. Vaginal metformin is mentioned as an anecdote which has not been proven to work we remembered Memorial Day. Introduction: Vaginal Metformin.  By Hasaney Sin, MD, and Hector Arreaza, MD.Today is May 31, 2021.  There’s a saying that I came across on social media that has always spoken to me which I find relevant to our vocation. “The more I learn, the more I find out I don’t know”. So comes the joys (and challenges) of our chosen career. Case in point, have you ever heard of vaginal metformin? Neither have I, until today. There was a randomized clinical trial plan in 2013 at Assuit University in Egypt studying the effectiveness of vaginal metformin for the treatment of polycystic ovarian syndrome (PCOS). As primary care providers, we are very aware of the gastrointestinal side effects of metformin when taken PO. This sometimes prevents compliance with metformin. The study at Assuit University was to study the effectiveness of metformin when given vaginally in the effectiveness of treating PCOS, while also decreasing the undesirable side effects of metformin when given PO in hopes of also ultimately improving adherence. Unfortunately, the study was planned to be finished in 2014, but no results have been published thus far[1]. Stay tuned in case there is any update.Arreaza: I had to do a search because I was very curious too. There is at least one occurrence when vaginal metformin was mentioned, at least in English. It was in an online forum where a doctor recommended vaginal metformin for PCOS to a patient. This has not been evaluated or approved by any organization, so I would not recommend it. You know what would be great? Metformin patches! There you have a business idea guys: The Metfo-patch®. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Introduction: Memorial Day. Written by Valerie Civelli, MD, read by Steven Saito, MD, and Hector Arreaza, MDWhat is Memorial Day? Memorial Day is an American holiday at the end of May to honor the men and women who died while serving in the US military. It has great historical meaning to Americans. It originated from the Civil War which claimed more lives than any other conflict in US history. Civil war ended in 1865.   A fun fact to know, is that Memorial Day, was originally called “Decoration Day”.  It was 3-years after the Civil war ended, May 5, 1868, that “Decoration Day” was declared as a time for the nation to decorate the graves of those lost in war.  Graves were adorned with flowers and their lives celebrated.  Maj. Gen. John A. Logan then declared that “Decoration Day” should be observed on May 30th. It is believed that this date was chosen because flowers would be in full bloom across the country. The “birthplace” of “Memorial Day” was recognized as coming from Waterloo, New York, because Waterloo was the first to use this term to expand honor and recognition of all US fallen soldiers of war from the Civil War and from World War I. In 1971, “Memorial Day” was officially declared a national federal holiday: The National Moment of Remembrance encourages all Americans to pause wherever they are at 3:00 p.m. local time on Memorial Day for a minute of silence, to remember and honor those who have died in service to the nation. If you value your freedom wherever you are, this Memorial Day at 3:00 p.m., pause for a minute to recognize all of our military men and women, both past and present who served and continue to serve our country. We honor every soldier who lost his or her life in any war against America. You are the reason for our freedoms.  You gave the ultimate sacrifice, and we do not take this for granted. To all military members who have died at war, we appreciate the privileges we have today because of you. We honor the costly price at which it came.  We remember you. We honor you. We sincerely thank you. Happy Memorial Day everyone! ___________________________A1C.By Hector Arreaza, MD, and Yodaisy Rodriguez, MD.   Definition. Glycated hemoglobin (glycohemoglobin, hemoglobin A1c, or just A1c) is a form of hemoglobin that is chemically linked to a sugar. Glucose spontaneously bind with hemoglobin, when present in the bloodstream of humans.A1C refers to the percentage of glycosylation of the hemoglobin A1C chain and correlates with the average blood glucose levels over the previous 2-3 months from the slow turnover of red blood cells in the body. A RBC lives 120 days.History of A1C. Huisman and Meyering separated glycohemglobin for the first time in 1958. A1c for monitoring the degree of control of glucose metabolism in diabetic patients was proposed in 1976 by Anthony Cerami, Ronald Koenig and coworkers.A1C was first included in the ADA guidelines as a diagnostic test for diabetes in 2010. Prior to that random glucose or fasting plasma glucose were used for diagnosis.For diagnosis of diabetes, A1C testing should be done by a technique certified by the National Glycohemoglobin Standardization Program and consistent with the Diabetes Control and Complications Trial reference assay.A1C levels. A1C 6.5% is diabetes.Of note, other criteria for diagnosing diabetes: Fasting plasma glucose >126 mg/dL, 2-hour plasma glucose > 200, random glucose >200 plus classic symptoms.In patients with prediabetes, A1C should be tested yearly.The American Diabetes Association (ADA) has recommended glycated hemoglobin testing (HbA1c) twice a year for patients with stable glycemia, and quarterly for patients with poor glucose control. Use ADA guidelines to assess targets.Point-of-care A1C (POC A1C): POC is not recommended for screening or diagnosis but it is good for monitoring.A1C limitations.There are some limitations to A1C testing, and an incomplete correlation between A1C level and average glucose level in certain individuals.Nonglycemic Factors That May Interfere with A1C MeasurementFalsely lower A1C: Acute blood loss, Chronic liver disease, Hemolytic anemias, Patients receiving antiretroviral treatment for human immunodeficiency virus, Pregnancy, Vitamins E and C. Patients being treated for iron, B12 or folate deficiency, EPO, chronic hemolysis (thalassemia). Lower or elevate A1C: Hemoglobinopathies or hemoglobin variants, Malnutrition Falsely elevate A1C: Aplastic anemias, Hyperbilirubinemia, Hypertriglyceridemia, Iron deficiency anemias, Renal failure, Splenectomy.For example, when RBCs have a short life, like in acute bleeding, the A1C is falsely low. On the other hand, when RBCs live longer (history of splenectomy and aplastic anemias) the A1C is falsely elevated. It’s a good idea to do CBC with A1C.Ethnic groups: Hemoglobinopathies or hemoglobin variants can change A1C levels and may be more prevalent among certain racial and ethnic groups. A1C tends to be higher in some races/ethnic groups: AA, Hispanic-Americans, Asian-Americans.Other A1C limitations: It gives you an average, patient may be experiencing hypoglycemia alternated with hyperglycemia and result in normal A1C. Screening for diabetes.ADA: Screen for diabetes or prediabetes all asymptomatic adults, according to the ADA, who have overweight or obesity with one or more risk factor (first degree relative with diabetes, high risk race or ethnic group, history of CVD, hypertension, dyslipidemia, PCOS, physical inactivity, severe obesity, acanthosis nigricans), patients with prediabetes (every year), women with GDM (every 3 years), all other patients after 45 years of age. If results are normal, test every 3 years, patients with HIV.USPSTF: Adults aged 40 to 70 years who are overweight or obese. The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. (Draft: Asymptomatic adults ages 35 to 70 years who are overweight or obese) This is a Grade B recommendation. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. The USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. This is a Grade B recommendation.Grade I recommendation (insufficient evidence): Asymptomatic pregnant women, Before 24 Weeks of Gestation. The USPSTF concludes that the current evidence is insufficient to screen for GDM in asymptomatic pregnant women before 24 weeks of gestation.A1C Targets.A1C goals can range from 6.5% to 8%. Target is individualized based on life expectancy, disease duration, presence of complications, CVD risk factors, comorbid conditions and risks for severe hypoglycemia. Sometimes your goal can be independent of A1C, for example, your goal can be to avoid complications. As a fun fact, A1C is not used in veterinary medicine.Conclusion.By Hector Arreaza, MD. Now we conclude our episode number 54 “A1C”, three characters that may not mean much for most people but for patients with diabetes, it is a very important number to remember. Remember to check the A1C in all your patients with poor control of diabetes every 3 months, or every 6 months in patients with good control. A1C has its limitations but it certainly is the best way to assess your patients’ glycemic control. We started this episode by giving you a random report about vaginal metformin, the study was unfinished, and we also reminded you of the importance of remembering our heroes during Memorial Day. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. 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. This week we thank Hector Arreaza, Hasaney Sin, Valerie Civelli, Yodaisy Rodriguez, and Steven Saito. Audio edition: Suraj Amrutia. See you next week!References:Vaginal Administration of Metformin in PCOS Patients, U.S. National Library of Medicine, Clinical Trials.Gov, https://clinicaltrials.gov/ct2/show/study/NCT02026869. Office of Public and Intergovernmental Affairs, U.S. Department of Veteran Affairs,  https://www.va.gov/opa/speceven/memday/history.asp, accessed on May 26, 2021.  Pippitt K, Li M, Gurgle HE. Diabetes Mellitus: Screening and Diagnosis. Am Fam Physician. 2016 Jan 15;93(2):103-9. Erratum in: Am Fam Physician. 2016 Oct 1;94(7):533. PMID: 26926406. https://www.aafp.org/afp/2016/0115/p103.html. Standards of Medical Care in Diabetes – 2021, Diabetes Care, January 1, 2021, vol 44 issue supplement 1, https://care.diabetesjournals.org/content/diacare/suppl/2020/12/09/44.Supplement_1.DC1/DC_44_S1_final_copyright_stamped.pdf.

