Podcasts about lfts

Episode 193: Gestational Diabetes IntroJesica Mendoza (OMSIII) describes the pathophysiology of gestational diabetes and the right timing and method of screening for it. Dr. Arreaza adds insight into the need for culturally-appropriate foods, such as vegetables in Mexican cuisine.    Written by Jesica Mendoza, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.DefinitionGestational diabetes mellitus (GDM) is a condition that occurs to previously non-diabetic pregnant women, caused by glucose intolerance at around the 24th week of gestation. PathophysiologyGDM arises due to an underlying pancreatic beta cell dysfunction in the mother which leads to a decrease in the amount of insulin produced and thus leads to higher blood sugar levels during pregnancy. The placenta of the fetus will produce hPL (human placental lactogen) to ensure a steady supply of sugars to the fetus, creating an anti-insulin effect. However, hPL readily crosses the placental barrier causing the mothers insulin requirement to increase, when the mother's pancreas cannot increase production of insulin to that level needed to counter the effect of hPL they become diabetic, and this leads to gestational diabetes. So, basically the placenta is asking for more glucose for the baby and the mother's pancreas struggles to keep the glucose level within normal limits in the body of the mother. If left untreated, high levels of glucose in the mother can cause glucotoxicity in the mother.“Glucotoxicity” refers to the toxic effect of glucose. Glucose is the main fuel for cell functions, but when it is high in the bloodstream, it causes toxicity to organs. Prevalence of GDM.The CDC reports mean prevenance of GDM is 6.9%. In U.S. mothers the prevenance increased from 6.0% in 2016 to 8.3% in 2021. Many different factors have played a role in increasing gestational diabetes in American mothers, some of those being the ongoing obesity epidemic with excess body weight being a known risk factor for insulin resistance. Another being advanced maternal age (AMA) as more American women have children later in life their body becomes less sensitive to insulin and requires a higher insulin output on top of the insulin that is required for the fetus. The “American diet” is also something that has a big effect in diabetes development. With the increase of high-carb foods that are readily available, the diet of Americans has declined and is affecting the metabolic health of mothers as they carry and deliver their children. Despite ongoing awareness of GDM, 6% to 9% of pregnant women in the United States are diagnosed with gestational diabetes, and the prevalence continues to increase worldwide. It is estimated that in 2017 18.4 million pregnancies were affected by GDM in the world, which then continued to increase to 1 in 6 births to women with GDM in 2019. It was also found that women living in low-income communities were disproportionately affected due to limited healthcare access. Additionally, women with GDM had a 1.4-fold increase in likelihood of undergoing a c-section, with 15% increase in risk of requiring blood transfusion. Screening for GDMGestational diabetes is screened between the 24th to 28th week of gestation in all women without known pregestational diabetes. In women who have high-risk for GDM the screening occurs during the first trimester, these women usually have at least one of the following: BMI > 30, prior history of GDM, known impaired glucose metabolism, and/or a strong family history of diabetes. The screening during the first trimester is to detect “pregestational diabetes” because we have to keep a good glycemic control to improve outcomes of pregnancy. So, if it's positive, you start treatment immediately. If these women are found to have a normal glucose, they repeat the testing again as done normally, at 24-28 weeks of gestation. How do we screen?The screening itself consists of two types of approaches. The two-step approach includes a 50-gram oral glucose tolerance test (OGTT), where blood glucose is measured in an hour and if it is below 140 they are considered to not have GDM, however if the reading is greater than 140 they must then do a 3-hour, 100g oral glucose tolerance test. The 3-hour OGTT includes measuring the blood sugars at Fasting which should be less than 95, at 1 hour at less than 180, at 2 hours at less than 155, and at 3 hours at less than 140. If 2 or more of these values exceed the threshold the patient is diagnosed with gestational diabetes mellitus. The one-step approach includes 75g after an overnight fast. Blood glucose is measured while fasting which should be less than 92, at 1 hour less than 180 and at 2 hours less than 153. If any one of these values is exceeded, the patient is diagnosed with GDM.If the mother is found to be GDM positive during pregnancy she will also need continued screening post-partum to monitor for any development of overt diabetes. The testing is usually 75g 2-hour OGTT at 6-12 weeks postpartum. If this testing is normal, then they are tested using HbA1c every 3 years. If the post-partum testing shows pre-diabetes, annual testing is recommended using HbA1c measurements. Maternal complications Women with GDM are at an increased risk for future cardiovascular disease, T2DM, and chronic kidney disease. GDM is also associated with increased likelihood of developing pre-eclampsia following delivery. Pre-eclampsia is a complication seen in pregnancy characterized by high blood pressure, proteinuria, vision changes, and liver involvement (high LFTs). Pre-eclampsia can then progress to eclampsia or HELLP syndrome, both of which can include end organ damage. Additionally, she can develop polyhydramnios which leads to overstretching of the uterus and can induce pre-term labor, placental abruption, and or uterine atony, all of which additionally put the mother at increased risk for c-section. All of these maternal complications that stem from GDM lead to complications and extended hospitalization. Child's complications Although there is an increased set of risks for the mother, the neonate can also develop a variety of risks due to the increased glucose while in utero. While the fetus is growing, the placenta is the source of nutrition for the fetus. As the levels of glucose in the mother increase so does the amount of glucose filtered through the placenta and into the fetal circulation. Over time the glucose leads to oxidative stress and inflammation with activation of TGF-b which leads to fibroblast activation and fibrosis of the placenta. This fibrosis decreases the nutrient and oxygen exchange for the fetus. As the fetus attempts to grow in this restrictive environment its development is affected. The fetus can develop IUGR (intrauterine growth restriction) leading to a small for gestation age newborn which can then lead to another set of complications. The low oxygen environment can lead to increased EPO production and polycythemia at birth which can then lead to increased clotting that can travel to the newborn brain. Newborns can also be born with fetal acidosis due to the anerobic metabolism and lactic acid buildup in fetal tissues which can cause fetal encephalopathy leading to cerebral palsy and developmental delay. And the most severe of newborn complications to gestational diabetes can lead to fetal demise. Furthermore, the increase of glucose can also lead to macrosomia in the infant which can often lead to a traumatic delivery and delivery complications such as shoulder dystocia and brachial plexus injury. Brachial plexus injury sometimes resolves without sequela, but other times can lead to permanent weakness or paralysis of the affected arm. The baby can be born too small or too big.Additionally, once the fetus is born the cutting of the umbilical cord leads to a rapid deceleration in blood glucose in the fetal circulation and hypoglycemic episodes can occur, that often lead to NICU admission. The insulin that is created by the fetus in utero to accommodate the large quantities of glucose is known to affect lung maturation as well. The insulin produced inhibits surfactant production in the fetus. Upon birth some of the newborns also have to be placed on PEEP for ventilation and some children require treatment with surfactant to prevent alveolar collapse and/or progression to NRDS created by the low surfactant levels. Additionally, neonates who are macrosomic, which is usually seen in GDM mothers, are larger and stronger and when put on PEEP to help increase ventilation the newborn's stronger respiratory effort can lead to higher pulmonary pressures and barotrauma such as neonatal pneumothorax.Long term complications to the child of a mother with GDM also occur. As the child grows, they are also at an increased risk for developing early onset obesity because of the increased adipose storage triggered by the increase in insulin in response to the high glucose in utero. This then can lead to a higher chance of developing type 2 diabetes mellitus in the child. With diabetes, also comes an increase in cardiovascular risk as the child ages and becomes an adult. The effects of GDM go beyond the fetal life but continue through adulthood.What can be done?Gestational Diabetes Mellitus has many severe and lifelong consequences for both the mother and the child and prevention of GDM would help enhance the quality of life of both. Many of the ways to prevent GDM complications include patient education and dietary modifications with a diet rich in whole grains, fruits, vegetables and lean proteins. Benefits of some vegetables in the Mexican cuisine that may be beneficial: Nopales, Chayote, and Jicama. Those are good alternatives for highly processed carbs.Mothers are usually offered nutritional counseling to help them develop a tailored eating plan. This and 30 minutes of moderate exercise daily is recommended to increase insulin sensitivity and lower the post-prandial glucose levels. If within 2 weeks of implementing lifestyle changes alone the glucose measurements remain high, then medications like insulin can be put onboard to manage the GDM. If they require insulin, I think it is time to refer to a higher level of care, if available, high risk OB clinic.Conclusion: Now we conclude episode number ###, “[TITLE].” [summary here]. _____________________References:Eades CE, Burrows KA, Andreeva R, Stansfield DR, Evans JM. Prevalence of gestational diabetes in the United States and Canada: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2024 Mar 15;24(1):204. doi: 10.1186/s12884-024-06378-2. PMID: 38491497; PMCID: PMC10941381. https://pubmed.ncbi.nlm.nih.gov/38491497/QuickStats: Percentage of Mothers with Gestational Diabetes,* by Maternal Age — National Vital Statistics System, United States, 2016 and 2021. Weekly / January 6, 2023 / 72(1);16. https://www.cdc.gov/mmwr/volumes/72/wr/mm7201a4.htm?utmAkinyemi OA, Weldeslase TA, Odusanya E, Akueme NT, Omokhodion OV, Fasokun ME, Makanjuola D, Fakorede M, Ogundipe T. Profiles and Outcomes of Women with Gestational Diabetes Mellitus in the United States. Cureus. 2023 Jul 4;15(7):e41360. doi: 10.7759/cureus.41360. PMID: 37546039; PMCID: PMC10399637. https://pmc.ncbi.nlm.nih.gov/articles/PMC10399637/?utmPerlman, J. M. (2006). Summary proceedings from the neurology group on hypoxic-ischemic encephalopathy. Pediatrics, 117(3), S28–S33.DOI: 10.1542/peds.2005-0620C.Low, J. A. (1997). Intrapartum fetal asphyxia: definition, diagnosis, and classification. American Journal of Obstetrics and Gynecology, 176(5), 957–959.DOI: 10.1016/S0002-9378(97)70609-0.Hallman, M., Gluck, L., & Liggins, G. (1985). Role of insulin in delaying surfactant production in the fetal lung. Journal of Pediatrics, 106(5), 786–790.DOI: 10.1016/S0022-3476(85)80227-0.Sweet, D. G., Carnielli, V., Greisen, G., et al. (2019). European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology, 115(4), 432–450.DOI: 10.1159/000499361.Raju, T. N. K., et al. (1999). Respiratory distress in term infants: when to suspect surfactant deficiency. Pediatrics, 103(5), 903–909.DOI: 10.1542/peds.103.5.903.Burns, C. M., Rutherford, M. A., Boardman, J. P., & Cowan, F. M. (2008). Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics, 122(1), 65–74.DOI: 10.1542/peds.2007-2822.Dabelea, D., et al. (2000). Long-term impact of maternal diabetes on obesity in childhood. Diabetes Care, 23(10), 1534–1540.DOI: 10.2337/diacare.23.10.1534.Dashe, J. S., et al. (2002). "Hydramnios: Etiology and outcome." Obstetrics & Gynecology, 100(5 Pt 1), 957–962.DOI: 10.1016/S0029-7844(02)02279-6.Long-term cost-effectiveness of implementing a lifestyle intervention during pregnancy to prevent gestational diabetes mellitus: a decision-analytic modelling study. Diabetologia.American College of Obstetricians and Gynecologists. (2018). Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics & Gynecology, 131(2), e49–e64. https://doi.org/10.1097/AOG.0000000000002501Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Dr Fahad Ashraf, Consultant Gastroenterology at University Hospitals of Derby and Burton NHS Foundation Trust, is helping us unblock any gaps in our knowledge when discussing abnormal LFTs, cholestatic derangement and management of obstructive cholangitis.Follow us on Instagram: #MEM (@mem.cast) • Instagram photos and videosJoin our Discord server via our Linktree: MEMcast - Listen on YouTube, Spotify - Linktree

O "Ulrich Responde" é uma série de vídeos onde respondo perguntas enviadas por membros do canal e seguidores, abordando temas de economia, finanças e investimentos. Neste episódio, falamos sobre assuntos como a dolarização, sanções comerciais, inflação, mercados internacionais e o impacto das políticas dos Brics. Oferecemos uma análise profunda, trazendo informações para quem quer entender melhor a economia e tomar decisões financeiras mais informadas. 00:00 - Hoje, no Ulrich Responde 01:12 - Dolarização: Qual o valor mínimo para começar? 02:26 - A nova moeda dos Brics pode ter relevância? 04:44 - Atualização da crise econômica da Turquia 06:46 - Impacto de uma vitória de Trump na economia brasileira 10:52 - Mercado sem Banco Central: é possível? 12:18 - Como o Índice Big Mac mensura o valor relativo das moedas? 13:34 - Sanções e protecionismo: qual o impacto? 17:27 - Compra de Bitcoin sem corretora, como funciona? 18:53 - Endividamento em LFTs: impacto nas contas públicas 20:05 - A moeda Brics ameaça a hegemonia do dólar? 22:06 - Definição de depressão segundo Keynes: o que está certo? 23:52 - Investimentos em bancos digitais são seguros? 25:05 - Dolarização na Argentina versus o Plano Real 26:57 - Crescimento do M2 pode prever a inflação? 28:55 - Aumento da oferta monetária e inflação real

