Podcasts about inr

Kiera is joined by the tooth-healer himself, Jason Dent! Jason has an extensive background in pharmacy, and shares with Kiera where his pharmaceutical experience has bled over into dentistry. This includes the difference between anti-quag and anti-platelet and which medications are probably safe, what to do to shorten the drag time in the pharmacy, how to write prescriptions most efficiently, and more. Episode resources: Subscribe to The Dental A-Team podcast Schedule a Practice Assessment Leave us a review Transcript: The Dental A Team (00:00) Hello, Dental A Team listeners. This is Kiera and today is a really awesome and unique day. It is, think the second time I've had somebody in the podcast studio with me live for a podcast and it's the one and only Jason Dent. Jason, how are you? I'm doing well. Good morning. Thanks for having me. It is crazy. I I watch Instagram real like this all the time where people are like in the podcast and they're hanging out on two chairs and couches and now look at us. We're doing it. Cheers. Cheers.   That was a mic cheer for those of you who are only listening, but yeah, Jace, how does this feel to be on the podcast? It's weird. Like I was not nervous at all talking about it. I got really nervous as soon as you hit play. So if I stumble over my words, please forgive me ahead of time. Well, Jason, I appreciate you being on the podcast because marketing had asked me to do a topic about teledentistry and I was like, oh shoot, that's like not my forte at all. so   You and I were actually chatting in the hot tub. call it Think Tank session and you and I, we have a lot of good ideas that come from that Think Tank. A lot of business. no phones. That's why. We do leave our phones out. But I was talking to Jason and this is actually a podcast we had talked about quite a while ago. Jason has a lot of information on pharmacy. And if you don't know, Jason isn't really, we were going through all of it last night. It's kind of a mock in the tub. And I think it's going to be great because I feel like this is an area, I'm working at Midwestern and   knowing about how dentists, pharmacology was surely not your favorite one. Jason actually helps a lot of dentists with their clearances. And so we were talking about it and I like it will just be a really awesome podcast for you guys to brush up on pharmacology, different things from a pharmacist's side. So Jason, welcome. Thank you. Yeah, no, we were talking about it and here's like, what should I talk about on the podcast next? I have all these different topics and she's like, what do you know? And the only real interaction I have with dentists is doing clearances for procedures. We get them all the time, which makes sense.   Lots of people are on blood thinner, I've always told Kiera, like, hey, I could talk about that. Like, that's kind of a passion of mine. I'm not a dentist. Or my name is Jason Dent. So in Hebrew, Jason means tooth. No, no, no, sorry. Nerves are getting to me. Jason means healer and Dent means tooth. So my name means tooth healer. So, here's a little set. Hold on, on, hold Can we just talk about? I brought that up before you could talk about it more. So.   My name means tooth healer but I did not become a dentist. I know you wanted me to become a dentist. did. I don't know why. I enjoy medicine. I know what you're going to get to already. The things you're going to ask me. There's been years of this. But nevertheless, that's my name. We'll get that out of the way. But you did give me a great last name. So I mean, it's OK. You're All is fair and love here. SEO's up for that. But yeah, Jason, I'm going to get you right into the show. And I'm going to be the host. And we're going to welcome to the podcast show. Jace, how are you?   Good, good, good. Good, good, good. So by getting into clearances, right? This is what you're kinda talking about with you know, before we get to clearances, I actually wanted Jason, for the listeners who don't know you, who haven't talked to you, who don't know, let's kinda just give them like, how did you go from, Kiera wanted you to be a dentist, to now Jason, you are on the podcast talking as our expert on pharmacy. fantastic. I've always really loved medicine, a ton. As a kid getting headaches and taking Excedrin, like you just feel like a miserable pile of crap.   and then you take two pills and all of a sudden you feel better. Like that's amazing, like how does that happen? Also getting ear aches as a kid, just being in so much pain and then taking some medicine and you start feeling a lot better. I always had a lot of appreciation for that. I've always been mechanically inclined. I went to, started doing my undergrad and took biology and learned about ATP synthase, which is a spinning enzyme that's inside the mitochondria, like a turbine engine. I used to work on small engines on my dirt bike and thought that is so cool. So I really got wrapped up into chemistry.   All the mechanics of chemistry really pulled me in. I'm not getting goosebumps. checking. I usually get goosebumps when I think about chemistry. But it's so cool. You think an engine's awesome, like pistons and camshafts and pressures, the cell is the same thing. It's not as loud, so it's not as cool. But it's fascinating. that's why we're like. ⁓   chemistry and really got into coagulation. So I did my residency after pharmacy school. we went to Arizona for three years. ⁓ You did and your main focus, you were never wanting to be the guy behind the counter. No, I haven't done that. Yeah. No, I love them though. I've always really want to go clinical. ⁓ But I love my retail ⁓ pharmacists. They're amazing resources. And ⁓ I use the retail pharmacist every day still to this day, but I went more the clinical route, really love the chemistry aspect of it.   did my doctorate degree and then I did my residency in Reno. Reno's kind That's how we got here everybody. Welcome to Reno. Strategically placed because I was really interested in critical medicine and where we're located we cover a huge area. So we pull in to almost clear, we go clear to Utah, clear to California, all of Northern Nevada. We get cases from all over. So we actually are kind like the first hub of care for lot of areas. So we really get an eclectic mixture of patients that come in that need-   all kinds of different cases that are coming to them. So it's what I really wanted. So I did my residency in critical care there. And then for the next 10 years, I worked in vascular medicine with my final five years being the supervisor of the clinic. Ran all the ins and outs of that. So my providers, two doctors were on our view. So when we talk about dentistry, talk about production, those kinds of things, totally get it. My doctors were the exact same way, my vascular providers. ⁓   There's some pains there, right? You wanna be seeing patients as much as possible, being able to help as many people, keeping the billing up. And had other nurse practitioners, four practitioners, a fleet of MAs, eight pharmacists. We also had that one location we had, going off the top of my head, I think we had eight locations running as well. And we took care of all the different kinds of vascular cases that came to us. Most common was blood clots, ⁓ which is just a...   which is an easier way of saying VTE. There's so many different ways to say a blood clot. Like you might hear patients say, I've had a PE or a DVT or a venous thromboembolism or a clot in my leg, right? They're all clots, but in different locations. Same with an MI, and MI can be a clot as well. ⁓ there's a lot of, everybody's kind of saying the same thing, but sometimes the nomenclature can make it sound hard, but it really is actually pretty simple.   No. And Jason, I love that you went through, you've been in like, and even in your, ⁓ when you were getting your doctorate, you were in the ER. You also worked in retail pharmacy. remember you having a little sticker on your hand. And retail pharmacy, I have a lot of respect for those guys. They have a lot of pressure on them. and then you also, ⁓ what was that test that you had to take that? I don't know. You were like studying forever for it. ⁓ board certification for, ⁓ NABP. Yeah. So I did that board certification as well.   And now you've moved out of the hospital side onto another section in your career. Now in the insurance, right? So it's really, really interesting. So now I'm on the other side reading notes and evaluating clinical appropriateness and trying to help patients with getting coverage and making those kinds of determinations. So yeah, I've really jumped all over. Really love my clinical days. I know. don't I don't I do miss them. But yeah, kind of had a good exposure to a lot of.   pharmacy a lot a lot of dentists actually with all the places that come through which Jason I really appreciate that and honestly I know you are my spouse and so it's fun to have you on but when I go into conversations like this I don't know any of this information and so finding experts and Jason I think here's me talk more about dentistry and my business than I do hear about him on pharmacy so as we were chatting about this I really realized you are a wealth of knowledge because you've been on the clinical side so you've done a lot of patient care and you've seen how   medications interact and I know you've had a few scares in your career and ⁓ you've known some physicians that have had a few scares and ⁓ you've seen plenty of patients pass away working in the ER and gosh in Arizona drownings were such a big deal. I remember when you were in the ER on your rotations I'd be like who died today? Like tell me the stories and you've really seen and now going on to the insurance side I felt like you could just be such a good wealth of knowledge because I know dentists are sometimes so   I would say like maybe just a little more anxious when it comes to medications. I know that dental students from Midwestern were like here was like four months and we had to like pass it, learn it. And Jason, you've done four years plus clinical residency, plus you've been in it. And something I really love about Nevada Medicine is they've been so collaborative with you.   like your heart, your cardiologist, they diagnose and then they send to you to treat with medicine and... Yeah, I've been really lucky being here in Reno too. The cardiology team has been amazing to work with. We started a CHF program, sorry, congestive heart failure program for patients. So we would collaborate with cardiologists. They'd see the cardiologists and then they send them to the pharmacist to really manage all the medications. So there's pillars of therapy ⁓ called guideline directed medical therapy and the pharmacist would take care of all that. So that's gonna be your...   your beta blockers, your ACEs, your ARBs, your Entresto, which would be a little bit better, spironolactone. So just making sure that all these things are dosed appropriately, really monitoring the heart, and make sure that patients are getting better. we've had real positive outcomes when the, sorry, this is totally off topic. do, talk about that study. When we looked at when patients were coming to see our pharmacists in our clinic that we started up, the patients were half as likely to be readmitted. And this was in 2018, and our pharmacists,   We're thinking about all the medications. We're usually adjusting diabetes medications too at the same time. Just kind of naturally just taking care of all the medications because we kind of got a go ahead from the providers, a collaborative practice agreement that we could make adjustments to certain medications within certain parameters. So we weren't going rogue or maverick, but we were definitely trying to optimize our medications as much as possible. And then years later, some studies came out with, I'm sure you've seen Jardins and Farseegh. not trying to, I'm not.   I don't get any kickback from them. I have no conflicts to share. But because our pharmacists were really optimizing that medication, those medications were later shown to reduce hospitalizations and heart failure, even though they're diabetes medications. Fascinating. So it wasn't really the pharmacists. It was just the pharmacists doing as much as they can with all the tools that were in front of them. And then we found out that the patients were going back to the hospital.   half as much as regular patients. So, yeah, being here, it's been so amazing to work with providers here. the providers here want help, want to help patients, don't have an ego. I mean, I just, it's awesome. I love it. I do love how much I think Jason sees me geek out about dentistry and I watching Jay's geek about his pharmacy and how much he loves helping patients. And ⁓ really that was the whole idea of, all right.   Dentistry has pharmacy as a part of it. And I know a lot of dentists are sending in clearances and I know working in a chair side, it would be like, oh no, if they're on warfarin or on their own blood clot, you guys, honestly don't even know half of what I'm talking about because this is not my jam, which is why Jason's here. But I do know that there was always like, well, we got to talk with their provider. And so having Jason come in and just kind of explain being the pharmacist that is approving or denying or saying yes or no to take them off the blood thinners in different parts, because you have seen several dental   I don't know what they're called. What is it? Clarence's? that what comes to you? don't even know. All day my mind, it's like, here is the piece of paper that gets mailed to you to the pharmacist and then you mail it back. So whatever that is. But Chase, let's talk about it because I think you can give the dentist a lot of confidence coming from a pharmacist. What you guys see on that side. When do you actually need to approve or disapprove? Let's kind of dig into that. Yeah. Well, first of all, I think I'm not a replacement for any kind of clinical judgment whatsoever. Every patient's different. But the American Diabetes Association, you   I work with diabetes a lot. American Dental Association has some really great guidelines on blood thinners and I would always reference them. I actually looked at their website today. Make sure I'm up to speed before I get back on this again. They have resources all around making decisions for blood thinners. And I think the one real important thing in putting myself in the shoes of a dentist or any kind of staff that's around a patient that's in a chair, if they say I'm on a blood thinner, right, a flag goes up. At least in my mind, that's what goes up.   Like, okay, how do we get across this bridge? And I think the important thing to really distinct right then when they say they're on a blood thinner is that is kind of a slang word for a lot of different medications, right? Like it's the overarching word that everybody pulls up saying, I'm on a blood thinner. It's like, okay, but I don't know what say. It's like, I have a car. You're like, okay, do you have a Mazda? Do you have?   Toyota, Honda, what do you have? or even worse it'd be like saying I have a vehicle, right? So when somebody says they're on a blood thinner, it opens up a whole box of possibilities of what they're Blood thinners are also, doesn't, when they're taking these types of medications that are quote unquote a blood thinner, it doesn't actually thin the blood, like adding water to the blood, if that makes sense, or like thinning paint, or like thinning out a gravy, right? It doesn't do the same thing. Blood thinners, really what they're doing is they're working on the blood, which.   