Podcasts about pcrs

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Play Episode Listen Later Mar 5, 2021 28:39

This episode is the second in a four-part series focusing on EMS patient care reports, or PCRs. This series has been developed in collaboration with the Oakland County Medical Control Authority (OCMCA) and various EMS providers as a way of providing information and guidance to EMS agencies and personnel. Although we reference the OCMCA and our local and State EMS protocols, this series is beneficial to all EMS agencies and providers. In this episode, we discuss the value of EMS PCRs. Primarily, our goal is to increase EMS’ appreciation and awareness of the value and relevance of EMS patient care documentation, as well as how to implement best practices into their work. To accomplish the goal, our guests help us aappreciate the hierarchy and role of laws related to EMS documentation, administrative rules, EMS protocols, and agency policies and how they all work in concert to cultivate quality and consistency amongst EMS patient care documentation. Then, we’ll list and describe applicable protocols related to drafting and submitting EMS patient care records. Visit EMSonAIR.com for the latest information, podcast episodes and other details. Follow us on Instagram @EMSOnAIR. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org. Geoff Lassers, Paramedic EMS-IC (QI@ocmca.org)Host, EMS on AIR PodcastEMS System Manager, Oakland County Medical Control Authority (OCMCA)Firefighter / Paramedic, West Bloomfield Fire DepartmentAmerican CME, Director of EducationGuests:Bonnie Kincaid (Bonnie@ocmca.org)Executive Director, Oakland County Medical Control Authority (OCMCA)Emily Bergquist, MSA, Paramedic, EMS-IC (BergquistE@michigan.gov)State of Michigan MCA Coordinator, MDHHS, BETPEmily Baker, BS, Paramedic, EMS-IC (emily.holstine@ascension.org)EMS Coordinator, Ascension Providence SouthfieldCQI Supervisor, Alliance Mobile HealthJohn Theut, MS, Paramedic, EMS-IC (Qi@ocmca.org)QA/QI Coordinator, Oakland County Medical Control Authority (OCMCA)Shift Captain / EMS Coordinator, Ferndale Fire Department Support the show (https://www.patreon.com/emsonair?fan_landing=true)

S2:E25 - "The Value of EMS Patient Care Reports." Recorded February 12, 2021

Play Episode Listen Later Mar 5, 2021 69:10

This episode is the first in a four-part series focusing on EMS patient care reports, or PCRs. This series has been developed in collaboration with the Oakland County Medical Control Authority (OCMCA) and various EMS providers as a way of providing information and guidance to EMS agencies and personnel. Although we reference the OCMCA and our local and State EMS protocols, this series is beneficial to all EMS agencies and providers. In this episode, we discuss the value of EMS PCRs. Primarily, our goal is to increase EMS’ appreciation and awareness of the value and relevance of EMS patient care documentation, as well as how to implement best practices into their work. To accomplish the goal, our guests help us: Appreciate the value of consistency and quality when drafting a PCR. Then, we’ll list and describe benefits experienced by patients, EMS providers, EMS agencies or systems and hospitals regarding consistency and quality when drafting a PCR. And finally, describe current data and trends identified in PCR quality assurance and quality improvement initiatives found throughout Michigan and the US. Visit EMSonAIR.com for the latest information, podcast episodes and other details. Follow us on Instagram @EMSOnAIR. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org. Geoff Lassers, Paramedic EMS-IC (QI@ocmca.org)Host, EMS on AIR PodcastEMS System Manager, Oakland County Medical Control Authority (OCMCA)Firefighter / Paramedic, West Bloomfield Fire DepartmentAmerican CME, Director of EducationGuests:Bonnie Kincaid (Bonnie@ocmca.org)Executive Director, Oakland County Medical Control Authority (OCMCA)Emily Bergquist, MSA, Paramedic, EMS-IC (BergquistE@michigan.gov)State of Michigan MCA Coordinator, MDHHS, BETPEmily Baker, BS, Paramedic, EMS-IC (emily.holstine@ascension.org)EMS Coordinator, Ascension Providence SouthfieldCQI Supervisor, Alliance Mobile HealthJohn Theut, MS, Paramedic, EMS-IC (Qi@ocmca.org)QA/QI Coordinator, Oakland County Medical Control Authority (OCMCA)Shift Captain / EMS Coordinator, Ferndale Fire DepartmentSupport the show (https://www.patreon.com/emsonair?fan_landing=true)

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S2:E28 - "EMS Patient Care Report Narratives." Recorded February 22, 2021

Play Episode Listen Later Mar 5, 2021 49:24

This episode is the fourth in a four-part series focusing on EMS patient care reports, or PCRs. This series has been developed in collaboration with the Oakland County Medical Control Authority (OCMCA) and various EMS providers as a way of providing information and guidance to EMS agencies and personnel. Although we reference the OCMCA and our local and State EMS protocols, this series is beneficial to all EMS agencies and providers. In this episode, we discuss the value of EMS PCRs. Primarily, our goal is to increase EMS’ appreciation and awareness of the value and relevance of EMS patient care documentation, as well as how to implement best practices into their work. To accomplish the goal, our guests help us list and describe the use of various EMS narrative writing methods including SOAP, CHART, the chronological method and DRATT. Then, we’ll list and describe the minimum information that should be included in the ePCR narrative of every EMS transport of a patient, as well as the additional information required for an EMS transport of patients with time sensitive emergencies. Finally, we’ll list and describe the minimum information that should be included in the ePCR narrative of every patient care refusal, as well as what must be included in the ePCR narrative of every EMS patient pronounced on scene. Visit EMSonAIR.com for the latest information, podcast episodes and other details. Follow us on Instagram @EMSOnAIR. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org. Geoff Lassers, Paramedic EMS-IC (QI@ocmca.org)Host, EMS on AIR PodcastEMS System Manager, Oakland County Medical Control Authority (OCMCA)Firefighter / Paramedic, West Bloomfield Fire DepartmentAmerican CME, Director of EducationGuests:Emily Bergquist, MSA, Paramedic, EMS-IC (BergquistE@michigan.gov)State of Michigan MCA Coordinator, MDHHS, BETPEmily Baker, BS, Paramedic, EMS-IC (emily.holstine@ascension.org)EMS Coordinator, Ascension Providence SouthfieldCQI Supervisor, Alliance Mobile Health.Support the show (https://www.patreon.com/emsonair?fan_landing=true)

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S2:E27 - "EMS Patient Care Reports - Data Elements and Requirements." Recorded February 16, 2021

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Play Episode Listen Later Mar 5, 2021 36:11

This episode is the third in a four-part series focusing on EMS patient care reports, or PCRs. This series has been developed in collaboration with the Oakland County Medical Control Authority (OCMCA) and various EMS providers as a way of providing information and guidance to EMS agencies and personnel. Although we reference the OCMCA and our local and State EMS protocols, this series is beneficial to all EMS agencies and providers. In this episode, we discuss the value of EMS PCRs. Primarily, our goal is to increase EMS’ appreciation and awareness of the value and relevance of EMS patient care documentation, as well as how to implement best practices into their work. To accomplish the goal, our guests help us list and describe the terminology related to PCR data entry. Then, we list and describe the minimum data elements that must be completed in the PCR of an EMS transport of a patient. From there, we’ll discuss the additional elements required in the PCR of an EMS transport patients with time sensitive emergencies. We round out the discussion by listing and describing the minimum data elements that must be completed in the PCR of an EMS patient care refusal, an EMS patient Dead on Scene and an EMS Termination of Resuscitation in the field.Visit EMSonAIR.com for the latest information, podcast episodes and other details. Follow us on Instagram @EMSOnAIR. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org. Geoff Lassers, Paramedic EMS-IC (QI@ocmca.org)Host, EMS on AIR PodcastEMS System Manager, Oakland County Medical Control Authority (OCMCA)Firefighter / Paramedic, West Bloomfield Fire DepartmentAmerican CME, Director of EducationGuests:Bonnie Kincaid (Bonnie@ocmca.org)Executive Director, Oakland County Medical Control Authority (OCMCA)Emily Bergquist, MSA, Paramedic, EMS-IC (BergquistE@michigan.gov)State of Michigan MCA Coordinator, MDHHS, BETPEmily Baker, BS, Paramedic, EMS-IC (emily.holstine@ascension.org)EMS Coordinator, Ascension Providence SouthfieldCQI Supervisor, Alliance Mobile HealthJohn Theut, MS, Paramedic, EMS-IC (Qi@ocmca.org)QA/QI Coordinator, Oakland County Medical Control Authority (OCMCA)Shift Captain / EMS Coordinator, Ferndale Fire Department.Support the show (https://www.patreon.com/emsonair?fan_landing=true)

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Max Igan | Historical Resets and Prophetic Scripts

The Melt Podcast

Play Episode Listen Later Mar 5, 2021

La Primera Llamada del Día: Félix Bariáin (UAGN) (24/02/2021)

Cadena SER Navarra

Play Episode Listen Later Feb 24, 2021 2:45

El presidente de la UAGN, Félix Bariáin, estima que unas 2.000 personasp ueden participar en la campaña de recogida del espárrago en Navarra. Será la primera campaña en la que se aplique el acuerdo entre Salud y la UAGN para practicar PCRs a todos los temporeros. Las pruebas las costeará el departamento de Salud.

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Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer Guideline

