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Salut les motivés du samedi ! Aujourd'hui, on parle d'un truc simple : agir au lieu de trop réfléchir. Parce qu'à force de cogiter, on finit par faire des nœuds au cerveau… et zéro action. Sur les marchés ou dans la vie, à un moment, faut arrêter de se prendre la tête et se lancer.
Les marchés sont sous pression. Wall Street tendue, les cryptos fébriles... Et toi, au milieu de tout ça, tu fais quoi ? Tu respires, tu observes, tu restes patient. Parce que parfois, ne pas bouger, c'est déjà prendre une décision.
"Le doute n'est pas une faiblesse. C'est un outil."Ce matin, on parle vrai : le doute fait partie du jeu. Trader, investir, entreprendre… c'est normal de douter. Ce qui compte, c'est de ne pas le subir mais de l'accompagner. Parce qu'un doute bien géré, c'est souvent une clarté qui se prépare.
Ce matin, c'est le calme plat sur les marchés. Pas de quoi réveiller Jean-Michel Moyenne Mobile. Mais justement… c'est là que la discipline entre en scène.
Dans cet épisode, découvrez l'histoire de Corentin, 27 ans, qui après des années de tâtonnements et une dette de plus de 10 000 €, a su rebondir grâce à la discipline, la persévérance et les bonnes habitudes.Sa rencontre avec IVT et l'impact des podcasts sur son quotidien lui ont permis de rembourser ses dettes, se former au trading et lancer de nouveaux projets.Un témoignage motivant qui prouve que le changement est possible avec la bonne approche.
Les marchés sont coincés dans un étau : les indices hésitent, le marché crypto reste au sol, et le moral suit la tendance... Mais comme toujours, on ne choisit pas les conditions de marché — on choisit notre réaction. C'est dur ? Oui. Mais on est là pour faire le job. Force et honneur.
Ned, Alissa, and Ivt attempt to explain March Madness to non-sports fan Ian, and we engage in a freewheeling conversation about the many films going head-to-head in this year's March Madness movie brackets.
La Vidéo sur Youtube : https://youtu.be/KL-6OQrxYDQ
Finding skilled labor is one of the big challenges facing America's farmers and ranchers. In this edition of Innovations in Agriculture, Meghan Grebner talks with Colton Rathman with PTx about OutRun - a self-contained retrofit kit that enables autonomous grain cart operation with John Deere 8R tractors that are equipped with IVT.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.
While some of us knew a good bit about mRNA prior to 2020, we all got a crash course on mRNA technology and its prophylactic and therapeutic potential as a result of the COVID pandemic and subsequent SARS CoV-2 vaccine development. In fact, most of us have now received at least one mRNA vaccine at this point. Our guest for this episode, Dr. Christian Cobaugh, Co-founder and CEO of Vernal Biosciences, was a passionate believer in mRNA medicines well before the pandemic. Join us to hear his story and his passion for this technology. He walks us through the molecular methods by which high-purity mRNAs are now made and purified, as well as going into the lipid nanoparticle technology by which they're commonly delivered. As a contract development and manufacturing provider, we get to learn about the state of the market and what clients of their care about today. As a seasoned expert in this space, Christian talks about the future potential of mRNA technology for applications such as personalized cancer vaccines. If you enjoy hearing smart people talk about interesting topics with a passion, you won't want to miss this episode! Subscribe to get future episodes as they drop and if you like what you're hearing we hope you'll share a review or recommend the series to a colleague. Download Transcripts: Speaking of Mol Bio Podcast | Thermo Fisher Scientific - US Visit the Invitrogen School of Molecular Biology to access helpful molecular biology resources and educational content, and please share this resource with anyone you know working in molecular biology.
Today's episode is part of a special series were doing to focus on the cutting-edge fluid power technologies and customer solutions on display at the 2024 iVT EXPO. iVT EXPO is an annual exposition for the off high vehicle design and engineering community, with exhibits that are highly focused on a number of key technologies, including new powertrains, electric and hybrid systems, control systems, sensors, and autonomous technologies. Hydraulics serve as a key enabling technology for these vehicles and many of these systems, iVT EXPO offers an ideal platform for growth and expansion of hydraulics, both in its affiliated education program and on its show floor. Today, our guests are DJ O'Konek and Andy Tobolewski. DJ is an Engineering Manager at Nott Company, a supplier of fluid power products and systems, industrial products and custom rubber fabrication including software and controls options to enhance performance and control of fluid power systems. Andy Tobolewski is the President of MRS Electronics, a Manufacture of smart electronic control products as well as customized hardware and software solutions for the automotive industry for over 25 years. Nott Company is sharing a booth with them at iVT this year. We've invited these guests into our forum to learn about the applications that MRS Electronics and Nott Company will be showcasing at their exhibit in late August. Connect with the host, Eric Lanke at elanke@nfpa.com or on LinkedIn at the National Fluid Power Association. Connect with our DJ: dokonek@nottco.com Connect with Andy: andy.tobolewski@mrs-electronics.com
Dr. Dan Ackerman and Dr. Silja Räty discuss the outcomes of patients with basilar artery occlusion treated with intravenous thrombolysis (IVT) only and compares IVT with endovascular thrombectomy. Show reference: https://www.neurology.org/doi/10.1212/WNL.0000000000209249
Dr. Dan Ackerman talks with Dr. Silja Räty about the outcomes of patients with basilar artery occlusion treated with intravenous thrombolysis (IVT) only and compares IVT with endovascular thrombectomy. Read the related article in Neurology. This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information. Disclosures can be found at Neurology.org.
Casquette rouge sur les indices européens et bleu à Wall Street ... bien nous en a pris avec une petite chute des marchés cette semaine. Je change la façon de présenter la semaine en expliquant toutes les étapes psychologiques et techniques de la gestion d'un Trade sur le marché.Je vous explique aussi les raisons de ce repli aux États-Unis, beaucoup plus intense sur le CAC40 et le DAX. Virginie et Rodolphe m'accompagnent dans ce débrief Hebdo qui j'espère vous plaira. Le Débrief Hebdo, c'est tous les dimanches à 10h00 en première
SA Inc watch list. Building a list of stocks that are cheap, very cheap, and could give good return n the next year or three. Criteria; Must be profitable, so positive PE ratio Must be cheap, so PE below 8x Small as in market cap under R8billion No REITs Using Koyfin I get 46 stocks including REITs and detail them in the podcast. I'll create a watchlist on Google docs and share that link in time. What about just the mid cap ETF from FNB? FNBMID. Sixty stocks but problem is the top holdings are; Sibanye-Stillwater*, Discovery*, Nedbank, Bidvest and Remgro. That's already ±25% of the ETF and none really for my requirements as above. Simon Shares Local crypto exchange, Revix, suspends trade or withdrawals on 24% of client crypto assets as their South Korean partner has issues with a provider. Naspers (JSE code: NPN) & Prosus (JSE code: PRX) plan to remove the complex web of cross holdings to a simple structure whereby Naspers owns 47% of Prosus who owns the stake in Tencent (Hong Kong code: 700). Good Invicta (JSE code: IVT) results. Rand all over the place. Brent weak, surely suggesting the global economy is weak. But so far the promised 2023 recession has not arrived, remember the hard vs. soft landing debate of late 2022? * I hold ungeared positions. Simon Brown
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A new research perspective was published in Oncotarget's Volume 14 on January 12, 2023, entitled, “Intraventricular immunovirotherapy; a translational step forward.” In this new perspective, researchers Joshua D. Bernstock, Sarah Blitz, Kyung-Don Kang, and Gregory K. Friedman from Harvard Medical School, Massachusetts Institute of Technology and University of Alabama at Birmingham discuss oncolytic virotherapy with intratumoral engineered type-1 herpes simplex virus (HSV). Intraventricular therapy (IVT) has been proven safe with promising efficacy in recent clinical trials for treatment of both pediatric and adult high-grade glioma. “Oncolytic herpes simplex virus type-1 (oHSV) has shown promise in clinical trials in both pediatric and adult brain tumors [6–9].” However, this approach excludes patients with tumors in surgically inaccessible and/or eloquent brain regions. Current delivery methods are also unable to access/treat those patients with metastatic disease in the spinal cord and/or leptomeningeal disease. A recent preclinical study has paved the way for clinical translation of intraventricular administration of oHSV by identifying and mitigating the toxicity associated with this route for therapeutic benefit in murine models of disseminated medulloblastoma. This work may ultimately allow for targeting of intractable disease and provides a feasible option for the repetitive dosing of clinically relevant immunovirotherapy, G207. “Overall, demonstrating the safety and efficacy of IVT with G207 is a significant step towards expanding the capabilities of oHSV, paving the way for new clinical trials, and increasing the potential of an already promising therapy.” DOI: https://doi.org/10.18632/oncotarget.28343 Correspondence to: Joshua D. Bernstock - jbernstock@bwh.harvard.edu, Gregory K. Friedman - gfriedman@uabmc.edu Keywords: oncolytic virotherapy, herpes simplex virus (HSV), G207, intraventricular therapy, leptomeningeal disease About Oncotarget Oncotarget is a primarily oncology-focused, peer-reviewed, open access journal. Papers are published continuously within yearly volumes in their final and complete form, and then quickly released to Pubmed. On September 15, 2022, Oncotarget was accepted again for indexing by MEDLINE. Oncotarget is now indexed by Medline/PubMed and PMC/PubMed. To learn more about Oncotarget, please visit https://www.oncotarget.com and connect with us: SoundCloud - https://soundcloud.com/oncotarget Facebook - https://www.facebook.com/Oncotarget/ Twitter - https://twitter.com/oncotarget Instagram - https://www.instagram.com/oncotargetjrnl/ YouTube - https://www.youtube.com/OncotargetYouTube LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Media Contact MEDIA@IMPACTJOURNALS.COM 18009220957
Por qué los grandes grupos de medios como la CNN, Hearst, y pronto uno de los más grandes grupos en español confían su estrategia publicitaria con la solución que ofrece Browsi, una compañía de Tel Aviv que está desarrollando soluciones muy valiosas para el mercado de medios de comunicación. Sandra Dionissio es Business Development de Browsi, y junto a Daniel Bejar, como responsable de desarrollo, explican cómo funciona Browsi y cómo los medios encuentran soluciones para que la publicidad que se emite en cada web tenga el alcance que se espera, y sean una experiencia favorable para el usuario final.
Rodolphe Steffan nous partage pendant 1 heure, sa vie, d'où il vient, comment il a fait pour en arriver à ce niveau, son organisation, les étapes de la vie où il est passé entre erreurs et réussites, en donnant ses astuces et idées dont chacun peut s'inspirer. Rodolphe m'inspire au quotidien depuis des années, tel un ami, un associé, un frère et bien plus, parce que c'est grâce à lui que j'en suis là aujourd'hui … et on fera tout pour reproduire cette expérience le plus rapidement sur les sujets de l'investissement avec un regard complémentaire à celui que je vous apporte au quotidien.Entre Trading et investissement, aujourd'hui nous abordons plein de sujets au sens large : comment il a réussi à être plus rigoureux dans ses choix de vie, plus saine, plus stable, avec des choix qu'il continue à faire toujours en avançant, en allant de l'avant, en franchissant les obstacles … le Mindset et la discipline est très importante dans son quotidien.Pour suivre Rodolphe :Suivre Rodolphe sur son Canal Telegram iciSuivre Rodolphe sur Twitter iciEt bien entendu , nous sommes tous les 2 avec toute l'équipe IVT tous les jours iciMerci à Rodolphe pour le temps accordé durant cette heure … et n'hésitez pas à m'envoyer vos questions pour son prochain passage.Un Kiff cette interview ... hâte de continuer, ENSEMBLE ✊XavierTous les matins en Podcast, je décrypte l'actualité économique, les marchés et Cryptos, et partage mes stratégies de Trading et d'Investissement.Tous les Samedis, l'Interview d'un expert ou d'un investisseur sur les marchés pour partager expériences, erreurs, parcours, et chercher des solutions dans notre parcours sur les marchés ou plus largement. Où me trouver ? :les dimanches à 10h00 pour le Débrief Hebdo sur ma chaine Youtube : InteractivTradingles mardis soir sur Twitchtous les jours sur InteractivTradingsur TwitterMERCI à toutes celles et ceux qui notent 5⭐ ce Podcast, vraiment ! Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.
Rodolphe Steffan nous partage pendant 1 heure, sa vie, d'où il vient, comment il a fait pour en arriver à ce niveau, son organisation, les étapes de la vie où il est passé entre erreurs et réussites, en donnant ses astuces et idées dont chacun peut s'inspirer. Rodolphe m'inspire au quotidien depuis des années, tel un ami, un associé, un frère et bien plus, parce que c'est grâce à lui que j'en suis là aujourd'hui … et on fera tout pour reproduire cette expérience le plus rapidement sur les sujets de l'investissement avec un regard complémentaire à celui que je vous apporte au quotidien.Entre Trading et investissement, aujourd'hui nous abordons plein de sujets au sens large : comment il a réussi à être plus rigoureux dans ses choix de vie, plus saine, plus stable, avec des choix qu'il continue à faire toujours en avançant, en allant de l'avant, en franchissant les obstacles … le Mindset et la discipline est très importante dans son quotidien.Pour suivre Rodolphe :Suivre Rodolphe sur son Canal Telegram iciSuivre Rodolphe sur Twitter iciEt bien entendu , nous sommes tous les 2 avec toute l'équipe IVT tous les jours iciMerci à Rodolphe pour le temps accordé durant cette heure … et n'hésitez pas à m'envoyer vos questions pour son prochain passage.Un Kiff cette interview ... hâte de continuer, ENSEMBLE ✊XavierTous les matins en Podcast, je décrypte l'actualité économique, les marchés et Cryptos, et partage mes stratégies de Trading et d'Investissement.Tous les Samedis, l'Interview d'un expert ou d'un investisseur sur les marchés pour partager expériences, erreurs, parcours, et chercher des solutions dans notre parcours sur les marchés ou plus largement. Où me trouver ? :les dimanches à 10h00 pour le Débrief Hebdo sur ma chaine Youtube : InteractivTradingles mardis soir sur Twitchtous les jours sur InteractivTradingsur TwitterMERCI à toutes celles et ceux qui notent 5⭐ ce Podcast, vraiment ! Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.
Deuxième interview du Samedi avec Virgine, Coach chez IVT, spécialiste des actions françaises et plus spécifiquement les Small Caps. C'est risqué ! Comment gérer ?Virginie a commencé le trading en 2009 et est passée progressivement d'un profil Intraday à un profil de Swing trader. Pourquoi ?Découvrez quels sont les indicateurs qu'elle utilise, et comment elle a réussi à améliorer son Money management dans une volatilité folle permanente, notamment en échangeant avec des personnes qui ont la même passion.J'espère que ce 2ème épisode vous plaira et vous permettra d'avoir des profils différents du mien pour trouver d'autres visions et expériences sur la façon d'investir sur les marchés.-----------------------------Tous les matins en Podcast, je décrypte l'actualité économique, les marchés et Cryptos, et partage mes stratégies de Trading et d'Investissement.Tous les Samedis, je partage un échange avec un investisseur, un expert, un intervenant sur les marchés pour comprendre sa manière d'intervenir sur le marché, sa vision du Trading et de l'investissement.L'idée de l'interview te plait ? Contacte moi par ces différents moyens
Deuxième interview du Samedi avec Virgine, Coach chez IVT, spécialiste des actions françaises et plus spécifiquement les Small Caps. C'est risqué ! Comment gérer ? Virginie a commencé le trading en 2009 et est passée progressivement d'un profil Intraday à un profil de Swing trader. Pourquoi ? Découvrez quels sont les indicateurs qu'elle utilise, et comment elle a réussi à améliorer son Money management dans une volatilité folle permanente, notamment en échangeant avec des personnes qui ont la même passion. J'espère que ce 2ème épisode vous plaira et vous permettra d'avoir des profils différents du mien pour trouver d'autres visions et expériences sur la façon d'investir sur les marchés. ----------------------------- Tous les matins en Podcast, je décrypte l'actualité économique, les marchés et Cryptos, et partage mes stratégies de Trading et d'Investissement. Tous les Samedis, je partage un échange avec un investisseur, un expert, un intervenant sur les marchés pour comprendre sa manière d'intervenir sur le marché, sa vision du Trading et de l'investissement. L'idée de l'interview te plait ? Contacte moi par ces différents moyens
The report is available for Sponsored Products, Sponsored Brands, and Sponsored Display. Invalid traffic (IVT) is any potentially fraudulent, involuntary, non-human, duplicate, or illegitimate traffic.5 Amazon ad lessons. 2 minutes read. 1 weekly email.https://georges.blog/subscribeFind every wrong with your Amazon ads in under 72 hours.https://georges.blog/audit
Skyzoo a commencé les Cryptos en 2021 avec un All-In sur le BITCOIN ! Depuis, il a amélioré sa Psychologie ... mais comment il a évolué, géré son portefeuille, diversifié ... comment il travaille et sur quels critères ? On verra les erreurs qu'il a commises et comment il les a corrigé ? Quels ont été ses freins et a t'il subit le bruit de marché ? Aujourd'hui a t'il trouvé des solutions pour mieux gérer son portefeuille Crypto ? Nous allons découvrir Skyzoo, membre d'InteractivTrading invité par Xavier Fenaux. Skyzoo s'est créé un portefeuille grâce au Télégramme de Rodolphe Steffan. Il a un profil long terme, plus dans la recherche sur les projets Cryptos que dans la performance. Découvrez ses erreurs et les solutions qu'il a trouvé pour faire le tri sur ses réseaux sociaux. ----------------------------- Tous les matins en Podcast, je décrypte l'actualité économique, les marchés et Cryptos, et partage mes stratégies de Trading et d'Investissement. Tous les Samedis, je partage un échange avec un investisseur, un expert, un intervenant sur les marchés pour comprendre sa manière d'intervenir sur le marché, sa vision du Trading et de l'investissement. L'idée de l'interview te plait ? Contacte moi par ces différents moyens
Lisa Bazinet RN,MSN,OCN, CNML is the Regional Nurse Manager of Oncology Services for Hartford Healthcare East Region. She has experience in the inpatient areas as well, being both a nurse manager for an inpatient oncology unit, 28 bed medical surgical as well as IVT. Lisa has been a RN for almost twenty years starting her nursing career first as an LPN. She has worked as a nurse at the bedside for over 17 years in various settings before going into a more formal leadership role. She is a graduate of St Joseph's College in Standish Main obtaining her Master's Degree in Nursing with a concentration in Administration. She is also an alumni of both the University of Connecticut and University of the State of New York. She holds two certifications in both oncology nursing and nurse management/leadership. She is also a 2006 receiptant of the Florence Nightingale award.In her spare time, Lisa enjoys walking with her dogs, two German shorthaired pointers, Chase and Echo, boating, reading mystery novels ( James Patterson, Tess Gerritsen) as well as spending time at the beach.The reason why I wanted to become a nurse manger several years into my nursing career was because I had a really great leader who could take even the busiest of days and make them better. I think because she made, the nurse at the bedside, feel supported and valued. Nursing is hard work emotionally, physically and mentally and to have your leader “get it" and support, hear you and value your opinion, is what I strive to do at all of my centers each and every day. Being a “hands on” manager is critical to a team's success. You have to walk the walk and talk the talk. My motto has always been “treat others as they would like to be treated”. Every day can be hard, but each day also can be a new opportunity as well. She is married to her husband Paul who teaches high school and her and husband have two sons, Alex and Jack. And of course the two dogs.1. Click the link to REGISTER for the next Stress Solution Series2. Download your FREE Mindfulness E-Book at stressblueprint.com/353. Follow the Nurse Wellness Podcast on Facebook and Instagram4. Join the Nurse Wellness Hub on Facebook 5. Email Nurse Wellness Podcast at hello@stressblueprint.com6. Background music produced by DNMbeats
Simon Shares Episode #500. Huge thanks to all, I go into some background about the show. Where and how it started, lessons learnt and more. Stage 6, the Rand lost 30c. Sun International* (JSE code: SUI) update for five months to 31 May 2022 shows they are nearly back at pre-pandemic revenue and this while we still had some restrictions and fewer international travellers. Naspers (JSE code: NPN) / Prosus (JSE code: PRX) results. Tencent (Hong Kong code: 700) is 125% of profits. The other businesses are all loss-making and in tough markets. They plan to sell down Tencent and buy back Prosus shares, but the discount to NAV remains around 50%, even after a massive move on the announcement. Grindrod (JSE code: GND) good update and share has been flying. This remains a very cyclical business and right now the cycle is paying off. Invicta (JSE code: IVT) saw strong results albeit some accounting points improved them a bunch. JSE (JSE code: JSE) trading update is surprisingly strong with HEPS expected +24%-32% for six months ending June. * I hold ungeared positions.