which is really cool, try not to tangent on that. ⁓ When they're working on the blood, it's not thinning it per se, but it's making it so that the proteins or platelets that are in it can't stick together and make a cloth quite as easy. So whenever somebody's on a blood thinner, I usually ask, what's the name of the blood thinner that you're on? It's not bad that they use that slang, that's okay, on the same page, but it's really broken into two different classes. There's anticoagulant and antiplatelet.   And a way to kind of remember which is which, when residents would come through our clinics, the way that I teach them is a clot is like a brick wall. You know, it's not always a brick wall. Usually the blood is a liquid going through. But once they receive some kind of chemical message, it starts making a brick wall with the mortar, which is the concrete between the and the bricks, the two parts. When it's an anti-quagent, it's working on that mortar part. When it's an anti-platelet, it's working on the bricks part, right? You need both to make a strong clot or strong brick wall.   But if you can make one of them not work, obviously like if your mortar is just water, it's not working, right? You're not gonna make a strong brick wall. So that's kind of the two deviants right there. So that's what I do in my mind real quickly to find out because antiplatelets are usually, so that's gonna be like your Plavix, Ticagrelor, Brilinta. And hold on, antiplatelets are bricks? Good job, bricks. They're the bricks. And so the reason I was thinking you could remember this because I'm, antiplatelets, it's a plate and a plate is more like a brick.   And anti coagulant, I don't know why quag feels like mortar to me, like quag, like, know, it's like slushy in the blood, like it's coagulating. It's a little bit of that, like, honestly, I'm just thinking like coagulated blood is a little bit more mortar-ish. And so platelet is your plate, like a brick, and anti-quag is like.   the gilly between the bricks. Okay, okay, I got it. Yeah, so there's an exception to every rule, but when they're on that Don't worry, this is Kiera, just like very basic. You guys are way smarter listening to this, and that's why Jason's here. No, no, you helped me pass pharmacy school. When we were doing all the top 200, you helped me memorize all know what flexorill is, all right? That's a muscle relaxant. Cyclo? I don't know that part. It's a cyclo, because you guys are cycling and flexing. I don't actually know. just know it's a muscle relaxant, so that's about as far as I got. When we're looking at antitick platelets, so that's the brick part, so that's going to be your, you know,   Hecagrelor, Breitlingta, Clopidogrel is the most common one. It's the cheapest one, so probably see that one the most. Those, I mean, there's an exception to every rule, but that's generally being used after like a stent's placed in the heart. It can be used for VTE, there's some out there, but that's pretty rare. But also for some valves that are placed in the hearts, it can be used for that as well. So antiplatelet, really thinking more like a cardiac event, right? Like I said, there's always an exception to every rule, but that's kind of where my mind goes real quickly, because we're gathering information from the patient.   They're on anticoagulant. Those are like going to be the new ones that you see commercials for all the time. So Xeralto, Alequis, those are the two big ones right now. They're replacing the older one. And also we were supposed to do a disclaimer of this is current as of today because the ADA guidelines do change. this will be current as of today. And Jason, as a pharmacist, is always looking up on that. I had no clue that you are that up to speed on dental knowledge. so just throwing it out there that if you happen to catch his podcast,   a few years back that obviously check those guidelines for sure. But the new ones are the Xarelto and Eloquist. They're replacing the older ones of warfarin. Warfarin's been around for a really long time. We've seen that one. Those are anti-coagulants. So when you're looking, when a patient says that, generally they're on that medication because they've possibly had a clot in the past or they have a heart condition called atrial fibrillation. Those are kind of the two big ones. Like I said, there's always caveats to it, but that's kind of where my mind goes real quickly. And then,   as far as getting patients cleared, the American Dental Association has really good resources on their website. You can look at those and they're always refreshing that up. They even say in their own words that there's limited data around studying patients in the dental chair and with anticoagulants or anti-platelets. It's pretty limited. There's a few studies, some from 2015, some from 2018. There's one as recent as 2021, which is nice. But really, all of those studies come together and it's really more of an expert consensus.   And with that expert consensus, they have kind of simplified things for dentistry, which is really nice. ⁓ comparing that to, we have more data for like total hip replacement, total knee replacement. We have a lot of data and we know really what we should be doing around then. But going back to dentistry, we don't have as much information, so they always say use clinical judgment, but they do give some really great expert guidance on that. So if a patient's on an anticoagulant, ⁓   they generally recommend that it doesn't need to be stopped unless there's a high bleeding risk for a patient. as a provider or as a clinician in the practice, you can be looking at high bleeding risk. Some things that make an oral procedure a little bit lower risk is one, it's in the compressible site, right? Like we can actually put pressure on that site. That's the number one way to stop bleeding is adding pressure. It's not like it's in the abdominal cavity where we can't get in and can't apply pressure. So number one, that kind of reduces the bleeding risk.   is number one. Two, we can add topical hemostatic agents. Dentists would know that better than me. There's a lot of topical ways to do that. So not only pressure, but there's those things as well. And also, but there are some procedures that are a little bit more likely to bleed. And that's where you and dentists would come in hand in What's the word in APO? Oh, the APOectomy. I got it right. Good job. like, didn't you tell me last night that the ADA guideline was like what?   three or four or more teeth? great question. So you can extract one to three teeth is what their expert consensus One to three teeth without. Without really managing or stopping anticoagulation or doing anything like that. I think that's some good guidance from them. I'm gonna add a Jasonism on that though. So with warfarin, I do see why dentists would be a little bit more conservative or worried about stopping the warfarin because warfarin isn't as stable as these newer agents. Warfarin, the levels.   quote unquote levels can go really high, they can go really low. And if the warfarin levels are high, they're more likely to bleed. So I do think it makes sense to have a really recent INR. That's how we measure what the warfarin's doing. I think that makes a lot of sense, but the ADA guidelines really go into the simplification version of all these blood thinners. Generally, it's recommended to not stop them because the risk of stopping them outweighs the benefit of stopping them in almost every case. Almost every case.   ⁓ So when you're with that patient, right, they say I'm on a blood thinner, finding out which kind of blood thinner that they're on, you find out that they're on Xeralto, right? How long have you been on Xeralto for? I've been on it for years. You don't know exactly why, but if they haven't had any recent bleeding, you're only gonna remove one tooth. ⁓ You can do what's called a HasBlood score. That kind of looks at the bleeding risk that they'd have. That'd be kind of going a notch above, but in my mind, removing one tooth isn't a real serious bleeding risk. I'd love to hear from my dentist friends if they...   disagree, right, but ADA says one to three tooth removals, extractions, that's the fancy word. Extractions, yeah, for extracting teeth out. Is not really that invasive. Sure. It's not that high risk, so it's usually perfectly fine. So if a patient was on Xarelto, ⁓ no other, this is in a vacuum, right? I'm not looking at any other factors, which you should be looking at other factors. I would be perfectly fine to just remove one to two.   And when those clearances come in, because dentists do send them, talk about what happens. You guys were working in the hospital and you guys would get these clearances all the time. do. We get them so often. I mean, we get like four or five a day. We'd love to give it to our students, student pharmacists, and ask them what to do. And they would usually look up the American Dental Association guidelines and come up with something. We're like, yep, that's what we say too. In fact, we say it so many times a day that we have a smart phrase.   which just blows in the information real quickly and faxes it right back to the So it's like a copy paste real quick. So what I wanted to point out when Jason told me this is dentists like hearing this and learning this, this can actually save you guys a ton of time to be able to be more confident, to not need to send those clearances on. And we were actually talking last night about how I think this might be a CYA for dentists. like, as we were talking, I think Jason, you seeing so many other aspects of medicine, like you've literally seen patients die, you've seen other areas.   And so coming from that clinical vantage point, we were realizing that dentists, we are so blessed to live in an injury. I enjoy dentistry because possibly there's someone dying, not super high, luckily in dentistry. The only time that I have actually had a doctor have a patient pass away, and it was only when they were completely sedated and doing ⁓ some other things, but that was under the care of an anesthesiologist. And so that's really our high, high risk. And so hearing this, Jason,   That was one of the reasons I wanted him to come on is to give you doctors more confidence of do we have to always send to a pharmacist? I mean, hearing that on the pharmacy side, they're just sending these back and not to say to not see why a to not cover this because you might be questioning like, well, do I really need to? But you also were talking about some other ways of so number one, you guys are just going to copy back the 88 guidelines. So so 88 guidelines. Yeah. And I think that that gives a lot of confidence to a provider or a dentist is that you can go to the 88 guidelines and read them, right? Like you're listening to some   nasally monotone pharmacist on a podcast. Rumor has it, people love him at the hospital. were like, you're the voice, he's been told he has a good radio So for the clinic, I was the voice. Like, yeah, you've reached the vascular clinic, right? And they're like, oh my gosh, you're the voice. But sorry, you me distracted. That'll be your next career, Jace. You're going to be a radio host. OK. I would love that. I love music. But you're hearing from a nasally guy, but you can actually read the ADA guidelines. You just go right to the ADA, click on Resources, and under Resources, it has the   around anticoagulants, I think that's the best way to get a lot of confidence about it because they have dentists who are the experts making calls on these. I'm just reiterating what they say, but I think it makes a lot of sense to help providers. And the reason why my heart goes out to you as well is having the providers that used to work underneath me, they're always looking for our views, which is a fancy way of making sure that they're drilling and filling. Can I say that? Yeah, can say drilling and filling. They're being productive, right? They're being productive, right?   They're always looking to make sure if a patient's canceling, like get somebody in here. Like I need to be helping people all day long. That's how I, we keep the lights on. That's how I help as many people. And so if you have a patient coming in the chair and it has an issue, they say I'm on Xeralto. Well, you can ask real quickly, why are you on Xeralto? I had a clot 10 years ago. my gosh. Well, yeah, we're pretty good to go. Then I'm not worried. We're only removing one tooth or we're just doing a cavity or a cleaning. Something like that. Shouldn't be an issue whatsoever because there's experts in the dental. ⁓   in the dental society, the ADA guidelines that recommend three teeth or less, minimally invasive. They really recommend if it's gonna be really high bleeding risk. And clinically, that's where you would come in, ⁓ or yourself. know, apioectomy is one that's like on the fence line. I don't know where implants set. though, and like we were talking, implants aren't usually like a date of procedure. Most people aren't popping in, having tooth pain, and we're like, let's do an implant. Now sometimes that can be the case, but typically that one's gonna have   a few other pieces involved. And so that is where you can get a clearance if you want to. ⁓ But we were really looking at this of like so many dentists that I know that you've seen will just send in these clearances because they are. And I think maybe a way to help dentists have more confidence is because you know, I love routines. I love to not have to remember things. So why don't we throw it in, have the team member set it up where every quarter we just double check the ADA guidelines. Are there any updates? Are there any other things that we need to do on that? That way you can just see like   getting into the language of this, of what do I need to do? Because honestly, you guys, know pharmacy was not a big portion for it, so, recommending different parts, but I think this is such a space where you can have confidence, and there's a few other things I wanna get to, and I you- I some pearls too. Okay, go. I'm so when she get me into talking about drugs, I'm not gonna stop. So, some other things around that too is these newer blood thinners like Xarelto Eloquist, they now have reversal agents, so a lot of providers in the past were really worried about bleeding because we can't turn it off. We can turn those off. Warfarin has reversal as well, right?   