Podcasts about grade iii

Guest: Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine. He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic.   Resources:  Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/ The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext  KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/    Outline: Steal Syndrome Definition & Etiology Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand. Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow.  Incidence and Risk Factors The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits. Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4  Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries' ability to vasodilate and adjust to decreased blood flow. Patient Presentation, Symptoms, Grading Steal syndrome is diagnosed clinically.  Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation. Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years. The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss.  There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow. Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5  Workup Duplex ultrasound can be used to analyze flow volumes. A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery. Upper extremity angiogram can identify proximal arterial lesions. Prevention Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter.  SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal. If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors, using the smaller end of the graft placed at the arterial anastomosis, although this has not yet been proven to reduce the incidence of steal.  Indications for Treatment Intervention is recommended in lifestyle-limiting cases of Grade II and all Grade III steal cases. If left untreated, the natural history of steal syndrome can result in chronic limb ischemia, causing gangrene with loss of digits or limbs. Treatment Options Conservative management relies on observation and monitoring, as mild cases of steal syndrome may resolve spontaneously. Inflow stenosis can be treated with endovascular intervention (angioplasty with or without stent) Ligation is the simplest surgical treatment, and it results in loss of the AV access. This is preferred in patients with repetitive failed salvage attempts, venous hypertension, and poor prognoses. Flow limiting procedures can address high volumes through the AV access. Banding can be performed with surgical cutdown and placement of polypropylene sutures or a Dacron patch around the vein or graft. The Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) technique employs a percutaneous endoluminal balloon inflated at the AVF to ensure consistency in diameter while banding Plication is when a side-biting running stitch is used to narrow lumen of the vein near the anastomosis. A downside of flow-limiting procedures is that it is often difficult to determine how much to narrow the AV access, as these procedures carry a risk of outflow thrombosis. There are also surgical treatments focused on reroute arterial inflow. The distal revascularization and interval ligation (DRIL) procedure involves creation of a new bypass connecting arterial segments proximal and distal to the AV anastomosis, with ligation of the native artery between the AV anastomosis and the distal anastomosis of the bypass. Reversed saphenous vein with a diameter greater than 3mm is the preferred conduit. Arm vein or prosthetic grafts can be used if needed, but prosthetic material carries higher risk of thrombosis. The new arterial bypass creates a low resistance pathway that increases flow to distal arterial beds, and interval arterial ligation eliminates retrograde flow through the distal artery.  The major risk of this procedure is bypass thrombosis, which results in loss of native arterial flow and hand ischemia. Other drawbacks of DRIL include procedural difficulty with smaller arterial anastomoses, sacrifice of saphenous or arm veins, and decreased fistula flow. Another possible revision surgery is revision using distal inflow (RUDI). This procedure involves ligation of the fistula at the anastomosis and use of a conduit to connect the outflow vein to a distal artery. The selected distal artery can be the proximal radial or ulnar artery, depending on the preoperative duplex. The more dominant vessel should be spared, allowing for distal arterial beds to have uninterrupted antegrade perfusion. The nondominant vessel is used as distal inflow for the AV access. RUDI increases access length and decreases access diameter, resulting in increased resistance and lower flow volume through the fistula. Unlike DRIL, RUDI preserves native arterial flow.  Thrombosis of the conduit would put the fistula at risk, rather than the native artery.  The last surgical revision procedure for steal is proximalization of arterial inflow (PAI). In this procedure, the vein is ligated distal to the original anastomosis site and flow is re-established through the fistula with a PTFE interposition graft anastomosed end-to-side with the more proximal axillary artery and end-to-end with the distal vein. Similar to RUDI, PAI increases the length and decreases the diameter of the outflow conduit. Since the axillary artery has a larger diameter than the brachial artery, there is a less significant pressure drop across the arterial anastomosis site and less steal. PAI allows for preservation of native artery's continuity and does not require vein harvest.  Difficulties with PAI arise when deciding the length of the interposition graft to balance AV flow with distal arterial flow. 2. Ischemic Monomelic Neuropathy Definition Ischemic monomelic neuropathy (IMN) is a rare but serious form of steal that involves nerve ischemia. Severe sensorimotor dysfunction is experienced immediately after AV access creation. Etiology IMN affects blood flow to the nerves, but not the skin or muscles because peripheral nerve fibers are more vulnerable to ischemia. Incidence and Risk Factors IMN is very rare; it has an estimated incidence of 0.1-0.5% of AV access creations.6 IMN has only been reported in brachial artery-based accesses, since the brachial artery is the sole arterial inflow for distal arteries feeding all forearm nerves. IMN is associated with diabetes, peripheral vascular disease, and preexisting peripheral neuropathy that is associated with either of the conditions. Patient Presentation Symptoms usually present rapidly, within minutes to hours after AV access creation. The most common presenting symptom is severe, constant, and deep burning pain of the distal forearm and hand. Patients also report impairment of all sensation, weakness, and hand paralysis. Diagnosis of IMN can be delayed due to misattribution of symptoms to anesthetic blockade, postoperative pain, preexisting neuropathy, a heavily bandaged arm precluding neurologic examination. Treatment Treatment is immediate ligation of the AV access. Delay in treatment will quickly result in permanent sensorimotor loss.   3. Perigraft Seroma Definition A perigraft seroma is a sterile fluid collection surrounding a vascular prosthesis and is enclosed within a pseudomembrane. Etiology and Incidence Possible etiologies include: transudative movement of fluid through the graft material, serous fluid collection from traumatized connective tissues (especially the from higher adipose tissue content in the upper arm), inhibition of fibroblast growth with associated failure of the tissue to incorporate the graft, graft “wetting” or kinking during initial operation, increased flow rates, decreased hematocrit causing oncotic pressure difference, or allergy to graft material. Seromas most commonly form at anastomosis sites in the early postoperative period. Overall seroma incidence rates after AV graft placement range from 1.7–4% and are more common in grafts placed in the upper arm (compared to the forearm) and Dacron grafts (compared to PTFE grafts).7-9 Patient Presentation and Workup Physical exam can show a subcutaneous raised palpable fluid mass Seromas can be seen with ultrasound, but it is difficult to differentiate between the types of fluid around the graft (seroma vs. hematoma vs. abscess) Indications for Treatment Seromas can lead to wound dehiscence, pressure necrosis and erosion through skin, and loss of available puncture area for hemodialysis Persistent seromas can also serve as a nidus for infection. The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines10 recommend a tailored approach to seroma management, with more aggressive surgical interventions being necessary for persistent, infected-appearing, or late-developing seromas.   Treatment The majority of early postoperative seromas are self-limited and tend to resolve on their own Persistent seromas have been treated using a variety of  methods-- incision and evacuation of seroma, complete excision and replacement of the entire graft, and primary bypass of the involved graft segment only. Graft replacement with new material and rerouting through a different tissue plane has a higher reported cure rate and lower rate of infection than aspiration alone.9     4. Infection Incidence and Etiology The reported incidence of infection ranges 4-20% in AVG, which is significantly higher than the rate of infection of 0.56-5% in AVF.11  Infection can occur at the time of access creation (earliest presentation), after cannulation for dialysis (later infection), or secondary to another infectious source. Infection can also further complicate a pre-existing access site issue such as infection of a hematoma, thrombosed pseudoaneurysm, or seroma. Skin flora from frequent dialysis cannulations result in common pathogens being Staphylococcus, Pseudomonas, or polymicrobial species. Staphylococcus and Pseudomonas are highly virulent and likely to cause anastomotic disruption. Patient Presentation and Workup Physical exam will reveal warmth, pain, swelling, erythema, induration, drainage, or pus. Occasionally, patients have nonspecific manifestations of fever or leukocytosis. Ultrasound can be used to screen for and determine the extent of graft involvement by the infection.   Treatments In AV fistulas: Localized infection can usually be managed with broad spectrum antibiotics.  If there are bleeding concerns or infection is seen near the anastomosis site, the fistula should be ligated and re-created in a clean field. In AV grafts: If infection is localized, partial graft excision is acceptable. Total graft excision is recommended if the infection is present throughout the entire graft, involves the anastomoses, occludes the access, or contains particularly virulent organisms Total graft excision may also be indicated if a patient develops recurrent bacteremia with no other infectious source identified. For graft excision, the venous end of the graft is removed and the vein is oversewn or ligated. If the arterial anastomosis is intact, a small cuff of the graft can be left behind and oversewn. If the arterial anastomosis is involved, the arterial wall must be debrided and ligation, reconstruction with autogenous patch angioplasty, or arterial bypass can be pursued. References   1. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and Characteristics of Patients with Hand Ischemia after a Hemodialysis Access Procedure. J Surg Res. 1998;74(1):8-10. doi:10.1006/jsre.1997.5206 2. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg. 1992;164(3):229-232. doi:10.1016/S0002-9610(05)81076-1 3. Valentine RJ, Bouch CW, Scott DJ, et al. Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg. 2002;36(2):351-356. doi:10.1067/mva.2002.125848 4. Malik J, Tuka V, Kasalova Z, et al. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access. 2008;9(3):155-166. doi:10.1177/112972980800900301 5. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35(3):603-610. doi:10.1067/mva.2002.122025 6. Thermann F, Kornhuber M. Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review. J Vasc Access. 2011;12(2):113-119. doi:10.5301/JVA.2011.6365 7. Dauria DM, Dyk P, Garvin P. Incidence and Management of Seroma after Arteriovenous Graft Placement. J Am Coll Surg. 2006;203(4):506-511. doi:10.1016/j.jamcollsurg.2006.06.002 8. Gargiulo NJ, Veith FJ, Scher LA, Lipsitz EC, Suggs WD, Benros RM. Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas. J Vasc Surg. 2008;48(1):216-217. doi:10.1016/j.jvs.2008.01.046 9. Blumenberg RM, Gelfand ML, Dale WA. Perigraft seromas complicating arterial grafts. Surgery. 1985;97(2):194-204. 10. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. doi:10.1053/j.ajkd.2019.12.001 11. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48(5):S55-S80. doi:10.1016/j.jvs.2008.08.067