Colorectal cancer screening update, COVID-19 vaccine update, and abnormal uterine bleeding basics.Today is May 24, 2021.Colorectal cancer screening update Written by Hector Arreaza, MD. Participation: Ikenna Nwosu, MD, and Daniela Viamontes, MD.Today is May 24, 2021.On august 29, 2020, we were in the midst of a pandemic and we woke up with the sad news about the death of Chadwick Aaron Boseman (also known as Black Panther). An interesting fact: The tweet in which his family announced his death on Twitter became the most-liked tweet in history. But why are we talking about Chadwick’s death? Because he died of colon cancer. I do not know if this recommendation came because of Chadwick, but it’s a good way to open this episode: remembering Black Panther.We heard the rumors, but now it’s official. On May 18, 2021, the USPSTF released their final recommendation statement about colorectal cancer screening. The age to start screening has been changed from 50 to 45 years old. This is a grade B recommendation. Grade B means that this recommendation has moderate to substantial net benefit, so offer this service to your patients. Screening adults between 76 and 85 years old who have been previously screened has a small net benefit (grade C recommendation). So, select patients may be screened for colorectal cancer in this age group (76-85), especially those who have never been screened.Do you remember this recommendation from medical school for high risk patients? Start screening at age 40 or 10 years before a patient’s direct-relative was diagnosed with colon cancer. This was a recommendation given by the US Multi-Society Task Force (which includes the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy). This same organization already recommended in 2017 to start screening at age 45 in African American patients, and the American Cancer Society recommended screening all patients at age 45 in 2018. The ACS does not have a guideline to screen high risk patients for colon cancer. Most organizations agreed on not screening after age 85.Strategies for screening:High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every yearDani: Stool DNA-FIT every 1 to 3 years (Cologuard®)  CT colonography every 5 years Flexible sigmoidoscopy every 5 years OR Flexible sigmoidoscopy every 10 years + annual FIT Colonoscopy screening every 10 yearsDiscuss different options with your patients, choose your favorite and do it!  Introduction: Update on COVID 19 vaccines  By Hector Arreaza, MD, and Lillian Petersen, RN. COVID-19 vaccines now can be co-administered with other vaccines according to the ACIP. COVID-19 vaccines and other vaccines may now be administered without regard to timing. They can be given on the same day or within the 14 days previously recommended between vaccines.  It is not known if reactogenicity of COVID-19 vaccine is increased with co-administration with other reactogenic vaccines (such as vaccines with live attenuated viruses).  How do you decide if you want to co-administer a vaccine? 1. Consider whether the patient is behind or at risk of becoming behind on recommended vaccines.2. Consider their risk of vaccine-preventable disease.3. Consider the reactogenicity profile of the vaccines. If multiple vaccines are administered at a single visit, administer each injection in a different injection site, at least one inch apart or in different limbs. Current or previous SARS-CoV-2 infection: Everyone should be offered COVID-19 vaccination regardless of their history of COVID-19 infection. Viral testing or serologic test is not recommended for the purposes of vaccine decision-making. People with current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and they have met criteria to discontinue isolation. This applies to patients who got the disease before receiving any vaccine or after receiving the first dose.  A minimum interval between infection and vaccination has not been established, but evidence suggests that the risk of reinfection is low in the months after initial infection but may increase with time due to waning immunity. People with a history of multisystem inflammatory syndrome in children (MIS-C) or adults (MIS-A):It is unclear if people with a history of MIS-C or MIS-A are at risk of recurrence of the same dysregulated immune response following reinfection with SARS-CoV-2 or in response to vaccination. People with a history of MIS-C or MIS-A may choose to be vaccinated but they should consider delaying vaccination until they have recovered from their illness and for 90 days after the date of diagnosis. Find more information at the CDC.gov website. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Abnormal Uterine Bleeding. By Sherika Adams, MS3, P. Eresha Perera, MS3, and Hector Arreaza, MD.  Definition. AUB is a symptom, not a diagnosis. It is equivalent to say: “This patient’s periods are abnormal.” Anything that falls out of what is considered “normal periods” is classified as abnormal uterine bleeding.These 4 elements are assessed when determining if a patient has AUB: Regularity, frequency, duration, and volume.  What is considered normal? Frequency = Every 24-38 days, regularity +/- 2-20 days over 12 months, duration = 4.5 to 8 days, volume = 5-80 mL. 10-30% of women of reproductive age may have AUB. According to the American College of Obstetricians and Gynecologists (ACOG), abnormal uterine bleeding is characterized by bleeding or spotting following sexual intercourse or menopause, between menstrual cycles, menstrual cycles lasting more than 38 days or shorter than 24 days, heavy bleeding during menstruation, and “irregular” menstrual cycles that have 7-9 days of variation.Terms no longer used: menorrhagia, metrorrhagia, and dysfunctional uterine bleeding (DUB). Not all symptoms reported as “vaginal bleeding” are coming from the vagina. For example, bleeding from anus, urethra, bladder, and perineum should be ruled out before establishing the diagnosis of AUB. Classification of Abnormal Uterine Bleeding (AUB). Abnormal uterine bleeding (AUB) in nonpregnant premenopausal women can be classified by the acronym PALM-COEIN, which was established by the International Federation of Gynecology and Obstetrics (FIGO) in 2011.  PALM-COEIN: Palm: Structural etiologies, Coein: Non-structural etiologies P is for polyps: Polyps are epithelial tumors in the endometrium or cervix and can be identified by hysterosonography or hysteroscopic imaging. A is for adenomyosis: Adenomyosis is endometrial stroma and glands in the myometrium and can be identified by histopathology, and now MRI and transvaginal ultrasound. L is for leiomyomas: Leiomyomas also known as uterine fibroids are benign smooth muscle tumors that are diagnosed by pelvic examination and pelvic imaging such as ultrasound with contrast or MRI. M is for malignancy and hyperplasia: Malignancy and hyperplasia are often abnormal epithelial tissue that is benign or cancerous that can be seen with transcervical endometrial sampling. C is for coagulopathy: Coagulopathy is bleeding disorders such as Von Willebrand disease is identified by laboratory testing. O is ovulatory dysfunctions: Ovulatory dysfunction occurs when there is a variation of more than seven days of the menstrual cycle in the past 12 months and ovulation is dysfunctional. In a woman without ovulation, there is no corpus luteum, and there is no progesterone, so estrogen goes unopposed, causing a buildup of endometrium and irregular bleeding.   E is endometrial causes: Endometrial causes can occur when there is normal ovulation, no other identifiable cause of AUB, and there is heavy menstrual bleeding, which includes intermenstrual bleeding. Primary disorders of endometrial hemostasis are likely due to vasoconstriction disorders, inflammation, or infection. Endometrial dysfunction is poorly understood; there are no reliable diagnostic methods, and it should be considered only after other causes are excluded. I is for iatrogenic cause: Iatrogenic causes include gonadal steroids (estrogen, androgens), anticoagulants, intrauterine devices, antipsychotics, antidepressants, and anti-hypertensives. N is for not otherwise classified: Example of an etiology under not otherwise classified might be AV malformations. This classification does not include pregnancy. Postmenopausal bleeding: Abnormal uterine bleeding can also occur in post-menopausal women and is an indication of potentially lethal endometrial cancer. Post-menopausal women should be worked up for cancer when they present with bleeding. However, most common cause of bleeding in this population is atrophy of the vaginal mucosa or endometrium. If younger than 45 patients but history of unopposed estrogen exposure (PCOS, obesity, estrogen therapy) should also undergo endometrial biopsy to rule out possibility of endometrial cancer.  Management of AUB. Management of the AUB can be initiated only after the etiology of the bleeding has been established. Firs of all, rule out pregnancy related bleeding by performing a pregnancy test. Also, rule out other sources of bleeding. The first question to answer would be: Does this patient need an emergent treatment for her AUB or can she be treated as outpatient? Determine that by checking the history, vitals, orthostatic vitals, physical exam, and labs.  If patient requires admission, the options for treatment include: uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. In case of severe bleeding without hemodynamic instability, patients can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid.For chronic AUB, once etiology has been established, the goal is to treat the underlying condition. The goal of treatment is to control the bleeding since AUB can persists until menopause.  Initial outpatient treatment is usually pharmacological. For those not wanting to conceive soon, consider IUD placement. “Among medical therapies, the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is most effective for decreasing heavy menstrual bleeding (71% to 95% reduction in blood loss) and performs similarly to hysterectomy when quality-adjusted life years are considered.”[8] Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, NSAIDs (nonsteroidal anti-inflammatory drugs), and depot medroxyprogesterone. Surgical treatment is often considered for patients on long term medical therapy with no response, or for severe cases of bleeding with recurrent need for emergent treatment. Some surgical options are endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Some structural lesions can be resected via hysteroscopy (polyps). Myomectomy and uterine artery embolization are options for patients with severe AUB who want to preserve fertility. Uterine leiomyomas or adenomyosis can be medically managed with OCPs but can also be treated with surgery as well, depending on the physician-patient discussion of options. Hysterectomy is the definitive treatment of severe AUB. Remember, PALM COEIN stands for: Polyps, Adenomyosis, Leiomyomas, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic cause, Not otherwise classified. ____________________________Conclusion. Written by Hector Arreaza, MDNow we conclude our episode number 53 “Abnormal Uterine Bleeding”. Eresha and Sherika did a great job explaining the Palm-Coein classification, and gave us a good overview of the management of AUB. Remember to start screening for colorectal cancer at age 45 now, what strategy for screening will you use? And for those patients who were hesitant about getting the COVID-19 vaccine with other vaccines, well, the ACIP said we can co-administer it with other vaccines. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. 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. This week we thank Hector Arreaza, Daniela Viamontes, Ikenna Nwosu, Lillian Petersen, Sherika Adams, and P. Eresha Perera. Audio edition: Suraj Amrutia. See you next week! _____________________References:U.S. National Library of Medicine, Clinical Trials.Gov, https://clinicaltrials.gov/ct2/show/study/NCT02026869. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States, Centers for Disease Control and Prevention, https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html#Coadministration, accessed on May 20, 2021.  Colorectal Cancer: Screening, Final Recommendation Statement, U.S. Preventive Services Task Force, May 18, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening. Abnormal Uterine Bleeding FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/abnormal-uterine-bleeding, accessed on May 17, 2021.  Fraser, Ian, et al. Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN etiology classification, Up to Date, last updated: Dec 16, 2019. https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-reproductive-age-women-terminology-and-palm-coein-etiology-classification?search=palm%20coein&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Goodman Annekathryn, et al, Postmenopausal uterine bleeding, Up to Date, last updated: Feb 02, 2021. https://www.uptodate.com/contents/postmenopausal-uterine-bleeding?search=abnormal%20uterine%20bleeding%20postmenopausal&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Kaunitz, Andre M, Abnormal uterine bleeding: Management in premenopausal patients, Up to Date, last updated: Aug 25, 2020. https://www.uptodate.com/contents/abnormal-uterine-bleeding-management-in-premenopausal-patients?search=abnormal%20uterine%20bleeding%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 1;99(7):435-443. PMID: 30932448. https://pubmed.ncbi.nlm.nih.gov/30932448/ 