So I'm looking at these patients. It's really low risk. It's in the mouth, generally speaking. Very rarely are they a high bleeding risk. Now if you're doing maxillofacial surgery, this does not apply, right? This does not apply whatsoever. you're like general dentist, you're pediatric dentist. Yeah, yeah, and it's kind of on the fly. So just trying to really help you to be able to take care of those patients on the moment, have that confidence, look at the ADA guidelines, have that in front of you. I don't think it's a bad thing to ever...   check with their provider if you need to. If you're thinking, I feel like I should just check with the provider, I would never take that away from you. But I just want to kind of steer towards those guidelines that I have to help. But what did you want to share? No, yeah, I love that. And I think there were just a few other nuggets that we were chatting about last night that can help dentists just kind of get things passed a little bit easier. So you were mentioning that if they were named to their cardiologist, what was it? was like, who is the last? Great question. Yeah, when a patient's on a blood thinner,   It could be prescribed by the cardiologist. It could be prescribed by the family provider or could have been punted to like a vascular clinic like where I was working. It can go to any of those. And when you send that fax, right, if it goes to the cardiologist and it's supposed to go to the family care provider, like it just kind of goes, goes nowhere, right, from there. So I think it's a really good idea to find out who prescribed it last. If the patient doesn't know who prescribed their blood thinner last, you can call their pharmacy. I call pharmacies all day long.   I have noticed in the last year, they are way easier to get a hold of, which has made my job a lot easier, working on the insurance portion. So reaching out to the pharmacy, finding out who that provider is and sending it to them, because they should be able to help with that. I thought that was a good shift in verbiage that you had of asking instead of like the cardiologist, because that's who you would assume was the one. But you said like so many times you guys would take care of them, and then they go back to family practitioner, and you guys would get the clearances, but you couldn't clear because you weren't overseeing. So just asking the patient.   who prescribed their medication for them last time. That way you can send the clearance to the correct provider. then- And they might not know. You know patients, right? They're like, I don't know, my mom's or else, I don't know who gave it to me. Somebody told me I need to be on this. But at least that could be another quick thing. And then also we were talking last night about-   ⁓ What are some other things that dentists can do when like writing scripts to help them get what I think like overarching theme of everything we discussed is one how to help dentists have less I think drag through pharmacy. ⁓ Because pharmacy can take a little while and so perfect we now know the difference between anti-quag and anti-platelet. We know which medications are probably safe. We know we can check the ADA guidelines so that we were not having to do as many clearances. We also know if they're on a medication to find out and we do need a clearance.   who we can go to for the fastest, easiest result. And now, in talking about prescriptions, you had some really interesting tips that you could share with them. Yeah, so with writing prescriptions, right, pharmacies are pharmacies. So I'm not gonna say good thing or bad thing. There are challenges working with pharmacies. I'm not gonna play that down at all. ⁓ If you're writing prescriptions and having issues and kickbacks from pharmacies, there's some interesting laws around ⁓ writing prescriptions. Say that you're trying to ⁓ prescribe   augmentin, you know, 875 BID, and you tell the patient, hey, I want you to take this twice a day for seven days, and then you put quantity of seven, because you're moving fast, right? You want it for seven days, quantity of seven. Quantity would actually be 14, right? It's not that big of a deal. Anybody with common sense would say if you're taking a pill for twice a day for seven days, you need 14 tablets. But LAHA doesn't allow pharmacists to make that kind of a change, unfortunately. They have to follow what you're saying there. So you're going to get a...   An annoying callback that says, you wrote for seven tablets. I know you need 14. Is that OK? Just delays things, right? So ⁓ I really like the two letters QS. That's Q isn't queen. S isn't Sam. Yeah. It stands for quantity sufficient. So you don't have to calculate the amount of any medication that you're doing. So for me, as a pharmacist, when I was taking care of patients, I hated calculating the amount of insulin they would need for an entire month. So I would say.   Mrs. Jones needs 15, I'd say 15 units ⁓ QD daily. ⁓ And then I say QS, quantity sufficient, ⁓ 90 day supply through refills. So the pharmacy can then go calculate how much insulin that they need. I don't have to even do that. So anytime you're prescribing anything, I like that QS personally. So that lets the pharmacy use ⁓ common sense, as I like to call it, instead of giving you a call. I think that's super helpful. I also thought of one thing too.   going back to blood thinners is when it's kind of like a real quick, like they're not gonna have you stop the blood thinner at all. like you're seeing if you can stop the blood thinner for a patient, there's some instances it's just not gonna happen. And that's whenever they've been, they've had a clot or a stroke or a heart attack within the last three months. Three months. Yeah, that's kind of like the.   Because so many people are like, they had a heart thing like six years ago. And so I think a lot of my dentists that I worked with were like, we got to stop the blood thinners. But it sounds like it's within three months. Yeah, well, I'm just the time. Like this is general broad strokes. What I'm just trying to say is when you want to expect a no real quick. Got it. Right. So because benefits of stopping a blood thinner within those first three months of an event is very, very risky versus the, you know, the benefit of reducing a little bit of blood coming out of the mouth. Right. Like that's not that bad.   when somebody's had a stroke or a heart attack or pulmonary embolism, a clot in the lung, like we can't replace the lung, heart or brain very easily. We can replace blood a lot better. We've got buckets of it at most hospitals have buckets of it, right? So I'm always kind of leaning towards I'd rather replace blood than tissue at all times. So that's kind of a quick no. If they've had one those events in the last three months, we are really, really gonna watch their brain instead of getting.   root canal, right? Like really worried about them. So you'll just say no. And they could the dentist still proceed with the procedure or would you recommend like a three month wait? Or is it provider specific way the pros and cons because sometimes you need to get that tooth out. Great question. think then it's going to come into clinical. That's that's when you send in the clearance, right? Like, and it's great to reach out to the provider who's managing it for you. But I think it's kind of good to know exactly when you get a quick no quick no is going to be less than three months.   ⁓ Or when it's going to be like a kind of a typical, yeah, no problem. If it's been no greater than six months, they're on the typical anticoagulants or alto eloquence. Nothing crazy is going on for them. You're only removing two teeth. This is very, very low risk. But again, I'd urge everybody to read the ADA guidelines. That way you feel more comfortable with it. I'm not as eloquent as they do. They do a real good job. So I don't want to take any of their credit. I think they do a real good job of simplifying that and making you feel confident with providing.   more timely care for patients. Which is amazing. And Jayce, one last thing. I don't remember what it was. You were talking about the DEA and like six month rule. yeah. Let's just quickly talk about that and then we'll wrap this because this is such a fascinating thing for me last night. Yeah. So when comes to prescribing controlled substances, most providers have to have a DEA license. OK. First of all, though, what's your take on dentist prescribing controlled substances? ⁓ I don't think, you know, I worked on the insurance side of things. Right. And I look at the requirements for the   as the authorizations, what a patient, the criteria a patient needs to hit in order to qualify for certain medications. A lot of times for those controlled substances, they have pretty significant issues going on, like fibromyalgia or cancer-related pain or end-of-life care versus we don't, in all my scanning thread, I don't have a ⁓ perfect picture memory. Sure. But I don't usually see oral.   pain in there. There is some post-operative pain that can be covered for those kind of medications but I really recommend to keep those lower and in fact in a lot of our criteria it recommends you know have they tried Tylenol first, they tried, have they filled NSAIDs or are they contraindicated with the patient. So really they should be last line for patients in my two cents but there's always going to be a caveat to the rule right? Of course. comes through that has oral cancer and you're taking   like that would make sense to me. Got it, so then back to the DEA. Yeah, okay. Okay, ready. So as a provider, you should be checking the, if you're doing controlled substances, you should be checking the prescription drug monitoring program, or sometimes called the PDMP, looking to see if patients are getting ⁓ controlled substances from another provider. So it's really just a check and balance to make sure that they're not going from provider to provider to getting too many narcotics and causing self harm or harm to others.   And so with checking that PDMP before prescribing, I think a lot of providers do that. A lot of softwares that I'm aware of, EMRs, electronic medical records, sometimes have links so that you can do that more quickly. However, I don't think it's as intuitive that they need to be checking that every six months in some states. And like here in Nevada, you're supposed to be checking it every six months, not for a patient, but for your actual DEA registration to see if anybody else is prescribing underneath you. Because if you don't check that every six months, you could get in some serious trouble with...   not only DEA, but even more the Board of Pharmacy and your state. Now, I don't know all 50 states, so I check with your state to see if you need to be checking that every six months, but set an alarm just to check that real quickly, keep your nose clean. ⁓ I've had providers, I've had to remind to do that. And if somebody was using your account, prescribing narcotics, you'd never know unless you went and checked that PDMP.   Yeah, I remember last night you were like, and if that was you, I would not want to be you. The Board of Pharmacy is going to be real excited to find you. So that was something where I was like, got it. So, and we all know I'm big on let's make it easy. And Jason, I love that you love this so much and you just brought so much value today. And like also for me, it's just fun to podcast. fun. Yeah. But I got a nerd out on my world a little bit. Bring it into yours. I work with dentists or at least you know, when I was working in Vascular Clinic all day long. Great questions that would come through. Yeah.   So I think for all of us, as a recap on this is number one, I think setting yourself ⁓ some cadences. So maybe every quarter we check our ADA guidelines and we check our, what is it, PDMP. PDMP. so each state, so they call it Prescription Drug Monitoring Program. We need that. Yeah, but there are different acronyms in different states, though. That's just what it's called in Nevada. I forget what it is in California, but you can check your state's prescription monitoring program, make sure that opioids aren't being prescribed under your name. Got it. So we just set that as a cadence.   We know one to three teeth most likely if they're on a blood thinner is According to the 88 as of today is good to go You know things that are going to get a quick know are going to be within the last three months of the stroke the heart attack or the Clot I'm thinking like the pulmonary embolus. Yeah, that's what we're trying to prevent   Those are gonna be quick knows and then if we're prescribing, let's do QS. We've got quantity is sufficient so that we're not getting phone calls back on those medications that we are. And then on narcotics, just being a bit more cautious. Of course, this is provider specific and in no way, or form did Jason come on here to tell you you are the clinical expert.   Jason's the clinical expert on medications. And if you guys ever have questions, I know Jason, you geek out and you want to talk to people so that anyone wants to chat shop. Be sure to reach out and we'll be able to connect you in. we've even talked about possibly, so let me know listeners. You can email in Hello@TheDentalATeam.com of ask a pharmacist anything. I talked to Jason. I was like,   We'll just have them like send in questions and maybe get you back on the podcast or we do a webinar. But any last thoughts, Jace, you've got of pharmacy and dentistry as we as we wrap up today? No, I think that's pretty much it. So check the ADA guidelines. I think it's really good to have cross communication between professions. Right. If you're working with the pharmacy, CVS, Walgreens or something like that or Walmart, I know that it can be challenging. Right. They're under different pressures. You're under different pressure. So I think ⁓ just coming in with an understanding, not being angry at each other.   you know what mean, is super beneficial and working together. When it comes to it, every dentist that I've talked to is actually worried about their patient. Every pharmacist that I've worked with is really worried about the patient as well. So we're trying to accomplish the same thing, but we have different rules and our hands are bound in different ways that annoy each other, right? Like I know Dr. Jones, want 14 tablets, but you said seven. And I know Common Sense says I should give them 14, but I've got to make that change.   knowing that their hands are tied by the law. They can't use as much common sense, which is aggravating. I mean, that's why I love what I gotta do here. I gotta just kind of help a lot more and use common sense and improve patient care. But those kinds of things I think are really beneficial as you work together and then not being so afraid of blood thinners, right? So I think those guidelines do a great job of giving you confidence and not worrying about the side effects. And there's a lot of things that you can do locally for bleeding.   You have a lot of control over that. I think that's pretty cool, the tools they have. Yeah. And at the end of the day, yes, you are the clinician. You are the one who is responsible for this. so obviously, chat, but I think collaborating, talking to other pharmacists, talking to them in your state, finding out what are the state laws, things like that I think can be really beneficial just to give you peace of mind and confidence. And again, dentistry, are maybe a bit more risk adverse because luckily we don't have patients dying That's great thing. Yeah, that's fantastic. I want my dentists to be risk adverse. I think so too. But Jason, I appreciate you being on the podcast today.   And for all of you listening, ⁓ more confidence, more clarity, more streamline to be able to serve and help our patients better. if we can help you in any way or you've got more questions, reach out Hello@TheDentalATeam.com. And as always, thanks for listening. I'll catch you next time on the Dental A Team podcast.  