Contributor: Jorge Chalit-Hernandez, OMS3 Typically presents with biliary colic Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours Often associated with fatty meals but not always Must rule out other causes of pain Peptic ulcer disease - typically presents with epigastric pain Pancreatitis - pain that radiates to the back or family history of pancreatitis Laboratory workup  LFTs including ALT, AST, and alkaline phosphatase are within the reference range Lipase and amylase within the reference range Imaging workup RUQ ultrasound is unremarkable Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal  Opiates may give false-positive results Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi Some patients may benefit from surgical intervention i.e. cholecystectomy Classic biliary-type pain (best predictor of response to cholecystectomy) Pain for > 3 months duration Positive HIDA scan References Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003 Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798 Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690 Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3 Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Dr Charlie Andrews speaks to Dr Jeremy Shearman about everything related to high iron levels (hyperferritinaemia).  We discuss how iron is regulated within the body, causes of raised iron levels, and then we dive into hereditary haemochromatosis - when to suspect, how to test, who to refer (and to whom!), and how the condition is managed.  Useful links to accompany this episode include:Welcome > Haemochromatosis: genetic iron overload disease (exeter.ac.uk)Haemochromatosis - British Liver TrustKey Learnings for Primary Care from the Ingest Podcast on HyperferritinaemiaKey LearningsUnderstanding Iron Regulation and FerritinFerritin is an acute-phase reactant and a marker of total body iron stores, but can be elevated in a range of conditions beyond iron overload, including inflammation, liver disease, and malignancy[2]. Understanding the physiological regulation of iron is crucial for interpreting ferritin results in context.Causes of HyperferritinaemiaRaised ferritin can result from: Hereditary haemochromatosis (genetic iron overload) Chronic inflammatory states (e.g., infection, autoimmune disease) Liver disease (e.g., alcoholic liver disease, hepatitis) Malignancy Metabolic syndrome It is important to consider these differential diagnoses when encountering an elevated ferritin[2].Hereditary Haemochromatosis: When to SuspectPrimary care clinicians should suspect hereditary haemochromatosis in patients with persistently raised ferritin and transferrin saturation, especially with suggestive symptoms (e.g., fatigue, arthralgia, diabetes, liver dysfunction) or family history[2]. Early recognition is key, as treatment can prevent complications.How to TestInitial investigations should include: Repeat ferritin measurement to confirm persistence Transferrin saturation (TSAT): TSAT >45% is suggestive of iron overload Liver function tests and assessment for other causes of raised ferritin[2] If hereditary haemochromatosis is suspected, genetic testing (HFE gene) should be considered.Who to Refer (and to Whom)Refer patients with confirmed iron overload (high ferritin and TSAT) or positive HFE mutation to hepatology or a relevant specialist for further assessment and management[2]. Referral is also warranted if there are signs of organ involvement (e.g., abnormal LFTs, diabetes, cardiac symptoms).Management PrinciplesFor hereditary haemochromatosis, mainstay of treatment is venesection (therapeutic phlebotomy) to reduce iron stores. Primary care plays a role in monitoring, supporting adherence, and managing comorbidities. For other causes, management is directed at the underlying condition.Practical Tips for Primary CareDo not ignore isolated raised ferritin-always interpret in clinical context. Exclude common secondary causes (infection, inflammation, liver disease) before pursuing rare diagnoses. Family screening may be appropriate in hereditary haemochromatosis cases[2]. Use local guidelines and specialist advice where available.Summary Table: Approach to Hyperferritinaemia in Primary CareStepAction/ConsiderationConfirm raised ferritinRepeat test... Chapters (00:00:00) - Ingesting: Iron overload and hereditary haemochromat(00:01:07) - Hemochromatosis 7, Regulation of iron stores(00:03:31) - What would you consider to be a high ferritin level?(00:04:57) - Ferritin and transfer and saturation(00:06:45) - High ferritin in liver, causes and treatment(00:09:05) - Hereditary Haemochromatosis in the UK(00:12:36) - Diagnosing hereditary haemochromatosis in primary care(00:15:58) - Hemochromatosis, C282Y homozygosity(00:19:26) - Cascade screening in haemochromatosis(00:23:07) - Hematology and hepatocellular cancer referral(00:25:30) - How to manage haemochromatosis in the UK?(00:32:27) - Hereditary haemochromatosis and iron overload(00:34:56) - Hemochromatosis(00:36:51) - Iron Overload

JAMA 2001;285:1711-18.Background Statin therapy had been shown to improve blood cholesterol and improve long-term outcomes in patients with stable coronary artery disease with significant effects evident after 2 years of treatment. These early trials excluded patients with recent acute coronary syndromes and thus, the possibility of early benefit from statin therapy in this patient population was untested. But, patients with ACS are the most vulnerable to experiencing recurrent events in the early period following an initial event and certain physiologic effects of statins were theorized to be beneficial during this period. These effects included improvement in endothelial function, decreased platelet aggregation and thrombus deposition, and reduced vascular inflammation. The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study sought to test the hypothesis that early treatment with high dose atorvastatin in patients with unstable angina or non-Q-wave AMI would reduce early ischemic events and death.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients Eligible patients were ≥18 years of age of experienced unstable angina or non-Q-wave AMI within the 24-hour period before hospitalization. The definition of unstable angina was strictly applied and in contemporary practice, all would meet criteria for NSTEMI. Patients were excluded for the following reasons: serum cholesterol >270 mg/dl but there was no lower limit; if coronary revascularization was planned or anticipated at the time of screening; evidence of Q-wave AMI within preceding 4 weeks; CABG surgery within the preceding 3 months; PCI within the preceding 6 months; left bundle branch block or paced rhythm; severe CHF; concurrent treatment with other lipid-lowering agents, vitamin E, drugs associated with rhabdomyolysis in combination with statins; severe anemia; renal failure requiring dialysis; hepatic dysfunction (ALT >2 ULN); insulin-dependent diabetes; pregnancy or lactation.Baseline characteristics The average age of patients was 65 years and two-thirds were men; 86% were white. Approximately one quarter of patients had a prior MI, 23% had non-insulin-dependent diabetes and 55% had hypertension. The average time to randomization from hospital admission was about 2.5 days. The inclusion event was unstable angina in 46% and non-Q-wave AMI in the remainder. Non-cholesterol lowering cardiac medicines were similar prior to, during and following the hospitalization index event.Procedures Between 24 and 96 hours after hospital admission, patients received either atorvastatin 80 mg per day or matching placebo for 16 weeks. Treating physicians were instructed not measure serum lipid levels in the local hospital laboratory during the study period. All patients received instruction and counseling on a low cholesterol diet. Patients were seen in follow-up 2, 6, and 16 weeks after initiation of therapy. Laboratory testing was performed centrally at baseline and at 6 and 16 weeks.Endpoints The primary endpoint was a composite of all-cause death, nonfatal MI, cardiac arrest with resuscitation, or recurrent symptomatic myocardial ischemia with objective evidence requiring emergency hospitalization. The recurrent ischemia endpoint required both exacerbation of the patient's usual symptoms and new objective evidence of ischemia with definite change from a comparison study performed after the index ischemic event. Secondary endpoints were occurrence of each component of the primary composite endpoint as well as nonfatal stroke; new or worsening heart failure requiring hospitalization, worsening angina requiring hospitalization but without objective evidence of ischemia, coronary revascularization, time to first occurrence of any primary or secondary endpoint, and percentage changes in blood lipid levels from baseline to 16 weeks.An initial sample size requirement of 2,100 was based on an assumption of a 20% primary composite event rate in the control group and 14% rate in the atorvastatin-treated group (17% overall rate), with an alpha of 0.05 and 95% power. The sample size was then increased to 3,000 upon the recommendation of the steering committee. This, after a blinded analysis of pooled data from the first 1,260 patients indicated the event rate was lower than anticipated (13% overall). A sample size of 3,000 would confer 95% power to detect a 30% relative treatment effect and 80% power to detect a 25% relative effect at an alpha of 0.05.Results 3,086 patients were included in the final analysis; 1,548 in the placebo group and 1,538 in the atorvastatin group. All patients were followed for 16 weeks. Compared to placebo, atorvastatin significantly reduced the risk of the primary composite endpoint (RR 0.84; 14.8% vs 17.4%%; 95% CI 0.70-1.00; p=0.048). For the individual components, there were no significant differences in death (4.2% vs 4.4%), nonfatal MI (6.6% vs 7.3%), or resuscitated cardiac arrest (0.5% vs 0.6%), but there was a statistically significant reduction in the endpoint of emergency rehospitalization for recurrent symptomatic ischemia (RR 0.74; 6.2% vs 8.4%; 95% CI 0.57-0.95).For the secondary endpoints, there were significant reductions in stroke in the atorvastatin group but this was based on a small number of events. Perhaps unexpectedly, there was a numerical increase in coronary revascularization procedures in the atorvastatin group despite there being a statistically significant reduction in emergency hospitalizations for recurrent ischemia as mentioned above.Data on subgroups was not presented.Compliance with prescribed study treatment was 86% in the atorvastatin group and 88% in the placebo group. Treatment was discontinued prematurely in 11.2% of the atorvastatin group compared to 10.3% in the placebo group. No serious adverse events occurred with a frequency of more than 1% in either group. An increase in LFTs (>3x ULN) occurred in 2.5% in the atorvastatin group and 0.6% of patients in the placebo group; 3 of these patients in the atorvastatin group were hospitalized with hepatitis and each case resolved following discontinuation of the drug. There were no documented cases of myositis.After 16 weeks, LDL cholesterol had increased by an adjusted mean of 12% to 135 mg/dl in the placebo group and decreased by an adjusted mean of 40% to 72 mg/dl in the atorvastatin group. Total cholesterol and triglycerides also decreased significantly in the atorvastatin group compared to placebo and there were no significant changes in HDL cholesterol.Conclusions In patients admitted to the hospital with non-Q-wave acute coronary syndromes, high dose atorvastatin significantly reduced a composite primary endpoint of cardiovascular events over the first 16 weeks of treatment with an NNT of 38; however, this was driven by a reduction in emergency hospitalizations for recurrent ischemia. There is no evidence from this trial that high dose statin therapy reduces the individual endpoints of death or nonfatal MI over this period; nor did it reduce coronary revascularization, which is counterintuitive given the significant increase in emergency hospitalizations for recurrent ischemia. Coronary revascularization events were twice as likely to occur as emergency hospitalizations.The external validity of the trial is limited by the restricted nature of the study population. Patients were excluded if revascularization was planned during initial admission, which in many places is the standard of care for ACS up to the present day. Furthermore, higher risk ACS subgroups were excluded, including patients with insulin-dependent diabetes, advanced heart failure and ESRD. The relatively unimpressive clinical benefit observed in MIRACL should not be assumed to extend to such patients. It would not be unreasonable to conclude that the results from MIRACL do not apply to the average patient with ACS in contemporary practice.Thank you for reading Cardiology Trial's Substack. This post is public so feel free to share it. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

Do you even LFTS bro? Jim sluts it up in a cut-off for this heavyweight Wednesday show as we tackle the pathetic state of legacy media and gym chicks. ROOK LOOK DraftKings Goal in First 10 Mins Boost: Bruins @ Oilers (NHL)

On this podcast episode, I discuss fenofibrate pharmacology, adverse effects, kinetics, drug interactions, and much more! Fenofibrate is typically only used for hypertriglyceridemia. The primary risk of hypertriglyceridemia is pancreatitis so we treat these levels because of this risk. LFTs elevation has been associated with fenofibrate use as well as myopathy. In the presence of myopathy, checking CPK may be considered. Fenofibrate is a weak CYP2C9 inhibitor. Warfarin and phenytoin are two important medications that may be affected by the use of fenofibrate.

LFTs show up in one way or the other on practically every USMLE exam. In this podcast, I lay a solid foundation and use numerous vignettes and conceptual integrations to help you understand the material. This should help tremendously with these questions on test day. I delve into some concepts that are not found in … Continue reading Divine Intervention Episode 503: LFTs and The USMLEs

CardioNerds Dr. Rick Ferraro (cardiology fellow at Johns Hopkins Hospital) and Dr. Eunice Dugan (cardiology fellow at the Cleveland Clinic) join episode lead Dr. Tiffany Brazile (cardiology fellow at the University of Texas Southwestern Medical Center and postdoctoral fellow at the Institute for Exercise and Environmental Medicine) to discuss the impact of obesity on cardiovascular disease risk, differential risk in specific populations, and effective strategies for counseling patients. They are joined by expert Dr. Jaime Almandoz, Medical Director of the Weight Wellness Program and an Associate Professor of Medicine at the University of Texas Southwestern Medical Center. Audio editing was performed by CardioNerds Academy Intern, student Dr. Tina Reddy. This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit. Claim CME for this episode HERE. CardioNerds Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Obesity & Cardiovascular Disease Risk The durability of metabolically healthy obesity (i.e., normal A1c, lipids, LFTs, BMP, normotensive) is limited. Within 5 years, a third of adults with “metabolically healthy” obesity will develop a cardiometabolic complication. The biomechanical and psychosocial complications of obesity are just as important as the cardiometabolic complications. Biomechanical and psychosocial complications, including obstructive sleep apnea, joint pain, and mood disorders also influence cardiovascular disease risk. Weight loss is not always the patient's goal. Meet patients where they are and understand their challenges, concerns, and long-term goals with respect to their cardiovascular health and obesity. This information provides an opportunity to frame the conversation in a supportive and engaging way that allows for patient education. Body mass index (BMI) is a screening tool for obesity, but is not sufficient for providing individualized care. Obesity management methods that result in rapid weight loss may not be appropriate for all patients. These methods, such as bariatric surgery and GLP1-receptor agonists, require regular monitoring, follow-up, and multidisciplinary care (e.g., nutritionist, exercise physiologist, endocrinologist, cardiologist, psychologist, etc.). Show notes - Obesity & Cardiovascular Disease Risk Is it possible to be healthy at any size? Whether an individual can be healthy at any size depends on the definition of health and its durability.Approximately 10-15% of adults with obesity are metabolically healthy.The risk for developing cardiometabolic disease is higher in obese versus non-obese adults. One in three adults with metabolically healthy obesity will develop cardiometabolic complications (i.e., insulin resistance/diabetes, hyperlipidemia, hypertension) within five years. Thus, metabolically healthy obesity may represent a transient phenotype with adverse long-term consequences. Consider non-metabolic health consequences of obesity that also influence cardiovascular disease risk. Obstructive sleep apnea, joint pain leading to decreased physical activity, and mood disorders are key considerations here and encompass the biomechanical and psychosocial consequences of obesity. Does large, rapid weight loss result in poorer long-term weight loss than slower, gradual weight loss? When approaches to weight loss are not sustainable, such as extremely low-calorie diets or extreme fitness regimens, the results and associated health benefits are less likely to be durable. Rapid, large-magnitude weight loss is appropriate for some adults with obesity and can be achieved throug...

