Podcasts about lgv

Une nouvelle ligne ferroviaire à grande vitesse doit relier d'ici 2029 les villes de Kénitra et Marrakech. Il s'agit d'étendre la liaison entre Tanger et Casablanca inaugurée en 2018. Avec 430 kilomètres de voies, une myriade d'ouvrages d'art et plusieurs gares à construire, le projet est évalué à près de 6 milliards d'euros. Le Maroc, seul pays d'Afrique à exploiter une ligne ferroviaire à grande vitesse à ce jour, compte aussi développer son réseau sur le continent. Développer la grande vitesse ferroviaire dans un pays du Sud, comme le Maroc, c'était un pari fou, une expérience unique dans le monde. « La grande vitesse était au départ un produit pour les pays développés, les pays à revenus très élevés, rappelle lors d'une intervention à la télévision marocaine Mohamed Smouni, le directeur général adjoint de l'ONCF, l'Office national des chemins de fer. Le Maroc a démontré qu'un pays à économie émergente peut prétendre avoir cette technologie de la grande vitesse. Les gens au départ imaginaient que seuls les riches pourraient y avoir accès. Avec la tarification qu'on a faite, on l'a démocratisée pour toutes les populations. Chacun trouve son prix. »Résider à Tanger, travailler à RabatLa LGV Tanger-Casablanca est un succès populaire. À moins de 30 euros le billet, le nombre de voyageurs est passé de 3 millions en 2019 à 5,5 millions l'année dernière. « Le Maroc capitalise sur l'expérience d'Al Boraq [le TGV Casablanca-Tanger, NDLR] qui a bouleversé radicalement la mobilité, observe Mohammed Jadri, économiste et directeur de l'Observatoire de l'action gouvernementale. On n'avait jamais pensé qu'à un moment donné, un jeune Marocain pourrait résider à Tanger et travailler à Rabat, Kénitra ou Casablanca et revenir le soir même à son domicile. Aujourd'hui, c'est le cas. »Répondre à la demande ferroviaire en Afrique de l'OuestL'extension de la LGV promet un trajet Tanger-Marrakech, 500 kilomètres, en 2 h 40 seulement. L'objectif est aussi de créer un écosystème ferroviaire industriel au Maroc. « L'avenir est en Afrique, prédit Mohammed Jadri. Le Maroc se prépare dès aujourd'hui à répondre à la demande de voies ferrées de pas mal de pays africains, surtout les pays de l'Afrique de l'Ouest. »L'ONCF et Alstom ont signé un contrat de 780 millions d'euros pour l'achat de 18 trains à grande vitesse de toute dernière génération. La multinationale française avait déjà fourni les rames de la LGV Tanger-Casablanca. « C'est un partenariat concret, commentait Laurent Saint-Martin, le ministre délégué chargé du Commerce extérieur français, en visite au Maroc le mois dernier. C'est une expertise française qui vient rencontrer une volonté de développement forte dans un pays qui, effectivement, a souhaité ensemble écrire une nouvelle page dans la relation bilatérale. »Les travaux de la LGV devraient être terminés d'ici à quatre ans pour une mise en service fin 2029, six mois avant la Coupe du Monde co-organisée par l'Espagne, le Portugal et le Maroc.À lire aussiAfrique : quel serait l'impact pour l'économie africaine d'un réseau ferroviaire à grande vitesse ?

durée : 00:03:24 - LGV : les gros travaux ont commencé - Du jeudi 8 mai au dimanche 11 mai 2025, aucun train ne circule entre Toulouse et Agen. Le trafic a été interrompu pour permettre la poursuite des travaux de la ligne à grande vitesse Bordeaux-Toulouse. L'arrêt de train Route-de-Launaguet, hors service depuis 2016, est en cours d'aménagement.

Christophe Bordet nous emmène à la découverte du marché immobilier haut de gamme du bassin d'Arcachon. Il nous présente des biens d'exception, avec des prix pouvant atteindre 11 millions d'euros, et explique les tendances du secteur, notamment l'intérêt croissant des acheteurs français et étrangers pour cette région prisée. Il aborde également les avantages de la facilité d'accès à Arcachon depuis Paris grâce au tramway et à la LGV. Un épisode qui donne un aperçu du luxe immobilier sur la côte atlantique.Notre équipe a utilisé un outil d'Intelligence artificielle via les technologies d'Audiomeans© pour accompagner la création de ce contenu écrit.

Join us for a special edition of VLGA Connect, as we come to you live from the launch of the results from the VLGA's Victorian Councillor Census. Hear from John Armitage at QDOS Research as he and Chris Eddy discuss how the census was conducted, and the key insights the data found. Mike Gooey from LGV joins to chat about how the state government will use the data to guide its policy decisions moving forward. Chris also chats to Councillors Jane Karslake, Mia Shaw, Jack Kowarzik and Kylie Spears about how the data reflects their own councillor experience. Joining in the flesh, Tony Raunic of Hunt & Hunt Lawyers discusses how the data could make a difference to the sector now and into the future.Learn more about why this work is so important here: https://www.youtube.com/watch?v=PQNkaC56WQs and read the full Census Report here: https://bit.ly/vlga_cr_censusSupport the showTo learn more about the events, programs, and training offered by the Victorian Local Governance Association (VLGA), please click here. If you'd like to contact us about the podcast, please send us an email to vlga@vlga.org.au or call us on 03 9349 7999

durée : 00:03:54 - A Saint-Jory, reportage à la ZAD sur le chantier des aménagements ferroviaires - Délogés mercredi 22 janvier par les gendarmes, de nouveaux écureuils opposés à la construction de la Ligne à Grande Vitesse se sont installés sur la ZAD de la Guinguette Vaillante, à Saint-Jory, à la limite avec Castelnau-d'Estrétefonds, au nord de Toulouse.

durée : 00:04:26 - L'Info D'Ici - 07h30 - Sur 150 Sarthois riverains de la ligne à grande vitesse vers la Bretagne qui ont saisi la justice, une centaine ont vu le tribunal administratif de Nantes reconnaître au moins en partie leur droit à être indemnisés du bruit. Mais ces condamnations ne sont pas définitives puisqu'il y a appel.

Le président français Emmanuel Macron a entamé, mardi 28 octobre 2024, une visite au Maroc. Il a été accueilli par le roi Mohammed VI, accompagné d'une importante délégation de ministres, mais aussi d'une quarantaine de chefs d'entreprises. Les journaux marocains détaillent les contrats de partenariat signés : « LGV, eau, décarbonation, énergie, gaming... 22 accords ont été conclus », rapporte TelQuel.« Back to business », « retour aux affaires », lance L'Opinion qui note que dans la capitale, « les drapeaux de la France et du Maroc flottent côte à côte ». « Après une trop longue absence, revoir ces deux drapeaux ensemble est une preuve supplémentaire que, malgré les errements, tout chef d'État finira par retrouver le chemin de Rabat ».« Des retrouvailles qui irritent l'Algérie »Le journal note que « jamais Paris n'était allé si loin dans l'adoubement de la thèse marocaine » sur le Sahara occidental. En juillet dernier, le président a reconnu « la souveraineté marocaine » sur ce territoire disputé, ce qui avait provoqué la colère d'Alger.En Algérie, TSA affirme que cette visite suscite « des inquiétudes en France quant à l'avenir de la relation très précaire avec l'Algérie », notamment en raison du différend sur le Sahara occidental. Le média algérien rappelle qu'Alger reste pour la France « un partenaire non moins important que le Maroc ».Selon Le Monde Afrique, « Paris espère amortir le choc en travaillant à une nouvelle offre mémorielle sur la guerre d'Algérie ou la conquête coloniale ». Le président français achèvera sa visite au Maroc mercredi 30 octobre 2024.À lire aussiAlgérie: le président Tebboune exclut toute idée d'une visite en FranceAu Tchad, une nouvelle attaque meurtrière de Boko Haram Au moins 40 personnes ont été tuées dans les rangs de l'armée, dans la région du Lac, proche du Nigeria, dimanche 27 octobre 2024. Au Burkina Faso, Le Pays estime que « Deby-fils doit se retrousser les manches... du treillis » et rappelle que son père, en 2020, avait lancé avec « succès » l'opération « colère de Bohoma », contre le groupe islamiste.De son côté, le quotidien guinéen Le Djely se demande s'il faut « craindre la résurgence de Boko Haram » et se rappelle que l'an dernier, le groupe, « affaibli », « avait piteusement changé de stratégie en procédant à des enlèvements » contre rançon.Désormais, si les combattants du groupe peuvent mener des attaques d'ampleur contre l'armée, cela « suppose qu'ils se sont renforcés tant au niveau de leur arsenal que de leur effectif », poursuit Le Djely. Avant de conclure : « il ne faut pas donner l'occasion aux partenaires occidentaux qui ont été chassés de là de nous renvoyer à la figure que, depuis leur départ, les djihadistes ont pris le contrôle de la région ».La campagne pour les législatives émaillées de violences au SénégalLa campagne se poursuit au Sénégal, avant les élections législatives anticipées, prévues le 17 novembre 2024. « C'est parti pour une campagne électorale violente », se désespère Walf, qui revient sur le saccage du siège de Taxawu Sénégal et les affrontements entre partisans de Barthélémy Dias et Abass Fall. « L'argument de la force, poursuit Walf, prend le dessus sur les programmes des candidats ».De son côté, le journal 24 Heures rapporte les appels au calme de diverses personnalités, notamment de candidats ou encore du ministre de l'Intérieur et de la sécurité publique.« L'enfer de Shakaola » au KenyaJeune Afrique publie une enquête sur la communauté religieuse dirigée par le pasteur Paul Mackenzie, accusé d'avoir « incité des centaines de fidèles à jeûner jusqu'à la mort ». L'article raconte la journée du 17 mars 2023. « Ephraïm n'a que 8 ans », habillé élégamment, « on pourrait le croire apprêté pour un baptême ou un mariage ». « Il n'a plus mangé depuis une semaine ». Ce vendredi doit être « le jour de sa rencontre avec Jésus ». Ses parents lui « lie[nt] les mains derrière le dos et le laisse[nt] pour mort, au milieu de la forêt de Shakaola ».Le petit garçon est finalement sauvé, mais des centaines d'autres ont péri, influencés par ce « sulfureux prédicateur kényan, Paul Mackenzie », pour qui l'apocalypse devait avoir lieu en août 2023. L'enquête de Jeune Afrique pointe le fait que « plus d'une semaine va s'écouler avant que la police interpelle le pasteur pour l'interroger ». À ce jour, « 448 corps ont été retrouvés » dans la forêt de Shakaola, mais des centaines d'autres sont toujours portées disparues.