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Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Get ready for a massive week in the world of cricket! In this episode, we dive deep into the upcoming 3rd Ashes Test at the Adelaide Oval, exploring the crucial matchups and who needs to step up to keep the series alive. With Australia currently leading the Ashes 2025/26 series, the pressure is mounting on England's key players. Our experts break down the pitch conditions, team changes, and provide their bold predictions for the decisive day/night Test match. The action isn't just Down Under; it's also about to explode at the IPL auction! The podcast shifts gears to preview the highly anticipated IPL 2026 mini-auction in Abu Dhabi. Is Australian all-rounder Cameron Green really set to break all previous auction records and surpass Rishabh Pant's massive INR 27 crore bid? We analyze which franchises have the biggest war chests, the key players available for bidding, and predict where the biggest surprises might land. Tune in for expert analysis on the Ashes, IPL news, and all the T20 buzz you need! Want to create live streams like this? Check out StreamYard: https://streamyard.com/pal/d/6313687373840384 Learn more about your ad choices. Visit podcastchoices.com/adchoices

In this Week 50 edition of the GMS Weekly Podcast, Grace and Ryan break down the latest ship recycling / demolition market developments across Bangladesh, India, Pakistan, and Turkey. Week 50 delivers “December Downers” as sentiment weakens into year-end: the Baltic Dry Index (BDI) slips nearly 4% (with Capes down 5.6%), and oil retreats over 3% to around $57.61/bbl. A strong U.S. Dollar, softer local steel plate prices, and limited tonnage continue to pressure bids—pushing many sub-continent indications toward $400/LDT and below. Bangladesh remains top-ranked but faces declining fundamentals—local plate prices drop about $9/ton into the high-$490s, and political risk rises with elections confirmed for Feb 12, 2026. India (Alang) stays the weakest as steel levels ease to roughly $377/ton, and the INR hits around 90.50 to the Dollar. Pakistan (Gadani) remains quiet despite ongoing Hong Kong Convention (HKC) progress; inflation sits near 6.1%, plate levels around $575/ton, and the PKR near 280.35. Turkey (Aliaga) is stable but slow, with the TRY near 42.70. Indicative price levels this week (USD/LDT): Bangladesh 410 / 430 / 440 (Bulker / Tanker / Container) Pakistan 400 / 420 / 430 India 380 / 400 / 410 Turkey 270 / 280 / 290 For the full report, rankings, and port positions, download the GMS Weekly via the GMS App or our website. Follow GMS on LinkedIn and social media for daily ship recycling market updates.

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

La Mesa - Jueves 04.12.2025 - Negro compareció en Diputados por atentados a Fiscal Ferrero e INR by En Perspectiva

V epizodi se pogovarjamo o stanju slovenskega trga, prihajajočih individualnih naložbenih računih (INR) in o tem, zakaj 25 milijard evrov na bančnih računih predstavlja tveganje, ne varnosti. Bombač razloži, zakaj meni, da bi moral vsak vlagatelj marca prihodnje leto opraviti prvo vplačilo v INR, ter izpostavi, da bodo znotraj računa vsi donosi neobdavčeni do dviga. Dotakneva se stroškov in pasti neobrokerjev, vloge pokojninskih skladov, možnosti slovenskega trga za preboj v višjo kategorijo ter njegove osebne naložbene strategije – kot pravi, je "hodler", ki stavi na disciplino in razpršitev, ne na dnevno trgovanje. Epizoda je bila posneta konec avgusta 2025. Objavljena je tudi na Youtube. V tokratni epizodi boste slišali: 00:00 Intro 03:00 – Se napihuje balon 05:10 – Koncentracija v SBITOP-u in vloga "svete trojice" 07:30 – Ali Slovenija lahko dočaka nove velike IPO-je? 10:00 – Individualni naložbeni računi: zakaj marca 2026 ne smeš zamuditi prvega vplačila 14:30 – Psihologija malih vlagateljev in lekcije iz krize 2007–2009 17:00 – Koliko slovenskih delnic naj ima vlagatelj v portfelju? 19:30 – Likvidnost Ljubljanske borze: miti in realnost 22:00 – Neobrokerji: zakaj "ničelna provizija" ni vedno najcenejša 25:00 – Zakaj hrvaški pokojninski skladi bolj verjamejo v slovenske delnice kot slovenski 28:00 – Preveč denarja na bankah: izguba tretjine vrednosti v 20 letih 31:00 – Vizija LJSE do 2028 in pot do trgov v razvoju 35:00 – Ljudske obveznice in prihod novih finančnih instrumentov 38:00 – Osebni portfelj in "hodler mindset" 42:00 – Pogled na FIRE: zakaj ga ne zanima zgodnja upokojitev 45:00 – Zaključek epizode *ustavrjeno s pomočjo umetne inteligence ____________________________ Money-How Premium: https://money-how.si/narocnine/ vključuje: - Modri AI - Finančni asistent, ki pomaga pri raznih finančnih dilemah https://money-how.si/modri-ai/ - Taxistent - Davčni asistent, ki pomaga pri oddaji davčne napovedi https://money-how.si/taxistent/ - poglobljene članke ____________________________ Bootcamp v živo: Investiranje – kako sploh začeti (omejeno število) Že dolgo razmišljaš o vlaganju in ne veš, kje in kako začeti? Nimaš energije, da bi raziskoval vse podrobnosti. Skrbijo te davki? Ne veš, kako investiranje vpliva na socialne transferje, kot so otroški dodatki? Presekaj in se nam pridruži v živo, kjer bomo skupaj naredili prvi korak v svet investiranja! Termin: 27. november 2025 med 17.00 in 20.30 Info: www.money-how.si/dogodki ______________________ Finančna delavnica je lahko čudovito darilo. Več preveri https://money-how.si/izobrazevanja ______________________ (delavnica) Investiranje v delnice: Kaj moram vedeti, ko se odločam za investiranje v delnice Prijava: https://money-how.si/izobrazevanja ______________________ (delavnica) Investiranje za začetnike. Praktično o osnovah investiranja. Prijava: https://money-how.si/izobrazevanja _________________________________ DISCORD skupnost: V finančnih zagatah nismo sami, pridružite se nam na Discord Money-How / discord ______________________________ Več o Money-How na https://money-how.si/