ASCO Guidelines Podcast Series

Play Episode Listen Later Jan 28, 2021 15:41

An interview from Dr. Larissa A. Korde from the National Cancer Institute and Dr. Dawn L. Hershman from Columbia University on “Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline.” This guideline covers the optimal use of neoadjuvant therapy for women with invasive, non-metastatic breast cancer. Read the full guideline at www.asco.org/breast-cancer-guidelines. Transcript ASCO: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one podcast.asco.org. My name is Brittany Harvey, and today I am joined by Dr. Larissa Korde from the clinical investigations Branch of the Cancer Therapy Evaluation Program in the Division of Cancer Treatment and Diagnosis of the National Cancer Institute in Bethesda, Maryland, and Dr. Dawn Hershman from the Herbert Irving Comprehensive Cancer Center at Columbia University in New York, New York, co-chairs on Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline. Thank you for being here Dr. Korde and Dr. Hershman. DR. LARISSA KORDE: Thank you for having us. DR. DAWN HERSHMAN: Yes, thank you. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines in ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available on-line with the publication of the guideline in the Journal of Clinical Oncology. Dr. Korde, do you have any relevant disclosures that are related to this guideline topic? DR. LARISSA KORDE: I do not. BRITTANY HARVEY: And Dr. Hershman, do you have any relevant disclosures that are related to this guideline topic? DR. DAWN HERSHMAN: No, I do not. BRITTANY HARVEY: Great, thank you both. Then, Dr. Hershman, to kick off the content of the guideline, first, can you give us a general overview of the scope and the purpose of this guideline? DR. DAWN HERSHMAN: Yeah, sure. In breast cancer, we have seen a plethora of studies looking at neoadjuvant therapy for breast cancer. And as we've learned over time, that neoadjuvant therapy has focused on the role of, really, response as a predictive marker and whether or not the improvement in a pathologic complete response rate translates into benefit in terms of long-term outcome. And the fact that several studies have shown that has really increased our interest in looking at pathologic complete response rate and its predictive value. So part of the guideline is really to help us really elucidate as the understanding of biology of breast cancer has evolved over time, what scenarios where neoadjuvant therapy is the best choice for patients, and what the real purpose of neoadjuvant therapy is. So the guidelines' purpose is really to help us develop recommendations concerning the optimal use of neoadjuvant therapy, whether it be chemotherapy, endocrine therapy, or targeted therapy for a variety of different biologic subtypes. And I think the overarching principle is that the expert panel strongly advocated for a multidisciplinary team in the management of these patients. Specific guidelines really go into details about each of the scenarios where we would use this therapy. BRITTANY HARVEY: Great. Then I'd like to review some of those key recommendations that you just mentioned for our listeners. So Dr. Korde, which patients with breast cancer are appropriate candidates for neoadjuvant systemic therapy? DR. LARISSA KORDE: So when we sat down to write this guideline, we thought through this question in many different ways. But we basically ended up sort of dividing patients by breast cancer subtype and then coming up with recommendations separately for each subtype. So broadly speaking for triple negative breast cancer patients and for HER2-positive breast cancer patients, we felt that the kind of most important triage point is that in both those diseases, there are effective treatments that can be used in the adjuvant setting in patients who do not have a pathologic complete response to neoadjuvant therapy. And so broadly speaking, it's those patients where there would be an adjuvant therapy decision point, or recommendation in whom the neoadjuvant response is important. Those would be the patients in whom we would most strongly recommend neoadjuvant chemotherapy. In ER-positive disease, we looked at both chemotherapy and endocrine therapy in the neoadjuvant setting. And we know that both of these can improve response. Pathologic complete response is less common in patients with ER-positive disease. But there are also benefits to neoadjuvant treatment in those patients in terms of being able to reduce the size of the surgery, reduce potentially morbidity from surgery, and then also in terms of being able to convert patients who were not lumpectomy candidates from mastectomy to lumpectomy. And so in the guideline we outline the scenarios for ER-positive patients in which neoadjuvant therapy would be recommended as well. BRITTANY HARVEY: Great, got it. Then Dr. Hershman, what do the guidelines say about how clinicians should measure response in patients receiving neoadjuvant chemotherapy? DR. DAWN HERSHMAN: Yes, so patients undergoing neoadjuvant therapy should really be monitored by their provider at each visit with a clinical examination at regular intervals. And we really felt that the role of breast imaging was really for patients where there was some clinical suspicion of progression during that therapy to ensure that patients were not progressing during treatment. And ultimately, the best modality for imaging was the modality that was most effective at the point of diagnosis, whether it be mammogram, ultrasound, or MRI, that should be the imaging modality used at follow up. We did not feel that there were any specific blood markers or tissue based markers at this time that should be used for monitoring patients undergoing neoadjuvant therapy. Much of that is done for clinical trial purposes, but not so much in the clinic. And that when patients had completed their treatment, pathologic complete response rate is the most important outcome and would be really assessed at the time of surgery as the absence of any invasive disease in either the breast or the lymph nodes. But in order for that to be good for clinical decision making, it's really imperative that the clinician and the surgeons make sure that the tissue is removed that is suspect to begin with, so to make sure that the clips that defined where the tumor was evaluated and that the tumor bed is clear of any evidence of disease. BRITTANY HARVEY: Great, that's helpful information. So then, Dr. Korde, you mentioned that the recommendations are divided up by biologic subtypes. So what are those neoadjuvant systemic therapy regimens recommended for the following patient population-- so first, those with triple negative breast cancer, second, those with HER2-negative hormone receptor positive breast cancer, and then finally, for those with HER2-positive disease? DR. LARISSA KORDE: So maybe we can divide this up a little. Let's start with the triple negatives. For triple negative breast cancer patients who are embarking on neoadjuvant chemotherapy, and that would be patients with clinically node positive disease, and/or at least T1C disease, and again, with the thought that the goal is really to think about whether adjuvant therapy recommendations would be altered based on PAP CR. But in that setting, we recommended that patients be offered an anthracyclines and taxane containing regimen. We also found data supporting the use of carboplatin with neoadjuvant therapy for the purpose of increasing the likelihood of PCR. So we noted that while there is good data showing that PCRs increase with carboplatin, there is more conflicting data regarding the effect of carboplatin on long-term outcomes. Although, hopefully, new clinical trials that are ongoing now or that are in follow up may clarify this question a little bit more. We felt at the time that we wrote the guideline, and certainly, this is potentially an evolving topic. But at this point, we felt that there was insufficient evidence to recommend routinely adding immune checkpoint inhibitors to neoadjuvant chemotherapy in patients with early stage breast cancer. And again, there may be more data on this upcoming in the next few years. So maybe Dawn can take the next category, the HER2-negative hormone receptor positive patients. BRITTANY HARVEY: Yeah, that would be great. DR. DAWN HERSHMAN: Absolutely. So we felt for this population of patients that neoadjuvant chemotherapy could be used instead of adjuvant chemotherapy in any patient where the chemotherapy decision could be made without the benefit of having the results from the surgical pathology data, or any results from the specific genomic testing. So if the decision was made that the patient was going to need chemotherapy regardless, that would be a patient that could get it neoadjuvantly. We felt that for postmenopausal patients with hormone receptor positive HER2 negative breast cancer that neoadjuvant endocrine therapy with an aromatase inhibitor could be offered to either increase local regional treatment options, if there was no intent for surgery, endocrine therapy could be used for Disease Control. So in a patient where they really were not a good surgical candidate, we could offer this therapy to try to control their disease. For premenopausal patients with hormone receptor positive HER2-negative disease, we did really not feel that neoadjuvant endocrine therapy should be routinely offered outside of a clinical trial. Because in this scenario, there really wasn't enough evidence to offer this approach. BRITTANY HARVEY: And then Dr. Korde, do want to finally address those patients with HER2-positive disease? DR. LARISSA KORDE: Absolutely. So in patients with HER2-positive disease that is either node positive or high risk node negative, we felt it would be appropriate to offer neoadjuvant therapy with either an anthracycline and taxane containing regimen, or a non-anthracycline-based regimen in combination with targeted therapy. And we did feel that targeted therapy should include trastuzumab and may also include pertuzumab. For patients with smaller tumors, really those in whom it's unclear whether the more aggressive for on-chemotherapy regimens or even any chemotherapy at all is needed, for example, those with very small tumors, T1A and T1B, we did not feel that neoadjuvant should be routinely offered. And we did note that in those patients with smaller tumors, an alternative regimen, the APT regimen of paclitaxel and Trastuzumab is something that has been studied in the adjuvant setting. But again those patients with these very small node negative tumors, in general, would not be routinely offered neoadjuvant chemotherapy. BRITTANY HARVEY: Great, thank you both for reviewing those neoadjuvant systemic therapy approaches for those specific patient populations. So Dr. Hershman, in your view, what is the importance of this guideline? And how will it impact clinical practice? DR. DAWN HERSHMAN: Yeah, that's an excellent question. I think as our data has shown more and more studies where there's a benefit to giving adjuvant treatment based on the response of patients in the neoadjuvant setting to get additional benefit long-term amongst patients with residual disease, I think that these guidelines really can help clinicians to understand those scenarios where we know we can maximize treatment. I think ultimately the goal of neoadjuvant therapy is that it gives us opportunities to both escalate treatment in patients that are at high risk that don't have great responses, and de-escalate therapy in patients that have outstanding responses. And so I think this will help clinicians understand what those benefits are. BRITTANY HARVEY: Definitely. It seems like it will provide some clarity for those scenarios. So finally, Dr. Korde, how do you envision that these guideline recommendations will affect patients with non-metastatic breast cancer? DR. LARISSA KORDE: Well, I think building on Dr. Hershman's answer to the previous question, really, the key here is to be able to personalize or tailor the therapy for individual patients. So in those patients whose disease is very high risk, or did not respond to initial therapy, patients can be given appropriate escalation of treatment. And for patients who have an excellent response to treatment in the neoadjuvant setting can potentially be spared other treatments. And so I think that the main use of neoadjuvant treatment and the use of this guideline in terms of how it affects patients is being able to offer the most appropriate therapy for each patient. BRITTANY HARVEY: Great, well, thank you both for your work on this guideline on neoadjuvant chemotherapy, endocrine therapy, and targeted therapy for breast cancer. Appreciate your leadership on this guideline. And I want to thank you also for taking the time to speak with me today, Dr. Korde and Dr. Hershman. DR. DAWN HERSHMAN: Thank you. DR. LARISSA KORDE: Happy to be here. Thanks so much. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/breast-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.

Dr. Magarelli is Back and Shares Amazing News for the Future of IVF!

Fertility Wellness with The Wholesome Fertility Podcast

Play Episode Listen Later Jan 26, 2021 48:36

Dr. Magarelli is a nationally noted Board-Certified Reproductive Endocrinology & Infertility (REI) specialist at CNY Fertility’s Colorado Springs location. He has been practicing in Colorado since 1998 and is well-known for serving the fertility needs of couples in the region, including a large number of military families. He was previously the founder and Medical Director of Magarelli Fertility Centers, LLC. Before that, he ran High Quality Affordable Fertility Centers, LLC, and Reproductive Medicine and Fertility Centers, LLC. Dr. Magarelli has presented and published groundbreaking research in integrating Eastern (Acupuncture) and Western medical treatments for infertility. Today, he continues to investigate the role of Traditional Chinese Medicine in treating IVF patients, forging the way for future treatment breakthroughs. Among his many accomplishments, Dr. Magarelli was honored as the recipient of the Reproductive Scientist Award by the American Society for Reproductive Medicine, the Practicing Physicians Award by the Pacific Coast Reproductive Society (PCRS), and recipient of the Pioneers in Integrated Reproductive Medicine Award. Dr. Magarelli is also a Medical Advisor to the ABORM and Reproductive Industry Partners, a past faculty member at Yo San University and the University of New Mexico, founder of the Institute for Sustained Health, founder of US Military Family Fertility Services 501 c3, and Past President of the PCRS. He is a graduate of Duke University Health Sciences Residency and UCLA RE&I Fellowship program. He earned his Ph.D. in Nutritional Biochemistry and Physiology at the University of Arizona and is a frequent presenter on topics such as infertility, PCOS, Menopause, Andropause, and the treatment of Insulin Resistance. https://www.cnyfertility.com/our-team-members/paul-magarelli/ For more information about Michelle, visit www.michelleoravitz.com The Wholesome Fertility facebook group is where you can find free resources and support: https://www.facebook.com/groups/2149554308396504/ Instagram: @thewholesomelotusfertility Facebook: https://www.facebook.com/thewholesomelotus/

E5 - Otra vez las PCRs (con cariño para un amigo)

Sospechosos Habituales

Play Episode Listen Later Jan 2, 2021 12:04

Este episodio sirve de contestación a una persona a la que aprecio y aunque estoy de acuerdo muchas veces con él, en algunas ocasiones discrepamos, como en el tema de las PCRs. Aprovecho para mandarte un abrazo...

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"Se veía venir, estan todo el día con los litros en la puerta"

Boulevard

Play Episode Listen Later Dec 28, 2020 6:41

Se sigue investigando la autoría de los destrozos causados en el centro médico de Sodupe, donde desconocidos han destrozado este fin de semana varios test PCRs del ambulatorio en un acto vandálico....

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Does IVF Benefit from Acupuncture? Dr. Magarelli has the Answers!

Fertility Wellness with The Wholesome Fertility Podcast

Play Episode Listen Later Dec 22, 2020 38:50

Hoy por Hoy Jódar Matinal 07:20 lunes (14/12/2020)

school immaculate immaculate conception pcrs

Play Episode Listen Later Dec 14, 2020 10:00

- Jódar, con 21 positivos:diagnosticados, vuelve a ser el municipio con más nuevos casos en la provincia, en el comunicado del viernes, donde se suman 131 casos, en total, según publicaba la web del Instituto de Estadística y Cartografía de Andalucía. La situación en Jódar, por el COVID 19, se agrava, con la aparición de decenas de casos. El viernes se suman 46 nuevos positivos:diagnosticados, aunque pueden ser muchos más, y 5 fueron trasladados al Hospital San Juan de la Cruz de Úbeda. A pesar de ello no se facilitan datos oficiales ni desde el Distrito Sanitario Jaén Nordeste ni desde el Centro de Salud de Jódar. Muchos vecinos optan por la realización de pruebas PCRs en clínicas privadas. - En los comunicados de la Consejería de Salud y Familias de la Junta de Andalucía durante este fin de semana, desde el viernes, curados (+749), confirmados-diagnosticados + 300 por COVID 19, 8 fallecidos LOS CONFIRMADOS alcanzan las 24.912 personas con coronavirus, en todo el periodo, desde el mes de marzo, en la provincia. En los centros hospitalarios a día de ayer 153 (-37) para un total 2.571 (+19). 34(+1) de ellos en UCI un total de 215 (+2). Fallecidos un total de 558 (+8). + 749 nuevos curados, Total Curados, 17.281 en total (69,37%) en total, continua el PERMANENTE repunte del índice de curados, de los últimos días. Con los nuevos diagnosticados, curados y fallecidos, los casos activos, continúan descendiendo hasta los 7.073 (-457) todos con seguimiento domiciliario, salvo 153 ingresos. - Ante esta situación la alcaldesa, María Teresa García, ha emitido un comunicado confirmando que el cribado, anunciado desde la Junta de Andalucía, en Jódar se desarrollará el próximo jueves y anima a vecinos y vecinas a someterse a ellas, una vez que sean seleccionados desde la Consejería de Salud, y haciendo una llamada a la responsabilidad de todos y todas, teniendo en cuenta, además, que el mayor número de casos se están produciendo entre los trabajadores del campo, en plena campaña

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Immaculate conception 2020

Fatherly Advice

Play Episode Listen Later Dec 9, 2020 7:16

The Immaculate conception homily for the School children of PCRS

E1 - Las famosas PCR

Sospechosos Habituales

Play Episode Listen Later Nov 28, 2020 10:58

En este primer episodio intento explicar de manera sencilla qué son las PCRs y qué utilidad tienen. Al mismo tiempo intento aclarar qué hay de cierto en algunas informaciones que se dan al respecto de esta prueba...

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Más Voces Villaverde - Programa 21 de noviembre

Canal Comunidad

Play Episode Listen Later Nov 23, 2020 24:24

¡Bienvenidos al tercer programa de Más Voces Villaverde! En el programa de hoy Rafael García y Damaris Rachel nos informarán de las noticias más relevantes sucedidas durante la semana, preguntarán a un biólogo sobre los PCRs y su funcionalidad y entrevistarán a un enfermero para saber cómo se vivió la primera ola del covid y todo lo que pudo ver. ¡Esto y mucho más en este programa!

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Respuestas vacunales y PCRs de aeropuerto

Qarentena

Play Episode Listen Later Nov 14, 2020 108:09

Episodio del podcast semanal de SH+Media. El podcast para los que nos quedábamos en casa. Una serie limitada para pasar juntos la pandemia. … Continue readingRespuestas vacunales y PCRs de aeropuerto

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Hoy por Hoy Jódar Matinal 08:20 miércoles (30/09/2020)

Play Episode Listen Later Sep 30, 2020 9:59

¡¡¡Última hora!!!! Ningún positivo, por COVID 19, Entre los 22 niños y niñas de la E.I.Antonio Machado, a los que se les ha realizado pruebas PCRs en mañana de ayer miércoles, a pesar de lo cual han de mantenerse en cuarentena, para poder volver a las aulas. Los padres y Madres han mantenido en gran parte la decisión de no llevar los niños/as de otras aulas, a pesar de no haber tenido contacto con el aula afectada. Todas las aulas se mantienen burbujas. ¡¡¡108 confirmados-diagnosticados, 37 curados!!, en el comunicado de la Consejería de Salud y Familias de la Junta de Andalucía y en la web del Instituto de Estadística y Cartografía de Andalucía. Que ya incorpora loas 6 casos activos en Jódar, que adelantábamos ayer desde estos micrófonos. En la provincia, este MARTES, 108 nuevos confirmados-diagnosticados, se alcanzan las 5.084 personas con coronavirus, en todo el periodo en la provincia. En los centros hospitalarios 86 ingresados (+11 que el viernes), para un total 990 (+9). 10 de ellos en UCI, para un total de 105 (+2). Fallecidos un total de 207). 62 curados, Total Curados, 2.782 (+37) en total (55,16%) en total, continúa el permanente descenso del índice de curados. Con los nuevos diagnosticados, por primera vez en muchos días descenso de los casos activos, 2.095, todos con seguimiento domiciliario, salvo 86 ingresos. 665 confirmados-diagnosticados en los últimos 7 días, en las dos últimas semanas 1.360. Por municipios las nuevas personas confirmadas-diagnosticadas se reparten: 1 en: Martos, Campillo de Arenas, Huelma, La Guardia, Valdepeñas, Mancha Real, Torredelcampo, Villanueva de la Reina, Arjona, Bailén, Guarromán, Vilches, Castellar, Begijar, Bedmar y Rus. 2 en: Alcaudete, Lopera, Porcuna, Pegalajar, Arquillos, Baeza y Jódar. 3 en: Torredonjimeno, Andújar, Marmolejo, Santo Tomé, Santiago de la Espada-Pontones y Villacarrillo. 4 en La Carolina. 5 en Jamilena y Siles. 6 en Canena. 9 en Linares. 12 en Úbeda. 14 en Jaén. Y 15 en Mengíbar. El diput