Tom Paladino is a scalar energy researcher based in Florida. Scalar energy is the fundamental life force found everywhere in the world, space, and universe. It originates from the sun and stars. Chi, prana, OM, mana, life force, pyramid energy or zero-point energy are synonymous terms for scalar energy. He theorized that all energy in the universe initiates as scalar energy; and that the sun of our solar system and the stars of the universe are the points of origin, “the storehouses,” for scalar energy. He further theorized that scalar energy is instructive energy, as the entire universe is instructed by this Divine Essence. Subsequently, all spiritual, cognitive, emotional and physical action in the universe is initiated and maintained by scalar energy instructions. Scalar energy provides order in the universe. Where can you connect with Tom? Insta @scalarlight FB @light_scalar YouTube @TomPaladinoScalar Brandon Handley 0:00 Go 54321 Hey, there's spiritual dope I am on today with Tom Paladino. Tom is a scalar energy researcher based in Florida. scalar energy is the fundamental life force found everywhere in the world space and universe. It originates from the sun and stars ci prana. On manna, lifeforce, pyramid energy or zero point energy are synonymous terms for scalar energy. Thomas theorized that all energy in the universe and this G's a scalar energy and that the sun of our solar system and the stars in the universe are the points of origin, the store houses for scalar energy. He further theorizes that scalar energy is instructive energy as the entire universe is destructed by this divine essence. Subsequently, all spiritual, cognitive, emotional and physical action of the universe is initiated and maintained by scalar energy instructions. scalar energy provides order in the universe, man, it's awesome. I've never heard about it until we connect it. So thanks for Tom for introducing scalar energy in this form to me. Tom Paladino 1:12 Thank you, Brandon, thanks for the opportunity to speak on your podcast Brandon Handley 1:16 100%. So I always like to open these up with the idea that, you know, we as human beings are vessels for this divine energy, right. And that's kind of what what's coming through us is meant for these explicit moments, you and I know we're gonna get something from this and the person who's listening to this podcast, there's a specific message that they're going to get that could only come through Tom palatino, what is that message today? Tom Paladino 1:45 Everybody possesses scalar energy, I have instruments but but even more importantly, your mind and your heart are scalar energy vessels. And as we get into this discussion, you'll see how important it is to think highly of yourself and highly of others, and to have a good heart. Because your mind and your heart trajet transmit scalar energy. It's so important. Brandon Handley 2:13 It's so great. I love the fact that I mean, you're scientifically based, right? You know, you've got the instruments, and you've got the tools. And you've got these use cases and factual applications, versus me who just certainly sits in here in my room and just tells everybody that they can, you know, do what they want and feel how they feel. And it's going to impact them, right. So you've got you've got tests, you've got things that you actually showing up for the one that's what I think is great, right? This is just it's kind of the pinnacle of, you know, science meets, you know, divine nature slash energy. And oh, yeah, by the way, it works. Unknown Speaker 2:55 Yes, Brandon Handley 2:55 I like so how did you? How did you find yourself in this space? Tom Paladino 3:00 I was always intrigued by what what some I called metaphysics, that, you know, the blending the merging of science and religion, science and religion, as far as I'm concerned is, is an equivalence, it's the same, it's just a different way of looking at reality. So, as a youngster, I started to study Nikola Tesla, the great scientist, and he was a mystic, but he also was a scientist. And he really could blend those two worlds. And that's why he's so prolific. That's why he his work was so monumental, because he didn't discount any approach. He accepted reality as it is, he had no preconceived notions, to discount something, he was an open vessel, if you will. And I want to be an open vessel, I want God just to help me and to show me the way. And as long as you don't put any impediment, he will do so. And you'll see how you can become a prolific inventor or, or theorists, if you will. Brandon Handley 4:03 So you brought up the idea of impediment. And I think that I've heard you say this a little bit. I'm listening to one of the other podcasts. What would some impediments be? Tom Paladino 4:15 Every everybody has an impediment. And the role has created those impediments. And sometimes sadly, we've bought into it. And you can't limit yourself. Don't let the road limit you don't limit yourself. People have unlimited potential. But you know, some people say they we live in a box and in many ways we do. don't define your life by by the way others want to place you in that box, you really have to live outside of that box. And you have to follow the truth. I've always prided myself and in following the truth, if you will. And I realized I'm iconic classic. I realize I'm cutting edge. But that's what it has to be. You can't necessarily Run with the pack all the time. The pack is not necessarily correct. Brandon Handley 5:05 Yeah, no, it's funny, right? Like, I've never been a big fan of the pack. I'm not sure whether or not that served me or not to date. But it sounds like you know, again, it's, it serves you and allowing you to, to follow a path less traveled and finding some pretty, pretty exciting spaces and places. So you tap into Nikola, and you realize that he's open, nothing is left out. And then, you know, what are what are some of the next steps, right, like walking through, like even bringing this up to your family and saying, Hey, you know what? I found this thing called scalar energy. And I'm all in what's your family saying to us? I mean, where are you? What's happened at that time in place? Tom Paladino 5:50 Well, God bless my parents are no longer with us. But they always looked at it with a critical eye, if you will. They were really, really not too keen on this, because they just didn't understand it. And I have a very supporting wife she's fully in. And thank God for that. But if you will, what am I describing? I'm describing a new technology. It's technology where we can harness the sun's energy or the stars energy. And many people think that that that is just a little bit too esoteric, then how could you possibly do that? Well, Nikola Tesla did that and was very successful. And in many ways, I'm walking in his footsteps. So it is a new and emerging science. It's the new way of looking at reality. And I consider myself a trendsetter. There's not many people on the planet that are doing what I'm doing. So for now, I stand alone. But I know that this will pay big dividends in the future, and then eventually, the world will see the merit of this research. So I'm at the vanguard, I'm happy to be at the Vanguard. I can't say that there's many people are following in my footsteps or the footsteps of Nikola Tesla, because it's, it's so laborious. And it's so difficult, and it's hard to get people to even convince people that this type of energy exists. Brandon Handley 7:14 So how have you been able to confirm that you're continuing Tesla's work? Right? Right? Tom Paladino 7:22 Well, it came to my observation that test the leader in his wife was not working with electricity, he himself said he was working with non hurting energy, meaning it's not electricity, it has no frequency. And that's what I'm working with this energy. scalar energy does not have a frequency, it's nine hertz. And so in that sense, I'm following in the footsteps of Tesla, Tesla had scalar energy instruments, I have scalar energy instruments. What's my point? Well, if you can go back to whoever the series of events that brought upon the computer that was quite unique, you know, there are many people who could lend their hand to that. But nonetheless, it was, at one time, it was a new science, that new and emerging science, and that's where we're at right now with scalar energy. There's very few researchers, it's the new and emerging science. I know I'm on the right track, I know that I have bonafide scalar energy instruments, and what I really want to inculcate is this, it's not electricity. I'm working in a different dimension. This is what it's hard for people to understand. It's not electricity. Brandon Handley 8:36 Tom, so non hurts in? And I'm just trying to let you know, right? I'm thinking of radio waves and frequency, if it's not hertz, and does that mean that there's like, there is no upper down amplitude or anything like that. And that is just it's available kind of at all times. Tom Paladino 8:56 It's the matrix it permeates the universe. Unknown Speaker 9:02 The universe. Brandon Handley 9:05 So we're already kind of immersed in it, we look at it like more like almost like holographic technology. Tom Paladino 9:11 Exactly. Okay, universals holographic. So in a hologram, there really is not point A and point B. Everything is one point. Brandon Handley 9:21 Right? Tom Paladino 9:22 There's terms that you use, such as quantum entanglement, meaning what that everything is connected pre connected. So if you will, let me use this analogy. If you're looking at the East Coast of the United States and the West Coast, those are two different regions. New York City is not LA. In the electromagnetic spectrum. Those are two cities in the scalar energy spectrum, New York and Los Angeles are connected. They are pre connected, meaning what it's a holographic representation of the United States. It's no longer that can be plotted out on the grid system. No, everything is one point. It's quite profound. Brandon Handley 10:04 I love that. Right? So there's no time and space in that. And then my interpretation, my understanding is that in a hologram, all information is contained in any single point of information. Yes. Okay. Really? Okay. So, so, so scalar energy is is, is all about there is no. Is it is it? Is it right to say that there is no specific, like variants in it, right? Like it's one size, energy that fits all type of thing. Tom Paladino 10:46 Yes, that's it. That's a nice way of describing it. It really is the mind of God, what some people call consciousness, you've heard that time consciousness, what does that refer to? It refers to information field, a universal holographic information field, that's what I'm working with. Now, you could you could see why if I had my druthers, the entire road would be on scalar. Because it's an infinite source of energy, it's kind of obvious. Brandon Handley 11:15 Here's what I liked about too, I heard your account, like I said, I listen to a couple of your podcasts. And one of the things that I really enjoy is like, you know, I'm working to, you know, maybe branch out and you know, connect with a few 1000 people, right? And and what is your vision for your practice, if you could share that with the audience, Tom Paladino 11:34 I want the world to convert to scalar energy, it's a much superior technology than that of electricity. And once we have this new technology in place, it will really forward the human race, this is really going to help to advance mankind. So if you look, look at our trajectory, look, look how mankind has has progressed over the centuries. And technology is one of the tools that really have made our lives enjoyable, affordable, comfortable. I'm saying that scalar energy is the next quantum leap, you know, the pun intended scalar energy is going to be the game changer for us. So your your, your your goal, your mission is to impact slightly more than 1000 or a couple 1000. Brandon Handley 12:22 Your goal is to impact the entire planet. Yes, Tom Paladino 12:27 that's my gut, Brandon Handley 12:27 which I love. I love that right? Um, yeah. And and the fun thing is, is there's no reason why that's not possible. Right? Right. If we look at the grand scheme of things, you're leveraging universal cosmic energy, which is the entire, you know, currently known universe to worldly, right, which is like this speck of dust. So why not? Why? Tom Paladino 12:59 Why not? Why not reach for the stars? Why think small Think Big? Right? Brandon Handley 13:05 Right. Right. So the tools that you've developed? How are they able to, you know, how many people can your current tools impact at one time? Well, Tom Paladino 13:20 I want to make this clear. When I work with people, I work with them by way of a photograph. Now, what do I mean people email me their photographs, and they I connected them in the quantum realm, there is no physical connection. It's all informational. So to answer your question, my instrument can easily work with 2030 40 million people a day by way of a photograph. Now you see why I'm thinking big scanner energy instrument can send energy by way of a photograph to 20 30 million people in one day. Brandon Handley 13:54 Yeah. So what Yeah, and I've heard some other stories, too, just the eradication of HIV, herpes, other viruses? You will Let's share a couple of those stories, I think, yeah, the story of how many people that did they went through an HIV study in Africa, Tom Paladino 14:14 right, right. Well, let me lay the groundwork. With this instrument, I can control molecular forms atomic forms. So people will send me photographs and I can I can buy wave their photograph, I can identify a virus that they have, by way of the quantum field again, everything I do is by way of a photograph. So I have been receiving photographs from an HIV AIDS clinic in Delhi, India, and many of those people are HIV positive. And by working through their photograph, I can detect the HIV virus from their photograph and I can negate it, break it down, transmute it, call you call it whatever term you want upon the photograph. So my work is directly and exclusively to a photograph. Well, lo and behold, these people are going out and getting a test. Some of them are polymerase chain reaction tests. And after I work with these people, they find that they have no HIV. It's been eradicated. It's been fragmented. So you can't, you can't explain the apple by the orange, so to speak. And if my scalar energy instrument is working in one paradigm, scalar energy, it's hard to relate that and to substantiate that and then the electromagnetic spectrum. But the evidence is becoming overwhelming. If I can eradicate breakdown a virus by way of a photograph, that usually translates into better health for a person in the electromagnetic spectrum, Brandon Handley 15:53 looking at reality, so you but but let's go back to you know, it was it was 50 people in the study, right? And how many of the 50 were you able to eradicate the HIV virus and Tom Paladino 16:05 Oh, so far, everybody that had a test, everybody gone to get a test, all of those tests are negative, HIV negative. So again, let me put this in the context. I live in the United States, I've never been to India, but people from India send me their photographs, people are HIV positive. And after working with their photographs for a few months, many of those people will subsequently get a test the polymerase chain reaction tests and those tests come back negative. Brandon Handley 16:36 and want to go back to kind of the beginning of the conversation, we said everybody can kind of do this. Right? How is does your tool like train the person to do it? I'm just kind of curious, like, how do you see that? Right? Unknown Speaker 16:53 here's, Brandon Handley 16:54 here's an, I'll bring it up for this reason. I'm like my sitting around, you know, Yogananda. Autobiography of a Yogi right. And one of the scenes, a couple of things, one of one of his masters in their chairs a person by giving like them a drop of oil, right, but the drop of oil is more of a prop. Right. So I guess the greater question would be, is it your machines? Or is it you, Tom? Who through your machines are curing people? Right? Yeah, Tom Paladino 17:26 I would say it's, it's, it's God's energy. This is what I've discovered about scalar energy. I don't claim any healing ability myself, I believe what I've tapped into scalar energies, the divine energy, what? consciousness or or the gift of the Holy Spirit. I know people have holy healing hands, holy hammer, if you will, right. That's pure energy hands. So what I'm working with in and of itself is a healing property. scalar energy is a healing property. And when I send that scalar energy to a photograph, although it's symbolic, it nonetheless seems to have a healing property. Brandon Handley 18:07 Right, right. Right. I mean, look, if it's working, I'm more of the I don't care how it works kind of guy. I mean, if you come up to me, and you cure me, like, I remember, who was it, it was the Wayne Dyer, you know, talking about crystals, right? And he's like, Listen, if I've got a if I've got hemorrhoids, right, and you told me that I sit on this crystal chair over here, and it's gonna cure my hemorrhoids, and I go sit on that crystal chair. Why wouldn't I? Right, right. Just like so just like this, if you've got if you've got a virus. And and let me go back to how quickly how much time does somebody need to be in treatment for that cure to occur? Tom Paladino 18:52 what I've seen, it only takes one day, one session, one treatment of a photograph, because everything in this scalar realm is instantaneous. There is no time lag. Right? So all action is instantaneous. Brandon Handley 19:07 And I know we haven't gotten to this part yet, but I mean, how much would it cost me today? If I wanted to sign up and get one day treatment? Tom Paladino 19:19 Sure. We we break this down by 30 day sessions, our least expensive is $89. It's a ongoing session. And it's it we break it down into 30 day calendar days, if you will, right. And a lot of people opt for that because it's inexpensive. If they feel comfortable, it does enhance their spiritual, mental and physical well being I have to you know, accentuated This is also a spiritual emotional and mental uplift if you will. We see great results spiritually and cognitively. Brandon Handley 19:58 Right. Let me when you when you talk about about dealing with divine energy. You got it? I mean, innately right there. It's spiritual, right? Like, I mean, there's Is there a Is there something required from DICOM patients clients? What do you call, Tom Paladino 20:16 I call them subscribers. Appreciate that, because they're not patients. This is not Western medicine. I'm trying. I've tried so hard to distance myself from Western medicine, not that I don't believe in western medicine. But by virtue of the fact, I have nothing to do with Western medicine or Newtonian physics, Brandon Handley 20:36 but it's a whole different paradigm. Tom Paladino 20:37 Exactly. It's a whole different paradigm. So I don't want to compare myself, or latch on to some certain buzzwords where it's confusing. Brandon Handley 20:46 Right, right. You also mentioned to the the idea of comparing the apples to apples and apples oranges. If I had to, though, what would the electromagnetic comparison beads to be able to weigh this thing out? Right? I mean, because look, if if I just made you off the streets, Tom, and I'm not like I'm and I'm not Captain spiritual, which I, which I already am, right? And I'm already a believer, like, it doesn't take much for me, but like for the non believer, like, what can how can how can we compare this? How can we help them to see that? The what's the benefit in it for them? Tom Paladino 21:23 It's tough. Let me let me frame it this way. All energy begins initiated from the stars that scatter energy, it's a double helix. And then when that energy breaks down, are converts into electricity and magnetism, that's an inferior, that's a substandard energy. So if it's like Grade A or a Grade B, what do you want in life, I prefer grade eight energy, which is scalar energy, which is the primal energy of the universe, whereas electricity and magnetism is a derivative, a derivative of scalar energy, and it's inferior. Why work with gray? b? Why work with the inferior energy? I don't want to hate grade v. Brandon Handley 22:07 So yeah, man, like, I mean, talk to me a little bit more about the journey, though, into it, right, like, so you got your parents that are kind of just believers are not necessarily just believers, but they're like, there goes Tom, right, with a scaler. You know, turning this into a career you've got, you've got an actual practice, as it were, you've got an office, you've got, you know, you run a business, right? So I gotta imagine there's some business loans here, there. There's, you know, some some people that you're trying to hire. And you know, there's some conversations and what Tom Paladino 22:41 is some of that like, because I'm curious if it's the necessary component, if you're going to bring this out to the, to the public, I've been at this now for 40 years, I've only had a public website for 10 years. So the previous 30 years, I was acquired researcher, and I enjoyed that. But there's only so much you can do. So I said to myself, in order for me, really, to get this out to the general public, I have to demonstrate something that's going to help people I have to prove it. And that's why I brought the website on. Otherwise, I would continue being a quiet, not unrecognized researcher. Well, to answer your question, after 10 years, it has been quite laborious, a website, hiring people advertising, although I enjoy it, nonetheless, a podcast every other day. All of this is an effort, and it's time consuming. And this is what has to be done. Now, and again, I'm one of the few scalar energy researchers out there. So this is quite a novel topic to most people. So again, I'm leading the I'm at the vanguard of this movement, but just a few people. Brandon Handley 23:53 So what's what's that space look like? Right now? How many people are invested in this? across the world? Tom Paladino 24:04 I see a growing awareness to answer your question. It's a growing awareness. How intrinsically involved are people that's that's hard to say. But at least I see a growing awareness and what the next five to 10 years should experience should be really hyper growth or or people should at least become aware of this to the point that it should be a household word in the next 10 to 20 years. So we still have a lot of growth to go, but the tough part is over. I can I can see that. You know, we are riding the wave, there is a wave now finally. Brandon Handley 24:40 Well, you know, I guess the other question, too, would be you know, you brought up Tesla who was a Marconi, who's your Marconi. Tom Paladino 24:50 I admire tests. I admire all scientists, but nobody can hold a candle to test them. I studied what I mean Brandon Handley 24:57 by that, right. So you remember like Marconi was the guy that It took a took the radio wave patent or the wireless technology patent, basically. And Tesla had already kind of figured it out. Like, there's got to be somebody else out, there's kind of maybe they're not stealing your stuff. But like, who would you say your peer is out there? Do you have a peer, Tom Paladino 25:15 I don't think I have a peer at least I haven't seen it quite yet. I don't mean to be condescending, but it's so hard to invent these instruments, control them, and then to be able to administer this energy. You know, I always give people that analogy. Now, a couple 100 years ago, we knew that there was electricity, we would get a static discharge, but from a static discharge to controlling and harnessing electricity and a conduit in a in a home environment, and to be able to control it without hurting yourself that that could took some doing so that that, if you will that timeline was a rather protracted timeline? Brandon Handley 25:58 No, you're right. I like it. I like in this type of energy to once you kind of tap into this divine source, right, very similar to what you say you can use it improperly. And you can do a lot of damage to yourself, how have you been able to harness it and focus it for for good? Yeah. What was that process like for you? Tom Paladino 26:24 Like anything, this is a tool and the tool can be used for good or evil. And I'll start off by saying that. So what do I do with these instruments, I have a a pro forma, I have a technique and I never deviate from it. And the technique that I've developed is, is help the getting it it is it does enhance our help our quantum help. And that's the key to follow those parameters and stay within those parameters. Tessa sometimes would prefer to scatter energies, the ability to eliminate the world he considered it radiant energy, and he was going to provide free energy for mankind. So his instruments were much stronger than mine. And, and some people think that the military tried to persuade him to develop this for for the sake of weaponry. I don't know how far that went or, or if Tesla ever shared any information. But that's the potential here. This energy is so strong, and it's a fundamental primal force in nature. This could be one heck of a weapon. Brandon Handley 27:35 Right, right. Yeah, if if I think some of the stories or documentaries that could be believed, like as soon as he died, right, like that his hotel room gets raided, and all the information is taken out. Right, right. The date, I gotta imagine that I got to imagine too. I'm not a super conspiracy theorist. Guy, but you know, it was him and Gosh, who's the other guy? Westinghouse. Edison, right, like the rivalry that was going on? And, and, you know, big business, if you're giving out free energy to everybody. I mean, what's that gonna do to all these other people that, you know, are kind of counting on right. And this is a monopoly era to where it's like, right that that was going on? Tom Paladino 28:20 Yes, yes. And as the story goes, JP Morgan was a one time financier for Tesla. And according to the story, once, once Morgan understood that Tesla had a free energy device, that ended their relationship. He never got a penny again from Morgan. Brandon Handley 28:40 Yeah, what a shame, what a shame. Um, you know, so much so much to dive down into about him. So I think some other questions I would have to a big part of this podcast is really, you know, kind of facing some of what you've had to face yourself already is kind of coming out with like, some of these non traditional beliefs and stepping into them, right, you open this up with one of those types of things where, like, you know, you surround yourself with positive energy and kind of move yourself forward through that. And you know, a lot of a lot of good things can happen for you. You did mention your children, how old are your children? Tom Paladino 29:17 I have two stuck kids 30 and 31. Brandon Handley 29:21 How do they How do they How are they with this for you? Tom Paladino 29:26 They're fine, they understand it? Because they see that I'm grounded on a fairly grounded person. I'm not up to the clouds, and they see the merit and they realize that this is a scientific process. Now they've seen the laboratory. So this this is not, if you will, anything but a scientific approach. No, Brandon Handley 29:48 I mean, great. And I love that. So have they, at any point, like tried to join you with the studies or anything like that? Tom Paladino 29:56 No, and I'll tell you why. For one glaring reason I don't mean to be condescending to anybody. There's no money in this. There is no career. Brandon Handley 30:07 We not an interest or cure a cure for the whole world. And there's no money. Tom Paladino 30:12 No, no. As as of right now, no, I, I live hand to mouth rankly. And it's amazing how this is suppressed technology. Let's let's just cut to it. And if what I'm saying is true and accurate. Well, you would think that responsible parties from the government, academia, to corporations to think tanks would approach from not one, Unknown Speaker 30:39 not one. Have you tried to approach any of them? Tom Paladino 30:43 Yes, yes. And there's no interest. Unknown Speaker 30:47 There's no way Tom Paladino 30:48 to cut to the chase so many. And I'm not pointing out any specific government corporation or individual, but so many people are in lockstep with the status quo? Yeah, I Brandon Handley 31:01 mean, there's the status quo, right, don't deviate from the norm. You know, that's kind of the old, old school, tribal, you know, scarcity, get thrown out of the getting thrown out of the tribe mindset. Right? If you if you deviate from from the norm. Do you have like, what the typical reason? I mean, I gather not interested but like, what do they say? They just say that that can't be real. There's no way Why would we do that? Like, what is the response? Tom Paladino 31:31 Most people look at my results, I'm results driven, I believe in performance. And after they look at my results in performance, they usually, they usually keep their mouth shut, because they know that that there is performance, and they know that this is just not hyperbole, but they don't want to help. You know, in general, people and entities do not want to help me, because it's against the status quo. And this is a threat to the establishment. I can't stress this enough, scanner energy is going to make obsolete many of the existing monopolies. And what I'm doing is such a threat to those who have this monopolistic control over society. Brandon Handley 32:16 Have you had anybody tried to, you know, kind of any such suppression, like, you know, just kind of like people trying to steal your equipment or break into labs kind of software? Like now I'm now I'm all in like, I'm just kind of like, you know, what can be happening? Because, like, you're saying, like, this is a technology that, you know, it's taking you years to build? I imagine that if somebody breaks in and, you know, messes with instruments that that's kind of set you back? Yeah, yeah. Tom Paladino 32:43 But I have to rely upon God's help. And you know, I can't stress this enough. I'm, I'm alone, there is no second scatter energy researcher, there is no research term. You're looking at the research term, team. Brandon Handley 32:57 Yes. I mean, God. So what do you mean? How are you going to propagate it? Right? How are you going to make sure that it enters Tom Paladino 33:06 your right? I'm 61 years old, and I don't have a there is no protege. Nobody shows any interest in this. So the world has to embrace this within the next 20 years? Because I don't, I don't I don't know if I'll be around much longer. So with that in mind, this is the challenge. And I just take this day by day, it's all in God's hand. Brandon Handley 33:34 So what if I don't know what somebody is listening to us today? And they're like, Hey, I'm totally interested in becoming a protege. I'm totally interested in becoming an understudy. Are you open to stuff like that? Tom Paladino 33:45 I am with this caveat. You have to be financially secure, there's no money in this. I'm gonna repeat that there's no money. Remember to you have to be willing to study, perform independent study for 1020 years before before you really understand this? How many people are financially stable, or perhaps well to do and want to spend the next 20 years laboring with a science that's not recognized that might not pay any dividends? After 20 years of research? Very few people want to make that commitment. Brandon Handley 34:26 is tragic. Right? Given given, given what you're saying and you've proven it can do that there's nobody else kind of willing to pick up and carry that torch with you. finance it or anything like that. That's, I mean, to me, that's, to me, that's mind boggling. Because we go back and you talked about the people getting cured from HIV, there's no news flashes. There's no you know, anything like that. There's nobody publicity like who's I mean, have you reached out to newspapers and anything like that what's happening there? What are the No, Tom Paladino 35:04 they don't believe it. It goes against their grain. And he you have to consider many of these media outlets. They're funded by Big Pharma. They're funded by big oil. They're they're in bed with with big government now. Brandon Handley 35:21 So what keeps you doing man? Well, what Tom Paladino 35:24 do I tell people just just help get the word out? It's all grassroots. And you know, we've got some of the greatest technology in the world. It should be headline is it's not, it won't be. It'll all be grassroots. And that's why I appreciate your platform. Brandon, I appreciate what you're doing. That's what it's gonna take grassroots. Brandon Handley 35:44 Yeah. I mean, it's just a different way of thinking. said it's possible. Right? And why not? I mean, the real question is, why not? Yes. Right. And if you're, if you're, if you've got studies and proofs and theorems, I mean, why not? That's, that's what's killing me. So, yeah, definitely a lot of fun. I'm sure we could probably, you know, go all over the all over his face with it. Um, let me help me. Um, so, one thing I was thinking about, right, as we're doing these, I almost think about these kinds of podcasts is as like, speed, dating, speed dating space, right? Like, you know, there. That's probably what it is, right, Tom? I mean, you know, somebody tunes in maybe they catch one or two words, eating somebody, whoever's picking up the podcast. Today, they're dating Tom palatino. Right. You know, so if we're, if we're going to speed date or something like that, what is, you know, find my questions, because I've got some and just top of mine, like, what's religion getting wrong today? Tom Paladino 36:51 I think this the centerpiece of any, any religious movement should be love. And I'm sure there's problems in the bro. But if you keep it positive, you're gonna get over many of those problems. Let's face it, most of the problems in the world or man created, we've created these problems. So I see the problems in the real, what do I try and do I try and pray every day, I try and pray for world peace, I treat people fairly. And I try always have a productive day. As a researcher, I do my part. And I always reach out and and I'm working with people that the indigent around the world, I'm providing free sessions, because you know, the people in India that we spoke about, they don't have a dime to their name. So you have to give back to society. And there has to be a new way of living. And money should not be the common denominator. It's a shame that it's the common denominator. Brandon Handley 37:49 No, I agree. I agree. One of the thoughts. And it's interesting, we have interesting conversations here at the house. Because my wife and I, we have new kinds of different upbringing backgrounds, right. And as I've grown older and older, the more I realized that we don't work, shouldn't be working, to earn money to be working to either kind of, you know, towards a meaning or purpose or adding value, right? And if I am at a job earning money, and it's a job that I don't love, then basically I should be looking at that as a paid internship, what can I learn at that job that I could use later in life? Right? to to do well, let's do one or two more questions of just kind of, you know, General, General stuff, you know, so what I was asking about in terms of, you know, bringing this to the forefront and talking about, you're sharing this information with your family. First, there's got to be some fear in there, right, that you were able to overcome and sharing that with them. Right. So Tom Paladino 38:56 here, I have brand new, I have no fear because I've been around the block one many times I could care less what people think. Brandon Handley 39:06 What what what does everybody else so afraid, often? Tom Paladino 39:11 You know, sadly, this is a world that that depends on a conventional approach, conformity, and a lot of people don't realize they're conforming to something that's wrong. The paradigm is broke. Look at the world. There's a lot of brokenness. There's a lot of tragedy in the ropes, stop doing the wrong things. If it's not working, we need a new approach. If the model is broke, is broke. Try a new approach. Stop conforming. What is wrong? If it's wrong, stop it. Unknown Speaker 39:45 Tom, if I'm conforming, how do I know what's wrong? Tom Paladino 39:48 Well, you judge that by the results, obviously, you judge that by the results, you know, I have a very wonderful charmed life. I have a very productive life. I always Look to improve it, but I know that I'm on the right path. Because it works. I'm not in misery. I'm very happy. If I was miserable, that I would change something for the better, right? Brandon Handley 40:12 Yeah. One of the things is not everybody's gonna see the video, I'm definitely gonna share the video out on certain platforms. But if you're not able to watch the video with Tom and I today, Tom, how do you again, Tom Paladino 40:25 I'm 61 years of age, Brandon Handley 40:27 man, you guys, I really want to look as good as Tom at 61 I'm just I'm just saying you know, Tom Tom, you got you got fresh skin, you've got like, You're, you're not sagging, you're not falling apart, you look like you're enjoying life. And I could only aim can only aim to, to get to that point, I'm going to tell you, for you, Tom Paladino 40:47 I'm going to tell you a secret there. With scalar energy, I can assemble nutrients. So 22 hours a day, I have a process where I can create assemble nutrients, vitamins, minerals, antioxidants, my body is slowed down my aging process significantly. That's why I look this this way at age 61. I don't have sagging skin. Brandon Handley 41:12 The the and that goes back to what scalar energy is is destructive energy. Is that correct? That's right. Correct. And, and so just by saying that, when you receive that energy that is instructive, creative force energy entering your body saying, we're gonna need, you know, we're gonna need like 99 sets of B, we're gonna need X, Y, Z of C and E and deliver these to Tom today. Is that is that, you know, a fair thing to say? Tom Paladino 41:42 I I'm not suffering from the free radical damage that other people are. Because I'm under the care of scalar. All day long. Brandon Handley 41:52 Nice. Nice. Love it. What is our greatest distraction? Tough? Tom Paladino 42:00 It's hard. that's a that's a singular approach for everybody. I think I think with many people that their greatest distraction is they don't concentrate on themselves. If you just cut that make them selfish. Well, no, I wouldn't say so. I'm not I'm not excluding mankind, but try and do your best. And don't try to extrapolate too much to the road. You can't control the road. Trying to make you try to make yourself and your family happy. I see the misery around the road. All I can do granted is pray for that. I take care of my wife, I take care of my, the people that I work with through scatter energy. That's my reach. That's all I can do. And that's my focus. Sure, I see the unrest in our country. Okay, I see that the the fighting I see the, the racism, all I can do is pray for that. Brandon Handley 42:59 You mentioned pray a few times. Tom, are you? Are you a Christian? Are you nondenominational or? I mean, Tom Paladino 43:08 I'm a Christian, by the way, I believe prayer is the analog to just give them in other words, my instrument is the scientific analog to prayer. Brandon Handley 43:20 Yeah. Look, I mean, it's like you said though, right. Like, you know, and I don't bring that up to to question. Any type of like, you know, is this tom tom stuff only works for Christians, right? Cuz clearly it doesn't, you know, you're, you're directing this at anybody who's open and receptive to it. And I think that, I think that it'd be great if they're, you know, I guess more Christians like Utah, right. More people in the world that are that are that practice their religion? Right. Right. embrace their religion and and appreciate everybody else for who and what they bring to the table as they as they are. Right? Um, anything that Oh, yeah, I mean, so yes, you do a 30 day but if I went to your website today, could I get a trial of scaler? Tom Paladino 44:09 Yes, yes, we we offer 15 days of free sessions to everybody you visit a website you can your entire family will be treated for free. No questions asked. We do that because of my humanitarian proclivity, I want to help people. website is scaler, light, calm visit. Upload your photographs. Remember, we work with you by way of your photograph, all you have to do is email us your photograph. Brandon Handley 44:36 And this includes pets. Unknown Speaker 44:37 Yes, very good. Brandon Handley 44:38 Yes. Yes. So this includes pets as well. And I think for this, I think it's remarkable that you're offering it for 15 days. It's kind of what I alluded to earlier in the conversation is if, if some of these things can be cured in one time in one session, who sounds like if it's me on the streets or anywhere you And I'm tuned in worst thing that could happen is that it takes me about five to five minutes to log into the website, enter the information, subject myself to cosmic energy and potentially be cured of viruses is that I mean, is that the worst case scenario here? Tom Paladino 45:21 That that's it sounds simple. This is it's deceptively simple. It's so simple people saying that can't be that easy. Yeah, Brandon Handley 45:29 no. Well, look, I mean, so I would have to say that anybody listening today that if you don't have it, the very least try this out for yourself today. You can be very remiss, right? I mean, because chances are in the same time today, somebody is going to go, you know, I know I've already bought something off Amazon today, right? Somebody is gonna go check prices somewhere else on something else. You could be cured of whatever ails you. There's a possibility than why wouldn't you do it? So, Tom, man, I really I really enjoyed this conversation. It's really been a pleasure to hop on here and connect with you. Thank you so much for being on the podcast today. Tom Paladino 46:10 Thank you for the opportunity. I enjoyed myself. Transcribed by https://otter.ai