Le président français Emmanuel Macron a entamé, mardi 28 octobre 2024, une visite au Maroc. Il a été accueilli par le roi Mohammed VI, accompagné d'une importante délégation de ministres, mais aussi d'une quarantaine de chefs d'entreprises. Les journaux marocains détaillent les contrats de partenariat signés : « LGV, eau, décarbonation, énergie, gaming... 22 accords ont été conclus », rapporte TelQuel.« Back to business », « retour aux affaires », lance L'Opinion qui note que dans la capitale, « les drapeaux de la France et du Maroc flottent côte à côte ». « Après une trop longue absence, revoir ces deux drapeaux ensemble est une preuve supplémentaire que, malgré les errements, tout chef d'État finira par retrouver le chemin de Rabat ».« Des retrouvailles qui irritent l'Algérie »Le journal note que « jamais Paris n'était allé si loin dans l'adoubement de la thèse marocaine » sur le Sahara occidental. En juillet dernier, le président a reconnu « la souveraineté marocaine » sur ce territoire disputé, ce qui avait provoqué la colère d'Alger.En Algérie, TSA affirme que cette visite suscite « des inquiétudes en France quant à l'avenir de la relation très précaire avec l'Algérie », notamment en raison du différend sur le Sahara occidental. Le média algérien rappelle qu'Alger reste pour la France « un partenaire non moins important que le Maroc ».Selon Le Monde Afrique, « Paris espère amortir le choc en travaillant à une nouvelle offre mémorielle sur la guerre d'Algérie ou la conquête coloniale ». Le président français achèvera sa visite au Maroc mercredi 30 octobre 2024.À lire aussiAlgérie: le président Tebboune exclut toute idée d'une visite en FranceAu Tchad, une nouvelle attaque meurtrière de Boko Haram Au moins 40 personnes ont été tuées dans les rangs de l'armée, dans la région du Lac, proche du Nigeria, dimanche 27 octobre 2024. Au Burkina Faso, Le Pays estime que « Deby-fils doit se retrousser les manches... du treillis » et rappelle que son père, en 2020, avait lancé avec « succès » l'opération « colère de Bohoma », contre le groupe islamiste.De son côté, le quotidien guinéen Le Djely se demande s'il faut « craindre la résurgence de Boko Haram » et se rappelle que l'an dernier, le groupe, « affaibli », « avait piteusement changé de stratégie en procédant à des enlèvements » contre rançon.Désormais, si les combattants du groupe peuvent mener des attaques d'ampleur contre l'armée, cela « suppose qu'ils se sont renforcés tant au niveau de leur arsenal que de leur effectif », poursuit Le Djely. Avant de conclure : « il ne faut pas donner l'occasion aux partenaires occidentaux qui ont été chassés de là de nous renvoyer à la figure que, depuis leur départ, les djihadistes ont pris le contrôle de la région ».La campagne pour les législatives émaillées de violences au SénégalLa campagne se poursuit au Sénégal, avant les élections législatives anticipées, prévues le 17 novembre 2024. « C'est parti pour une campagne électorale violente », se désespère Walf, qui revient sur le saccage du siège de Taxawu Sénégal et les affrontements entre partisans de Barthélémy Dias et Abass Fall. « L'argument de la force, poursuit Walf, prend le dessus sur les programmes des candidats ».De son côté, le journal 24 Heures rapporte les appels au calme de diverses personnalités, notamment de candidats ou encore du ministre de l'Intérieur et de la sécurité publique.« L'enfer de Shakaola » au KenyaJeune Afrique publie une enquête sur la communauté religieuse dirigée par le pasteur Paul Mackenzie, accusé d'avoir « incité des centaines de fidèles à jeûner jusqu'à la mort ». L'article raconte la journée du 17 mars 2023. « Ephraïm n'a que 8 ans », habillé élégamment, « on pourrait le croire apprêté pour un baptême ou un mariage ». « Il n'a plus mangé depuis une semaine ». Ce vendredi doit être « le jour de sa rencontre avec Jésus ». Ses parents lui « lie[nt] les mains derrière le dos et le laisse[nt] pour mort, au milieu de la forêt de Shakaola ».Le petit garçon est finalement sauvé, mais des centaines d'autres ont péri, influencés par ce « sulfureux prédicateur kényan, Paul Mackenzie », pour qui l'apocalypse devait avoir lieu en août 2023. L'enquête de Jeune Afrique pointe le fait que « plus d'une semaine va s'écouler avant que la police interpelle le pasteur pour l'interroger ». À ce jour, « 448 corps ont été retrouvés » dans la forêt de Shakaola, mais des centaines d'autres sont toujours portées disparues.

durée : 00:53:24 - franceinfo: Les informés - Autour de Thomas Séchier, les informés débattent de l'actualité du samedi 12 octobre 2024.

Appel citoyen à renforcer la législation sur les armes à feu - Climat : l'activité humaine, responsable aussi des inondations en Europe centrale - LGV en Tchéquie

Appel citoyen à renforcer la législation sur les armes à feu - Climat : l'activité humaine, responsable aussi des inondations en Europe centrale - LGV en Tchéquie

This episode discusses four recent articles about lymphogranuloma venereum (LGV) including the effectiveness of a 7-day doxycycline course and the increasing prevalence of asymptomatic LGV in the era of HIV PrEP. View episode transcript and references at www.std.uw.edu.This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs. Editor and host Dr. Meena Ramchandani is an Assistant Professor of Medicine at the University of Washington (UW) and Program Director of the UW Infectious Diseases Fellowship Program. 

Après une série d'actes de sabotage sur les lignes à grande vitesse vendredi, le week-end a été perturbé, mais la SNCF assure que les travaux de réparation sont "totalement terminé" et "qu'il n'y aura plus de perturbation ce lundi matin". Un mail reçu samedi par plusieurs médias se félicite des attaques contre le réseau LGV et critique les Jeux olympiques, sans pour autant fournir de détail sur les actions menées. Patrice Vergriete, Ministre délégué chargé des Transports est l'invité de RTL Matin. Ecoutez L'invité de RTL avec William Galibert du 29 juillet 2024.

Après une série d'actes de sabotage sur les lignes à grande vitesse vendredi, le week-end a été perturbé, mais la SNCF assure que les travaux de réparation sont "totalement terminé" et "qu'il n'y aura plus de perturbation ce lundi matin". Un mail reçu samedi par plusieurs médias se félicite des attaques contre le réseau LGV et critique les Jeux olympiques, sans pour autant fournir de détail sur les actions menées. Patrice Vergriete, Ministre délégué chargé des Transports est l'invité de RTL Matin. Ecoutez L'invité de RTL avec William Galibert du 29 juillet 2024.

Jean Anselyn, directeur de Barnes Bassin d'Arcachon, était l'invité de Lorraine Goumot dans Tout pour investir, ce mardi 16 juillet. Il s'est penché sur le profil des clients d'Arcachon et l'évolution des prix dans la région face à la demande, sur BFM Business. Retrouvez l'émission du lundi au vendredi et réécoutez la en podcast.

Maxime Chatard, directeur territorial d'SNCF Réseau en Bourgogne-Franche-Comté, nous a présenté la feuille de route de l'année 2024 ! Une année « d'enjeux et de grandes perspectives », dont le projet LGV+, qui permettra une augmentation de la capacité de près de 25% sans nouvelle infrastructure. Au total, 382 millions d'euros de travaux sont prévus sur le réseau ferroviaire régional. Chantiers, perturbations, emploi… On fait le point.

There's a concerning rise in sexually transmitted infections (STIs) across Europe. That's according to the European Centre for Disease Prevention and Control (ECDC). In a new report they focus on three specific STIs: chlamydia, gonorrhoea, and lymphogranuloma venereum (LGV).Lina Nerlander, the lead STI expert at the ECDC, explains some of the factors that may be contributing to the increase. So how do you know if you have an STI? Michelle Roberts, a doctor and health reporter with the BBC, talks us through some of the symptoms.And Adriana Stinga, a sexual health counsellor in Romania, discusses how she's working to improve sexual health education in her country. Email: whatintheworld@bbc.co.uk WhatsApp: +44 0330 12 33 22 6 Presenter: Hannah Gelbart Producers: William Lee Adams, Mora Morrison Editors: Emily Horler and Simon Peeks

Coast 2 Coast Season 5 Episode 13 : Let's Get Vocal with Whiskey In this episode: We have a blast with LGV guest Whiskey! A lot of laughs, and Farris throws an interesting little game at us, Name That Fart.. Thanks Farris, lol... We had so much fun we lost track of time so it's a long one.. Thanks for joining us this week and we hope to see ya next time! https://linktr.ee/C2CPodcast1 Contact Maumee Bay Lawn Care If you're in the Toledo Ohio area for lawncare and snow plowing! 491-351-2458 maumeebayservices@yahoo.com Tap the link below and complete the form if you'd like to be a Smule guest on our “Let's Get Vocal” podcast event! https://docs.google.com/forms/d/e/1FAIpQLSevWLWRWbHBgimG6FEb1oADlN5eelbLnRHW6ZygyXC2apO2LQ/viewform?usp=pp_url Smule group on FB: https://www.facebook.com/groups/1654381394909853 --- Send in a voice message: https://podcasters.spotify.com/pod/show/goodolboysoundroom/message Support this podcast: https://podcasters.spotify.com/pod/show/goodolboysoundroom/support

Neste episódio, a ginecologista e editora médica do WB, Dra. Caroline Oliveira, aborda o LGV. O linfogranuloma venéreo é uma infecção sexualmente transmissível (IST) causada por determinadas cepas das bactérias do gênero Chlamydia trachomatis. Essa infecção afeta principalmente os órgãos genitais, causando inflamação e danos nos linfonodos próximos à área afetada. Confira todo o conteúdo!

On Air! The SkillpresentaSkill ProEpisodio 88Il caso Mixed by Erry Anni '90 tra pirateria ed evoluzione del dirittoCon l'avv. Simona Lavagnini (LGV Avvocati - Presidente Gruppo Italiano AIPPI)

Dr. John Toney, Professor of Medicine at the USF Morsani College of Medicine, presents this STI treatment refresher updated for 2022-2023. Dr. Toney begins by reviewing the new changes to the latest 2021 STI guidelines (updated from 2015). He next discusses Chlamydia and Neisseria, Chancroid and LGV. Next, he discusses syphilis. Topics discussed related to syphilis includes differentiating primary, secondary, and latent disease, diagnostic testing and treatment. Dr. Toney closes by discussing genital Herpes and Trichomoniasis.

durée : 00:01:47 - Si j'osais de France Bleu Béarn Bigorre - Réécoutez le si j'osais de ce vendredi où il est question du TGV Bordeaux/Toulouse, de son financement, de Burosse-Mendous, Lème, Garlède-Mondebat, Sallespisse et Lanneplaà.