Merhabalar. Bu yazımızda Amerikan Kalp Derneği ve Amerikan İnme Derneği tarafından hazırlanan 2022 Spontan İntraserebral Hemoroji (ISH) Olan Hastaların Yönetimine İlişkin Kılavuzun1 6. ve 7. bölümlerinden özet olarak bahsedeceğiz. İyi okumalar diliyorum. Kısaltmalar CLEAR III Pıhtı Lizizi: İntraventriküler Kanama Faz III'ün Hızlandırılmış Çözünürlüğünün DeğerlendirilmesiEVD: Extraventriküler drenajDNAR: Canlandırma girişiminde bulunulmazGCS: Glasgow Koma SkalasıICH-İSK: intraserebral kanamaICP: kafa içi basıncıIVH: intraventriküler kanamaIVT: intraventriküler trombolizLOE: Kanıt DüzeyiMIS: minimal invaziv stratejiMISTIE III: Minimal İnvaziv Cerrahi Artı İntraserebral için rt-PARCT: randomize kontrollü çalışmaSTICH: İntraserebral Kanamada Cerrahi Denemesi 6. Cerrahi Müdahaleler 6.1. Hematom Tahliyesi 6.1.1. İSK'nın Minimal İnvaziv Cerrahi ile Tahliyesi Supratentoryal İSK için MIS, hematom hacmini rahatlatma, perihematomal ödemi azaltma ve geleneksel kraniyotomi ile karşılaştırıldığında sağlıklı beyin dokusunun bozulmasını en aza indirme şansına sahiptir. Bu nedenle, akut faz sırasında orta ila büyük İSK'leri tedavi etmek için MIS teknikleri ilgi görmektedir. Bununla birlikte, büyük randomize klinik çalışmaların sonuçları kesin değildir.Birinci öneri, trombolitik kullanımı olsun veya olmasın endoskopik veya stereotaktik aspirasyon ile minimal invaziv hematom tahliyesi güvenlidir ve mortaliteyi azaltmak için faydalı olabilir. Fonksiyonel sonuçları iyileştirebilse de, bunun için kanıt düzeyi düşüktür. Kraniyotomi ile karşılaştırıldığında, MIS'in mortalite yararı belirsizdir, ancak literatür MIS'in geleneksel kraniyotomi ile karşılaştırıldığında fonksiyonel sonuçları iyileştirdiği düşünülebileceğini desteklemesine rağmen MIS müdahaleleri, bu tavsiyelerin temeli olarak cerrah ve merkezin beceri ve deneyimini gerektirir. 6.1.2. İSK'nın Minimal İnvaziv Cerrahi ile Tahliyesi İSK'nın intraventriküler yayılımı, hastaların %30 ila %50'sinde meydana gelir ve hastaların yaklaşık yarısında hidrosefali gelişimine yatkınlık oluşturur. IVH, artan IVH hacmine ve inflamatuar menenjit ve hidrosefaliyi destekleyen kan yıkım ürünlerine ikincil olarak daha kötü bir prognoz öngörür. Kafa içi hipertansiyonu tedavi etmek ve kan ürünlerini çıkarmak için bir EVD'nin yerleştirilmesi sağ kalımı iyileştirir. Alteplaz veya ürokinaz ile trombolitik irrigasyonun eklenmesi, intraventriküler pıhtı çıkarılmasını hızlandırır ve mortalitenin azalmasını sağlar. Mevcut öneriler (Şekil 1'te gösterilmiştir) -Birinci öneri, intraventriküler trombolizli EVD güvenlidir ve klinik hidrosefalisi olan ve bilinç düzeyi düşük hastalarda tek başına EVD'ye (veya salin irrigasyona) kıyasla sağ kalımı artırır. -Bununla birlikte, EVH'nin fonksiyonel sonuçları iyileştirmedeki yararı belirsizdir. -Büyük hacimli İSK'yı çıkarmak ve kalıcı şant bağımlılığını azaltmak için çalışılan diğer müdahaleler arasında, IVT ile birlikte kontrollü lomber drenaj ve hedeflenen intraventriküler nöroendoskopi yer alır. Şekil-1: IVH'nin cerrahi tedavisi mevcut öneriler 6.1.3. Supratentoryal Kanama için Kraniyotomi Çoğu hasta için, spontan İSK için kraniyotomi, tek başına tıbbi tedaviyle karşılaştırıldığında belirsiz bir yarar sağlar. Sınırlı veriler, durumu kötüleşen hastalarda kraniyotominin hayat kurtarıcı bir prosedür olarak kabul edilmesinin makul olduğunu düşündürmektedir. 6.1.4. Posterior Fossa Kanaması İçin Kraniyotomi Spontan serebellar kanama sıklıkla hidrosefali, beyin sapı kompresyonu ve posterior fossanın sınırlı alanında herniasyon ile ilişkilidir. Bu nedenle, randomize kanıt olmamasına rağmen sıklıkla hematom tahliyesi önerilir. Mevcut kılavuz öncelikle eğilim skoru eşleştirmesi, sistematik inceleme ve birkaç geriye dönük çalışma ile büyük bir bireysel hasta verisi meta-analizinden elde edilen verilere dayanmaktadır. Birinci öneri, nörolojik olarak kötüleşen,
Welcome to Risk Revolution, a monthly series of Voices in Validation, brought to you by the IVT Network. The goal of this series is to advance the maturity of risk management practices within the industry, by covering topics that challenge quality professionals to seek opportunities to improve and advance the ways in which they perceive and manage risk. This week, series coordinator Nuala is joined once again by Risk Revolution co-hosts, Valerie Mulholland and Lori Richter with another old friend of the IVT network, Dr. James Vesper. Dr. Vesper will share his unique insights and deep learning on a very interesting aspect of RBDM, Risk Appetite, and the distinction between that and Risk Tolerance. About Our Guest: Dr. Jim Vesper James Vesper, MPH, Ph.D. established and is president LearningPlus, Inc., and has had more than 30 years experience in the pharmaceutical industry, including 11 years at Eli Lilly and Company. Dr. Vesper worked eleven years at Eli Lilly and Company, Indianapolis. Since 1991, he and his firm, LearningPlus, have worked with pharma/biopharma, device, and blood products organizations around the world consulting on risk management, performance solutions, and custom GMP learning events. He has been a special advisor/consultant to the World Health Organization's (WHO) Vaccine Quality Network – Global Learning Opportunities working as a mentor and instructor for a number of different learning courses. Dr. Vesper has written five books, including Risk Assessment and Risk Management: Clear and Simple, and multiple technical articles. He has a BS in biology (Wheaton College), an MPH (University of Michigan School of Public Health), and a Ph.D. in Education from Murdoch University in Perth, Western Australia. Dr. Vesper may be contacted at jvesper@learningplus.com. Resources From This Episode: What Are Risk Appetite & Risk Tolerance In Pharma & Medical Devices? Risk Revolution: The Best of Year One - an Anniversary Episode Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
Our feature interview is with András Váradi, research director with podcast sponsors Commsignia. Andras talks roadside infrastructure, pedestrian protection, ultra wideband and 5G. Plus news and conversation with iVT editor Tom Stone and editor-at-large Saul Wordsworth. Interview starts at 5:45
This week, Karen Ginsbury shares her ideas on data integrity lapses, and how automating now can save your business in the future. Karen looks at how the pharmaceutical industry and even society misunderstand what integration truly is. Karen shares her thoughts on how the industry can advance forward despite self-inflicted obstacles. About Our Guest: Karen Ginsbury is a pharmaceutical consultant who brings hands-on experience in designing and implementing environmental control programs within multinational pharmaceutical companies. She started her career in the industry by taking EM samples on the factory floor and brings her own unique perspective to her lively and instructive presentations. Ms. Ginsbury has over twenty years of industry-based experience in quality assurance and compliance and has published a book on compliance auditing for pharmaceutical manufacturers. Ms. Ginsbury is a past holder of IVT's Presentation of the Year and Web Seminar Presenter of the Year and regularly lectures around the world on pharmaceutical topics. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
On Episode 11 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the December 2021 issue of Stroke: “Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 Trial” and “Serious Adverse Events and Their Impact on Functional Outcome in Acute Ischemic Stroke in the WAKE-UP Trial.” She also interviews Dr. Mark Parsons about his article “Stroke Patients With Faster Core Growth Have Greater Benefit From Endovascular Therapy.” Dr. Negar Asdaghi: 1) Can the presence of a high-grade asymptomatic carotid stenosis result in development of early dementia? 2) Have you ever wondered if a random poststroke urinary tract infection or hospital-acquired pneumonia can impact the 90-day poststroke outcome? 3) When it comes to the beneficial effect of endovascular thrombectomy, what is the concept of late window paradox, and why do we need to know about this and its relation with the speed of infarct growth? These are the questions that we will tackle in our December podcast. We're covering the best in Stroke. Stay with us. Dr. Negar Asdaghi: Welcome back to the Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine and your host for the monthly Stroke Alert Podcast. For the December 2021 issue of Stroke, we have a large selection of topics, from whether adjusting antiplatelet therapies after stenting for intercranial aneurysms can potentially reduce ischemic events, to studying the outcomes of patients with reversible cerebral vasoconstriction syndrome and analysis from a nationwide study in the United States, which I encourage you to review in addition to listening to our podcast today. Later in the podcast, I have the pleasure of interviewing Dr. Mark Parsons, from the University of New South Wales in Sydney, Australia, on his work suggesting that the beneficial effect of endovascular thrombectomy may be modified based on the speed of infarct growth, from the time of symptom onset to the time when the patient is being considered for reperfusion therapies. But first with these two articles. Dr. Negar Asdaghi: It has been suggested that the presence of chronic high-grade carotid stenosis can result in early cognitive decline, even in the absence of ischemic stroke secondary to the carotid disease. Multiple mechanisms for this decline have been proposed, including an alteration of cerebrovascular reactivity and ipsilateral hemispheric hypoperfusion. Now, if this is true, then asymptomatic patients harboring a high-grade carotid stenosis would have a lower cognitive status than their age and risk factor in matched counterparts. And this is the exact topic that Dr. Ronald Lazar from the Department of Neurology at the University of Alabama and colleagues studied in this issue of the journal, in their article titled “Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 Trial.” Dr. Negar Asdaghi: Now, a very quick recap of the CREST-2 Trial. You will recall that CREST-2 is an ongoing randomized trial of patients over 35 years of age with asymptomatic carotid disease of equal or greater than 70%. Asymptomatic is defined as absence of ipsilateral stroke or TIA symptoms within 180 days prior to randomization. Also, a reminder, that to be able to be enrolled in the CREST-2 Trial, patients had to be independent, with no diagnosis of dementia, and they were then randomized to either intensive medical management versus carotid artery stenting, or intensive medical management alone versus carotid endarterectomy. It's important to keep in mind that a secondary outcome of CREST-2 is to see whether carotid intervention over intensive medical management is better in reducing cognitive decline over time in this patient population. Dr. Negar Asdaghi: Obviously, we'll have these results after the completion of the CREST-2 trial and its follow-up completion, but in the current study, the authors were interested to compare the baseline cognitive function of the CREST-2 candidates, and they were able to compare this baseline cognitive status to participants of the REGARDS population-based study. Now, the acronym for REGARDS stands for "Reasons for Geographic and Racial Differences in Stroke." This was a population-based study in the United States that included over 30,000 community-dwelling White and Black adults over the age of 45. So, think about the REGARDS cohort as the stroke-free participants without the high-grade carotid stenosis. Dr. Negar Asdaghi: So, to match the two populations, the authors included only CREST-2 participants that were older than 45 years of age and did not have any prior strokes. So, that gave them a sample size of 786 patients for the current analysis with a complete neurocognitive battery of four tests administered over the phone, in the same order in both studies. So, let's go over these cognitive tests. The test included the Word List Learning Sum, assessing the cognitive domain of learning; the Word List Recall, which is a test of memory; and the two tests for executive function, Word Fluency for animal names and fluency for the single letter 'F'; and a brief screen for depression. Dr. Negar Asdaghi: So, simply put, we have four cognitive tests assessing the three cognitive domains of learning, memory, and executive function. And depending on how the person did on each test, it gave the investigators Z scores for each participant in each category and then they compiled the Z scores in a percentile tabulation for the CREST-2 population and compared these percentiles to the normative data obtained for the REGARDS population. Dr. Negar Asdaghi: So, what they found was that, well, not surprisingly, the population of CREST-2 had a higher prevalence of cardiovascular risk factors, things like hypertension, elevated lipids, smoking and diabetes. Slightly more than half, exactly 52% of the CREST-2 patients, had a target carotid stenosis vessel on the right side. And then they did some complex statistical models, adjusting for age, race and educational level, and then further adjusting for some vascular risk factors, such as hypertension, diabetes, dyslipidemia, and smoking, for each cognitive test, and they found that the overall Z score for patients in CREST-2 was significantly below expected for higher percentiles and marginally below expected for the 25th percentile for all four cognitive tests, as compared to the normative population. Dr. Negar Asdaghi: For example, if they were expecting that 90% of the CREST-2 population would score in the 75th percentile for a particular test, or at 95th percentile on a different test, these percentages were significantly lower in the CREST-2 candidates. The greatest cognitive differences were detected for Word List Delay, which is a test of memory, followed with the Word List Learning, which is a test for learning. And the results really did not change when they adjusted for the vascular risk factors, and importantly, unchanged when they adjusted for right- or left-sided stenosis of the carotid, which is important, as language plays an important role in assessment of memory function. Dr. Negar Asdaghi: So, what did we learn from this study? Well, number one, poor cognition is associated with harboring high-grade asymptomatic carotid occlusive disease, an effect that was only modestly attenuated by further adjustment for other risk factors. Number two, patients with high-grade carotid stenosis showed a significantly lower cognitive performance in the learning and memory domains. This profile of cognitive decline is different than what was typically expected to be seen in the case of vascular dementia, where abnormalities are predominately seen in the test of executive function. Number three, though we don't know the precise mechanism for cognitive impairment in the setting of carotid stenosis, cerebral hypoperfusion seemed to be the leading plausible cause as hippocampus and amygdala are known to be susceptible to hypoperfusion, and the findings of the current study show that the predominant impairment seen in patients with carotid disease seemed to be involving memory and learning. So, really important findings, and lots to still learn on this topic. Dr. Negar Asdaghi: The occurrence of adverse events during acute treatment and within the first few weeks of acute ischemic stroke are common and can negatively influence the course and clinical outcomes of stroke patients. Serious adverse events, or SAEs, are defined as life-threatening events resulting in death or requiring hospitalization, prolongation of hospitalization, or resulting in significant disability, and they can be either neurological, such as recurrent ischemic events, hemorrhagic complications, seizure disorders, but also can include a myriad of systemic complications, including, but not limited to, occurrence of deep vein thrombosis, pulmonary emboli, cardiac arrhythmias, various infections, GI bleeds, to name a few. Dr. Negar Asdaghi: In a setting of a clinical trial, patients are regularly and systematically monitored for SAEs, and from these studies we know that, indeed, both adverse events, or AEs, and SAEs are quite common poststroke and are reported in up to 95% of participants of prior randomized trials. Intravenous thrombolysis increased the risk of symptomatic intracerebral hemorrhage, but in general, the rate of SAEs are similar in thrombolyzed and non-thrombolyzed patients. Which clinical characteristics prone stroke patients to what type of side effects is, of course, an intriguing subject for a stroke neurologist. Similarly, it's important to know how, for example, a seemingly indirect complication of ischemic stroke, such as a hospital-acquired urinary tract infection, can potentially affect the stroke outcomes. Dr. Negar Asdaghi: So, in this issue of the journal, Dr. Iris Lettow from University Medical Center in Hamburg, Germany, and colleagues looked at the subject in the paper titled “Serious Adverse Events and Their Impact on Functional Outcome in Acute Ischemic Stroke in the WAKE-UP Trial.” This was a post-hoc analysis of the WAKE-UP Trial, which was a multicenter randomized trial of MR-guided intravenous thrombolysis with alteplase in ischemic stroke patients with unknown time of onset. The WAKE-UP Trial included 503 patients, and they had 199 SAEs reported for 110 patients, meaning that one in five patients had at least one serious adverse event in the trial. Of those patients who did suffer an SAE, 20 patients, which was 10%, had a fatal outcome. Dr. Negar Asdaghi: The rate of SAEs were not different between thrombolyzed and non-thrombolyzed patients. But, when they categorized the patients based on who did and who did not experience an SAE, they found that those who experienced an SAE were older, presented with more severe strokes, and were more likely to have a large vessel occlusion. But only higher age and male sex were independent predictors of development of an SAE poststroke. So, let's pause and think about these findings. This was in contrast to the previous studies, where traditionally, the severity of stroke was a predictor of complications, and importantly, the first study to identify male sex as an independent predictor of SAE, whereas, traditionally, female sex had been identified as a risk factor for development of adverse events poststroke. Dr. Negar Asdaghi: Perhaps what we're seeing with a paradigm shift in improvement in poststroke quality of care. Now, another important finding of this study was that the presence of any SAE, whether neurological or non-neurological, resulted in reduction of favorable outcome by half and almost quadrupled the odds of poor outcome, defined as modified Rankin Scale of four to six at 90 days, even after accounting for all the known confounders. Now, the authors also looked at some interesting details. The organ most effected by serious adverse events poststroke was indeed the nervous system. Almost 50% of all SAEs were neurological in nature. This was then followed by cardiac events. Some examples would include an acute coronary syndrome, MI, various arrhythmias. And the surgical and medical procedures were the third most common category of serious adverse events in this study. Dr. Negar Asdaghi: And what they found was that SAEs by organ of involvement had a significant association with 90-day outcomes, where any neurological serious adverse events significantly affected 90-day functional outcome poststroke. When adjusting and accounting for important variables, such as age, sex, LVO, this still remained true in terms of a predictor of outcome. In contrast, cardiac serious adverse events, infectious serious adverse events, did not have any effect on the 90-day functional outcome. Dr. Negar Asdaghi: So, what are the top takeaway messages from this study? Number one, SAEs occur commonly poststroke, and in this particular study, occurred in one in five ischemic stroke patients. Number two, 10% of those who suffer from an SAE had a fatal outcome. Number three, nervous system disorders and cardiac disorders were the most frequent classes of side effects poststroke. And finally, patients suffering from at least one serious adverse event had a lower odds of reaching favorable outcome at 90 days. These findings emphasize the importance of dedicated stroke care, neurointensive care units, and all poststroke efforts to reduce preventable adverse events poststroke. Dr. Negar Asdaghi: Time is an exceedingly important concept in treatment of patients with acute ischemic stroke. As an example, in a typical stroke related to a proximal large vessel occlusion, the ischemic brain loses an average of two million neurons per minute. Now, endovascular therapy is the standard reperfusion treatment for patients with acute ischemic stroke secondary to a large vessel occlusion. It is an effective treatment to restore blood flow and reperfusion to the brain and had been shown to improve outcomes in stroke patients. Dr. Negar Asdaghi: Therefore, one would naturally anticipate that the benefits of endovascular therapy would be dramatically reduced with treatment so late. If this is true, then why is it that the beneficial treatment effect from endovascular therapy was even larger in patients treated in the late time window trials, and you will recall that these were patients included from 6 to 16 hours, or 6 to 24 hours, from their symptom onset time. This compared to treatment effects noted in patients enrolled in the early time window trials. This concept is known as the "late window paradox" and does not mean that we have to wait to provide reperfusion therapies to patients. It actually refers to those fortunate few that have robust collaterals and, as a result, have slow infarct growth, which will afford them that extra precious time to remain eligible to receive this life-saving treatment. Dr. Negar Asdaghi: Joining me now on the podcast is Dr. Mark Parsons from the University of New South Wales in Sydney, Australia, to talk to us about the concept of infarct growth. Dr. Parsons is one of the senior authors of the study published in the current issue of the journal titled “Stroke Patients With Faster Core Growth Have Greater Benefit From Endovascular Therapy,” and will discuss how the beneficial effect of endovascular treatment may be modified by the speed of infarct growth in the early time window after symptom onset. As in every podcast, when I have the pleasure of interviewing a pioneer in the field of stroke, that my guest needs no introduction, but truly Dr. Parsons needs no introduction to our listeners. He's a Professor of Neurology at the University of New South Wales in southwestern Sydney. He's an internationally recognized leader in the field of stroke, stroke clinical trials, and brain imaging whose research has helped improve patient selection for acute stroke reperfusion therapies. It's truly an honor to have him on the podcast today. Welcome, Mark. Thank you so much for joining us all the way in Sydney on a Saturday morning. Dr. Mark Parsons: Yes, thank you, Negar. It's OK, I have been up for a little while. So, yes, lovely to chat with you, and we haven't chatted in person for quite a long time, and I think I actually remember the last time was in Hamburg, in Germany, at a big stroke conference. I remember it quite well. We had a very pleasant evening with a group of Canadians and Australians, and I had to present a major tenecteplase study finding the next day, and I was a little bit off my game, some of my friends said, and I think that's probably your fault, Negar. Dr. Negar Asdaghi: Mark, you did really great, and we really, truly, look forward to getting back to in-person meetings. So, let's start with the study here. Can you please tell us about the INSPIRE registry? Dr. Mark Parsons: So, the INSPIRE registry, that's an acronym. So, it's best to spell out this acronym, so that stands for the "International Stroke Perfusion Imaging Registry." So, that was something we set up quite a while ago when perfusion CT was quite considered advanced or novel. We set that up, I think, in about 2010, and because that was obviously one of my areas of interest, perfusion imaging, we started collecting perfusion CT and CT angiography , and noncontract CT, for that matter, from our stroke patients from a number of centers in several countries. And over time, that built up to over 20 centers around the world, so predominantly Australia and China, because of the close connections that we've got there, but also one site in Canada, actually two sites now. We have so many sites that I sometimes overlook a few. Dr. Mark Parsons: So, it is international. And what we do is, we collect prospective data from stroke patients, both clinical and their acute imaging, follow-up imaging, follow-up clinical information, and in the majority of patients, we also get three-month Rankin. So, there's now over 3,000 patients in that database with complete datasets from acute baseline imaging through to three months. And that was the dataset that we used for this current study. Dr. Negar Asdaghi: So, Mark, this is truly an impressive registry. It is not easy to do large-scale imaging-based registries, and this is really impressive to have so many centers involved. Can you tell us about the current study population? Who did you include in the current study paper? Dr. Mark Parsons: Firstly, we specifically looked at patients that had a large vessel occlusion, or LVO. Of course, the definition of large vessel occlusion varies a bit from place to place, but essentially, that means a clot in a proximal artery to the brain that's potentially retrievable via endovascular thrombectomy. I guess the beauty of the INSPIRE registry is, we started collecting stroke patient data well before endovascular thrombectomy was a routine treatment. We had quite a large number of large vessel occlusion patients in this study who didn't receive endovascular thrombectomy because it simply wasn't available at the time. And then, of course, with all of those big trials that came out in 2015, as you know, and beyond, with thrombectomy becoming routine at all of our INSPIRE sites and many other places around the world, we then had a, I guess, a historical cohort comparison of large vessel occlusion patients that were not given EVT and then, more recently, a cohort of large vessel occlusion patients who were treated with thrombectomy. Dr. Mark Parsons: The non-thrombectomy patients, in the vast majority, received intravenous thrombolysis because they were in the 4.5-hour time window. I guess the only other thing, the main other inclusion criteria, was we specified that patients in this particular study needed to have a relatively small