In this podcast episode, I discuss naltrexone pharmacology, adverse effects, drug interactions, and much more. Naltrexone is an opioid antagonist and can blunt the effects of opioid agonists. Because of this, the medication can be used to manage opioid use disorder. Hepatotoxicity is a concern of naltrexone and because of this, it is recommended to monitor LFTs. There is an injectable, long-acting formulation of naltrexone that can be used for opioid and alcohol use disorder treatment.

A spo0o0ky, exclusive edition of an LFTS classic: Jim takes on the traditional Halloween Power Hour solo, throwing back eight beers for 60 minutes of progressively terrifying takes.

RF, CRP, FBC and LFTs. Sometimes it seems doctors use more acronyms than words. In this episode Dr Bird breaks down some of the key laboratory tests used to in diagnosing psoriatic arthritis & monitoring treatment.         Developed and owned by Janssen Australia, July 2023. Always refer to your healthcare professional about current treatments, possible side effects and other considerations. Janssen Australia, Macquarie Park NSW. 1800 226 334. CP-382345

On this Episode of LFTS we talk with Madame Helen Tekori. The Queen of community building, the life of the party and everyones favourite person here in Toulouse, France. We talk about everything from working in a factory in NZ to living the WAG life in the South of France. Madame Tekori is a safe haven for a lot of us women here in France, she's the first person we meet, the first person we get drunk with and just the ultimate socialite! We are so grateful for women like Helen and a lot of us families would not have lasted here in France without the Tekori family.

On this episode of LFTS we talk to Rachelle Faumuina and go down memory lane as she reminisces on her life from the side lines being the wife to All Blacks Legend Charlie Faumuina. Rachelle talks to us about her and her husbands passion for community  and real estate and how they've intertwined those passions into rugby to help them prepare for the next chapter; Life after Rugby. We are blessed to know, love and have Rachelle as a big sister and to get to have spent years on this side of the world with her. WE WILL MISS YOU FAUMUINA FAMILY!

On this episode of LFTS we discuss how Ann Marie manages balancing her amazing career as a Lead Soft Tissue Therapist  for England Rugby and The British Lions, Managing her Business Offical Sport Services and being a supportive wifey to her Pro Rugby Player husband Thretton Palamo. We chat about long distance, Mindset, timing and even preparing for life after Rugby.

One of the most common questions we get asked about medicines where there isn't a straight forward answer is how to work out whether a medicine is harming someone's liver, or whether someone's liver is affecting a medicine. For kidneys we have eGFR and CrCl. For liver we have LFTs. But why is it not that simple, and how can we start thinking about these sorts of questions to try to make it a bit simpler? This isn't a podcast about what a specific LFT means at specific levels (because - spoiler alert - LFTs don't work like that) but does try to give an overview of what sorts of things to think about and what common pitfalls might be.

It's an LFTS tradition as Alex G and Solesky return to pop three bottles on the bro-cast for Episode 300. Your boys run through our current stats and record-holders to celebrate seven years of debauchery—talking divine coincidence, childhood memories, and manifesting your destiny.

Dr. Dwight Owen presents the first update to the ASCO living guideline on stage IV NSCLC with driver alterations. He identifies the latest trials that informed this update, and the updated evidence-based options for second- or later-line therapies for patients with advanced non-small cell lung cancer and an activating HER2 mutation or a KRAS-G12C mutation. Additionally, he provides important context on the reported toxicities associated with these therapeutics. Read the update, “Therapy for Stage IV Non–Small-Cell Lung Cancer Without Driver Alterations: ASCO Living Guideline, Version 2022.2“ and view all recommendations at www.asco.org/living-guidelines. Listen to Part 1 for recommendations for patients with stage IV NSCLC without driver alterations. TRANSCRIPT Brittany Harvey: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network; a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at: asco.org/podcasts. My name is Brittany Harvey, and in our last episode, we addressed the living guideline updates for ‘Therapy for Stage IV Non-Small-Cell Lung Cancer Without Driver Alterations.' Today, Dr. Dwight Owen from Ohio State University in Columbus, Ohio, is joining us again to discuss the updates for therapy for stage IV non-small cell lung cancer with driver alterations, as the lead author on, 'Therapy for Stage IV Non–Small-Cell Lung Cancer With Driver Alterations: ASCO Living Guideline, version 2022.2.' Thank you for being here, Dr. Owen. Dr. Dwight Owen: Thanks for having me. Brittany Harvey: First, I'd like to note the ASCO takes great care in the development of its guidelines and ensuring that the ASCO Conflict of Interest policy is followed for each guideline. The full Conflict of Interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Owen, do you have any relevant disclosures that are directly related to this guideline topic? Dr. Dwight Owen: Yeah, thanks for asking that really important question. My institution has received research funding for me to conduct clinical trials from Merck, BMS, Pfizer, and Genentech and Palobiofarma. I have no employment, stocks, stock options, or other disclosures to declare. Brittany Harvey: Thank you for those disclosures. Then getting into the content of this update, this is the first update to the living clinical practice guideline for systemic therapy for patients with stage IV non-small-cell lung cancer with driver alterations. What new studies were reviewed by the panel to prompt an update to this guideline? Dr. Dwight Owen: Thanks for that question. This is a particularly exciting update because as we were preparing for this update, reviewing two manuscripts that we think offer new options for our patients with driver alterations, there were actually updated presentations at a recent meeting that showed us even more data for these targets. So, it's really an ongoing and dynamic place. So, we really focused on two updates; one was for KRAS-G12C alterations, and then one was for HER2 alteration-positive non-small cell lung cancer. So, I'll take them one at a time; for KRAS-G12C, we included an updated recommendation based on the CodeBreak 100 study - this was a multi-center, single group, open-label, phase II study of sotorasib, which is a KRAS-G12C inhibitor, in patients with non-small cell lung cancer positive for KRAS-G12C, who had received prior systemic therapy that could either be with chemotherapy or immune therapy, and the majority of patients had received both. 124 patients were evaluable for response, and the objective response rate was 37%, with the impressive median overall survival of over 12 months, of 12.5 months, specifically. Now, there were some notable toxicities. There's GI toxicities such as diarrhea and nausea, as well as some elevations in LFTs. We also heard recently at ESMO about CodeBreak 200, which was a randomized study of sotorasib compared to docetaxel in previously treated patients with KRAS-G12C non-small cell lung cancer. And that study did meet its primary endpoint of improvement in PFS for sotorasib-treated patients compared to docetaxel, and we are very much looking forward to seeing that final publication. For HER2 alteration-positive non-small cell lung cancer, we really focused our efforts on DESTINY-Lung01. Now, this was a multi-center, multinational, open-label, phase II study evaluating trastuzumab deruxtecan in patients with previously treated HER2-positive non-small cell lung cancer. In this study, 91 patients were evaluable for response, and 50, which was 55%, had a confirmed objective response, and the median survival was presented at 17.8 months. A pretty unique toxicity was observed here. So, drug-related interstitial lung disease or pneumonitis occurred in just over a quarter of patients, and there were two deaths related to this. So, this needs to certainly be monitored for. Also at ESMO, we heard results for DESTINY-Lung02, which was a multi-center, multi cohort, randomized blinded study, which was also a dose optimization study. And this study eventually led to the accelerated approval of the 5.4 milligrams per kilogram dose that seemed to be just as effective as other doses, but perhaps with less toxicity. Again, we're currently awaiting the final publication of DESTINY-Lung02. However, these results are particularly impressive and especially leading to the FDA accelerated approval for a new treatment option for our patients with HER2 alteration positive non-small cell lung cancer. Brittany Harvey: I appreciate you reviewing that data and the new updates for both of these drugs and targets in this population. So then, I'd like to review the recommendations that the panel updated for our listeners. First, what is the new recommendation for patients with advanced non-small cell lung cancer and in activating HER2 mutation? Dr. Dwight Owen: So currently, these patients should continue to receive standard first-line treatment as we do not have head-to-head trials for HER2-directed therapy in the first line. However, for patients who have previously received systemic therapy and have a HER2-activating mutation, trastuzumab deruxtecan certainly should be offered to these patients. Brittany Harvey: Understood. And then the second category of patients that you identified, what does the expert panel recommend for patients with advanced non-small cell lung cancer and a KRAS-G12C mutation? Dr. Dwight Owen: So, similarly, these patients should continue to receive standard first-line treatment, as we do not have head-to-head trials for KRAS-directed therapy in the first line. However, for patients who have previously received systemic therapy and have a KRAS-G12C mutation, sotorasib can be offered as a subsequent therapy. Keep in mind that this is only approved in patients with the KRAS-G12C mutation, and not other KRAS alterations. Brittany Harvey: Thank you for reviewing those two recommendations for second or later-line therapies. What should clinicians know as they implement these updated recommendations? Dr. Dwight Owen: So, I think what we're really excited about is that both of these agents offer new treatment options for patients who historically did not have a personalized targeted treatment option. We are awaiting publication of additional studies to help interpret these data, but for now, clinicians should discuss these treatment options with their patients, and also keep in mind the pattern of toxicities that seem to be unique to each treatment. Brittany Harvey: Great. And then, you've just addressed some of this in your last response, but what does this change mean for patients with stage IV non-small lung cancer with a HER2 or KRAS-G12C mutation? Dr. Dwight Owen: I think the bottom line is that our patients for whom their cancer does not respond, or where it progresses after first-line treatment, will now have additional effective and approved treatment options that are really tailored to the unique characteristics of their tumor and cancer cells. Brittany Harvey: Absolutely. It's great to have new options for patients in this field. So then finally, are there future research developments that the panel is considering for future living guideline updates? Dr. Dwight Owen: So, we're particularly looking forward to the final publication of the studies that were recently presented, including the CodeBreak 200, and DESTINY-Lung02 trials. There are multiple ongoing studies for additional targets, including in the targets that we talked about; so, KRAS-G12C as well as HER2, as well as a number of other targeted options that may benefit subsets of our patients with metastatic non-small cell lung cancer. Brittany Harvey: Great. Well, I appreciate you reviewing all this data and the updated recommendations, and thank you for your time today, Dr. Owen. Dr. Dwight Owen: Thanks for having me. Brittany Harvey: And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. To read the full guideline, go to: www.asco.org/thoracic-cancer-guidelines.  There's a companion living guideline update on therapy for stage IV non-small-cell lung cancer without driver alterations, available there and in the JCO. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available on iTunes, or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.  

Parade of Techniques: 1. If you want to do something that you are uncomfortable with, make a commitment to your team and make sure they follow up with you next week that you made your commitment. 2. How to answer the question, “Why did the other buyer walk away?”, when you are representing the seller? Ask the Experts: 1. The hurricane decimated neighborhoods… It completely canceled all my LFTs. So, I got to snap out of this wound-licking and get some momentum back. How do I do that? 2. My number one goal is to not let the seller drive me crazy. Negative attitude! Call after call, after call! Calls me, I don't answer, calls three more times. I mean, immediately! So, what do I do?

Our Covid-19 LFTs cost £9m, free pools a postcode lottery, Tim Glover MHK resignation, Manx aerospace industry problems & fertiliser under "very serious threat". It's Update with Andy Wint #iom #news #manxradio

Dr. Navin Kumar, an attending Gastroenterologist at Brigham and Women's Hospital, medical educator at Harvard Medical School, and co-founder of the Run the List podcast and host Blake Smith discuss how to approach a patient presenting with acute right-upper quadrant (RUQ) pain. Together, they discuss the various causes of RUQ pain, in addition to how to approach a set of liver function tests (LFTs), differentiating hepatocellular injury from a cholestatic pattern. They then discuss how various forms of imaging (RUQUS, CT) can guide diagnosis and management, leading to a discussion about the use of ERCP and cholecystectomy in such cases. Lastly, the episode closes with a diagnosis and three clinical pearls about RUQ pain and abnormal LFTs.

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

A follow up to Episode #27 on labs and alcohol use disorder. So you're at work and you have a patient who you're pretty convinced has an alcohol use disorder, but you're not sure which test you should order to assess their alcohol use. LFTs? Carbohydrate deficient transferrin? Ethyl glucuronide? Phosphatidylethanol? In this episode we take another look at lab tests that can help you with your assessment of patients who use alcohol...including some lab tests that you probably have never heard of (but might find useful)

One serious challenge in the overall management of Fatty Liver disease involves creating cost-effective methods for "early" diagnosis. The term "early" is relative because, as Ian Rowe puts it, a "substantial proportion" of people admitted to hospital with various symptoms of decompensating cirrhosis or hepatic encephalopathy never received a diagnosis of advanced liver disease before they presented. Simply diagnosing these patients during advanced fibrosis (F2 or F3) can save lives, improve longevity and quality of life for these patients and save money for healthcare systems, all at the same time. Ian spends the first ten minutes of this episode describing a model he and Richard Parker developed to evaluate five diagnostic strategies:Targeted -- simple non-invasive liver screening Targeted + risk stratification -- targeted assessment plus FIB-4 or VCTE (FibroScan) for patients believed to be at high riskiLFT -- automated assessment of abnormal LFTs analyzed with other systemic measures in a medical record system "Comprehensive" -- a "kitchen sink" approach that runs iLFT analysis and conducts FIB-4 +/- VCTE on every patient"Fibrosis first" -- an approach that deploys viroserological and iron testing plus FIB-4 +/- VCTE for every patient "Fibrosis first" scored best in cost effectiveness (cost per correct diagnosis of treatable liver disease) and "decision curve analysis", which looks at true positive outcomes and false positive outcomes, correctly identifying 85% of treatable liver disease patients (vs. 90% for the comprehensive approach and less than 15% for the current targeted approach.)  Fibrosis first has the added benefit of not progressing treatment for people who may have steatosis without fibrosis. The rest of the conversation entails Ian, Louise Campbell and Roger Green sharing questions and observations. Highlights:Louise agrees that the current targeted pathway approaches do not work and  identifies lack of access to advanced testing in primary care as a central issue. She asks how many additional patients with Type 2 Diabetes, other metabolic diseases or CVD could be identified through this approach. Ian cannot answer because the question is outside the scope of the research. He points out that to assess different approaches accurately, researchers and policymakers need to settle on whether the goal is to identify steatohepatitis or something broader. Louise asks about the frequency and nature of referrals. Ian notes that one issue with iLFT is a high level of referrals for conditions that might not require treatment, the most common of which is "abnormal LFT without fibrosis."Roger notes that iLFT might help patients who complain they never heard about their NASH earlier. He also recalls Quentin Anstee and Stephen Harrison discussing recently that FIB-4 can serve as a prognostic measure not only for liver-related deaths, but also CV deaths and all-cause mortality. Louise suggests that patients will do better if they adopt a  behavior belief model instead of a sick patient approach and that the earlier in disease we intervene, the more success we will have. Roger and Ian note that Louise's focus is broader in scope than his model. Ian further notes that we do not know when non-fibrotic patients should be tested again, although he has some thoughts about this. Louise notes that one element that might make iLFT costly is that only 45% of patients picked up on iLFT are referred into the model. Ian notes that this insight might require changes in the model.As the conversation winds down, it shifts toward policy issues: should we focus testing on the workforce (Louise) and it the best point of intervention to limit advertising of unhealthy foods (Ian). 