La Mesa - 17.11.2025 - Dispararon contra la sede del INR y dejaron una carta con una amenaza para su directora by En Perspectiva

In this Week 45 edition of the GMS Weekly Podcast, global ship recycling markets remain subdued as weak fundamentals, falling steel prices, and currency volatility continue to pressure recyclers across South Asia. From Bangladesh and India to Pakistan and Turkey, sentiment stays fragile while inflation, sanctions, and lack of supply define the tone. Global Market Overview Markets limped through early November as macro pressures persisted. The Baltic Dry Index gained about 7% for the week, with Capes up 3.1%, Panamaxes 0.9%, and smaller segments rising 0.5%. Oil slipped again, closing just above USD 60 per barrel, while renewed U.S. sanctions and weaker global demand continue to cloud forecasts. Inflation in key recycling nations remained uneven: Pakistan saw renewed price pressure, Turkey and Bangladesh stayed unstable, and India's figures remain pending. Bangladesh Chattogram stayed on top in name but not in action, with no viable tonnage arrivals and local buyers offering above-market rates just to keep yards active. The Taka depreciated further to BDT 121.93 per USD, and domestic steel plate prices collapsed, ending the week with no trading reported. Inflation hovered at 8.17%, while political and economic uncertainty weigh heavily heading into 2026. India Alang continues to show resilience despite ongoing price weakness. Steel plate levels fell to USD 388.95 per ton, while the INR slipped to 88.67 per USD. Despite those declines, two mini-VLCCs arrived this week, showing India's growing dominance as an HKC-compliant recycling destination. Pakistan Gadani's market remains under heavy strain, with offers below USD 400 per LDT as cheap Iranian steel imports flood the market. Local steel prices held around USD 614 per ton, but the PKR weakened to 282.5 per USD, and inflation jumped to 6.2%. Still no HKC-approved yards, leaving Gadani struggling for competitiveness. Turkey Aliaga stayed mostly silent this week. The Lira plunged nearly 40 basis points to TRY 42.23 per USD, while local recyclers tried to lift prices slightly to attract tonnage, with little success so far. Market Sentiment With global inflation, currency devaluation, low supply, and soft steel fundamentals, the world's ship recycling sector continues to drift through uncharted waters. Optimism now shifts to 2026 as recyclers await a long-overdue "Trading Day."   For full details, vessel rankings, and port positions, download the GMS Weekly on our website or mobile app. Follow GMS on LinkedIn, Facebook, Instagram, and Twitter for daily updates.

(Seminarhaus Engl) Der mittlere Weg vermittelt zwischen Extremen. Dadurch entstehen Räumen, in denen wir uns bewegen können, flexibel reagieren können. Das Gleiche gilt für die Übung der Brahmavihara durch die wir unser Herz weit für alle Wesen öffnen. Achtsamkeit öffnet Raum indem sie allen Erfahrungen gleichermaßen ohne Werten begegnet und sein lässt. Weisheit kann dann unheilsames aus den Raum heraustragen und heilsames hineinbringen. In Räumen können wir uns entwickeln, verändern, wie können sie gestalten. Räume ermöglichen, dass wir uns weiten können, atmen können, frei fühlen können, wohin die Fesseln des Anhaftens uns limitieren und beschränken. In diesen Räumen können sich Freude, Kreativität, Spontanität entfalten.

(Seminarhaus Engl) Der mittlere Weg vermittelt zwischen Extremen. Dadurch entstehen Räumen, in denen wir uns bewegen können, flexibel reagieren können. Das Gleiche gilt für die Übung der Brahmavihara durch die wir unser Herz weit für alle Wesen öffnen. Achtsamkeit öffnet Raum indem sie allen Erfahrungen gleichermaßen ohne Werten begegnet und sein lässt. Weisheit kann dann unheilsames aus den Raum heraustragen und heilsames hineinbringen. In Räumen können wir uns entwickeln, verändern, wie können sie gestalten. Räume ermöglichen, dass wir uns weiten können, atmen können, frei fühlen können, wohin die Fesseln des Anhaftens uns limitieren und beschränken. In diesen Räumen können sich Freude, Kreativität, Spontanität entfalten.

In this Week 44 edition of the GMS Weekly Podcast, the global ship recycling industry closes October on a haunting note as weak fundamentals, volatile currencies, and scarce tonnage continue to shadow the sub-continent markets. From India and Bangladesh to Pakistan and Turkey, sentiment stays fragile while inflation trends, oil movements, and new HKC developments keep recyclers on edge. Global Market Overview October ended with more tricks than treats. The Baltic Dry Index slipped 1.3 percent week-on-week and nearly 8 percent for the month, marking its first monthly drop since April. Oil eased almost 1 percent to around USD 60.67 per barrel as OPEC+ announced fresh Q1 2026 cutbacks. A temporary U.S.–China trade truce brought brief relief, but volatility and policy uncertainty persist. Limited vessel supply kept yards mostly idle, with buyers hesitant to commit amid falling plate prices and a widening two-tier market for sanctioned ships. Bangladesh Chattogram showed faint sparks as a few hungry recyclers chased prompt deals, but domestic steel demand failed to ignite. Local plate levels slipped USD 3 to USD 529.50 per ton, and the taka weakened to BDT 122.37 per USD. HKC certifications continue to climb, with 21 yards expected to be approved by year-end, a bright spot in an otherwise subdued market. India Alang faced another quiet stretch as the rupee dropped 1.25 percent to INR 88.70. Steel prices ended flat, while discounted sanctioned vessels pushed legitimate bids lower, unsettling buyers and widening the pricing gap. Inflation remains low at 1.54 percent, hinting at potential relief through cheaper financing if confidence returns. Pakistan Gadani recyclers endured renewed “imports ire.” Cheap Iranian steel and a lack of HKC-compliant yards kept activity muted despite plate values roughly USD 230 above India's. The PKR closed at 283.17 per USD as margins tightened and sentiment weakened. Turkey Aliaga continued to face a supply pinch. Local recyclers raised offers slightly to attract owners, but the lira slid to TRY 42.06 and inflation rose above 33 percent. With few vessels arriving, operational pressure remains heavy. Market Sentiment As we sail into November, recyclers confront familiar headwinds: weak demand, currency stress, HKC uncertainty, and a vanishing pipeline of ships. Whether markets rebound or remain haunted will define the rest of 2025. For full details, vessel rankings, and port positions, download the GMS Weekly on our website or mobile app. Follow GMS on LinkedIn, Facebook, Instagram, and Twitter for daily updates.

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda10 - तत्त्वबोध हिन्दी | अद्वैत जागरण युवा शिविर | सत्संग 10 | सितम्बर 2025Youtube Link : https://youtu.be/bd1zITcK18sPodomatic Link : https://www.podomatic.com/podcasts/swatmananda/episodes/2025-10-28T05_46_24-07_00

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

In this Week 43 edition of the GMS Weekly Podcast, we review another subdued week in the global ship recycling markets as currencies fluctuated, steel plate prices softened, and sentiment across India, Bangladesh, Pakistan, and Turkey remained weak. Global Market Overview Markets slowed across the board as the Baltic Dry Index slipped about 3.2% to its lowest level since early October. Oil prices found mild traction, firming to USD 62.14 per barrel, up roughly 1% on expectations of a possible China–U.S. trade deal. Inflation in the United States rose to 3%, while sanctions and tariff pressures added further uncertainty. Recycling prices across the Sub-continent continued to fall, with levels below USD 400 per LDT now widely discussed. Supply of tonnage remained extremely limited, leaving yards mostly idle despite steady freight markets. Bangladesh Chattogram showed sporadic activity with a few larger LDT units drawing attention, including LNG carriers PUTERI NILAM and PUTERI DELIMA sold en bloc on private terms, and bulker MONICA P (7,779 LDT) sold at USD 380 per LT LDT “as is” Belawan. The Taka weakened to BDT 122.35, while local steel plate slipped another USD 3 per ton. Elections scheduled for February 2026 continue to shape local sentiment. India Alang endured another quiet week as Diwali holidays passed with little recovery. Steel plate prices remained near USD 389 per ton, and the rupee closed at INR 87.54. More than 100 HKC-certified yards remain empty, as prices for clean tonnage fall below USD 400 per LDT and the arrival of shadow-fleet vessels further depresses sentiment. Pakistan After recent optimism, Gadani slowed again due to an influx of cheap Iranian scrap steel. Local recyclers hesitated to offer on limited tonnage as plate prices held near USD 614 per ton. The rupee weakened to PKR 283.50 per USD. Larger dry units remain preferred, while smaller vessels are avoided amid certification delays. Turkey Little movement was recorded in Aliaga as the Lira slipped to TRY 42.08 per USD and local steel values remained largely unchanged. Offers stayed within USD 250–270 per LDT as sentiment stayed weak. Market Sentiment With October ending, global freight remains firm and oil prices higher, but the recycling sector continues to face record-low supply, fading prices, and growing uncertainty. For full details, vessel rankings, and port positions, download the GMS Weekly on our website or mobile app. Follow GMS on LinkedIn, Facebook, Instagram, and Twitter for daily updates.