On this edition of The Milk Check, T3 and Anna join our dairy market sage and patriarch, Ted Jr., on a trip down memory lane to talk about how the dairy industry has developed over more than 50 years. They discuss changes in trucking, processing and entrepreneurship, among many other topics. The trio also debates how the Federal Order System has impacted the industry, whether it still holds water in today's market and the perception that dairy producers are often the most impacted by market downturns. T3: I thought this podcast would be a great opportunity to just talk a little bit about history. Talk a little bit about what were markets like back in the '60s and how have they evolved into what we're dealing with today? And maybe what are some of the things that are still the same and what are some of the things that are different? And I just thought it would be a great perspective to talk about how milk and cheese and whey and cream, how it all moved back then, and how it all moves around and gets balanced today. We really haven't talked about things from a historical perspective, and I thought it would just be a great conversation. T2: Well, let's start in the '50s. Tank trucks came in in the mid-'50s. They were relatively small, they were about 30,000, 35,000. By the time you got to 1960 or so, you're up to a load somewhere between 45,000. In those days, the Class 1 utilization was paramount. Depending on where you were located, you had basically 60%-plus Class 1 utilization and milk move from upper Wisconsin, Eau Claire and Bloomer and Turtle Lake, during the short period of the year, we...back to almost everywhere, to Florida to Louisiana, New Orleans, Dallas, you name it, St. Louis was a big market. Indianapolis in the '60s had 20 to 30 loads a day moving out of basically the Fond du Lac area down to Indianapolis, which is why Foremost is prominent in Indiana these days is because a lot of that milk was Foremost Milk, they actually had an office in Indiana, which wasn't closed until a few years ago. The market was much different. Class 1 utilization was the big item and we had a much more cyclical milk production profile, if you will, where in the fall of the year when it got hot, and it seems to me, if my memory serves, it got much hotter in the '60s and '70s than it does today. And production really languished, particularly down in the Southeast. And so huge volumes of milk moved and most of that milk was moved directly out of plants. It wasn't moved directly from the farm, never moved directly from the farm until, oh, probably sometime in the '90s. Farms got big enough and the technology of dairy farming reached that point. That was the way the industry was structured in those days. And it's a much different structure today. T3: To be back in the '50s and 60s, you also had a lot of Grade B milk, we don't ever talk about Grade B milk anymore. How did that affect the industry? T2: Actually, we didn't have that much Grade B milk, and most of what we had stayed home. Yeah, we moved a little, it wasn't really that much. There were quality standards when you moved. Acid was the primary quality standard, acid and temperature. And you expected the milk to show up at a bacteria count of something less, basically, than 750,000 or half a million. Again, depending on where you were, and temperature less than 45 degrees. So that was the standard. And it wouldn't make any difference whether it was B or A in those days. Quality was not a matter of somebody saying that it was B or A, it was a matter of what showed up at the plant. And if it wasn't suitable when it showed up at the plant, it was rejected. It wasn't a question of arguing about it, it was rejected. That fell back upon the seller, in our case, usually as the seller's agent, us, to dispose of it accordingly, and we did. As time went on, the volatility in certain areas caused a lot of construction. In late '70s,