Your boys blow the lid off Millennial singles, nature survival, and the 9-to-5.

RF, CRP, FBC and LFTs. Sometimes it seems doctors use more acronyms than words. In this episode Dr Bird breaks down some of the key laboratory tests used to diagnose rheumatoid arthritis.    Developed by Janssen Australia, Dec. 2021. Always refer to your healthcare professional about current treatments, possible side effects and other considerations. Janssen Australia, Macquarie Park NSW. CP-308575

Dr. Mark Korson from Tufts Floating Hospital for Children gives a "crash course" in interpreting lab values! Most patients with mitochondrial disease have faced a page of test results comprised of letters and numbers that would help them understand their current illness if the information made sense. CBC, CMP, LFTs, CPK, OAA and more...join us as we figure it out! CBC CMP Lactic acid pyruvic acid amino acids organic amino acids ammonia electrolytes glucose bicarbonate/co2 metabolic labs CPK LFTs carnitine TFTs: TSH, T4, T3 cerebral folate About The Speaker: Mark Korson graduated from the University of Toronto medical school and completed his pediatric residency nearby at The Hospital for Sick Children. He came to Boston to do a fellowship in genetics and metabolism at Children's Hospital. Following that, he directed the Metabolism Clinic at Children's until 2000, transferring then to Tufts Medical Center's Floating Hospital for Children. He is currently the Director of the Metabolism Service and an Associate Professor of Pediatrics at Tufts University School of Medicine. Besides clinical medicine, a key focus for Dr. Korson is education. He is concerned about the growing crisis in metabolic health care due to the shortage of clinicians available to treat this community. To complicate this situation, there are too few people entering this subspecialty. In the fall of 2007, Dr. Korson launched the Metabolic Outreach Service, for which he has travelled on a regular basis to five teaching hospitals in the northeastern US where there is no on-site metabolic service. The goal is to provide educational and consultative support so that non-metabolic clinicians can learn how to participate more in the diagnosis and management of patients with metabolic disease. A component of this effort is the Patient-As-Teacher Project, which engages patients and family members to participate actively in the teaching of medical students, house-staff, primary care providers and specialists. The Outreach Service is funded by a consortium of corporate and disease foundation sponsors. In addition, Dr. Korson co-directs the North American Metabolic Academy, a one-week intensive course about metabolic disease for genetic and metabolic trainees. NAMA is sponsored by the SIMD, the Society for Inherited Metabolic Diseases.

Show Notes: PID is often missed because the exam can be unimpressive. Remember more than 50 percent of men and more than 80 percent of women have no symptoms with chlamydia, so if you use your logical brain, it follows many cases are mild. In terms of risk, remember that PID is not always an STI; it is caused by vaginal flora in about 15 percent of cases. Fitz-Hugh-Curtis (FHC) is also often missed, and you are probably missing it if you are not diagnosing about one case a year. The classic case is pleuritic RUQ pain in a sexually active woman, normal LFTs, elevated D-dimer, and normal CT angiograph of the chest. If it is from chlamydia, patients almost never have pelvic symptoms. Incubation is usually about three weeks. Do a sexual history. If there is a new partner, consider FHC even if the pain is nonpleuritic. Gallstones can be a red herring.

1.CBC, U&Es, ESR, calcium, phosphate and LFTs 2.Vitamin D levels. 3.Prostate-specific antigen (PSA) tests 4.Parathyroid hormone (PTH) level - Generally, this must be transported to the laboratory on ice within an hour. 5.If elevated alkaline phosphatase is discovered, isoenzymes may be necessary to determine whether it originated in the liver or the bone.For the complete details kindly stay tuned

Show Notes: Return Precautions: These are your safety net, and there's a huge variance in what physicians write. The nucleus should always be to return if not improving or worse or if anything new happens. Logic: Most people don't want to return for the same thing that you just sent them home for, so you must emphasize this, focusing on things like syncope, abdominal pain, fever, and vomiting. Incidental Findings: Diagnose lung and adrenal nodules, ovarian cysts, etc., and give them copies, tell them to follow up, and write it in the aftercare. This can be a big medicolegal risk. It's important that it is not so incidental when someone who doesn't ovulate has free fluid in the abdomen. Abnormal Labs and BP: From most common to least common include hypertension, glucose >LFTs, K+, Na+ >others. Sedating Medications: Not just driving. Even taking a bus or walking home. Don't rely on the pharmacist.  Malpractice usually doesn't cover third parties. Read more: https://bit.ly/3K8tPs6.

News and UpdatesOn the menu this morning:Staff talking about spring statement and inflationSpring statement and deprived communitieshttps://www.theguardian.com/uk-news/2022/mar/23/spring-statement-2022-key-points-rishi-sunak-budgetLess growth 3.8%, was predicted 6%Inflation 7.4%1.25% NI rise staysLess borrowing - some dry powderCut fuel duty by 5p/lNI Threshold increased to £12,570 - lifting proportion of income out of NI deductions, so tax cut for someCutting income tax in 2024No new Money for General PracticeGP contract changes 2022-23https://www.bma.org.uk/pay-and-contracts/contracts/gp-contract/gp-contract-changes-england-202223Global sum 3%QOF 3.2%PCN ARRS uplifted, IIF upliftedAnticipated 2.1% pay upliftSqueeze like 2008 and austerity eraFirst PCNs hire GPs in ‘portfolio' roles to work across networkshttps://www.pulsetoday.co.uk/news/pulse-pcn/first-pcns-hire-gps-in-portfolio-roles-to-work-across-networks/‘Uberisation' of general practice is harming continuity of care, warns Jeremy Hunthttps://www.pulsetoday.co.uk/news/politics/uberisation-of-general-practice-is-harming-continuity-of-care-warns-jeremy-hunt/Moving away from continuity a big mistake‘I'm afraid we're moving towards the Uberisation of general practice where you see a different GP every time you contact the NHS, just like you see a different Uber driver. That cannot be a good thing for safety and care.'‘I personally think it's a big mistake to move away from continuity of care.'Should have done more on the named GP agendaSaying much more sensible things when out of favour and chair of health select committeeGPs can't access Covid tests as Government asks public not to order themhttps://www.pulsetoday.co.uk/news/breaking-news/gps-cant-access-covid-tests-as-government-asks-public-not-to-order-them/The Government told the public that free LFTs would be available until the end of this month, but the ordering website now says that ‘most tests are now needed for people at higher rHow can PCN PLUS help you as a new or established clinical director or network manager in your primary care network?Sign up here: bit.ly/PCNPLUSJoin Gandhi, Andy, and our friends Ben Gowland from the General Practice Podcast and Tara Humphries from the Business of Healthcare podcast for our complete, practical course to help you manage your PCN.Join above. Being a GP trainer is more complex than ever, so let GP5T faculty help you train your trainees better at GP5T3. Our third conference will focus on supporting trainers to manage key issues like the exams, consultations skills, and challenging situations with trainees, including our first-ever session on gamification of training. GP5T3 is also punctuated by our keynote session by RCGP Vice-chair Dr Margaret Ipkoh.&n

Sign Sarah's petition here: https://www.change.org/p/boris-johnson-we-want-free-lateral-flow-tests-available-to-those-who-are-clinically-extremely-vulnerable?recruiter=88671692&utm_source=share_petition&utm_medium=facebook&utm_campaign=psf_combo_share_initial&utm_term=share_for_starters_page&recruited_by_id=7d3d9f85-1a0e-4f46-a04f-a6e821f4a689&utm_content=fht-32443340-en-gbFollow us on social: @LeonardCheshireVisit our website: https://leonardcheshire.org/Email us at: disabilitydownload@leonardcheshire.org 

In the latest Hot Topics podcast with Dr Neal Tucker, we reflect on the government removing covid measures and how this affects general practice.  In research, we have a look at a timely BMJ paper on the accuracy of lateral flow tests? As we prepare to stop testing, does the data provide us with some reassurance? We also have a look at a new way of assessing the risk of DVT and whether it can safely identify low-risk patients and reduce referral rates. And remember Zika? A new paper in the NEJM highlights to risks for children exposed to zika in utero.ReferencesBMJ Accuracy of Covid LFTsBMJ Diagnosing DVTNEJM Zika infant mortality

France has lifted the travel restrictions for UK travellers as Omicron waves come and go. Hurrah! I hear you shout. But before you dash off to the Eurostar terminal there's still plenty to consider in regards to what you need to have to be able to travel without hassle.PCRs, LFTs and points of entry will all be discussed as I find my way to France when the travel ban is lifted, which is some time on Friday 14th January (they've not actually said when yet.)Of course this podcast is completely free, as is my weekly travel email. You can sign up at independent.co.uk/newsletters. See acast.com/privacy for privacy and opt-out information.

Parade of Techniques: 1. How to boost attendance at your next client appreciation event 2. What our agents are up to in the first month of 2022. Inspired to take time off next year? LFTs? Marketing plan? Ask the Experts: 1. My buyer is asking for a list of properties to look at. How do I avoid sending them homes they've already looked at online? 2. How can I hit the ground running as a new agent? If you like what you're hearing each week on the podcast, we encourage you to get involved in R Squared Coaching: floydwickman.com/r-squared-coaching

Liver function tests (LFTs) are a group of blood tests that provide information on the function of a person's liver. This episode Dr Matt & Dr Mike explain what each liver function test represents. This includes bilirubin, albumin, AST, ALT, ALP, and GGT. **This episode is not intended to diagnose. It is for education purposes only. Always consult your healthcare provider if you have issues with your health**

Drs Lisa and Sara are joined by GP Dr Nikesh Vallabh, Consultant Cardiologist Dr Karthikeyan and Consultant Gastroenterologist Dr Bliss to discuss advice and guidance. For those unfamiliar, the advice and guidance system came about to try to ease pressure on the long outpatient waiting lists, providing a different way of managing some cases. It is in place for a number of specialties for primary care clinicians to ask questions to consultants, getting an answer that will help guide patient care within a matter of short weeks at most. We talk about the system and where it can fit in to make a difference to patient care. We take the opportunity to go through some common themes and glean learning points from these to help our own practice. Useful resources:  Wigan, Wrightington and Leigh have their own LFTs guideline that should be available on the intranet or contact the local CCG BMJ LFTs Algorithm 2017: https://www.bsg.org.uk/wp-content/uploads/2019/12/Guidelines-on-the-management-of-abnormal-liver-blood-tests.pdf Greater Manchester Guidelines for managing patients with dyspepsia in primary care: https://gpexcellencegm.org.uk/resources/guidelines-for-managing-patients-with-dyspepsia-in-primary-care/#.YFEP4C2l23U NICE guidelines Chronic Heart Failure in Adults: Diagnosis and Management (2018) https://www.nice.org.uk/guidance/ng106 ___ We really want to make these episodes relevant and helpful: if you have any questions or want any particular areas covered then contact us on Twitter @PCKBpodcast, or leave a comment on our really quick anonymous survey here: https://pckb.org/feedback ____ This podcast has been made with the support of Greater Manchester Health and Social Care Partnership, GP Excellence, Greater Manchester Training Hub and the GP Fellowship Programme, as well as Wigan Borough CCG. Given that it is recorded with Greater Manchester clinicians, the information discussed may not be applicable elsewhere and it is important to consult local guidelines before making any treatment decisions.  The information presented is the personal opinion of the healthcare professional interviewed and might not be representative to all clinicians. It is based on their interpretation of current best practice and guidelines when the episode was recorded. Guidelines can change; To the best of our knowledge the information in this episode is up to date as of it's release but it is the listeners responsibility to review the information and make sure it is still up to date when they listen. Dr Lisa Adams, Dr Sara MacDermott and their interviewees are not liable for any advice, investigations, course of treatment, diagnosis or any other information, services or products listeners might pursue as a result of listening to this podcast - it is the clinicians responsibility to appraise the information given and review local and national guidelines before making treatment decisions. Reliance on information provided in this podcast is solely at the listeners risk. The podcast is designed to be used by trained healthcare professionals for education only. We do not recommend these for patients or the general public and they are not to be used as a method of diagnosis, opinion, treatment or medical advice for the general public. Do not delay seeking medical advice based on the information contained in this podcast. If you have questions regarding your health or feel you may have a medical condition then promptly seek the opinion of a trained healthcare professional.