infarct core, less than 70 mL, and we can talk more about that later, if you like, and a significant area of tissue that's potentially salvageable with reperfusion, the so-called penumbra. Dr. Negar Asdaghi: Thank you. Just to recap for our listeners, so your current study population included patients presenting early on, within 4.5 hours from symptom onset, with a large vessel occlusion, and because, as you mentioned, the study had been ongoing even before endovascular therapy became a standard of care, you have a group of patients in whom endovascular therapy was offered and you have the comparison to this group to those patients who had an LVO, large vessel occlusion, but simply received intravenous thrombolysis only. Can you now tell us about these two groups, basically, IV thrombolysis versus endovascular therapy group. What were the differences between the two groups, and what were the main clinical outcomes in your study? Dr. Mark Parsons: Yes. We had about 400 patients in each arm. And though reasonably well matched, I mean, of course, registry, it's not randomized, so you can't have perfectly matched groups, and indeed, in the more recent era where most patients with large vessel occlusion, particularly with this small core, big penumbra on imaging, would go to thrombectomy because they had the so-called ideal target population. So, in the modern era, if patients don't receive EVT, then there's probably a good reason for that. But, essentially, they are around 70 years of age. Their NIH Stroke score was around 15, or the median score, so that's reasonably consistent with large vessel occlusion. And then if you look at the perfusion imaging, so this was all with perfusion CT in our studies, so the core volume was quite small, 15 mL, but there was quite a large range. And the median penumbra volume was actually a bit bigger in the EVT group; it was 80 versus 65 in the penumbral group. Dr. Mark Parsons: We probably don't need to go into the details of how those core penumbral volumes are calculated, but that might be a bit over-technical for our audience, but happy to elucidate further if you want. Dr. Negar Asdaghi: Actually, I think it's important to, just briefly, talk about how those values were measured. Dr. Mark Parsons: Yes, OK. The other thing I should say is that, interestingly enough, we specified the 4.5-hour time window, but in fact, the median time from stroke onset to imaging was just under two hours in both groups, which is quite short. Dr. Mark Parsons: And indeed, some of the people that are less enthusiastic about perfusion CT than I am would say, "Well, maybe measures of core are not so reliable in that early time window with perfusion CT." I would probably debate that to some degree. But, if we talked to the technicalities, there's quite a lot of data to suggest that the cerebral blood flow threshold is probably the most robust for identifying core, or at least tissue that's destined to infarct. It may not actually be infarcted at the time we measure it, particularly at two hours, but there's quite a lot of data now showing that with perfusion CT with a cerebral blood flow threshold of 30%, depending on software variations, that's a pretty accurate estimate of the final infarct in people that have rapid reperfusion fairly quickly after the perfusion CT. Dr. Mark Parsons: So, all of these figures that we use are based on, for example, the core threshold on perfusion CT relates to, we validate that from patients, particularly that have had thrombectomy, so we know when they've reperfused. And the theory should be that if the CT perfusion core is an accurate measure of the final infarct, that there should not be much change from the baseline CT perfusion core to the follow-up infarct because there's been reperfusion not long after the perfusion scan. Now, with the penumbral volume, we use software that measures a delay time. Other software, particularly in North America, you would use a Tmax, but they're both basically direct measures of collateral flow. Dr. Mark Parsons: So, as you know, when you have a large vessel occlusion, say, of a middle cerebral artery and in one segment, the way that blood gets to the cortex, it's typically supplied from the middle cerebral, is via retrograde flow from the anterior cerebral and the posterior cerebral via leptomeningeal collateral, so you actually get blood coming back retrograde bypassing the occlusion. And these measures on perfusion CT delay time in Tmax, actually, give you a measurement in seconds of how long it takes the blood to travel to that part of the brain. And, obviously, the longer the delay in seconds means the poorer the collateral flow. And then, typically, that means the poorer the collaterals, the less time you've got to salvage the penumbra, and the quicker the infarct core will expand. Dr. Negar Asdaghi: Right. So, in your study, using these perfusion parameters. First, before even we come to the perfusion parameters, you found that overall, when you adjusted for all confounders, endovascular-treated patients had a better, or higher, odds of achieving good 90-day outcomes. This was not a surprising finding when you compare this population of endovascularly-treated patients to those treated with intravenous thrombolysis alone. But what was interesting was, indeed, those analyses related to infarct growth rate. Can you tell us a little bit about this concept of infarct growth rate, and you already mentioned how you measured infarct growth by perfusion imaging. Dr. Mark Parsons: Thanks, Negar. I guess that's the novel part in it. I guess it would have been quite surprising if we didn't show that EVT was superior to IVT in the early time window. So, that certainly wasn't unexpected, that finding. But I guess the novel part of this study is this relatively new concept of infarct core growth rate. I'm not saying we're the first that's described it because, as you know, there are a number of papers in the literature and talking about the concept of slow infarct core growers versus fast infarct core growers. And you mentioned the late time window thrombectomy studies, DAWN and DEFUSE 3, which actually showed a dramatic benefit in the later time window, up to 24 hours after stroke, in patients who had evidence of perfusion core mismatch. And the concept then was suggested that the reason that these people benefited so much in that late time window was that they had very slow infarct core growth because they had great collaterals. Dr. Mark Parsons: The treatment effect was bigger in those late time window studies than it was in the early time window thrombectomy studies, which was hypothesized might have included a lot of patients with fast infarct core growth rate, which wasn't really measured in a number of the thrombectomy studies in the early time window. We wanted to look more at, does the rate of infarct core growth have an influence on the effective treatment, with both IV and endovascular treatment? Dr. Mark Parsons: So, the way we measured infarct core growth was pretty simple, actually. It's basically, we excluded patients with uncertain time of stroke onset because we had more than double this total number of LVO stroke patients with target mismatch, but we had to exclude the patients with uncertain time of onset, which included wake-up stroke and others. So, in this group, where there was a defined time of onset, basically, the infarct core growth rate was simply measured from the volume of the infarct core measured on perfusion CT divided by the time from stroke onset. So, just simplistically, if you've got a core of 50 mL, and it's two hours after stroke onset, then the infarct core growth rate is 25 mL per hour. That's simple, but that obviously assumes a linear core growth rate. And we based that linear model on previous studies of repeated diffusion MR imaging, which is another measure of core, that showed that the core growth rate was linear. Dr. Mark Parsons: Now, of course, you could criticize that because I suspect, in some patients, the core growth rate is not linear. This is an estimate of core growth rate. Dr. Negar Asdaghi: Right. So, your study actually found something quite interesting, which I really want you to go over for us and for our listeners, and that's that the beneficial effect of endovascular therapy is superior in those with a fast infarct growth rate, and was not superior, in fact not any different, in those patients who had a slow infarct growth rate. Can you walk us through that, and also tell us how that does not contradict what we've found as part of DAWN and DEFUSE with the slow infarct growers? Dr. Mark Parsons: Thanks, Negar. It is slightly complicated, so we'll go one step at a time. So, first of all, the core growth rate varied quite a bit in this population. A number of patients, and this is because you saw that the median core in this group was 15 mL, so there was quite a large population of patients that had a core growth rate of less than 15 mL per hour. So, they're your traditional slow growers, slow core growers, who have really great collateral flow. You probably have a number of hours to save the penumbra. Now, I'm not saying that you should waste time in this group of patients, but it might be particularly relevant, for example, if you're transferring from a primary stroke center to a comprehensive stroke center. You know that you're going to have time to save that penumbra because the infarct core is going to grow slowly. Dr. Mark Parsons: In, for example, in Australia, at least half of our thrombectomy patients come from regional or out of metro centers, where there is a significant transfer time from the primary stroke center to the comprehensive center. So, that may be a particularly important finding to look at in the future for longer transfer times from primary to comprehensive stroke centers. So, then, at the other end of the scale, we had a proportion of patients who had what we call a fast core growth rate of more than 25 mL per hour. And then there were people in the middle between 15 and 25 who we called sort of moderate core growth. So greater than 25 mL per hour was a fast core growth. Dr. Mark Parsons: We categorized it into those sort of three categories. Again, that's a bit arbitrary, but the reason we did that was that if you look at the IVT group alone, those who had slow core growth rate, less than 15 mL per hour, their rates of good outcome, so a Rankin 0 to 2, so getting back to close to normal function at three months, their rates of a good outcome were almost 60% in the slow core growth rate with IVT. Then, if you go to the other end of the scale with fast core growth with intravenous therapy, the rates of good outcome in that group were only 30%. So, there was a clear decline in terms of three-month good outcomes with intravenous thrombolysis versus core growth rate. So, as the core growth rate increased, the chances of good outcome with intravenous thrombolysis decreased. Dr. Mark Parsons: Then, if you looked at the EVT group, it was quite interesting that this core growth rate effect had minimal impact on the outcome of the EVT patients. So, in the EVT patients with slow core growth rate, less than 15 mL, the rates of good outcome at three months were, again, close to 60% and identical to the IV therapy group. But, at the other end of the scale, with fast core growth rate above 25 mL with the EVT group, they had a much higher rate of good outcome compared to the IVT group. Their rates of good outcome were around 45%. So, they are a little bit lower than the slow core growers with EVT, but there wasn't much drop-off with core growth rate, and there was a significant increase in good outcomes in the EVT group who had fast core growth compared to the IVT group. Dr. Negar Asdaghi: So, I just want to summarize this so that I understand it and, of course, want to make sure that it's simplified also for our listeners. So, you found that those people, and it should be noted these are all within the first 4.5 hours. Dr. Mark Parsons: Yes. Dr. Negar Asdaghi: So, we understood in that time frame. Those people who had a fast growth rate, they had the greatest benefit from endovascular therapy in this time frame. And those people who had the slow growth rate, that is defined in your study as less than 15 cc per hour, they actually had a similar benefit from endovascular therapy as they did with intravenous thrombolysis. Did I summarize that? Dr. Mark Parsons: Yes. That's correct. Dr. Negar Asdaghi: So, Mark, how do you explain this from a pathophysiological standpoint? Dr. Mark Parsons: Fortunately, there's a relatively simple explanation. So, because of the way that we set up INSPIRE, we collected follow-up infarct volumes as well. From the time window for follow-up infarct measurement was a little bit variable, but it was around 48 hours after stroke onset. In this group of patients, we actually were able to measure final infarct volume and essentially, in the slow core group, so less than 15 cc growth per hour, in that group, with both IVT and EVT, there was minimal infarct growth by the time we measured it at 48 hours. So, both therapies basically led to minimal infarct growth after the treatment, whereas in the fast core growth group, more than 25 cc per hour, the IVT group had much greater infarct growth by 48 hours, about 40 or 50 mL more, on average, than the EVT group. Dr. Mark Parsons: I guess also, to explain that a touch more, if you look at the slow core growth EVT group versus the fast core growth EVT group, there was still more infarct growth in the fast core growth rate. And this is because you measure the core at a certain time on the CT or the MR. And then, even with the very best system, you're not going to get reperfusion with EVT for at least 30 minutes after that because you have got to get into the angio lab, you have to puncture the groin, and you have got to get up there, and you have got to pull the clot. So, even if you get complete perfect circumstances, it's still usually at least a 30- to 60-minute delay between the perfusion CT and when you're fully reperfused. Dr. Mark Parsons: But the theory should be, if there's a minimal delay from the perfusion CT to reperfusion, the core at that time should be identical to the follow-up, final infarct volume. And that's what we actually found in the slow core group. It was almost the same. The interesting thing was, it was the same in both IVT and EVT, which basically, we don't know for sure, because we don't know exactly when the IVT group reperfused, but it probably means that because the core growth is so slow in this group, even if you reperfuse later with IV therapy, which we know is the case, often with IV thrombolysis the recanalization is a bit slower than with EVT, so even if you've got delayed reperfusion, if you've got slow core growth rate, you may not get much infarct expansion at all, whereas if you've got fast core growth rate, getting reperfusion as quickly as possible after your CT is crucial to limit subsequent infarct growth before reperfusion. And that's exactly what we found in the fast core growers, that EVT substantially limited that subsequent infarct growth and led to better clinical outcomes as well. Sorry, again, that was a long explanation. Dr. Negar Asdaghi: Mark, but these are really important findings, and as you alluded to earlier, I believe that they have major implications in how the systems of care are organized and our transfers are going to be decided upon in the future. We have a few minutes before we end the podcast here, and I want to ask you, do you think it's fair to have a similar concept that's studying the infarct growth rate in the late time window, especially in the sort of past 12 hours time window in the future? Dr. Mark Parsons: Yeah, it's a fascinating question, Negar. In fact, we do have a paper somewhere under review. I think Stroke might have knocked it back. Anyway, but it's actually looking exactly at this concept, but the fascinating thing is, in the late time window, you see very few true fast growers because they actually present early. This is what the paper under review is talking about. So, in fact, most people that you see with a favorable imaging pattern in the late time window, such as DAWN and DEFUSE 3, the core is relatively small. In patients with fast core growth, by the time you get to six hours, you've got a massive core and no penumbra, so they are typically not offered endovascular therapy because there's no salvageable tissue and there's already lots of damage, even on the non-con CT. Dr. Mark Parsons: So, it would be actually really interesting to look just at the late time window, and I'm sure others are doing that, too, but I suspect what we'll find is that the distribution of core growth is pretty narrow. It's mostly the slower core growers, and it's very clear that most of the really fast, and we're actually looking at this now in people with large infarct core over 70 mL, in fact, they present, the ones that we've got at least, present very early. So, it'll be a fascinating area to look at, for sure. Dr. Negar Asdaghi: Mark, it is definitely fascinating. We look forward to covering that paper, hopefully in our future podcast. But I want to leave you, reminding you that I'm a mild stroke person, so I am definitely interested in looking at these slow grow rate infarct patients because there are also, as you know, some studies suggesting that the slow growth infarct actually can happen sub-clinically on only a radiographic basis, and especially important in the mild group patients. But, we are out of time. Professor Mark Parsons, thank you so much for joining us all the way from Sydney, and it's been a pleasure interviewing you. Dr. Mark Parsons: Thank you, Negar. Lovely to chat and hope to see you very soon in person. Dr. Negar Asdaghi: Thank you. Dr. Negar Asdaghi: And with that, we end our podcast for the December 2021 issue and close the first year of the Stroke podcast. A year ago, Dr. Ralph Sacco, the Editor-in-Chief of Stroke, approached me to talk about the importance of starting a podcast for Stroke as an accessible means to highlight the great work published in the journal, and also introduce me to the amazing Stroke editorial staff. Dr. Negar Asdaghi: One year, hundreds of reviewed papers, and 11 podcasts later, from missed deadlines to late night emails, early morning texts, and weekend recordings, our podcast has become a bit more than just a quick review of the literature. It has truly become our podcast family. Overcoming the time differences and impossible schedules, you made time to interview with us, listen to us, and work with us as we reached out to researchers across the globe who contributed to this journal and to the podcast. Lots of laughter and a few tears. Like every family, ending the year reminds us of some good times and, of course, the difficult times. Dr. Negar Asdaghi: So, I want to end our final podcast of the year with a topic that we haven't really covered in our journal, but I think may sprinkle some magic on your holiday season, and that's the topic of quantum biology. Wrapped in mysticism with a pseudoscientific flavor, physicists, neurologists, anesthesiologists, and philosophers have been hard at work deciphering whether consciousness may have similar properties to quantum particles. From superposition to entanglement and coherence, is it possible that your mind may have something to do with the epigenetics, up and down regulation of genes and presentation treatment and, importantly, outcome of various medical or neurological disorders? Now, even if this was proved to have a low scientific validity, as a stroke scientist, isn't it amazing to be working in the one field that ensures the brain, which is the home of consciousness, remains healthy? So, let's think about the power of consciousness in altering the outcome of medical conditions with our ever-excitement to stay alert with Stroke Alert. Dr. Negar Asdaghi: This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit AHAjournals.org.
Our feature interview is with David Braunstein, president of Together for Safer Roads. David talks about the recent increase in road risk, near-miss analysis and minimising the distractions of smart phones. Plus news and conversation with iVT editor Tom Stone and editor-at-large Saul Wordsworth.
Jimmy and Charles met when they were 18 and 19 years old, just a few years after Charles had been diagnosed with idiopathic ventricular tachycardia (IVT). At 13 he underwent surgery to implant a pacemaker, which regulates his heart rate during IVT episodes when his heart beats chaotically. Charles was […]
This week, Stacey and Nuala invite a regular IVT contributor and industry disruptor Karen Ginsbury to innovate and revolutionize the future of quality management within the pharmaceutical and biopharmaceutical, and med device sectors. Karen will share her views on ICH Q10 and what must happen next. Resources from this episode: One Voice of Quality Website One-Voice-of-Quality (1VQ) Solutions Part 2 - Podcast Episode | IVT One-Voice-of-Quality (1VQ) Solutions – an Enhanced Science and ... Elon Musk Hiring Ad What Is Industry 4.0? About Our Guest: Karen Ginsbury Karen is a pharmaceutical consultant who brings hands-on experience in designing and implementing environmental control programs within multinational pharmaceutical companies. She started her career in the industry by taking EM samples on the factory floor and brings her own unique perspective to her lively and instructive presentations. Ms. Ginsbury has over twenty years of industry-based experience in quality assurance and compliance and has published a book on compliance auditing for pharmaceutical manufacturers. Ms. Ginsbury is a past holder of IVT's Presentation of the Year and Web Seminar Presenter of the Year and regularly lectures around the world on pharmaceutical topics. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
This week, Stacey is joined by Dr. Tim Sandle to discuss developing effective contamination control strategies to deal with all aspects of contamination such as particulate, microbial, product carryover, chemical (like cleaning material residues) as well as viral. Dr. Tim Sandle details the common types of contamination, what regulators are seeking from control strategies, the challenges of implementing control strategies, and much more. Resources for this Episode: Biocontamination Control for Pharmaceuticals and Healthcare, by Tim Sandle EU GMP Annex 1 Revision: Manufacture of Sterile Medicinal Products (Draft) ISO 14698-1: 2003, Cleanrooms and associated controlled environments FDA Guidelines on Contamination Control Sterile Drug Products Produced by Aseptic Processing 〈797〉 Pharmaceutical Compounding—Sterile ... - USP About Our Guest: Dr. Tim Sandle Ph.D. is a pharmaceutical microbiologist, with over 25 years of experience, who has worked for different healthcare organizations and pharmaceutical companies, in microbiology and broader quality roles. Dr. Sandle currently works for an international sterile products manufacturer and he is additionally a visiting tutor with the University of Manchester (lecturing in pharmaceutical microbiology), a committee member of the Pharmaceutical Microbiology Interest Group (Pharmig), and a supporter of several other societies relating to pharmaceuticals and healthcare, including IVT. Dr. Sandle also serves on several advisory committees and standards boards. Dr. Sandle has written or edited over 25 books, more than 100 book chapters, 125 peer-reviewed papers, and some 400 technical articles. Dr. Sandle is a regular presenter at conferences and webinars, having delivered over 150 presentations. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
Smile Identity received a $7 million Series A investment from Costanoa Ventures and CRE Venture Capital. Smile Identity intends to utilize the extra funds to strengthen its services, expand into new locations, and serve a larger range of ID kinds. John Cowgill, a Costanoa partner, will join Smile Identity's board of directors. Smile Identity provides ID solutions in Africa and throughout the world for banking, telecoms, financial services, and shared economy applications.IBM plans to acquire BoxBoat Technologies, a well-known DevOps consulting firm and Kubernetes-certified enterprise service provider. BoxBoat will join IBM Global Business Services' Hybrid Cloud Services business, which is constantly growing. BoxBoat provides a wide range of services, including customized Kubernetes and Enterprise Container Platform adoption strategies, application containerization, and DevSecOp training and facilitation.Peter Boyce II, a General Catalyst partner, has left the company to form his own firm called Stellation Capital. He plans to raise $40M for his company's fund. Mr. Boyce joined GC in 2013 and is in charge of Ro, Macro, towerIQ, and Atom investments.Switzerland's national postal service has acquired a major stake in the end-to-end cloud-based file synchronization and management software provider, Tresorit. It said that the move falls in line with its broader aspirations of supporting the Swiss economy in times of digital transformation.Rootly, a startup helping companies recover and learn from incidents, has announced the raise of $3.2 million in seed round funding led by Ross Fubini at XYZ Venture Capital with participation from 8VC (investors in Asana, Palantir) and Y Combinator.Toronto-based Clearco, a fintech capital provider, has raised $215 million in new funding round, just months after it turned unicorn, rebranding itself from Clearbanc, raising Canadian Dollars (CAD) $125 million ($100 million) in Series C at $2 billion valuation.Nairobi-based MarketForce, a B2B end-to-end platform that helps customer brands deliver essential goods and services, has announced the raise of $2 million in a pre-Series A funding round.With this round, its total funding stands at $2.5 million. Investors who participated in this round were – Y-Combinator and P1 Ventures joined by V8 Capital, Future Africa, Greenhouse Capital, Launch Africa, Rebel Fund, Remapped Ventures, and a couple of strategic angels.Botman, a cybersecurity software-as-a-service business, has received $200K from Modulor Capital and Pentathlon Venture in a seed round. The funds will be used to grow the company's software-as-a-service (SaaS) solution for the digital advertising supply chain. The company wants to get rid of IVT (invalid traffic) from the digital ad ecosystem.Avataar Ventures and Ascent Capital led a Series B investment of $16 million for CRMNEXT. Avataar Ventures and Ascent Capital lead a $16 million Series B investment for CRMNEXT. Across 100 major banking and insurance firms around the world currently use the startup's services.