Hot 2 Trot will be heading to Penn National for the Grade III Penn Mile, but first we sit down with Penn National's Chris McErlean who lets us know what will be going on the Penn Mile and what else we can expect this summer from our Penn National properties. 

Erin Orford/ Equissage Pulse Para Gold Grade III

Featuring perspectives from Dr Matthew Lunning, including the following topics: ·      Introduction (00:00) ·      Case: A woman in her mid 20s with T1cN0M0, ER/PR-positive, HER2-negative breast cancer, Recurrence Score® (RS) of 26 — Dr Partridge (10:03) ·      Case: A woman in her late 20s with a 2.8-cm ER/PR-positive, HER2-positive Grade III intraductal carcinoma — Dr Miller (26:42) ·      Case: A woman in her mid 30s with a 3.5-cm ER/PR-negative, HER2-negative breast cancer with a BRCA2 mutation — Dr Partridge  (41:01) ·      Case: A woman in her early 30s with ER/PR-positive, HER2-negative inflammatory breast cancer — Dr Miller (52:28) CME information and select publications  

Featuring perspectives from Drs Aditya Bardia, Matthew Goetz, Virginia Kaklamani, Kevin Kalinsky and Hope Rugo, including the following topics: Current Role of Genomic Assays for Hormone Receptor (HR)-Positive Localized Breast Cancer  Introduction (0:00) Case: A premenopausal woman in her early 40s with 9-mm, Grade III, ER/PR-positive, HER2-negative, node-negative infiltrating ductal carcinoma (IDC) – 21-gene Recurrence Score® 22 — Alan B Astrow, MD (3:39) Case: A premenopausal woman in her mid 30s with 3.6-cm, ER/PR-positive, HER2-low (IHC 1+), sentinel node-positive (4/4) multifocal IDC after bilateral mastectomies, adjuvant AC-T and ovarian function suppression (OFS)/aromatase inhibitor, Ki67 50% — Laila Agrawal, MD (9:40) Dr Goetz presentation (19:43) Optimizing the Management of Localized ER-Positive Breast Cancer  Case: A woman in her early 40s with 5.5-cm, ER/PR-positive, HER2-negative, node-positive (20/21) IDC after bilateral mastectomies, bilateral salpingo-oophorectomy, adjuvant AC-T and initiation of letrozole/abemaciclib, Ki-67 3% — Susmitha Apuri, MD (32:22) Case: A woman in her mid 50s with de novo ER-positive, PR-negative, HER2-negative ulcerated breast cancer with pulmonary and extensive spinal metastases — Jennifer L Dallas, MD (40:45)  Dr Kaklamani presentation (45:32) Selection and Sequencing of Therapy for Patients with ER-Positive Metastatic Breast Cancer (mBC)  Case: A woman in her early 50s with ER/PR-positive, HER2-low mBC with a PI3KCA mutation who experiences a dramatic response to rechallenge with fulvestrant and a CDK4/6i (abemaciclib); now with progression and cytopenias — Kapisthalam (KS) Kumar, MD (59:07) Dr Kalinsky presentation (1:09:53) Recent Appreciation of HER2 Low as a Unique Subset of HR-Positive Breast Cancer  Case: A premenopausal woman in her late 30s with ER/PR-positive, HER2-low (IHC 1+) IDC after adjuvant tamoxifen and OFS x 5 years, now with bone and liver metastases — Dr Agrawal (1:19:45) Dr Bardia presentation (1:24:29) Novel Strategies Under Investigation for Patients with HR-Positive mBC  Case: A woman in her early 90s with ER/PR-positive, HER2-low (IHC 1+) mBC and progressive disease on multiple lines of endocrine and chemotherapy receives T-DXd — Dr Astrow (1:38:44) Case: A woman in her mid 40s with ER/PR-positive, HER2-low (IHC 2+) mBC who has received fulvestrant/abemaciclib, now receiving exemestane/everolimus – ESR1 and PIK3CA mutations — Dr Dallas (1:44:15) Dr Rugo presentation (1:49:58) CME information and select publications

Rachel lives by God first and family second. She has been a Christian all her life, but her normal life was challenged in 2016 which inspired her to encourage, inspire and challenge ladies to discover and raise their self worth, not settle and walk in God's will. The Lord had to physically break me to help me and get me on the path He'd have me be on. All through a Grade III brain tumor, radiation, chemo and being bald twice. And the dream He blessed me with during rehabilitation that has led to the business, R. Lindsay Unlimited. Be sure to follow TheMarissaBaker on TikTok and instagram so you never miss an episode! 

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On tonight's Big Monday show Barry and I talk about todays hearing re: NYRA vs Baffert and how that seemed to go on Day 1. We previewed the Pegasus World Cup and Barry tries to convince me an upset is a possibility (he didn't convince me) and a little weather coverage that would make Jim Cantore jealous. (It's gonna be

Featuring perspectives from Dr Brian Hill, including the following topics:  Introduction: ASH 2021 — Diffuse Large B-Cell Lymphoma (DLBCL) (0:00) Case: A man in his late 70s with relapsed/refractory DLBCL — Syed F Zafar, MD (16:55) Case: A man in his late 60s with advanced DLBCL — Shaachi Gupta, MD, MPH (20:47) Case: A woman in her mid 70s with Hodgkin lymphoma — Ferdy Santiago, MD (27:37) Faculty Survey Results (32:34) ASH 2021 and Journal Club with Dr Hill — Part 1 (34:39) Case: A man in his early 60s with relapsed mantle cell lymphoma — Sulfi Ibrahim, MD (36:20) Case: A man in his late 80s with Grade III follicular lymphoma — Laurie Matt-Amaral, MD, MPH (51:00) ASH 2021 and Journal Club with Dr Hill – Part 2 (55:00) CME information and select publications