In questo nuovo episodio di INDICAMonAIR, gli avv.ti Simona Lavagnini e Alessandro Bura dello studio LGV Avvocati approfondiranno il tema dell'Intelligenza Artificiale. Lo studio legale LGV si occupa di Intelligenza Artificiale e delle sue implicazioni, assistendo imprese innovative attive nel campo dei videogiochi ovvero nello sviluppo dell'intelligenza artificiale per i servizi di text to speech.

VLGA Connect, Episode 315 - Governance UpdateThis week, Chris Eddy is joined by guest co-host Julie Reid, a former Council CEO and Executive Director at LGV, to unpack the local government news of the week.Topics include councillors elected to State Parliament (note there have been updates since the recording of this episode); approaching the finish line of mayoral election season in Victoria; an innovative Council partnership to improve community reporting of issues; a NSW Council to be subject of a parliamentary inquiry on integrity; and much more from another busy week in local government.The VLGA Connect Governance Update is sponsored by Hunt & Hunt Lawyers.

durée : 00:17:02 - C'est bientôt demain - par : Antoine CHAO - LES TER sont bondés et mal entretenus et en pleine urgence climatique et énergétique ce ne n'est pas une nouvelle ligne LGV Bordeaux Toulouse Dax, énergivore et hors de prix, qui va remplacer les trains du quotidien et dont le territoire et la planète semblent avoir besoin !

You're gonna love this LGV listeners!    In this interview Kelly Chase, interviews me, Dr. Morgan!    She asks me everything you all want the answer to.    Here is a break down of the interview itself:    Getting to know Dr. Morgan Anderson  [2:13] “I knew from a very young age that I wanted to help people. Even from a young age I just wanted to help people and get to know people ” Dealing with Pain [7:58] “I knew that not dealing with the wound is going to hurt me again and again.” To the People Who Are Stuck [11:00] “We actually owe it to ourselves to stop numbing and to feel the pain that we are feeling. I am in pain and I need to change.” Healing and Relationships [15:30] “Some people come into your life to open your eyes to something different. Rejection is redirection.” The Attachment Theory [22:35] “There is a unique attachment style for every person. All of us have different pieces from each attachment style.” Anxious Attachment [27:52] “Fear of abandonment is very strong. You're not just born with anxious attachment.” “Sometimes we get so fearful of speaking what's on our mind and being vulnerable because they're going to think something about us and leave us.” Dismissive or Avoidant Attachment Style [29:57] “It is the fear that I'm not good enough or this person isn't gonna be there for me.”  Disorganized Attachment Style [31:36] “A mix of anxious and dismissive. You might just go back and forth.” Secure Attachment Style [36:15] “Both should decide that they want a secure relationship. You need someone who's willing to create that secure attachment with you.”  Tips on Becoming More Secure [44:56]  “Awareness is the first step. Do a relationship inventory.”   Kelly and I covered so much during this interview! I hope you loved it.    Make sure you connect with Kelly on IG @chaselifewithkelly     You can also check out her podcast: Chase Life with Kelly - available everywhere podcasts are aired.   If this episode inspired you to take action in your dating life, I want to invite you to apply to the Empowered.Secure.Loved. Program.    If you're ready to get off the dating rollercoaster and become the securely attached version of you; I want to invite you to apply to the E.S.L. program today.   The time is NOW to intentionally invest in your healing.    Click Here to Apply!

Whoa!    A topic we've never explored on LGV.    Buckle up, this is a vulnerable episode.    And I think it deserves a Part 2, so on Wednesday you will get an episode dedicated to helping us make sense of what to do with the information in this episode.    Inside of today's episode:    -The link between ADHD and Insecure Attachment Styles  -My own journey with ADHD and healing my attachment style  -How your early childhood experiences impact ADHD and Attachment Styles  Aaaand more!    This is a great episode for connecting some dots, and having some AHA moments!   Next week will take it even further.    Are you ready to become securely attached?    What if you knew how to trust yourself in your dating decisions, and you knew you were attracting high quality securely attached partners?    It's all available to you when you learn to become the securely attached version of you!    If you're ready to get off the dating rollercoaster and become the securely attached version of you; I want to invite you to apply to the E.S.L. program today.   The time is NOW to intentionally invest in your healing.    Click Here to Apply!

I have made a declaration!    There will be no more boring first dates!    You see what makes first dates boring is usually the fact that we're not focused on truly connecting. And we're not asking GREAT questions.    Inside of this episode you will find: :    -4 Essential Shifts for a Great First Date  -10 Questions You can Ask any First Date -My guide to approaching intentional vulnerability when dating    You don't want to miss this one! It is packed full of pure dating GOLD!    Also-if you are ready to be in the room with myself, and Julie Mennano MFT of @ thesecurerelationship so that we can help you let go of your past, and finally welcome in the relationship you deserve - make sure you grab your spot for Empowered.Secure.Loved. LIVE !!    For all the details, ,and to grab your spot before they are gone go to:    Empowered.Secure.Loved. LIVE: REGISTER HERE   Aaaaaand since I am extra grateful to all of you loyal LGV listeners, you can get $200 off of your ticket by using this special discount code when you sign up-   Your Code: LASTCHANCE2022   I hope to see you there! You are so worthy of doing the work to heal. And it would be my honor to support you on your journey to high self-worth and great relationships.    Xoxo- Dr. Morgan 