Hora 14 Jódar miércoles (30/09/2020)

Play Episode Listen Later Sep 30, 2020 14:45

Este 30 de septiembre se completa el año Hidrológico 2.019/20, con unas precipitaciones de unos 503 litros/m2, según los datos que diariamente aporta a esta emisora su colaborador Francisco Cortes. Datos que suponen un incremento de 109 litros, con respecto al año anterior, cuando se recogieron 394. Incluso por encima de la media en los últimos 5 años que se sitúan en torno a los 466 litros, incluido el año 2.017/18, en el que las precipitaciones se elevaron a los 720, muy por encima de la media. ¡¡¡Última Hora!!! Una vez que todos los niños/as de la E.I. Antonio Machado daban NEGATIVO en las pruebas PCRs realizadas ayer, se podrán INCORPORAR a clase el próximo MARTES, 6 de octubre, una vez cumplida la cuarentena. Hoy se han empezado a incorporar, paulatinamente, los de las otras aulas. ¡¡¡148-152 confirmados-diagnosticados, 28 curados!!, en el comunicado de la Consejería de Salud y Familias de la Junta de Andalucía y en la web del Instituto de Estadística y Cartografía de Andalucía. Que ya incorpora loas 9 casos activos en Jódar, contra los 7 que nos comunican desde el Cenro de Salud. En la provincia, este Miércoles, 152 nuevos confirmados-diagnosticados, se alcanzan las 5.236 personas con coronavirus, en todo el periodo en la provincia. En los centros hospitalarios 86 ingresados (=), para un total 1.001 (+11). 11 de ellos en UCI, para un total de 105 (=). Fallecidos un total de 207. 28 curados, Total Curados, 2.840 (+37) en total (54,24%) en total, continúa el permanente descenso del índice de curados. Con los nuevos diagnosticados, por primera vez en muchos días descenso de los casos activos, 2.189, todos con seguimiento domiciliario, salvo 86 ingresos. 694 confirmados-diagnosticados en los últimos 7 días, en las dos últimas semanas 1.422. La Diputación Provincial de Jaén ha celebrado hoy su pleno correspondiente al mes de septiembre, en el que como punto más destacado del orden del día ha aprobado la convocatoria del Plan Provincial de Cooperación a las obra

salud instituto datos incluso estad junta familias uci provincial andaluc negativo cooperaci consejer incorporar antonio machado la diputaci cartograf pcrs francisco cortes

Hoy por Hoy Jódar Matinal 07:20 miércoles (30/09/2020)

Play Episode Listen Later Sep 30, 2020 9:54

¡¡¡Última Hora!!! Ayer miércoles se realizaban las pruebas PCRs a los 22 alumnos/as de la E.I. Antonio Machado ante el positivo de su profesora. Los primeros datos, a los que ha tenido esta redacción, apuntan que no se ha dado ningún positivo, a pesar de lo cual han de mantenerse en cuarentena, para poder volver a las aulas. Los padres y Madres han mantenido en gran parte la decisión de no llevar los niños/as de otras aulas, a pesar de no haber tenido contacto con el aula afectada. Todas las aulas se mantienen burbujas. ¡¡¡108 confirmados-diagnosticados, 37 curados!!, en el comunicado de la Consejería de Salud y Familias de la Junta de Andalucía y en la web del Instituto de Estadística y Cartografía de Andalucía. Que ya incorpora loas 6 casos activos en Jódar, que adelantábamos ayer desde estos micrófonos. En la provincia, este MARTES, 108 nuevos confirmados-diagnosticados, se alcanzan las 5.084 personas con coronavirus, en todo el periodo en la provincia. En los centros hospitalarios 86 ingresados (+11 que el viernes), para un total 990 (+9). 10 de ellos en UCI, para un total de 105 (+2). Fallecidos un total de 207). 62 curados, Total Curados, 2.782 (+37) en total (55,16%) en total, continúa el permanente descenso del índice de curados. Con los nuevos diagnosticados, por primera vez en muchos días descenso de los casos activos, 2.095, todos con seguimiento domiciliario, salvo 86 ingresos. 665 confirmados-diagnosticados en los últimos 7 días, en las dos últimas semanas 1.360. Casi 200.000 euros para que no se escape ni el frío ni el calor, todo es ahorro. La Diputación Provincial de Jaén ejecuta tres actuaciones para mejorar la eficiencia energética. Va a suponer el cambio de todas las ventanas de la Casa de la Cultura, Casa de la Juventud y edificio de Rentas.El diputado de Servicios Municipales, José Luis Hidalgo, visita junto a la alcaldesa de Jódar, Teresa García, tres edificios municipales de la localidad –la Casa de la Cultura, la Casa de la Juventud y el E

va casa todas cultura salud instituto ayer estad madres junta juventud familias uci provincial andaluc consejer matinal antonio machado la diputaci cartograf teresa garc pcrs

Hoy por Hoy Jódar Matinal 07:20 martes (29/09/2020)

Play Episode Listen Later Sep 29, 2020 9:57

¡¡¡Última Hora!!! Confinada una aula de los niños/as de 3 años, 22 EN TOTAL, en la E.I. Antonio Machado ante el positivo de su profesora. Gran parte de los padres y Madres procedían a la retirada a los niños/as de otras aulas, a pesar de no haber tenido contacto con el aula afectada. Todas las aulas se mantienen burbujas. De las 20 pruebas PCRs del pasado viernes 2 nuevos casos confirmados-diagnosticados. A esta hora, Jódar suma 17 casos en Jódar, en todo el periodo desde marzo, con 11 curados, solo 6 activos, en dos brotes distintos, con 4 y 6 casos. Ninguno de los trabajadores del Ayuntamiento, que ha abierto sus instalaciones con normalidad. Aunque no va a poder celebrar el pleno previsto para esta semana, al igual que las dependencias del INEM- SAE, que ayer abría sus instalaciones, tras haber estado cerradas jueves y viernes, por un falso caso de COVID. ¡¡¡346 confirmados-diagnosticados, 63 curados y 4 nuevos fallecidos!!!, en el comunicado de la Consejería de Salud y Familias de la Junta de Andalucía, durante el fin de semana. En la provincia, este fin de semana, 346 nuevos confirmados-diagnosticados, se alcanzan las 4.986 personas con coronavirus, en todo el periodo en la provincia. En los centros hospitalarios 76 ingresados (+1 que el viernes), para un total 977 (+13). 10 (+5) de ellos en UCI, para un total de 104 (+2). Fallecidos un total de 205 (+2). 62 curados, Total Curados, 2.745 en total (55,16%) en total, continúa el permanente descenso del índice de curados. Con los nuevos diagnosticados, por primera vez en muchos días descenso de los casos activos, 2.024, todos con seguimiento domiciliario, salvo 76 ingresos. 664 confirmados-diagnosticados en los últimos 7 días, en las dos últimas semanas 1.285. 'Conectando la provincia', programa a través de las emisoras de la Cadena SER en la provincia, con entrevista al presidente de la Diputación Provincial de Jaén, Francisco Reyes. Con relación a las medidas contra el COVID 19 por Diputación y Ayuntamientos. La Consejerí

Hora 14 Jódar martes (29/09/2020)

founders culture entrepreneur va radio show vas collar frankel david m freeup nathan hirsch perky phillippines show hosted outsource school outsourceschool pcrs sicc warmest regards

Play Episode Listen Later Sep 29, 2020 14:57

¡¡¡Última Hora!!! Esta mañana se han realizado las pruebas PCRs a los 22 alumnos/as de la E.I. Antonio Machado ante el positivo de su profesora. Los primeros datos, a los que ha tenido esta redacción, apuntan que no se ha dado ningún positivo, a pesar de lo cual han de mantenerse en cuarentena, para poder volver a las aulas. Los padres y Madres han mantenido en gran parte la decisión de no llevar los niños/as de otras aulas, a pesar de no haber tenido contacto con el aula afectada. Todas las aulas se mantienen burbujas. ¡¡¡108 confirmados-diagnosticados, 37 curados!!, en el comunicado de la Consejería de Salud y Familias de la Junta de Andalucía y en la web del Instituto de Estadística y Cartografía de Andalucía. Que ya incorpora loas 6 casos activos en Jódar, que adelantábamos ayer desde estos micrófonos. En la provincia, este MARTES, 108 nuevos confirmados-diagnosticados, se alcanzan las 5.084 personas con coronavirus, en todo el periodo en la provincia. En los centros hospitalarios 86 ingresados (+11 que el viernes), para un total 990 (+9). 10 (=) de ellos en UCI, para un total de 105 (+2). Fallecidos un total de 207 (=). 62 curados, Total Curados, 2.782 (+37) en total (55,16%) en total, continúa el permanente descenso del índice de curados. Con los nuevos diagnosticados, por primera vez en muchos días descenso de los casos activos, 2.095, todos con seguimiento domiciliario, salvo 86 ingresos. 665 confirmados-diagnosticados en los últimos 7 días, en las dos últimas semanas 1.360. El diputado de Servicios Municipales, José Luis Hidalgo, visita junto a la alcaldesa de Jódar, Teresa García, tres edificios municipales de la localidad –la Casa de la Cultura, la Casa de la Juventud y el Edificio de Rentas– en los que se están ejecutando actuaciones de mejora de la eficiencia energética. Esta intervención se acoge a la convocatoria de proyectos singulares en entidades locales que favorezcan el paso a una economía baja en carbono, enmarcada en el programa operativo Feder.

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Programa 53- Una noche con el Doctor Camacho (parte I)

Radio El Respeto

Play Episode Listen Later Sep 23, 2020 114:38

El Dr. Tomás Camacho, es doctor en medicina y cirugía por la Universidad de Santiago de Compostela, Fellow of the American College of Medical Toxixology y experto Internacional en Toxicología por el Colegio Oficial de Químicos de Sevilla. Además, es el coordinador del área de Toxicología Clínica de AETOX (Asociación Española de Toxicología) y ha trabajado en el Departamento de Inmunología y Enfermedades Infecciosas de la Universidad de Harvard (Boston). Su pasión por la investigación y por avanzar en su especialidad de toxicología, le llevaron a estar en uno de los principales epicentros mundiales de este área médica, Estados Unidos, desde donde a finales de 2011 reclamaron su colaboración en una serie de investigaciones para la Agencia Espacial Norteamericana NASA, que analizaban las repercusiones de los tóxicos en la misiones espaciales donde los astronautas tuvieran que permanecer más de 180 días en el espacio. Tratamos las últimas noticias de la pandemia de la COVID19, hablamos sobre las PCRs y la carga viral en lenguaje sencillo, y lo que está aún por llegar. En la parte final de la entrevista conocemos la pasión del Dr. Camacho por los microscopios, ya que junto a su mujer, posee la mejor colección del mundo, tanto por su valor científico como histórico y cultural. Esta colección está compuesta por 230 microscopios, representativos de los existentes desde el siglo XVII hasta principios del siglo XX, ademas de numerosos libros, catálogos y otros documentos. El Doctor nos cuenta la rocambolesca historia de cómo se hizo con un microscopio de Leeuwenhoek original construido en el ano 1680, y con una edición original del libro Micrographia publicada por Robert Hooke en 1665, dos piezas de incalculable valor y ya catalogadas como Patrimonio Histórico nacional.

Interview with Nathan Hirsch, Founder of Outsource School and Free Up- Perky Collar Radio Show- Hosted by David M. Frankel

Perky Collar Radio Show

Play Episode Listen Later Sep 21, 2020 30:38

Have you ever considered hiring a virtual assistant? If so, check out this interview with 10-year Entrepreneur Nathan Hirsch, Founder of Outsource School, as we discuss the do's and don'ts of hiring a virtual assistant. What tasks are the easiest for VAs (virtual assistants) to do for you when getting started? How much time should they free up in your busy life? Is 5 extra hours a week a good start? Where is the best place to find VAs? Nathan encourages business owners to adopt the acronym SICC when hiring VAs. SICC stands for Schedule, Issues, Communication & Culture. Learn how these principles are crucial to the success of VA implementation in your business. Learn why Nathan feels the Phillippines is one of the best places to find VAs. You will find answers to these questions and many more in this impactful interview. To learn more from Nathan visit www.OutSourceSchool.com or find him on Facebook, Linkedin and Instagram as Nathan Hirsch or RealNathanHirsch. To enroll go to www.OutsourceSchool.com/enroll Use coupon code: PCRS to save 10% on enrollment. Outsource School Links: Facebook: https://www.facebook.com/outsourceschool1 LinkedIn: https://www.linkedin.com/company/outsourceschool Twitter: https://www.twitter.com/SchoolOutsource OutsourceSchool: https://www.outsourceschool.com Email: support@outsourceschool.com and nathan@outsourceschool.com Personal Links: Facebook: https://www.facebook.com/nathan.hirsch Facebook: https://wwwfacebook.com/FreeeUpNathanHirsch Twitter: https://wwwtwitter.com/realnatehirsch LinkedIn: https://www.linkedin.com/in/nathanhirsch/ Instagram: https://www.instagram.com/realnatehirsch/ Thank you for listening to another episode of the Perky Collar Radio Show. Warmest Regards, David M. Frankel Perky Collar Radio Show Host, Perky Collar Inventor and Perky, LLC- The Clothing Innovation Company Founder Info@PerkyLLC.com To join my Entrepreneur Group, visit https://www.facebook.com/groups/CharlotteEntrepreneurThinkTank Feel free to learn more about The Fenx and join fellow successful Entrepreneurs https://entrepreneurs-maclackey.thrivecart.com/the-fenx-monthly/?ref=cettsupport Connect with me on Linkedin https://www.linkedin.com/in/davidmfrankel/ --- Support this podcast: https://anchor.fm/perkycollaradioshow/support

Festivales y salas hablan: ¿qué futuro espera a la música en directo?