Welcome to Hang the Holly. I'll introduce you to THE ROGUES as we take an inside look at artists in the latest episode of the Celtic Christmas Podcast.    "The Snows That Melt the Soonest" is the 4th episode of 2020 and show #58. It features Christmas music from Runa, Stephanie Claussen, David Pedrick, Matt & Shannon Heaton, Steel Clover, Mark O'Connor, Marc Gunn, deCeadaoin, Andrew D. Huber, The Rogues, Sheri O'Meara, Abbots Cross, Reilly, Prydein, The Jig Is Up!.   The show is generously brought to you by the Patrons of the Celtic Christmas Podcast on Patreon. Please show your Celtic Christmas Cheer, make a pledge to support the show.   If you enjoy the show, you can rate the show or post comments on Apple Podcasts or your favorite podcatcher.  Subscribe to the podcast at CelticChristmasPodcast.com.   And now on to The Rogues...     The Rogues have been producing music since wayyyyy back in 1994 when they got their start at the Texas Renaissance Festival. This Celtic band didn't stay put in Houston for long though, and soon they were off--traveling all over the U.S., and even abroad. They've performed in Canada, Scotland, and Greece, among other places over the years, as well as providing entertainment on a number of different cruise ships. This great mixture of experiences has allowed the band the opportunity to truly hone their live shows, and put a shine on their ability to play together in a variety of different contexts. It has also given them a great deal of expertise in terms of playing Celtic tunes.   The Rogues are no amateurs when it comes to playing their instruments either, and band members have won prestigious music competitions, including first place in the World Pipe Band Championships in Grade III in 1998. If pressed to describe them, you could say they take their music seriously, but they don't take themselves too seriously, which results in a nice mash up of outstanding musicianship and good fun—it really works out well. Plus, you know a band is not messing around when they wind up with their own tartan in the Scottish Register of Tartans. That's dedication to the Celtic genre at a deep level.   You can't help but notice a full pipe sound and a lot of percussion when you listen to this band play, but they are also capable of music that pulls at the heartstrings. The variety of instruments, arrangements, and pairings keeps things interesting, no matter how familiar the tune. This is especially evident on The Rogues 2013 Christmas album, Hellbound Sleigh, where you'll hear tried-and-true favorites such as “We Wish You a Merry Christmas” and “God Rest Ye Merry Gentlemen” in a very different light. Be sure to listen to the "O Holy Night / Ave Maria” track, which has an almost haunting feel to it—in the best possible way. And—don't miss "Jingle Bells/Good King Wenceslas” for a rousing take on this classic that showcases the pipes front and center.   The best part about this festive album though is the fact that there are also a few tracks you won't find in every Christmas collection, making it a great pick for your music rotation this holiday season. Keep it all to yourself and enjoy listening at home, or ship it over to a friend or family member that needs a little bit ‘o cheer in the stocking.   Find out more about The Rogues at therogues.com    If you hear music you love, then support the artists. Buy something from them. Sign up to their mailing lists. And share the episode with your friends on social or in your community.     The Celtic Christmas Podcast is free to enjoy. However, it is supported by the generosity of Celtic music fans like you over on Patreon. Get Christmas Cheer. Subscribe at CelticChristmasPodcast.com . Nollaig shona daoibh.

Podcast by Cherish from grade-III - Speaking on ' Tips for Healthy and Happy Life ' - AVIS, Secunderabad Campus

Equipage Pulse Para Gold - Grade III: Erin Orford with LJT Diamond Crusador 

Proceedings from the second in a 2-part nursing webinar series. Featuring perspectives from Ms Jamie Carroll and Dr Sara Hurvitz, including the following topics: Introduction (0:00) An Overview of Breast Cancer in 2021 Case: A premenopausal woman in her early 40s with ER-positive, HER2-positive, node-negative breast cancer — Laurie Matt Amaral, MD, MPH (3:17) Management of Localized HER2-Positive Breast Cancer (7:22) Case: A woman in her early 70s with clinical T4 ER/PR-negative, HER2-positive breast cancer —Dr Matt Amaral (11:35) Sequencing of Agents for Metastatic HER2-Positive Breast Cancer (14:57) Case: A woman in her early 70s with a 10-cm Grade III, ER/PR-negative, HER2-positive infiltrating ductal carcinoma and pleural metastases — Alan B Astrow, MD (30:30) Case: A woman in her mid-30s with heavily pretreated ER/PR-positive, HER2-positive breast cancer and bone metastases — Estelamari Rodriguez, MD, MPH (36:34) Systemic Treatment of Brain Metastases in Patients with HER2-Positive Breast Cancer (51:33) Case: A Middle Eastern woman in her early 40s with HER2-positive breast cancer and brain metastases — Yanjun Ma, MD (51:49) Case: A woman in her early 40s with ER/PR-negative, HER2-positive breast cancer with brain metastasis — Atif Hussein, MD, MMM (55:06) NCPD information and select publications

Featuring perspectives from Dr Mark D Pegram on the following topics: Case presentations and San Antonio Breast Cancer Symposium (SABCS®) review of locally advanced and high-risk HER2-positive breast cancer Introduction (0:00) Case: A 49-year-old woman who received neoadjuvant TCHP, currently awaiting surgery — Estelamari Rodriguez, MD, MPH (5:12) Case: A 55-year-old woman with Stage I HER2-positive breast cancer — Kelly Yap, MD (23:46) Case: A 45-year-old woman who received postoperative T-DM1 after neoadjuvant TCHP — Philip Glynn, MD (26:30) Case: A 39-year-old woman with localized disease and a positive cervical node on PET scan — Dr Rodriguez (32:00) Case presentations and SABCS review of metastatic HER2-positive breast cancer Case: A 70-year-old woman with a 10-cm Grade III, ER/PR-negative, HER2-positive infiltrating ductal carcinoma and pleural metastases — Alan B Astrow, MD (38:24) Case: An 87-year-old woman with pretreated HER2-positive metastatic breast cancer now with negative (low) HER2 — Yanjun Ma, MD (43:25) Case: A 60-year-old woman with malignant pericardial effusion — Dr Glynn (50:23) Case: A 43-year-old woman who develops brain metastases after prior TCHP — Dr Yap (53:09) CME information and select publications

With the province back in lockdown and horse racing in no man's land, Mary Jane Sibbitt created a petition to let Doug Ford know how safe horse racing can be. The race stoppage was a huge impediment to Anthony MacDonald whose thestable.ca has 121 horses and nowhere in Ontario to race. They could not stop the Sovereign Awards and Mighty Heart could not be stopped in his quest for the Horse of the Year Trophy. Sam-Son Farm's Danceforthecause was named the Outstanding Broodmare and two days later, one of her sons won a Grade III at Keeneland. Chantal Sutherland keeps winning races at Gulfstream, and we also have race calls from Yonkers, the Meadowlands, and just for fun, a race at Oaklawn that gave announcer Vic Stauffer fits.

Featuring a roundtable discussion with Drs Virginia F Borges, Sara Hurvitz and Ian E Krop, including the following topics: Introduction Impact of COVID-19 vaccinations on screening for breast cancer (0:00) Management of HER2-positive early breast cancer Case: A woman in her early 40s with ER/PR-positive, HER2-positive breast cancer achieves a pathologic complete response with docetaxel/trastuzumab/pertuzumab — Alan B Astrow, MD (6:30) Therapeutic approach for patients with HER2-positive breast cancer and residual disease after neoadjuvant therapy (10:04) Case: A woman in her early 70s with Grade III, ER/PR-negative, HER2-positive breast cancer develops shortness of breath after neoadjuvant chemotherapy — Dr Astrow (19:57) Disease-specific factors in the selection of neoadjuvant therapy for patients with HER2-positive breast cancer (28:00) Selection of HER2-targeted therapy in the adjuvant setting  (33:31) Selection and sequencing of therapies for HER2-positive metastatic breast cancer Case: A woman in her early 40s with HER2-positive breast cancer and brain metastases — Yanjun Ma, MD (36:11) Case: A woman in her mid-30s with ER/PR-positive, HER2-positive breast cancer and brain metastases — Estelamari Rodriguez, MD, MPH (40:56) Case: A woman in her mid-60s who presents with a large, ulcerated breast mass and is diagnosed with HER2-positive breast cancer and liver metastases — Dr Astrow (48:38) Choice of initial therapy for patients with metastatic HER2-positive breast cancer (55:08) Management of HER2-positive breast cancer with brain metastases; intracranial activity of tucatinib in patients with metastatic HER2-positive breast cancer (1:00:00) CNS penetration and intracranial response with the antibody-drug conjugates trastuzumab deruxtecan and T-DM1; efficacy and tolerability of neratinib after disease progression on tucatinib (1:07:28) Perspective on the use of hormonal therapy for patients with ER/PR-positive, HER2-positive breast cancer (1:12:45) Efficacy of PARP inhibitors in patients with HER2-positive breast cancer and BRCA mutations; emerging data from the OlympiA trial evaluating olaparib as adjuvant therapy for patients with HER2-negative breast cancer and germline BRCA mutations (1:18:53) Benefits and risks of the novel anti-HER2 antibody margetuximab for patients with HER2-positive advanced breast cancer (1:25:10) CME information and select publications