It's Crunch Week (again) for Boris Johnson as he tries to get Plan B Corona restrictions past a mob of increasingly rebellious and COVID-sceptic Tory MPs. Meanwhile the party-that-wasn't and the world's most unwise Christmas quiz continue to dog our unfortunate PM. Oh, and there's the North Shropshire by-election on Thursday too. New PM by Christmas? Ros Taylor alerts you to what's coming in the week ahead.   • “Johnson can't bring himself to cancel Christmas – even though for lots of people, Christmas is cancelled already.” • “If you see a pack of LFTs around, I would grab it now.” • “Johnson isn't in immediate trouble but honestly, who would want to take over at this point?”   Presented and produced by Andrew Harrison. Assistant producers Jacob Archbold and Jelena Sofronijevic. Music by Kenny Dickinson. Audio production by Robin Leeburn. THE BUNKER is a Podmasters Production Learn more about your ad choices. Visit megaphone.fm/adchoices

Diazepam is also known as Valium and Diastat. It comes as a tablet, solution, nasal liquid, rectal gel, and concentrated solution. There are a wide variety of uses for diazepam such as for the treatment of anxiety, pre-op sedation, procedural sedation, alcohol withdrawal, muscle spasms, and seizures. A common dosing range when treating anxiety is 2-10 mg PO bid-qid. There are also approved uses in pediatrics such as for anxiety, muscle spasms, and status epilepticus. The benefits from diazepam are often linked to the enhancement of the GABA-A, not the GABA-B, receptors. The most common side effects are drowsiness, confusion, libido changes, and irritability. There are several Black Box Warnings to be aware of such as concomitant opioid use, the risk of abuse/misuse/addiction, and the risk of dependence/withdrawal reactions. Make sure to monitor the patients' LFTs if prolonged usage as well as their blood pressure and mental status. FREE Drug Card Sheet is available for this episode at DrugCardsDaily.com along with ALL past FREE drug card sheets! Please SUBSCRIBE, FOLLOW, and RATE on Spotify, Apple Podcasts, or wherever your favorite place to listen to podcasts are. I'd really appreciate hearing from you! Leave a voice message at anchor.fm/drugcardsdaily or find me on most all socials @drugcardsdaily or send an email to contact.drugcardsdaily@gmail.com to leave feedback, request a drug, or say hello! --- Send in a voice message: https://anchor.fm/drugcardsdaily/message