New Day Rising

Play Episode Listen Later Sep 7, 2020 70:37

Si quieres que alguien te escuche, tienes que hablar. Y eso es precisamente lo que han hecho José Gallardo (Tomavistas), Carolina Rodríguez (Low Festival / Warm Up), Gabi Ruiz (Primavera Sound), Alfonso Santiago (BBK Live / Azkena / BIME) y Carmen Zapata (Associació de Sales de Concerts de Catalunya) en la inauguración oficial de la tercera temporada de Radio Primavera Sound. New Day Rising, el programa de las mañanas en la emisora oficial de Primavera Sound, ha hecho de marco para esta puesta en común protagonizada por representantes de algunos de los agentes más importantes del sector de la música en directo en España, renqueante después de vivir su verano más difícil y abocado a una larga temporada otoño-invierno si no se actúa con rapidez. En ese sentido, Zapata ha advertido de que “las salas no van a llegar a final de año (...) Marula ya ha cerrado en Madrid y el goteo de cierres será una constante en otoño”. “Estamos perdiendo empresas que nos daban servicio y que ya no estarán aquí. Hay grandes profesionales que ahora están sin trabajo y no podrán aguantar. Me recuerda a cuando empezamos, que había que pedir cosas de fuera”, ha añadido Ruiz. El problema, a fin de cuentas, quizá sea de base. ¿En qué consideración se tiene a la cultura por parte de las autoridades? “Las instituciones han actuado como en todas las crisis, nunca hemos sido un sector prioritario. A mí eso no me ha sorprendido”, ha lamentado Santiago. “No se tiene claro que la cultura es un bien esencial. Tenemos que luchar porque la cultura sea un bien esencial porque realmente lo es: la gente tiene necesidades culturales. Es imposible que paremos nuestra actividad (...) No se puede discutir que somos un sector esencial; las salas, los cines, los teatros son nuestro patrimonio”, ha señalado Ruiz. En palabras de Rodríguez, “el desconocimiento del Ministerio de Cultura es profundo”. Mientras un escenario incierto aparece ya en el horizonte, queda atrás un verano atípico en el que la posibilidad de realizar algunos eventos puntuales al aire libre ha maquillado a duras penas la situación. “Decidimos adaptarnos al formato grande, sacar un escenario al aire libre para rescatar la programación de las salas y recaudar dinero para las salas de pequeño aforo porque están en peligro”, ha comentado Carmen Zapata, directora del ciclo Sala BCN que durante el verano ha llevado música en directo a diferentes espacios de Barcelona. Respecto a una iniciativa similar como las Nits del Primavera, Gabi Ruiz ha subrayado que “no hemos tenido ningún caso. La organización ha estado bien, el público se ha comportado”. “Los que hemos ejercido la práctica musical en este período hemos demostrado que somos capaces de adaptarnos y seguir las normas”, ha reivindicado Rodríguez. Gallardo, por su parte, ha recordado “la incertidumbre hasta el último minuto” con la que el festival que dirige, Tomavistas, ha tenido que trabajar durante estas últimas semanas. “Llevamos una frustración tras otra”. De cara al futuro, en opinión de Alfonso Santiago, urge la creación de “un lobby más fuerte (...) somos 700.000 familias, deberíamos de tener una manera de llegar a las instituciones”. Gallardo coincide en que la unión, una vez más, puede volver a hacer la fuerza: “Necesitamos que las instituciones validen nuestras decisiones y para eso hace falta poder grupal”. Además de abrir la puerta a un protocolo en el que “los tests rápidos permitirán hacer PCRs con resultados al minuto”, Gabi Ruiz ha querido concluir con un mensaje optimista. “Nos han criminalizado, pero la música en directo va a seguir y la vuelta va a ser muy fuerte. La gente tiene muchas ganas de música en directo y vendrán años buenos haciendo nuestro trabajo”.

Hoy por Hoy Jódar Matinal 07:20 lunes (31/08/2020)

Play Episode Listen Later Aug 31, 2020 9:52

¡¡ 138 nuevos confirmados y 13 curados en la provincia!!, En los PCR a los contactos del Brote de Bedmar, el viernes, con un positivo en Bedmar (hasta 13 en total), y uno NUEVO EN JÓDAR (2 en total). DURANTE EL FIN DE SEMANA, según LOS comunicados de la Consejería de Salud y Familias, se alcanzan las 2.687 personas con coronavirus, en todo el periodo. En los centros hospitalarios 20 actuales ingresados, del total 823. 4 de ellos en UCI, para un total de 94. Fallecidos un total de 194. 13 curados. Total Curados, 1.911 en total (74,93%) en total, continúa el permanente descenso del índice de curados. Con los nuevos diagnosticados, continua el paulatino incremento de casos activos, 582, todos con seguimiento domiciliario, salvo 20 ingresos. EL Ayuntamiento DA POR FINALIZADO EL BROTE SURGIDO A MEDIADOS DE AGOSTO| Actualizamos la última informacion facilitada por el Ayuntamiento de Bedmar a las 21:30 horas de este sábado 29 de agosto sobre el brote de Covid19 y los ultimos PCRs realizados viernes. ** Test PCRs realizados: 26 ** NEGATIVOS: 25 ** POSITIVOS : 1 RESUMEN DEL BROTE: **Pruebas PCRs hechas: 90 **Positivos: 13 **Negativos: 77 COMUNUCADO DEL AYUNTAMIENTO SOBRE RESULTADOS DE LAS ÚLTIMAS 26 PCR REALIZADAS A PERSONAS DE BEDMAR DURANTE EL PASADO VIERNES Los resultados de las 26 PCR realizadas durante el día de ayer a vecinos y vecinas de BEDMAR que estuvieron en contacto con los últimos 5 positivos y los resultados han sido los siguientes: Ha habido UN nuevo POSITIVO, haciendo un total de TRECE POSITIVOS los registrados desde el comienzo del brote en BEDMAR informado en los últimos días. El resto de los 25 TEST han dado NEGATIVO todos, haciendo un total de 77 negativos desde el inicio, no quedando nadie por saber el resultado de su prueba. Todos/as ellos/as se encuentran en CUARENTENA. Reiteramos que seguimos en comunicación con las autoridades sanitarias para el SEGUIIENTO de los casos, evitar la propagación y así seguir informando a nuestros vecinos y vecinas. MUY IMPORTANTE :

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Hoy por Hoy Jódar Matinal 07:20 lunes (31/08/2020)

PaperPlayer biorxiv bioinformatics

Play Episode Listen Later Aug 31, 2020 9:52

covid-19 salud cuarentena pcr positivo familias uci negativo ayuntamiento negativos brote consejer matinal pcrs bedmar

metabaR : an R package for the evaluation and improvement of DNA metabarcoding data quality

Play Episode Listen Later Aug 31, 2020

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2020.08.28.271817v1?rss=1 Authors: Zinger, L., Lionnet, C., Benoiston, A.-S., Donald, J., Mercier, C., Boyer, F. Abstract: DNA metabarcoding is becoming the tool of choice for biodiversity studies across taxa and large-scale environmental gradients. Yet, the artefacts present in metabarcoding datasets often preclude a proper interpretation of ecological patterns. Bioinformatic pipelines removing experimental noise have been designed to address this issue. However, these often only partially target produced artefacts, or are marker specific. In addition, assessments of data curation quality and the appropriateness of filtering thresholds are seldom available in existing pipelines, partly due to the lack of appropriate visualisation tools. Here, we present metabaR, an R package that provides a comprehensive suite of tools to effectively curate DNA metabarcoding data after basic bioinformatic analyses. In particular, metabaR uses experimental negative or positive controls to identify different types of artefactual sequences, i.e. reagent contaminants and tag-jumps. It also flags potentially dysfunctional PCRs based on PCR replicate similarities when those are available. Finally, metabaR provides tools to visualise DNA metabarcoding data characteristics in their experimental context as well as their distribution, and facilitate assessment of the appropriateness of data curation filtering thresholds. metabaR is applicable to any DNA metabarcoding experimental design but is most powerful when the design includes experimental controls and replicates. More generally, the simplicity and flexibility of the package makes it applicable any DNA marker, and data generated with any sequencing platform, and pre-analysed with any bioinformatic pipeline. Its outputs are easily usable for downstream analyses with any ecological R package. metabaR complements existing bioinformatics pipelines by providing scientists with a variety of functions with customisable methods that will allow the user to effectively clean DNA metabarcoding data and avoid serious misinterpretations. It thus offers a promising platform for automatised data quality assessments of DNA metabarcoding data for environmental research and biomonitoring. Copy rights belong to original authors. Visit the link for more info

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SMKP015 -Return of the Nick-

Sunday Morning Kicker Podcast - Kicker und Punter in der NFL

Play Episode Listen Later Aug 25, 2020 53:46

Nick Folk ist wieder zurück bei den Patriots und Cairo Santos ist wieder bei den Bears. Dazu ganz viele News rund um Kicker und Punter in der NFL und ordentlich was zu lachen mit den Outtakes aus den letzten Folgen. Oh, und ein 15 Minuten Exkurs wie man PCRs verpfuschen kann...

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Mediodía COPE 25 de agosto de 2020 de 14 a 15

Mediodía COPE

Play Episode Listen Later Aug 25, 2020 37:13

El presidente del Gobierno npone a disposición de las comunidades autónomas 2.000 militares para labores de rastreo. Además, ha anunciado los presidentes de las CCAA que podrán pedir un Estado de Alarma en su territorio, que no significa un nuevo confinamiento. Pedro Sánchez ha pedido unidad a las distintas administraciones para sacar adelante los presupuestos y se ha dirigido a los ciudadanos para pedir pruedencia.Después de que los sindicatos de profesores hayan convocado una huelga solo en Madrid para el comienzo de curso, la Comunidad de Madrid presenta su plan para este próximo curso escolar. Un plan flexible según la evolución de la pandemia. Se van a alternar clases presenciales con clases a distancia. En COPE te hemos adelantado que una de las medidas pasa por la instalación de más de 6.000 cámaras en las aulas para que los alumnos confinados puedan seguir la clase desde su casa por ordenador.Madrid y Murcia son las comunidades que más apuestan por la semi-presencialidad. En Cataluña detallan su plan adelantado por Torra este lunes. Se basa en 3 medidas: medio millón de PCRs a estudiantes y profesores, menos de 20 alumnos por clase y mascarilla obligatoria para niños mayores de 12 años.Con todo...

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Enfoque Internacional - El Covid-19 se lleva por delante la temporada turística en España

Enfoque internacional

Play Episode Listen Later Jul 28, 2020 2:09

Ante el aumento de los casos de coronavirus en España, varios países europeos han vuelto a imponer restricciones. Alemania se dice preocupada por la subida en los contagios y desaconseja los viajes no esenciales a tres regiones españolas: Aragón, Cataluña y Navarra. Es un nuevo golpe al turismo español, tras la decisión de Reino Unido de imponer una cuarentena a los viajeros provenientes de España. El gobierno español se afana por repetir que sus destinos turísticos son seguros pero los hoteleros y restauradores ya están sintiendo las consecuencias. Barcelona es uno de los principales destinos turísticos en Europa, pero esta temporada los hoteles han sufrido una avalancha de cancelaciones después de los rebrotes registrados de Covid-19 en julio en la región de Cataluña y de las restricciones impuestas en varios países europeos para viajar a España: como cuarentenas a la vuelta en el caso de Reino Unido, prohibición de ir como los belgas, tests PCRs como los alemanes o simplemente recomendaciones para evitar la península, como los franceses. En el casco histórico de Barcelona, en el barrio del Raval, el Andante Hotel de 134 habitaciones tiene sus puertas cerradas desde el inicio de la pandemia en marzo. Habían previsto reabrir este mes de agosto, sin embargo, como nos explica su director Pablo Bofill, van a tener que posponer su reapertura. "Ha habido un parón en las reservas y han aumentado las cancelaciones. La ocupación para agosto estaba en un 34% pero tras las medidas adoptadas por el gobierno autonómico, se redujo hasta el 28%. Viendo la evolución de la pandemia en territorios próximos, decidimos posponer la reapertura a septiembre", explica a RFI. Los hoteles y restaurantes contaban con el verano para poder salvar la temporada pero los profesionales son pesimistas. Las consecuencias económicas serán tremendas. "Es muy complicado. Estar más de medio año cerrados lógicamente tendrá consecuencias. Habrá empresas que lo soporten mejor y habrá quienes tendrán que desprenderse de sus activos para seguir avanzando", explica Bofill. Barcelona tiene más de 500 hoteles y la tasa de ocupación en los establecimientos del centro entre mayo y octubre oscila alrededor del 90% en tiempos normales pero la pandemia ha obligado a que la mayoría cierren sus puertas, solo el 25% de los hoteles están abiertos dejando en la ciudad una imagen inédita: desierta y sin turistas.

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MALDITA LA HORA 37: bulos de coronavirus y PCR, packs de mascarillas gratis y políticas de privacidad.

Maldita la hora

Play Episode Listen Later Jul 23, 2020 10:31

¡Hola Malditas y Malditos! Bienvenidos a un nuevo episodio del podcast de Maldita.es. Esta semana os vamos a hablar de PCRs y rebrotes, y de los bulos que tratan de desaturizarlos. También de una cadena que te avisa de que los mayores de 60 años tendrán mascarillas gratis a partir del 29 de julio. Os contamos qué mentiras nos han intentado colar nuestros políticos y también os damos unos consejos sobre en qué fijarte cuando aceptas una de esas largas y tediosas políticas de privacidad.

coronavirus os tambi bienvenidos packs la hora maldita privacidad malditos mascarillas bulos pcrs

Masks & Face Coverings: Healthy Choice or Hysteria?