What is the Dyatlov Pass incident? Well, as we’ll find out, it was when nine Russian hikers died in the northern Ural Mountains between February 1st & 2nd in 1959, under supposed uncertain circumstances. The experienced trekking group, who were all from the Ural Polytechnical Institute, had established a camp on the slopes of Kholat Syakhl, in an area now named in honour of the group's leader, Igor Dyatlov. During the night, something caused them to cut their way out of their tent and attempt to flee the campsite while not being dressed for the heavy ass snowfall and subzero temperatures. Subzero was one of my favorite Mortal Kombat characters… god I loved that game. After the group's bodies were grusomly discovered, an investigation by Soviet authorities determined that six of them had died from hypothermia while the other three had been killed by physical trauma. One victim actually had major skull damage, two had severe chest trauma, and another had a small crack in the skull. Was all of this caused by an avalanche or from something nefarious? Four of the bodies were found lying in running water in a creek, and three of these had soft tissue damage of the head and face – two of the bodies were missing their eyes, one was missing its tongue, and one was missing its eyebrows. It’s eyebrows! The Soviet investigation concluded that a "compelling natural force" had caused the untimely deaths. Numerous theories have been brought forward to account for the unexplained deaths, including animal attacks, hypothermia, avalanche, katabatic winds, infrasound-induced panic, military involvement, or some combination of these. We’ll discuss all these in further detail later on. Recently, Russia has opened a new investigation into the Dyatlov incident in 2019, and its conclusions were presented in July 2020: Simply put, they believe  that an avalanche had led to the deaths of the hikers. Survivors of the avalanche had been forced to suddenly leave their camp in low visibility conditions with inadequate clothing, and had died of hypothermia. Andrey Kuryakov, deputy head of the regional prosecutor's office, said: "It was a heroic struggle. There was no panic. But they had no chance to save themselves under the circumstances." A study published in 2021 suggested that a type of avalanche known as a slab avalanche could explain some of the injuries. However, we’ll run through everything and you can come to your own conclusion.   Ok, let’s dive into the details of the event. In 1959, the group was formed for a skiing expedition across the northern Urals in Sverdlovsk Oblast, Soviet Union. According to Prosecutor Tempalov, documents that were found in the tent of the expedition suggest that the expedition was named for the 21st Congress of the Communist Party of the Soviet Union, and was possibly dispatched by the local Komsomol organisation.Which was a political youth organization in the Soviet Union, which was sometimes described as the youth division of the Communist Party of the Soviet Union. Igor Dyatlov, a 23-year-old radio engineering student at the Ural Polytechnical Institute; now Ural Federal University, was the leader who assembled a group of nine others for the trip, most of whom were fellow students and peers at the university.Ok, so they were mostly students. Each member of the group, which consisted of eight men and two women, was an experienced Grade II-hiker with ski tour experience, and would be receiving Grade III certification upon their return. So, this trekk was like a test. I hated tests. Especially ones that could KILL YOU! At the time, this was the highest certification available in the Soviet Union, and required candidates to traverse 190 mi. The route was designed by Igor Dyatlov's group in order to reach the far northern regions of Sverdlovsk Oblast and the upper-streams of the Lozva river. The route was approved by the Sverdlovsk city route commission, which was a division of the Sverdlovsk Committee of Physical Culture and Sport. They approved of and confirmed the group of 10 people on January 8th, 1959. The goal of the expedition was to reach Otorten, a mountain(6.2 mi north of the site where the incident took place. This path, taken  in February, was estimated as a Category III, the most difficult time to traverse.   On January 23rd, 1959 the Dyatlov group was issued their route book which listed their course as following the No.5 trail. At that time, the Sverdlovsk City Committee of Physical Culture and Sport listed approval for 11 people. The 11th person was listed as Semyon Zolotaryov who was previously certified to go with another expedition of similar difficulty (that was the Sogrin expedition group). The Dyatlov group left the Sverdlovsk city (today called Yekaterinburg) on the same day they received the route book.   The members of the group were Igor Alekseyevich Dyatlov, Yuri Nikolayevich Doroshenko, Lyudmila Alexandrovna Dubinina, Georgiy (Yuri) Alexeyevich Krivonischenko, Alexander Sergeyevich Kolevatov, Zinaida Alekseevna Kolmogorova, Rustem Vladimirovich Slobodin, Nikolai Vladimirovich Thibeaux-Brignolles, Semyon (Alexander) Alekseevich Zolotaryov, and Yuri Yefimovich Yudin   The group arrived by train at Ivdel, a town at the centre of the northern province of Sverdlovsk Oblast in the early morning hours of January 25, 1959. They took a truck to Vizhai, a little village that is the last inhabited settlement to the north. As of 2010, only 207 really, really fucking cold people lived there. While spending the night in Vizhai, and probably freezing their baguettes off, the skiers purchased and ate loaves of bread to keep their energy levels up for the following day's hike. On January 27, they began their trek toward Gora Otorten. On January 28, one member, Yuri Yudin, who suffered from several health ailments (including rheumatism and a congenital heart defect) turned back due to knee and joint pain that made him unable to continue the hike. The remaining nine hikers continued the trek. Ok, my first question with this is, why in the fuck was that guy there, to begin with??  Diaries and cameras found around their last campsite made it possible to track the group's route up to the day before the incident. On January 31st, the group arrived at the edge of a highland area and began to prepare for climbing. In a wooded valley, they rounded up surplus food and equipment that they would use for the trip back. The next day, the hikers started to move through the pass. It seems they planned to get over the pass and make camp for the next night on the opposite side, but because of worsening weather conditions—like snowstorms,  decreasing visibility... large piles of yeti shit—they lost their direction and headed west, toward the top of Kholat Syakhl. When they realised their mistake, the group decided to set up camp there on the slope of the mountain, rather than move almost a mile downhill to a forested area that would have offered some shelter from the weather. Yudin, the debilitated goofball that shouldn’t have even been there speculated, "Dyatlov probably did not want to lose the altitude they had gained, or he decided to practice camping on the mountain slope."   Before leaving, Captain Dyatlov had agreed he would send a telegram to their sports club as soon as the group returned to teeny, tiny Vizhai. It was expected that this would happen no later than February 12th, but Dyatlov had told Yudin, before he departed from the group, that he expected it to actually be longer. When the 12th passed and no messages had been received, there was no immediate reaction because, ya know… fuck it. Just kidding, these types of delays were actually common with such expeditions. On February 20th, the travellers' worried relatives demanded a rescue operation and the head of the institute sent the first rescue groups, consisting of volunteer students and teachers. Later, the army and militsiya forces (aka the Soviet police) became involved, with planes and helicopters ordered to join in on the search party. On February 26th, the searchers found the group's abandoned and super fucked up tent on Kholat Syakhl. The campsite undoubtedly baffled the search party. Mikhail Sharavin, the student who found the tent, said “HOLY SHIT! THIS PLACE IS FUCKED UP!”... No, that’s not true. He actually said, "the tent was half torn down and covered with snow. It was empty, and all the group's belongings and shoes had been left behind." Investigators said the tent had been cut open from inside. Which seems like a serious and quick  escape route was needed. Nine sets of footprints, left by people wearing only socks or a single shoe or even barefoot, could actually be followed, leading down to the edge of a nearby wood, on the opposite side of the pass, about a mile to the north-east. After approximately 1,600 ft, these tracks were covered with snow. At the forest's edge, under a large Siberian pine, the searchers found the visible remains of a small fire. There were the first two bodies, those of Krivonischenko and Doroshenko, shoeless and dressed only in their tighty whiteys. The branches on the tree were broken up to five meters high, suggesting that one of the skiers had climbed up to look for something, maybe the camp. Between the pine and the camp, the searchers found three more corpses: Dyatlov, Kolmogorova, and Slobodin, who died in poses suggesting that they were attempting to return to the tent. They were found at distances of 980, 1,570, and 2,070 ft from the tree. Finding the remaining four travellers took more than two frigging months. They were finally found on May 4th under 13 ft of snow in a ravine 246 ft further into the woods from the pine tree. Three of the four were better dressed than the others, and there were signs that some clothing of those who had died first had been taken off of their corpses for use by the others. Dubinina was wearing Krivonishenko's burned, torn trousers, and her left foot and shin were wrapped in a torn jacket.   Let’s get into the investigation. A legal inquest started immediately after the first five bodies were found. A medical examination found no injuries that might have led to their deaths, and it was concluded that they had all died of hypothermia.Which would make sense because it was colder than a polar bear’s butthole. Slobodin had a small crack in his skull, but it was not thought to be a fatal wound. An examination of the four bodies found in May shifted the overall narrative of what they initially believed transpired. Three of the hikers had fatal injuries: Thibeaux-Brignolles had major skull damage, and Dubinina and Zolotaryov had major chest fractures. According to Boris Vozrozhdenny, the force required to cause such damage would have been extremely high, comparable to that of a car crash.Also, the bodies had no external wounds associated with the bone fractures, as if they had been subjected to a high level of pressure. All four bodies found at the bottom of the creek in a running stream of water had soft tissue damage to their head and face. For example, Dubinina was missing her tongue, eyes, part of the lips, as well as facial tissue and a fragment of her skullbone, while Zolotaryov was missing his friggin eyeballs, and Aleksander Kolevatov his eyebrows. V. A. Vozrozhdenny, the forensic expert performing the post-mortem examination, judged that these injuries happened after they had died, due to the location of the bodies in a stream. At first, there was speculation that the indigenous Mansi people, who were just simple reindeer herders local to the area, had attacked and murdered the group for making fun of Rudolph. Several Mansi were interrogated, but the investigation indicated that the nature of the deaths did not support this hypothesis: only the hikers' footprints were visible, and they showed no sign of hand-to-hand struggle. Oh, I was kidding about the Rudolph thing. They thought they attacked the hikers for being on their land.  