MASS means MORE! MASS, Michigan Agricultural Surplus System, is a grant-funded program with the State of Michigan through the Food Bank Council of Michigan. Using the grant funding, we purchase ‘cosmetically challenged’ produce that Michigan farmers are unable to sell to large retailers. This type of produce has many names; Grade B, seconds, #2’s, and the uglies. While there is nothing wrong with the produce, it just is not ‘perfect’. MASS keeps produce from going to waste in landfills and has a phenomenal Return on Investment [ROI], with average costs ranging from 12 - 14 cents per pound. Tune in for Food First Michigan on WJR Radio tonight at 9 PM with Dr. Phil Knight, Gerry Brisson, president and CEO of Gleaners Community Food Bank, and Stephanie Johnson, managing partner of Khoury Johnson Leavitt, to hear how the legislative budget process works, how the legislature views the MASS program, and how MASS will mean MORE this budget cycle – MORE for our farmers and the families we serve. Michigan was the first state in the nation to create a program like this, with 25 – 30 other states following in our footsteps over the years. There is over 70 billion [yes, billion] pounds of food in the United States that is either grown and unharvested or harvested but not sold. We in turn have a surplus of food and waste, yet millions remain food insecure. The MASS program is a small piece to solving the puzzle of food insecurity. It is a win for everybody; the farmers, the environment, food banks, and most importantly, the families we serve! FBCM is asking for an increase in the MASS line item to accommodate higher food insecurity rates and the loss of USDA food programs. An increase in the MASS line item will allow our food bank network to continue distributing #MoreFoodMoreOften2MorePeople in the months ahead. Help us succeed in this mission by keeping #FOODFIRST! We are asking for a CALL TO ACTION: please contact your state legislator to share your support for the impactful MASS program line item! When you support the MASS program, you support Michigan family farms. Find this episode and all past Food First Michigan episodes at foodfirstmi.org, on Apple Podcasts, or iHeartRadio. Apple Podcasts --> https://apple.co/38UUpFk iHeartRadio --> https://ihr.fm/38WJ2wN #FoodFirstMI #FoodSecurity

We are still a few weeks out from our return to your regularly scheduled Nerd News program. That being said, I AM still doing SOME things. Since I am a bit of a HUGE Mortal Kombat nerd it seemed fitting that a movie review for the reboot be the thing to use to bridge the gap.I liked it overall in spite of the glaring issues.Grade: BYou can support this show by visiting our merch store, or by leaving us an Apple Podcasts review.

We are still a few weeks out from our return to your regularly scheduled Nerd News program. That being said, I AM still doing SOME things. Since I am a bit of a HUGE Mortal Kombat nerd it seemed fitting that a movie review for the reboot be the thing to use to bridge the gap.I liked it overall in spite of the glaring issues.Grade: BYou can support this show by visiting our merch store, or by leaving us an Apple Podcasts review.

Episode 47: Hearing Carotid Lung.  Dr Civelli explains the updates on screening for lung cancer, hearing loss and carotid artery stenosis; Kafiya explains the use of bupropion and naltrexone in methamphetamine abuse, question of the month pneumonia.Introduction: Methamphetamine useBy Kafiya Arte, MS4, and Ariana Lundquist, MD.Today is April 12, 2021.Bakersfield, California, has a methamphetamine (meth) epidemic currently ravaging this area. We as health care workers believe we can spot somebody addicted to meth from a mile away by their characteristic “older-than-stated-age” appearance and obvious “meth mouth”. However, the actual scope of the epidemic is much larger. It’s not just people who are experiencing homelessness that are addicted to, and dying from, meth.  I saw while volunteering at a needle exchange at Weill Park, people getting out of nice-looking cars wearing clean, pressed clothes with sharps containers full of used needles ready to exchange. One man even had a teacup poodle in tow. It’s clear that meth can affect anybody.  Between May 10 and June 10, 2014, 31.8% of randomly selected patients in the ED of Kern Medical admitted to having used methamphetamine at least once in their life. It’s not just the individual who addicted to meth who is affected. 36.1% of children removed from their home by child protective services in Kern County during the month of May 2014 were cases that involved methamphetamine[1]. Meth accounted for nearly 75% of all drugs seized by the Bakersfield Police Department[2]. Statewide, meth kills more Californians than any single opioid alone[3]. Amphetamine overdose deaths have increased 212% from 777 in 2012 to 2,427 in 2018 in California. In 2020, Kern County had more than double the rate of deaths related to overdose of psychostimulants, of which meth was the dominant drug, compared to the state of California (20.48/100k residents versus 8.21/100k residents, respectively)[3]. This devastating problem, unfortunately, does not have a currently FDA-approved drug to treat it. A promising study called Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. Bupropion decreases the dysphoria of meth withdrawal that drives continued use; while naltrexone decreases cravings, therefore preventing relapse, as it does with alcohol use disorder.  A total of 403 participants with nearly daily meth use were included in the two-stage randomized, double blind trial conducted at 8 different sites from May 23, 2017 to July 25, 2019. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  The results of the study showed a 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. A response was defined as at least three meth negative urine samples out of four samples obtained at the end of each of the two stages.  The trial concluded that although the response rate among participants that received naltrexone and bupropion was low, it was higher than that among participants who received placebo. Although the ADAPT-2 trial did not provide any recommendations that can be adapted to clinical practice, it serves as a starting point for further research of the additive or synergistic effects of bupropion and naltrexone in the treatment of meth use disorder.  Hopefully, it will also serve as a catalyst for more pioneering research regarding the legitimization of meth use disorder as a treatable disease with major medical, psychiatric, socioeconomic and legal consequences. Clinicians should stay up to date with research regarding meth use disorder such as ADAPT-2, as it is our duty to understand the health crises that affect our patients on a daily basis, and the tools we can use to treat them.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ________________________________Question of the MonthWritten by Hector Arreaza, MD, read by Jennifer Thoene, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!     Hearing Carotid LungBy Valerie Civelli, MD, and Ariana Lundquist, MDScreening for hearing loss in older adultsHearing loss definition: To answer this, let’s first talk Hertz and Decibels. Many studies and guidelines define mild hearing loss as the inability to hear frequencies associated with speech processing under 25 dB and moderate hearing loss as the inability to hear those frequencies under 40 dB[5].  The most important range for speech processing is typically 500 to 4000 Hz. To check hearing, we often use pure-tone audiometry, which is the most standard quantitative measurement; however, this is not a perfect test. There is often discordance between objectively measured deficits and subjective perceptions of hearing problems. In one study, 1 in 5 persons who reported hearing loss had a normal hearing test result, while 6% of those with severe hearing loss detected on audiometry did not report feeling that they had hearing loss.[6]  I wonder if their significant other would agree with the 6% who self-reported no hearing loss but failed the hearing test?  That would be a great study! Risk factors for hearing loss: The #1 risk factor for hearing loss is increasing age. Hearing loss increases with age after 50 attributable to normal degeneration of hair cells in the ear.  This leads to the most common cause of hearing loss in older adults: Presbycusis.  Presbycusis is your diagnosis for patients with gradual, worsening of perceived high-frequency tones. Insufficient evidence for screening: If the patient reports hearing loss, you should order a hearing test. However, on March 23, 2021, for asymptomatic adults 50 years or older, the US Preventive Services Task Force (USPSTF) published a statement that re-confirmed the 2012 recommendations. That is, current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults without symptoms. This statement aligns with the AAFP and is referenced in their practice guidelines. This recommendation applies to asymptomatic older adults (age >50 years) who have not noticed any issues with their hearing. It excludes adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.Screening for Carotid Artery StenosisDo not screen: For the general adult population without symptoms of carotid artery stenosis, do not screen. This is a Grade D recommendation for all adults without a history of stroke or neurologic signs or symptoms of a transient ischemic attack. This is a re-endorsement statement made in Feb of this year, 2021, recommitting to 2014 statements.  The evidence continues to show that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. The USPSTF has made other recommendations related to stroke prevention and cardiovascular health. These include: Screening for high blood pressure in adultsScreening for abdominal aortic aneurysmInterventions for tobacco smoking cessation in adults, including pregnant personsInterventions to promote a healthy diet and physical activity for the prevention of cardiovascular disease:In adults with cardiovascular risk factorsIn adults without known cardiovascular risk factorsAspirin use to prevent cardiovascular disease and colorectal cancerStatin use for the primary prevention of cardiovascular disease in adultsLung Cancer Screening Grade B recommendation: On March 9, 2021, there are updated Grade B recommendations by the USPSTF.  For patients 50-80 years old, with a 20 pack-year history of smoking and still smoke or quit within 15 years, annual screening with low dose CT is now recommended.Stop screening when a person has not smoked for 15 year, or has a condition that substantially limits life expectancy or limits their ability to undergo curative lung surgeryThe USPSTF modified guidelines so we are screening earlier and with lower pack years.  It used to be recommended to do low dose Chest CT at age 55-80, but it’s now at 50-80.  Also, pack-years was 30 but it’s now at 20 pack-years that we should screen for lung cancer.  So, screen sooner at 50, and at lower threshold of 20. Screen for lung cancer in male and female patients.Conclusion: Now we conclude our episode number 47 “Hearing Carotid Lung”. Dr Civelli gave us an update on USPSTF screening in asymptomatic adults. For hearing loss, there is insufficient evidence to give a recommendation. For carotid artery stenosis, there is a grade D, meaning do not screen. And for lung cancer screening, it is a grade B recommendations, meaning screen your patients. Don’t forget to order a low dose CT of chest in patients of ANY sex, OLDER than 50 years, WITH a 20 pack/year smoking history, and currently smoking or quit less than 15 years ago. That’s a mouthful, but once you start following the guideline, it gets easier to recall.Remember, even without trying, every night you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek. 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. This week we thank Hector Arreaza, Jennifer Thoene, Valerie Civelli, Kafiya Arte, Arianna Lundquist, Jacqueline Uy, and voluntarily unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! _____________________References:The Impact of Methamphetamine in Kern County: 2014, Update September 2014, Kern County Mental Health Department, https://transforminglocalcommunities.com/wp-content/uploads/2018/05/tlc-the-impact-of-meth-in-kern-county-2014-update.pdf Klein, Kerry, To Bakersfield Cops, Concern For Opioids Grows - But Meth Is Still King. Valley Public Radio News, NPR for Central California. May 1, 2019, https://www.kvpr.org/post/bakersfield-cops-concern-opioids-grows-meth-still-king#stream/0 California Opioid Overdose Surveillance Dashboard, California Department of Public Heallh, https://skylab.cdph.ca.gov/ODdash/, accessed on March 27, 2021. Klein, Kerry, Meth Is Making A Comeback In California – And It’s Hitting The San Joaquin Valley Hard. Valley Public Radio News, NPR for Central California. June 28, 2019, https://www.kvpr.org/post/meth-making-comeback-california-and-it-s-hitting-san-joaquin-valley-hard#stream/0 Feltner C, Wallace IF, Kistler CE, et al. Screening for Hearing Loss in Older Adults: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Mar. (Evidence Synthesis, No. 200.) Chapter 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK569275/   US Preventive Services Task Force. Screening for Hearing Loss in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(12):1196–1201. doi:10.1001/jama.2021.2566. https://jamanetwork.com/journals/jama/fullarticle/2777723.    Screening for Hearing Loss in Older Adults, March 23, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening#fullrecommendationstart Screening for Asymptomatic Carotid Artery Stenosis, February 02, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening. Lung Cancer: Screening, March 09, 2021, US Preventive Services Task Force, https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening.    