Gut Check Project

Play Episode Listen Later Jul 9, 2020 65:43

Hello gut check project fans and KBMD health family It is now time for COVID believe it or not episode installment number eight. We can't escape it. It will not go away this this is going to be probably the most controversial episode to date that we've ever done on on COVID. Your co host here, Dr. Kenneth brown along with me, Eric Rieger. Ken, what's happening?Not much, Eric. I mean, this is this this episode the way that we're getting into some murky waters. Now we're talking about some controversial things here. And, you know, after watching that video of that Scottsdale woman, barge into the target, and tear apart that mass display. She was wearing that $40,000 watch and it really got me wondering, What is she doing shopping at target with a $40,000 watch on I mean isn't that more of a Neiman's thing or she used to be tearing apart the mask station at Neiman's or I don't know.You'd think you could use that watch to get somebody to go shopping for you.It's just such an odd world we're living in. All of this stuff is being captured. And it's not like somebody filmed her. She sent out front filmed herself said this is what I'm gonna do. With a $40,000 watch on. I'm gonna go into this target and I'm gonna destroy this mask display because masks. So Eric Rieger this episode is controversial. What are we going to talk about today?Well, it sounds to me like we're going to be talking about Karens on Reddit. Is that right?No, not even close we're gonna be talking about.Honestly you know what I'll get we got some fans out there and I know two friends of mine whose names are Karen and I think that sucks that they always have to be under fire for a good name. Oh, your poor Karen friends. They're taking a beating right now. Ridiculous. But regardless, so no, Karen's on Reddit, what are we going to be doing?Well, we're gonna talk about masks, and we're just gonna kick some science like we always do. So this isn't a political thing. This isn't a controversial Well, it's controversial for some people. And I don't really understand why because I just want to go over the science of this. So before we get into that, let's talk about what's going on locally. And certainly one thing happened that you and I could not participate in, and it's our good friend, Nick and Jessica's wedding that happened on Friday. Why? Because big shout out to them. Congratulations. That's awesome. Nick is one of our most valued employees. He started the company with us. Love the fact that he got married and I hate the fact that you and I couldn't go.Yeah, unfortunately, the procedure center that we do all of the endoscopies at...we had a confirmed at least two cases of people that came through we were advised as healthcare providers that we needed to be diligent for at least five days and make certain that we did not insert our presence into crowds of more than 10 publicly and that was, I mean, not to be able to go and support someone that we care a lot about such as Nick and then his new wife Jessica was no fun at all. But on top of that, it also led to doing next to nothing for five days over the Fourth of July weekend. So our freedom was basically sit at home and just trying to get people sick.That's exactly it. I've got a great firework display of me with a one of those little sparklers in my backyard alone.Yeah, that's that's about as far as is it gotta be here. We fortunately I live in the country. So there is a handful of folks who shot off fireworks but that pretty much concluded the Fourth of July weekend for 2020.A quick shout out to my mom just turned 78 on July 4th, got a bunch of pitches from her love the fact that she's still kicking it staining her own deck staining her own deck, taking care of her own yard. 78 mom Happy birthday.Happy birthday. Diana Brown. That's awesome.Um, so this is a really interesting thing. I'm a little bit shocked about the whole way that we're kind of approaching this whole mask situation and all these other things right now. This is July 2020, we're in the middle of a pandemic, we're having a resurgence of everything. Everybody's flipping out again, we had the first flip out, and now we're having flip out number two, and everybody's wondering what the government's gonna do, but I don't blame them because we're six months into this pandemic. And there's so many things that have had misinformation from organizations that we traditionally would say, Oh, they said it, it's perfect. So like the CDC and the who the World Health Organization. Let's just go over a couple quick things. And if you look back at the earlier episodes of gut check project on COVID. We've been ahead of the science the whole time, and we've really just tried to talk science not conjecture, not scary, nothing like that. So this is initially, the who said, there's no evidence that this has human to human transmission. Wrong, learned that very quick, that was very wrong. And then the CDC came out and said masks don't matter. And wrong. Now they're mandatory. And we were told that hydroxychloroquine plaquenil was a panacea, it's gonna fix everything. It's gonna cure everybody. And then this article comes out and it says, no, it's harming people. And then everybody retracted articles from the Lancet and the New England Journal of Medicine and said, what are we doing publishing this, this crap? And really, an article came out last week that said, no a much more refined, well done study actually shows that it saves lives. And then when they looked back and looked at the original study, that it was probably poorly done, and they didn't equate for certain risk factors and stuff. So it's really hard to know what to actually do this is, this is unprecedented times, this is not something that we have ever dealt with before. So it's okay to be wrong. just own it and know that you're wrong.It is. And I do want to point out something before we get too far if you're watching this and you feel as if something's going to be presented from a political slant, trust me that is the furthest thing from what Ken and I want to do on this topic whatsoever. Science should be agnostic to any political affiliation. And I think what you're going to hear from Ken and I as we move forward, is just utilize data. That's what science is about. And that's how we save lives. It has zero to do with a with a political party whatsoever.Dude, this totally reminds me This is deja vu for me, though. I mean, you have to understand remember, I take polyphenols every single day. So I remember back in the 1940s and 50s when seatbelts were first proposed Getting in huge arguments with people. Oh, yeah, just like yeah, seat belts. It aroused heated debates, despite increasing scientific research. It was between, I think it was in 1947 I get in a huge argument with somebody that affirming that the this actually saves lives. And among the arguments put forth against the seat belts, there were all these other things. And they were all disputed by researchers. But the opposition to seat belts remained in place and it took all up to the 1980s to actually make it so that you all cars had to have three point seat belts. And I don't even know when the law went into place where basically you get a ticket if you don't so, I've been through this before I've been through arguments for science tries to win. And so I remember 1948, that was tough.That's it's amazing how young you look for having been around just after the World War Two and old enough to have that kind of conversation. So my hat's off to you for being around in the 40s. And, and and really just kind of keeping it together and passing for a 40 year old yourself now, so that's kind of weird.You know it. It's odd. It's a little bit odd.Yeah, it's really, really strange. I mean, like, seriously, you were so far ahead of the curve on polyphenols alone that, well, I don't even want to go through it. But regardless, that's amazing that you were there for 40 for four decades, just to...the 80s.But isn't it funny because we're going to talk about masks here for a second and the seatbelts went through the same not quite with the, with the, I guess, emotional power that's going on. But a lot of people fought seatbelts and said, that's my constitutional right. If I want to die, I can die. And it took forever, from 1940 to 1980 to actually make it that it was a mandated thing in cars. My grandmother was one of those who was vehemently opposed to having to wear seatbelts so much so that she had talked about that she was going to sew something that looked like a seat belt on to her shirts just so that she wouldn't have to have one on, but.Not to put you on the spot here because I know how much you loved your dad. But tell me that story about you driving with your dad in the car. Oh, in the 70s Yeah, some of my earliest memories of riding with my dad. We lived in a small town and there was a lake nearby and I can still remember my dad and his buddy Jim. We it was commonplace, I guess for us to go out to the lake. Well, occasionally, dad, let me was probably about three or four years old sit in his lap, and, you know, work the steering wheel while he worked the pedals and he would hang his left hand up the, at the window, so he could ash his cigarette, you know, it was all the good stuff.Was that was certainly that was certainly the time so. So now it's, it's 2020 I hop on Reddit, you know, the front page of the internet, whatever. And I see all these public freak outs and a lot of them are over this whole mask issue. So I just wanted to talk some science. I don't want to make it political. I just want to have some fun dialogue about viruses, and masks. And I found three studies that are pending publication meaning they've been accepted. They're not in print yet. They just came out like last week that I just want to talk into that I just want to talk about a little bit. Let's do it. I mean, this is this is what it's about. Let's get into some data on why we would believe one thing or another.Yeah. So all right, starting one article from China, which is really interesting, because when everything first came out, Hey Ken your sound went off.Oh, my goodness. It sure did that. Sorry about that.Sorry about that. You said in China just start over you're good.Yeah. So in China, so this article comes out of China. It's it's pending publication here. What I thought was really cool is that they went back and they looked at the very beginning. And they said, well, let's do a deep epidemiological dive, it's a hard word for me to say, of a cluster of people. And so they looked at a group of people in the Zhang province, which next to the Wu Han area, which I forgot what the province is called, has had a very, very high concentration of COVID. But they're going back to the beginning of covid. So this is like early January, that kind of thing. They tracked down a person that came from Wu Han, so he was probably exposed there. And then he ultimately very quickly infected seven other people, then what they did, it's really cool because this has not been done yet. They tracked out who ever they had contact with. Primary contact, secondary contact. So we've been speculating about a lot of different things. And what they're able to show is that these seven people had contact, direct or indirect, meaning close or not close with 539 people in a very short period of time. So that's shows how much we interact with people, even though we don't really realize it. What they what they were able to determine. And all these people, the seven people were asymptomatic. So they didn't had no idea that COVID covered was just breaking on the scene. It's all this other stuff. And what they showed is that all these people, if they had close contact to somebody, almost 30% or 29% of the people actually contracted COVID-contracted it: proven positive and had symptoms and all this other stuff. The secondary contact, meaning no direct contact, and what I'm talking about is people that did have never actually talked to the people that they talked to the person that talked to the person that may have done that, or maybe it was a waiter that delivered food, that kind of thing. It was .6%. So this is the first article to come out and actually delineate the exposure to risk of infection. So .6%. So what this does, is this strongly highlights a droplet theory because I remember, and I remember having like very early on Mike Logsin asked me He's like, Hey man, is this aerosolized or is this droplet and that's what we're gonna talk about today. Because it's terrifying. If you start talking about this being aerosolized, this kind of thing, and this is what all this is about. So what this highlighted was a droplet theory, meaning that if you're close to somebody, then you have a higher likelihood of getting infected. The US published a very similar article to this and this is why the CDC said it appears that it could be droplet transmission, as opposed to aerosolized. Now, a couple interesting other caveats that we won't get into because I think it should be its own show, is the median incubation period was seven days of these people to develop symptoms. And the people that actually had it, almost all of them initially had negative PCR tests, and then they continued to go back and then they'd started then they go back and they look and they go, Oh look, you had an elevated CRP and an elevated ferritin. And they kept checking them and then they got a PCR positive. And what I mean by this is, maybe when we're sitting there saying go get tested. So I recently had a patient that was PCR negative on one day PCR negative two days letter, because you're like, man, she's gotta have COVID this is crazy. And then PCR positive three days later, which is very odd in the sense that you develop a seven day incubation period, your viral loads peaking at that time, that's why you're having these issues. And two PCRs were negative. So hanging your hat on the fact that it's a PCR meaning that nasal swab where they poke your brain, it's it even happened in this study. So I don't know what your thoughts are, but definitely, the odds are way higher than what the R not meaning the number of people that could be infected. If it's a close familial unit, what they showed is when you're in close contact with somebody, you have a very high likelihood of contracting COVID if you take the necessary precautions. And they were they weren't even taking the necessary precautions at this, but the secondary to secondary transmission. So this brings up the whole idea that if we can squash it before other people are carrying it makes a huge difference because this is early on in COVID. I don't think you'd see those same numbers if they did it again.No, I totally agree. And what you just described for the patient isn't, I mean in and of itself as what could be seen as anecdotal. However, there's a couple of different stories that have played out exactly like that. There's a there's another anesthesia provider that you and I both know. And she experienced the same thing after coming into exposure she had two PCR negatives only to have really bad symptoms set up. I think it was three days between the first two and then three days after she had the next test showed up positive because she had bad symptoms, and sure enough, she was COVID positive at that point. So that that's not really that big of an anomaly. I don't I don't think at all. No, I don't think it is either. And, you know, we did a whole show on antibodies and we are still sitting on the, we're still waiting to determine what is the best antibody test. And we really at the data that we had, we were so confident. This is what it's this is what we were going to do. This is how it was going to be. And it was gonna be so exciting. And now that is pulling up. So all we can do is just kind of look at the data that's here. So this article shows that if somebody has it and they're in close contact, they can easily infect seven close family members, those seven family members have contact to 529 people or 39 people really quick because they went to a wedding which is why you and I didn't go to Nick's.Precisely the reason we didn't goYeah. And so what they the now the the critique that I have of this article is that what they did is they they did a great job of tracking down 529 people or 39 can't remember what it was. 539 sorry, 539. And they just called him up and said, Did you have this? Did you have that? So and So, and they didn't. So those people that didn't have symptoms, they said they probably didn't get it. And we know that's not right anymore. We know that a lot of people are essentially asymptomatic, or they just blame it on allergies or whatever. So the point of this is close contact. Proximity makes a difference.Yeah, yeah, I'm sure it does. And knowing that proximity matters, what do they call the, and maybe one of the studies that you're gonna reference today shows it but not the...graph, that's what shows the displacement of air whenever we breathe in, but there's, there's these UV light and infrared light scanners that show the airflow that comes out of your mouth when you're uninhibited, right? And then you can see distance etc. But having an object even if it happens to be really crappy cloth really does drive down the distance and area by which your droplets can travel.Yeah, that's awesome. Next time you do that, say spoiler alert, please, because that's all we're going to talk about for the rest of the show. Just so y'all know, he never tells me which studies he's gonna reference. I'm learning as we all go.You know what I always like about this is this is why you always ask great questions because you're a healthcare provider, you're super smart. And you know, and that's exactly where we're gonna go. But we're not just going to say, Oh, do this, I'm gonna get into the science of it. So now let's talk about the second article. All right, so we already have an article from China that shows close contact makes a difference. We believe it's more droplet than aerosolized meaning in the air. And an article from Germany came out two days ago, actually, and they looked at the effectiveness of mask wearing after masks were made mandatory countrywide. So there is a general perception in Germany that public wearing og face masks reduces the incidences of COVID-19 significantly. Now this perception came mainly from one city. So one city named Jena spelled jena Jena immediately said we should all wear masks, which was really cool of Mayor there to say let's do this. So they introduced mass on April 6 2020. And the number of new infections fell to essentially zero. So based on that one city, the country of Germany said okay, we need to make it compulsory in all federal states, and it started on April 20, and worked its way through to April 29. That all the all of Germany has to wear masks. The conclusion is that the introduction of face masks reduced the number of new infections over the next 20 days by 25%. Impressive 20 days 25% drop. Then they compared this to a synthetic control group so they had a control group where they could actually look at this, it was, admittedly, it's a lot of science, epidemiologic manipulation and stuff like that, because you can never have a control group where you say you can't wear a mask. But what they did is they synthetically did it. It's pretty easy to do that because you can look at certain