Trong cuộc điều trần trước Hạ Viện Pháp hôm 13/07/2022, lãnh đạo SGDSN cơ quan đặc trách về Quốc Phòng và An Ninh Quốc Gia khẳng định gián điệp Trung Quốc hoạt động ở « quy mô lớn » trên lãnh thổ Pháp, quan tâm đến « nhiều lợi ích của chúng ta ». Các trường đại học, viện nghiên cứu, doanh nghiệp là những « miếng mồi ngon ». Không hẹn mà trong chưa đầy một tháng, Anh, Pháp và Mỹ đồng loạt lên tiếng về các hoạt động tình báo của Trung Quốc nhắm vào phương Tây. Đầu tháng 7/2022 giám đốc MI5 cơ quan tình báo nội địa Anh và lãnh đạo Cục điều tra Liên Bang Mỹ FBI báo động Trung Quốc « gia tăng các hoạt động gián điệp thương mại ». Ngày 22/07 đến lượt ông Richard Moore, giám đốc MI6 theo dõi các hoạt động của các thực thể nước ngoài, tuyên bố Luân Đôn sẽ « huy động nhiều phương tiện hơn về Trung Quốc ». Giữa hai thời điểm đó, trung tuần tháng 7, tại Paris, tổng thư ký cơ quan đặc trách về Quốc Phòng và An Ninh Quốc Gia Pháp – SGDSN, ông Stéphane Bouillon, trong cuộc điều trần tại Hạ Viện khẳng định : « Nhiều người Trung Quốc quan tâm đến những lợi ích » của Pháp bằng cách « xâm nhập », « theo dõi », các đối tượng cần quan tâm. Tựa như một con ma cà rồng hút máu, ở mọi cấp, tình báo Trung Quốc « hút » những thông tin cần thiết. Cũng trong cuộc điều trần đó, quan chức này của Pháp đã nhấn mạnh : « Mỗi khi một thực tập sinh từ một số quốc gia –và chúng tôi đặc biệt chú ý đến những trường hợp từ Trung Quốc và Iran đến, ghi danh vào các trường đại học trong các ngành vật lý và hóa học SGDSN cho mở điều tra và có quyền can thiệp để từ chối đơn của các thí sinh nước ngoài nếu đánh giá đó là những hồ sơ khả nghi ». SGDSN có nhiệm vụ ngăn chận « một số công ty, đặc biệt là của Trung Quốc, để số này không phát triển, chiếm một vị trí quá lớn tại Pháp ». Stéphane Bouillon nêu rõ « viễn thông và một số lĩnh vực được coi là nhậy cảm » đối với an ninh quốc gia. Một cách cụ thể hơn, trong trường hợp của Pháp, nhân viên tình báo Trung Quốc hoạt động dưới hình thức nào, đâu là những mục tiêu trong tầm ngắm của Bắc Kinh và Pháp có những phương tiện nào để tự vệ,  hiệu quả đến đâu ? RFI tiếng Việt mời Pierre- Antoine Donnet, tác giả cuốn sách phát hành năm 2021 mang tựa đề Chine, le grand prédateur - Trung Quốc một kẻ săn mồi lớn, NXB Editions de l'Aube trả lời các câu hỏi này. Ông Donnet nguyên là tổng biên tập hãng tin Pháp AFP và là cộng tác viên thường xuyên của báo mạng chuyên về châu Á, Asialyst.   Từ khi nào Trung Quốc đã trở thành mối lo ngại hàng đầu của cơ quan đặc trách về an ninh Pháp, SGDSN và tại sao ? Pierre-Antoine Donnet : « Tháng 9/2021 một báo cáo đươc công bố đã cho thấy hoạt động tình báo của Trung Quốc nhắm vào phương Tây nói chung và đặc biệt là vào châu Âu đã tinh vi đến mức độ nào. Đó là báo cáo của Viện Nghiên Cứu Chiến Lược Trường Quân Sự Pháp-IRSEM, một cơ quan trực thuộc bộ Quân Lực. Theo tài liệu hơn 650 trang với rất nhiều chi tiết này, tình báo Trung Quốc đa hình đa dạng và hoạt động trong những lĩnh vực khác nhau : từ kinh tế đến công nghiệp, quân sự hay dọ thám để định hướng dư luận. Mọi người đều biết, trong quá khứ một số lãnh đạo hàng đầu của Pháp từng rơi vào những tình huống tế nhị đối với Bắc Kinh (...) Các hoạt động tình báo đó dựa trên cơ sở một bài diễn văn của Tập Cận Bình hồi năm 2014. Lãnh đạo Trung Quốc đã định nghĩa cái gọi là « an ninh toàn diện » trong 5 lĩnh vực. Quan trọng nhất tất nhiên là « an ninh về mặt chính trị » kế tới là « an ninh kinh tế », là sự « ổn định của chế độ », là « an ninh về đối ngoại » và sau cùng là những điều cơ bản trong các hoạt động tình báo dựa theo mô hình của Nga, mà đứng đầu là những hoạt động dọ thám trong lĩnh vực quân sự, quốc phòng. Chính trong mục tiêu này Bắc Kinh đã gài người vào các cơ quan nhà nước của quốc tế, vào các chính quyền để phục vụ quyền lợi của Trung Quốc ».   Trong tác phẩm gần đây nhất ra mắt độc giả năm 2021, Pierre-Antoine Donnet đã dành nhiều trang để nói về các hoạt động dọ thám của Trung Quốc. Với RFI tiếng Việt ông giải thích : Trung Quốc chịu tung tiền để mua chuộc các quan chức phương Tây và đã « có nhiều chính khách hàng đầu của Pháp rơi vào bẫy ». Ở vào thời đại mà mạng xã hội là vua, thao túng thông tin, phao tin thất thiệt hay bóp méo sự thật, sử dụng cả một đội ngũ hùng hậu những « người lính cyber » để bôi nhọ đối phương, hướng dẫn dư luận không phải là chuyện khó làm. Trong trường hợp của Pháp, gián điệp Trung Quốc nhắm vào những mục tiêu nào ?  Pierre-Antoine Donnet : Những công nghệ của Pháp đã cho phép các kỹ sư Trung Quốc tiến bộ rất nhanh trong lĩnh vực hạt nhân dân sự, trong ngành xây dựng các hệ thống đường sắt cao tốc LGV, trong ngành công nghiệp hàng không dân sự và quân sự. Nếu như Pháp và nhiều nước phương Tây khác mất hàng chục năm nghiên cứu và đã phải đầu tư rất nhiều mới đạt đến đỉnh cao trong những lĩnh vực này, thì Trung Quốc chỉ mất từ 10 đến 15 năm. Xin đơn cử một thí dụ rất rõ ràng : Trung Quốc đã xây dựng được một mạng lưới hơn 40.000 km đường sắt cho tàu cao tốc LGV trong chưa đầy 20 năm. Pháp đã phải mất đến 4 chục năm để có được chưa đầy 10.000 km. Nhân viên Trung Quốc đã hoạt động rất tốt trong nhiệm vụ đánh cắp thông tin công nghệ của Pháp. Một hồ sơ gián điệp công nghiệp khác Pháp nói riêng và châu Âu nói chung vẫn chưa « nuốt trôi » liên quan đến ngành công nghiệp chế tạo máy bay dân dụng : Pierre-Antoine Donnet : Airbus đã phát hiện là các dữ liệu mật của tập đoàn bị đánh cắp mà thủ phạm rõ ràng là những tin tặc Trung Quốc. Ít lâu sau thì Trung Quốc trình làng kiểu máy bay dân sự COMAC C919, giống loại A320 của Airbus như hai giọt nước. C919 của Trung Quốc đã dễ dàng vượt qua các đợt bay thử nghiệm. Thế nhưng nhà sản xuất Trung Quốc chưa làm chủ toàn bộ các khâu sản xuất và đang bị kẹt ở chặng thiết kế động cơ. Đây là một lĩnh vực mà Trung Quốc còn lệ thuộc vào công nghệ của Mỹ và châu Âu. Làm thế nào để giải thích Trung Quốc đã dễ dàng rút được những bí quyết công nghiệp, về công nghệ cao của Pháp như vậy ? Pierre-Antoine Donnet : Ở đây có hai yếu tố quyết định. Thứ nhất là « tiền » : Ai cũng ham lợi. Thí dụ hiển nhiên nhất là các tập đoàn Pháp trong lĩnh vực hạt nhân dân sự, từ AREVA, FRAMATOME đến EDF đều đã chuyển giao công nghệ cho các đối tác Trung Quốc vì muốn chen chân vào thị trường đầy tiềm năng này. Các tập đoàn đó chỉ nhìn thấy tiền và triển vọng tươi sáng ở Trung Quốc nên đã dễ dàng và bất cẩn ký hợp đồng với đối tác này. Nhờ vậy Trung Quốc giờ đây đã làm chủ toàn bộ ngành công nghiệp hạt nhân dân sự : từ khâu thiết kế nhà máy điện nguyên tử đến công tác bảo trì và nhất là các kỹ thuật tân tiến nhất. Nhờ công nghệ của Pháp, hai nhà máy điện hạt nhân thế hệ mới EPR đã hoạt động tại Trung Quốc từ 2018 và 2019. Pháp thì nhà máy ở Flamanville đã trễ hơn 15 năm, giá thành liên tục bị đội lên. Yếu tố thứ nhì là một sự ngây thơ đến phải hổ thẹn của phương Tây, để bây giờ mọi người mới bừng tỉnh, hốt hoảng nhìn lại vấn đề và tự hỏi « vì sao ra nông nỗi này ? ». Âu Mỹ từng lầm tưởng rằng Trung Quốc biết giữ chữ « Tín » và mãi mới phát hiện ra rằng, Trung Quốc không tôn trọng các điều khoản trong hợp đồng, không sòng phẳng, không thẳng thắn. Giờ đây Pháp, Mỹ hay Nhật … mới thấy rõ rằng Trung Quốc không chỉ là cơ xưởng của thế giới mà đang trở thành « phòng thí nghiệm » của thế giới. Mất trộm rồi mới rào giậu ? Liệu đã quá trễ hay chưa để ngân chận các hành vi đánh cắp thông tin mật về kinh tế, những bí quyết về kỹ thuật ? Trung Quốc có còn cần đến những bí quyết đó của phương Tây nữa hay không ?  Pierre-Antoine Donnet : Cá nhân tôi không nghĩ rằng Trung Quốc sẽ đạt đến đích, bởi vì phương Tây đang bừng tỉnh để nhận thấy rằng chính quyền nước này – tôi không nói là người Trung Quốc, mà chính quyền Bắc Kinh, gian dối. Trung Quốc từ lâu nay lừa bịp thiên hạ và còn tiếp tục theo hướng đó. Phương Tây thì bây giờ mới hiểu ra rằng không thể tin được Trung Quốc. Chính vì ngây thơ mà Âu Mỹ đã đánh mất hàng ngàn, hàng chục ngàn công việc làm và còn nhiều hơn thế nữa. Pháp có thể làm được gì để giữ công nghệ và những phát minh trước các hoạt động ráo riết của ngành tình báo Trung Quốc ? Những công cụ đó nếu được áp dụng một cách nghiêm chỉnh có hiệu quả đến đâu ? Pierre-Antoine Donnet : Trước hết là ngừng mọi chương trình chuyển giao công nghệ mà không có những bảo đảm hay những cơ sở pháp lý vững chắc. Trong mọi hợp đồng với các đối tác Trung Quốc, mỗi chi tiết đều phải được  « soi rọi », cân nhắc rất kỹ với những điều khoản rất, rất chính xác. Thứ hai nữa là Pháp có cả một cơ quan phản gián để ngăn chận những hoạt động tình báo của tất cả các quốc gia khác, đứng đầu là Trung Quốc, để ngăn chận những vụ bòn rút thông tin mật. Công cụ thứ ba theo tôi đơn thuần là chiến lược tự chủ về công nghiệp, về kinh tế. Trong giai đoạn dịch Covid chúng ta thấy là Pháp lệ thuộc đến 80 % vào chất giảm đau paracétamol nhập từ Trung Quốc và 20 % nhập từ Ấn Độ. Từ đó Pháp nói riêng, Liên Âu nói chung đã rút ra được một bài học đó là không để lệ thuộc vào quốc gia nào trong các lĩnh vực then chốt đối với kinh tế, an ninh … và nhất là trong các công nghệ mới mà chúng ta thường gọi là « công nghệ của tương lai ». Cơ quan an ninh Pháp SGDSN không được thông báo về chương trình hợp tác giữa hệ thống các trường đào tạo kỹ sư ParisTech của Pháp với trường đại học nổi tiếng của Tây An bị nghi là có liên hệ chặt chẽ với quân đội Trung Quốc. Tháng 10/2022 thượng nghị sĩ Stéphane Piednoir vùng Maine et Loire, miền tây nước Pháp, chất vấn bộ trưởng đặc trách về Giáo Dục cấp Đại Học, về các chương trình Nghiên Cứu và Phát Minh, bà Frédérique Vidal về các biện pháp ngăn ngừa các tổ chức nước ngoài xâm nhập vào các trường đại học và các viện nghiên cứu quốc gia. Ông cũng đã nêu bật trường hợp cụ thể về hợp tác với đại học Tây An. Từ đó tới nay, bộ Giáo Dục cấp đại học Pháp đã đổi chủ, Paris vẫn chưa trả lời câu hỏi của thượng nghị sĩ Piednoir. Theo tiết lộ của báo Télégramme (03/07/2022), vùng Bretagne (tây bắc nước Pháp) có sức hấp dẫn cao đối với Trung Quốc nhờ vào các trường đại học, các trường kỹ sư công và tư vào các phòng thí nghiệm trong lĩnh vực phòng thủ không gian. Đây cũng là nơi có căn cứ hải quân và các trường võ bị. Một vùng hẻo lánh khác là Châteauroux, cách thủ đô Paris 270 km về phía tây nam cũng có sức « thu hút cao » bởi đây là một trong bốn trung tâm Hải Quân Pháp liên lạc với các tàu ngầm hoạt động ở bất cứ nơi nào trên thế giới. Tờ báo địa phương này cho rằng không phải tình cờ mà Hoa Vi mở nhà máy tại Brumath, vùng Bas Rhin, (đông bắc). Chung quanh thành phố với chưa tới 10.000 dân cư này có nhiều căn cứ của « các đơn vị lục quân chuyên thu thập thông tin tình báo, và một cơ sở của Tổng Cục An Ninh Đối Ngoại DGSE ».  

Aujourd'hui dans Le Vacher Time, Jeremie est membre du jury du Hello Planet Film Festival. Le festival a pris le parti de passer par l'humour, l'ironie, la polémique ou encore la poésie pour sensibiliser et éduquer le grand public aux enjeux climatiques et environnementaux. Victor Pachon a fait de sa vie un combat contre ces projets LGV, il nous expliquera en quoi ces derniers sont destructeurs de l'environnement. Sandrine est une chercheuse-semeuse d'utopies. Elle est perspectiviste, conférencière, éditrice, essayiste et romancière. Sandrine nous fera aujourd'hui un coup de gueule sur la fiction déprimante, qui nous entraîne dans un monde pourri qui met en avant l'effondrement. Retrouvez Vacher, Niko, Anne-So et Lul en direct tous les jours de 9h à 11h, en podcast sur funradio.fr et sur l'application Fun Radio.