Merhabalar... Bu yazımda, acil serviste zamanla yarıştığımız hastalıklardan olan akut iskemik inme ile ilgili Avrupa İnme Örgütü (ESO)'nün kılavuzundan bahsedeceğim. Kılavuzun tamamına buradan ulaşabilirsiniz. Akut inmeli hastalara, hızlı intravenöz tromboliz (IVT) sağlamak için, acil sevk merkezleri, birinci basamak sağlık hizmetleri, ambulans hizmetleri, acil servisler, radyologlar ve nörologlar veya inme doktoru tarafından koordine edilen inme ekipleri ile birlikte iyi işleyen bir sağlık sistemi gereklidir. İnme doktorunun optimal hasta seçimini ve hızlı karar verilmesini sağlaması gerekir, çünkü IVT inmeden hemen sonra verildiğinde daha etkilidir. ESO (European Stroke Organisation) kılavuzları, akut iskemik inme için intravenöz tromboliz ile ilgili klinik kararlarında doktorlara yardımcı olmak için kanıta dayalı öneriler sağlar. Burada, özellikle geç zaman aralıklarında ve alteplaza kontrendikasyonu olan hastalarda, daha geniş IVT kullanımını destekleyen randomize ve gözlemsel çalışmalardan gelen tavsiyeler gözden geçirilmiş ve öneriler yapılmıştır. Literatürün sistemik incelemeleri ve meta analizleri gerçekleştirilmiştir. Mevcut kanıtların kalitesi değerlendirilmiş ve önerilerde bulunulmuştur. Yeterli kanıt olmayan durumlarda uzman fikir birliği beyanları belirtilmiştir. İntravenöz tromboliz, akut iskemik inme hastaları için onaylanmış tek sistemik reperfüzyon tedavisidir. Semptom başlangıcından sonraki 4,5 saat içinde, akut iskemik inmeli hastalarda fonksiyonel sonucu iyileştirmek için alteplaz ile intravenöz trombolizi öneren yüksek kaliteli kanıtlar bulunmuştur. Ayrıca 4.5 saatten daha önce normal olarak görülen ve uykudan uyandığında akut iskemik inmeye sahip, MRI DWI-FLAIR uyumsuzluğu olan ve mekanik trombektomi planlanmayan hastalarda alteplaz ile intravenöz trombolizi öneren yüksek kaliteli kanıtlar bulunmaktadır. Bu kılavuzlar, hasta alt grupları, geç zaman aralıkları, görüntüleme seçim stratejileri, alteplaz ve tenekteplaz için göreceli ve mutlak kontrendikasyonlar hakkında daha fazla tavsiye sağlar. İntravenöz tromboliz, akut inme tedavisinin temel taşı olmaya devam etmektedir. Uygun hasta seçimi ve zamanında tedavi çok önemlidir. Sonuçlar 1. Başlangıçtan itibaren 4,5 saat içinde tedavi: 1.1:
Simon Shares Level 4 lockdown. Remember the podcast of last week when I delved into the various leisure socks. Argent (JSE code: ART) results. Long a stock not worth covering or owning, but they've changed things up the last few years. Invicta (JSE code: IVT) another successful turnaround and really good results. JSE (JSE code: JSE) trading update, no surprise earnings under pressure. Nike (NYSE code: NKE) results absolutely crushed it last week. Revenue +96%. Anchor Capital published a note showing that the US had increased the number of US$ in circulation (M3) has gone up 33% over the course of the pandemic. Absa's Q2 2021 manufacturing survey shows very positive manufacturer confidence. EOH (JSE code: EOH) new board suing founder Asher Bohbot for R1.6billion. A US judge kicks out the Federal Trade Commission's (FTC) antitrust case against Facebook. It was requesting that Facebook sell their Whatsapp and Instagram businesses. They can bring the case back again, but the bigger issue is antitrust cases against big tech in the US and EU. SAB Zenzele Kabili (JSE code: SZK) has been coming down, now around R120. Still, double far value. Thungela Resources (JSE code: TGA) trading at almost 4000c. Coal may be dirty and coal may be dead in time. But so far it's been a great investment, but this is probably fair value. South African Reserve Bank (SARB) turned 100 years old on Wednesday 30 June. Euro Zone inflation slipped to 1.9% for June. Popia is live from today. SA recorded another trade surplus in May of R54.6billion. This is the 3rd month in a row that the surplus has been above R50billion. Watch ~ Rand, stronger for longer
TEMPORADA 17 - LA SEGUNDA SERIE DE LOS EMPRENDEDORES101 - Leo Pereira en San Luis Potosí. Hay que impactar positivamente23 de junio de 2021Duración: 44 minutos 36 segundosLeo lleva seis años viviendo en la ciudad mexicana de San Luis Potosí. En este episodio nos relata su camino por el mundo del emprendimiento y el proceso de creación de su empresa “Leitos Antojitos y Botanas Divertidas” que se dedica a introducir los tequeños y las arepas en el mundo gastronómico mexicano mediante la adopción de sabores locales.Si quieres saber más de Leo y su trabajo, lo puedes seguir en @leitosfood///Transcripción (por corregir)René Mendizábal: Damos inicio a nuestro episodio número ciento uno, temporada diecisiete, que va a ser la segunda serie de los emprendedores en la ciudad de San Luis Potosí para conversar con Leo Pereira, economista, cocinero, autodidacta, creador de lejitos Leo. Bienvenido a los trabajos y los días. Muchas gracias por aceptar nuestra invitación.Leo Pereira: Muchas gracias a ti, René, de verdad que estoy complacido de esta invitación de poder conversar contigo y y con toda esa gente que está pendiente de lo que hace, de lo que haces tú, de lo que hace gente en positivo que nos une la nacionalidad de Venezuela.RLM: Y la ganas echar para adelante, no?LP: Por supuesto.RLM: Leo, tú tienes seis años ya viviendo en México. Qué fue lo primero que pasó por tu mente? El día que llegaste a San Luis Potosí, sabiendo que ya llegaba para vivir.LP: Mucha incertidumbre. Por decirlo así, mucha incertidumbre. Teníamos algo de unos ahorros en la cuenta e teníamos salud. Yo soy Chie, casado con Giovanna desde hace 16 años y tenemos dos iba adolescent Villa. Allí dentro no eran tan eran coexistan de niño y por ellos dos. Y este. Nos vinimos a vivir a esta ciudad, entonces. Este con algo de ahorro, con algo de estabilidad familiar, por llamarlo de una forma. Los cuatro llegamos aquí con las ocho. Maleta. Ah. A. Básicamente aquí. Matarnos socialmente, diría yo. Y de la palabra. Es decir, no teníamos la. La necesidad inmediata de salir a trabajar para poder comer. Y eso nos dio cierta, cierta comodidad. Este que creo que quiero que no la vea así. Tampoco una comunidad alegre de millonario ni nada. Sino bueno, vamos a explorar. Vamos a conocer mamá. A ver que. Que qué nos depara en esta ciudad que ya habíamos conocido. El país como. Como turista. Décadas atrás vinimos una vez y nos encantó México, México, su cultura, su idioma, su historia y esa esa cosa tan tan latina que tenemos. Este hoy no auto mucho, pero bueno, ya para vivir. Entonce sin embargo rápidamente vino vino momentos de de como desea li certidumbre se mostró que tai nos estaba atacando I want.RLM: Leo y yo quisiera entrar a hablar de tu emprendimiento, porque tú no solamente vendes, sino que eres un embajador del pequeño en México, tienes ya años haciendo eso y es algo que yo tengo tiempo sabiendo de tu emprendimiento. Me llamó muchísimo la atención, sobre todo te confieso, Chop. Me preguntaba si podía funcionar o no, porque tenía la oportunidad de estar en varias regiones de México y en cada uno de esos lugares en el este, en el oeste, en el Caribe, en el centro. La gastronomía es riquísima en todas partes. Te sirven mucho. Muy sabroso y te lo cobran muy barato. Entonces me parece un desafío enorme ir a vender comida a México y especialmente una comida que lo mexicana a lo mejor no conoce mucho. Cómo te surge la idea? Cómo te planificas de cómo llegas tú a la conclusión de que llevar el pequeño a México es algo que podía funcionar?LP: Tengo que hacer un poquito de historia. Vamos a ver como lo golpeamos en página o compaginarlo, eh? Yo soy cocinero de toda mi vida. Autodidacta como tú, escribe. Pasé por Bagres ETAP, por ejemplo. Yo cocino de niño y allí recuerdo completamente que a mi casa. Mi mamá lleva una revista que compraba la todos los meses. La revista Buen Hogar. En la revista Buen Hogar vi en una sesión de cocina y venía incluso recetarios, algo que yeta desviacion probablemente de joven hoy no conoce provenia o no cartoncito con la foto de del platillo o menú y. Y yo leía me gusta mucho LEF y así fui aprendiendo a cocinar. Luego en una segunda etapa me convertía restaron restaurantero, tenía restaurante, mъsica invertí en este tipo de negocio, me formé como como Orbyt pero y y y luego como emigre. Entonce me fui, pero no me llevé los restaurant.RLM: Obviamente.LP: Yo soy franquicia de software, fui diez años franquiciado de esa cadena donde aprendí muchísimo. Y te cuento esto porque cuando llego aquí ya era como como natural para mí mirar el tema de la comida como. Como un negocio. Primero pudiera haber sido y llegar a una tienda software y trabajar ahí porque ya tenía esa experiencia y convertirme en un empleado. Luego decir bueno, vamos a pudiéramos evaluar unas unasociedad franquiciar nos este con una tienda software aquí en México y empecé a ver lo rudo del negocio y la comida de como acabas de describir, es decir, un sándwich de showing. Vale, vamos a hablar de eso mexicano vale. En oferta treinta y cinco pesos 35 pesos son prácticamente este cuadro tacos IVT, taco de proteína de comida que la gente se lava delicioso entonces competir en el EPT? Yo dije no, imposible Zowie con y lo que yo sé hacer, lo que yo sabía hacer. No, no lo podía ser. Empecé a ver este una oportunidad interesante en los cines, en los cines. Una pena muy grande. Y este líder de cines en México vende tequeños más de 300 salas de cine. Y tú llegas ahí en el mostrador ic bucho vía y pi, digamos, donde venden las cositas más sabrosa pero más caras. Por cierto, ahí en esas esquinas venden que los venezolanos también emprendedores y ya tenían un músculo de en el negocio y los pequeños Venezuela, el país más nos está llevando a otros países e incluso Jack Mjico, pero sólo ahí en ese espíritu nicho de negocio para comprar pekeños aquí. Entonce en esta ciudad tenía que ir Alci.RLM: Al cine y a la sala, vià y pijama.LP: Sí. Entonces yo dije bueno, ya sí, ya al este, el universo de mexicanos, todos hablan de 130 millones de personas. Este se ha conseguido con este producto. Bueno, yo creo que aquí hay una oportunidad. Y empezamos a hacer algunas pruebas. Yo en mi vida, te confieso, René había hecho un pequeño. A pesar de que soy cocinero. Y te digo por qué? Porque yo soy un cocinero. Este orientado a la comida de cocción rápida. No soy repostero, por ejemplo. Ahí hablamos siempre de él. Yo hablo de una carretera que se hace una yí y el cocinero tiene que decidir o me voy a convertirme en un reportero o repostero, o soy cocinero. Y ahí nos divide y nos divide. Por un lado, los reposteros son de caudillaje stack. La química tiene que ser perfecto. Medidas y yo en mi vida, en mi vida, he seguido reglas para hacer las cosas. Yo soy un emprendedor y un reloj bre. Las ideas me llaman. A vecesRLM: 1.LP: Soy generador de idea. Algunas las concreto, otras no. Me gusta regalar ideas a la gente. Eso a veces la gente lo toma, llega a eso, lo toma muy bien abecé.RLM: A veces no?LP: Este tipo que viene a decirme bueno, los cocinero evidentemente nos gusta la interpretación, la imaginación plasmada en plasmarla en un platillo, no repetir ingredientes. Una es una dinámica crítica al cocinar. No es mi sello. No repito plato y. Y dije bueno, en la cocina me gusta hacer cosas rápido fast web, pero hacer un pequeño es una masa. HayRLM: R.LP: Que hacer un poco el proceso y jamás lo hice. Siempre los compraba en dondequiera y ya en Venezuela. Entonces creo que hay una oportunidad. Vamos a estudiar cocina, cosa que nunca hice en mi vida. Tuve restaurante, manejé equipo de trabajo, me formé en las escuelas de de Zowie, me formé. Luego un negocio de su cheque tuvimos en Penan hacer sushi. A mí me gusta mucho ejercer el liderazgo en cualquier lugar, en mi familia, en equipo de trabajo. Si la relación con mi amigo y una de las cosas que que estoy convencido y lo tengo muy claro, que el liderazgo se ejerce con autoridad. Autoridad de la palabra autoridad. No sé si griego o relativo me ayudara de fuera a descubrir. Este siempre tenía un sādhu y ahorita significa el que aporta. Entonces yo si voy a tener autoridad aparear para presentar un producto como éste. Yo digo que que saben hacer muy bien. Tengo que saber cómo combinar de la mejor manera las cosas para que el producto sea muy bueno. Estudio cocina aquí. Mesa típico con programa de 6 a 8 meses estuvimos estudiando para chef profesional una especie de diplomado, pero no es lo mismo. Un joven de 17 y 18 años que estudia este este programa es seis meses, 8 meses y dice bueno, aquí tienes tu título de chef profesional. Ah! A que lo haga Leonardo, a que lo haga yo que tengo. Treinta años cocinando y manejando restaurantes y cocinas. Y entonces una culminación muy positiva. A mí, a mi mirada, a mi prácticaRLM: C.LP: Culinaria por llamar una fore y positivos, una muy buena receta Teke que se diferenció muchísimo de referenteRLM: Muy bien.LP: Y empezamos a presentar yo. Yo estaba claro que no podía apostarle al al mercado venezolano. Por qué? Porque somos muy poco. San Luis Potosí está en el centro de centro centro, en el mero centro y a un mexicano de México.RLM: N?LP: Y aquí se han arraigado en aproximadamente mil 500 venezolanos, todos dispersos por una ciudad muy grande. Yo lo vi clarito. No es mi mercado para que esto sea un negocio. Este redituable no lo es. Tiene que ser el mercado local, mi mercado mexicano. Y traté de replicar algo que creo que es muy importante en el negocio de la comida. Que nosotros en este negocio no vendemos comida. Nosotros vendemos experiencia. Entonces, si era un producto distinto o innovador, diferente. Este no es un tradicional taco o torpe cosa mexicana. Este realmente no importaba porque lo importante era diseñar y hacer la entrega de una experiencia a la hora de de probar. Y esto tiene una explicación, una experiencia, tiene tres componentes una experiencia se atesora y te comes un pequeña deleitas que lo guarda en el corazón, en tu cabeza. Que sabroso estoRLM: Kija.LP: Y lo guardas en tu lo atesoré una experiencia que cenar. Llegas al lugar a vuelta a casa. Oye mi esposa e hijos, provea lo que quiera de un día también brevet o traje conmigo para que lo pruebe y bueltas un poco el queso se derrite este hay una salsita. Pero bueno, y dónde está? No está Quimi Cabeza es algo que me pasó, es un periodista que cenar y por último las experiencias se recrea. Bueno, este fin de semana vamos a pedir pequeños deley, vamos a repetir eso. 12 Este teniendo eso claro, ya no importaba mucho si el producto era o no era conocido, yo tenía que presentar experiencia diaria. Entonces nos concentramos e preparamos este esta, esta receta nueve quesos distinto para llegar al al queso que era, aunque es muy parecido al venezolano. Me encontré frases como esta todavía Wyeth me llevasteis de mi ciudad, hoy es San Cristóbal, me llevaste con lo que me comí allá al mercado de Chihuahua en Garak, o sea elRLM: Bmg.LP: Sabores que se oye si había unas señoras y todavía hoy y hacen pequeñas, pero en esa dinámica muy a la venezolana que hacemos un producto se lo vendemos a algunos amigo, pero no es un un negocio. El es más bien.RLM: Claro, no tienes la posibilidad de escalar Nonell, de crecer. Y fíjate, Leo, que cuando estábamos hablando, mientras tú conversará metia en Google y efectivamente autoritas giné del latín y quiere decir el que cultiva, el que argumenta, el que aporta, no? Y dentro de ese espíritu de autoridad de aportar, tú me comenzadas más temprano que que no solamente está el pequeño de Leito con el queso muy similar al venezolano, el sabor tradicional, sino que también tage incorporado los sabores de México, porque México se come con picante y con salsa. Cómo fue ese camino para llegar hasta ahí?LP: Casualmente, estudiando la cocina, estudiando el pasó me en nardo a muy sabroso producto, pero este tiene una salsa aquilón lo mexicano como un conces y yo entendiendo eso que me dijo y tratando de responder la pregunta que yo me hice cuando cuando yo empecé la cocina aquí, yo quería entender cuál es la reacción que tiene el mexicano con el Chile, porque evidentemente y en ese período de llegar, de sentarnos a sentarnos aquí a vivir en San Luis Potosí este estamos comiendo, estamos probando comida, que por cierto también me pasa algo y probablemente alguno amigo que nos escuche, que también sea cocinero lo lo va a reconocer. Y de los cocineros tenemos una maldición. Nosotros sufrimos lo que llaman eso, el mal del cocinero que comemos en un lugar o un restaurante, la comida de otro y no nos gusta o no sentí muy satisfecho o no decimos es propieda serio, propor seiyu. Tendría que ser una cosa muy maravillosa este que. Pero igual al final si Bako a una almeja a cocinar algo que aquي un erizo de mar, un cocinero en aguas técnicas para para con comida es Comín. Entonces, en ese mal en Cemal, en cocinero, me conseguí con otra cosa. Peor era probando, probando. Y hay algo en México que es muy común que se llama La maldición de Mog de suma.RLM: Ah, ah, ah, ah, ah, ah, ah, ah, que eso.LP: Una intoxicación estomacal. Las comiendoRLM: Bokeh.LP: Acuérdate que en este país bendecido por Dios, los mexicanos han aprovechado la la milpa que llaman naturalis, la tierra en su máxima expresión. Y yo eso lo valoro mucho. No desperdicio nada. Un ejemplo clarísimo el cactus. Nosotros en Venezuela. Bueno, el chiva paraun para los miembros de decoro knot cactus lo veía. Que bonito ese ese árbol. Bueno akelarre Ren la hoja del cactus que el nopal y se la come y es sabrosa la cadista del cerdo la cabeza después que ya agarroRLM: G?LP: Del animal o de garré la cabeza también la cocina y hace tacos de cabeza. Entonces probando cosas Hansi y probando picante. Tuve tres episodio de La maldición de Moctezuma. Mira qué tan grave es que viaje tomar antibióticos, tirajes. Lo sé. Se te hincha el estómago, te da una fiebre, un un dolor en los hueso. Malestar que dura 3 4 Hayley y la inflamación del estómago tremenda. Y por supuesto que el picante es un ingrediente, un protagonista que puede ser, puede ser un asesino. Yo hice algunas unos aderezos, por supuesto. La salsa tártara venezolana que no, que nos gusta, que nos encanta. Si para los pequeños la intervinimos con habanero, entonces tenemos una tarta habanero. Me recomendaron mira, aquí la gente le encanta porque yo yo hablé mucho con Collegi, con mexicanos, yo habla con mucha gente, hice pocos amigos Venezolano, Tamarindo, Prévert, Tamarindo, intervi. Entonces hicimos la Tamarindo en Chipotle y una mexicana escribía en alguna página de Facebook. Esta salsa no tiene madre, una expresiónRLM: Dijo.LP: Muy mexicana, muy, muy, muy coloquial. Y yo por supuesto que no lo entiendo y la respondía, pero ya va. Búdico por si quiere padre, si tiene padre, el padre es nació Perera y laRLM: Admiti.LP: Cantada CUP. La gente mexicana recuerda que el dicho a nosotros sigue siendo el objetivo principal a la hormiga. Entonces nuestro pequeño, que perfectamente se pueden comer con una salsa de tomate como con sémola, ketchup, la cátsup como se llama aquí? Bueno, empezó a presentarse con Santamarina en Chipote un poquito Guus y fuimos un poquito más allá, cosa que yo no he visto e iniciativas de tequeños de Venezuela no ha habido en el planeta a través de las redes sociales que lo veo. El Chile lo empezamos a colocar dentro, es decir, un poquito de jalapeño con queso enrollado, pero después de ella vamos a hacer algo mejor. Liquidamos el chile y tenemosRLM: Vivie.LP: Versión pico. Cita un pequeño pico йxito y tú lo ves, es naranja por fuera. Por qué? Porque la pasta, la masa y.RLM: Team Chile.LP: Lo sé yo hoy resolví el asunto de de cómo mimetizar nuestro producto a ubicar. Mira Prosi, tenemos una versión que viene picante y ahí entonces empieza a descubrir cierta cosa mil versiones de pequeños de arepa, que es ahora un producto que acabamos de presentar. Este Tabby de una forma con una receta y 4 en 4 presentación hacemos arepa de harina de maíz blanco de harina de maíz amarillo, una arepa dulce con plata nigun con papelon y una arepa y cositaRLM: Uuc.LP: Una arepa completamente tú. La vez naranja pica y la masa entonces y la salsa al final son como como 12 producto en nuestro portafolio y donde siempre hay presidente hay algunos que tienen Chile en mi humilde y así se lo digo de cara a la gente en humil intepretación como el Chile veo estaba presente la comida a que la gente no sufren la maldición de Moctezuma que pains y la que te quema que te quiete en flama todo lo que entonce encontrado que existe un debate muy muy encarnado entre propio mexicano. Hay gente que no le gusta Chile, no? Bien de qué? Que bueno que mata por el chip. Yo soy esclavo siendo parte de la conversación, siendo parte de la de la dinámica especi y rituales a la hora de comer con productos que. Que hay para todos los gustos.RLM: Déjame ver si te estoy entendiendo. Entonces me dices que tienes. Como ya sabes, más pequeño tradicional el ticket yotambién que tiene el Chile dentro de la masa y la salsa doces de tamarindo con chipotle. Y por ahí viene también la cosa con la arepa. O sea que le está dando al pequeño la arepa comuna o la nacionalidad.LP: Si teníamos que entregar nuestra cultura y ponerla en la mesa y decir mira, aquí estamos nosotros. Qué pasó con el castillo? El castillo, el emplatar, italianos, la lasaña. Con su característica es ricotta, que si este la salsa de tomate y ya. Pero el patito es muy venezolano, pero también es muy italiano con la comida árabe, el mismo taco al pastor mexicano que uno de los tacos más importante de mi americana su origen de époque. Los árabes que lo que hacían con sus trompos de carne especie de shawarma tuvieron que mimetizado. Le pusieron piña, le pusieron chile en la en la hora de la cocción. Y por eso la carne del pastor es tan roja, porque Tafur de Chiles y hoy día la gente lo apropio y nosotros no queremos que el mexicano se apropie de esta comida. Y ahí estamos y estamos convencido que no pasa nada negativo. Todo es positivo.RLM: Ya no se pierde nada, más bien se está ganando.LP: Estamos ganando, estamos ganando los de Cultura y de hecho, fíjate que en la estrategia de mercadeo Ito es una marca antojitos y más divertida y tiene los colores, la bandera, Venezuela, pero solo los colores. Y tiene esa propósito, este también asociado al despertar a estimular el apetito y la gente, el rojo, el amarillo, el azul brillante son colores que que hablan de la comida o no inducen a comer. Entonces yo todo mi paso están un poquito meditado. Yo pienso mucho la cosa que hago si tengo que dar una cortesía a alguien este en una estrategia detrás de eso eh? Porque le doy una cortesía a una, a una chica que no dos mil quinientos seguidores aquí en su instagram, pero en la ciudad y sus pasón etiquetando a al lugar del chillado vidaque San Luis Potosí. C Yo pienso muchas cosas y he entendido que qué regalar nuestra cultura gastronómica venezolana que es deliciosa. Hoy AWM mítico el pie la lamería aquí, majete, come arepa este Warwick. Bueno, ahí tienes a nómeno a ir apagase 20 años solo se consigue invert suela whites sp3 paíse.RLM: Ahora Leo, me estás hablando