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

There is something inside Ira. It's growing. It's alive. And it is not a baby.Listen to EP 01 HereEpisode 2 of Rakt Lekha is a descent into pure, unfiltered body horror. The secret of the Sehajeevi is about to be born, and the revelation is a grotesque nightmare. This is the Hindi horror story everyone is talking about, a terrifying kahani that takes the classic Monkey's Paw legend and injects it with a horrifying, biological twist.Prepare yourself for a darawni kahani that doesn't hold back. This is a monster story unlike any other, where the greatest horror is the one that grows within.[Hindi Horror Story, Horror Story, Kahani, The Monkey's Paw, Rakt Lekha, Indian Horror Story, SciFi Horror, Body Horror, Darawni Kahani, Bhutiya Kahani, Cursed Wish, Supernatural Thriller, Audio Story, Horror Podcast, Hindi Kahani, Rahasyamayi Kahani, Monster Story, Alien Story, Sehajeevi]Join this channel to get access to exclusive perks @just 59 INR a month!! Follow me on YouTubeFacebookInstagram

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Dobrodošli v 6. sezoni podkasta Money-How. Nova sezona, nova spletna stran, številne novosti in izboljšave. Predstavljamo Modri AI, ki je kot nekakšen finančni pomočnik, ki pomaga pri reševanju finančnih zagat. Z enim klikom dobite informacije, kot so, kako investira Damian Merlak ali Ivo Boscarol, kaj je INR, preverjen seznam ETF in brokerjev ... Tam dobite tudi povzetke epizod. Novost, ki bo precej olajšala oddajo davčne napovedi je, davčni pomočnik Taxistent, ki pripravi dokumente za uvoz v eDavke. Pripravljamo tudi velik dogodek Money-How FIRE: Kako do finančne svobode? Izpostavljamo tudi pasti investiranja v slovenske delnice ter potrebo po kritičnem razmišljanju o informacijah, ki jih prejemamo iz medijev. V 6. sezoni bo več poudarka na upravljanju osebnih financ. Hvala, da ste z nami. Vabljeni, da nas spremljate še naprej. V tokratni epizodi boste slišali: 00:00 Uvod v šesto sezono Money-How 02:47 Finančno-izobraževalna platforma 06:12 Bootcampi in delavnice za mlade 09:05 Finančna neodvisnost in Money-How FIRE 11:50 Modri AI - pomočnik pri reševanju finančnih dilem 15:00 Imam 20 tisočakov. Naj počakam na INR? 20:06 Investiranje v slovenske delnice (o patriotizmu) 23:56 Taxistent - davčni asistent pri oddaji davčne napovedi Obiščite spletno stran www.money-how.si

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

Please support this podcast by pressing the follow button and support Chinmaya Mission Mumbai projects taken up by Swami Swatmananda, through generous donations. Contribution by Indians in INR can be made online using this link: https://bit.ly/gdswatmanDonors outside India who would like to offer any Gurudakshina/donation can send an email to enquiry@chinmayamissionmumbai.com with a cc to sswatmananda@gmail.com to get further details.These podcasts @ChinmayaShivam are also available on Spotify, Apple iTunes, Apple Podcasts, Podomatic, Amazon music and Google PodcastFB page: https://www.facebook.com/ChinmayaShivampageInsta: https://instagram.com/chinmayashivam?igshid=1twbki0v3vomtTwitter: https://twitter.com/chinmayashivamBlog: https://notesnmusings.blogspot.comLinkedIN: www.linkedin.com/in/swatmananda

¡Vacuna a tu lomito! Campaña antirrábica esta semana en Benito Juárez  Sin liberación de rehenes, no hay embajada en Palestina: MacronMás información en nuestro Podcast

Contributors: Travis Barlock MD, Jeffrey Olson MS4 Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points. Case 1 25 M, presents to the ED with chest pain. Stabbing, started a few hours ago, substernal. Thinks it is GERD. After 2-3 minutes, pain worsens and radiates to the back. VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA. Additional VS: Temp of 37.2, height of 6'5”, BMI of 18. PMH: None, doesn't see a doctor. Meds: None FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes Physical Exam: Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric MSK: Knees, elbows, and wrists are hypermobile. Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion CTA/MRA doesn't come back until after the case.  ECG: Sinus Tach Labs: NT-proBNP 500 pg/mL D-Dimer: 7000 ng/L CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180 LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4, Ca: 7.8 LDH: 2200 PT: 20.5, INR: 2.2, Fibrinogen: 170 5th gen High-Sensitivity Troponin:

Lyssa Rome is a speech-language pathologist in the San Francisco Bay Area. She is on staff at the Aphasia Center of California, where she facilitates groups for people with aphasia and their care partners. She owns an LPAA-focused private practice and specializes in working with people with neurogenic communication disorders. She has worked in acute hospital, skilled nursing, and continuum of care settings. Prior to becoming an SLP, Lyssa was a public radio journalist, editor, and podcast producer. In this episode, Lyssa Rome interviews Liz Hoover about group treatment for aphasia.   Guest info Dr. Liz Hoover is a clinical professor of speech language and hearing sciences and the clinical director of the Aphasia Resource Center at Boston University. She holds board certification from the Academy of Neurologic Communication Disorders and Sciences, or ANCDS, and is an ASHA fellow. She was selected as a 2024 Tavistock Trust for Aphasia Distinguished Scholar, USA and Canada. Liz was a founding member of Aphasia Access and served on the board for several years. She has 30 years of experience working with people with aphasia and other communication disorders across the continuum of care. She's contributed to numerous presentations and publications, and most of her work focuses on the effectiveness of group treatment for individuals with aphasia.   Listener Take-aways In today's episode you will: Describe the evidence supporting aphasia conversation groups as an effective interventions for linguistic and psychosocial outcomes. Differentiate the potential benefits of dyads versus larger groups in relation to client goals. Identify how aphasia severity and group composition can influence treatment outcomes.   Edited transcript Lyssa Rome Welcome to the Aphasia Access Aphasia Conversations Podcast. I'm Lyssa Rome. I'm a speech language pathologist on staff at the Aphasia Center of California and I see clients with aphasia and other neurogenic communication disorders in my LPAA-focused private practice. I'm also a member of the Aphasia Access Podcast Working Group. Aphasia Access strives to provide members with information, inspiration and ideas that support their aphasia care through a variety of educational materials and resources.   I'm today's host for an episode that will feature Dr. Elizabeth Hoover, who was selected as a 2024 Tavistock Trust for Aphasia Distinguished Scholar, USA and Canada.   Liz Hoover is a clinical professor of speech language and hearing sciences and the clinical director of the Aphasia Resource Center at Boston University. She holds board certification from the Academy of Neurologic Communication Disorders and Sciences, or ANCDS, and is an ASHA fellow. Liz was a founding member of Aphasia Access and served on the board for several years. She has 30 years of experience working with people with aphasia and other communication disorders across the continuum of care. She's contributed to numerous presentations and publications, and most of her work focuses on the effectiveness of group treatment for individuals with aphasia. Liz, welcome back to the podcast.   So in 2017 you spoke with Ellen Bernstein Ellis about intensive comprehensive aphasia programs or ICAPs and inter professional practice at the Aphasia Resource Center at BU and treatment for verb production using VNest, among other topics. So this time, I thought we could focus on some of your recent research with Gayle DeDe and others on conversation group treatment.   Liz Hoover Sounds good.   Lyssa Rome All right, so my first question is how you became interested in studying group treatment?   Liz Hoover Yeah, I actually have Dr. Jan Avent to thank for my interest in groups. She was my aphasia professor when I was a graduate student doing my masters at Cal State East Bay. As you know, Cal State East Bay is home to the Aphasia Treatment Program. When I was there, it preceded ATP. But I was involved in her cooperative group treatment study, and as a graduate student, I was allowed to facilitate some of her groups in this study, and I was involved in the moderate-to-severe group. She was also incredibly generous at sharing that very early body of work for socially oriented group treatments and exposing us to the work of John Lyons and Audrey Holland. Jan also invited us to go to a conference on group treatment that was run by the Life Link group. It's out of Texas Woman's University, Delaina Walker-Batson and Jean Ford. And it just was a life changing and pivotal experience for me in recognizing how group treatment could not be just an adjunct to individual goals, but actually be the type of treatment that is beneficial for folks with aphasia. So it's been a love my entire career.   Lyssa Rome And now I know you've been studying group treatment in this randomized control trial. This was a collaborative research project, so I'm hoping you can tell us a little bit more about that project. What were your research questions? Tell us a little bit more.   Liz Hoover Yeah, so thank you. I'll just start by acknowledging that the work is funded by two NIDCD grants, and to acknowledge their generosity, and then also acknowledge Dr. Gayle DeDe, who is currently at Temple University. She is a co- main PI in this work, and of course it wouldn't have happened without her. So you know, Gayle and I have known each other for many, many years. She's a former student, doctoral student at Boston University, and by way of background, she and I were interested in working together and interested in trying to build on some evidence for group treatment. I think we drank the Kool Aid early on, as you might say.   And you know, just looking at the literature, there have been two trials on the evidence for this kind of work. And so those of us who are involved in groups, know that it's helpful for people with aphasia, our clients tell us how much they enjoy it, and they vote with their feet, right? In that they come back for more treatments. And aphasia centers have grown dramatically in the last couple of decades in the United States.   So clearly we know they work, but what we don't know is why they work. What are those essential ingredients, and how is that driving the change that we think we see? And from a personal perspective, that's important for me to understand and for us to have explained in the literature, because until we can justify it in the scientific terms, I worry it will forever be a private-pay adjunct that is only accessible to people who can pay for it, or who are lucky enough to be close enough to a center that can get them access—virtual groups aside, and the advent of that—but it's important that I think this intervention is validated to the scientific community in our field.   So we designed this trial. It's a randomized control trial to help build the research evidence for conversation, group treatment, and to also look at the critical components. This was inspired by a paper actually from Nina Simmons Mackie in 2014 and Linda Worrell. They looked at group treatment and showed that there were at least eight first-tier elements that changed the variability or on which we might modify group conversation treatment. And so, you know, if we're all doing things differently, how can we predict the change, and how can we expect outcomes?   Lyssa Rome So I was hoping you could describe this randomized, controlled trial. You know, it was collaborative, and I'm curious about what you and your collaborators had as your research questions.   Liz Hoover So our primary aims of the study were to understand if communication or conversation treatment is associated with changes in measures of communicative ability and psychosocial measures. So that's a general effectiveness question. And then to look in more deeply to see if the group size or the group composition or even the individual profile of the client with aphasia influences the expected outcome.   Because if you think about group treatment, the size of the group is not an insignificant issue, right? So a small group environment of two people has much more… it still gives you some peer support from the other individual with aphasia, but you have many opportunities for conversational turns and linguistic and communication practice and to drive the saliency of the conversation in a direction that's meaningful and useful and informative.   Whereas in a large group environment of say, six to eight people with aphasia and two clinicians, you might see much more influence in the needed social support and vicarious learning and shared lived experience and so forth, and still have some opportunity for communication and linguistic practice. So there's conflicting hypotheses there about which group environment might be better for one individual over another.   And then there's the question of, well, who's in that group with you? Does that matter? Some of the literature says that if you have somebody with a different profile of aphasia, it can set up a therapeutic benefit of the helper experience, where you can gain purpose by enabling and supporting and being a facilitator of somebody else with aphasia.   But if you're in a group environment where your peers have similar conversation goals as you, maybe your practice turns, and your ability to learn vicariously from their conversation turns is greater. So again, two conflicting theories here about what might be best. So we decided to try and manipulate these group environments and measure outcomes on several different communication measures. We selected measures that were linguistic, functional, and psychosocial.   We collected data over four years. The first two years, we enrolled people with all different kinds of profiles of aphasia. The only inclusion criteria from a communication perspective, as you needed some ability to comprehend at a sentence level, so that you could process what was being said by the other people in the group. And in year one, the treatment was at Boston University and Temple University, which is where Gayle's aphasia center is housed. In year two, we added a community site at the Adler Aphasia Center and Maywood, New Jersey, so we had three sites going.   The treatment conditions were dyad, large group, and then a no treatment group. So this group was tested at the same time, didn't get any other intervention, and then we gave them group treatment once the testing cycle was over. So we call that a historical control or a delayed-treatment control group. And then in years three and four, we aim to enroll people who had homogeneous profiles.   So the first through the third cycle was people with moderate to severe profiles. And then in the final, fourth cycle, it was people with mild profiles with aphasia. This allowed us to collect enough data in enough size to be able to look at overall effectiveness and then effects of heterogeneity or homogeneity in the group, and the influence of the profile of aphasia, as well as the group size.   And across the four years, we aim to enroll 216 participants, and 193 completed the study. So it's the largest of its kind for this particular kind of group treatment that we know of anyway. So this data set has allowed us to look at overall efficacy of conversation group treatment, and then also take a look at a couple of those critical ingredients. Does the size of the group make a difference? And does the composition of your group make a difference?   Lyssa Rome And what did you find?   Liz Hoover Well, we're not quite done with all of our analysis yet, but we found overall that there's a significant treatment effect for just the treatment conditions, not the control group. So whether you were in the dyad or whether you were in a large treatment group, you got better on some of the outcome measures we selected. And the control group not only didn't but on a couple of those measures, their performance actually declined. And so showing significantly that there's a treatment effect. Did you have a question?   Lyssa Rome Yeah, I wanted to interrupt and ask, what were the outcome measures? What outcome measures were you looking at?   Liz Hoover Yeah. So we had about 14 measures in total that aligned with the core outcome set that was established by the ROMA group. So we had as our linguistic measure the Comprehensive Aphasia Test. We had a primary outcome measure, which was a patient reported measure of functional communication, which is the ACOM by Will Hula and colleagues, the Aphasia Communication Outcome measure, we had Audrey Holland and colleagues' objective functional measure, the CADL, and then a series of other psychosocial and patient reported outcome measures, so the wall question from the ALA, the Moss Social Scale, the Communication Confidence Rating Scale in Aphasia by Leora Cherney and Edie Babbitt.   Lyssa Rome Thank you. When I interrupted you to ask about outcome measures. You were telling us about some of the findings so far.   Liz Hoover Yeah, so our primary outcome measures showed significant changes in language for both the treatment conditions and a slightly larger effect for the large group. And then we saw, at a more micro level, the results pointing to a complex interaction, actually, between the group size and the treatment outcome. So we saw changes on more linguistic measures. like the repetition sub scores of the CAT and verb naming from another naming subtest for the dyad group, whereas bigger, more robust changes on the ACOM the CADL and the discourse measure from the CAT for the large group.   And then diving in a little bit more deeply for the composition, these data are actually quite interesting. The papers are in review and preparation at the moment, but it looks like we are seeing significant changes for the moderate-to-severe group on objective functional measures and patient reported functional measures of communication, which is so exciting to see for this particular cohort, whose naming scores were zero, in some cases, on entrance, and we're seeing for the mild group, some changes on auditory comprehension, naming, not surprisingly, and also the ACOM and the CADL. So they're showing the same changes, just with different effect sizes or slightly different ranges. And once again, no change in the control group, and in some cases, on some measures, we're seeing a decline in performance over time.   So it's validating that the intervention is helpful in general. What we found with the homogeneous groups is that in a homogeneous large group environment, those groups seem to do a little better. There's a significant effect over time between the homogeneous and the heterogeneous groups. So thinking about why that might have taken place, we wonder if the shared lived experience of your profile of aphasia, your focus on similar kinds of communication, or linguistic targets within the conversation environment might be helping to offset the limited number of practice trials you get in that larger group environment.   So that's an interesting finding to see these differences in who's in the group with you. Because I think clinically, we tend to assign groups, or sort of schedule groups according to what's convenient for the client, what might be pragmatic for the setting, without really wondering why one group could be important or one group might be preferential. If we think about it, there are conflicting hypotheses as to why a group of your like aphasia severity might have a different outcome, right? That idea that you can help people who have a different profile than you, that you're sharing different kinds of models of communication, versus that perhaps more intense practice effect when you share more specific goals and targets and lived experiences. So it's interesting to think about the group environment from that perspective, I think,   Lyssa Rome And to have also some evidence that clinicians and people at aphasia centers can look to help make decisions about group compositions, I think is incredibly helpful.   Earlier, you mentioned that one of the goals of this research project has been to identify the active ingredients of group therapy. And I know that you've been part of a working group for the Rehabilitation Treatment Specification System, or RTSS. Applying that, how have you tried to identify the active ingredients and what? What do you think it is about these treatments that actually drives change?   Liz Hoover I'll first of all say, this is a work in process. You know, I don't think we've got all of the answers. We're just starting to think about it with the idea, again, that if we clinically decide to make some changes to our group, we're at least doing it with some information behind us, and it's a thoughtful and intentional change, as opposed to a gut reaction or a happenstance change. So Gayle and I have worked on developing this image, or this model. It's in a couple of our papers. We can share the resources for that. But it's about trying to think of the flow of communication, group treatment, and what aspects of the treatment might be influential in the outcomes we see downstream.   I think for group treatment, you can't separate entirely many of the ingredients. Group treatment is multifaceted, it's interconnected, and it's not possible—I would heavily debate that with anybody—I don't think it's possible to sort of truly separate some of these ingredients. But when you alter the composition or the environment in which you do the treatment, I do think we are influencing the relative weight of these ingredients.   So we've been thinking about there being this group dynamics component, which is the supportive environment of the peers in the group with you, that social support, the insider affiliation and shared lived experience, the opportunity to observe and see the success of some of these different communication strategies, so that vicarious learning that takes place as you see somebody else practice. But also, I think, cope in a trajectory of your treatment process.   And then we've got linguistic practice so that turn taking where you're actually trying to communicate verbally using supported communication where you're expanding on your utterances or trying to communicate verbally in a specific way or process particular kinds of linguistic targets. A then communication practice in terms of that multimodal effectiveness of communication.   And these then are linked to these three ingredients, dynamic group dynamics, linguistic practice and communication practice. They each have their own mechanism of action or a treatment theory that explains how they might affect change. So for linguistic practice, it's the amount of practice, but also how you hear it practiced or see it practiced with the other group participant. And the same thing for the various multimodal communication acts. And in thinking about a large group versus the dyad or a small group, you know you've got this conflicting hypothesis or the setup for a competing best group, or benefit in that the large group will influence more broadly in the group dynamics, or more deeply in the group dynamics, in that there's a much bigger opportunity to see the vicarious learning and experience the support and potentially experience the communication practice, given a varied number of participants.   But yet in the dyad, your opportunity for linguistic practice is much, much stronger. And our work has counted this the exponential number of turns you get in a dyad versus a large group. And you know, I think that's why the results we saw with the dyad on those linguistic outcomes were unique to that group environment.   Lyssa Rome It points, I think, to the complexity of decision making around group structure and what's right for which client, maybe even so it sounds like some of that work is still in progress. I'm curious about sort of thinking about what you know so far based on this work, what advice would you have for clinicians who are working in aphasia centers or or helping to sort of think about the structure of group treatments? What should clinicians in those roles keep in mind?   Liz Hoover Yeah, that's a great question, and I'll add the caveat that this may change. My advice for this may change in a year's time, or it might evolve as we learn more. But I think what it means is that the decisions you make should be thoughtful. We're starting to learn more about severity in aphasia and how that influences the outcomes. So I think, what is it that your client wants to get out of the group? If they're interested in more linguistic changes, then perhaps the dyad is a better place to start. If they clearly need, or are voicing the need, for more psychosocial support, then the large, you know, traditional sized and perhaps a homogeneous group is the right place to start. But they're both more effective than no treatment. And so being, there's no wrong answer. It's just understanding your client's needs. Is there a better fit?   And I think that's, that's, that's my wish, that people don't see conversation as something that you do at the beginning to build a rapport, but that it's worthy of being an intervention target. It should be most people's primary goal. I think, right, when we ask, what is it you'd like? “I want to talk more. I want to have a conversation.” Audrey Holland would say it's a moral imperative to to treat the conversation and to listen to folks' stories. So just to think carefully about what it is your client wants to achieve, and if there's an environment in which that might be easier to help them achieve that.   Lyssa Rome It's interesting, as you were saying that I was thinking about what you said earlier on about sort of convincing funders about the value of group treatment, but what you're saying now makes me think that it's all your work is also valuable in convincing speech therapists that referrals to groups or dyads is valuable and and also for people with aphasia and their families that it's worth seeking out.   I'm curious about where in the continuum of care this started for the people who were in your trial. I mean, were these people with chronic aphasia who had had strokes years earlier? Was it a mix? And did that make a difference?   Liz Hoover It was a mix. I think our earliest participant was six months post-onset. Our most chronic participant was 26 years post-onset. So a wide range. We want, obviously, from a study perspective, we needed folks to be outside of the traditional window of spontaneous recovery in stroke-induced aphasia.   But it was important to us to have a treatment dose that was reasonable and applicable to a United States healthcare climate, right? So twice a week for an hour is something that people would get reimbursed for. The overall dose is the minimum that's been shown to be effective in the RELEASE collaborative trial papers. And then, you know, but still, half, less than half the dose that the Elman and Bernstein Ellis study found to be effective. So there may be some wiggle room there to see if, if a larger dose is more effective.   But yeah, I think it's that idea of finding funding, convincing people that this is not just a reasonable treatment approach, but a good approach for many outcomes for people with chronic aphasia. I mean, you know, one of the biggest criticisms we hear from the giants in our field is the frustration with aphasia being treated like it's a quick fix and can be done. But you know, so much of the work shows that people are only just beginning to understand their condition by the time they're discharged from traditional outpatient services. And so there's a need for ongoing treatment indefinitely, I think, as your goals change, as you age, and as your wish to participate in different things changes over a lifetime,   Lyssa Rome Yeah, absolutely. And I think too, when we think about sort of the role of hope, if you know, if there is additional evidence showing that there can be change after that sort of traditional initial period, when we think that change happens the most, that can provide a lot of hope and motivation, I think, to people.   Liz Hoover yeah, we're look going to be looking next at predictors of change, so looking at our study entrance scores and trying to identify which participants were the responders versus the non-responders that you know, because group effects are one thing, but it's good to see who seems to benefit the most from these individual types of environments.   And an early finding is that confidence, or what some people in the field, I'm learning now are referring to as actually communication self-efficacy, but that previous exposure to group potentially and that confidence in your communication is inversely correlated with benefits from treatment on other measures. So if you've got a low confidence in your ability to communicate functionally in different environments, you're predicted to be a responder to conversation treatment.   Lyssa Rome Oh, that's really interesting. What else are you looking forward to working on when it comes to this data set or other projects that you have going on?   Liz Hoover Yeah. So as I mentioned, there's a lot of data still for us to dig into, looking at those individual responders or which factors or variables might make an impact. There is the very next on the list, we're also going to be looking very shortly at the dialogic conversation outcomes. So, it's a conversation treatment. How has conversation changed? That's a question we need to answer. So we're looking at that currently, and might look more closely at other measures. And then I think the question of the dose is an interesting one. The question of how individual variables or the saliency of the group may impact change is another potentially interesting question. There are many different directions you can go.   You know, we've got 193 participants in the study, with three separate testing time points, so it's a lot of data to look at still. And I think we want to be sure we understand what we're looking at, and what those active ingredients might be, that we've got the constructs well defined before we start to recruit for another study and to expand on these findings further.   Lyssa Rome When we were meeting earlier, getting ready for this talk, you mentioned to me a really valuable video resource, and I wanted to make sure we take some time to highlight that. Can you tell us a little bit about what you worked on with your colleagues at Boston University?   Liz Hoover Yes, thank you. So I'll tell you a little bit. We have a video education series. Some of you may have heard about this already, but it's up on our website so bu.edu/aphasiacenter, and we'll still share that link as well. And it's a series of short, aphasia-friendly videos that are curated by our community to give advice and share lived experiences from people with aphasia and their care partners.   This project came about right on the heels of the COVID shutdown at our university. I am involved in our diagnostic clinic, and I was seeing folks who had been in acute care through COVID being treated with people who were wearing masks, who had incredibly shortened lengths of stay because people you know rightly, were trying to get them out of a potentially vulnerable environment. And what we were seeing is a newly diagnosed cohort of people with aphasia who were so under-informed about their condition, and Nina that has a famous quote right of the public being woefully uninformed of the aphasia condition and you don't think it can get any worse until It does.   And I thought, gosh, wouldn't it be wonderful to be able to point them to some short education videos that are by people who have lived their same journey or a version of their same journey. So we fundraised and collaborated with a local production company to come up with these videos. And I'll share, Lyssa, we just learned last week that this video series has been awarded the ASHA 2025 Media Outreach Award. So it's an award winning series.   Lyssa Rome Yeah, that's fantastic, and it's so well deserved. They're really beautifully and professionally produced. And I think I really appreciated hearing from so many different people with aphasia about their experiences as the condition is sort of explained more. So thank you for sharing those and we'll put the links in our show notes along with links to the other articles that you've mentioned in this conversation in our show notes. So thanks.   Liz Hoover Yeah, and I'll just put a big shout out to my colleague, Jerry Kaplan, who's the amazing interviewer and facilitator in many of these videos, and the production company, which is Midnight Brunch. But again, the cinematography and the lighting. They're beautifully done. I think I'm very, very happy with them.   Lyssa Rome Yeah, congrats again on the award too. So to wrap up, I'm wondering if there's anything else that you want listeners to take away from this conversation or from the work that you've been doing on conversation treatments.   Liz Hoover I would just say that I would encourage everybody to try group treatment. It's a wonderful option for intervention for people, and to remind everyone of Barbara Shadden and Katie Strong's work, of that embedded storytelling that can come out in conversation, and of the wonderful Audrey Holland's words, of it being a moral imperative to help people tell their story and to converse. It's yeah… You'll drink the Kool Aid if you try it. Let me just put it that way. It's a wonderful intervention that seems to be meaningful for most clients I've ever had the privilege to work with.   Lyssa Rome I agree with that. And meaningful too, I think for clinicians who get to do the work.   Liz Hoover, thank you so much for your work and for coming to talk with us again, for making your second appearance on the podcast. It's been great talking with you.   Liz Hoover Thank you. It's been fun. I appreciate it.   Lyssa Rome And thanks also to our listeners for the references and resources mentioned in today's show. Please see our show notes. They're available on our website, www.aphasiaaccess.org. There, you can also become a member of our organization, browse our growing library of materials and find out about the Aphasia Access Academy. If you have an idea for a future podcast episode, email us at info@aphasia access.org.   Thanks again for your ongoing support of Aphasia Access. For Aphasia Access Conversations. I'm Lyssa Rome.       Resources Walker-Batson, D., Curtis, S., Smith, P., & Ford, J. (1999). An alternative model for the treatment of aphasia: The Lifelink© approach. In R. Elman (Ed.), Group treatment for neurogenic communication disorders: The expert clinician's approach (pp. 67-75). Woburn, MA: Butterworth-Heinemann   Hoover, E.L., DeDe, G., Maas, E. (2021). A randomized controlled trial of the effects of group conversation treatment on monologic discourse in aphasia. Journal of Speech-Language and Hearing Research doi/10.1044/2021_JSLHR-21-00023 Hoover, E., Szabo, G., Kohen, F., Vitale, S., McCloskey, N., Maas, E., Kularni, V., & DeDe., G. (2025). The benefits of conversation group treatment for individuals with chronic aphasia: Updated evidence from a multisite randomized controlled trial on measures of language and communication. American Journal of Speech Language Pathology. DOI: 10.1044/2025_AJSLP-24-00279   Aphasia Resource Center at BU   Living with Aphasia video series Aphasia Access Podcast Episode #15: In Conversation with Liz Hoover