Kevin, a Perry and Shawna Mornings listener, was angry, frustrated. His family was feeling the weight of his anger. Finally Kevin realized why he was acting out in such destructive ways—it was guilt eating him alive. So he wrote down every sin he ever committed, that he could think of, even went to many of the people he wronged, and Jesus freed him from the guilt. With this we talk about when it might not be best to go to the person we've wronged. Then Robert, another Perry and Shawna Mornings listener shares how Jesus found him—He grew up not knowing about Jesus. He graduated from college, launched his career, pursued pleasure in relationships and was left feeling empty. In desperation he went to a Catholic priest and what the priest shared with him changed his life forever. And now thirty years into Robert's journey, he's launching a new website Life Giving Verses. LGV features fifty bible verses that simply and powerfully share what the bible's all about—being in a relationship with the God who loves you! Whether you're a saint, skeptic, seeker, or spiritual but not religious, LGV is all about inspiring you to move forward in your friendship with God. Check it out! See omnystudio.com/listener for privacy information.

durée : 00:03:43 - Le témoin de l'actu dans les Landes

Help! How do I know if it's my attachment style or my gut instinct?    This question comes up a lot; so I thought it was time to answer it!    In today's episode I discuss:    A framework for making securely attached decisions  The dangers of not doing the internal work  How to know if a decision is coming from lack of compatibility vs. your attachment style    I know this episode will help you whether you are in a relationship, dating, married, or wherever you are currently on your journey to high self-worth and great relationships!    Ready to do the internal work so that dating feels effortless and fun?    Here is the link to apply to the Empowered.Secure.Loved program!    P.S. Over 200 episodes?! Wow! You all are amazing! Thanks for your support as the LGV podcast has grown! Make sure you share an episode with someone who needs dating and relationship support!

In this episode, governance issues spring from the sports pages; Lucy Dalton from LGV provides an update on LGA2020 implementation and other topical sector issues; it's mayoral election season in Victoria; conflict of interest lessons from ICAC and South Australia; and the councillor calling out abuse of elected representatives and council staff.

durée : 00:08:02 - 18h50 franceinfo - Invitée sur franceinfo vendredi, la porte-parole d'Europe Ecologie Les Verts, Eva Sas, a défendu un projet alternatif à la LGV Bordeaux-Toulouse basé sur la "rénovation des lignes existantes".

durée : 00:56:22 - franceinfo: Les informés - par : Jean-François ACHILLI, Pierre NEVEUX - Tous les soirs, les informés débattent de l'actualité sur franceinfo.

LGV en Nouvelle-Aquitaine, "un projet insensé" pour le Maire de Bordeaux

This is a VERY special episode. Experiencing Cheating can totally destroy your world It can leave you feeling “not good enough” and like you did something wrong. I can be downright devastating! But there IS a way through it and I know this episode will help anyone who has ever been cheated on Inside this episode: I answer a real-life scenario sent to me by a LGV podcast listener. I explain the real roots of cheating. I walk you through your options when you are on the receiving end of it.   Seriously, you don't want to miss this one! It will help you SO MUCH if you have ever in your life experienced cheating. Of course, make sure you share this episode with someone if you know they need to hear it! If you're ready to leave your past relationships in the past and heal fully, I'd highly encourage you to apply to the Empowered.Secure.Loved (E.S.L.) Relationship Program! We have limited spots left in September!  CLICK HERE TO APPLY!

AUDIENCE QUESTION ANSWERED! Today's episode was dedicated to a loyal LGV listener who sent in a question. Her questions were: Why do people seem securely attached and then become avoidant a couple months into the relationship? How do I move on from being ghosted? How can I continue to become more securely attached? I answer these questions and MORE inside of this juicy episode! Don't miss it - tune in now! P.S. If you're ready to move on from being ghosted, welcome in LOVE, and focus on your personal development and growth with a partner, then make sure you apply to the E.S.L relationship program. Spots are limited in the remainder of August and you don't want to miss out!   Click HERE to apply today!

Buckle up and let’s get vulnerable with an amazing guest Chad Savage!    We had such a fun interview where he shared openly about his experience of going on @hbomax HBO Max’s series: 12 Dates of Christmas!    Inside this episode you will hear us discuss:  The journey to finding healthy love  His best dating advice (and it definitely lines up with what I would preach )  What mattered most to him when picking a partner  OOOOH and what it was like meeting his fiancé in a Castle in Austria on a Tv Show!! lol   Seriously, you don’t want to miss this episode! It might be one of my all time favorites!   Chad @chadbsavage has such a good heart, and I am personally very excited for him and his fiancé, Kate @itskatesteinberg. Make sure you’re following them if you’re not already!    Also, go leave the LGV podcast a 5 star written Apple podcast review if you haven’t already! That is how we can help others find the valuable show content-help me, help others!

Oie, tudo gay? Nesse episódio eu falei sobre o filme Paraíbano sobre Cura Gay que foi indicado a premiação internacional de melhor filme no Human Rights Film Festival. Trouxe informações sobre o assassinato brutal da adolescente trans Keron Ravach no Ceára, ela se tornou a vítima mais jovem de transfeminicídio no Brasil com apenas 13 anos. Investiguei porque o Ministério de Damares Alves não gastou nem um centavo do orçamento destinado à Diretoria de Políticas de Promoção e Defesa dos Direiros LGBT em 2020. E falei sob a pressão de conservadores que fez o CNJ alterar uma resolução que dava direito a pessoas travestis condenadas pela justiça de escolherem se querem cumprir pena em presídio masculino ou feminino. Na área de saúde eu falei sobre um estudo inglês que indicou aumento de LGV entre homens gays e bissexuais na Inglaterra. E por fim te informei sobre o desfecho da polêmica do Queermuseu em Porto Alegre que finalmente chegou ao fim. O Banco Santander fechou um acordo com oMinistério Público e pagará multa de 400 mil reais por ter banido a exposição que tratava sobre diversidade sexual em 2017. ☎ Atendimento em Psicanálise com Dann Bonfim: https://bit.ly/terapialgbt ★ Dann Bonfim nas redes sociais: https://bit.ly/3nbUPeX ✉ Assinar minha newsletter: https://bit.ly/2K8Td7U

#32. Neste episódio, falo sobre o Dezembro Vermelho e a infecção pelo Papiloma Virus Humano (HPV). Abordamos:- DST ou IST?- O que dizem as pesquisas da Sociedade Brasileira de Urologia sobre as ISTs?- Os 4 grupos de ISTs:1) As silenciosas: HIV/AIDS; Hepatite B; Hepatite C2) Úlceras: herpes genital, cancróide (cancro mole), sífilis (ou cancro duro), linfogranuloma venéreo (LGV) e donovanose3) Lesões verrucosas: HPV4) Secreções uretrais: uretrites VERRUGAS GENITAIS, CONDILOMA ACUMINADO E PAPILOMAVÍRUS HUMANO (HPV)- Tipos de HPV- Diagnóstico- Tratamento- Prevenção com Vacina:- Um Feliz 2021 a todos!- Ouça e aprenda mais! Se gostar, compartilhe e não esqueça de deixar seu comentário e nota nas plataformas de Podcast. Isso ajuda a disseminar o conhecimento.- Ouça também em meu site e deixe seu comentários, ficarei muito feliz em tirar suas dúvidas. Link to http://www.ourologista.com.br/podcast/episodio32

Das Licht des Herrn strahlt... "Gott kommt zu mir, es ist wie eine unsichtbare Realität" bekennt ein gläubiger Christ Martin Siehler im Gespräch über die Spiritualität von "Glauben leben". Ein herrliches Bild! Martin Siehler ist heute als Prediger zu Gast in der "Schon". Herr Siehler ist seit vielen Jahren Prediger im LGV. Heute ist er der Personalleiter beim LGV (Liebenzeller Gemeinschaftsverband) in Bad Liebenzell. Hören Sie eine spannende Predigt am 3. Adventssonntag 2020 aus der Christlichen Gemeinde in Nürnberg.

Jules and Shane speak to David Palmer. If you have learned how to ride a motorcycle or learned how to drive an LGV in Shrewsbury, you will most likely know who David is!  David is from Fast Trak, a company that has huge amounts of experience when is comes to training others road safety. In fact discussed in this episode is how David's experience is somewhat unappreciated by the young whipper-snappers of today. But he's been there, he's seen it and he has the ancient highway code books to prove it! "I sat in on the interview and let Jules and Shane do their thing. It was great to sit back and watch the show unfurl, especially as Shane got to talk about vehicles for a change. David is a great guy and it was great getting to chat with him!"

One of the MOST IMPORTANT topics for the early stages of dating…   RELATIONSHIP PACING    Do you know what I am talking about?   A lot of you are in the deep end of the pool, while your partner is hanging out in the 3ft section–dipping a toe in...    Uh-Oh; been there done that, got that t-shirt and I’m telling you: it.doesn’t.end.well   In this episode: I explain relationship pacing using an Attachment Theory lens   This episode is a MUST LISTEN for anyone on the dating scene who is serious about having a healthy relationship   I openly discuss:  Understanding “Investment” and why some of you are way too quick to commit  The Keys to Relationship Pacing The importance of “Balance” and what it means when it comes to Pacing   LGV listeners–I would LOVE to know your takeaways from this episode–so make sure you tag me in your IG stories with what you learned!    P.S. Send me a DM if you would like to be invited to the exclusive LIVE training I will be doing on “ Successfully Having the Define the Relationship Talk” aka not peeing your pants during the “what are we conversation” LOL. You don’t want to miss this!

We answer our fourth LGV question, talk about future planning, overcoming insecurities, and more!!

Welcome to the Let’s Get Vulnerable Podcast!  Whoa, we did it! This is episode one where I do a deep dive on the birth of “Let’s Get Vulnerable.” I discuss the vision for this podcast, and what you can expect when tuning in. I also do a quick shoutout to all the people who have supported me in getting to this point-including all of you: my amazing followers.  I discuss why I appreciate my @drmorgancoaching IG followers so much and ways that this space has truly become a community.  I share with you that you can expect the following from LGV:  2 episodes a week  3 different types of episodes: solo (me teaching directly to you), special guest expert interviews (all done in LIVE format), and live coaching sessions  Lots of real talk, vulnerability and humor (because let’s have some fun, shall we?)  I also talk about why a podcast about relationships, also includes the relationship with YOURSELF. We gotta start at the foundation, y’all! Thank-you for being here with me on this journey and supporting me as I embark on this new way to connect with you all. Please leave me a 5 star I-Tunes review, and share the podcast with people in your life who can benefit from expert advice on relationships.    Remember, the best place to stay connected with me is on instagram @drmorgancoaching    Eeeeeeek!  So, BUCKLE UP and - Let’s.Get.Vulnerable!