states in the US where the majority people don't wear masks and you could say, what is the rise? So, the conclusion of the authors was that they believe that the reduction in the growth rates of infection, were at least between 40 to 60% is the best estimate. And then they stressed that if you use the model like Jena, that 40 to 60% reduction in viral transmission is really lowball estimate. Because if you would have started it earlier, you would have decreased the number of people that had the virus, the R not meaning the number of those people that they could have infected would have gone down significantly. So we have a country like Germany that looked at one city and said It's down to zero. We got to do what they're doing. And they immediately jumped on it. And that's pretty impressive. So I think it's if we're arguing whether or not masks work, it's pretty easy to look at other countries like Japan and Germany that were very aggressive about this. Now, Japan has always had a pretty liberal roll of masks. It's it's part of the culture. So it's not a big deal. Germany didn't. Germany, it's not like people were walking around wearing masks. But they all collectively agreed to do this. And it is just if you looked at their worldometers, their cases are just plummeting. So I just want to say those two articles. So one from China talks about close contact two from Germany, where a country that isn't used to doing that clearly is showing a significant drop in this. And so the third article is all about how and why that's it.No, that makes sense. And then when you reference the fact that you have Germany being a country that didn't typically wear them. I think historically, when you look at the way they apply engineering, the way they utilize the base stem, they probably embrace the idea that science is at least supporting a reduction in transmission only to see it play out, as you said, I think you said 20 days a reduction of 25%. That's awesome. Probably not accounting for non compliance and some probably pockets of people that didn't really embrace it as a whole. So that would probably be that would equate at least to a trigger on why there was still some transmission afterwards.Yeah, it's just it's super impressive. We'll get into why a lot of this is going on. But so now I found this super cool article. It's pending publication. And it's the article is actually titled COVID-19 and aerosol's point of view from expiration to transmission.Whoo nice. I like the crowd noise there too.For everyone listening the studio audience is all wearing masks so they're actually just a little bit so this is really cool because this is you know, we have these people that are flipping out but let's let's talk about the physics of stuff. Let's talk about what's actually going on how, what masks do what viruses do. So this whole article is about that and it's I just found it super interesting that it's, it gets in all this stuff. I don't know what are your What are your thoughts?No, I that's this is the explanation This is why I think that we can remove the the politics behind the use of a mask and the oddity of of using a mask and then start getting down to the explaining of why a mask and it hopefully this makes sense to those who may be on the fence. It'll be less of a I don't know your your heels in the dirt right. You'll be more open to like, whenever you're going into a communal area, just throw on a mask, at least you're not going to be contributing to the problem. Totally.Hey, Karen, can you not? Can you not? All right? Let's just be quiet for the show for now. Okay. That's the last time I do a live audience. Alright, so anyways, let's talk about a few things for you to become infected. For a respiratory infection to happen there needs to be a sufficient amount of virus, you need to have a viral load. Now, here's something that's interesting when you read the literature, when they discuss when a virus is outside of a body, it is referred to as a verion. So the verion is being car is being carried in an aerosolized vessel which is a droplet. So we know that h2 receptors you and I did the original podcast on how co on how SARS cov2 infects us and becomes COVID-19 on the h2 receptors, those h2 receptors are located in the lungs and in the GI tract. They're heavily populated in the posterior pharynx. And bronchus, which you know, much better than I do, because you did the whole episode on the lungs. But that's the conductive zone and then the respiratory zone, the alveoli is the gas exchange area. So that's further down in am I saying that right?Yeah, pretty much. But does those h2 receptors of course they affect if y'all remember correctly, pneumocytes, there are two types of pneumocytes in your lungs. And one of them in particular has more ACE2 receptors, and it happens to be the ones that help us breathe. And so when these things get disrupted, we don't breathe through those pneumocytes anymore.That's right, go back to that COVID episode because Eric goes into crazy detail about surfactant and all these other things and why we get so sick and that was back early on when we were trying to piece it together and you know fortunately I think we found the right literature that makes sense. Because it's true.Yeah definitely I believe that.So what you're describing is when you get down into the alveoli, and what I'm talking about is the conductive system, which is your trachea and the main bronchus. What we're talking about is, what size of aerosol meaning if something is in the air is important on making this virus infective or how do we control it? So who the World Health Organization says that the virus is primarily spread through droplets from sneezing and coughing, when these droplets reach a person's nose, mouth or eyes, pow. Now you have an infection. And then the indirect way is when these droplets land, then they land on something called a fomite. Fomite is a fancy term for anything that a virus lands on. So this pen could be a fomite if I sneezed it. And if you touch it and then touch your eyes, you could potentially have an infection. So, right now, don't touch my fomites. All right?Hands off your fomites for sure. Hands off my fomites. I think one of the reasons why people are fighting the mask thing is the confusion on what the CDC said early on on this COVID-19 pandemic. And basically, they almost implied if you don't have an N 95, that fancy mask, then are you going to be safe, and we didn't know all that stuff. And so now we know quite a bit more about this. And the CDC essentially was saying that to protect healthcare workers, I don't think they really understood it. But in this is unprecedented times in a pandemic, they have to sit there and land on a stance, and it's okay to have a hard stance to try and make sure that we have enough protective equipment for everyone out there. And then it's okay to retract. So at one point, they're sitting there saying, the masks don't help. And then they're saying now they're mandatory. And I think that's why we're having this emotional response. SoWell, I think an invasion into anyone's normal everyday activity with a poor explanation, which, if we're going to be honest, in the early days of all of this, things, things happened quickly, but it didn't. I would say, for many people, it didn't appear as if the right information was always readily available. Everything seemed very ambiguous and with ambiguity, you, you allow people to breed some elements of content, and they just weren't, weren't excited about what they were hearing. And then when you go back and forth, I think that people, they they say, Well, once you told me this, and now you're telling me this, without a full understanding that sometimes the things change, and they were they require just just different things from people to do different activities. So it there's there's definitely some vitriol from people who don't want to give up more of their liberties, I think is probably a big piece of the issue 100% we're going to get into that about all this. This is not trying to shove it down. You're not trying to placate one side to the other. This is the science of what's going on. And what we do know is you're like, Well, why do you care if you touch my fomite well, you would be shocked at how many people touch their eyes after they touch something you're always scratch your eyes. That is a that is also a point of entry, which this article did not get into. But that's how come we say we're I'm guilty of doing it on this podcasts already. I mean, I know I've done it.It's it's super hard not to so it's alright, so one of the things is that airborne transmission when it first came out, it is somewhat terrifying to think that this thing could be just floating around in the air. But when Mike asked me, is this aerosolized or is this droplet what I'm going to say is airborne transmission is through the air. So they're both airborne transmission and that that is another part of the confusion that the that the news media was saying this is not transmitted airborne, but it's transmitted through droplets. I'm saying that a droplet is that. So droplets and aerosolized are airborne transmission, it just comes down to size, which is the definition of it. So a respiratory droplet is saliva and secretions expelled from the upper airway, posterior pharynx. nose. And this happens with sneezing, coughing, talking, even breathing, you're going to be expelling some of this. Generally, they are considered to be between five to 10 microns in size. And this is just relevant for the masks when we start talking about that. But due to the size, they are brought down by gravity after shooting out, so when I cough or sneeze, they get shot out. And you could say, Oh, well, how do you know that? Well, the reality is in 1934, a doctor named Dr. Wells came up with this really cool wells, evaporation, falling curve, which I always find interesting as a scientist. So you could I always think it's funny when these guys do these things. The I joke around like somebody named the fever that you get with malaria is called a double quotidian fever of not Nagle. I always have this funny vision in my head that somebody walks into doctor not nagels lab because you're never amount to nothing, you're worthless. He goes screw you. I'm gonna name this double quotidian fever of not Nagel, and this is kind of what I feel about this. So like, I'm gonna prove to that when I sneeze. My droplet has a predictable mathematical equation on when it evaporates and when it lands. In other words, when does it become a fomite? And when does it become aerosolized, and there's actually a math equation on this. So once the wells curve has evaporated, the droplet is now a is now a verion, and then that verion is aerosolized and it can hang out in the air for an hour. We can kind of explain that. So there's reasons why this is relative. So if it's less than five microns, then it can hang out in the air for up to an hour, up to an hour. So all right, so my question to you, Eric, is, we're hanging around, and then I want to know how far back you should stand when I do this.It sounded like a sneeze. And then how far back should I stand? When you sneeze, I would say probably just knowing how hard people sneeze, probably, at least 10 feet back would be the beginning of the edge, it seems to me I mean, there's lots of turbulent flow that happens once it exits the body. And that's by design believe it or now but at the same time the virus is is smarter, quote unquote smarter than what we give it credit for. They know why they want in mammals because they want to be transmitted. They want people to sneeze. That's how it gets passed around. Yeah so that's, that's better. I thought you're gonna say I thought you're going to use the old CDC rhetoric of six feet away now, but if I sneeze, my particles can be in the air droplets. Large droplets can be in the air for around 19 feet a little over 19 feet. Wow so tens not even get enough wow okay.Yeah. So that's that was little shocking to me to find out that because we talked about six feet, and then a droplet nuclei. And what I mean by droplet nuclei means that in the wells evaporation curve, you've got these big droplets that land on a fomite, right? And then you touch your eye and then you get infected, or in a dry area evaporates and becomes less than five microns. And then it floats and it can actually travel almost two miles. Yeah, so two miles. And that is a little bit scary in the sense that we think about that. So now, why? Why isn't it worse? Because, I mean, you're talking about the fact that I can actually sneeze if I'm outside or cough and I have COVID-19. And it's dry, my verion will be carried in the air and travel up to two miles. And they've actually documented this it isn't it isn't. It isn't specifically related to COVID. It's related to all viral protocols and things like that. And so what you were referring to earlier are those either heat or laser or different ways to show the transmission of different things but when you get out when other studies have been done, and these are studies from 2004 studies from 17. That's pretty wild. Oh shit, we're screwed if I can infect somebody two miles away. So now what we have to talk about is that's the physics of the virus. Now let's talk about how do we get infected? Are you up to speed on yours?Yeah, hundred percent. I would say that small caveat would be, even though we know that the virus probably can travel up to two up to two miles in a really dry environment, etc. back to what you said earlier in the podcast, it's in all likelihood, it still requires several strains of RNA to all basically kind of be there wants to overcome mucus, saliva, different things that actually our body's always producing to prevent invasions or infections like that.So hundred percent. And so now let's talk about how we actually get infected. So there's several. So this is not all. Now this particular article is directly in relation to COVID-19. But the references we have the data from other viruses and things like that. So several factors do play into the infectivity. So the virus characteristics we know that SARS cov2 is unlike anything else we've ever faced the fact that the infectivity due to the Furin protein, the binding furin protein that won't get into it but Weinstein talks about about how it's inserted there. And then the ACE2 receptor, which is a ubiquitous receptor, would explain how easy it is to get infected. You get infected through your GI tract, through your eyes, through your nose, breathe it in, get it in the back of your throat, all you got to do if you if you're 18 feet away, I don't know you and you sneeze and I go. I could be infected.You could be that easy. AbsolutelyIt's crazy. Alright, so we know that the infectivity of this virus is exceptional in the way that it is exceptionally good at infecting other people. Now the other thing is the host the sneezer. So what if you have the virus and let's depend on your viral load. So this is why I brought up the original article about the epidemiologic study out of China. If your viral load is really high, and you're a powerful sneezer, you're going to send a lot of virus out in droplets, where it's going. And so the hosts themselves could potentially have a high viral load. And we know that it took up to seven days or the mean of seven days before they started showing symptoms, which means six days and a half. They're sneezing, coughing, thinking, it's just allergies, it's nothing. And there, that's where the R not are the other people that could be infected. So that's the other thing. So there's the virus characteristic. There's the host, the sneeze, are we going to say something? Sorry? No, no, I completely agree with that. And then the really thing that nobody's talking about is the transmission, the big drop or little drop, and that's kind of what you were getting at right there. Before we get into this Yeah. Now when you have a big drop are we gonna want to talk about the number of RNA viral strands all in one drop, that's kind of the concentration of the vehicle. We're gonna get into that. And then something else that nobody's really talking about is that the victim, I'm going to call them the victim. So you're the host of the virus, your sneeze. several aspects come in play also. The victim's breathing patterns play a role that nobody's talking about yet. And I just I just got the book by Nestor. His last name's Nestor heard him on Ben Greenfield podcast about breathing like, we're apparently breathing wrong, but anyways, breathe through your nose helps. If I'm breathing deep and fast, I'm creating an environment where I'm bringing in further air there. So the victim's breathing capacity, meaning if you're breathing big, you're getting in more air you have the you have the possibility and then of course the victim's immune system. And we always say healthy gut equals a healthy immune system if you are under stress, you're not sleeping well, you're, you're a target. So imagine being a stressed person. And somebody with the virus is 19 feet away, they sneeze, you hear the sneeze, you're already freaked out and you start mouth breathing, bringing in posterior pharynx, the conducting system of the lungs, the trachea, tons of ACE2 receptors. All you need is a couple the viral load coming in, gets there. So my recommendation if you're out in public, you're not wearing a mask. That person is not wearing a mask. You see somebody sneeze, shallow, control breaths through your nose is at least a physiologic way to not back yourself into the corner. So...No without question, you know, and maybe someday just go over the we could we could even talk about the physiology of breathing and we have these little bitty structures in our nose called turbinates and they are specifically designed to make it Air swirl so that the mucus which is already in place that doesn't just protect us from COVID. It protects us from all kinds of stuff. It's really there to trap things like a virus, and.You've got IGA sitting there. You've got IGG sitting there IGM sitting there, those are your antibodies. So when you take in a big breath, we should all be nose breathers, not mouth breathers. But anyways, that's a whole separate. That's a whole separate discussion. So these are several factors that play into it, the host and the infected person play into it. Now getting back to what you're talking about, which is really where masks come into play. big drop, drop top, cooking up drugs in the crock pot. Is that right?Hip hop show.It's really hard to try and throw a little levity into a discussion that's...Into disease and pandemics. Yes. All right, so big drop. When you have a big drop the big droplets, when they come out, you're exactly right. They're a drop and they hold more virions, meaning they hold more virus more virus to infect you. Big drops deposit in the upper airway, and the pharynx, where there's lots of ace2 receptors, droplet nuclei, which is the scientific term for little tiny virions. So what happens is, I sneeze, cough, talk, droplets come out, and in the wells evaporation curve, big drops carry these viruses down and imagine them splashing, microscopic splashing down and then that fomite could be there. worse. I sneeze and my big droplets go 19 feet and you inhale a big droplet. That's super dangerous, the evaporation curve when the big droplet starts