Although the temperature was very low, around −13 to −22 °F with a storm blowing, the dead were only partially dressed, as I mentioned.  Journalists reporting on the available parts of the inquest files claim that it states: Six of the group members died of hypothermia and three of fatal injuries. There were no indications of other people nearby on Kholat Syakhl apart from the nine travellers. The tent had been ripped open from within. The victims had died six to eight hours after their last meal. Traces from the camp showed that all group members left the campsite of their own accord, on foot. Some levels of radiation were found on one victim's clothing. To dispel the theory of an attack by the indigenous Mansi people, Vozrozhdenny stated that the fatal injuries of the three bodies could not have been caused by human beings, "because the force of the blows had been too strong and no soft tissue had been damaged". Released documents contained no information about the condition of the skiers' internal organs. And most obviously, There were no survivors. At the time, the official conclusion was that the group members had died because of a compelling natural force.The inquest officially ceased in May 1959 as a result of the absence of a guilty party. The files were sent to a secret archive. In 1997, it was revealed that the negatives from Krivonischenko's camera were kept in the private archive of one of the investigators, Lev Ivanov. The film material was donated by Ivanov's daughter to the Dyatlov Foundation. The diaries of the hiking party fell into Russia's public domain in 2009. On April 12th, 2018, Zolotarev's remains were exhumed on the initiative of journalists of the Russian tabloid newspaper Komsomolskaya Pravda. Contradictory results were obtained: one of the experts said that the character of the injuries resembled a person knocked down by a car, and the DNA analysis did not reveal any similarity to the DNA of living relatives. In addition, it turned out that Zolotarev's name was not on the list of those buried at the Ivanovskoye cemetery. Nevertheless, the reconstruction of the face from the exhumed skull matched postwar photographs of Zolotarev, although journalists expressed suspicions that another person was hiding under Zolotarev's name after World War II. In February 2019, Russian authorities reopened the investigation into the incident, yet again,  although only three possible explanations were being considered: an avalanche, a slab avalanche, or a hurricane. The possibility of a crime had been discounted.   Other reports brought about a whole bunch of additional speculation. Twelve-year-old Yury Kuntsevich, who later became the head of the Yekaterinburg-based Dyatlov Foundation, attended five of the hikers' funerals. He recalled that their skin had a "deep brown tan". Another group of hikers 31 mi south of the incident reported that they saw strange orange spheres in the sky to the north on the night of the incident.Similar spheres were observed in Ivdel and other areas continually during the period from February to March of 1959, by various independent witnesses (including the meteorology service and the military). These sightings were not noted in the 1959 investigation, and the various witnesses came forward years later. After the initial investigation, Anatoly Gushchin summarized his research in the book The Price of State Secrets Is Nine Lives. Some researchers criticised the work for its concentration on the speculative theory of a Soviet secret weapon experiment, but its publication led to public discussion, stimulated by interest in the paranormal.It is true that many of those who had remained silent for thirty years reported new facts about the accident. One of them was the former police officer, Lev Ivanov, who led the official inquest in 1959. In 1990, he published an article that included his admission that the investigation team had no rational explanation for the incident. He also stated that, after his team reported that they had seen flying spheres, he then received direct orders from high-ranking regional officials to dismiss this claim. In 2000, a regional television company produced the documentary film The Mystery of Dyatlov Pass. With the help of the film crew, a Yekaterinburg writer, Anna Matveyeva, published a docudrama of the same name. A large part of the book includes broad quotations from the official case, diaries of victims, interviews with searchers and other documentaries collected by the film-makers. The narrative line of the book details the everyday life and thoughts of a modern woman (an alter ego of the author herself, which is super weird) who attempts to resolve the case. Despite its fictional narrative, Matveyeva's book remains the largest source of documentary materials ever made available to the public regarding the incident. Also, the pages of the case files and other documentaries (in photocopies and transcripts) are gradually being published on a web forum for nerds just like you and i!. The Dyatlov Foundation was founded in 1999 at Yekaterinburg, with the help of Ural State Technical University, led by Yuri Kuntsevitch. The foundation's stated aim is to continue investigation of the case and to maintain the Dyatlov Museum to preserve the memory of the dead hikers. On July 1st 2016, a memorial plaque was inaugurated in Solikamsk in Ural's Perm Region, dedicated to Yuri Yudin (the dude who pussed out and is the sole survivor of the expedition group), who died in 2013.   Now, let’s go over some of the theories of what actually took place at the pass. Avalanche On July 11 2020, Andrey Kuryakov, deputy head of the Urals Federal District directorate of the Prosecutor-General's Office, announced an avalanche to be the "official cause of death" for the Dyatlov group in 1959. Later independent computer simulation and analysis by Swiss researchers also suggest avalanche as the cause.   Reviewing the sensationalist "Yeti" hypothesis , American skeptic author Benjamin Radford suggests an avalanche as more plausible: “that the group woke up in a panic (...) and cut their way out the tent either because an avalanche had covered the entrance to their tent or because they were scared that an avalanche was imminent (...) (better to have a potentially repairable slit in a tent than risk being buried alive in it under tons of snow). They were poorly clothed because they had been sleeping, and ran to the safety of the nearby woods where trees would help slow oncoming snow. In the darkness of night, they got separated into two or three groups; one group made a fire (hence the burned hands) while the others tried to return to the tent to recover their clothing since the danger had passed. But it was too cold, and they all froze to death before they could locate their tent in the darkness. At some point, some of the clothes may have been recovered or swapped from the dead, but at any rate, the group of four whose bodies was most severely damaged were caught in an avalanche and buried under 4 meters (13 ft) of snow (more than enough to account for the 'compelling natural force' the medical examiner described). Dubinina's tongue was likely removed by scavengers and ordinary predation.” Evidence contradicting the avalanche theory includes: The location of the incident did not have any obvious signs of an avalanche having taken place. An avalanche would have left certain patterns and debris distributed over a wide area. The bodies found within a month of the event were covered with a very shallow layer of snow and, had there been an avalanche of sufficient strength to sweep away the second party, these bodies would have been swept away as well; this would have caused more serious and different injuries in the process and would have damaged the tree line. Over 100 expeditions to the region had been held since the incident, and none of them ever reported conditions that might create an avalanche. A study of the area using up-to-date terrain-related physics revealed that the location was entirely unlikely for such an avalanche to have occurred. The "dangerous conditions" found in another nearby area (which had significantly steeper slopes and cornices) were observed in April and May when the snowfalls of winter were melting. During February, when the incident occurred, there were no such conditions. An analysis of the terrain and the slope showed that even if there could have been a very specific avalanche that found its way into the area, its path would have gone past the tent. The tent had collapsed from the side but not in a horizontal direction. Dyatlov was an experienced skier and the much older Zolotaryov was studying for his Masters Certificate in ski instruction and mountain hiking. Neither of these two men would have been likely to camp anywhere in the path of a potential avalanche. Footprint patterns leading away from the tent were inconsistent with someone, let alone a group of nine people, running in panic from either real or imagined danger. All the footprints leading away from the tent and towards the woods were consistent with individuals who were walking at a normal pace. Repeated 2015 investigation[edit] A review of the 1959 investigation's evidence completed in 2015–2019 by experienced investigators from the Investigative Committee of the Russian Federation (ICRF) on request of the families confirmed the avalanche with several important details added. First of all, the ICRF investigators (one of them an experienced alpinist) confirmed that the weather on the night of the tragedy was very harsh, with wind speeds up to hurricane force,(45–67 mph, a snowstorm and temperatures reaching −40 °C. These factors weren't considered by the 1959 investigators who arrived at the scene of the accident three weeks later when the weather had much improved and any remains of the snow slide had settled and been covered with fresh snowfall. The harsh weather at the same time played a critical role in the events of the tragic night, which have been reconstructed as follows: On 1 February the group arrives at the Kholat Syakhl mountain and erects a large, 9-person tent on an open slope, without any natural barriers such as forests. On the day and a few preceding days, a heavy snowfall continued, with strong wind and frost. The group traversing the slope and digging a tent site into the snow weakens the snow base. During the night the snowfield above the tent starts to slide down slowly under the weight of the new snow, gradually pushing on the tent fabric, starting from the entrance. The group wakes up and starts evacuation in panic, with only some