We tend to forget that many sexually transmitted diseases are in fact forms of a virus we pass through oral or genitalia contact.  Thus, when antibiotics are used to fight them off, they change and evolve in order to live.  This creates new strains of venereal diseases that the medical community my not have a way of curing, like HIV did back when it was at it's peak.  We talk about those 4 relatively new strains that are on the rise.   Neisseria meningitidis Mycoplasma genitalium Shigella flexneri Lymphogranuloma venereum (LGV). Amorist Eclectic Copyright 2019 --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/amorist-eclectic/support

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections. Try to create a rapport that is comfortable and open for your patient to provide as much detail as they can. Nachi: And as with any infectious work up, tachycardia, hypotension, and fever should all raise the concern for possible sepsis. In your sepsis source differential, definitely consider PID in addition to the usual sources. As a mini plug for a prior issue, PID was actually covered in the December 2016 issue of Emergency Medicine Practice, in detail. Jeff: Getting back to the physical exam: though some question the utility of the pelvic exam as our diagnostics get better, the literature suggests the pelvic definitely still has a big role both in diagnosing and differentiating STDs and other pathology. Don’t skip this step when indicated. Nachi: Now that we have a broad overview, let’s talk about specific STDs, covering diagnosis, testing, and treatment. Jeff: If following along in the article, appendices 1, 2 and 3, list detailed physical exam findings for the STDs were going to discuss, while table 3 lists treatment options. A great resource to use while following along or as a reference during a clinical shift! Nachi: First up, let’s talk chlamydia, the most common bacterial cause of STDs, with 1.7 million reported infections in 2017. Most are asymptomatic, which increases spread, especially in young women. Jeff: Chlamydia trachomatis has a 2-3 day life cycle in which elementary bodies enter endocervical and urethral cells and replicate, eventually causing host cell wall rupture and further spread. Nachi: Though patients with chlamydia are often asymptomatic, cervicitis in women and urethritis in men are the most common presenting symptoms. Vaginal discharge is the most common exam finding followed by cervical ectropion, endocervical mucus, and easily induced bleeding. Other presenting symptoms include urinary frequency, dysuria, PID, or even Fitz-Hugh-Curtis syndrome, which is a PID induced perihepatitis. In men, epididymitis, prostatitis, and proctitis are all possible presenting symptoms also. Jeff: And of note, chlamydia can also cause both conjunctivitis and pharyngitis. Nachi: This article has a ton of helpful images. Check out figures 1 and 2 for some classic findings with chlamydial infections. Jeff: When testing for chlamydia, nucleic acid amplification is the test of choice as it has the highest sensitivity, 92% when tested from a first-catch urine sample vs. 97% from a vaginal sample. While these numbers are similar, and you’re gut may be to forego the pelvic exam, consider the pelvic exam to aid in the diagnosis of PID and to evaluate for cervicovaginal lesions or other concomitant stds. Nachi: Similarly, in men, the test of choice is also a nucleic acid amplification test, with a first catch urine preferred over a urethral swab. Jeff: And lastly, nucleic acid amplification is also the test of choice from rectal and oropharyngeal samples, though you need to check with your lab first as nucleic acid amplification is not technically cleared by the FDA for this indication. Nachi: Treatment for chlamydia is simple, 1g of azithromycin, or doxycycline 100 mg BID x 7 days. Fluoroquinolones are a second line treatment modality. Jeff: In pregnant women, chlamydia can lead to ectopic pregnancy, premature rupture of membranes, and premature delivery. The single 1g azithromycin dose is also safe and effective with amox 500 mg TID x 7 days as a second line. Pregnant women undergoing treatment should have a documented test-of cure 3-4 weeks after treatment. Nachi: Next up, we have gonorrhoeae, the gram-negative diplococci. Gonorrhea is the second most commonly reported STD, affecting 0.8% of women and 0.6% of men, with over 500,000 reported cases in 2017. Jeff: Gonorrhea attaches to epithelial cells, altering the surface structures leading to penetration, proliferation and eventual systemic dissemination. Nachi: Though some may be asymptomatic, women often present with cervicitis, vaginal pruritis, mucopurulent discharge, and a friable cervical mucosa, along with dysuria, frequency, pelvic pain and abnormal vaginal bleeding. Jeff: Men often present with epididymitis, urethritis, along with dysuria and mucopurulent discharge. Proctitis, pharyngitis, and conjunctivitis are all possible complications. Nachi: In it’s disseminated form, gonorrhea can lead to purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: In both men and women the test of choice for gonorrhea again is NAAT, with endocervical samples being preferred to urine samples due to higher sensitivity. In men, urethral and first catch urine samples have a sensitivity and specificity of greater than 97%. Nachi: And as with chlamydial samples, the FDA has not approved gonorrhea NAAT for rectal and oropharyngeal samples, but most labs are able to process these samples. Jeff: Yeah, definitely check before you go swabbing samples that cannot be run. Lastly, in regards to testing, though it won’t likely change your management in the moment, the CDC does recommend a gonococcal culture in cases of confirmed or suspected treatment failure Nachi: It’s also worth noting that although NAAT can be used in children, but culture is additionally preferred in all settings due to legal ramifications of sexual abuse. Jeff: It pains me just to think about how awful that is. Ugh. Moving on to treatment: when treating gonorrhea, the current recommendation is to treat both with cefitriaxone and azithro. 250 mg IM is the preferred dose, up from just 125 mg IM which was preferred dose two decades ago along with 1g of azithro. Nachi: And if ceftriaxone IM cannot be administered easily, 400 mg PO cefixime is the second line treatment of choice. If there is a documented cephalosporin allergy, PO gemifloxacin or gentamycin may be used. And for those with an azithomycin intolerance, a 7 day course of doxycycline may be substituted instead. Jeff: In pregnant women, gonococcal infections are associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortions. Pregnant woman therefore should be treated with both ceftriaxone and azithro in the same manner as their non pregnant counterparts. Nachi: There is also one quick controversy to discuss here. Jeff: oh yeah, go on… Nachi: The CDC currently recommends the IM dose of ceftriaxone, not IV. And this is because of the depot effect. However, it’s unclear if this effect is in fact true, as IM and IV ceftriaxone levels measured in blood 24 hours later are similar. So if the patient has an IV already, should we just give the ceftriaxone IV instead of IM? Jeff: I think it is probably okay, but I’ll wait for a bit more research. For now, I would continue to stick with the CDC recommendation of IM as the correct route. Nachi: And with the continuing rise of STD’s and the public health and economic burden we are describing here, I think the IM route, which is known to be effective, should still be used -- until the CDC changes their recommendations. Next up we have the great imitator/masquerader, syphilis, caused by the spirochete Treponema pallidum. LIke the other STDs we’ve discussed so far, cases of syphilis are also on the rise with over 30k cases in 2017, a 10% increase from 2016. Jeff: Syphilis is spread via direct contact between open lesions and microscopic abrasions in the mucous membranes of vagina, anus, or oropharynx. The organism then disseminates via the lymphatics and blood stream. Nachi: Infection with syphilis comes in three stages. Primary syphilis is characterized by a single, painless lesion, or chancre, which occurs about 3 weeks after inoculation. 6-8 weeks later, secondary syphilis develops. This often presents with a rash, typically on the palms and soles of the feet, or with condyloma lata, or lymphadenopathy. Jeff: Tertiary syphilis doesn’t appear until about 20 years post infection and it includes gummatous lesions and cardiac involvement including aortic disease. Nachi: Patients at any stage may go long periods without any symptoms, which is known as latent syphilis. In addition, at any stage a patient may develop neurosyphilis, which can present with strokes, altered mental status, cranial nerve dysfunction, and tabes dorsalis. Jeff: In early syphilis, dark-field examination is the definitive method of detection, though this is impractical in the ED setting. There are, instead, 2 different algorithms to follow. The CDC traditional algorithm recommends a nontreponemal test like rapid plasma reagin or RPR or the venereal disease research lab test also called VDRL, followed by confirmational treponemal test (fluoresent treponemal antibody absorption or FTA-ABS or T pallidum passive agglutination also called TP-PA). More recently there has been a shift to the reverse sequence, with screening with a treponemal assay followed by a confirmatory nontreponemal assay. Nachi: The reason for the change is that there is an increased availability of rapid treponemal assays. And where available, the reverse sequence offers increased throughput and the ability to detect early primary syphilis better. The CDC, however, still recommends the traditional testing pathway -- that is nontreponemal tests first like RPR or VDRL, followed by treponemal tests like FTA-ABS or TP-PA. The article also notes that emergency clinicians should rely on clinical manifestations in addition to serologic testing, when determining whether to treat for syphilis. Jeff: For neurosyphilis, the CSF-VDRL test is highly specific but poorly sensitive. In cases of a negative CSF-VDRL but still with high clinical suspicion, consider a CSF FTA-ABS test, which has lower sensitivity, but is also highly specific and may catch the diagnosis. Nachi: Treatment for primary, secondary, and early latent syphilis is with 2.4 million units of Penicillin G IM. For ocular and neurosyphilis, treatment is with 18-24 million units of pen G IV every 4 hours or continuously for 10-14 days. In patients who have a penicillin allergy, skin testing and desensitization should be attempted rather than azithromycin due to concerns for resistance. Jeff: For pregnant women, PCN is the only proven therapy. Interestingly, there is some evidence to suggest that a second IM dose may be beneficial in treating primary and secondary syphilis in pregnancy though data are limited. Nachi: We also have to mention the Jarisch-Herxheimer reaction before moving on. This is a syndrome of fevers, chills, headache, myalgias, tachycardia, flushing and hypotension following high dose PCN treatment due to a massive release of endotoxins when the bacteria die. This typically occurs in the first 12 hours but can occur up to 24 hours after treatment. Treatment is supportive. Concern of this reaction should never delay PCN treatment!! Jeff: The next condition to discuss is Bacterial vaginosis, or BV, which, interestingly, is not always an STD. It is therefore critically important to choose your words wisely when speaking with a patient who has BV. Nachi: That is an important point that is worth repeating. BV is not always an STD. So what is BV? BV occurs when there is a decrease or absence of lactobacilli that help maintain the acidic pH of the vagina leading to an overgrowth of Gardnerella, bacteroides, ureaplasma and mycoplasma. BV does not occur in those who have never had intercourse and it may increase the risk of other STDs and HIV. Jeff: 50% of women with BV are asymptomatic, while the others will have a thin, grayish-white, homogeneous vaginal discharge with a fishy smell, along with pruritis. Nachi: To diagnose BV, most use the amsel criteria, which requires 3 of following 4: 1) a thin, milky, homogeneous vaginal discharge, 2) the release of a fishy odor before or after the addition of potassium hydroxide, 3) a vaginal pH > 4.5, and 4) the presence of clue cells in the vaginal fluid. These criteria are 90% sensitive and 77% specific, with clue cells being the most reliable predictor. Jeff: And for those of us without immediately available microscopy, you can make the diagnosis based on characteristic vaginal discharge alone. Treat with metronidazole, 500 mg BID for 7 days, metronidazole gel, or an intravaginal applicator for 5 days, with the intravagainal applicator being better tolerated than the oral equivalent Nachi: BV in pregnancy increases risk of preterm birth, chorioamnionitis, postpartum endometriitis and postcesarean wound infections. Pregnant patients are treated the same as nonpregnant or with 400 mg of clindamycin BID x 7 days. Jeff: Always nice when there is really only one treatment regimen across the board. And that will be a general theme for treatment options in pregnancy with a few exceptions. Nachi: Next up we have Granuloma inguinale, or donovanosis, which is caused by Klebsiella granulomatis. Jeff: Granuloma inguinale is endemic to India, the Caribbean, central australia, and southern africa. It is rarely diagnosed in the US. Nachi: Granuloma inguinale presents with highly vascular, ulcerative lesions on the genitals or perineum. They are typically painless and bleed easily. If disseminated, Granuloma inguinale can lead to intra-abdominal organ and bone lesions and elephantiasis-like swelling of the external genitalia. Jeff: Granuloma inguinale can can be diagnosed by microscopy from the surface debris of purulent ulcers. Nachi: Once you have the diagnosis, the CDC recommends treatment with azithromycin for at least 3 weeks and until all lesions have resolved. Jeff: Next we have lymphogramuloma venereum or LGV. Nachi: LGV is a C. Trachomatis infection of the lymphatics and lymph nodes. This is predominantly a disease of the tropics and subtropical areas of the world. Jeff: On exam, in the primary stage, you would expect a small, painless papule, pustule, nodule or ulcer on the coronal sulcus of the penis or on the posterior forchette, vulva, or cervix of women. The primary stage eventually progresses to the secondary stage, which is characterized by unilateral lymphadenopathy with fluctuant, painful lymph nodes known