to go down. As it evaporates with speed, now you have a tiny little droplet called a droplet nuclei. This has much smaller amounts of virions, the so if you inhale one of these droplet nuclei, the ability of those virions to infect you is much less than a big droplet that just you're taking a bolus of something. So, keep that in mind because you're exactly right, smaller amounts of virions, you have to expose yourself to higher levels of these droplet nuclei to infect. Now, the downside is that they're so small that you can inhale them into those type two pneumocytes which is a whole separate deal. Yeah, and once again, I keep saying the same thing. We're going to get to this because it all just kind of ties up together. So the who states that droplet transmission is the primary way of infection. But if there's enough concentration of these droplet nuclei, then your infection rate goes up. Hence the health care workers that are our frontline people that are sacrificing their lives. So a nurse that's taking care of an ICU patient or not an ICU patients not ventilated, not in a closed loop that is just continually breathing out these droplet nuclei. Well, it's hard to get infected by them, but if you put enough of them in a concentrated area, you can be infected. So the who is not completely right on that, but it's the best that they can do for the general public. And it has been shown that exhalations, sneezing and coughing have droplets, but also this is interesting what you're talking about why viruses want to infect mammals. One of the reasons why is because they come out with a cloud of mist. In other words, the humidity surrounding it. you sneeze out your own little clouds. And that is an evolutionary thing that keeps the humidity up. So that the viruses do not disperse immediately. So big, the virus wants to be in a big droplet. And as we do this, our bodies end up doing this through evolutionary reasons. So it keeps this cloud of mist that keeps the humidity up. And it's looking to delay that evaporation curve. Because it's survival is best if it either goes in somebody right away, or if it lands somewhere. And we know that SARS CoV2 the causes COVID-19 can live on like plastic for what what do we say 96 hours or something like that?Yeah, something like that. A couple of days anyway.Yeah. All right. So now, what's finally unmasked how masks play a role into this by wearing a mask and this is this is the easy part of the podcast. So it shouldn't be too difficult, but I think it's really important to understand the physiology because when you understand it, maybe public freak outs will slow down a little bit. So by wearing a mask, we introduce a resistance barrier to the droplets. And this is exactly what you said in the first five minutes of the show. You're exactly right. It doesn't have to be an N95 you produce resistance to the droplets, the mask will reduce the expired air velocity. So as I'm talking to you, if you're sitting across the table from me, and I'm shouting, or I'm singing, or I'm doing things that create a lot of air, that is the viral that is the velocity of the air, which can shoot a viral load further out. So just by creating a little bit of resistance, and I have worked out with a mask, and it is a little it's a little you know, I mean, I like it personally because I feel like once we get out of this, we're all gonna be like, you know, phenoms aerobically, because if you go out for a jog with a, with a mask on, it's a, you're like woo, it's it's a, it's a little bit harder. So the mask will reduce the expired air, thus slowing the, the droplet down, and it will essentially fall quicker. So it's like, think of that your pitcher throwing a really fast 90 mile per hour, you know, fast pitch and me throwing with my left hand, you know, just barely making it halfway to you know, home plate, the virus is gonna drop. And as long as we're using proper contacts, fomites stuff, and there's some new evidence to show that maybe the whole fomites transmission and we can talk about that later. is probably less important than we initially thought. So putting it there, if you have it, you're not gonna put it out there. You're not gonna be able to eject a virus so far and it will shrink the radius of Where the virus goes. So we know that on those different laser type shots where they show where a sneeze goes, it's like a cloud. And it just goes and kind of covers this big radius. Well, when you do that you actually control the radius. So it comes like here and here. So that's at least does that now the droplet nuclei, the tiny little micron things are now moving slower, which means they evaporate quicker, so they can't join the droplet. Yeah, although it seems dangerous that you're like, Yeah, but you said earlier that the nuclei can travel two miles. But what I'm saying is that those nuclei, they have to gather in sufficient amounts, otherwise, your own immune system can kick their ass, and that's what you really want. You want to be able to fight something as opposed to being overwhelmed by something. Now, the mask wearer also has something which is really interesting and this gets back to the exercise your your reduced inhalation velocity. So you're 19 feet away. you sneeze. I'm wearing a mask I breathe in. Well, I'm only breathing in air that I can that's just nearby my mask. It protects me also. So it's all physics, about how when you're wearing a mask, you're decreasing the velocity and you're decreasing the velocity out. Which is why a lot of people are flipping out with a like I'm having trouble breathing. I'm like, that's okay. Any type of mask is there trouble breathing if you breathe through your nose and you do it controlled, you get enough oxygen in it is I understand there's a million reasons why people feel claustrophobic and all this other stuff but you know, the six feet away thing that makes sense. If everybody's wearing a mask that makes sense because your my ability to inhale your virus is decreased your ability to expel your virus is decreased. Now, the who World Health Organization got everyone all scared and felt If you don't have an N 95, then you're completely screwed. This is not true. And that's part of the problem is that and I've, I'm part of it, I go to the hospital, I wear a surgical mask. And people say that's doing nothing for you. And I actually had this conversation with a couple doctors. And they're like, I'm not wearing a mask because I don't have an N 95 not true. from day to day standpoint. Any barrier helps, I don't care, any barrier help you pull your shirt up, wear whatever, but the more layers, the better. So they did do this show on ABC, where they show different ways through a laser of how far a sneeze goes. And definitely the N 95 is the best and then followed that would be like a multi layer with some sort of filter in the middle or some sort of quilt. So that's awesome. So let's get back to the frontline workers really quick. They still need those in 95 because if someone is shedding droplet nuclei in a room, the overall amount of virions goes way up and the longer that healthcare worker is sitting in the room Have a statistically higher chance of becoming infected through these aerosolized or droplet nuclei. So that is, if you're an extreme environment where you're treating COVID people 12 hour shifts. Yes. But if you're going to the supermarket, it's so easy to block this Germany showed us.Yeah, without question. I mean, what you're talking about is I love the way you use the word extreme, because what we're talking about here is environmental air turnover time. If I'm, if I'm in an enclosed environment in a closed room with somebody else who is sick or infected, and they're sneezing. There's obviously a high concentration probably, of trends of virions, right? All in the air suspended, falling on objects, etc. It's kind of all around me. But if I'm in a grocery store, where doors are constantly opening up over and over again in a gigantic, you know, 30 foot ceiling, air turnover time is actually rather rapid everywhere that you stand, and there happens to be airflow or you're outside. So really open air space, not closed in environments, avoiding people who are sick. Having a barrier. All of these things play a role. It's it's really just physics. It's notIt's physics. This is not politics. This is not a constitutional or any of that. It's physics. The physics and ineffective process just makes sense to wear something around other people. Not only to protect others, but it's also to protect yourself. So I've heard from people, I've had several patients where I've talked to them, I'm just like, hey, out of curiosity, are your friends wearing masks they're like no. And the answer usually is because they've not been directly affected, which is something that we've heard and what what I think we're seeing is burnout of the information. And so what it's what's happening is intelligent. Fact somebody that you know, then it becomes important again What I'm saying is, it's not a big deal wear something cover up anything, and you can make a difference. So this is this isn't I don't really understand how it's become. Well, I think nothing of putting on my seatbelt now. And at one point that was a huge political and constitutional thing. Do you wear a seatbelt? Absolutely, definitely do because if I were to be in an accident, I want to survive it. I've got a family that I still want to see. I mean, I I assume if you don't want to or if you're okay with being mamed then don't that don't buckle up. But that's not where I'm at. I like buckling up.Yeah. And so it's it's just it's just that I don't know. I really, I hate seeing other countries do so well and controlling it and I hate being in this position right now where we're we can't go to weddings because we're being exposed where my hospitals 99 percent full. Houston looks like most of the ICU beds are filling up scary just because it hasn't happened to you or a friend doesn't mean that it's not actively going on. So I don't know just physics don't make it about you know, let's get some assets just physics. You just real quick I know we don't want to keep the show going going too long specifically on this but what are your thoughts on on people who probably more or less just don't want to wear a mask but they they've heard other rhetoric I guess you could say over I have asthma or I have some type of breathing condition and I probably can't, can't stand wearing a mask just for me personally, we you and I have several colleagues and co workers that have asthma. And just like us they wear a mask all of the time when at work and have for years long before Coronavirus or COVID issues whatsoever. So I don't know, I hear the excuses. And it's unfortunate because I feel like that it's that's it's it's a it's a pathway that's not really genuine. And it drives more angst than it does solutions.You know, I don't know if I totally agree with you, because I think if somebody has that feeling that is genuine to them. And I think if they educate, then they can do this, then they might be able to tolerate the mask a little bit better. So if somebody were to have, let's say, I'm going to go through different scenarios. I have, I have claustrophobia. And I didn't, I didn't say claustrophobia. I was just talking asthma. Yeah, I'm just I'm just thinking of arguments by having a background as to why and the protectiveness and the fact droplet versus droplet nuclei and an understanding that educating yourself to understand I'm going to put this on, I'm not very comfortable. You and I have to wear N 95s at work and we both frickin hate them. They hurt.They give you a bloody nose. I mean, they do lots of really cool stuff.All kinds of stuff. So I'm just thinking of I'm just trying to think of different things. So somebody may be claustrophobic somebody may be I'm trying to think of anything physical, the asthmatic, the the person, just something away from the political stance, because I don't think that I think anybody that's doing this from a political perspective, or a constitutional perspective probably has some cognitive dissonance. And I don't really want to address that what I want to address is the person that has, let's just address the asthmatic person, so the asthmatic person is already at risk that if they get exposed, then they have a higher likelihood of having a bad outcome. Right. If you have asthma and you're listening to this, what I suggest is you continue to pursue the type, any barrier, any barrier that you can tolerate, just find some sort of barrier. It doesn't have to be the thing. That face shield where face shield that helps a ton. That stops those droplets realize that those droplets are coming out. We should I mean, I'm, I'm a I'm a very salivary person. Can't even imagine what's on this microphone right now. So I, you know, I mean I'm animated when I talk and stuff and I know that I'm probably causing lots of saliva and things to come out a face shield. That's a great example just a simple face shield, if you're asthmatic. Do me a favor and just wear a face shield, because that's not for, yes, you're helping other people. But that's also for you. Because if you were to get it, then you have a higher likelihood of having a bad outcome. The claustrophobic person should probably do well with the face shield as well. And I don't know I'm.I guess I guess my point was there, there are alternatives versus trying to find a subversive way to get around what some are seeing as a rule rather than a measure of public safety and really for your own safety, if you're already subjected to respiratory issues similar to asthma or even asthma, then you're right. You're actually already at higher risk if anyone should be taking some cautionary measures it's you and let's let's talk about ways that that if a mask is going to work for you, that's fine then then 20 feet is something that you may want to examine and a face shield or some kind of alternative. But the takeaway is, just because you have a reason where there may not be a suitable fit for a mask does not eliminate the need that you need to watch out for your own health.Just want to reiterate, we had one study from China that just got published last week showing that close contacts have a very high likelihood of if you're talking to somebody, we have a study from Germany, which shows that the effective decrease in viral transmission countrywide. It absolutely was completely proven. And now we're looking at the physics of this. It just makes sense. So just look at the science. Look at the physics of it. I don't want your big ass droplet landing in my upper airway.That's right. Well, you know what else, we have something special and an email will go out. We've got a patient. And I should have brought the mask and we will show them next time, but we have a patient who actually showed up and made masks for you and I so for Miss Unger, we will. We'll add a little place where if you would like a designer mask, she'll make you one that'll look cool. Gave you a Texas Tech mask and I got myself a Nebraska Cornhuskers mask.Definitely and they're really really cool and might I add far more comfortable than the ones that we get when we're working at the endo centers. So But anyhow, yeah, so there's there's all kinds of alternatives, I guess is is the takeaway and we'll definitely share that with everyone so that they can get outfitted if they'd like.Yeah. And so if you're listening to this, you know, we try and make a little bit of science fun we try and talk about some different things go to KBMDhealth.com, we've got some downloadable we've got a great downloadable ebook because I personally believe that you need a healthy endocannabinoid system to have a healthy immune system you need a healthy gut to have a healthy immune system all the above we're offering you know these free downloads so just go and take a look at it to try and augment your life.Yeah, so as we as we put together all these podcasts Ken is exactly right. Be sure and send people to gutcheckproject.com or to KBMDhealth.com it's technically right now go to the same spot anyhow to our homepage, but start showing people that they can begin to build their knowledge base. So many of you who write to us every single week, we certainly appreciate it. And that's really why we're producing this particular one. both in person and online. We've been asked, okay, y'all are in healthcare is a mask really going to help? And that's exactly why Dr. Brown put together the research, etc. on why we're talking to everyone today specifically about this, because it's a burning question, as cases kind of took a dip and are hitting back up, we got tons of email questions, phone calls, like I said, in person, is this really something that I need to be doing? So we want to build upon that go ahead.Yeah, I just gonna say I think if you get one thing out of this podcast out of today's episode, the one thing that I really learned, if you ever want to own a $40,000 Rolex shop at Target not at Neiman Marcus if you don't know what I'm talking about just look at the news.And major apologies to all of our Karen fans out there. For Sir, we know that you all did not pick for that name to be the brunt of bad behavior in public. But unfortunately, that's just the way it's going at the moment.Alright, so I convinced myself that I will always have some sort of barrier on when I'm in public.Oh without question. Without question. I hope you feel the same way. And I it just makes sense. If somebody says, Why are you wearing a mask? I'm gonna be like, Oh, it's all about droplets. It's all about virions. It's all about the distance that I can hit you with my droplet and so on and so on. It just there's science makes sense physics. Definitely science. Definitely. Well, what an awesome episode and keep the emails coming. We as we as we keep trying to shape up the the next the next topic. A lot of this stuff is driven by we've got an influx of questions just like we did over the last two weeks, let's hear from you. This is what we're here for. So thanks to all of you who wrote in and wanted to hear a little bit more about masks and none of the thing we got to controversial, but at the same time maybe for some, it's it's a, it's not exactly what they thought that we would say, but that's okay. Because it's not like we we contrived the message. This is what the data says.Yeah, and I'm not gonna raise a big ruckus if I go to Costco or something and somebody isn't wearing a mask rather than be six feet away. I'm gonna mean 19 feet away.That's exactly right. that'll probably do it then for installment number eight, of the COVID files for gut check project. Thanks for bringing all the info. That was awesome.All right, Eric. Thank you so much. And as always, you didn't even have to read the articles. You knew the answers before I even started so strong work. I don't know if that's an as always, but yeah, we'll see.Everyone, everyone like liking share, please. We're really trying to get some of these messages out there. If you have any questions, please send it to us. We will try and contact if we don't know it. If we can't find the literature on it, we will at least find an expert on it. And like, share, subscribe, whatever it is all the other things people do, go to our website, download that ebook, because it is very informative. So.Stay safe everyone. See y'all next time.