able to put on warm clothes. With the entrance blocked, the group escapes through a hole cut in the tent fabric and descends the slope to find a place perceived as safe from the avalanche only 1500 m down, at the forest border. Because some of the members have only incomplete clothing, the group splits. Two of the group, only in their underwear and pajamas, were found at the Siberian pine tree, near a fire pit. Their bodies were found first and confirmed to have died from hypothermia. Three hikers, including Dyatlov, attempted to climb back to the tent, possibly to get sleeping bags. They had better clothes than those at the fire pit, but still quite light and with inadequate footwear. Their bodies were found at various distances 300–600 m from the campfire, in poses suggesting that they had fallen exhausted while trying to climb in deep snow in extremely cold weather. The remaining four, equipped with warm clothing and footwear, were trying to find or build a better camping place in the forest further down the slope. Their bodies were found 70 m from the fireplace, under several meters of snow and with traumas indicating that they had fallen into a snow hole formed above a stream. These bodies were found only after two months. According to the ICRF investigators, the factors contributing to the tragedy were extremely bad weather and lack of experience of the group leader in such conditions, which led to the selection of a dangerous camping place. After the snow slide, another mistake of the group was to split up, rather than building a temporary camp down in the forest and trying to survive through the night. Negligence of the 1959 investigators contributed to their report creating more questions than answers and inspiring numerous conspiracy theories. In 2021 a team of physicists and engineers led by Alexander Puzrin published a new model that demonstrated how even a relatively small slide of snow slab on the Kholat Syakhl slope could cause tent damage and injuries consistent with those suffered by Dyatlov team. Ok, what about the Katabatic wind that I mentioned earlier? In 2019, a Swedish-Russian expedition was made to the site, and after investigations, they proposed that a violent katabatic wind was a plausible explanation for the incident. Katabatic winds are a drainage wind, a wind that carries high-density air from a higher elevation down a slope under the force of gravity. They are somewhat rare events and can be extremely violent. They were implicated in a 1978 case at Anaris Mountain in Sweden, where eight hikers were killed and one was severely injured in the aftermath of katabatic wind. The topography of these locations were noted to be very similar according to the expedition. A sudden katabatic wind would have made it impossible to remain in the tent, and the most rational course of action would have been for the hikers to cover the tent with snow and seek shelter behind the treeline. On top of the tent, there was also a torch left turned on, possibly left there intentionally so that the hikers could find their way back to the tent once the winds subsided. The expedition proposed that the group of hikers constructed two bivouac shelters, or just makeshift shelters, one of which collapsed, leaving four of the hikers buried with the severe injuries observed. Infrasound Another hypothesis popularised by Donnie Eichar's 2013 book Dead Mountain is that wind going around Kholat Syakal created a Kármán vortex street, a repeating pattern of swirling vortices, caused by a process known as vortex shedding, which is responsible for the unsteady separation of flow of a fluid around blunt bodies. which can produce infrasound capable of inducing panic attacks in humans. According to Eichar's theory, the infrasound generated by the wind as it passed over the top of the Holatchahl mountain was responsible for causing physical discomfort and mental distress in the hikers. Eichar claims that, because of their panic, the hikers were driven to leave the tent by whatever means necessary, and fled down the slope. By the time they were further down the hill, they would have been out of the infrasound's path and would have regained their composure, but in the darkness would have been unable to return to their shelter. The traumatic injuries suffered by three of the victims were the result of their stumbling over the edge of a ravine in the darkness and landing on the rocks at the bottom. Hmmm...plausible. Military tests In another theory, the campsite fell within the path of a Soviet parachute mine exercise. This theory alleges that the hikers, woken up by loud explosions, fled the tent in a shoeless panic and found themselves unable to return for their shit. After some members froze to death attempting to endure the bombardment, others commandeered their clothing only to be fatally injured by subsequent parachute mine concussions. There are in fact records of parachute mines being tested by the Soviet military in the area around the time the hikers were out there, fuckin’ around. Parachute mines detonate while still in the air rather than upon striking the Earth's surface and produce signature injuries similar to those experienced by the hikers: heavy internal damage with relatively little external trauma. The theory coincides with reported sightings of glowing, orange orbs floating or falling in the sky within the general vicinity of the hikers and allegedly photographed by them, potentially military aircraft or descending parachute mines. (remember the camera they found? HUH? Yeah?)  This theory (among others) uses scavenging animals to explain Dubinina's injuries. Some speculate that the bodies were unnaturally manipulated, on the basis of characteristic livor mortis markings discovered during an autopsy, as well as burns to hair and skin. Photographs of the tent allegedly show that it was erected incorrectly, something the experienced hikers were unlikely to have done. A similar theory alleges the testing of radiological weapons and is based partly on the discovery of radioactivity on some of the clothing as well as the descriptions of the bodies by relatives as having orange skin and grey hair. However, radioactive dispersal would have affected all, not just some, of the hikers and equipment, and the skin and hair discoloration can be explained by a natural process of mummification after three months of exposure to the cold and wind. The initial suppression by Soviet authorities of files describing the group's disappearance is sometimes mentioned as evidence of a cover-up, but the concealment of information about domestic incidents was standard procedure in the USSR and thus nothing strange.. And by the late 1980s, all Dyatlov files had been released in some manner. Let’s talk about Paradoxical undressing International Science Times proposed that the hikers' deaths were caused by hypothermia, which can induce a behavior known as paradoxical undressing in which hypothermic subjects remove their clothes in response to perceived feelings of burning warmth. It is undisputed that six of the nine hikers died of hypothermia. However, others in the group appear to have acquired additional clothing (from those who had already died), which suggests that they were of a sound enough mind to try to add layers.   Keith McCloskey, who has researched the incident for many years and has appeared in several TV documentaries on the subject, traveled to the Dyatlov Pass in 2015 with Yury Kuntsevich of the Dyatlov Foundation and a group. At the Dyatlov Pass he noted: There were wide discrepancies in distances quoted between the two possible locations of the snow shelter where Dubinina, Kolevatov, Zolotarev, and Thibault-Brignolles were found. One location was approximately 80 to 100 meters from the pine tree where the bodies of Doroshenko and Krivonischenko were found and the other suggested location was so close to the tree that anyone in the snow shelter could have spoken to those at the tree without raising their voices to be heard. This second location also has a rock in the stream where Dubinina's body was found and is the more likely location of the two. However, the second suggested location of the two has a topography that is closer to the photos taken at the time of the search in 1959. The location of the tent near the ridge was found to be too close to the spur of the ridge for any significant build-up of snow to cause an avalanche. Furthermore, the prevailing wind blowing over the ridge had the effect of blowing snow away from the edge of the ridge on the side where the tent was. This further reduced any build-up of snow to cause an avalanche. This aspect of the lack of snow on the top and near the top of the ridge was pointed out by Sergey Sogrin in 2010. McCloskey also noted: Lev Ivanov's boss, Evgeny Okishev (Deputy Head of the Investigative Department of the Sverdlovsk Oblast Prosecution Office), was still alive in 2015 and had given an interview to former Kemerovo prosecutor Leonid Proshkin in which Okishev stated that he was arranging another trip to the Pass to fully investigate the strange deaths of the last four bodies when Deputy Prosecutor General Urakov arrived from Moscow and ordered the case shut down. Evgeny Okishev also stated in his interview with Leonid Proshkin that Klinov, head of the Sverdlovsk Prosecutor's Office, was present at the first post mortems in the morgue and spent three days there, something Okishev regarded as highly unusual and the only time, in his experience, it had happened. Donnie Eichar, who investigated and made a documentary about the incident, evaluated several other theories that are deemed unlikely or have been discredited: They were attacked by Mansi or other local tribesmen. The local tribesmen were known to be peaceful and there was no track evidence of anyone approaching the tent. They were attacked and chased by animal wildlife. There were no animal tracks and the group would not have abandoned the relative security of the tent. High winds blew one member away, and the others attempted to rescue the person. A large experienced group would not have behaved like that, and winds strong enough to blow away people with such force would have also blown away the tent. An argument, possibly related to a romantic encounter that left some of them only partially clothed, led to a violent dispute. About this, Eichar states that it is "highly implausible. By all indications, the group was largely harmonious, and sexual tension was confined to platonic flirtation and crushes. There were no drugs present and the only alcohol was a small flask of medicinal alcohol, found intact at the scene. The group had even sworn off cigarettes for the expedition." Furthermore, a fight could not have left the massive injuries that one body had suffered.   Ace’s Depot http://www.aces-depot.com   BECOME A PRODUCER! http://www.patreon.com/themidnighttrainpodcast   Find The Midnight Train Podcast: www.themidnighttrainpodcast.com www.facebook.com/themidnighttrainpodcast www.twitter.com/themidnighttrainpc www.instagram.com/themidnighttrainpodcast www.discord.com/themidnighttrainpodcast www.tiktok.com/themidnighttrainp   And wherever you listen to your favorite podcasts.   Subscribe to our official YouTube channel: OUR YOUTUBE