"MRS. FENWICK SAVES THE WORLD."

The crew talk about one of our favorite movie genres Grade B Horror Movies --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

A dive in the billion dollar story, and a dive in Elie Ferzli as a prototype for grade B politicians in Lebanon aspiring to acquire a Metternich-like role, while achieving a Rasputin-like space in reality.

Episode 24: Alcohol in Clinic[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 21, 2020. Fresh from the oven! The USPSTF issued the following recommendation on August 18, 2020: All sexually active adolescents and adults at increased risk should receive behavioral counseling to prevent Sexually Transmitted Infections (STIs).Counseling results in a moderate net benefit in prevention of STIs, a Grade B recommendation, which means the benefit is moderate to substantial, so offer this service to your patients.Some examples of patients who can benefit from counseling are those who have a current STI, do not use condoms, have multiple partners, belong to a sexual and gender minority, HIV patients, IV drug users, persons in correctional facilities, and others.Offering counseling in person for 30 minutes or less in a single session may be effective, but the strongest effect was found in group counseling for more than 120 minutes, delivered in several sessions. Other options include referring patients for counseling services or inform them about media-based interventions. Of note, there are about 20 million new STIs every year in the US (1). [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][Quote]“The illiterate of the 21st century will not be those who cannot read and write but those who cannot learn, unlearn, and relearn” –Alvin Toffler.Sometimes there are things we need to unlearn. We see that frequently in Medicine. New guidelines, recommendations, tests, and treatments are updated regularly. We need to make sure we never stop learning, unlearning and relearning; and residency is just part of the beginning of a life-long commitment to learn. Today we have a dynamic intern. She started just one month ago her residency. I’m happy to welcome Ariana Lundquist today.     Question number 1: Who are you?Hi, my name is Ariana and I am a first-year resident at Rio Bravo Family Medicine Residency.  I am a California girl through and through from Orange County, California.I grew up surfing every weekend with my dad who also is a family physician.Early on I knew I wanted to be a doctor because I really loved being at my father's private practice. My mom had her private practice at my father's clinic, and so every day after school she would pick my sister and I up and take us to clinic.  We would run around and interact with every patient.  We truly grew up in the clinic and I cherish those memories as an adult.   I went to Canyon high school where I did water polo and swim.  For undergrad, I went to Cal State Long Beach where I majored in cell molecular biology with a minor in general chemistry and surfing.  I then went to the beautiful island of Dominica to attend medical school at Ross University.   My last 2 years of medical school were spent in Bakersfield.  As someone who loves the heat and sweet hospitality, Bakersfield was really fit for me.  I truly am excited to learn and grow as a physician here in Bakersfield with the Rio Bravo family medicine team.   For fun, I still try to surf whenever I get a chance, free dive, scuba dive, karaoke, and spend time with my family. Question number 2: What did you learn this week?This week I was working on my quality improvement project with my co-resident Dr. Civelli on alcohol withdrawals in a hospital setting.  During the research, I was wondering about how you would treat alcohol withdrawals in a clinic setting.  We encounter a lot of patients who, when they are willing to open up about it, admit to having alcohol dependency.   It is never a simple subject to talk about with patients because most people either feel that they have their alcoholism under control or that they are ashamed by the amount that they drink.  Once the patient is honest with you about the amount they drink and you realize that they are above the recommended daily intake, that is when you start to assess their willingness to quit.  That alone is another subject for a pod cast in the future, but if someone is willing to quit you have to consider if that patient is somebody who might have withdrawal symptoms.           Timing of alcohol withdrawal syndromesSyndrome Clinical findings Onset after last drink Minor withdrawalTremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, gastrointestinal upset; normal mental status6 to 36 hoursSeizuresSingle or brief flurry of generalized tonic-clonic seizures, short postictal period; status epilepticus rare6 to 48 hoursAlcoholic hallucinosisVisual, auditory, and/or tactile hallucinations with intact orientation and normal vital signs12 to 48 hoursDelirium tremensDelirium, agitation, tachycardia, hypertension, fever, diaphoresis48 to 96 hours  Patient assessment 1) Substance use history questions include:-Duration of disorder?-When was your last drink?-How many drinks per day, and days per week?-History of withdrawal seizure or delirium tremens-Medical complications related to alcohol-Number of prior supervised withdrawal episodes?   2) General Physical Exam w/ vitals 3) Labs: CBC w/diff, blood glucose, electrolytes, calcium, magnesium, phosphorous, anion gap, renal and hepatic function 4) Withdrawal Symptoms  Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA): There are 10 areas to examine in this scale. Evaluate each area and assign a score (see details below):1. NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 2. TACTILE DISTURBANCES: Ask "Do you have any itching, pins and needles sensations, burning sensations, numbness, or the feeling of bugs crawling on or under your skin?" Observation.3. TREMOR: Arms extended and fingers spread apart. Observation. 4. AUDITORY DISTURBANCES: Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 5. Paroxysmal sweats. Observation. 6. VISUAL DISTURBANCES: Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 7. ANXIETY: Ask "Do you feel nervous?" Observation. 8. HEADACHE, FULLNESS IN HEAD: Ask "Does your head feel different? Does it feel as if there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 9. AGITATION: Observation. 10. ORIENTATION AND CLOUDING OF SENSORIUM: Ask "What day is this? Where are you? Who am I?" Count forward by three. Interpretation of CIWA score0 to 9 points:Very mild withdrawalOutpatient management10 to 15 points:Mild withdrawal 16 to 20 points:Modest withdrawalInpatient management21 to 67 points:Severe withdrawal    5) Co-morbidities  If patient shows no symptoms in first 24 hours and they are not at risk for major withdrawal, no medication is indicated as symptoms are unlikely to develop.Ambulatory Criteria:•A patient with mild symptoms of alcohol withdrawal (CIWA-Ar

Episode 17 – Tension HeadacheThe sun rises over the San Joaquin Valley, California, today is June 19, 2020. This week we welcomed a new group of residents who started on June 15, 2020. Welcome aboard, Drs. Amodio, Civelli, Grewal, Lorenzo, Lundquist, Martinez, Nwosu, and Viamontes. We are excited for you and all the experiences you will have in the next 3 years. On Jun 9, the USPSTF recommended to screen for unhealthy drug use all adults age 18 years or older. This a Grade B recommendation (moderate to substantial benefit). Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Screening in this case refers to asking questions about unhealthy drug use, not testing biological specimens(1).The search for the miraculous antiviral drug against COVID-19 continues. We previously mentioned remdesivir, which was granted Emergency Use Authorization (EUA) by the FDA on May 1, 2020 in the US. Another drug you should be aware of is avifavir. Avifavir is based on Favipiravir, originally sold in Japan as an antiviral medication to treat influenza. Avifavir has been approved to be used in Russia, and is being tested in the US and the UK as well. Let’s keep avifavir on our radar, if it works, we’ll surely know about it.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. “[Feedback], like rain, should be gentle enough to nourish a man’s growth without destroying his roots.” – inspired by Frank A. ClarkBeing corrected is not easy. It takes a lot of courage to accept that we may be wrong sometimes, and trying to fix our mistake requires diligence. Remember that your attendings are not trying to humiliate you (or at least the attending I know), but they are correcting you to help you succeed in your career. Today we have a resident who is excited to talk about his topic. Welcome, Dr Brito.1. Question Number 1: Who are you?I was born and raised in the center of the Cuban island. I had the opportunity to study and practice Medicine in my native country. After graduating from medical school, I completed my social service year in an underserved area on the beautiful north coast. Most of my patients were farm workers or fishermen. I also worked in the ER for 6 years before emigrating to the United States. Once in the US, and after years of preparation, I was accepted into the UCLA IMG Program in 2018, and the following year I matched in the Rio Bravo program.I like fish keeping, outdoor sports such as running, sports in general, my favorite Movie director is Pedro Almodovar. I also love jazz music, Miles Davis, and Chucho Valdes. 2. Question number 2: What did you learn this week?I learned about the treatment of Tension-type Headache (TTH).PREVENTIVE THERAPYProphylactic therapy ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions. Prophylactic treatment is indicated if headaches are frequent, long-lasting, or account for a significant amount of total disability. Such as, frequent episodic subtype (1 to 14 headache-days a month) and chronic subtype (>15 headache-days a month) Preventive therapy may be also indicated when acute therapy (such as acetaminophen and NSAIDs) fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications. Pharmacologic preventive therapies: Evidence of efficacy is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications - mirtazapine and venlafaxine, topiramate, gabapentin, tizanidine have limited data. Trigger point injections require more research. In contrast, SSRIs are not effective.  Dosing and duration of therapy: Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved. Benefit is often first noted only after four to six weeks of therapy. Avoid overuse of analgesic medication, in fact eliminate it, or preventive therapy will likely be ineffective. Measure the effectiveness of therapy by use of a patient headache diary. For example, amitriptyline at 10-12.5 mg nightly, and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated, maximum dose of 100 to 125 mg. TCA are associated with cardiac conduction abnormalities and arrhythmias. Before initiating treatment, patient should be screened, 40 years and older with EKG, younger than 40 can be screened by history for evidence of cardiac disease.  Behavioral therapies: Regulation of sleep, exercise, and meals. CBT, relaxation, biofeedback—These therapies may be suited for patients who prefer no pharmacologic treatment; those who have insufficient response to, or poor tolerance to pharmacologic treatments; pregnant, nursing, excessive use of analgesics; those who have significant stress or deficient stress-coping skills. Studies suggest treatment using biofeedback combined with relation therapy rather than other behavioral therapy options. Biofeedback: Electrical sensors connected to a monitor are hooked up to your body. The sensors measure one or more signs of stress. This can include heart rate, muscle tension, or body temperature. The measurements provide feedback about how your body responds to different stimuli. Patients learn to interpret those signals and control them.Other no pharmacologic therapies such as acupuncture which suggests any benefit is likely to be modest and Physical therapies with unproven benefits. ACUTE TREATMENTThe acute or abortive therapy of TTH ranges from nonpharmacologic therapies to simple and combination analgesic medications. In most cases, the treatment of TTH is largely self-directed using OTC medications without any input from a medical provider. Nonpharmacologic treatments include heat, ice, massage, rest, and biofeedback.  Precipitating factors include of TTH: Stress and mental tension are reported to be the most common precipitants. Other precipitants anxiety, major depression, overwork, Lack of sleep, Incorrect posture, etc. Controlling these triggers may help in the acute treatment of TTH.Medications: Given the available data, the recommended treatment is with simple analgesics such as NSAIDs or aspirin for patients with pure episodic TTH. Acetaminophen 1000 mg is probably less effective than NSAIDs or aspirin. Reasonable choices include ibuprofen (200-400), naproxen (220 or 550 mg) or aspirin (650 to 1000). For failing, diclofenac (25 to 100 mg). For those who cannot tolerate NSAIDs or aspirin, acetaminophen 1000 mg is the preferred choice. How to judge the success of acute treatmentReasonable goals:- Is the patient pain-free and functioning normally in two to four hours after treatment? - Does the treatment work consistently without routine headache recurrence? - Is the patient able to plan his or her day? (disability)- Is it tolerable?The treatment should be considered ineffective if two or more of these criteria are consistently not met. What to do in case of treatment failure Consider diagnosis of TTH is inaccurate, less likely secondary etiology, most likely migraine without aura Dx is correct but wrong medication choice, inadequate dose, timingMedication overusePatient has depression, and/or anxiety disorder. Other acute interventions: Combination analgesics containing caffeine (recommended in suboptimal response), butalbital and codeine (not recommended as initial therapy), Parenteral (chlorpromazine, metoclopramide (limited evidence), Ketorolac, Muscle relaxant (not recommended) 3. Question number 3: Why is that knowledge important for you and your patients? Tension-type headache is the most prevalent headache in the general population and the second-most prevalent disorder in the world. Yearly, prevalence rates for episodic TTH are approximately 80 % in men and women. Understanding the pathophysiology and clinical aspects of TTH is important for accurate diagnosis and optimum treatment. However, TTH is a relatively featureless HA, making it the least distinct of all the primary HA phenotypes. In addition, it is the least studied of all the primary HA disorders, despite having a high socioeconomic impact. Societal impact: The prevalence of TTH is greater than migraine and the overall cost of TTH is high. In one population study, persons with episodic TTH reported a mean of nine lost workdays and five reduced- effectiveness days, while persons with chronic TTH reported a mean of 27 lost workdays and 20 reduced-effectiveness days.  4. Question number 4: How did you get that knowledge?That knowledge came first from medical school, and second, after years of practicing Medicine. During those years, we as doctors, evaluate and manage a large number of patients with one of the most common medical complaints, headache. In terms of finding out more of what to do with patients, how to make them feel better, I had to look some stuff up. My trusty sources in clinic are 1) Up to Date, 2) Faculty, 3) Review/Journal articles. Not necessarily in that order. 5. Question number 5: Where did that knowledge come from?The information comes from multiple reliable medical sources such as “Frequent Headaches: Evaluation and Management” by Anne Walling, downloaded from the AAFP website, and “Tension-type headache in adults: Preventive treatment and Acute Treatment” in Up-to-Date. ____________________________Speaking Medical: CholuriaHi this is Harjinder Sidhu, I’m a 3rd-year medical student. I’m here to present the medical word of the week: Choluria. Has your patient ever inform you their urine color is brown (Coca-Cola color)? Choluria has 2 roots, “chol” and “uria.” “Chol” is the combination of bile and gallbladder. “Uria” is the presence of something in urine that should not be present. So choluria is the presence of bile in the urine. What causes the urine to become brownish in color? The presence of bile in urine is caused by an underlying liver disease such as cirrhosis, hepatitis and/or hemolysis. Choluria usually manifests when the serum levels of bilirubin are above 1.5mg/dl. Now that you understand what choluria is, in the future you can look out for our patients by asking any changes in urine as a sign of potential liver problems. Stay tuned for next week’s word of the week!____________________________Espanish Por Favor: Señale con un dedoHi this is Dr Carranza on our section Espanish por favor. This week I wanted to share a tool for a follow-up question. Not too long ago we learned that DOLOR means pain, and we learned about body parts like “cabeza” head, “rodilla” knee, “pecho” chest, etc. Next you will probably want to ask where the “dolor” exactly is, and to simplify things we can ask the patient to point with one finger to where it hurts. We can do this by saying “dónde” which means where, followed by “señale con un dedo”, which means point with one finger. “Señalar” means to point, and “dedo” means finger.I hope you can use this in your practice, “señale con un dedo”, and you can always ask nicely and add “por favor” which means please. Have a great week!Now we conclude our episode number 17 “Tension Headache”. Dr Brito briefly explained the treatment of tension headache. Lifestyle modifications are key in the treatment, and many non-pharmacological options are available with different degrees of evidence. Thinking about prophylaxis of tension headaches? Amitriptyline is likely a good choice, but remember the side effects as well. Dr Carranza taught us how to ask about location of pain with the phrase “señale con un dedo”, and then we remembered the word choluria, which is bilirubin in the urine. Stay tuned for more next week.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, Ariel Brito, Claudia Carranza, and Harjinder Sidhu. Audio edition: Suraj Amrutia. See you soon! _____________________References:Unhealthy Drug Use: Screening, June 09, 2020, US Preventive Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening“Avifavir, first COVID-19 drug from Russia: What you need to know”, MSN News, https://www.msn.com/en-ae/news/other/avifavir-first-covid-19-drug-from-russia-what-you-need-to-know/ar-BB14UKvN, accessed on June 15, 2020.“Biofeedback” by Healthline, https://www.healthline.com/health/biofeedback#procedure, accessed on June 15, 2020.Walling, Anne, Am Fam Physician. 2020 Apr 1; 101(7):419-428Taylor, Frederick R, “Tension-type headache in adults: Preventive treatment” (https://www.uptodate.com/contents/tension-type-headache-in-adults-preventive-treatment?search=tension%20type%20headache%20treatment&source=search_result&selectedTitle=2~108&usage_type=default&display_rank=2), and “Tension-type headache in adults: Acute treatment” (https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20type%20headache%20treatment&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1), Up to Date, accessed on June 15, 2020.