mercadeo y hay una cosa que me llama la atención porque yo tengo rato siguiéndote por por Instagram y yo veo que tú, tú siempre estás publicando video, comentario, etcétera. Pero sobre todo tú hablas de restaurantes de otra gente, no tanto de Leito, sino yo tengo de restaurantes, restaurante probando un plato aquí, una hamburguesa por allá, como así.LP: Pero primero, donde me sigue, yocreo René. Es importante decírselo a la Hoid y Garrotxa laicos food ahí bokeh, no en el Instagram, en Facebook, sino en Twitter, arroba litos food. Ahí pueden conseguir vierno. Fíjate, yo hablo del platillo. Toda mi vida he cocinado para amigos, para mi familia, para mis clientes, mi restaurante. Pero yo hacía una foto y la montaba por ahí ya. Y siempre que había una reunión, o una fiesta o un encuentro, yo tenía que ver con. con lo que iba a pasar el entornar a la comida. Pero era algo muy personal. No entendí rápidamente que esas son las bienvenidas que te entre un país. Oye paites, recibe, te abraza. Pero Gachí con su camino sea a quienes Leo Pereyra, que no es nadie. O sea, señor, lo otro lo estudié en ninguna parte. Pero esta está la literatura de mercadeo que se llama reconocimiento por asociación. Bueno, a mí nadie me conoce, pero yo voy a hablar en 12, en el restaurante de Reni, que si es conocido, que tiene muchos seguidores, que tiene muchos clientes. Yo voy a hablar entonces de su comida y empecé de esa forma a que la gente también me asociará a ciertas marcas que ya están aquí en la ciudad. Y entonces empezó.LP: O sea, eso que llaman que un studi, una persona que va a prueba la comida, la comidita, le da un eje hasta puntuación y problema. Se ha vuelto muy popular este. Eso era antes, nada más. Para gente muy especial, un catador gastronómico era una cosa muy rockstar. Hoy día hay mucha gente que se dedica a eso. Entonces yo ni mi modelo de negocio a la hora de presentarme ante los aliados, que por cierto no fue el primer día, nosotros veníamos pequeños de mercadito en la calle Un Diam. Esa fue nuestra prueba de fuego para ver si la gente le gustaba, para ver el bio. Mira, prueba este producto, aquí estamos 50 personas vendiendo productos, una que una plaza un domingo cuando el modelo negocio de Leito santo y de y divertida empezó a coger forma. Dejamos de ir a los mercadillos y empezamos a ir a restoran en el nicho de menú americano. Rápidamente entendimos que la gente no iba a aceptar en el menú de un restaurante mexicano de taco de acogería que llama al antojitos venezolano no iba a aceptar. No hay, no hay, no tenía entrada, pero si tenía entrada como lo tienen Venezuela como en otras partes en el menú americano, porque bueno, ese fría papá y donde se hagan alitas de pollo ahí, o sea en una freidora, ahí van a estar los Thick.LP: Entonces yo les presento a los aliado, a los clientes. Mira, es mi producto, se lo tenía que dejar a consignación, por cierto, es otra. Otro modelo aquí tiene pulmón para aguantar muchas cosas, pero no tanto como financiero, sino también el pulmón emocional para aguantar un negocio que tú crees que va a ser bueno. Crees que va la rueda va a rodar, pero el empuje para que la rueda empiece a moverse milímetro a milímetro. Realmente muy, muy fuerte. Bueno, veamos, pequeño es el restaurante y no se vendía. Antes tenían que darle muestra y no se vendía entonce nada. Me fui paya vez de hacer foto de las hamburguesas futbo de la jaulita, foto de la pizza, el platillo principal. Igual es imperativo que tú +20 taip y yo compraba la comida. Se la sigo comprando porque soy muy solidario en eso. O sea, gente que me abrió la puerta en su restaurante que tenemos tres arbolillo, ya que tiene un menú de 20 40 opciones. Yo tenía claro a Huete quellos y es muy sabroso porque yo tengo 30 40 platos de menú. Chef cómo vamos a hacer? Pues de un pequeñoRLM: Claro, el plato cuarenta y uno.LP: Le cambiamos el nombre en el sentido de que lo presentamos como delitos de mucho queso para PAS, para diferenciarnos del mozarella Smits, por ejemplo, el dedito.RLM: Perder.LP: Aquí estamos en una masa muy fina, harina de trigo con un cierto dulzor escrita. Al momento su niño la va a disfrutar. Preparamos material piropea. Tom Seguimos haciendo, por cierto, llega a un lugar listo y va a conseguir algo de lo que llama Google hace muchos años. Este el momento cero. El momento cero. Antes Procter Gamble hace muchos años planteaba que el momento, el primer momento desde un cliente fue el producto sex en el anaquel cuando llega a su McAdoo el champú. Ah bueno, enquista en el llevo. Pero hoy día el momentos es breve en alumn@ previo a esqu en cero en internet. Entonces bueno, estala y yo ponía la foto de la hamburguesa del restaurante tal, agarraba el logo del restaurant, lo ponía y la publicidad le ponía una esquinita. No? Ni siquiera el logo de Lait. Porque yo les decía Pro-pia, te apropiaste de esto, tengo fotos muy bonita que se hicieron en algún momento de alta calidad de los pequeños y se las enviaba el correo agarra tu logo, tu color de tu lugar y pone esta foto que esta en formato PNG asi lista namá para que las coloque y Ilaves como lo quieras llamar delito es mucho queso y mi consejo de quello puede ser y hoy me siento muy orgulloso. Ren Époque claro, después de tres años en esto el restaurante tu abres menús de restaurante aquí en salud de mis aleado y mucho cuando tu haber tu consigue la palabra pequeño y yo no la pedí. Yo no le sigo. Yo no le dije esto.LP: Este no está en el menú. Y su pequeño dedito de de queso blanco que copiaron. Pegaron lo que nosotros estamos planteando, los precios que les sugerimos nosotros que se venda Araki. Entonces bueno, vamos a poner el menú de niños, por ejemplo. Porque también entiendo que es tu negocio a largo plazo, o sea, este ya no podemos captar el señor mayor que está casado con su gordita mexicana. Bueno, vamos a Lillo, tienes a el joven que te quiere explorar y que conoce cosas nuevas. Nos pusimos a merced a la orden completamente localia y empezó a tener muy buena aceptación. El que yo recomendara comidas en los restoranes y la gente me está ahora que no es mi aleado, me manda una hamburguesa misme no quiero pero es mia porque dice que hable quiero que premisa la llave de la vida. Hoy día leí Ttos en una Barker y Leo Pereira es una marca personal que es una de las ventajas que tienen el emprendimiento en una empresa cuando invierte igual en ninguna empresa la empresa Ren la imagen, pero cuando tu puedes tener también al hombre, a la mujer, al individuo, que es también la imagen hecha realidad, el apuesto cara que puedes conversar y no puedes comer, sacó el logo de Naito o el logo de Apple, a ver si puedes conversar con el creador, con el fundador, con el que la hace como la amas. Entonces eso es esa marca personal, nosotro la estamos potencia. Eso me ayuda tambien, por cierto, a mantener una relación a largo plazo.RLM: Lo que yo te estoy escuchando desde este lado de la conversación Leo, y que tú no iniciaste tratando de vender un producto venezolano ni dirigido a venezolana, sino a comunidad mexicana, Main Street en general. Y sin embargo, cómo se ha ido cerrando el círculo que hoy por hoy actuadores los menudo de tu aldea y el producto se llama pequeño.LP: Entre paréntesis, algunos dice votarÃa venezolana una banderita.RLM: Ni?LP: Yo no lo perdí. Creo que no es lo correcto, pero hay otro enfoque. Oye. Hay gente ávida de conocer cosas de otras culturas.RLM: Leo menera leí en San Luis Potosí, en México, principal desafío de vivir en México.LP: Me dijeron una frase cuando llegué a México es más capitalista que Estados Unidos. Te va a sorprender. Lo voy a repetir para que nuestra audiencia. Este locate me mata. Mejor México es más capitalista que Estados Unidos y te va a sorprender. Hoy me quedo con la frase bueno, en efecto, si Quito e compra dieran crédito, no dieron crédito muy rápido, tarjetas de crédito muy rápido y de una vez nos lo dan. Y los intereses son muy altos y fueron desafío. Perdimos lo ahorro, llegamos con Punzado EM en azul y terminamos al año en salud rojo. Esa forma tan venezolana de ser nosotros, del como vamos viendo, vamos viniendo. Como dice la frase oye, México. No, no es así. México. El costo de la vida es relativamente barato, pero los sueldos también. Se trabaja mucho y se gana poco. Es una realidad más allá de las grandes ciudades que de conglomerados que tiene el país, que son México, Distrito Federal y todo su su periferia. Guadalajara y Monterrey. Más allá de esas tres grandes ciudades y su foco de diferencia en el paíse, eh? Hay pobreza. Pero como insisto, la frase hay un capitalismo híper salvaje. El Tratado de Libre Comercio llegó a este país, se acaba de renovar, puso condiciones de negocio adversas para México, pero México sacó lo mejor de sí. Y bueno, si hay que trabajar con baja, con bajos salarios, no vamos a trabajar y la gente trabaja diez horas, diez horas al día.RLM: Pero ya pasaron seis años. Si tú pudieras retroceder el tiempo sabiendo las cosas que ya sabes, tú vuelves a elegir. México Maravedí.LP: Claro que volvería a escoger amigos. Para nosotros es muy. Es muy tradicional, sobretodo para el maracucho Ethernet. La referencia para migrar ha sido Estados Unidos. Estados Unidos. Por qué no irme Estados Unidos? Por qué no nos fuimos? Creo que la barrera del idioma. Yo hablo inglés casi un 70 por ciento o 60 por ciento. Mi esposa lo habla 40 por ciento. Entonces teníamos esa debilidad del idioma. Haré más que la migración formal. Estados Unidos, además de compleja, es costosísima.RLM: Pudé.LP: Un año de migración legal. La tarjeta migratoria que yo tengo vale 100 dólares. Nuestro grupo familiar con 500 dólares podía estar legalmente PAII.RLM: Tú me lo comentabas ayer y en cuánto tiempo te nacionaliza?LP: Y a partir del segundo año cumplido podemos hacerlo mexicano. Eso pronto lo vamos a hacer. Y creo que la cultura que nos une en torno al idioma, el el origen histórico, son pueblos muy parecidos, son pueblos hermanos. Como digo yo, lo decíamos ayer el Mar Caribe nace en Venezuela y termina en la costa sur de México.RLM: Mira, Leiv, déjame poner tu viaje en contexto. Cuando nosotros conversábamos anoche, tú me hablabas de cómo trabajaste en mercadeo en Venezuela, en restaurantes, te involucraste en política, etcétera. Muchas puertas se abrieron, otras se cerraron, tú me fié, lo anoté. Aquí te voy a citar entre comillas. Me dices que hay que impactar positivamente, que buscar la oportunidad de impactar positivamente. Tú has conseguido en tu emprendimiento en México o a través de tu emprendimiento en México, la oportunidad de impactar positivamente?LP: Definitivamente, sí.RLM: Por qué?LP: Esto. Una mirada muy personal que creo que vamos a nadar. Tú me advertiste. No hablemos de política, Heffernan, no hablemos de política. Pero qué cree? Somos políticos. Yo descubrí la cruda que no podía cambiar de la realidad de mi país. No la pude cambiar. Me deprimí, me sentí mal porque no puedo. Por más que quiera convencer a la gente que que hay que cambiar esta realidad política nacional, no puedo. Yo no puedo. Entonces empecé a hacer política, a ser micropolítica, micropolítica y empecé a hacer política en los entornos donde si yo podía transformar realidad, problema de economía de la vecindad, yo vivía estose bueno, terminaba ataño las paredes bien bonita de las áreas verdes y. Había una vigilancia que funcionaba e el colegio de mi hijo. Yo ahí la pasé muy bien, porque hay estar cerca de ello, vivir esa experiencia, ese estar ahí cerca e descubríamos cosa que estaban pasando e caso de bullying. Nos involucramos. Por qué? Porque mañana pueden tocar a mi hijo. El liderazgo tiene algunos componentes, como que son muy crudo. Manipular, persuadir, convencer. Mira esa frase, esas palabras tan poderosa manipular, convencer. Pero no impositivo, eh? Y ese ha sido nuestro norte y yo llegué a hacer lo mismo aquí. La gente puede ser un poco recelosa con el mexicano. Pues oye, pero por qué usted viene a. Bueno, pero yo creo que es positivo, yo creo que se pueden hacer cosas pusé por ejemplo aquí hay un una macula muy negativa y la en la sociedad mexicana que es el feminicidio, elRLM: Ni?LP: Filmo a su máxima expresión. Y eso tiene grado de autó nivel. Bueno, hasta que el machismo se convierta finar un feminismo chic, pero un emprendedor. Público objetivo. Mira mujer, y yo le vengo pequeño entonces. Y en esa, en esa dinámica, me empezaron a invitar a Mercadito 2, que era exclusivo de mujeres y yo era el único hombre. Bueno, por qué? Porque yo llegaba el dije yo, yo aporta más que la vez. Entonces yo decía bueno, si es que ven de pequeño, pero mira si hay una situación, yo, yo creo que esto se puede hacer así puedes seguir e ideas para América día del mercadito para llega la invito se me ganaba espacio que eran vedados para para hombre, por ejemplo. Esto se está impactando? Sí, claro. Dejamos de ir al mercadito y usamos promotores como Atencia, somos embajadores. Entonces la gente hoy me escribió una chica de que tiene un mercadito, que si quiero participar en nuestro modelo de negocio ya no es a ir al mercadito. Pero créeme que vamos a difundir tu mercadito desde Eimi de Deivid. Entonces estamos de un hit. La gente agradece. Hoy como dice, yo hablo de una hamburguesa, pero también mañana me encuentro cuvo un mezcal bien sabroso y lo pruebo y lo recomiendo. Le abro el Ajit e incluso estoy con mi radar abierto siempre en el sentido de que me abro el Facebook e Instagram y alguien pregunta mira, exíjase hace torta tortas decoradas para para fiesta. Ah bueno, la lista de amigas mías que hacen eso. Yo les etiqueto. No me cuesta nada hacerlo. Pero créeme que si se produce la venta lágri el agradecimiento de esa señora a ese señor. Eh, Esport es de por vida. Entonces mira, impactara, eh? Yo estudié cocina de cuando iba a estudiar cocina. Llegué a un lugar a comer antes de intranquilas y la señora bueno, me sirve. Era comida mexicana Dort una torta mexican sandwich. Como te Philibert, la torta del chavo del ocho. Bueno, la señora me oye hablar y tú me. No, yo soy. Soy venezolana. Ay, yo también. Y la ciudad tenía dieciochoRLM: E.LP: Años viviendo ahí.RLM: Ejje.LP: Y su negocio se llama El manantial del manantial. Y me dice llevaba a escena Where you have a un sábado? Y las vidita yo señora. Esta mañana su pasó hace 3 4 años. Este oye, pagaré pa todos los días. Vamos a Sare para su fruto. Muy sabroso. Y bueno. Volví a ir otro día, movian a desayunar y seguíamos practicando un poquito ni. Con el pasar de los tiempo he yome. Yo procuré hacer varias cosa con la comunidad venezolano, oh paisano, el tema negocio por debajo no decía bueno. Cuál es el propósito? Vamos a reunir a los venezolanos, vamos a conectar y bueno, gente se conoció y hoy día son buenas. Amio Gracias a que nosotros impulsamos encuentro venezolana, hicimos 4 encuentro 4 encuentros en los restaurantes de de los cuatro lugares el venezolano hay obviamente y en algunos se vinieron unos pequeños infelíz de la vía buenísmo operaciones alinearlo import y en ese lugar del manantial en el centro que la señora VI se hacia arepa. Hicimos el tercer encuentro. Fueron más de 60 venezolanos. Comieron arepa. Comieron de Kikyo y que CalSci hoy día el lugar se llama Il Manantial. El rinconcito venezolano y la señora Menos ganas de Shrike agarra.RLM: Etiquetes.LP: Hras es mi aliada. Ven a mi pequeño y hoy día tiene un menú venezolano junto al menú mexicano. En su lugar está super agradecido. Entonces si se simpata, si se hace cosa positiva, ajetreo, reconoce Ivana IVAM.RLM: Leo Hemos abusado bastante de tu tiempo el día de hoy. Me voy con la. Con la impresión de que el principal secreto de tu negocio y de tu operación es que no hay secretos. Eres un libro abierto. Comparte ese conocimiento con todo el mundo. Regalas ideas, como me decía más temprano. Pero para terminar, quería preguntarte si alguien te está escuchando en este momento. Está pensando ir a vivir a México? A lo mejor a San Luis Potosí. Qué te gustaría si esta persona?LP: Guau! Me gustaría decirle que deje el miedo donde lo pueda dejar. Que se. Que venga abierto con una mirada en positivo, que no traiga. Ese sentimiento de. De que nos han quitado todo, de que nos merecemos aquello que nos quitaron. Que no venga, que con un vaso y prometo aquí medio vacío que veía con el vaso medio lleno. Aquí lo vamos a apoyar, aquí lo vamos a recibí.RLM: Bueno, el Leo Pereyra en San Luis Potosí, México D. Leídos todos tus links, los vamos a tener en la descripción de este episodio. Agradecerte por habernos acompañado el día de hoy. Agradecerle a nuestra audiencia por su sintonía. Y con esto concluimos entonces el episodio ciento uno de los trabajos y los días disponible como siempre en los trabajos y los días puntocom. Redes sociales arroba, trabajos, días y desde Toronto les deseamos paz. Písalo.///ACERCA DE LOS TRABAJOS Y LOS DÍASLOS TRABAJOS Y LOS DÍAS es el podcast que conecta a los venezolanos globales. Todas las semanas conversamos con venezolanos que viven fuera de Venezuela, para que nos cuenten sus historias migratorias (sus procesos de adaptación, sus experiencias laborales y sus consejos para los próximos migrantes). Cada entrevista que hacemos es en una ciudad diferente del mundo. Nos puedes encontrar todos los martes en www.lostrabajosylosdias.com, y las principales aplicaciones de podcast, a partir de las 7:00 a.m. (Toronto).RSS Feed: https://feeds.transistor.fm/los-trabajos-y-los-diasDATOS DE GRABACIÓNAudio: MP3/Mono/44100Hz/128kbps Consola: Zoom Livetrack L-8 Micrófono: Shure SM7B Edición: Adobe Audition para MacOS Música: Lee Rosevere: Music for Podcasts 1, 3 y 4 Chris Hauge: Front Porch Blues Bleeker Street Blues John Deley: Beer Belly Blues
Čeští Bulánci si na přelomu tisíciletí podmanili školní učebny IVT a teď převálcovali všechny ostatní kampaně na Startovači. Jak na buclaté polštářky vzpomínáme my? A co nového je na poli velkolepých strategií od Paradoxu? A jak se nám líbil nový filmový Mortal Kombat?
durée : 00:01:45 - Les offres d'emploi France Bleu Normandie (Rouen)
This week, Stacey is joined by Karen Ginsbury to chat about the guidances available for the Quality Management System, the progression of regulatory guidance and expectations, whether or not they are helping or hindering the process, and how we can move forward with risk-based critical thinking. Karen is a pharmaceutical consultant who brings hands-on experience in designing and implementing environmental control programs within multinational pharmaceutical companies. She started her career in the industry by taking EM samples on the factory floor and brings her own unique perspective to her lively and instructive presentations. Ms. Ginsbury has over twenty years of industry-based experience in quality assurance and compliance and has published a book on compliance auditing for pharmaceutical manufacturers. Ms. Ginsbury is a past holder of IVT’s Presentation of the Year and Web Seminar Presenter of the Year and regularly lectures around the world on pharmaceutical topics. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
This week, Stacey is joined by Roberta Goode to talk about patient safety and how medical packaging is a key component of that. Stacey and Roberta discuss the nuts & bolts around “Selecting medical device packaging materials and sterilization methods to achieve appropriate sterility assurance levels and sterile barrier integrity throughout the labeled shelf life.” Resources from this episode: ISO 14971:2019 Medical devices – Application of risk management to medical devices - https://www.iso.org/standard/72704.html ISO 24971:2020 Medical devices – Guidance on the application of ISO 14971 - https://www.iso.org/standard/74437.html ISO 11607:2019 Packaging for terminally sterilized medical devices - https://www.iso.org/standard/70799.html ISO 13485:2016 Quality Management System for medical devices - https://www.iso.org/standard/59752.html 21 CFR 820 Quality System Regulation - https://www.govinfo.gov/app/details/CFR-2011-title21-vol8/CFR-2011-title21-vol8-part820 ASTM D4169 -16: Standard Practice for Performance Testing of Shipping Containers and System - https://www.astm.org/DATABASE.CART/HISTORICAL/D4169-09.htm ISTA 2a: Partial Simulation Performance Tests - https://ista.org/test_procedures.php Roberta Goode, Principal, Altrec Twice awarded IVT’s Speaker of the Year, Roberta Goode is the founder of Goode Compliance, where she created over 350 jobs, forming an astonishingly talented team of biomedical engineers. After she and her team remediated enforcement actions for 17 of the world’s 20 largest medical device manufacturers, Roberta turned her attention to sharing that wealth of accumulated knowledge. In 2018, she founded Altrec, LLC to lead paradigm-shifting programs including CDRH’s Benefit-Risk Collaborative Community, and to provide custom technical training and mentoring to the medical device industry. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
There is a saying that you can't see the forest through the trees. However, a visionary just might actually see the forest through the tree. In this podcast, Tim will share his skills and experiences in creating a successful log exporting company. Tim never saw himself as a leader. He sees himself as a take-charge type of guy. And in this podcast, you will hear that he does take charge of a situation, yet he also takes into account the concerns of others. So people indirectly looked to him for his leadership. Remember, you don't make yourself a leader, others do! BIO Tim Sprink is an owner and managing partner of International Veneer & Timber (IVT), a company specializing in hardwood log procurement with export sales around the globe. Tim has worked in the forest timber industry since earning a bachelor's degree in Forestry and Business from the University of Wisconsin Stevens Point in 1989. His career background was with private industry wood manufacturing companies until starting his own log exporting company, IVT in 2009. Today, Tim stays engaged in a growing company with a portfolio of foreign partnerships, domestic and international wood production facilities, site locations in four U.S. states and Germany along with hardwood log procurement in a vast portion of the Eastern U.S. The focus of IVT is to provide “wood to the world” and continues to grow and expand through the shipment of hardwood logs by container to direct manufacturers around the globe, including their partner companies in the US and Europe. Their success is driven by dedicated employees with a vast knowledge of wood science and natural wood manufacturing backgrounds in both lumber and veneer. With the great advancements in communication technology, IVT looks to be on a path of continued growth for years to come. The world's manufacturing may be in all corners of the globe but the available wood resource here in the US leads the way in the supply chain. Recently, Tim's son William has joined the company and the two hope to see the success and dedication of IVT carry on for future decades.