Two years ago this week, the US Para Dressage team re-wrote the form book by picking up its first ever global championship medals, during the World Equestrian Games in Tryon, North Carolina. Leading that charge was Rebecca Hart, who won individual bronze and freestyle silver in Grade III. In this episode of The Para Dressage Podcast she looks back on that moment, reflects on the stellar rise of Team USA, and talks about her early starts working for a world famous coffee chain.

Brian, Michael and Rich get together for an emergency podcast in the wake of Gordon Hayward being sidelined for a month with a Grade III ankle sprain. How will the Celtics proceed without their versatile forward against the Sixers and potentially Raptors? Plus, leftover thoughts and observations from Game 1 of the C'-Sixers series. 

International Left-Handers Day by Viva Punjabi, Grade III, Akshara Vaagdevi International School, Secunderabad Campus. For admissions visit www.pallavimodelschools.org *

Kargil Vijay Diwas by Viva Punjabi, Grade III, Akshara Vaagdevi International School, Secunderabad. For admissions visit www.pallavimodelschools.org

Contributor: Nick Hatch, MD Educational Pearls: An AC (acromioclavicular joint) separation in the shoulder is a common traumatic injury XRs can help rule out other injuries as well as help with grading the injury There are six different grades for AC separations: Grade I: is stretching of the AC ligament without disruption or displacement of the clavicle and recovers with time. Grade II:  is partial tearing of the AC ligament with some displacement but will also heal with time. Grade III: is a full separation with ligament rupture and may require surgery but is not always indicated. Surgery is more common in active patients. Grades IV, V, and VI are severe separations and all require surgery. Other ligament damage or tears, like a slap injury, can mimic an AC separation and often require surgery but should remain on the differential diagnosis when working up shoulder trauma. Setting expectations is key. Patients with a grade 1 or 2 separation should expect 6+ weeks of limited range of motion and up to 12 weeks until return to full function. Cosmetically there may be a persistent bump on the shoulder. References van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop. 2017;8(12):861‐873. Published 2017 Dec 18. doi:10.5312/wjo.v8.i12.861   Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Ruth Kavanagh is a 39 year old female who was diagnosed with a rare form of brain cancer (Grade III anaplastic ependymoma) at the age of 34. Ruth is now a two time brain cancer survivor/thriver! She has had conquered brain cancer twice and is now cancer-free!

In mid-January, 1959, a groupe of students and recent graduates from Ural Polytechnic Institute departed from the city of Sverdlovsk, Russia on an expedition into the Northern Ural Mountain.s Each member of the group was extremely experienced in lengthy ski tours and mountain expeditions, and would all earn the distinguished Grade III hiking certification- the highest obtainable in the country, upon completing their journey. When the hikers hadn't arrived back home as expected, a search and rescue mission began. Over the span of the next few months, a horrifying discovery would be made: the bodies of all 9 hikers would be found scattered in various states of struggle, within a mile of their last campsite. Some with fatal blunt force trauma to their head or chest, many missing shoes and clothing, and another was even missing her tongue. The prosecutor at the time closed the investigation stating that "The hikers died of an unknown, compelling force." A vague determination that has left room for many theories in the past 60 years, ranging from UFOs to Government conspiracy. What caused these experienced hikers to flee their only shelter into total blackness, sub-zero temperatures, and imminent death that night in February, 1959? Support the show (https://www.patreon.com/creepitrealpod)

This week on PA Study Sesh, we will be covering disorders of the knee and proximal tibia. Medial and lateral collateral ligament injuries (MCL & LCL) MCL=valgus stress LCL= varus stress MCL more common than LCL injury Grade I & II (sprain & incomplete tear)= conservative Grade III (complete) = surgical ACL (anterior cruciate ligament) … Continue reading Knee Disorders →