https://jamanetwork.com/journals/jama/fullarticle/2751726 uspstf now grade B for asymptomatic urine in preggo https://pediatrics.aappublications.org/content/144/6/e20192739kids do shoot their eye out! https://www.nejm.org/doi/full/10.1056/NEJMoa1908142Metoprolol does not treat COPD https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2754809?guestAccessKey=d3ef4800-287b-43aa-9d58-fd3c1e8359c2&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=111819 HIV and social media!! 

Our first 2019-2020 show, with an interview of Pierre-Loïc by the CM1B(4th Grade B)

And we are back, after a one-week hiatus, with loads of national security law debate and discussion, not to mention some Grade B frivolity! On tap for Professors Vladeck and Chesney: Detention of Enemy Combatants:...

Credits: 0.25 AMA PRA Category 1 Credits™ Claim CME/CE credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-113-deprescribing Overview: According to the latest data, 1 in 7 US women experience perinatal depression, described as depression occurring during pregnancy and up to one year after childbirth. There is compelling evidence that perinatal depression can have short and long-term effects on both women and their children. The USPSTF has published new recommendations encouraging clinicians to screen pregnant and postpartum persons for depression and provide those who are at increased risk of perinatal depression with counseling interventions. (Grade B recommendation). Guest: Susan Feeney, DNP, FNP Landing Page: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-121

Credits: 0.25 AMA PRA Category 1 Credits™ Claim CME/CE credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-113-deprescribing Overview: According to the latest data, 1 in 7 US women experience perinatal depression, described as depression occurring during pregnancy and up to one year after childbirth. There is compelling evidence that perinatal depression can have short and long-term effects on both women and their children. The USPSTF has published new recommendations encouraging clinicians to screen pregnant and postpartum persons for depression and provide those who are at increased risk of perinatal depression with counseling interventions. (Grade B recommendation). Guest: Susan Feeney, DNP, FNP Landing Page: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-121

Discover the secrets to cooking with maple syrup as Andi Anderson from Gale Woods Farm joins us to help us in the kitchen. We discuss how to substitute syrup for sugar in recipes. We also help you uncode the meaning of Grade A and Grade B syrup.

Episodio de curiosidades, pero primero platicamos sobre la película Lords of Chaos del grupo Mayhem, el cameo de Tobias Fünke de Arrested Development en Infinity War, Critters: A New Binge, Armie Hammer como Batman, tema tenso de suicidios en YouTube Kids. las cajas sorpresa de la Deep Web, los Human Uber, cómo afecta el hambre en la decisión de los jueces para libertad condicional, OJ Simpson no fue Terminator porque no parece asesino, tips de Pari para asesinar sin evidencias en tu contra, video de Arnold sobre King Conan y el juego que causaba ataques llamado Polybius. Escúchanos en: Spotify / iTunes / ivoox / stitcher Síguenos: Twitter/ Facebook/ Instagram: holamsupernova holamsupernova@gmail.com

Episodio de curiosidades, pero primero platicamos sobre la película Lords of Chaos del grupo Mayhem, el cameo de Tobias Fünke de Arrested Development en Infinity War, Critters: A New Binge, Armie Hammer como Batman, tema tenso de suicidios en YouTube Kids. las cajas sorpresa de la Deep Web, los Human Uber, cómo afecta el hambre en la decisión de los jueces para libertad condicional, OJ Simpson no fue Terminator porque no parece asesino, tips de Pari para asesinar sin evidencias en tu contra, video de Arnold sobre King Conan y el juego que causaba ataques llamado Polybius. Escúchanos en: Spotify / iTunes / ivoox / stitcher Síguenos: Twitter/ Facebook/ Instagram: holamsupernova holamsupernova@gmail.com

It's long seemed obvious that if we want to truly fix education, actually make it work for the 21st century, we need to kill a stockyard full of our sacred cows. And we had just the man for the job on The Bill Walton Show this week. Bryan Caplan, a professor of economics at George Mason University and author of “The Case Against Education: Why the Education System is Waste of Time and Money,” described the findings in his book and provided some stark recommendations based on them. First, he said, we need to understand what we're doing in school. There is the romantic version, he said – you go, learn skills employers are interested in, then get jobs with those employers performing those skills. More likely is what he calls the “signaling school of education.” You mostly go to school to get certification, “a bunch of seals of approval saying, ‘Grade A worker' or ‘Grade B worker.'” But, regardless of the grade, you need a seal. The certification, Caplan argues, has become so accessible it has lost its value. Decades ago, a high school diploma was enough for most jobs. Now, thanks to what he labels “credential inflation,” a bachelor's degree is often not enough. That's why he devotes a chapter in the book to the premise that we need a lot less education. And, failing that, we need to spend a lot less money for what we're getting now. To the first point, he divides students into four categories – excellent, good, fair and poor. Parents, he said, need to honestly assess, or have others do so, which category their children fall into. If the answer is “poor,” trying to get into college and major in math or science or management may not be wise, but pursuing skilled trades may be. Wherever you fall, the emphasis should be on maximizing the investment. To the second, he says the main feedback he gets from education leaders is that few say the system works well, but many say, “Give us more money and then we can do the job.” Caplan says we need to turn that logic on its head and cut funding for public schools by 30 percent. Education officials will demand “an exact blueprint” for where to cut. “And I say, ‘You know, there's a strange double standard here. When people say we need more money for schools, people don't usually say, ‘No way until you give us an exact blueprint of how you plan to spend the money.” But “when you say ‘less money,' that's where people say, “I can't even consider your idea until you write an encyclopedia about where every dime of budget cuts are going to come from.” And where would Caplan cut? For starters, he would limit or eliminate foreign language classes. “Almost no American adult uses a foreign language,” Caplan said. “It's just a fact. Second, whether or not you agree with that, virtually no American adult even claims to have learned to speak a foreign language very well in school, despite the fact that it's standard to do two or three years. So, essentially, you're teaching people something that they almost never use and where almost no one even claims to have learned it, despite the fact that you're putting a lot of years and classroom material on it. To me, that's crazy.” Go after the shibboleths as well, Caplan urges, and be thorough. Some kids are not as bright as others, and schools and parents need to rethink expecting the same things from those kids. To claims that there's nothing more important than education, he says, “How about food? Of course food is more important than our children's education.” One thing does bother Caplan. Economists who don't specialize in this area hear his ideas and want to learn more. Those fresh out of the education experience find his message spot on. But education experts are another story. “It's sort of a weird case where the people who know the most disagree with me the most, and the people on the other hand who have sort of an intermediate level of knowledge are often very much in agreement with me. “So I'm like, ‘Gee, the people who know the most think I'm wrong, so maybe they know something I don't know.” Or maybe they have not let go of those shibboleths.

Megumi gets motherly, Eden Zero introduces Not-Erza, and we finally get our first look at Wano. My Hero Academia ch. 189 – 4:19Food Wars ch. 269 – 16:02Eden Zero ch. 2 – 28:40Alice & Taiyo ch. 1 – 48:13Seiji Tanaka ch. 2 – 52:21Dr. Stone ch. 64 – 53:37We Never Learn ch. 69 – 1:02:36The Promised Neverland ch. 93 – 1:10:54Seven Deadly Sins ch. 273 – 1:19:55Black Clover ch. 163 – 1:28:03One Piece ch. 909 – 1:33:53Weekly MVPs – 1:51:51

Say what you want about the Redskins front office, but these guys got the Draft right! The Redskins come out of the 2018 draft with first day starters, project players, special teams aces, and a whole lot of value! This week we breakdown our best and worst picks, and the overall grade we would give to the Redskins staff based on this year's draft. Get your Redskins Rundown fix in... this is our last episode until training camp.2:00- Bills' Grade: A-8:45- Drew's Grade: B+14:30- Abie's Grade: B24:00- Was Vita Vea their guy? DaRon Payne plan B?26:38- Bee's Grade: A+30:47- Who gets the credit in the Redskins front office?39:00- The case for the late-round injury history flier47:30- Waaay too early Redskins 2018 Predictions_________________Intro & Outro: "Too Complex Instrumental" -6th SenseFollow us on Instagram- @TheRedskinsRundown

Tune in this week to hear from Carl Bednarski, president of Michigan Farm Bureau, the true voice of agriculture and the family of companies. Carl shares his wide depth and knowledge of agriculture to food security - from food waste from the field to the restaurant. Did you know that approx. 20 BILLION pounds of fruit and vegetables are left in the field / discarded every year due to labor shortages or the produce's imperfections? Imperfect produce is often referred to as Grade B or #2's. Since 1990, the Food Bank Council of Michigan has partnered with Michigan farmers to help move their fresh produce, dairy and eggs in the secondary market - in 2017, 51,170,103 pounds of #2 produce were distributed!

This episode is all about our favorite sugary syrup: maple! Our quest to learn more takes us to a maple farm in upstate New York, where we learn everything from how it's made to the confusing grading system (Grade A, Grade B?). Plus a few of our favorite recipes on how to use it, including our most popular one: bliss bites.     How to grow herbs   Recipes: Bliss bites | A Couple Cooks Tart cherry greek yogurt bowl | A Couple Cooks Get your greens pizza | A Couple Cooks   Ben Hoelscher, Roxbury Mountain Maple Website | Order maple A Couple Cooks on Instagram and Twitter

  Episode 012- Top Chef cheftestant, Gerald Sombright is a regular guy who made his bones in the professional cooking world, not by flashing a degree from a fancy culinary school.  Instead, he worked his way up from the bottom rung of the kitchen hierarchy. On this episode, he takes us on his food journey, working his way up from restaurant work in Saint Louis to being Chef De Cuisine at Ario in Marco Island, Florida to being a  contestant on what is arguably the best cooking competition show on television, Top Chef. He'll give you the inside scoop on what it's like to be on the show and how he almost didn't make it past the application phase, but for his Indiana Jones-like determination.  You'll also find out his biggest challenge and what he would do differently if he were to do the show again.  Note: The Top Chef Season 14 finale is on Thursday, March 2nd. Also, if you listened to Episode 011 of Guys and Food, you know that I was on a  pie kick during the last week (Psssst-- I still am).  It had me looking at some of my pie cookbooks.  I was intrigued by a few different recipes for maple pie.  Many of these recipes call for the darker and robust tasting Grade B maple syrup. When I asked the folks on one of my Facebook food groups where one might be able to locally source the harder to find Grade B syrup, I was told that the ABC grading system for maple syrup no longer exists.  Just like everyone gets a trophy these days, so too, all maple syrup is now Grade A.  Here is an article explaining the new grading system and how to distinguish one type of maple syrup from another. Remember, if you are an interesting food guy (or you know one), find out how to become a guest on Guys and Food!