We are all aware that mental/emotional well-being is essential to maintain on a surface level. But on a deeper level, research shows us over & over that emotional skills are thee foundation to human happiness & success. There is no such thing as a solely logical person. Emotions are what make us human, and we must learn how to interact with them, not because we're whiny or soft, but because emotions drive humanity. Emotions are at the root of everything humans do, and whether or not we will survive.(Please excuse my runny nose in this one

*****To sign up and get started with GlintPay, go to glintpay.com and make sure to use the code SNIDER.*****The dollar is surging again. And while it's primary the euro taking the other side, just as importantly, if not more importantly, currencies like the rupee are tanking worse. INR hit another record low and that along with the euro's sharp reverse is a canary singing in the eurodollar coalmine...perhaps gasping. Eurodollar University's Money & Macro Analysishttps://www.eurodollar.universityTwitter: https://twitter.com/JeffSnider_EDU

Contributor: Jorge Chalit-Hernandez, OMS4 Educational Pearls: What is the toxic dose of acetaminophen? 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver. This is equivalent to fifteen 500mg pills. What are the symptoms of acetaminophen toxicity? First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic. 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion) Fulminant liver failure at 72-96 hours Liver function tests (LFTs) peak at 72-96 hours. When would you give activated charcoal? Within 4 hours of ingestion. The risk of activated charcoal is that it can be very dangerous if aspirated so use with caution with a poorly mentating patient When would you give N-acetylcysteine (NAC)? The peak absorption of acetaminophen occurs at about 4 hours with acute ingestions Use the Rumack–Matthew nomogram to plot the serum level of acetaminophen versus the time since ingestion to see if you are above the treatment line. If the ingestion time is unknown then just give it. How do you dose NAC? 3 bag system: First, a 150 mg/kg bolus is administered IV over 15-60 minutes (Bag 1), then a 50 mg/kg drip is administered over 4 hours (Bag 2), then a 100 mg/kg drip is administered over the following 16 hours (Bag 3). This is the Prescott Protocol that requires three bag of IV fluids 2 bag system: There is a simplified protocol that only requires 2 bags, 200mg/kg IV over 4 hours (Bag 1) followed by 100mg/kg over 16 hours (Bag 2) Less risk of anaphylactoid reactions with a 2-bag system due to the high rate of IV NAC given in the 3 bag system. What are the endpoints for stopping NAC? If the INR is