as buboes. Nachi: Check out figure 11 for a great classic image of the “groove sign” which is involvement of both the inguinal and femoral lymph nodes, and is seen in 15-20% of cases. And actually even more common than the groove sign is a presentation with proctitis. Jeff: Testing for LGV should be based on high clinical suspicion, and NAAT should be performed on a sample from the primary ulcer base or from aspirate from a bubo. Nachi: Treatment for LGV is with doxycycline 100 mg BID x 21 days. Jeff: So, to summarize, for LGV, remember painful lymphadenopathy, especially in those with proctitis. Treat with doxy. Nachi: Next we have Mycoplasma genitalium, which causes nongonococcal urethritis in men and mucopurulent cervicitis and PID in women. Jeff: Unfortunately, there is no diagnostic test for M. genitalium, and it should be considered clinically, especially in the setting of recurrent urethritis. Nachi: Treat with azithro, but not 1g x 1. Instead, M. Genitalium should be treated with a course of azithro, with 500 mg on day 1 followed by 250 mg daily for 4 days. Moxifloxacin is an alternative. Jeff: Simple enough. Moving on to everybody’s favorite, genital herpes. Nachi: umm, I’m not sure sure anybody would call herpes their favorite. Why would you even say that? Jeff: i don’t know, seemed natural at the time… Regardless, primary genital herpes is caused by either HSV1 or HSV2. Though only an estimate, and likely an underestimate at that, it is estimated that at least 1 in 6 people in the US between 14 and 49 have genital herpes. Nachi: That’s much higher than I would have thought. Jeff: Patients usually contract oral herpes from HSV-1 due to nonsexual contact with saliva and genital herpes due to sexual contact with an infected person. Nachi: Keep in mind, however, that HSV1 can and will also cause genital infections if spread via oral sex. Jeff: Localized symptoms include pain, itching, dysuria, and lymphadenopathy and systemic symptoms include fever, headache, and malaise. In women, look for herpetic vesicles on the external genitalia along with tender ulcers in areas of rupture, see figure 12 for a characteristic image. Nachi: Though symptoms tend to be more severe in woman, men may present with vesicles on the glans penis, penile shaft, scrotum, perianal area, and rectum or even with dysuria and penile discharge. Jeff: HSV1 and 2 infections also have the ability to recur, though recurrences tend to become less frequent and severe over time. Nachi: It’s noteworthy that there is also a direct correlation between stress levels and the severity of an HSV outbreak. Jeff: Herpes can be diagnosed by viral culture of an unroofed vesicle or by NAAT. PCR based assays can also differentiate between HSV1 and HSV2 Nachi: While there is no cure, antivirals may help prevent and shorten outbreaks. Ideally you should begin treatment within 72 hours of lesion appearance. Treat with acyclovir, valacyclovir, or famciclovir. In addition, don't forget about adjuncts like analgesia, sitz bathes, and urinary catheter placement for severe dysuria. Jeff: HSV can also be vertically transmitted from mother to child so in pregnancy, treat with acyclovir 400 mg 3x/day for 7 days or valacyclovir Nachi: And because transmission is so easy, babies born to mothers with active lesions should be delivered by cesarean section. Jeff: Let’s move on to human papillomavirus, or HPV. There are over 100 types of HPV with 40 being transmitted through skin to skin contact, typically via vaginal and anal intercourse. Nachi: Most infections are asymptomatic and clear within 2 years. Jeff: Right, but one of the main reasons this is such a big deal is that HPV types 16 and 18 are oncogenic strains and can lead to cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Amazingly, HPV is responsible for more than 95% of the cervical cancers in women. Nachi: Hence the importance of the new vaccine series that most young adults and children are now opting for. Vaccination should occur in women through age 26 or men through age 21 if not previously vaccinated. Jeff: Critically important to take advantage of a vaccine that can prevent cancer! Nachi: And though not as important in terms of health consequences, just be aware that HPV 6 and 11 may lead to anogenital warts, known as condyloma acuminata. Jeff: In terms of exam findings, as you just mentioned, most infections are asymptomatic and self-limited. If symptoms do develop, HPV typically causes those cauliflower like or white plaque like growths lesions on the external genitalia, perineum, and perianal skin. Nachi: For testing, there is a limited role in the ED. Diagnosis should be made by visual inspection, followed eventually by a biopsy. Jeff: And just like the biopsy, which is unlikely to be done in the emergency department, most treatment is also not ED based. Treatment options include cryotherapy, immune-based therapy, and surgical excision, which has both the highest success rates and lowest recurrence. Nachi: Next up, we have trichomoniasis. Jeff:Trichomoniasis is a single-celled, flagellated, anaerobic protozoa, that directly damages the epithelium, causing microulcerations in the vagina, urethra, and paraurethral glands. Nachi: With an estimated 3.7 million infected people in the US, this is something you’re also bound to see. Jeff: Risk factors include recent or current incarceration, IV drug use, and co-infection with BV. Nachi: Note the common theme here - co infection. It’s very common for patients to have more than one STD, so make sure not to anchor when you think you’ve nailed the diagnosis. Jeff: On exam the majority of both women and men are asymptomatic. In women, you may find a purulent, frothy vaginal discharge, vaginal odor, vulvovaginal irritation, itching, dyspareunia, and dysuria Nachi: And don’t forget about the classic colpitis macularis, or the strawberry cervix. Though this is frequently taught and stressed, it’s actually only seen in 2-5% of infected women. Jeff: But to be fair, a strawberry cervix and frothy vagianl discharge together have a specificity of 99% for trich, which is really not bad. Nachi: While many EDs sadly aren’t blessed with a wet mount, the wet mount has the advantage of being simple, convenient, and generally low cost. Jeff: While all of that is true regarding the wet mount, it’s no longer first line, again with NAAT being preferred, as it’s highly sensitive, approaching 100%. Nachi: And for those of us who don’t have access to NAAT, there are also antigen-detecting tests which don’t perform quite as well, but they are much more sensitive than the traditional wet mount. Jeff: Treatment for trichomoniasis is with oral metronidazole, 2g in a single oral dose a or 500 mg twice a day for 7 days. Alternatively, the more expensive tinidazole, 2g for 1 dose, is actually superior according to the most recent evidence. Nachi: For pregnant patients, trichomoniasis is unfortunately associated with premature delivery and premature rupture of membranes, with no improvement following treatment. Still, patients should be tested and treated, preferentially with metronidazole, to relieve symptoms and prevent partner spread. Jeff: We have two more special populations to discuss in this month’s issue - those in correctional facilities and sexual partner treatment. If you are lucky enough to be involved in treating those in correctional facilities, keep in mind that rates of gonorrhea, chlamydia, syphilis, and trichomoniasis are higher in persons in both juvenile and adult detention facilities than the general public. Nachi: In general for patients in correctional facilities, maintain a lower threshold for just about everything. This is just an at-risk population. Jeff: Let’s move on to sexual partners, and expedited partner therapy or EPT. Nachi: Once you’ve diagnosed a patient with an STD, you can also provide a prescription or medication to the patient to give to their partner or partners. Jeff: This practice is critically important to stop partners from unknowingly spreading the STD further which is a real problem. Unless prohibited by law, emergency clinicians should routinely offer EPT to patients with chlamydia, gonorrhea, or trichomoniasis. To see your states’ current status, the CDC maintains a list of the status in all 50 states. Nachi: In terms of specific partner therapies, for chlamydia, EPT can be accomplished with a single 1g dose of azithromycin or doxycyclin 100 mg bid for 7 days. Consider concurrent treatment for gonococcal infection also. Jeff: For Gonorrhea, EPT includes a single oral dose of 400 mg of cefixime and a 1g oral dose of azithromycin. Nachi: For EPT for syphilis, unfortunately the partner has to present to the ED for a single IM injection of penicillin G. While this does place a burden on the partner, it opens up an opportunity for additional serologic testing and possibly treatment of his or her partners as well. Jeff: Routine EPT for those with BV is not recommend as the data shows that partner treatment does not affect rates of relapse or recurrence. Nachi: For genital herpes, you should counsel patients and their partners that they should abstain from sexual activities when there are lesions or prodromal symptoms. Make sure to refer partners for evaluation as well. Jeff: Since there isn’t much data on HPV partner notification, for now, encourage patients to be open with their partners so they may seek treatment as well. Nachi: And lastly, for Trichomoniasis, EPT includes 2 g of metronidazole or 500 mg BID for 7 days or that single 2g dose of tinidazole. Jeff: In general, it is always better to have the partner present to a physician for diagnosis and treatment, but EPT is an option when that seems unlikely or impossible. Nachi: Also, when possible be sure to inquire about drug allergies and provide some guidelines on ER presentation for allergic reactions. Jeff: So that wraps up EPT. Let’s discuss disposition. Though most will end up going home, a few may require IV medications, such as those with severe HSV, disseminated gonococcus, and neurosyphilis. Nachi: Admission should also be strongly considered in those who are pregnant or with concern for complications. Those with severe nausea, vomiting, high fever, the inability to tolerate oral antibiotics, and those failing oral antibiotics should also be considered for admission. Jeff: But if your patient doesn’t meet those criteria, as most will not, and they are headed home, stress the importance of follow up. Especially for those with gonorrhea and chlamydia, for whom a test of cure after completion of their medication is recommended. This is even more important for pregnant women. Nachi: Chlamydia, gonorrhea, HIV, and syphilis are among the many infectious diseases that require mandatory reporting. Definitely familiarize yourself with your states’ reporting laws, as most of these patients will be headed home and you’ll want to make sure you don’t miss your chance to prevent further spread. Jeff: Perfect, so that’s it for this month’s issue. Let’s close out with some high yield points and clinical pearls. Nachi: STDs are under recognized by patients and healthcare professionals. They can often present with minimal or no symptoms and are passed unknowingly to partners. Jeff: STD’s can have devastating effects during pregnancy on the fetus. Treat these patients aggressively in the ER. Nachi: The rising rate of STD’s continues to be an economic burden on the U.S. healthcare system. Jeff: Patients can present with multiple STD’s concurrently. Avoid premature diagnostic closure and consider multiple simultaneous processes. Nachi: Urinary tract infections and STD’s can present similarly. Be sure to do a pelvic exam to avoid misdiagnosis. For the exam, always have a chaperone present. Jeff: Acute unilateral epididymitis is most commonly a result of chlamydia in men under the age of 35. Nachi: Chlamydia is the most common bacterial STD. The diagnostic test of choice is nucleic acid amplification testing (NAAT). Treat with azithromycin or doxycycline. Jeff: Gonorrhea is the second most common STD. The diagnostic test of choice here is again NAAT. Treat with ceftriaxone and azithromycin. Nachi: Gonorrhea can lead to disseminated infection such as purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: Syphilis has a wide variety of presentations over three stages. For concern of early syphilis, send RPR or VDRL for nontreponemal testing as well as an FTA-ABS or TP-PA for treponemal testing. Nachi: Tertiary syphilis can present with gummatous lesions or aortic disease many years after the primary syphilis infection. Jeff: At any stage of syphilis, the central nervous system can become infected, leading to neurosyphilis. Nachi: Bacterial vaginosis presents with a white, frothy, malodorous vaginal discharge. Treat with metronidazole. Jeff: Genital herpes is caused by HSV-1 or HSV-2. Diagnosis can often be made clinically. If sending a sample for testing, be aware that viral shedding is intermittent, so you may have a falsely negative result. Antivirals can help prevent or shorten outbreaks and decrease transmission. Nachi: Lymphogranuloma Venereum presents with small, painless papules, nodules, or ulcers. Groove sign is present in only 15%-20% of cases. Jeff: Consider Fitz-Hugh-Curtis syndrome in your differential for a sexually active patient with right upper quadrant pain. Nachi: Offer expedited partner therapy to all patients with STD’s to prevent further spread Jeff: So that wraps up Episode 27 - STDs in the ED! Incredibly high yield topic with lots of pearls. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: I’ll repeat that, since saving money is important. APPs, use the promotion code APP4 at checkout to receive 50% off on your subscription. Speaking of PAs - for those of you attending the SEMPA conference in just a few weeks, make sure to check out the EB Medicine Booth, #302 for lots of good stuff. For those of you not attending the conference, just be jealous that your colleagues are hanging out in New Orleans. Nachi: And the address for this month’s credit is ebmedicine.net/E0419, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr- 03):1-137. (Expert guidelines/systematic review) 5. Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years- -United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review) 98. Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) 103. Centers for Disease Control and Prevention. 2018 National Notifiable Conditions (Historical). National Notifiable Diseases Surveillance System (NNDSS). Accessed March 10, 2019. (CDC website) 105. Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies)