This week, Stacey is joined by Dr. Willis Thomas to talk about reducing human error in pharmaceutical manufacturing. Efforts to investigate root causes aretypically incomplete or poorly performed. Most regulatory authorities no longer accept human error as a justifiable cause of errors, making it necessary, now more than ever, to ensure proper systems are in place, employees are thoroughly trained, procedures are being followed and equipment is not deficient in any way to reduce or preventhuman error. Dr. Thomas has worked for large corporations and academic institutions in the areas of human resources, learning and development, quality assurance, project management, sales and marketing, measurement and evaluation, andoperations. He has been in senior management for life sciences companies for the past 15 years. Dr. Thomas, in his current full-time role, is involved in preventing and reducing human error from an HR perspective. He is also adjunct faculty at the Lake Forest Graduate School of Management, International Institute for Learning and Institute of Validation Technology. Dr. Thomas’ publications have received global recognition from associations such as the Project Management Institute (PMI) where he received the Cleland Award for “The Basics of Project Evaluation and LessonsLearned.” This book was an 8-year effort that enhanced the framework for the evaluation of projects using the PMBOK® Guide. He has been a featured speaker on an international basis and has received the Apex Publication Excellence Awardfor implementing useful tools for project management, evaluation and training, and has been a member of the speaking faculty for IVT since 2005 and responsible for US Human Resources for PQE Group, Inc. In addition, he holds the certified performance technologist certification (CPT) from ispi.org.Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
Intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) both improve outcomes for patients with acute ischemic stroke. Jeffrey L. Saver, MD, director of UCLA’s Comprehensive Stroke and Vascular Neurology Program and a JAMA Associate Editor, discusses 2 randomized trials comparing outcomes for stroke patients treated with IVT prior to EVT vs EVT alone. Related Article: Intravenous Thrombolysis Before Endovascular Thrombectomy for Acute Ischemic Stroke
This week, Stacey is joined once again by Dr. Tim Sandle. On this episode Stacey will speak with Dr. Tim Sandle about the potential risks to cleanrooms and laboratories posed by some of today’s fads.Links:Microbial Contamination Concerns Linked With E-Cigarettes And Vaping Products: https://www.ivtnetwork.com/article/microbial-contamination-concerns-linked-e-cigarettes-and-vaping-products Alternative Risks To Cleanrooms Presented By People: Tattoos, Piercings, Sunbeds: http://www.ivtnetwork.com/article/alternative-risks-cleanrooms-presented-people-tattoos-piercings-sunbeds FDA (2019) Think Before You Ink: Are Tattoos Safe?: https://www.fda.gov/consumers/consumer-updates/think-you-ink-are-tattoos-safe Dr. Tim Sandle Ph.D., is a pharmaceutical microbiologist, with over 25 years of experience, who has worked for different healthcare organizations and pharmaceutical companies, in microbiology and broader quality roles. Dr. Sandle currently works for an international sterile products manufacturer and he is additionally a visiting tutor with the University of Manchester (lecturing in pharmaceutical microbiology), a committee member of the Pharmaceutical Microbiology Interest Group (Pharmig), and a supporter of several other societies relating to pharmaceuticals and healthcare, including IVT. Dr. Sandle also serves on a number of advisory committees and standards boards. Dr. Sandle has written or edited over 25 books, more than 100 book chapters, over 125 peer reviewed papers and some 400 technical articles. Dr. Sandle is a regular presenter at conferences and webinars, having delivered over 150 presentations.Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
OVERVIEW: Jason A. Duprat, Entrepreneur, Healthcare Practitioner and Host of the Healthcare Entrepreneur Academy podcast talks about how occasionally saying no to new opportunities can help you achieve business success. EPISODE HIGHLIGHTS: Jason explains why deciding on what not to do is as important as deciding on what to do. Saying yes is an easy thing to do and it’s a trap. It’s similar to the shiny object syndrome. Jason recommends sitting on a potential opportunity for 1-2 weeks before making a final decision. Let it marinate. If you’re still enthusiastic about it, then pursue it. Recently, Jason has been approached to consider new product and service line ideas, speaking opportunities, franchise partnerships and 1:1 coaching. He’s decided to focus on his live Q&A for the Ketamine and IVT academies and to launch a new Course Creator Academy. He also agreed to speak virtually at his alma mater, University of Central Florida’s School of Nursing to talk about what it’s like being a CRNA and business owner. . Mastering and improving your craft as a business is important before venturing out. 3 KEY POINTS: Opportunity cost is the cost of choosing one opportunity over the other. Making smart business decisions can foster better opportunities with greater gain. Focus on doing one or two things exceptionally well as a business. TWEETABLE QUOTES: “Being the jack-of-all-trades is the surefire way to be the master of none.” - Jason Duprat “Once you’re in business, you can’t say yes to everything.” - Jason Duprat RESOURCES MENTIONED: Healthcare Entrepreneur Academy for Digital Businesses - https://www.facebook.com/groups/HeathcareEntrepreneurAcademy/ Healthcare Entrepreneur Academy for Brick & Mortar Businesses - https://www.facebook.com/groups/HealthcareEntrepreneurAcademyBrickandMortar/ #HealthcareEntrepreneurAcademy #HealthcareBoss #healthcare #entrepreneur #entrepreneurship #justsayno #businessdecisions #businesssuccess
What is John Deere CommandPRO? CommandPRO is an ergonomic joystick option in the new IVT tractors. What that means is that CommandPRO is not a new transmission. It is a new way to control the current transmission that we already have. While it’s a fairly new – and unique way – to control a tractor, it’s already proving to be beneficial for customers. Tune in and listen to the advantages of the CommandPro joystick – and how it might be beneficial in your tractor. ----- Visit www.rdoequipment.com/more/resources/podcasts to find and view this episode's transcript. ----- Missed an episode? Get caught up by visiting the Episode Archive on our website: www.rdoequipment.com/more/resources/podcasts ----- Each month, we share the latest in agriculture technology. Don’t miss an episode by subscribing to our podcast on iTunes, SoundCloud, or anywhere you listen to podcasts. Have a story idea or a precision ag topic we should highlight? Connect with us on social media: Instagram | Facebook | YouTube | Twitter and connect with podcast host, Tony Kramer on Twitter at: (at)RDOTonyK. ---- Visit us at rdoequipment.com to find all episodes of the podcast, learn more about Precision Agriculture solutions from RDO's team of experts, or browse new and used farm equipment.
Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2020.08.23.262055v1?rss=1 Authors: Alnasir, D. J. J., Shanahan, H. P. Abstract: Given the wide variability in the quality of NGS data submitted to public repositories, it is essential to identify methods that can perform quality control on these datasets when additional quality control data, such as mean tile data, is missing. This is particularly important because such datasets are routinely deposited in public archives that now store data at an unprecedented scale. In this paper, we show that correlating counts of reads corresponding to pairs of motifs separated over specific distances on individual exons corresponds to mean tile data in the datasets we analysed, and can therefore be used when mean tile data is not available. As test datasets we use the H. sapiens IVT (in-vitro transcribed) dataset of Lahens et al., and a D. melanogaster dataset comprising wild and mutant types from Aerts et al. The intra-exon motif correlations as a function of both GC content parameters are much higher in the IVT-Plasmids mRNA selection free RNA-Seq sample (control) than in the other RNA-Seq samples that did undergo mRNA selection: both ribosomal depletion (IVT-Only) and PolyA selection (IVT-polyA, wild-type, and mutant). There is considerable degradation of similar correlations in the mutant samples from the D. melanogaster dataset. This matches with the available mean tile data that has been gathered for these datasets. We observe that extremely low correlations are indicative of bias of technical origin, such as flowcell errors. Copy rights belong to original authors. Visit the link for more info
This week, Stacey is joined by Holly Baldwin, Quality Validation CSV, Sanofi Pasteur. Stacey and Holly discuss the most important questions when talking about security and data integrity when dealing with third-party suppliers. Top 10 Questions: Can I perform a vendor audit virtually or in-person?What kind of intrusion detection system does SaaS vendor use?Where is the primary and secondary (disaster recovery) data centers? Are either in a co-location site?Where and when is Quality personnel in the validation process? Pre-approval, post-approval, change management?How often does the SaaS vendor audit their offshore resources or third-party companies? What are the consequences if offshore company fails an audit?Does SaaS vendor have documentation on their APIs (Application Programming Interface) , including any existing application assessment results and reports that demonstrate security best practices and audit results?If your company, as Data Controller, needs to notify supervisory authority in 72 hours; what is the timeframe in which SaaS vendor will notify your company?How will you be notified and how long before the implementation of the releases, upgrades and patches is the notification?What is the SaaS vendor’s definition of an emergency change and when is Quality involved?For an unplanned system outage, when will you be notified? How will you be notified? When will you have access to SaaS vendor’s Postmortem and/or CAPA created for unplanned outage?Holly Baldwin has more than two decades in the Life Science Industry, primarily as a Computer System Validation/Quality authority and resource. She is also an expert in 21 CFR Part 11 Assessments, System Development Lifecycle documentation, audit preparedness and System Validation. Holly has been a speaker and trainer, sharing her expertise globally through organizations such as IVT, ISPE, American Society of Quality, China Medical Device association and for the China FDA now called the National Medical Products Administration. More detailed presentation at IVT’s 26th Annual Validation Week October 28-30, 2020 in San Diego2017 Q&A addendum to 21 CFR Part 11 (Clinical Investigations): https://www.fda.gov/files/drugs/published/Use-of-Electronic-Records-and-Electronic-Signatures-in-Clinical-Investigations-Under-21-CFR-Part-11-%E2%80%93.pdfMHRA Rules and Guidance for Pharmaceutical Manufactures and Distributors, EU Guidance on GMP, Section 2, Part 1, subsection 7: Outsourced Activities EU GMP Annex 11, Section 3: Suppliers and Service Providers: https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-4/annex11_01-2011_en.pdfFDA Data Integrity and Compliance With Drug cGMP, Dec 2018; http://www.gmp-compliance.org/guidemgr/files/UCM495891.PDFWHO TRS 996, Annex 5; http://www.gmp-compliance.org/guidemgr/files/WHO_TRS_996_ANNEX05.PDFFDA 21 CFR Part 820.50: “Each manufacturer shall evaluate and select potential suppliers, contractors, and consultants on the basis of their ability to meet specified requirements, including quality requirements”GDPR: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/ and https://gdpr.eu/data-privacy/ Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
All new 2020 Hyundai Creta has set a benchmark of booking 10000 units on its first 10 days of launch. Hyundai unveiled the beast Hyundai Creta on the Auto Expo 2020. The entry of all-new Hyundai Creta facelift makes a buzz among all Automobile enthusiasts and wannabe customers. The prebooking of Hyundai Creta started on 2nd march with a booking amount of 25000. It's said that the next-generation Hyundai Creta will come with massive cosmetic updates along with power upgrades. The BS6 Hyundai Creta comes in Diesel and Petrol variant sharing their engines with Kia Seltos. By seeing the 2020 Hyundai Creta it is clear that the machine will have direct competition with other SUVs. As a result, the competitor for Creta includes Kia Seltos, Tata Harrier, MG Hector, and the Renault Duster. Hyundai Creta will launch in five sub-variants E, EX, S, SX, and SX (Option). While, Other three motor options 1.5-litre petrol, 1.5-litre VGT diesel and the 1.4-litre Turbo GDI petrol. The machine will include 6-speed manual transmission across the range. Adding to the specs 1.5-litre diesel engine for an optional torque converter. The 1.4-litre turbo petrol for 7-speed DCT and 1.5 litre motor for iVT automatic. In other words, 2020 Hyundai Creta comes with a huge package of cosmetics updates. In addition, 3D grille flanked by the huge LED headlamps with new boomerang inspired DRLs adds a catchy look to the front. Adding the new 17inch diamond cut alloys to side gives an appealing feel to the machine. --- Support this podcast: https://anchor.fm/latestnewssuno/support
Voices in Validation Why is it important to contribute to industry publications? On this episode, Stacey Bruzzese is joined by Paul Pluta, Editor-In-Chief of the Journals of Validation Technologies and GXP Compliance. Stacey and Paul talk about the need for more contributors to industry publications, not only for industry growth but personal growth as well. Why role did IVT originally serve?How to network between industry personnel and consultants?The differences between JVT and GXPWhat are some of the most impactful topics covered in JVT and GXP?How does IVT stay relevant in an ever changing landscape?Why does contributing to IVT help personal growth? IVT has been around for more than 20-years. As its name suggests the purpose of IVT has always been to provide learning, networking and industry growth opportunities for professionals in the validation and compliance space. Over the years many things within the industry have changed, but IVT continues to work to expand the knowledge base for those working in FDA Regulated industries. Today we are going to chat with Paul Pluta, Editor-In-Chief of the Journals of Validation Technologies and GXP Compliance.Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
Stacey Bruzzese welcomes Roberta Goode back to the show. Today, Stacey and Roberta will be covering the essentials of designing for manufacturability. Roberta details the 8 essentials of DFMWhy is Designing for Manufacturability important for medical device manufacturers?Does standardization of materials help shorten the product development cycle?What’s the next step after determining the practical part count?What is Poka-Yoke?What other points should be considered when scaling up manufacturing? DFMA ReferencesAssembly Automation and Product DesignG. Boothroyd, Marcell Dekker, Inc. 1992Product Design for Manufacture and AssemblyG. Boothroyd and P. Dewhurst, G. Boothroyd Dewhurst, Inc. 1989Marcell Dekker, Inc. 1994Design and Analysis of Manufacturing SystemsProf. Rajan Suri University of Wisconsin 1995Product Design for Assembly: The Methodology AppliedG. Lewis and H. ConnellySimultaneous Engineering Study of Phase II Injector Assembly LineGiddings & Lewis 1997Design for Manufacturing Society of Manufacturing Engineers,(VIDEO)Introduction to Design for (Cost Effective) Assembly and Manufacturing DavidSteinstra, Rose-Hulman, 2015IVT’s Medical Device Handbook: http://www.ivtnetwork.com/article/medical-device-validation-handbookTwice awarded IVT’s Speaker of the Year, Roberta Goode is the founder of Goode Compliance, where she created over 350 jobs, forming an astonishingly talented team of biomedical engineers. After she and her team remediated enforcement actions for 17 of the world’s 20 largest medical device manufacturers, Roberta turned her attention to sharing that wealth of accumulated knowledge. In 2018, she founded Altrec, LLC to lead paradigm-shifting programs including CDRH’s Benefit-Risk Collaborative Community, and to provide custom technical training and mentoring to the medical device industry. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
On today’s episode, Stacey Bruzzese presents a recording with clips from a mock audit. The mock audit was recorded at a recent IVT conference and was facilitated by Alyce Deegan, Vice President of Data Integrity at Compliance Path LLC.What factors impede a zero-findings review?How can I prepare for an audit review?What can I expect from the inspectors?What kinds of questions do they ask?What is the best way to answer these questions?These questions and more are covered during the mock audit. This episode has a lot of useful tips for anyone preparing for an audit. For additional information about Alyce’s presentation got to http://www.ivtnetwork.com/article/data-integrity-mock-inspection-mitigating-risk Alyce Deegan has over 20 years of experience in Pharmaceutical, Medical Device and Gene Therapy industries. Most recently, Alyce was the IT Director of Manufacturing and GxP Lab Systems at Juno Therapeutics a CAR-T Cell Therapy Manufacturing Plant located in Bothell, WA. Throughout Alyce’s career she has held leadership positions in Quality, Validation and IT at companies such as Pfizer, Biogen and ThermoFisher. Throughout her career she has built and continues to build "Unified Compliance Models" within companies to address the ever changing regulations and has been directly involved with multiple agency inspections throughout the years.Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
On today’s episode, Stacey Bruzzese welcomes Roberta Good, the founder of Goode Compliance for the final part of our 3-part series. Stacey and Roberta review the steps necessary for a successful product launch.Stacey and Roberta cover a variety of topics:Roberta outlines the steps associated with the final phase prior to product launchDo you still need to be thinking about verification and validation?Is this the right time to be thinking about marketing and branding?What data are you looking for with a product release into Limited Test Markets or Clinical Trial Sites?How thorough should your completed technical documentation need to be prior to full product launch?Roberta reviews all that is needed to fully launch the productWhat does the post-market surveillance entail and how long does it take to complete?What are the best practices for capturing this data?How does cloud-based computing affect the requirement for maintaining post-market data integrity?What kinds of problems could occur after product launch?Roberta talks about how listeners can make use of the information presented in this 3-part seriesThe following links have useful companion information for this episode:Post-Market Requirements:https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/postmarket-requirements-devicesIVT’s Medical Device Validation Handbook:http://www.ivtnetwork.com/article/medical-device-validation-handbookTwice awarded IVT’s Speaker of the Year, Roberta Goode is the founder of Goode Compliance, where she created over 350 jobs, forming an astonishingly talented team of biomedical engineers. After she and her team remediated enforcement actions for 17 of the world’s 20 largest medical device manufacturers, Roberta turned her attention to sharing that wealth of accumulated knowledge. In 2018, she founded Altrec, LLC to lead paradigm-shifting programs including CDRH’s Benefit-Risk Collaborative Community, and to provide custom technical training and mentoring to the medical device industry. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
On today’s episode, Stacey Bruzzese welcomes Roberta Good, the founder of Goode Compliance for the second part of our 3-part series. Stacey and Roberta dive into the design and development of medical devices.Stacey and Roberta cover a variety of topics:What are the tasks that make up the design and development phase?Do people develop prototypes and when is the right time to do that?How is human factors design applied to engineering medical device?What records and documents need to be considered during the design and development?How do Design for Manufacturing and Six Sigma get incorporated?Roberta highlights the typical challenges when planning for packaging, labeling and product deliveryWhat’s the difference between validation and verification?How does managing compliance through the risk management cycle help ensure quality and safety are built into the product?How do labeling requirements affect the expiration date?The following links have useful companion information for this episode:FDA Labeling (General)https://www.fda.gov/medical-devices/overview-device-regulation/device-labelingUDI System:https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/unique-device-identification-system-udi-systemInvestigational Device Exceptions:https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?CFRPart=812Test method validation article on IVT Network:http://www.ivtnetwork.com/article/test-method-validation-medical-deviceshttp://www.ivtnetwork.com/article/method-validation-medical-devices-regulatory-guidanceMethod Validation Guidelines:https://www.fda.gov/science-research/field-science-and-laboratories/method-validation-guidelinesDesign Controls:https://ubm.box.com/s/gwkqg1wweccrjs683bjp28x8zsu7qnhc Twice awarded IVT’s Speaker of the Year, Roberta Goode is the founder of Goode Compliance, where she created over 350 jobs, forming an astonishingly talented team of biomedical engineers. After she and her team remediated enforcement actions for 17 of the world’s 20 largest medical device manufacturers, Roberta turned her attention to sharing that wealth of accumulated knowledge. In 2018, she founded Altrec, LLC to lead paradigm-shifting programs including CDRH’s Benefit-Risk Collaborative Community, and to provide custom technical training and mentoring to the medical device industry. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
On today’s episode, Stacey Bruzzese welcomes Roberta Goode, the founder of Goode Compliance. Stacey and Roberta talk about the planning stage to get your medical device to market.Stacey and Roberta cover a variety of topics:Roberta start by outlining the steps covered in this first episodeHow do we ensure we’re building a product the meets a clinical need?What goes into a product launch plan?What are the considerations if you plan to introduce the product outside of the United Sates?Why do investors need to be aware of how regulatory bodies classify your product?How does the business plan for a medical device differ from other products?What should be included in an initial risk management plan?What are the key elements to streamline the funding process?Should I try to fund the full project or just the first few phases/milestones?The following links have useful companion information for this episode:EU Medical Device Standards: http://eumdr.com/Risk management Standards: ISO 14971 - https://www.emergobyul.com/services/worldwide/iso-14971-consultingEU Directory: https://ubm.box.com/s/2nqk6h7m0r69gb8bp4a3gvx7j16zlm9pFDA: CDRH Guidance: https://www.fda.gov/medical-devices/guidance-documents-medical-devices-and-radiation-emitting-products/cdrh-proposed-guidance-developmentSearchable product classification: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfmFDA Good Guidance Practices: https://ubm.box.com/s/ejdhq3ta2n8j0jzaod0bb3qjm3bre6pcFunding ResourcesFDA 510(k) Premarket Submission https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfmTwice awarded IVT’s Speaker of the Year, Roberta Goode is the founder of Goode Compliance, where she created over 350 jobs, forming an astonishingly talented team of biomedical engineers. After she and her team remediated enforcement actions for 17 of the world’s 20 largest medical device manufacturers, Roberta turned her attention to sharing that wealth of accumulated knowledge. In 2018, she founded Altrec, LLC to lead paradigm-shifting programs including CDRH’s Benefit-Risk Collaborative Community, and to provide custom technical training and mentoring to the medical device industry. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
During this episode of “Marketing Today,” host Alan Hart interviews Dr. Augustine Fou, who is an industry-recognized thought leader in digital strategy and integrated marketing and an ad fraud researcher and auditor for several companies and publishers around the world. He's had 20 years of management consulting experience creating and optimizing marketing strategies across traditional and digital channels. Fou shares the many myths and misconceptions that marketers have about ad fraud. We tackle some questions like: If you have ad fraud detection, are you safe? Shouldn't I be immune if I'm only paying for performance? And, why don't we hear more from industry trade groups? Fou helps to define and categorize ad fraud. He walks us through the various ways that fraud occurs. He shares the limited capability of bot detection companies, which are just looking for invalid traffic (IVT), and how the algorithms are not tuned for anything else. Marketers need to know that whatever you are paying on [click, conversion, etc.] is the specific thing the "bad guys" are going to fake. Fou gives us some fantastic tips on how to combat the pervasive fraud throughout the industry. Highlights from this week’s “Marketing Today”: How we define Ad Fraud. 02:41 Categorization of Fraud 05:11 Limitations of Bot-detection companies and quick ways to detect other types of fraud. 08:43 Fou's thoughts on estimates of fraud occurring currently in the industry. 10:38 A discussion on "Asymmetric Warfare." 13:21 Question 1: I've got fraud detection in place, am I not safe? 17:33 Question 2: I only pay for performance, so I must be immune to ad fraud. 21:39 An interesting study looking across 800 mobile exchanges. 22:46 An Example: the Uber lawsuit. 23:49 The key lesson for marketers to know and examples of loopholes. 24:39 The importance of looking at your data and not relying on industry trades alone. 29:03 A discussion on certifications and accreditations. 30:37 The importance of auditing. 31:54 What are the multi-million dollar detection companies not seeing, and why? 35:05 What should marketers be doing to combat fraud? 40:54 What does the world look like without ad fraud? 44:39 Resources Mentioned: Episode 73 with Dr. Augustine Fou Uber lawsuit against Ad Nets and Publishers Affiliate fraud from Ad Blocker extensions ANA & White Ops report Example of in-app fraud from VPN apps Background on Ad Fraud with Augustine Fou from The CMO Club Support the show.