Subscribe to our Benzinga Crypto Youtube Channel Episode Summary:Chintai x Chimera Wealth InterviewMoon or Bust - To Play Moon or Bust go to https://www.benzinga.com/markets/cryptocurrencyGuests:-Chintai is a Singapore-based company with offices in Germany that uses blockchain technology to modernize capital markets for asset managers, banks, and enterprises.-Chimera Wealth is a registered investment advisory (RIA) firm focused on empowering clients to enjoy their lives today while designing their tomorrow.Meet The Hosts:Logan RossBlockchain Analyst @ Benzinga | President @ Wolverine Blockchain | Crypto investor and educator since 2016https://twitter.com/logannrossRyan McNamaraBought sub $90 ETH during the bear market | Liquidated on ByBit | Was into DeFi before it was cool | Ran ASIC mining operation in 2016 (sorry planet Earth) | $UNI Bag Holderhttps://twitter.com/ryan15mcnamaraDisclaimer: All of the information, material, and/or content contained in this program is for informational purposes only. Investing in stocks, options, and futures is risky and not suitable for all investors. Please consult your own independent financial adviser before making any investment decisions.Check Out Other Benzinga Podcasts Here:Check Out All Benzinga Crypto News HereGet Moon or Bust Crypto Merch Here Join the Telegram: https://t.me/moonorbustBZ for 25% of Moon or Bust Podcast swag.Claim 1000 ZING airdrop: https://www.benzinga.com/zing Unedited Transcript:GM zinger nation. My name is Logan Ross, and I'd like to welcome you back to moon or bust your home for all things, altcoins and DFI. We've got a great show prepared for you today. Uh, but how you doing Ryan? What what's going on? Well, GM Logan happy Thursday and happy Monday to our view. Yes indeed. So before we can get started, I want to let you guys know about a couple of things we have down in the description below.So if you're here for crypto content, uh, we have a new Benzinga crypto channel that we're building out right now. It's the top link in the description below. Uh, and so make sure you get subscribed to that. If you're new to the Benzinga channel overall, make sure you subscribe to this channel that we're on right now.And while you're down there, take a second to smash the like button for us. Uh, Ryan, can you tell us a little about the, the Benzinga swag that we have. Yeah, we got a ton of Benzinga swag. We'd have some Mooner bus specific swag. You've probably seen Logan, or I wear that Eve hat. We have a Shiba Inu, had a Bitcoin hat.We've got some pretty cool shirts. So definitely check that out. And if you want a discount code, join the telegram and we'll toss you 25% off. You heard it there first, uh, and on that note, make sure to connect with us on Twitter. Send us a DM. We'd love to hear from you. Um, but yeah, let's just get right into the show notes for today.Uh, so without further ado, I would like to welcome AIJ and David to Mooner bust. How are you both doing today? Thanks for having me. Yup. Good to meet you. Yeah, pleasure is all ours. So let's just dive right into it. Um, David, you are the, the founder of the crypto project, chin tie, uh, and Asia you're coming from the investment side from Kymera wealth, uh, could starting with David, could you walk us through, you know, your background in crypto, how you found yourself, where you are.Yeah. I mean, my background, uh, maybe isn't that uncommon, but it's certainly different from probably a lot of people who are in the crypto space right now. Um, particularly this current generation just coming in. I, uh, found my way in via a 20 year career in financial services, working for banks and asset managers.And so I got to live through the 2008, nine financial crisis. Uh, from St seeing it from the very inside and, uh, and really got a sense of just how flawed the existing system was, um, that it really wasn't working for us generally. Um, and that, that led me to start looking in 20 15, 16 onwards to wards, uh, disruptive technologies that I could use allies to help, uh, improve prove the financial system in petite.Um, so that, that led me down that first, uh, crypto rabbit hole. You know, I started looking at Ethereum, uh, beyond Bitcoin and getting a sense of what was possible with small contracts and, and beyond. Um, but, but really then, uh, that's what led us to, uh, creating Gentiles, which is a digital asset platform for dynamic forms of issuance and market creation.And, and, uh, yeah, I mean, th the whole growth of the DFI sector over the last three years is a phenomenal, uh, illustration. I think of that potential. Awesome. An agent. Yeah. So I am a managing partner and chief investment officer of a registered investment advisory firm here in the United States. We're talking about my crypto expertise.Well, I dabbled, you know, right when it became a bit popular in 2017, uh, not gotten to extensively until actually I was introduced to David and what their project is over I and tie. Uh, that's where not only for my own. Personal portfolio, but also as a firm, we've started to do well a bit more into the space, especially with clients nowadays on both sides of the spectrum, whether you have the younger generation or those who are nearing retirement, really just looking to diversify their assets and portfolios through different areas.So, um, yeah, that's pretty much where my exposure came into this. Awesome mate, Jay, we're really happy to have both of you on here today. It's great to see both sides, uh, you know, both the builders and the investors. Uh, so we're going to get right into it. So, David, could you tell us what chin tie is from a very high.Yeah. From, from a very high level. Um, we actually started out, I guess, in the defy space before he got called defy, um, back in, in 2017, we decided we were going to build out a full on chain, uh, order management system and an exchange, and actually try a new concept, which was trading of the utility of. Um, in this case, we started off with network capacity and, and it was a great initial use case, although it didn't last that long.Um, but really once we actually spent all that time building that out, we started to realize the sheer amount of time and effort we'd spent issuing our own network, token, the checks. Um, uh, we, we did that post, the kind of ICO, boom, if you all recall back in 2017, and it was just around the time that the governments were starting to crack down on some of the scans that had had erupted throughout that period.And we're starting to make noises like this is actually a security and things, and that really scared off a business and the promise of mass adoption for a couple of years, um, during that period. But nonetheless, we. Did a full issuance of the checks token, uh, during that period. And we built an exchange and we realized the entire process of doing that was incredibly complex, um, and very, very challenging for anybody else who really wanted to follow in our footsteps.So it really, the moment you looked at every other project, though, they had a need by and large to issue some sort of. To deploy on a, on a secondary market and, uh, and have liquidity with it. And so that was the fundamental foundation, uh, underlying Gentile as a platform, which was to say we were going to provide a solution that would enable dynamic forms of issue and spit utility tokens, and NFTs write down.Um, securities real estate. Um, so, so we've pursued licensing out of Singapore to ensure that we'll be able to, uh, do that type of thing with a fully compliant, uh, framework as well. And, uh, and that that's a fundamental differentiator too, between what we're doing at anything else in, in that everything is operating, um, on a compliance control framework so that, uh, whenever you've got an asset that's, that's red needs to be red compliant and, and handle that way.It can have rules in place. Uh, while still interfacing, uh, long-term potentially with the defy system too. So we kind of, uh, tend to tend to describe it to two outsiders as we're building the regulatory bridge between traditional finance and defy, and we're going to enable that mass adoption curve. And so it's a, it's an exciting time because the networks, uh, about to launch next next month.And, uh, yeah, so we're delighted to have, uh, Comera wealth on board with us. Awesome. So AIG, I know Kymera wealth has a background in real estate. Could you tell me specifically what interested you in the chin type? Yeah. So before I forget, um, and we're, we're going to get into this later on. Uh, I do need to disclose that, uh, Kymera wealth, as well as myself and the partners do have an investment in shin, Thai, uh, as backers.So, uh, yeah, just have to disclose that out there. But yeah, what really interested us is, as I mentioned, we're coming from the traditional financial space, right? There's kind of two aspects. One of those is acting as a fiduciary for our clients, really trying to develop a portfolio that's in their best interests.And as we're getting into this even more complex economic environment, we're having to diversify our investments, not just from the traditional stocks, bonds mutual funds, right. But also in different. Classes. And that's where the digital asset space is growing, not just in popularity, but acting as a very beneficial, uh, diversification tool, regardless of if you believe.Bitcoin or what have you and the fundamentals of it. It is acting as a diversifier for client portfolios, and I'm not talking about going 100%. Right. Uh, you can do something as small as one or five. And then so yeah, I come here a wealth, not all the way we're doing that aspect. And that's really what attracted us to, uh, what the team that shouldn't ties really do.Providing that platform, but also the compliance and regulatory aspect. Uh, as I just mentioned earlier, right? I have to disclose that well, we're investors in shin Tai. And so our area is very heavily, regular. Especially following the global financial prices and it's for good things, it's for the protection of the investors.And so that's really what attracted us is. We're seeing a lot of these projects out there and the digital asset and the crypto space, you know, initial issuance and such, but nothing really. That's kind of providing that regulatory or compliance framework and all that. David of course, top more in depth. I don't want to steal any thunder from him, but.Uh, that's one component. And then the other side is yes. What we're working on on a private funding side. I can't give too much information, uh, but we do have some expertise in the real estate as well. Some of the venture capital area. So really partnering machine tie on providing that, uh, through this new asset class digital assets versus doing the traditional route of either bringing up a venture capital firm and only being able to.Give that exposure to accredited investors and more towards the retail investor, right. The general population. And again, everything we want to do is in a compliant regulatory mindset. So having project like shin type to partner with is just perfect for us. Aja. I'm curious to know, did you receive any pushback from your big investors, uh, for moving into the crypto space where any of them kind of spooked by it?Uh, and if so, how did you handle that? How did you explain it and did they come up. Yeah. So right now we haven't really gotten much pushback. Uh, I will say there are some clients that we have that, uh, it is a new space to them and really what we try to do. And this is an all aspects of how we deal with clients is really focused on the educational aspect.Right. What I've found is most. Portion is just the financial literacy, whether you're talking about crypto or anything, stocks, bonds, and it's really our job to educate our clients that, Hey, this is a digital assets, uh, that we're really looking into, whether it's Bitcoin, Ethereum, a platform like shin tie or something that we're trying to privately issue.Once you educate the client from my experience, it's a lot easier to get them to jump on board versus just saying, Hey, there's this hot trending? Token that's out there. I want to invest 10%. Right. Um, so that's really where we focus and we don't really typically get much pushback once we educate those clients on just informing them.It's great to hear. So, David, my next question is for you, which blockchain does chin use and what does your multi chain architecture look like? Ooh, what a technical question. I mean, before that, I have to say again, I'm somewhat sheltered and being, pushing your clients into.No, I wouldn't do that. No, no. I would say that might be wise from a long-term hold perspective, but who knows? So yeah, the underlying protocol. Um, so, um, one of the other lead investors in the round for us was Dijuan. The role team known for launching the ESI protocol. Um, however, um, we, we select start because it's highly scalable and configurable.Um, and although it's had a bit of an interesting, uh, I think period over the last two and a half years, uh, since the original, uh, wider public blockchain was launched, uh, it's actually been very well maintained during that period. And it's is, I think there's some encouraging signs in that wider ecosystem, but.What I generally look at now is what is the underlying linkage potential to multiple other protocols? And that's just a general demand. That's coming from all clients that we were talking to you. Now, they want to be able to have that flexibility to lest on the very best protocols and in the, in the best potential markets, or they want to be highly selective, maybe about what they do as well.So, as an example, if you were to spend all the time going through an issuing a security token and putting controls around the marketplace, Who's a participant and maybe you're putting in place mandatory KYC, AML anti-money laundering checks in there as well. And so on and so forth. Uh, you defeat the whole purpose.If you just decide you're going to go and list it on unit swap, for example, because at that moment you get the, the, the, one of the great aspects of defy, which is that it's decentralized in censorship resistant. But the problem with that too, is that at that point, frankly, you know, your securities could be going off and being used for money laundering or being sold.You know, a country where somebody maybe is blacklisted elsewhere out of the business environment, because. The links to terrorism or something. So from an issuer point of view, this is where the they're more interested in other compliance solutions too, and saying it will be great to have options to connect in.And so the good news there for us is that we've got a really strong partner. Um, the announcement will be going out soon. Which provides us conductivity full conductivity to about 30 different other blockchain protocols. And I think that's broadly the future that we're going to see, which reminds everybody.I think, of the whole, uh, you know, underlying protocols of the internet itself, which is no one really. What's some of the technical connectivity issues are, you know, w w we're talking right now across this, and I know it's very easy to get really passionate about some of the blockchain protocols, the layer one stuff, but actually they can intercommunicate increasingly well, and, and I think from an end user perspective, you can imagine log-ins, you're on the line of account.You see, you're asking. The fact that you might then go and choose to trade a sale on one exchange or another. And under the surface, it's actually transferring between those chains as part of that process really shouldn't matter to you. And that's broadly where we're moving towards, which is encouraging, I think.And it's a, it's, it's an exciting, uh, component we need to needed to collect a, we get over the line for achieving mass adoption. Yeah, I think that's a good take. Do you have any plans on integrating with Ethereum in the future? Uh, yes, we're, we're already able to connect to it. Um, so for example, uh, the checks token, uh, network token, uh, we had to be.Limited by the initial listings. Uh, we are about to push a hat with listings or a number of, uh, Ethereum based, uh, exchanges. And, uh, and it's such a rich ecosystem that even though it has obviously some evident flaws, people talk about like the gas fee issue and so on. It's it's got an incredible number of talented developers in that pushing out some really innovative models, uh, related to everything from, you know, insurance to lending.And I think it's that type of innovation, which is fantastic for the wider financial system, because it really, it gives ideas to the, the wider financial system on what's possible. Uh, even if you know, it is subsequent stage, we find that some regulatory controls maybe start to creep in from governments or, or maybe not.Um, but, uh, yeah, I, I personally love what they've been doing over the last two years on the device space on, on the Ethereum. Totally me too, for sure. Uh, can you give us an overview of the process it takes to tokenize a real-world asset on the blockchain? Yeah, it's actually really easy. So, so from, from the perspective of actually tokenizing anything, it's a much over-hyped, uh, process in that it really is, is relatively straightforward.So within our platform, for example, now we were on a life, uh, call, call with a client the other day where they, they set up the. Got registered and have configured in and tokenized and issued an asset within about five minutes. And it was live on the chain to their exact parameters and they were able to then deploy a secondary market and commence, active trading with other people.Now that, that is all well and good, but the problem is if you're doing that with anything, that's actually like a, like a security, for example, with, with controls that need to be placed around that. This is where regulatory compliance and this other more complex side kicks in. And that's really where, um, I would say.90% of the value app really kicks in because tokenization is, is inherently going to be something that we all have, uh, disposed increasingly. I mean, if you think about it with NFTs, what that's shown us is with things like open seas, anybody can issue a token, right? I mean, you guys could have, have a Benzinga token, right, right now in a variety of different forms and you could issue it out pretty fast.Um, so the same really does apply here, but where it comes, uh, becomes really relevant. Ensuring that all the underlying controls and rules are put in place so that you can not only then say you've issued a security token, but that it actually combined and be handled in exactly the same way as the security.And that's how we eventually moved to all of the financial system going digital, going to tokens and, uh, and all the associated benefits we'll get from that. And how does holding custody of these real world assets work? Uh, yeah, it's it. Can sorry, go on. Finish your question in the custody of the real world assets that are tokenized on the platform?Uh, well, in, in the case of the regulatory ones, we've actually signed partnerships with several. Local and international, um, digital asset custodial solution providers. Um, again, there, there are announcements that are going to be going out very soon, um, on that side of things. However, when you get to things like utility tokens, um, we absolutely could be custodians as well.I think it then becomes something of a network security issue generally. Um, so why should use as necessarily have to trust and throw, throw the dice with every single thing athletes are up to or particular. Uh, asset, it kind of generally makes sense that particularly when the, um, doing anything that involves cross chain, that there, that utilizing a provider who maybe has got aspects like insurance, um, and is a established player who's in type business is looking after your people, digital assets securely.Now that doesn't mean that they couldn't still take control. You know, put them in their own wallet and maintain the key, but there are points in time where you are going to want to hand that off to somebody in a secure way and know that yes, it's moving around the underlying defy system here, but, but we're generally comfortable with it.So where we were definitely very focused on partnering with firms of that kind of quality to ensure that our users have the maximum. Yeah, that's great to hear. It seems like custody is becoming more and more popular, which maybe the earliest adopters of crypto didn't always like, or, you know, see the need for.But I think, you know, to get some sort of mass adoption events, Retail won't even realize they're interacting with blockchain and we'll all be taken care of for them. Uh, w which is, you know, it's good for some people in certain applications, especially when there's there's high value assets at stake. Uh, so speaking of those high value assets, can you tell us, uh, what, what is the main type of asset that, that Shantae is focused on tokenizing?Um, and how is it bringing this type of asset to a new audience or a new market? Yeah, well, actually it's, it's entirely being client driven. So as an example, comment or wealth, um, I think, uh, agent, maybe you could speak to this, but I know, you know, for example, Definite interest in, in the fractionalization and tokenization of real estate, because it fundamentally disrupts an asset class like that and adds liquidity to, to an illiquid asset class for the first time, which is not to be underestimated, what a big deal that could be, but there's a variety of other things possible.Um, and if you think about a firm like Kymera wealth, that's. Got back potential. It really, to some extent it's almost imagination is to, to is one of the core limits as well as what their client base might be. But I'm just broadly curious what you would say to that one in terms of what you think that the primary asset classes will be served for you over the next three years beyond real estate.Yeah. So I mean, one of the things we've been exploring is of course, real estate, so tokenizing that aspect, and it's not just the physical real estate work, just mentioning it it's conversation, but also the forms of. Right. So if you actually look at financial markets, the bond market is a massive market.Of course you can probably second me on this. It's it's bigger than what we have is this. So that's an area where also looking at Kymera as well. Um, whether it's into the mortgage real estate space or just in and of itself, just from my experience in my network, talking to other individuals as well, some of these businesses, uh, I think debt will probably be one option.Ty's biggest players. Um, I know one who's doing. And I think David, I introduced them to you. I can't recall, but they're really looking at doing like a Def con reconsolidation right. And seeing if they can have somehow tokenize that there's other areas too. I think it's very interesting how innovative some of these entrepreneurs are being in regards to another one I had project I had run into is looking at doing the like solar energy credits and how that could somehow be tokenized to help incentivize individuals.I Kymera wealth. I would say our biggest area is, as I mentioned, the real estate space, uh, that just seems to be where a lot of our clientele is kind of driving us and part of our network and in house as well as, as I mentioned, the loan space for the private debt dealing area. Yeah. And actually an interesting, uh, illustration of, of how difficult this is, is, is to predict is that I would have never predicted for example, that AF first go live market next month would be a carbon.So, you know, I thought all expands would be real estate or it's bound to be securities or, or just the standard utility token. But no, it's actually the global carbon market is forecast, for example, to be, um, up to $50 trillion by 2050. Um, because obviously the, the, the issue related to. Um, climate change and so on.And just the general challenges of the amount of carbon being dumped into the atmosphere is whether or not people fully agree with all of, all of that. And it's a relevant, because there's wider global consensus on the need to remove it, the statistical test written. So actually there's a huge potential that.The global carbon market is a great example of why blockchain technology will gradually pervade and, uh, move into lots of other sectors beyond what we've seen so far, because it's a corrupt sector and the carbon credit market can be faked. And you can end up with stale credits being Retraded elsewhere, which is a great way of kind of saying, no one really can control this properly.And it becomes somewhat meaningless. Uh, You know, your audience are gonna get it better than anybody, uh, that blockchain and be able to link some carbon directly removed and then burn those tokens. When they've actually been consumed, say by government to offset that that's a perfect use case for blockchain.And so. If we've got that as our launch market, who knows actually what some of the other, you know, really big use cases out there will actually be. Um, I think it's, that's the exciting thing about digital assets is that it extends to really, almost anything in any way that we, we exchange value. Um, and that's, that's where it's going to be a fascinating one for us to watch how this evolves over the next one.I want to touch on the tokenization of real estate a little bit more. How does tokenizing real estate benefit retail investors? So say one is providing greater access. Uh, so I had mentioned earlier, right? In regards to tokenizing, not just real estate, but other areas where it's only privy to, for, to give you an example, there's a.Particular investments, basically a non-traded REIT, a real estate investment trust. Typically you have to have certain requirements that the investor meets, whether they're an accredited investor, meaning they have like a $1 million net worth or earn 200,000 a year. For the past two years, there are certain income requirements that.So tokenizing some of these real estate's whole physical assets can provide greater access to retail investors versus, you know, other areas of the market where they weren't privy to. And that's, again, that's one of the reasons why, as I kind of hear our wealth is really interested in this area of.Providing greater access on all these different areas, not just real estate, but those private companies who maybe want to tokenize their equity in some sort of form or fashion to give it to the people. And you're seeing that trend grow right. We have crowdfunding and stuff like that. They're even online platforms that have been doing these kinds of deals, just in a different method.And so it's greater access for me that I would say is the biggest factor, David. I'm not sure what you would like to have. Uh, yeah, no, I think I broadly agree with everything you've said. I mean, really fundamentally to, um, tokenization of real estate. Uh, it doesn't have the potential to, to, uh, unlock access to an asset class that a huge proportion of the population right now, the, the, the younger adult population or affects will be priced out of.We can argue whether or not it's actually a good time to do that, given that we're at cyclical, highs on everything. But, uh, outside of that, it's fundamentally. One of the few asset classes that has literally solid backing in terms of asset backing behind it. So it's fundamentally undervalued right now because of the liquidity issues and the, and the lack of access, uh, for, for many, to be able to trade in and out of it.So for me, I just look at it as a way that, uh, people will be able to fundamentally change how they interact with real estate. They'll, there'll be. Utilize it and dip in and out of it in the same way we do it securities, um, over time. But also over time, I think it's going to disrupt how we have all the financing aspects of, of, uh, of, of real estate as well.You know, that they'll, they'll come a time when the concept of a mortgage may end up becoming obsolete as we know it now, because there's the tokenized. I mean, if you can imagine owning a house, and this is looking ahead in the future of the potential of it, if you can tokenize it in, in sort of say a mil, a fraction of, uh, And each token, therefore is linked to one Millington of the property.Well, the underlying market, um, would be able to effectively you, you could borrow those tokens off the market, in the form of leasing and pay the holders. The equivalent of view you, the way you pay the bank right now. And, uh, and over time you acquire through some special permissions, more and more of those tokens off the market to do eventually on the house.If you want in such scenario. Now that's the type of mechanism that could come into play eventually as an alternative way of actually funding out something as simple as, uh, over some of these fundamental as a house. So. Um, yeah, I think it's not to be underestimated the potential of all of this. And again, it's really going to come down to a combination of the, the innovators coming out with these types of concepts and trying to deploy them.And obviously the regulators and governments globally getting comfortable with such, such a design as well. AJ you mentioned, uh, that you suspect real estate bonds, and that may be one of Shanghai's biggest, you know, uh, platforms or applications in the future. Um, could one of you speak to, uh, you know, a little bit, little bit more detail on how this might work?Well, I can talk about the mechanics of it. That's for sure. I mean, I definitely agree with AJS point that bonds is probably the. Biggest potential market of all digital assets. I mean, like it or not, there is a hell of a lot of debts watching around the world. And, uh, it's also fairly fundamental for the way that we, uh, we actually conduct different forms of, of, uh, commerce generally.As well. Um, and it's actually very important. It's not always about a thing. So as an example, um, there are ways that if you, if you're a company, for example, you don't want to necessarily sell equity in your company, just because you need to access to investment capital, the idea that you could far more cheaply access and issue your own kind of corporate bond to, uh, to token holders, uh, backed by, you know, various fundamentals that you've provided related to cash flow and so on, and then pay them off over two or three.And access that farm in a way that currently most small companies are priced out of as is the type of thing that's possible. I mean, even some, just a single use case like that is a huge deal. And, uh, so I do think that broadly it's going to be a big one, but as to how it mechanically works well, it's programmatically, not that dissimilar to the underlying permissions you have with things like a security, it's just the.Whereas with a security, you might have things like voting rights and dividends and that type of permissioning built in and actions. Uh, with bonds, you just have bond blind ones instead. So you have coupon payments and you have the underlying dates related to them and you'll have certain default criteria.And what typically can happen, um, in, in a variety of other scenarios. They just get programmed in and then they get handled. Um, and of course, if it's a digital bond, well then you're logically also going to