Johnny has fallen on an outstretched hand, and comes to you with a swollen, painful elbow.   Position of comfort, analgesia, xrays, and now what?   What am I seeing -- or not seeing -- here?     First a refresher on radiographic anatomy of the elbow --   Images courtesy of Radioglypics (Open Access Radiology Education). Used with permission. Now that we have our adult anatomy reviewed, let's go through the development of the elbow in a child. We are all born with primary ossification centers -- the basic shapes of our long bones.  Secondary ossification centers then develop around the ends of our long bones, and make interpretation of films in the context of suspected injury difficult. Elbow Interpretation Roadmap: CRITOE More pragmatic and utilitarian than a prosaic mnemonic, CRITOE helps us to remember the order of ossification of the pediatric elbow. Although children develop at different rates, the order of ossification is programmed into us.  Images courtesy of Radiopaedia.   Capitellum By age one, the capitellum ossifies. On the AP view, imagine a little white oval balloon floating in the darkness between the radius and the humerus.  Radial Head By age three, the capitellum gets another little balloon to join the party. The radial head is a bony little balloon that floats just above the floor.  If you see both little balloons floating on either ends of the space between the humerus and the radius – you know this child is about three years old. Internal Epicondyle By the age of five, the capitellum and radial head are no longer little floating balloons, but now taking on shapes that resemble what they will look like as an adult. By age five, you’ve grown out of balloons, and have moved on to Frisbees.  The internal epicondyle (meaning the medial epicondyle) starts to ossify by age five – a little bony Frisbee.   Trochlea By age seven, another little Frisbee flies around. On the AP view, the trochlea is superimposed on the humerus – if you look at the distal medial humerus, you’ll see the trochlea like a little oval Frisbee taking shape (see combined film below).   Olecranon By age nine, the olecranon of the ulna is ossifying.  In a nine year old, you’ll see a capitellum, radial head, internal epicondyle, trochlea, and olecranon. External Epidondyle By age 11, you start to ossify your external epicondyle (lateral epicondyle).           Pediatric Elbow Films: Putting It All Together Watch this dynamic video by Dr Jeremy Jones from Radiopaedia:   Fracture Saviors: Fat Pads and Drawn Lines These three things can save us: fat pads, the anterior humeral line, and the radiocapitellar line. Non-annotated images courtesy of Heidi Nunn. Normal anterior fat pad                 Sail sign: billowing hypodensity, indicating blood; sometimes the only (indirect) sign of an elbow fracture                 Posterior fat pad: always pathologic                 Radiocapitellar Line: anterior humeral line bisects the capitellum   Baumann’s angle (carrying angle): Normal is 70 to 75 degrees.  A difference between extremities of just 5 degrees or more is abnormal. Supracondylar fractures: Gartland Classification             Compartment Syndrome Pain out of proportion to exam, paresthesias, pallor, poikilothermia, pulselessness, and paralysis                   The 6 Ps of compartment syndrome are not sensitive in children. The only thing that may alert you to increasing compartment pressures in children is an increasing need for analgesics.       Volkmann's ischemic contracture Untreated compartment syndrome results in thrombosis, edema, ischemia, and disabling contracture.     Other Elbow Injuries (Details in podcast audio) Lateral Condyle Fracture Medial Epicondyle Fracture Radial head and radial neck fractures Olecranon fractures Elbow dislocation Radial head subluxation (nursemaid’s elbow) Medial epicondylar apophysitis (Little leager’s elbow)   Test your retention: check out this interactive post from the team at Don't Forget the Bubbles.     Key Points and Summary The most important pediatric elbow injury is the supracondylar fracture. Grade I is minimally displaced and needs a cast; Grade II is displaced, but with the posterior cortex intact; after closed reduction, the child may still need surgery; Grade III fractures all need closed reduction, internal fixation, and close monitoring for compartment syndrome. CRITOE gives us the order of ossification for the pediatric elbow – capitellum, radial head, internal epicondyle, trochlea, external epicondyle, and olecranon -- typically occurring at year 1, 3, 5, 7, 9, and 11 – remember the order is the most important thing – all ossification centers should be accounted for.  Make sure one is not missing – or where one has been “created” traumatically. If you don't see the obvious fracture, you can be "saved" by the sail sign and/or a posterior fat pad.  Also, make sure to look for the anterior humeral line – on the lateral view, a line drawn down the anterior humerus – if it intersects with the middle third of the capitellum, that is normal – it not, suspect a supracondylar fracture. The radiocapetellar line runs along the radial neck through the radial head and should line up nicely with the capitellum. If not, assume a fracture-dislocation. Close communication and coordination with the orthopedist will help us to get the right care at the right time – there is some variability with orthopedic practice, so be open to that – we can make out biggest impact by making the right diagnosis, and aggressively treating pain and effectively providing procedural sedation when needed. References Alton TB et al.  Classifications In Brief: The Gartland Classification of Supracondylar Humerus Fractures. Clin Orthop Relat Res. 2015 Feb; 473(2): 738–741. Hardwick J, S Srivastava S. Volkmann’s contracture of the forearm due to an insect bite: a case report and review of the literature. Ann R Coll Surg Engl. 2013 Mar; 95(2): e36–e37. Kanj WW et al. Acute compartment syndrome of the upper extremity in children: diagnosis, management, and outcomes. J Child Orthop. 2013 Jun; 7(3): 225–233. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 18;1:CD007759. Leung S, Paryavi E, Herman MJ, Sponseller PD, Abzug JM. Does the Modified Gartland Classification Clarify Decision Making? J Pediatr Orthop. 2016 Mar 11. [Epub ahead of print] Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998 Jul;102(1):e10. Mallo G, Stanat SJ, Gaffney J. Use of the Gartland classification system for treatment of pediatric supracondylar humerus fractures. Orthopedics. 2010 Jan;33(1):19. Bonus! Watch Larry Mellick Reduce a Nursemaid's Elbow! https://www.youtube.com/watch?v=-0ROu4hCXwQ This post and podcast are dedicated to Andy Neill, MBBS.  Thank you for your humanism and your dogged dedication to connect with the learner and simplify complex concepts.  Welcome back, Andy! Supracondylar Fractures Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

When dealing with a high ankle sprain (syndesmosis injury) Grade I never requires surgery whereas Grade III always requires surgery. But what about Grade II? In this episode we explore predictors of syndesmotic instability when assessing a Grade II sprain and the return to sport prognoses. All this while JW approaches absolute zero!

ResearchToPractice.com/VPB110 – A 54yo woman with bipolar disorder is diagnosed with a 1.6-cm, Grade III, strongly ER+, weakly PR+, HER2-, node- IDC and an Oncotype DX RS of 32. Interview conducted by Neil Love, MD. Produced by Research To Practice.

ResearchToPractice.com/VPB209 - Case 9: A 62-year-old woman with bilateral (10 centimeters and 15 centimeters), Grade III, node-positive, ER-positive, HER2-negative IDCs with focal lobular features and bone metastases. Interviews conducted by Neil Love, MD. Produced by Research To Practice.

ResearchToPractice.com/VPB209 - Case 10: A 47-year-old premenopausal woman with a family history of breast and ovarian cancer who refuses hormonal therapy for a 1.9-cm, Grade III, node-positive, ER-positive, PR-positive, HER2-positive IDC. Interviews conducted by Neil Love, MD. Produced by Research To Practice.

ResearchToPractice.com/SABCS_2008 – Second Opinion: Proceedings and Interviews from a 2-Part CME Satellite Symposia Held at the 31st Annual San Antonio Breast Cancer Symposium. Case: 38-year-old premenopausal woman with a 2-cm, Grade III, ER/PR-positive, HER2-positive IDC and a 1.8-cm, biopsy-confirmed hepatic metastasis. Interviews conducted by Neil Love, MD. Produced by Research To Practice.

Backround The treatment of acute acromioclavicular (AC) joint injuries depends mainly on the type of the dislocation and patient demands. This study compares the mid term outcome of two frequently performed surgical concepts of Rockwood grade III AC joint separations: The temporary articular fixation with K-wires (TKW) and the refixation with an absorbable polydioxansulfate (PDS) sling. Findings Retrospective observational study of 86 patients with a mean age of 37 years underwent either TKW (n = 70) or PDS treatment (n = 16) of Rockwood grade III AC joint injuries. Mid term outcome with a mean follow up of 3 years was measured using a standardized functional patient questionnaire including Constant score, ASES rating scale, SPADI, XSMFA-D and a pain score. K-wire therapy resulted in significantly better functional results expressed by Constant score (88 ± 10 vs. 73 ± 18), ASES rating scale (29 ± 3 vs. 25 ± 5), SPADI (3 ± 9 vs. 9 ± 13), XSMFA-D function (13 ± 2 vs. 14 ± 3), XSMFA-D impairment (4 ± 1 vs. 6 ± 2) and pain score (1 ± 1 vs. 2 ± 2). Conclusion Either temporary K-wire fixation and PDS sling enable good or satisfying functional results in the treatment of Rockwood grade III AC separations. However functional outcome parameters indicate a significant advantage for the K-wire technique.

www.MeetTheProfessors.com – Case from the practice of Carolyn B Hendricks, MD; 44-year-old woman diagnosed two years prior with a 2.2-cm, Grade III, triple-negative IDC with negative axillary node dissection presented to Drs Cobleigh, Holmes