On the first show of 2019 the chaps start with some Follow Up. VW is being sued by a German State Government, IAV pleads guilty in the US in connection with #Dieselgate, Ghosn is rearrested, two senior Nissan execs take some leave, Ghosn appears in court to refute claims against him, December and 2018 New Car Registrations are down, New Year's Honours for some special car people, London launches a van scrappage scheme, Tottenham Court Road to ban all but buses and bikes from March, Greater Manchester may bring in charges for LGV and HGVs, BMW to face criminal proceedings in Korea, Takata airbag recall still slow in the UK, Highways England doesn't like touchscreens in cars, Formula E is back at the weekend and so is the Rookie Test, Hyundai WRC gets a new boss, an excellent Lunchtime Read from Jalopnik and the cars and props from Fast and Furious Live are up for auction.

In this session, we will review chancroid, a genital STI caused by H. Ducreyi. This bacterium causes ulcers presenting as painful sores (soft chancre) on the genitalia. We will cover presentation, diagnosis, and treatment. We will also review the differences between the genital ulcers of syphilis, LGV, and granuloma inguinale.

Dans cette nouvelle émission Causerie d'Entrepreneur Investisseur, je discute avec Adeline, ma soeur et l'auteur du blog www.elleinvestit.fr Il raconte dans cette emission son parcours d'investisseuses. Comment elle a commencé l'investissement locatif presque par hasard. Elle explique comment elle s'est lancé seule et décrit la vie d'une investisseuses d'abord seule puis avec son compagnon. Nous y opposons nos points de vue : elle la cadre qui cherche la sécurité et moi l'entrepreneur investisseur qui prend plus de risque. =========================== LES RESSOURCES DE L'EMISSION : Le blog d'Adeline : http://www.elleinvestit.fr Le livre de Robert Kiyosaki dont elle parle : http://amzn.to/2mPT6Pi =========================== LES DISCUSSIONS DE l EMISSION : 00:01 : Introduction : Explication de nos perceptions différentes de voir l'entreprenariat et l'investissement 05:00 : Adeline explique comment elle s'est lancée dans la location meublée 08:00 : Achat Revente pour sa 2ème opération 08:33 : Achat 2 studios en même temps dans la région Toulousaine 09:30 : Lancement de la colocation toujours à Toulouse 11:00 : Investissement à Bordeaux avant l'arrivée de la LGV. Achat de 2 studios 11:35 : Achat d'un studio qui s'est révelé une très bonne affaire en abattant une cloison... 14:30 : Comment gérer les travaux alors qu'on est salarié... 15:30 : La différence entre investir seule et en couple... 16:00 : On parle des travaux dans les différents appartements. 18:40 : Astuce : Se mettre à la place des gens. 19:30 : Comment trouver de bons locataires pour les biens 20:30 : Jeune travailleur ou étudiant : son avis... 22:00 : Mettre son numéro dans les annonces 23:30 : La différence entre le marché de Bordeaux et de Toulouse 24:00 : La différence entre le marché antillais et la métropole 25:50 : Son taux de remplissage de dingue sur le bien en Martinique... 27:50 : Ses astuces pour avoir un bon taux de remplissage 30:00 : Acheter une formation c'est gagner du temps car le savoir est disponible gratuitement 33:10 : Propriétaire de 6 biens mais locataire de leur résidence principale 34:00 : 6 opérations immobilières en 2 ans... 34:50 : Comment amadouer les banquiers :-) 37:45 : Le lancement du blog www.elleinvestit.fr pour partager son expérience 40:30 : Pourquoi il pense s'arrêter à 6 biens... 43:30 : Des nouvelles de ses investissements à la bourse 46:30 : Pourquoi elle n'est pas du tout entrepreneur... 48:20 : Pourquoi elle n'aime pas les gourous du Web ------------------------------------------ - Investis dans l'immobilier grâce à mon guide gratuit et à ma formation gratuite sur les locations saisonnières et les locations meublées : http://www.mycatisrich.fr/lp-immoyt/ - Gagne TON indépendance financière en téléchargeant mon guide gratuit : http://www.mycatisrich.fr/telecharger-guideyt =========================== TOUTES MES FORMATIONS: http://www.mycatisrich.fr/produits/ =========================== Suis moi via mon podcast Soundclound : https://soundcloud.com/belrix-mycatisrich Suis-moi sur Facebook : https://www.facebook.com/mycatisrich/ --------------------------------------------- Lien vers l'article : http://www.mycatisrich.fr/cei09/ ----------------------------------------- QUI EST BELRIX ? Entrepreneur Investisseur martiniquais, je débute ma carrière dans l'informatique à Paris puis à Lyon. Parallèlement à mon activité salariale, j'ai toujours investi dans des entreprises classiques, fait de la location saisonnière, investit en bourse et lancé plusieurs sites internet. En 2015, j'ai réalisé que mes activités hors salariale couvraient l'ensemble de mes dépenses : j'avais atteint l'indépendance financière. Je décide donc quitter un poste très enviable de responsable informatique et de rentrer en Martinique avec ma famille pour être plus près de mes proches, car j'avais compris que c'était çà la véritable richesse ! Pour en savoir plus : http://www.mycatisrich.fr/a-propos/

Logistics Growth In Today’s Business World Watch all our business programmes at www.businessconnectionslive.com. Samantha Earl,  General Manager Pertemps Driver Training, talks to Steve Hyland about how the responsibilities of the fleet operator.What are the key issues when recruiting drivers and what issues face the industry? These include the lack of drivers, skills erosion. We look at what can be done about it. The logistic industry has a number of challenges, we discuss, How the industry has changed, the impact of more legislation, DCPC, higher demand for experienced drivers who appreciate best practice regarding fuel efficient, telematics and insurance criteria Why the industry needs to work together to change the perception of a career in logistics and why all fleets operators should look to the future and encourage ongoing investment. On this edition of Business Connections Live we talk to Samantha Earl, General Manager, Pertemps Driver Training. Pertemps has lead the way with its strategy within logistics, investing in the next generation of LGV drivers, investing in a fully funded LGV academy, whilst going to market with a bespoke driver training company that helps its clients reduce road risk, take seriously their corporate responsibility, engage more proactively with employing drivers and save unnecessary costs to their company. On this edition of Business Connections Live, Samantha will explain: What problems the industry may be facing How the industry has changed Why we all need to work together to change the perception of a career in logistics Why all fleets should look to invest Learn the business fundamentals on how your business can achieve: What problems are the industry may be facing – Lack of Drivers, skills erosion, what can be done about it. What we have done about it. How the industry has changed – More legislation, DCPC, higher demand for experienced fuel efficient drivers, telematics, insurance criteria Why we all need to work together to change the perception of a career in logistics Under-promoted, treat All drivers as professional, supply decent equipment, get involved with PR for the next generation, career potentials Why all fleets should look to invest It will take more of us in logistics to reduce the skills gap, invest and take seriously our responsibility as fleet operators to ensure we are fit for the future What impact can training have on a business? Positive workforce engagement, Reduction in collisions, meeting legal requirements, resulting in a reduction of costs. For more great information visit our Guests website or follow them on Social Media. Website: www.pertempsdrivertraining.co.uk Twitter: @PertempsDT Facebook:  https://www.facebook.com/Pertemps-Driving-Academy-526997807472626/