have to apply a different set of compliant compliance rules as well. So they'll have to be in coded and built around that to ensure that the, the market operates in it in a legitimate manner too.But, um, yeah, other than that, it really is just one of another multitude of new digital asset classes. I think we're going to see in the, in the coming two or three. Yeah. The point you make about kind of requiring reporting of, of, uh, financial data and, you know, kind of putting on chain, the risk that's associated with certain bonds, I think is really interesting.Um, I I'm by no means an expert in the real estate sector. But like, I know that that's one of the big things that led to the financial crisis of 2007, 2008, was that the, the, the debt ratings or like the risk ratings on these bonds, uh, were completely fraudulent. And, you know, synthetic bonds were created with, with just like never-ending leverage and, and an entire market was made out of basically thin air.Right. Um, so. I see the huge need for this, uh, product and the service that you guys are providing with, with the regulation as well. Um, so maybe we could touch a little bit on the regulatory, uh, you know, position we find ourselves in, uh, across the world than in the us specifically. Um, what type of measures are you guys, you know, proactively taking to avoid security issues in the future?Well, certainly speaking from perspective because compliance is one of the biggest areas we're focused on. Uh, it's kind of not a problem. Uh, how, however insane and restrictive a set of regulations may be passed by any given, uh, government gloves, but really there's still a set of rules that we can encode and feed into the rules engine, the compliance engine and enforce.For example, at the most extreme level, we can enforce China's current rules on crypto, which is a complete ban and just simply block them from any utilization because you put mandatory KYC around the regulated markets. Right? And so there's a degree of that. That's not to say obviously, breaches couldn't take place, but you can do that now.Um, it, it, it depends really in terms of how complex and difficult the system maintain on how frequently they change the underlying rules. Um, Typically regulators publish them out in a consultation period and make updates. And they don't tend to rock the boat and change rules too dramatically, too fast because they need time to see how they're going to play out.And in terms of whether the intent behind the rule is actually what ends up playing out or not. Um, and just generally the way most regulators operate globally is, is through a kind of consultation. Um, a process with the underlying industry that they're operating and regulating. So, um, the, the, the, um, uh, a jurisdiction like Singapore is, is very, very high quality.I would argue it's, it's comparable with London and New York as a financial center. And it's really, I think, set itself now as the premier, uh, APAC, uh, financial hub for me, which is why we selected it as our HQ. They've also got an, a regulator that's treading an interesting line between trying to ensure that everything's done the right way, but still trying not to stifle innovation and therefore pass rules that enable that too.So from that perspective, um, you know, I find regulators like that very easy to work with. We can encode their rules and give them guidance. And feedback and help shape that process. I think when you get to the U S it's a slightly different case because the U S is it's got a lot of conflicting different perspectives, and obviously it's kind of federal too.So it's got different states with different perspectives as well. Um, That makes it more challenging from, from an operational perspective, I think. And, uh, you know, I, I would hope that the U S will gradually get to a point where it has a cohesive set of rules that, that everybody can understand that if you're like a level playing field, even if it's not the absolute best.Um, because right now, I think it's generally very challenging for a lot of the digital asset firms in the U S to, uh, to be able to not just meet every role, but, but also be able to be as competitive as some who are based on. Totally. And we saw that the sec went after, you know, swap for supporting tokenized stocks earlier this year.Do you guys have any plans on tokenizing stocks as well? Or are you going to stay away from that? I mean, it's not on our roadmap right now. Um, but there is absolutely nothing to stop. Um, you know, an existing exchange for example, but may, maybe does do all that as part of its business, um, leveraging our platform to deploy out a digital version of.Now, in fact, we, we certainly could in theory, do that, I suppose. Uh, I don't get that excited by the idea of tokenizing stock generally, because it's already fairly liquid, it's accessible and relatively cheap. I mean, you just need to look at the size of the equities market. And the average retail investor is in an able to trade in it almost as they ought to be more easily than they are with, with crypto right now.So from that perspective, I think you have to ask the question, well, why generally have certain. Stop tokens appeared as a, as a concept or one is to kind of prove that you don't just have to tie something like a stable coin to the U S dollar. For example, you actually can tie it to something as dynamic as a security.Um, but broadly is one. I do think that there is ideologically a very big group in the, in the crypto area who are generally, um, determined to try and completely upend and replace the financial system from the inside out. And. They are awesome in, in many ways, in terms of what they're looking to do, that the challenge with something like that is that if you just go out and flagrantly, ignore the regulators and just say, we're going to do that.And we're going to have no controls in place. No KYC, no transaction monitoring, no anti money laundering controls. Eventually they, you know, you can imagine a scenario where they turn around and say, well, we've analyzed all this chain activity and we can see direct flows of capital going back to . Um, and that's where, you know, the, the DFI system won't do itself any favors.So it, you know, I think there's ideologically some issues here between, uh, the, the pragmatic side, like ourselves who want to actually, you know, enable controls and mass adoption through that, and then gradually helping influence and change the system and allowing that disruptive technology to kind of do that as well.And then there's another group that just generally want to stick two fingers up the entire system and just deploy everything out regardless. But, yeah, I mean, you only have to look at the likes of finance for the, they actually issued stock tokens as well, and had to pull them quite rapidly to see that, you know, even an exchange like that with, with a level of parent influence, it has, was unable to withstand pressure from growth global regulators.So I think. What we're seeing with that level of innovation and experimentation is more likely to end up being adopted and pushed out by the rest of the financial system with some appropriate controls around that. Yeah. I was certainly two camps as far as like strict centralization and strict de-centralization for a long time.Uh, and this market cycle, we've seen a whole bunch of products pop up. They kind of embrace both sides and find some middle ground, uh, you know, with an acceptable level of decentralization for the application. So they've uh, could you talk about how decentralized exactly shouldn't have. Yeah. And, and I think we're a very good example of exactly that kind of a thing that's coming out.So, um, on network launch, we've made a conscious decision to operate on a permission chain, which is effectively a private chain, uh, at this stage. And the reason we've done that is because there are a lot of benefits to launching a network and a project of this nature. With, with centralization. Um, so having gone from the inside, out of a network, a blockchain network launched the, went for the full decentralized option.The problem is that decision-making is extremely challenging in those environments. And, and I would argue. Uh, decentralized governance is probably one of the big unsolved challenges for crypto over the next five years. It's something that still hasn't been necessarily mastered. We're still trying different types of governance models.Um, but the intent certainly for, since I longer-term, that is to actually decentralize our bus network and chain and govern. Working with the underlying users and clients to find a model that works for everybody. So one example of that could be that all the largest, uh, clients become no validators on that.And gradually, and obviously, um, take part in that or that you can end up with a proposal system related to how upgrades to the network and enhancements are made. That that becomes a vote based system. I mean, these, these are things that we see you're already operating on on other kinds of downtime structures.But that's that's, you know, certainly the longer-term vision, there will be a de-centralization of the network, um, fundamentally over time, but it needs to be done in a way that also the regulators generally are happy with it as well. Um, so for them, they may want to say, well, if you're going to wish you and, and do all of these regulated products, we still need to have some central point where we can effectively say you're accountable.And therefore, you know, we know who we're talking to because one of the big problems with dowels in general, Yeah. People then resigned from the whistle positions and no one's clear who, who actually runs it. And people have a habit thinking that means they're no longer, there's no liability risk. But of course, what actually happens is that the regulators can just go after anybody.Who's a public figure for that network could be the, the validators. It could be the, the governance people, or it could be the developers. And as soon as they apply pressure at that level, you, you realize that actually decentralization as a concept. Quite malleable. And once, uh, once all authorities put a degree of pressure on you, you can see these things actually.I'm not, not proving to be quite as resistant as perhaps when we first thought, do you think that this level of regulation is bad for innovation or causes capital flight? Uh, yeah. I mean, I definitely think that, uh, the smartest thing that broadly governments could do with the defensive. Um, it's only cracked down on, on areas where they can see absolute flagrant examples, um, that are, that are having a negative impact.So an example of that, they cracked down on the ICO. Boom. Now it was innovative, but with zero controls in place, we saw massive. People being ripped off access scams. We saw wine, we needed some, some rules in place to, to keep it open and honest. So that's an example that where I think fine, but, uh, when you're getting experimental token models, uh, trying out a variety of different things and the, the pace of innovation, if anything is accelerating to me, it's, it's not healthy to try and impose rules on something.Moving that fast. It's actually more interesting and probably wiser generally to step back and let it evolve. For say another couple of years. And then one, as it looks to be starting to mature and maybe problems that are more clearly identified, then you can start to actually put in place controls. Um, I do think that generally, if you over-regulate, you end up stifling innovation and so.I, I very much hope that the more light touch approach generally with regards to digital asset rent regulation is something that regulators globally continue to push for. And I think in many cases they are, but, uh, you do get some who, for example, can't even do something as basic as differentiate between a utility token and a security token.And when we're not doing that fast, a good adoptive stifling innovation couldn't agree more. Ryan. I think you have the next question here. Oh yeah. So how does single-sided liquidity provision work? Because it's, double-sided on stuff like unit swap, right? You're providing two assets with single sided.You're just providing one, correct? That's absolutely correct. Yeah. Um, so it's been, uh, something of a holy grail for a long time and different types of groups that have come from. Approaches to try and remove this concept of impermanent loss. So for those not familiar, when you act as a liquidity provider on something like Eunice, SWAT, you inject liquidity on both sides of the pool.So it could be, you know, let's say Bitcoin on one side and the, the uni token that it's paired to on the other side. Now the problem with that is as inherently, whichever way the market moves. Whether it goes one way or the other, you, you then suffer something called in permanent loss and it's, um, it's something that only then gets realized when you take you up a seat back end of the market, but you can end up in that loser to quite substantial amounts, um, in terms of what you end up getting.Without going into specifics as to why. And therefore, the only way that, that, that, that is generally handled is by paying very high amounts of the liquidity providers, which actually makes liquidity provision more expensive than it needs to be. Um, if you look at ways around this one example is insurance whereby um, collective groups will provide a degree of, uh, that they will take the impermanent loss when realized, but they will, um, broadly give you coverage for a certain.So that you, you've got a degree of certainty, you'll get back what you are that you're, you're going to accept that there's an inherent cost to that as well. Um, that is okay. But actual one side of the Quincy is possible. If you actually create an underlying, uh, automated market-making algorithm that can happen.Um, I won't go to the specifics of it, but we patented a, um, a mathematical algorithm we developed in house on that front. Um, and it checks out and broadly what that means is it introduces two concepts or, um, impermanent loss still exists as a possibility for LPs, but so there's a concept called impermanent game.And you can therefore, as a liquidity provider, Choose whether or not you could lock in an impermanent game and actually realize a gain or simply a loss, uh, and they will, they will do so in response to market conditions and, uh, things like the underlying rates being provided well, PS, um, it's going to add some interesting dynamics to that, but what that fundamentally means from a, you know, the perspective of define, for example, is that provided we get full interfacing.With our regulatory markets to define the future as well, which is that the long-term goal you'd be able to onboard your, your. Collateral from somewhere else in the defy system, the same way we move it around right now, you build to then inject liquidity into just one side of the protocol and you build to get that amount back out again as well, but you'd be able to effectively, you know, um, access additional yields, but what they should do, uh, is also broadly, uh, reduce the fees that actually, uh, LPs need to be paid because they're not taking as much risk anymore.Interesting. So this, uh, impermanent gain, it does not come from the. No, it comes from the movements of the, of the, of the market in the same way as impermanent loss does. So, um, you've got a given exchange rate, let's say between, uh, Bitcoin and the checks like an athlete, and then checks appreciates by a certain amount versus Bitcoin.And at that point, when you, you, as the LP, Um, so, so you've gone on the, uh, on the check side, you suffer or you, you get you, uh, having permanent game. If you've gone on the Bitcoin side, you'd, you'd have some internet loss in that example without the balance. Um, but likewise, it, it provides you with a way of actually making a decision as to whether or not you think that that movement in the market is law short term.And you can effectively as a, an LP participate in the market by making those decisions yourself and saying, I'm going to. Uh, our exposure, um, as a liquidity provider here, because I think actually this is just a short-term spike. So we're locking the impermanent, uh, gain hit, and then we'll, we'll actually inject more liquidity back then when we feel it's reached a more balanced level again.So these are interesting dynamics or what it will require instead is for higher rates to be paid, to maintain the depth of the pool. Now, uh, we're going to be quite interested to see how some of these dynamics play out, but, um, broadly it's, it's definitely uncharted territory in terms of. Uh, this is going to walk right across the market.Yeah, most definitely. And I don't want to dwell on this for too long, but I know this is a complicated topic. So I'd like to show a quick example on unit swap. So this is an LP position that I have, it's represented by an NFT, and you can see as providing liquidity between the east and Manoj pair, uh, of which my Manor was drained as it took off against Eve.Uh, and so I may have made $300 from fees, but I definitely lost money and missing out on all of the gains that men have made in the media. Um, yeah. So that is the kind of impermanent loss that we're referring to here. Yeah. That's a good example of, uh, well that one's also partly opportunity costs. So. It could be just even if you ignored, um, something like staking rewards and the fee side of things.If, if you get a movement in that market and then took it back out, you might end up with less money than you put in, in that scenario, for example. And that's another side to impermanent loss. Um, that is yeah. Generally going to be, you know, an interesting one. I think it's quite a complex area that the average defy user generally struggles to fully understand.And, uh, that in itself is kind of unhelpful because what people really want is a degree of certainty. They want to know that I'm putting in I'm contributing, say liquidity services, and therefore I'm going to get reasonably well paid for it. And I have some high degree of certainty as to what I'm going to get paid for it.They don't really want to sit there and go might work out really well. It could be a complete disaster for me. That's never really a, you know, a helpful model. And that's, I think, again, it shows points to the innovation of defy, but also the continued innovation as we're stopping. Try out different, uh, configurations that could enhance that further.Most definitely. So, uh, one of the big arguments I see long-term for the success of crypto and tokenization is purely for the sake of capital efficiencies alone. So could you talk about how you're able to reduce overhead by over 50% through digital asset issuance? Yeah, I mean, this, this is, um, I think reasonably well understood by a lot of the, uh, the defy community, but maybe not.Um, as somebody who's a more casual crypto user, who's, who's just dabbling. The different token markets, they probably don't fully appreciate the efficiency gains that come from blockchain generally. Um, because they, they won't necessarily understand the existing structure of the, the, uh, the current financial system.So if you think about every different, um, asset manager and bank global, To varying degrees, they are going to be operating their own internal systems. They're going to have their own, uh, teams that, that carry out different forms of, uh, checks. And they're going to have to reconcile that with anybody that they, who was a counterparty that they tried with on the markets, or if they're going through a broker, they're still going to have to go through that same underlying process.So if you, if you think about what that sucks up in terms of time, energy jobs, resources, It's actually astronomical. I mean, we're talking hundreds of thousands, probably millions of white collar jobs, which are means people earning well over a hundred thousand dollars a year. And their job is to check data and to make up for the inefficiencies of the fact that we're all sitting around with lots of different computer systems, arguing over what the positions are on databases that can be corrupted and not reflect properly.Now, you know, a distributed database, I a block. That sits in the central event, on my process, dramatically lows, all of those costs and adds massive efficiency. So really, um, the best estimates are from the likes of Accenture, um, are that between 50 and 70% of the back office, which is the side that handle all of these reconciliation of positions and settlement can be completely removed out of the global financial system by, uh, embracing blockchain.So that is probably why we're also seeing some. Substantial, um, adoption, uh, and the interest in adoption amongst financial institutions, even though they're not participating with us yet in the don't defy side, they can see the underlying potential for them just to shoo this into their existing, um, structures in a, in a more efficient way.Yeah. And I can second that just coming from a financial services firm, right. We have to do audits third party audits. And the maternal or the partners, and I do the accounting. So having this kind of platform where it'll speed up the process, not only saved time and hours with what we prepare ourselves or an associate, but also just having a trusted, full blockchain in this scenario.Sorry, one thing I was thinking that there is an interesting, other perspective on this, which from a regulator perspective too, they don't really know what the hell is going on in the financial system. So they're relying on people sending them reports and, and, you know, data dumps of their positions. And then they sort of retroactively may analyze it, or may not.If you think about a blockchain though, where they have site permissioned access and can see. And it's the central golden source of truth throughout the trade life cycle for a given market. It gives them a very powerful position because they can get instant preemptive reporting. They can keep a very close eye on things and they don't need to go back.And I'll say AGA and Carnera wealth to send things through. They can just generate it themselves and look at it themselves too. And that I think is a fundamental change in how regulators are gonna be able to, um, interact in, in the system. So on a kind of related tangent, we see these automations in blockchain, these automations in AI machine learning self-driving cars self-driving or not self-driving, but you know, you see these checkout kiosks at McDonald's there's no longer like the people needed a and the greater trend towards automation.Uh, a lot of people think that this presents, uh, an issue. Um, but there's also the counter. That there may be metaverse jobs opening up to replace these. And I've heard people like Gary V say the potentially long-term, uh, there could be more jobs in the metaverse than in the real world. Do you guys see this as a possible outcome?What do you think? I mean, if time has shown us anything, I think when we have innovative technology, Right. It's really just coming down to adoption. Right? As we have things that are automating, that take a factories right now, we're training those who had those industrial jobs into other aspects of our society.Whether it's going to be metaverse is going to take place more than the physical that I don't know, maybe David, you can provide some clarity there, but I think in the long run it all, just come to where we adopt as a system. Yeah. I mean, my perspective on it broadly is that nothing that Facebook now called Matta, that what they presented was original, um, or hasn't already been largely put together in different forms by the VR community already, um, on a, on a variety of levels.So even the concept of LFTs, although are tokenization digital assets of existing. In gaming environments, um, with some quite high value secondary markets for a long time, as well, as well as skins and other things like that. Now, um, the, the, the question is how can it actually fundamentally disrupt how we, we engage with each other, particularly in a remote world, you know?Um, and, and I'm definitely bought into that idea. We could, you know, my team is, is located primarily in Germany and Singapore, and I'm on the east coast of the U S the idea that I can actually sit in a virtual office space with them for meetings, where we actually feel like we're, we're in the presence of one another and just engage in a much more, uh, dynamic way than we are right now with four squares on, on a, on a little screen staring at it.Um, that definitely appeals to me. And I think it will appeal to a lot of other. And probably the way therefore the will be able to interact, not just in business, but other forms of, uh, um, sports and other things too. It could feed into those two for sure. And certainly gaming is a given. Um, so I think that personally, therefore it will overtake the real world from a commerce perspective, undoubtedly, um, because you'll be able to do things more efficient.In that environment too, you won't be constrained by physics and other aspects of it. Um, and, and therefore, I think we will see a point where people prefer doing business in, in that metaverse concept. Um, but the real world is not going to lose its place. Right. I mean, we're, we're still gonna want to get out and walk on the beach and get fresh air and need to look out for our health and sunshine.And frankly, No, no, no. My back a few beers, virtual beer doesn't sound as good to me as real. So, you know, I think that you, people have to be realistic about this. There has to be, uh, you know, just like we say, there has to be work life balance that will have to be met a real real-world balance. I think, uh, in that, in that future too.And people will realize that it's not healthy to just sit there and one is in front of a screen all day. Um, but yeah, I, I think broadly it has the potential to fundamentally disrupt, um, You know, crypto itself will form the under arching backbone that enables the, of that to function. Certainly a crazy world and metaverse that we live in right now.Um, I know that we are getting close to running out of time. Uh, so I wanna thank you, both David and AIG for stopping by today. Um, but before we wrap it up, I'd just like to give you both the chance. If there's anything else you want to mention, let the people know where to connect with you, where to follow along with, with your respective, uh, projects.The floor is yours. Yeah, I'll go first and then I'll let you close. But, uh, yeah, if anyone wants to contact me, my email is aij@kymerawealthdotcomoryoucanvisitourwebsiteinmarijuana.com. All I would say is just as an investor perspective, right? Always conduct your due diligence. We were joking about me and coins and stuff like that.Um, from the perspective of a financial services, I definitely agree that we are getting to a point where, especially in the United States into a transitionary period, Crypto or digital assets will be massively adoptive. Uh, I don't know how that will look like. Um, luckily not one of those people that makes the rules, but I think we are getting into that position.So a platform like shin Tai, those firms like Conger wealth, um, and those individuals who are trying to be innovative to have. Provide greater access. How I mentioned earlier to the retail investor, whether it is tokenized assets of real estate or debt issuance, another form of equity, um, just always conduct your due diligence.Uh, whether you talk with a financial advisor like us, or just hit Reddit as much as possible to find that information. Yeah. And from our side, um, you can follow us on Twitter app, chin time network. Um, and we're also on telegram with that same handle actions I network. Um, but yeah, I think for anybody in, in the crypto space, who's interested in mass adoption and wants to see where the regulatory compliant, digital assets side.So things like where tokenized real estate. And securities and funds and other types of bonds and those types of products, if they want to follow and see that starting to actually emerge in real, tangible, blockchain based markets, give us a follow. Um, and likewise, if the passionate about it as we are about this idea of bridging between defy and.You know, um, the underline checks token is going to play a core role to that. Then again, um, I encourage them to come and join the community and, um, we are definitely going to be having an interesting six to 12 months. So, uh, we hope to see more of your all right. Thank you guys. Both so much great talking with you.We'd love to have you back on in the future. Um, but yeah, that's it. Thanks guys. Thank you.Alrighty, Ryan, that is it for this episode of moon or bust. I thought that was one of our best conversations ever on the show. I know you're personally really interested in real estate. Uh, so what did you think about that? Yeah, I thought it was so cool. And there's so many far reaching ideas that they brought up with tokenization of real estate and bonds.It reminded me of radical markets. I know we've both read that book and I need to read it again. Now after this interview, most definitely. If you guys tuned in after the start, we want to point out the Benzinga crypto channel top link in the description below. If you're new, around Benzinga or moon or bust, I'd like to say welcome, uh, and make sure you're subscribed to the main channel and also smash the like button while you're down there.Um, but that's all we have for you today. Ryan, do you have any closing thoughts for. You know what I'm about to say, what follow you on Twitter? Check me out on Twitter. I still don't have as many followers as Logan. It's cause I'm cooler than you, man. It's that simple, I guess. Oh, well you do have a Bitcoin license plate though.So that's gotta be where it's something. Hopefully one day. Maybe one day. Alright, that's enough. Let's get out of here. All right. Visa guys.Support this podcast at — https://redcircle.com/moon-or-bust/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Fine-tune your approach to liver tests!  It's LFTs Triple Distilled! Paul and Matt channel the wisdom of hepatologist, Dr. Elliot Tapper (@ebtapper) to cover hepatocellular vs cholestatic vs mixed patterns, which tests to order, which ones to skip, how to handle isolated alkaline phosphatase elevation, mild, chronic ALT elevation, and even how to interpret liver test abnormalities in pregnancy.  Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for shows #293 at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME! Credits Written, Produced, and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP   Infographic by: Elena Gibson Cover Art: Matthew Watto MD, FACP Editor: Matthew Watto MD, FACP (written materials); Clair Morgan of nodderly.com Sponsor: Birch by Helix Birch is giving $200 off ALL mattresses and 2 free eco-rest pillows at BirchLiving.com/curb  Sponsor: Locumstory Visit Locumstory.com to see if a locum tenens assignment is right for you. CME Partner: VCU Health CE The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.  Show Segments Intro, disclaimer, guest bio Hepatocellular pattern Cholestatic pattern Chronic ALT elevation Isolated Alkaline phosphatase elevation Liver test abnormalities in pregnancy Outro