Some people have mistakenly believed that Grade B maple syrup was less processed and more nutritious than other grades, but that was just a myth.  Listen in this week as Dee talks about why grade B is now the new grade A.

The Close Call (Rickhouse, San Francisco)1 oz applejack1 oz Bols aged genever.25 oz yellow Chartreuse.25 oz Grade B maple syrup.5 oz heavy cream.5 oz freshly squeezed orange juice1 dash Fee Bros. Whiskey Barrel Bitters.5 oz Port such as Six GrapesCinnamon stick for grating Fill a Collins glass with crushed ice. Place applejack, genever, yellow Chartreuse, maple syrup, heavy cream, orange juice, and bitters in a cocktail shaker. Shake vigorously and pour over crushed ice. Top with port and garnish with freshly grated cinnamon. Salty Maple Buttered Cider (Maria Del Mar Sacasa)Maldon saltHalf of 1 lemon1 tablespoon softened butter2 tablespoon pure maple syrup.5 vanilla bean pod, seeds scraped out4 oz dark rum8 oz apple cider Scatter Maldon salt on a small plate. Rub the rim of two heatproof glasses or mugs with the lemon half, then dip in salt. Combine the butter, maple syrup, and vanilla bean seeds in small bowl. Set aside. Combine rum and cider in a small saucepan and bring to a simmer over medium-high heat. Pour into prepared glasses, then top each with half of the butter. Serve immediately. The Bamboozled Angel2 oz bourbon, preferably Heaven Hill.75 oz lemon juice.75 oz cinnamon syrup (see Editor's Note)1 oz grapefruit juice3 dashes Angostura bittersGrapefruit peel for garnish Combine all ingredients in shaker over ice and shake.Strain into rocks glass over large draft cube. Top with angostura bitters; express a grapefruit peel over drink and garnish. Spiced Pear Punch6 oz roasted pear purée*6 oz Old Tom Gin6 oz ginger liqueur (such King’s Ginger)6 oz Cognac3 oz fresh lemon juice18 oz prosecco (use a dry, fruity one)Ice block (frozen in a 1-qt. container)lemon wheels, pear slices and star anise to garnish Combine all ingredients except prosecco in a pitcher and chill for several hours. When ready to serve, place ice block in a punch bowl and pour chilled mixture over. Top with chilled prosecco, float garnishes and serve immediately. *Roasted pear puréePreheat oven to 350 degrees F. Peel, halve and core 5 ripe pears (Carlson uses Bartlett and Anjou, but any variety will work as long as they’re ripe). Arrange in a roasting pan with 4 tablespoons of demerara sugar, 4 ounces of brandy or Cognac, 6 cinnamon sticks, 8 star anise and 12 cloves. Cut 1 vanilla bean lengthwise; scrape out the seeds and add them to the roasting pan along with the pod. Roast for 30 minutes. Remove the spices and vanilla bean pod, then purée the pears and liquid in a blender or food processor.

Please join Dr Daniels today, January 12 at 6pm EDT for the Healing with Dr Daniels Show. The show's title is 'Is your doctor giving Grade B advice?'  Grade B is a term made popular by the movie industry.  Generally a low budget exploitation movie.   So, are you getting  exploited by Grade B Medical care?  Dr Daniels shares some grade B recommendations rated as such by the Medical industrial complex itself.  Tune in Think Happens?  Listen by phone 914-338-0695 or online click http://www.blogtalkradio.com/blakeradio Questions:Call: 914-338-0695 or online go to http://healingwithdrdaniels.chatango.com/

We have a passionate cook and baker with us today.  Her name is Nancy Beechy.  We will be talking about paleo eating and what it’s all about.   By day Nancy is a pediatric occupational therapist and by night you’ll find her in the kitchen where her passion for cooking and baking come alive! Once she discovered the importance of nutrition and the paleo diet through her best friend, a chiropractor, she noticed a positive change in her physical and emotional health, and made the choice to adopt it as her lifestyle. Through her own paleo journey of living healthy and fit, she started to share her love for nutrition with the parents of her patients as well as her co-workers and friends. This lead to the birth of Naughty Turned Nice Sweets & Treats. WHAT THE PALEO? Adopting the paleo lifestyle Saturday, January 9th 10-11am Location: Crossfit Natus Vincere 815-522-2874 1159 E. 9th Street, Lockport, IL 60441 You will walk away knowing: →The different phases of adopting the paleo lifestyle →How to eat clean →How to shop and meal prep →Understanding Macronutrients →Rules of the 4 week Challenge and Your Assigned Team Chocolate Mousse Recipe: 2 medium sized ripe avocados 1/2 cup pure maple syrup (Grade B) or Local Raw Honey 1/2 cup raw cacao powder (or cocoa powder) 1 tablespoon coconut oil 1 teaspoon vanilla extract Pinch of sea salt   Mix everything in a blender and Bon Appetit Fresh berries and shredded coconut for garnish    Morning Smoothie: 1 Cup Unsweetened Almond or Coconut Milk 2 Cups Organic Spinach or Mixed Greens 1/2 Banana  1 scoop of Vanilla Plant Protein (see link below) (http://www.plantfusion.net) Blend with your Vitamix or Favorite Blender Enjoy!  info@naughtyturnednice.com naughtyturnednice.com Online store http://www.naughtyturnednice.com/#!online-store/c99x 331-642-5288 Facebook, Twitter, Instagram – naughtyturnednice Visit www.ericwsu.com for all other podcasts   The post #64 Nancy Beechy – Paleo eating and what it’s all about. #hlwes appeared first on Eric W Su.

·      This week we talk to Joe Raya, owner of the Gin Joint in Charleston, South Carolina.  He & his wife also make delicious syrups for bartenders called Tippleman’s.  There are 6 varieties and they are all awesome:o   Burnt Sugaro   Island Orxatao   Falernumo   Ginger Honeyo   Lemon Oleo Saccharumo   Barrel Smoked Maple·      Its Bartender Journey Podcast # 129 !·      First lets do a cocktail of the week!  Its a Bourbon/Maple Old Fashioned using the Tippleman’s Barrel Smoked Maple syrup.  The syrup is made using barrels from Willett Distillery. I used about ½ oz.  I happened to have a lovely bottle of Willet Pot Still Reserve Bourbon, so I figured lets use that in our Old Fashioned!  It’s a pretty incredible Bourbon and it’s tempting to just drink it neat or with one ice cube, but I used it anyway -- 2 oz of Willet Bourbon in my quite decedent Old Fashioned.  I used Basement Bitters from Tuttletown distillery.  These are the guys that make the great Hudson Whiskey among other things and their bitters are great!·      If you don’t have any Tippleman’s syrups yet, consider ordering some at tipplemans.com.  But meanwhile, try experimenting with a good quality maple syrup in your old fashioned.  Grade B is what is recommended for using in cocktails.  You might consider mixing it with a little hot water to make it easier to mix into your cocktail.  And if you don’t have the Basement Bitters, try substituting other aromatic bitters – Angostura is of course an awesome choice and widely available, but perhaps try experimenting with a few other brands too!·      To make an Old Fashioned – mix the sugar (or syrup in this case) with the bitters in the bottom of your Old Fashioned or rocks glass.  Add the whiskey and some ice – ideally one big hand-cut ice cube and a twist.  Usually it would be an orange twist in an Old Fashioned, especially if it were a Rye Old Fashioned, but I used lemon in this case.  A little extra citrus “zing” from the limon goes better with the Bourbon and maple flavors.·      Book of the week is Its All About The Guest by Steve Difillippo.  ·      The subtitle of this book is Exceeding Expectations in Busines and in Life The Davio’s Way.·      Steve is a great businessman.  In his book he has lots of great lessons for us, including: “every decision you make: is this going to make things better for the guest?”·      There will always be demanding guests who are ready to get upset about nothing.  They will require a lot of attention, but you can’t let that distract you from the other guests.·      Figure out how much it costs to make what you are selling, otherwise you may be loosing money without even knowing it.·      Its not just WHAT you do, its how people PERCEIVE what you do.·      Our Toast this week: ‘tis better to spend money like there's no tomorrow
 than to spend tonight like there's no money!  

Churchill’s Breakfast1.5 oz Rye whiskey.5 oz cold brew coffee1 cinnamon stick.33 oz Grade B maple syrup2 dashes Angostura bitters Toast a cinnamon stick on an open flame until it smokes, and place it under an overturned, chilled coupe filling it with smoke. Shake other ingredients with ice until well chilled and strain into the coupe. Drop the cinnamon stick in for garnish. La Louche1.5 oz Hendricks Gin1 oz Lillet rouge.5 oz lime juice.25 oz Yellow Chartreuse.25 oz simple syrup. Shake with ice and strain into a chilled coupe. No garnish. Hemingway Daiquiri2 oz white rum.75 oz fresh lime juice.5 oz Maraschino liqueur.5 oz fresh grapefruit juice Shake with ice until well chilled and strain in to a chilled coupe. Garnish with a lime wheel.

The incidence of high grade B cell lymphoma in western countries has increased over the last decades. Improvement of conventional chemotherapy regimens has significantly contributed to prolonged 5-year survival rates which currently reach around 60%. However, relapse after conventional chemotherapy is an important challenge, especially in high grade B cell lymphomas. The potential benefit of immunological approaches for the elimination of such lymphomas still remains unclear. In this study, we attempted to address whether the forced expression of foreign antigens in a tumor of B cell origin leads to immune recognition and elimination of the tumor and to assess the potential role of IFN-gamma (IFN-g) in tumor rejection. To this end, we used a transgenic mouse lymphoma model, where the human proto-oncogene c-myc (a foreign antigen for the mouse host) is under the control of regulatory elements of the immunoglobulin lambda locus, thereby recapitulating the important features of a t(8;22) translocation as found in human Burkitt’s lymphoma. From these spontaneously developing tumors, lymphoma cell lines were established that either express (line 291) or are deficient (line 9) in Stat1- a key signaling molecule in the response to interferons. We found that the expression of foreign antigens such as chicken ovalbumin (OVA) and green fluorescent protein (GFP) in Stat1-competent 291 cells led to immune responses that delayed tumor progression and improved survival of wild-type animals. Consistent with this, loss of foreign antigen inevitably led to accelerated tumor progression upon transfer into immunocompetent wild-type mice. Transfer of immunogenic 291-OVA-GFP lymphoma cells led to increased tumor progression without loss of foreign antigen upon transfer into IFN-γ-/- and Stat1-/- mice indicating that no selection of antigen loss-variants occurred in these mice. The rejection of 291-OVA-GFP cells in wild-type mice was at least in part mediated by CD8+ T cells as measured by enrichment of the OVA antigen-derived MHC class I-restricted SIINFEKL epitope-specific cells in wild-type recipients.. Interestingly, Stat1-deficient lymphoma cells (9-GFP and 9-OVA-GFP) were rejected by immunocompetent UBQ-GFP transgenic wild-type C57BL/6 mice irrespectively of the presence of a foreign antigen, indicating the existence of immunosurveillance against these Stat1-deficient lymphomas. To evaluate the key players behind lymphoma rejection, we transferred 9-GFP cells into IFN-γ-/- and Stat1-/- recipients. This led to enhanced tumor growth indicating that endogenous IFN-γ production and Stat1 signaling are critical for tumor rejection. To gain an insight into the mechanistic aspects of innate immunosurveillance against the Stat1-competent and Stat1-deficient lymphomas, NK cell functionality was evaluated. We found that NK cells could efficiently lyse both Stat1-competent and Stat1-deficient lymphoma cell lines in vitro. Treatment with IFN-γ increased the susceptibility of Stat1-deficient lymphoma cells to NK cell killing, but decreased that of Stat1-competent cells, presumably by upregulating MHC class I expression. The results of this work show that host IFN-γ and Stat1 signaling are important for tumor clearance, and that paradoxically, the absence of Stat1 within the lymphoma is required for rejection.

This week Mr Gaskins got busy with 10 new issues to cover. As usual, he provides his analysis as well as proprietary grade and rank. For more details on the analysis please visit the website http://www.gaskinsco.com/This the following companies are covered:Airvana (AIRV) an infrastructure company in the mobile broadband sector: Grade B-, Rank 9 Dice Holdings (DHX) the long popular technology and finance career website: B-, 8 Encore Banc (EBTX) a bank holding company out of Texas & Florida: C+, 7 hhgregg (HGG) an online retailer of video/audio/appliances/etc: C+, 7ImaRX Thera (IMRX) who produces therapies for blood clots: C, 6 Limco-Piedmont (LIMC) providing services in aerospace maintenance: C+, 6 MF Global Ltd. (MF) a broker of exchange-listed futures and options: C+, 8 Netezza (NZ) manufacturer of data warehouse appliances: B-, 8Orbitz Worldwide (OWW) a leading online travel search service: C+, 7 SemGroup , L.P. (SGLP) operating in crude oil midstream services: C+, 7