Au programme : Maud Alloul fondatrice dePoupée Odette, Anne-Sophie Bérard commissaires de l’exposition Causes toujours du hashtag à la rueau Maif Social club, Laurence Poitou pour son livre jeunesse La forêt de Phénoménoauxéditions L.C, Emmanuelle Laborit et Jennifer Lesage-David codirectrices d’International Visual Théâtre IVT, Cinéma : Angry Birds : copains comme cochons, Livre : La petite fille qui nettoie le métro de Françoise Février et Valéria Aussibal aux éditions L.C. Que faire des mômes, votre magazine 100% famille, le samedi à 14h sur Radio Air Show et nos radios partenaires. A écouter aussi en podcast sur www.quefairedesmomes.fr et toutes le plateformes audio. Cette émission vous ai proposé en partenariat avec Etoile de rêve. Laissez-vous séduire par Etoile de Rêve Animations et ses 15 ans années d’expérience, d’écoute avec les enfants et les parents.
Episode 10 - Laura - Blog Des Signes et des paillettes. A l'occasion du #SigneChallenge initié par Sophie Vouzelaud (1ère Dauphine de Miss France 2007), j'ai eu le plaisir de recevoir la blogueuse LoOoraaa. Une jeune femme de 29 ans qui exerce la profession d'interface de communication en langue des signes. Depuis plusieurs semaines elle réalise des "stories" de "chants signés". Tout de suite, j'ai eu envie d'aller à sa rencontre et d'en apprendre davantage sur la langue des signes et d'échanger avec elle sur la surdité par la prisme des réseaux sociaux. Aujourd'hui, il faut savoir que, l’Organisation mondiale de la Santé (OMS) estime que 466 millions de personnes souffrent de déficience auditive incapacitante dans le monde, dont 34 millions d'enfants. Pour la France, l'Inserm estime que la surdité affecte 6 % des 15-24 ans, et plus de 65 % des 65 ans et plus. Toujours selon le même organisme, chaque année, près d'un millier d'enfants naissent atteints de surdité dans le pays. Laura souhaite sensibiliser sa communauté à surdité et nous apprendre au quotidien des signes afin de pouvoir nous initier à la langue des signes. Si ce podcast vous plaît, vous pouvez le noter sur Itunes à l'aide des étoiles, ou n'hésitez pas à me laisser un commentaire :). Laura : https://www.instagram.com/lo0oraaa/ Carine : https://www.instagram.com/carine_parisguinguette/ Révolution Influence : https://www.instagram.com/carine_parisguinguette/ Camille : https://www.instagram.com/ch_171/ LSF Combat : https://www.instagram.com/lsfcombat/ IVT théâtre : http://ivt.fr/ Influenceurs suivis par Laura : Daphné Moreau : https://www.instagram.com/daphnemodeandthecity/?hl=fr Carnet Prune : https://www.instagram.com/daphnemodeandthecity/?hl=fr Lapalatine : https://www.instagram.com/daphnemodeandthecity/?hl=fr Swannandtheberries : https://www.instagram.com/swannandtheberries/?hl=fr
Dr Paul Wang: Welcome to the monthly podcast, On the Beat for Circulation: Arrhythmia, and Electrophysiology. I'm Dr Paul Wang, editor in chief, with some of the key highlights for this month's issue. In our first paper, Pasquale Vergara and Associates develop a predictive risk score to assess the outcome of ventricular tachycardia ablation creating what they call the IVT score. The authors examined 16 demographics, clinical, and procedural related variables in 1,251 patients. They used a technique called survival tree analysis, which uses a recursive partitioning algorithm to find relationships among variables. They then compared the survival time and time to VT recurrence in groups derived from survival tree analysis using a log rank test. A random forest analysis was then run to extract a variable importance index and internally validate the survival tree models. They found that the left ventricular ejection fraction, ICD, or CRT device, previous ablation were the best predictors of ventricular tachycardia recurrence. While left ventricular ejection fraction, previous ablation, electrical storm was identified as best predictors of mortality. They identified a high-risk group in which 65% of patients survived and 52.1% were free from VT occurrence. A medium risk group in which 84% survived and 72% were free of VT, and a low risk group in which 97% of patients survived and 88% were free of VT recurrence. In our next paper, Alwin Zweerink and Associates examined the relationship between cure restoration and left ventricular dimension as predictors of outcomes after cardiac re-synchronization therapy. The present study evaluates the effect of normalization of the cure restoration to left ventricular dimension on the prediction of survival after CRT implantation. They study 250 heart failure patients with left ventricular ejection fraction less than or equal to 35% in cure restoration greater than or equal to 120 milliseconds, and they normalize the cure restoration based on the left ventricular dimension. The left ventricular and diastolic volumes obtained using cardiac magnetic resonance imaging. Before CRT implantation were used for cure restoration normalization. During a follow up period of 3.9 years, 79 patients or 32% reached the primary end point, which combined death, left ventricular assist device, or heart transplantation. Using univariable cox regression they found that although the unadjusted cure restoration was unrelated to CRT outcome, P=0.116, the normalized cure restoration was a strong predictor of survival. Hazard ratio 0.81 per 0.1 milliseconds per milliliter, P=0.008. Women demonstrated higher normalized cure restorations than men, 0.2 milliseconds per milliliter, versus 0.55 millisecond per milliliter, P=0.003, and showed better survival after CRT. Hazard ratio 0.52 with P=0.018. In our next study, Markus Linhart and Associates examined the impact of catheter ablation gaps on outcomes after first pulmonary vein isolation. Using delayed gadolinium enhancement cardiac magnetic resonance imaging three months after radio frequency ablation, they found that in 94 patients, 62% with paroxysmal atrial fibrillation, that there was a mean number of 5.4 gaps per patients. Atrial fibrillation recurrence within the first year of ablation was observed in 21 patients with paroxysmal AF, 36%, and 19 patients with persistent atrial fibrillation, 53%. In the unit variate analysis, CHA2DS2 -VASc score, afib type and relative gap length were predictors of recurrence. In multi-variant analysis, only relative gap length was significantly associated with recurrence. Hazard ratio 1.16 per each 10% of the gap. In our next paper, Antonius van Stipdonk, Iris ter Horst, Marielle Kloosterman, Alexander Maass, Kevin Vernooy and Associates examined the value of cueres area compared to that of cure restoration and morphology as predictors of clinical echocardiographical outcomes following cardiac resynchronization therapy. The authors found that in 1,492 cardiac resynchronization therapy patients during a mean follow up of 3.4 years, 32% of patients reached the combined prior endpoint of all-cause mortality, cardiac transplantation, and left ventricular assist device implantation. The authors found that cure restoration identified patients that did not experience the primary endpoint better than QRS morphology in cure restoration area under the curve 0.61 versus 0.55 and 0.51, P value less than 0.001. They also found that QRS area identifies patients with echocardiograph remodeling in response to CRT better than the QRS morphology and duration, area under the curve 0.69 versus 0.58 and 0.58, P < 0.001. In addition, QRS area was the only independent electrocardiographic determine associated with the primary endpoint. Hazard ratio 0.50 QRS area retained its significant associative outcomes in both patients with and without left bundle branch block in cure restoration greater than 150 milliseconds. Our next paper is a research letter in which Brian Hansen, Ning Li and Associates report the first in-vivo use in a canine model of near infrared optical mapping. In-vivo optical action potential showed a sharp upstroke that corresponded with atrial activation at a neighboring electrode. Imaging during in-vivo atrial fibrillation episodes showed re-entrant activation around the sinoatrial region minimizing the effect of motion artifact in validation in structurally remodeled hearts would be the next steps for this promising technology. Also, in a research letter, James Hummel and Associates studied whether infrared thermography over a six-centimeter segment can be effectively used to guide atrial fibrillation ablation. Thermography continuously sampled 7,680 points over a full 360 degree and refreshed every second. Ablation was guided by 3D mapping and performed using a 3.5-millimeter irrigated tip. Power was reduced to 25-watts on the left atrial posterior wall and could be further reduced to 20-watts in areas where there was excessive esophageal temperature rise. Esophageal temperature cutoff for radio frequency power delivery was initially 46 degrees and progressively raised to 50 degrees throughout the study at the discretion of the operators. All patients underwent upper endoscopy on post-ablation day one to three by a gastroenterologist blinded to temperature data. Thirty-four patients were studied, 94% of patients had luminal esophageal temperatures above 40 degrees during ablation of the posterior wall. Thermal events with Tmex greater than 40 degrees occurred commonly averaging 6.5 seconds during a procedure. On average, 231 seconds of ablation were performed with Tmex greater than 40 degrees centigrade. However, the excursions above threshold cutoff Tmex greater than 50 degrees centigrade lasted only 1.5 seconds per patient. In total, 38% of patients, 13 out of 34 had at least one energy delivery discontinued for exceeding threshold. This occurred eight out of 17 times or 47% when the cutoff was 46 degrees centigrade and five out of 15, or 33% at 50 degrees centigrade. On endoscopy one patient, 3% had thermal injury related to malpositioning of the infrared thermal probe below the region of ablation. Another patient had three lesions spanning 16 centimeters likely related to mechanical trauma with probe placement. The authors concluded that esophageal injury does not seem to occur with esophageal temperatures less than 50 degrees centigrade using thermography. In a review paper in this issue, Bruce Lerman and Associates discussed adenosine as a potent but underutilized tool that is useful in clarifying in clinical diagnoses of arrhythmias. Adenosine mediates its electrophysiological effect through binding to the cell surface adenosine receptor A1R, a G-protein receptor. In the sinoatrial node, activation of IKADO by adenosine results in negative chronotrophy, a manifestation of its modern effects on membrane hyperpolarization and a decrease in the rate of phase four depolarization. Adenosine also mediates its cellular effects in atrial and AV nodal cells predominantly through activation of IKADO. In atrial myocytes, this results in a shortening of action potential duration in decrease in refractoriness. By shortening the atrial refractory period without changing atrial conduction velocity, the wavelength of activation is shortened. A mechanism through which adenosine can facilitate induction of atrial fibrillation. Adenosine also exerts an antiadrenergic effect in atrial tissue, reducing cyclic AMP stimulated levels of L-type calcium current. Adenosine has a negative dromotropic effect on the AV node. The most potent effects of adenosine are expressed in N-cells. In these cells, as well as AN-cells, adenosine decreases excitability by reducing the plateau amplitude in abbreviating action potential duration. In addition, it reduces the rate of rise of the upstroke of N-cells. NH-cells are insensitive to adenosine. Adenosine terminates permanent form of junctional recipriatachycardia in the retrograde accessory pathway limb. The mechanism in which adenosine causes block in the retrograde decremental accessory pathway is thought to be by hyper-polarizing the pathways membrane potential. Adenosine has been helpful in illuminating differences in etiology of decremental conduction in three predominant antigrid decremental accessory pathways. Atrial ventricular pathways, atrial physicular pathways, and nodoventricular pathways. Adenosine can elicit dormant conduction defined as a restoration of excitability by adenosine in tissue rendered inexcitable by partial cellular damage secondary to ablation. There are three discrete clinical scenarios in which adenosine reveals dormant conduction - after pulmonary vein isolation, after achieving bi-directional cavo-tricuspid isthmus block, and following successful ablation of antegrade and retrograde accessory potential. Adenosine, through activation of IKADO hyperpolarizing these cells so that the sodium channels are reactivated, restoring excitability. Adenosine, though its inhibition of cyclic ANP mediated increases in the slow inward calcium current and its downstream inhibitory effects on SR-calcium release, INCX and ITI, terminates focal arrhythmias caused by triggered activity. The response to adenosine may indicate triggered activity where termination occurs versus insensitivity of localized re-entry to adenosine. That's it for this month, we hope that you will find The Journal to be the go-to place for everyone interested in the field. See you next time.
Another 1000 Ripple Effects author, Deborah Howcroft-Miles was introduced to yoga in her early twenties. Back then she thought of it as a form of physical exercise. Fast forward more than a decade and she has used yoga and other mindfulness meditation techniques to assist through the emotional stress of IVT, miscarriage and the impending thorugh of never becoming a mother. Once she made peace with that thought that mothering and nurturing takes many forms she found herself using mindfulness to help through Breast Cancer. Deborah has combined her knowledge to now be helping people move through their own physical and emotional pain.