Daniel Ruiz Tizon, a man on his fifth nose, is, he'd like the world to know, Available, and dissecting the minutiae of everyday life. Another 7 days in the life of the latte ponce. This week, LFTs, a spectacular hygiene fail, mid-mastication greeting and more.  Out every Monday. Follow the show on Twitter @1607WestEgg And you can support the show via patreon.com/drtavailable or www.danielruiztizon.comSubstackSupport this show http://supporter.acast.com/danielruiztizonisavailable. See acast.com/privacy for privacy and opt-out information.

When we order liver function tests (or “LFTs”) we get the blood levels of 4 liver enzymes: AST, ALT, GGT and ALP. Often the way they become elevated in pairs, helps us work out where the problem is. 

There is a shortage of blood bottles in the NHS. Here is why.There is a shortage of blood bottles across the entire at the UK. The company Becton Dickinson supply the blood bottles that we used to test patients' blood across the entire of the UK and in most places across the world.  Unfortunately, due to increased testing because of Covid and because of the backlog of patient activity now there's a shortage of his blood bottles which is causing a strain on the NHS. Why has this happened?This is in part due to changes with resources, increasing demand, and problems with international distribution like the Suez canal incident and in the UK. It is made worse due to port changes, lorry driver shortages, and other aspects caused in part by Brexit. As a result, NHS England has announced that there should be a reduction and rationing of the types of blood tests that are done across the entirety of the UK.There was previous guidance issued on 10th August about checking stock, maximising the use of existing supplies, and looking at alternative supplies and options. Alternative supplies has been hampered by the worldwide use and distribution issues. On 26th August NHS England has recommended a rationing of blood tests to survive this crisis. This relates to: 1. 5mls Yellow top – SST 2 – clotted sample (e.g. U&E, LFTs etc) 2. Purple top – EDTA (e.g. FBC, HbA1c) This shortage is an immediate issue likely to continue till mid-September but may continue to occur in the next few months. Changes include (taken from the document)All primary care and community testing must be halted until 17 September 2021, except for clinically urgent testing. Examples of clinically urgent testing include: • Bloods that are required to facilitate a two-week wait cancer referral • Bloods that are extremely overdue and/or essential for safe prescribing of medication or monitoring of conditions• Bloods that if taken could avoid a hospital admission or prevent an onward referral • Those with suspected sepsis or conditions with a risk of death or disabilityIn hospitals, each area is asked to make a 25% reduction in blood testing using add-on policies and local laboratory guidance. There will be monitoring on activity in the hospital especially UE and FBC testing. Testing for routine things like wellness checks, vitamin D*, fertility testing* allergy testing* with some minor exceptions for these recommendations. The guidance accepts this may cause harm. There is an ask to support other local areas, and routes to do this if shortages are expected within 48 hours. The guidance also states that regulators have been informed including CQC and NHS resolutions and that any complaints as a result of the shortages will be captured in the Clinical negligence scheme for GPs and trusts, respectively. This unfortunately is not the directive many practices would hope for as it doesn't help manage the complaints directly sent to the practice.Possible implications Risk to patient health of delay in diagnosis and possible inability to test for vital issues if the shortages are worse. Risk of increase complaints to practices and NHS services due to delays in blood testingFurther compounding the back log of work that is building due to COVID and now a blood bottle shortageFurther delay in referrals where they are required ‘mandatory blood tests'. Noting these have been recommended to stop due to the shortagJoin the Medics Money New To GP partnership course for the leaders in finance, wellbeing, workload management, and your peers on the same journey to become a safe, effective, healthy GP partner. Join at medicsmoney.co.uk/gpcourse and reference eGPlearning

44 new - now 452 cases, 14 in Nobles, 1 in ICU, teenagers vax, 4th wave of COVID-19 on the way, LFTs, gas price consultation, Isle of Wight TT plus Keys candidate Alfred Cannan. It's Mannin Line with Andy Wint #iom #manninline #manxradio

There are many facets when it comes to interpreting Elevated Liver Enzymes (LFTs). In this episode we will be going through the most common presentation and primary care so that you will feel confident in knowing what steps to take when you come across these abnormal labs, and as a result, put your mind at ease and keep you from freaking out!Together, we will cover:Key anchors of LFTs that you need to rememberTwo main factors to know what labs to order and when Three points to start with during your initial approach to LFTsFour main questions to ask with every labSymptoms, causes, evaluation, and algorithm specifically for mild AST and ALTCheck out the Lab Interpretation Crash Course for Nurse PractitionersDownload FREE Ultimate Resource Guide for the New NP See acast.com/privacy for privacy and opt-out information.

Thank you for Listening Please Share The PlanPt 11: Finishing EducationToday we are getting back to the Lift Every Voice plan from Joe Biden. Heading into the first 3 points on healthcare, let's get into it. Sections Covered:Make Far-Reaching Investments in Ending Health Disparities By Race = DEnsuring access to Health Care During This Crisis = DInvest in the Diverse Talent at HBCUs and MSIs to solve the country's most pressing problems, inc [...]

103 new cases, voter denial, flumes, wolf whistles, affordable housing, price increase on Liverpool Terminal & where are the LFTs? It's Mannin Line with Andy Wint #iom #manninline #manxradio

95 new cases now 696 in total, views on what's happening, Douglas Prom progress, MT fibre, Ivermectin, Castletown public meeting, where are the LFTs? Plus Keys candidate Martyn Perkins. It's Mannin Line with Andy Wint #iom #manninline #manxradio