Episode 38 is part of the Spring 2017 issue! Read ahead by picking up your copy here: http://www.glittership.com/buy/ She Shines Like a Moon by Pear Nuallak It's cold in London but you glow with warmth. You travel limbless and limned from your core, throat crossed with black silk just as it was in your first days. Yes, you were naked then, washed clean in monsoons, dried by storm winds. When was the last time your sly hunt was wreathed in rice flowers? Do you recall how dtaan-tree fronds stroked your secret self as you rose, star-bound? Hello! Welcome to GlitterShip episode 40 for May 23, 2017. This is your host, Keffy, and I'm super excited to be sharing these stories with you. Today we have two reprints, "She Shines Like A Moon" by Pear Nuallak and "The Simplest Equation" by Nicky Drayden. Pear Nuallak is a writer and illustrator whose work has appeared in Interfictions, Unlikely Academia, and The Future Fire. Born in London and raised by Bangkokian artists, they studied History of Art jointly at SOAS and UCL, specializing in Thai art. Thai and British recipes appear semi-regularly on their food blog, The Furious Pear Pie, and they have an upcoming illustration this summer in Lackington's magazine. Nicky Drayden is a Systems Analyst who dabbles in prose when she's not buried in code. She resides in Austin, Texas where being weird is highly encouraged, if not required. Her debut novel The Prey of Gods is forthcoming from Harper Voyager this summer, set in a futuristic South Africa brimming with demigods, robots, and hallucinogenic hijinks. She Shines Like a Moon by Pear Nuallak It's cold in London but you glow with warmth. You travel limbless and limned from your core, throat crossed with black silk just as it was in your first days. Yes, you were naked then, washed clean in monsoons, dried by storm winds. When was the last time your sly hunt was wreathed in rice flowers? Do you recall how dtaan-tree fronds stroked your secret self as you rose, star-bound? Now your London home shivers you into clothes. A length of black at your neck doesn't suffice; you add to old habits—night journeys sensibly hatted, the frank, coiled shapes below your neck wrapped in silk layered with batting and wool, each piece hand-made by the wearer herself. No other clothier would believe your particular sensitivities; only krasue know krasue. (You make a fine new flying outfit each season. You like having things, you're the lord and lady of things.) London's cross-hatched with forgotten waterways, the Krungthep of the Occident, murky and decadent. The Heath hides the Fleet in its hills, earth over arteries water-fat; it surfaces as a rivulet, gleams and whispers and winks knuckle high in leaf-lined silt before it talks away, louder and deeper into the festering heart of the city, but you drink it here, the source. The tumulus field brings food best savoured like an egg with bael-sap yolk—slowly, thoughtfully, the red of it so rich on your tongue after eating bland pale without. In the viaduct pond you dump his fixie and clean your face. After the meal you play with foxes. Your city friends have great thumping tails, on hind legs they yelp delightedly. (When you first heard sharp cries in the hills you thought it was another krasue. Foxes came instead, sniffed you wonderingly, ears flicking. You didn't find each other appetising in the least. Their company is brief, precious: city foxes live a year each.) You peer into the Hollow Oak. When you were new here you asked your first fox friend, lovely old Chalk Scrag, if this was their den. No, friend, no—my burrow smells like forest all dark and close, she says. This smells like witch. One day I will show you the best smells of my home, yes, yes, but not that witch tree, no; that is hers to show. You wonder if she's shy. You think about whether she's a person who also knows what it's like to be apart from others. Under the bark and earth there's always the smell of black tea and sugared fruit, sometimes cake, sometimes curry. That one's never come out, says Liquorice Grin, who counts Chalk Scrag as eightieth great-grandparent. She is busy. Leaves us gifts, but never comes out to play with us like you do, friend. Four score years you've hunted here and no corner of Heath is unexplored but this. (You're shy, too.) Before setting off home, you linger by the Oak as you always do. She is shy, she is busy, but you can ask. So for a change, tonight you say, “Your home smells wonderful,” into the hollow. Your eerie heart beats strong as you fly home. Strong teeth and supple tongue open the night-hatch to your flat. You shed your flying clothes and look at yourself on the bed; in your own light you consider the soft limbs, the clean red hollow between your shoulders. What are you truly hungry for? You enfold your secret self with a body that accepts you neatly and completely. The black silk remains at your throat. It is good to lay your head on the pillow. In the morning your longer self stretches her limbs, washes, thinks about being 'she' as she pulls on a turquoise jumper, so good on skin the colour of tamarind flesh, a long skirt in pig's blood, Malvolio tights, black boots laced up. Before a mirror she wanders her hands over the pleasing stubble on the back and sides of her head, dressing the length on top into a sleek pompadour. (Your grandmothers' hairstyle is now subculture fashionable but you wear it anyway, you're the age of two grandmothers together and want to remember what you had.) The morning walk to the cafe brings smells from the flats: running water and clean skin, burnt toast, bacon fat sizzling, hot dusty radiators. There's strange comfort in witnessing others' routines. Coffee is taken quickly before the man with a rough-haired jack comes for his—tame dogs never like you, the cafe's too small for a scene. For two decades you've been teaching. You like interaction structured around things you know and love, boundaries defined. Every 5 years you make yourself move; you enjoy this while you can. Knitting today. To make the cowl you've planned, students discard needles and knit like this: thick yarn knotted onto wrists, loops drawn over fists, wool on skin, weaving on flesh. Your students' concentration is your delight; it staves the hunger somewhat. Once you tended silkworms and cotton bolls, had a great loom under the belly of your stilt house; your family once wore the fabric you grew, span, wove. Now it's only you, the narrowness of your single self. (But the cowls will warm your students, so this will do.) That evening returns you to your alma mater. Female Abjection and the Monstrous Feminine in Thai Cinema, the email said. Open to all. It's sure to be diverting. You've not yet been to the Bloomsbury buildings—when you studied languages, it was the School of Oriental Studies at 2 Finsbury Circus and you were a man hatted and trousered, as it sometimes suits your fancy. The institution's re-invented itself: cosmopolitan, international, politically active, inclusive. (Coy about its hand in training Empire: to control a people you know their tongues, their hearts.) You sit and are lectured on a self Othered through others' eyes. Except for one Thai man, the lecturer cites theorists and academics like her, white and Western. She says, “There are no feminists in Thailand—Thai women don't really identify as feminists; it's just not done. People talk about South-East Asian women having power and ownership, but…” she shrugs. (It's never occurred to the lecturer to ask what a Thai woman thinks of herself, let alone a krasue's view of her own condition.) You think of spitting in her tea. Wouldn't make much difference to the taste; your lips are primed. But her words will survive a thousand years: she's adding to the sum of human knowledge. She doesn't need your curse—no, it wouldn't make much difference at all. There is loyalty, still, though you've been here so long and it's your countrywomen who fear you most, who have always kept their distance from you, who would reject and destroy and silence you instantly if they knew your tastes. But you were made by them. You are their monster. It's hard to believe others would believe you. The hunger you've mastered, mostly, but grieving anger and loneliness thunders through your whole interior. You suck your teeth and go home, fill yourself with sweet warm rice. A collection on your kitchen shelves: rice scraped white, rice left red or brown or black, rice so delicious wives forget husbands. (Is it good or bad you've only found husband-forgetting rice? Perhaps men are more easily forgotten by wives. You've no inclination for husbands: the sum of your knowledge on this subject is that they're common.) Once your fork and spoon are closed, an invitation appears, curling hand tracing bright in the air: You are invited to A Midnight Cake Tasting for the delight of the Witch Ambrosia at the Hollow Oak, Hampstead Heath You hesitate, chewing your lip. Perhaps she's only inviting you out of kindness, politeness, obligation. Perhaps she won't be there. Perhaps this is a trick. But she's asked, and you accept. You go as yourself, your honest, smallest self. When the clock strikes the hour you hover, unsure. “Come in, love, I've been waiting so long,” says Ambrosia. The witch leads you in, steps winding like shell chambers into the earth. Her home smells like a home should, is full of things neatly kept, herbs bunched, cables sorted. In the lamp light you see her fine umber self dressed in a gown of fresh plum, face framed with raincloud hair in a thousand braids. You know at once she is splendid. “Oh, is that for me?” she says as you give her a rich saffron scarf. Thanks is a gentle touch to your cheek. The table is spread. Together you enjoy black rum cake and rose-bright sorrel, dark fruits wondrously spiced. You begin with, “I thought I'd say hello.” “So did I,” says Ambrosia, “it was about time.” “Will you come with me tonight?” (why are you so awkward, what could she possibly—) “I was thinking you'd never ask,” she smiles. Up above, Liquorice Grin says, Ah, you've brought a new lovely friend. You dance together, fox fur coppered in ghost light. Ambrosia shines like a moon. Your heart shouts. You are full up of her. The Simplest Equation by Nicky Drayden I'm doodling in the margins of my Math 220 syllabus when she walks into the classroom like a shadow, like a nothing, like an oil slick with pigtails. She scans the empty seats in the most calculating manner and I shudder when she spots the one next to me. Her knees bend all the wrong ways in her jeans as she walks up my aisle, and her head is a near perfect ellipsoid that could've fallen out of any geometry primer. She sets her backpack on the floor between us, then maneuvers into the chair with the grace of a lame giraffe. "I hope I'm in the right place," she says as she finally settles—her English impeccable, though she exhales the words more than speaks them, typical of her kind. "Partial Differential Equations?" I nod, trying not to notice all those rows of tiny pointed white teeth crammed into her mouth, but then she smiles and it becomes impossible not to. I swallow hard, somehow managing to extend my hand. "I'm Mariah," I say, my eyes tracing along the brown of my skin until it intersects the blue-black of hers. "Kwalla," she says. "Two syllables. Not like the bear." I force a laugh. It comes out easier than expected. "Nice doodle," she says, looking at the squares and swirls and meandering lines. "Very symmetrical." "Mmm..." I purse my lips and cock my head, then with a single tap on the screen, I reset my syllabus to its virginal form. She's not the first Ahkellan I've met. There are a couple hundred here on campus. They come to Stanford when they can't get into Vrinchor Academy or Byshe, or any of the other prestigious schools in their system. Bring us your next best brightest, has become our new school motto. Yale, Harvard, and the other Ivy League schools split a couple dozen Ahkellans between them, but California's consistent temperatures are much more appealing to a race that goes into involuntary stasis when the weather dips below forty-three degrees. After brief introductions, Professor Gopal drones on about semilinear equations. I listen and take notes attentively, afraid to let anything slip past me. I used to love math. Now it's the bane of my existence, always more of the same lifeless problems. But I've got too many credits and too little money to think about changing majors now. So I buckle down and frequently pull all-nighters just to squeak by with Bs. I glance over at Kwalla who's busy solving problem sets on her notebook, two chapters ahead of the professor already. This class is probably a joke to her, just a way to rack up a few credits before applying for an interstellar transfer. But she seems pleasant enough, and none of the other Ahkellans I've met have ever shown anything that resembled a sense of humor, or an appreciation for art for that matter. "Hey," I whisper, keeping the resentment out of my voice. "You looking for a study partner?" Kwalla nods, then smiles at me again. I desperately resist the urge to protect my soft spots. # Every Tuesday and Thursday evening, we meet at Meyer Library, hustling through the stacks for table space among towers of old, dusty books. When my grades slip, we add another study session Saturday afternoons in her dorm room. It smells vaguely of sandalwood, and the paneled doors of her closet are neatly lined with posters of angst-ridden Ahkellans. Their slick, black faces are dour and their postures nonchalant—reminiscent of late twenty-first century brood bands, stuff my parents used to listen to. We sit cross-legged on her bed... well, I sit cross-legged, and she sits in some variation of the lotus position that teeters on an optical illusion with all those joints of hers. Our notebooks are spread out between us. Kwalla's explaining Fourier transforms to me for the third time, and we're both beyond frustrated. I try to listen, but my mind drifts, and before I know it I've created a doodle that spans half the page, covering the miniscule amount of calculations I'd started. Kwalla sees and makes a purring sound I've come to recognize as mild irritation. "Sorry," I grumble. I lean back against the wall and stare out the window at her prized lake view of Lagunita. Students horseplay on its shore, blue-gray water lapping at their ankles. They laugh, living life and enjoying the "college experience," while I'm cooped up in here, breathing stale circulated air and staring at integral curves until my eyes bleed. I heave a sigh. "Maybe I should drop the class. Drop out of college. Drop off the face of the Earth while I'm at it." Kwalla smirks. "You're depressed. Good." "Good?" I slam my notebook shut, turn away from her, and fume like a shuttle on its launch pad. Just when I was beginning to think she was a pretty decent person, or Ahkellan. Or whatever. "Yes, it means you're close to understanding the story of this equation. It's a classic tale of love and loss. It's meant to be depressing, yet beautiful at the same time." I roll my eyes as she resets to a clean page and starts the equation again. She works downward, shuffling constants and variables, swaying like a concert pianist. When she's done, a single tear trickles down her cheek. She glances up at me and notices that I'm crying, too. "You saw the story this time?" she asks with hopefulness in her voice. I slowly shake my head, more confused now than ever. "Not even close. I was just trying to figure out how to tell my parents that I've wasted their hard-earned money and the last two and a half years of my life. I hate math." Kwalla recoils as if my mathematical slur negates her very existence. "You shouldn't say things like that." "Give me a break," I say, rubbing my eyes. "I might not get your 'stories' but you don't get how incredibly hard this is for me. I wasn't born a genius like you, solving proofs while still in the womb." From the grit in my words, I expect Kwalla to ask me to leave, but instead she lays a spindly hand on my knee. "I've worked hard to get here, Mariah, but what you say is partially true. Math is our first language, and we crave it when we're born like you crave your mother's milk. It is our first friend. Our first love. Our first everything." Kwalla pauses, face riddled with uncertainty, then draws a black pouch from her backpack. She unties the drawstring and slips a large, tear-shaped crystal into the palm of her hand. Hundreds of facets speckle the ceiling with light, so beautiful. "I've never shared this with anyone," she says timidly. "It's amazing..." "I haven't even started yet," she says with a laugh, then leans close so I can get a better look. Foreign symbols are etched into each cut side of the crystal. "It's a yussalun, a calling piece. It's similar to your auditory instruments, except... well, it's probably easier just to show you." Kwalla holds the piece up in front of her like a trumpet, but several inches away from her mouth. Her thin fingers tap across the facets and the air above the piece crystallizes into an intricate fractal pattern, a living snowflake that blooms sideways and then stretches for the ceiling with all its might. Buds gracefully unfurl to the rhythm of an inaudible beat, stirring up a sense of wonder within me. Then the ice crystals slow, becoming thinner and more delicate until they peter out with a hopelessness that fills me with inexplicable grief. "That was the equation we've been working on," she says after we've both had a chance to catch our breath. "Now do you see?" I nod, feeling wounded and vulnerable. There's a terrible rawness inside my chest that I wouldn't wish on anyone, and yet I crave more. I need more. "Do another," I whisper. So she shares her favorite stories with me, and together we sit pensive for mysteries, hold our breath for thrillers, and giggle at the titillation of cheap romance—each fractal evoking an emotion, pure and intense and untamed. After the sun no longer shines through her window, each fractal leaves a slight chill in the air, so we slip halfway under the covers and Kwalla shares with me a fractal with a perfect heart at its base that dazes me with childlike joy—an equation simple enough to solve itself. Then we throw the covers over our heads and I can't tell where I end and she begins, so I giggle and Kwalla giggles, then she laughs, and I laugh. # Our professor posts the scores to our midterm exam outside the classroom door. With great trepidation, I type in the last four digits of my student ID and the page slowly scrolls down, pointlessly melodramatic. My finger shakes as I trace my way across the screen over failure and mediocrity and more failure until I reach the grade for last week's exam. My chest explodes with delight when I see the 98.5. I'm so giddy I can barely stay seated as I wait for Kwalla to arrive. Thanks to her, I've rediscovered my passion for math. I busy myself solving practice problems that tell tales of triumph in the face of adversity. I'll pick the best one and share it with Kwalla tonight. In these last couple weeks, she's taught me how to play her yussalun, turning water molecules in the air into icy fractals the size of a toy poodle, though mine pale in comparison to hers. The bluntness of my fingertips makes it difficult to tap the right facets, but what I lack in accuracy I make up for in perseverance. I've caused more than my fair share of fractals to wilt, however, when I get it right, math and story collide, forming something exponentially more magnificent than the sum of its parts. Her seat is still empty. I wait as long as I can stand it, then ditch class a few minutes into Professor Gopal's lecture. The phone rings and rings as I race to Kwalla's dorm. Through her door, I can hear her speaking in an Ahkellan dialect sounding something like a rooster trying to fog up a mirror. A deeper voice follows with the tin ring of an IVT, an instantaneous voice transmission, cheapest way to call intragalaxy. Against my better judgment, I knock softly. Kwalla answers with an uncontainable smile, and nods for me to have a seat at her desk. Her conversation stretches on for another ten minutes, and as she paces barefoot across the blue carpet, I admire all the ways her legs bend from beneath her skirt, and how the fluorescent light overhead glints on her skin—like iridescent rainbows set adrift across the night's sky. "I can't believe it!" she shrills after she finally disconnects. "It couldn't be more perfect! I've been accepted, Mariah. I'm going to Byshe!" "That's wonderful!" I say, and despite the rip in my heart, I really mean it. Getting into Byshe is worse odds than matching all the balls in the Bippho Trans-Galactic pick-twelve. Optimism has never been my strong suit, but maybe if I study hard and get my grades up, I could apply to Byshe next year. Kwalla could tutor me the rest of this semester and maybe even a few weeks into the summer. I nod to myself, impervious to the laws of probability and blissfully ignoring the fact that I can barely afford out-of-state tuition, much less out of solar system. "I've got some news, too," I say. Kwalla sits down next to me, and her eyes get wide and glassy. "You passed!" "Nu-uh. I nearly aced it!" "This calls for a celebration!" She pulls her yussalun out from its pouch and hands it to me. "Here, you play something nice while I pack." Her voice trails off at the end, a whirlwind of excitement deflated by a sudden prick from reality. "Pack?" "If I don't catch the next shuttle up ..." Kwalla says, voice pitched high and words running together as she tries to stitch together some sort of excuse for wanting to get the hell out of here. I don't blame her, not with the life she has waiting for her across the stars. Kwalla tilts her head forward, and after a weighty silence, she leans against my shoulder. "I'm leaving for Byshe in the morning." # I can't let her go without showing her how I feel, so after she's fallen asleep, I slip out of bed and onto a spot on the floor where moonlight from her window falls across my dimly backlit notebook. I work through the whole night, scribbling down the story of us, the fun we've had in our short time together, and all the could-have-beens for our future. It becomes unwieldy, our equation, and even with the tiniest font, it still won't fit on one screen. By the time I finish, my fingers are cramped, my brain is tight, and I can barely see straight. But the story is magnificent, engrossing, tragic. Careful not to wake her too soon, I cradle the yussalun in my hands and prepare to share. Our story takes nearly thirty minutes to play, and when I'm done, I sit back and let it expand into the room. Two concentric buds sleepily emerge and form a base, then sprout three arms each, spiny like a starfish. They curl and coil, each arm to the beat of its own drummer. I marvel at the beginnings of their different stories, and my heart flutters as I try to keep up with them simultaneously. At a meter high, I start to rouse Kwalla so she can see it as the first bits of sunlight shimmer across the fractal's crystalline surface, but just as I lay a soft hand on Kwalla's shoulder, the fractal begins to wilt. It steals my breath as I watch, my mind churning over the equation, wondering if I'd made a bad calculation or misplayed a note. But I couldn't have made a mistake, not on something this important. All at once, the arms spiral up with the grace and might of a dancer, recursive shapes predictable yet mesmerizing. My creation reaches for the ceiling, and I grin in anticipation of the final blossom, but the fractal is thickening like an insatiable sapling and not tapering into delicate buds. I exhale and my breath lingers in the air, coldness striking through my nightshirt as I realize this thing is far from stopping. "Kwalla!" I scream, lips cracked from the moisture being sucked from the air. She doesn't respond and I shake her. Kwalla stirs for a moment, as if trying to fight through impending stasis, but then she goes still. I take a swing at the fractal with her desk chair, smashing off one of the frosty tendrils, but it grows back with a vengeance until all is symmetrical again. Logic gives way to adrenaline and I scoop Kwalla's body up into my arms. "Fire!" I say, over and over through the hallways at the top of my lungs, figuring it will draw more attention than yelling "fractal!" Someone pulls the alarm, and we all scatter outside and across the street. I rub warmth back into Kwalla's limbs as onlookers wait for signs of smoke and flames. Of course they never come, and when rumors start circulating about a prank, I think that maybe I'd overreacted. An explosion of terra cotta tiles silences those thoughts as the fractal pierces the roof of Kwalla's dormitory. Exposed to the night air and the moisture from the nearby lake, the fractal accelerates, busting brick and shattering glass. It's odd, but no one panics or frets over lost possessions. We just watch, completely captivated. The fractal doesn't slow until it's demolished both wings of Lagunita Court and the adjacent parking lot, and even then, it's not quite finished. A single thin stalk stretches up for the stars, and it reaches, reaches, reaches—wispy recursions sprouting like a vine on its way to the stratosphere. With some effort, I pull my gaze away and watch the crowd. There's not a dry eye to be found, including Kwalla's, her body cradled comfortably against mine. "I had no idea," she exhales weakly, "...that you felt so deeply. It's the most incredible story I've ever seen." "I'll miss you," I say before she has a chance to make well-meaning promises we both know it'd be impossible to keep. I savor this moment, because in a few hours, she'll be on a plane to Houston, just one small step on her long journey home. # There's a flurry of media coverage and threats of my expulsion, but the Board of Trustees changes its tune when news of the fractal reaches Ahkel and impresses even their most renowned intellectuals. Suddenly I'm no longer a disgraceful delinquent, but one of Stanford's brightest scholars, and any blemishes on my academic record are written off as me being a genius misunderstood in my own time. I laugh at their antics. At least it distracts me long enough for the numbness inside me to fade. A week later, my phone hums in my pocket while I'm doodling in Professor Gopal's class. I fish it out so I can check the caller ID. My heart slips to my toes when I see it's an IVT number, and I scramble out of the classroom on rubbery legs. "Hello?" I say into my phone. "Hello?" I say again, harder this time, as if it'll get my words across subspace faster. There's only a slight time dilation, but the seconds drag on like days. I hang onto the sounds of rustling static, waiting for Kwalla's voice. Only it's not Kwalla. My disappointment is short lived, however, when the caller identifies herself as the dean of the Mathematics department at Vrinchor Academy. She says she's eager for the opportunity to take a closer look at how I derived my equations, and that if I'm interested, there's a spot for me in the upcoming school year, full scholarship. I don't bother holding back my elation, and even though a billion miles separate us, I'm sure the dean's ear will be ringing for days. I return to class and respectfully gather my belongings, though my classmates couldn't have missed my screams. I nod at Professor Gopal, and he smiles knowingly. I can't believe I'll be living a dream, studying under the best minds in the galaxy, devouring math in all its forms. And of course it doesn't hurt that I'll be a quick shuttle's ride from Kwalla, just two planets away. I race across campus, cutting through manicured lawns, dodging traffic, and pushing myself through the knot of tourists gathered in front of our fractal. I fall to my knees, chest heaving and smiling wider than any sane person ought to. My warmed skin braces me against the deep chill the fractal emits. Despite my best efforts not to look like a complete fool, I still draw stares and the attention of a camera lens or two. From the corner of my eye, I swear I see our fractal moving. Changing. Of course that's impossible after all this time—probably just an odd reflection of sunlight or the shadow of a passing cloud. Doesn't matter. I've got a date with destiny tonight: a passport to find, flights to book, a whole planet to say goodbye to and above all, I've got a new story that's itching to be told. “She Shines Like a Moon” was originally published in Lackington's and is copyright Pear Nuallak, 2015. "The Simplest Equation" was originally published in Space and Time Magazine and is copyright Nicky Drayden 2014. This recording is a Creative Commons Attribution-NonCommercial-NoDerivatives license which means you can share it with anyone you’d like, but please don’t change or sell it. Our theme is “Aurora Borealis” by Bird Creek, available through the Google Audio Library. You can support GlitterShip by checking out our Patreon at patreon.com/keffy, subscribing to our feed, or by leaving reviews on iTunes. Thanks for listening, and I’ll be back soon with a poem by Joanne Rixon, and an original story by A.C. Buchanan.
Simon Shares Now Sea Harvest coming to market mid March hot on the heels of Premier Fishing. Spar (JSE code: SPP) another weak retailer trading update, BuildIt very weak, local weak, Ireland alright but hurt but currency and Switzerland also poor. MTN (JSE code: MTN) reports they will have a headline loss for FY2016 after a 1204c HEPS in FY2015. Lots of reasons, mostly Nigeria. Two new Satrix ETFs coming. One property (capped at 10% per stock) and a government inflation-linked bond ETF. Understanding the DCCUSD ETF that tracks US Treasury Bonds. Upcoming events JSE Power Hour: Tax-free investing Momentum portfolio stock picks for 2017/8 JSE Power Hour: Finding that perfect share JSE Power Hour: Anthony Clark 2017 small cap picks Jean Pierre Verster Portfolio Manager - Fairtree Capital Chatting market fears and opportunities specifically; Hudaco (JSE code: HDC), Naspers (JSE code: NPN), MTN and Invicta (JSE code: IVT). We Get Mail Anton Do you know why I am paying double the share price to purchase a share at my broker? Is it brokerage fee? Hendrik At which point do we have to outsource the investment club to protect the alliance. Each member's share is now quite substantial. JSE – The JSE is a registered trademark of the JSE Limited. JSEDirect is an independent broadcast and is not endorsed or affiliated with, nor has it been authorised, or otherwise approved by JSE Limited. The views expressed in this programme are solely those of the presenter, and do not necessarily reflect the views of JSE Limited.
BACKGROUND: It is not established whether sex influences outcome and safety following intravenous thrombolysis (IVT) in acute stroke. As a significant imbalance exists between the baseline conditions of women and men, regression analysis alone may be subject to bias. Here we aimed to overcome this methodical shortcoming by balancing both groups using coarsened exact matching (CEM) before evaluating outcome. METHODS: From our local prospective stroke database we analyzed consecutive patients who suffered anterior circulation stroke and received IVT from 1998 to 04/2013 (n = 1391, 668 female, 723 male). Data were preprocessed by CEM, balancing for age, NIHSS, lesion side, hypertension, diabetes, atrial fibrillation, smoking, coronary heart disease, and previous stroke, which yielded a matched cohort of 502 women and 436 men (n = 938). Outcome was estimated by adjusted binomial logistic regression analysis incorporating matched weights. RESULTS: No effect of sex was seen to predict good outcome (OR 1.04, CI 0.76-1.43) or mortality (OR 1.13, CI 0.73-1.73). However, female sex was a strong independent predictor of symptomatic intracerebral hemorrhage (sICH - ECASS-II definition, OR 3.62, CI 1.77-7.41) and fatal ICH (OR 4.53, CI 1.61-12.7). CONCLUSION: In balanced groups, the two sexes showed comparable outcomes following IVT. A novel finding was the higher rate of sICH and fatal ICH in women. In this analysis we also demonstrate how CEM can reduce multivariate imbalance and thereby improve estimates, already in crude, but more importantly, in adjusted regression analysis. Further investigations of multicentre data with improved analytical approaches that yield balanced sex-groups are therefore warranted.
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