Rebrotes, PCRs de aeropuerto y reencuentros

Qarentena

Play Episode Listen Later Jun 27, 2020 104:30

Episodio del podcast semanal de SH+Media. El podcast para los que nos quedábamos en casa. Una serie limitada para pasar juntos la pandemia. … Continue readingRebrotes, PCRs de aeropuerto y reencuentros

aeropuerto reencuentros pcrs sh media

COVID-19 Files: Ep. 5.5

Gut Check Project

Play Episode Listen Later May 15, 2020 34:46

What's up everyone? Here we are, again, we're on episode 5.5, I had to bring back my favorite second favorite co host, Dr. Akerman, because what we're going to talk about today is really interesting. It's the thing that everybody has been discussing in the news. It's how do we test people? Everyone needs to be tested. And then people go, Oh, well, there's these bad tests out there. Oh, with a sensitivity specificity. Nobody's explaining any of it. So as it turns out, Dr. Akerman is really smart at this stuff. And we've been working with a company because we want to introduce rapid testing here in North Texas. And Dr. Akerman has actually helped this company a ton in the type of tests that they're doing, how to explain it. And we're talking sensitivity, specificity, negative predictive value, positive predictive value stuff that I struggle with a ton, well as it turns out, the other guy on the side of the screen here is super smart at it. So Dr. Akerman, can you comment on that real quick?Yeah. First of all, Make sure you don't burn any bridges with your first favorite co hosts.Yeah, right.And, and you're right. I mean, we've pretty much turn on the TV go on the internet, and we're talking about, you know, testing, what kind of testing, is it available, how much do we need? And then you kind of hear from the other side that there may be tons of tests, but too many, and they're not as good. And, you know, you sort of take that all at face value. But what does that mean that the test is no good, what makes it a good or a bad test? And I think that's where, you know, maybe we can do a better job of explaining it to people. And you're right, it's it's super confusing. So...We did Episode 4.5, where we talked about different the mcas and the antibody testing and things. So we kind of hinted at it. But now we're getting to this point where we're saying, Yeah, but what does all that mean? Nobody's talking about it. You You and I got in a discussion John Oliver. You watched a show on that. Yeah. So you know, I don't want to sort of rehash I don't think we're going to do it justice. John Oliver with his extensive medical degree, did an excellent job last week explaining some of the differences between the tests and some of the pitfalls. But I think where we can add a little value to the discussion is to discuss why. Why is it that the test you might go get at your local, you know, minuteclinic, or doctor's office or anything, why that might not offer you the value that you're really looking for.Yeah, and we can we talked before about the pros and cons of that. We don't know that. But what we're going to talk about today is why that's why getting a test may mean something different if you're in New York or if you're in Plano, Texas,right? And you want to know the characteristics of the test the characteristics of the disease process, where you are, and what you're trying to get out of the test. And that will determine whether or not it number one makes sense for you to get tested, and how you can get a better result.Yeah, so we've been seeing that the FDA is saying that you have to apply for this and then you have to achieve a certain. Let's start with the basics, a certain sensitivity and specificity, sensitivity, my friend.So actually, what I want to do is I'm gonna I'm gonna share my screen with a couple slides here. And, you know, I want to I want to go over some important definitions. There's tons of stuff and you don't need a degree in statistics to figure this out. But it can be confusing. So I think if we sort of write it down, and might it might hit home a little bit better. SoI'm still impressed that you actually left New York I really because you seem like somebody who would be teaching at NYU or Mount Sinai or something like that. So, thank you for joining our group.I wanted to have more time for podcasts.There we go.So a couple six definitions that I want to I want to go over here. And the first you alluded to sensitivity and specificity. The best way I would explain sensitivity is what percentage of patients that actually have the disease will test positive. Right? So the true positives coming out of the, of the test. And the specificity is the opposite. It's the percentage of the patients that don't have the disease and will test negative. So the patients who appropriately test negative for this disease process. Those are intrinsic qualities of the test itself. So you can apply the specificity and the sensitivity to any different population because the test characteristics don't change. What does change and this is the difference is the positive and the negative predictive values. So the positive predictive value, are the percentage of those positive tests that are accurately positive, and the negative predictive value is the percentage of negative tests that are accurately negative to say it another way, when I get a test, if it tells me I'm positive, what are the chances that it's right? That's what I really care about. I want to know If I think I have strep, and I go get a strep test, and it's positive, should I be taking antibiotics? And will I get better? That's what we're really asking. And it is different than the sensitivity and specificity, which I will clarify in a second. The other two really important definitions are the incidence of disease and the prevalence of the disease because these are two different things. The easiest way to differentiate is the incidence are the proportion of people who actively currently have the disease. The prevalence is how many people were affected, not necessarily currently infected. So when you talk about it in terms of the test that we're talking about the PCR test looking for active viral replication, that's looking at the incidence of disease, who's got it now. But the antibody testing, looks at who's got it or who had it. And that's more a test for the prevalence of the disease.Well explained. Okay, yeah.All right. So the classic way we look at this is using this, it's called a two by two table or a two by two plot. And you basically up on the, in the in the top bar here, that's the disease or the process that you're looking at whether you have positive or negatives. And then along the margin here, you're talking about the test characteristics, a positive or a negative test. So when you want to calculate the sensitivity, you're looking at this row right here. So the people who have true positives over the total number of positives, so 80, excuse me, if you've got 100% of people ten, let's say people who have a positive test and only eight of them actually have the disease. That means eight out of ten or 80% sensitivity for that test. When you look on the, the the right column here, that's where you're gonna figure out your specificity. That's your negative side. It's the total number of true negatives, people who actually don't have the disease and tested negative over all the negative tests that's going to tell you your specificity.So I remember...Sorry?Go ahead. No, I was just gonna dumb it down to a level that this...I just remember that when I had somebody explained it to me that think of sensitivity and the specificity. If you were to look at these graphs, think of it like a car alarm, that if you make everything so sensitive, so that you could catch the person trying to steal your car. That means that a horn or a loud noise will set it off. If you make it super specific, that it only means that one method of a car being stolen. And so you have this issue of you have this trade off where you have the you want a car alarm that's super sensitive and will catch everything but you're going to get false positives all the time or do you want a specific test that only catches but every once in a while, they're gonna be able to steal your car a different way.Right. And the ideal test is going to be high at both. It's gonna be really great at ruling people in and great at ruling people out. And the question that often comes up is how do you know the sensitivity and specificity? And the answer is you have to validate every study against the gold standard test ones where you know the numbers and see how it performs. The positive and negative predictive values are different. That's looking across the rows. So if you have the percentage of positive tests accurately positive, now you're looking at of all the tests you did and all the positives you got, how many were right, how many actually are getting positive for a person who has a disease as opposed to missing it, right. So to say it a different way, the percentage of positive tests that are accurately positive, because it's how many people in there have it and showed it versus how many have it and you missed them. The negative predictive value is the bottom row, kind of similar, how many of the people who the tests that are negative, actually are negative, and you've missed and got these false positive results and people who actually don't have the disease. That's so fascinating, because once you got me thinking about this, and I've learned this for every board exam, and then I've kind of forgotten it, and then I have not applied it. And then I started thinking about this, you got me thinking, we need to be using this type of logic in the area they're at with the incidence prevalence. It's got me kind of rethinking how to look at this whole thing.Yeah, and it doesn't this is not something that's unique to COVID testing. This is true of every single test that we do. If you get flu swab if you get a strep test, a culture, everything...Oh a UA for a UTI, I mean you name it, we're you're gonna use this on every single test. as clinicians we tend to move away from this a little bit because well, we're just treating symptoms and we're kind of moving on but this is such an it's such a fun exercise and if you're...if anybody's listening to this, and they've got a child, niece, nephew, friend, anybody who's in med school, this is a great way to learn it. This is not how they teach you in med school, they teach it way harder. That's why it never sinks in.Yeah, well, I've had time to think about it and marinate for a bit. So I just want to finish this without leaving too many slides here. But what I want to do is I want to show now how the disease prevalence how much disease there is in the population that you're testing will affect the positive and negative predictive values. Okay. So to say it a different way, the more prevalent your disease is, the more chance there is of having a true positive, and therefore your positive predictive value will go up. Whereas when you have a lower incidence of disease, it's more likely that the random person you test is negative, so that's going to favor having a better negative predictive value. Okay. So as I said in the beginning sensitivity and specificity, that doesn't change that's inherent to the test. So if I tell you that there's a 10% incidence of disease, and an 80% sensitivity of the test that we're applying, eight people will test positive who have the disease, two who have the disease will be missed and test negative. For the specificity I'm using in this test, an arbitrary value of 94% I'm just telling you that that's the parameter of this test. 90 people because it's a 10% incidence disease 90% don't have it. So 85 will test negative based on a 94% specificity. And five will test positive, even though they don't have it, they're false positives. So looking across here, eight out of 13 people will test positive and have the disease that's a positive predictive value is 62%. That means if you go today, and you go get tested, and it's positive, almost a flip of a coin, if that test is accurate for you, whereas it does a great job of telling you you don't have it if it's negative, so you can feel a lot more confident in that negative study than you can in the positives. When you flip this around, and you increase the disease incidence, and instead you got 20% of people now, the sensitivity and specificity didn't change, you're using the same exact test. So I know that the sensitivity and specificity are 80 and 94 doesn't make a difference.Just to clarify. So to get the sensitivity and specificity it's usually Done where they have the known disease negative known disease positive, they go to a clinical lab and they run it. And then they can show, okay, because that's what's going on right now. Right, they compare it to a gold standard. And that's one of the issues here. We don't have gold standards, but we've got good ideas. And we know that people who are positive with the PCR testing, that's the time to check people because that becomes our gold standard. And those have a very, very high sensitivity and specificity. The assays that we've been using for PCRs, have sensitivity and specificity of 98 and 99%.Of the test, but then we can talk about technique, which is a whole different thing.Which changes, and can lower your sensitivity...part of the problem. So here in this in this example, we're gonna say that 20% of the people that you're testing have the disease process. So now, up here 20% 20 people out of 100 habit 80 don't so now 80% of them 2016 20% is for on the flip side here 75 test negative don't have it five do. So now when you calculate the positive predictive value, because more people around you have it, there's more of a chance a positive will be right. 16 out of 21 increases your positive predictive value to 76%. But the flip side to that, since more people have the disease, there's a slightly lower chance that a negative will catch you appropriately. So now 75 out of 79 give you a negative predictive value of 95%. So to summarize that one more time: the higher the prevalence of the disease, the higher the positive predictive value, the better a positive test indicates true disease. In a lower incidence population, there's less disease there. The test is much better at giving you a true negative result and ruling the test the ruling the disease out for you.Got it. Hope that makes sense. I mean, I think that...Let's, let's play around with a little bit I went ahead and pulled up an Excel spreadsheet. And if you'll let me share real quick I'll do the same thing. Let's play with this. Let's say that there's 100,000 person population. And we can change these parameters. Let's say that it's infected by SARS CoV. There's 2000 not infective. So the prevalence we are now in where are we...Plano? What do you think? What do you think our prevalence will end up being?So tough to say but there's actually data in Dallas, and our prevalence is somewhere between 11 and a half and 12%?Oh, really? Yeah, that is way higher than when I was thinking. It's published data by the Dallas department of health.Okay, so who let's say that there's a 1% prevalence, then what that means is just like you were explaining, if we have a sensitivity of 98%, and a specificity of 99,So a very ideal test.It is the ideal test. And so if you have this, the positive predictive value is literally a flip of a coin. That is, with the best test you can have. That is fascinating with what you just showed. And then of course, the negative predictive value, just like you explained is 100%. So let's say and you're part of the solution, because as we talked about last time, and as we've been working with these companies, we want to be part of the solution. We want to be able to do rapid point of care, IgG IgM tests, and we want to get that data and we want to show it but let's say that here in the state of Texas we are at 12%. That positive predictive value goes to 93% So the more that we know about how many people are infected, the more that we can help these companies with their testing, and the more that we can say things. So I want you to explain this. You have a patient that says, Dr. Akerman, I watched your podcast. And let's assume that we're going to split the difference or whatever, somewhere around 5%. So I got a positive test. What would you tell your coworker, patient friend that did this looking at that?So which tests are we talking about?Oh, we're talking about, I thought I had COVID, two months ago, and I tested IgG positive.Right. So if you've got an antibody test, that's positive, assuming all these characteristics, I'd say there is a very good likelihood you in fact had the disease but if you tested negative, I will tell you almost certainly you haven't had it or been exposed.So let's get back to those tests there. I'll stop my share. The value of doing antibody tests. Everybody on the news is talking, we need to get tested, we need to get tested. nobody's talking what type of tests, the FDA tries to say, sensitivity specificity, you just showed very clearly that it really depends on where you're getting it done. So we'll be able to gather some of this data. And as we start doing this, what are you going to tell your patients that do test positive as we're gathering the data? So that's, that's an ideal. We can play with the numbers. We don't know what the numbers are yet in each segment. So what would you say to that just so that everybody is very clear about what an antibody test is.So right now, the only thing that we can tell you if you're If you have antibodies is whether or not you've been exposed. The assumption is that there's immunity because that's how immunity works for all kinds of viruses. But the The X Factor here, is that what that means for each virus is different. How much do you need for immunity? How long does that immunity last? Can you lose that? Will it wane over time? And these are all the questions that we can't yet answer. So if you're going to get tested, it doesn't help you so much at the moment, because we don't know what it means for immunity, but it helps the population because it helps us better define how prevalent the disease is and that starts helping us then figure out well, when are we going to get closer to herd immunity because we know a certain a certain amount of the population needs to have been exposed. Right?Can you just define herd immunity really quick because that gets thrown around a whole lot by the media. But the reality is herd immunity is a very definitive or it's not a definitive thing. It's a theoretical thing. But...Right, so if you have the disease, and you're walking around, and all these other people around you that you could potentially, infect, that's not going to be great, right? And that's kind of what happened in the beginning, right? People were walking around, they didn't know that they were infected themselves, and therefore able to infect other people. But if enough people walking around you are for lack of a better term at the moment immune so they can't get infected, then the fact that you have the infection isn't as big a deal. And that's what herd immunity is that if enough people around you are immune, your ability to affect the population as a whole goes down. And that's the idea behind immunity and vaccination to create this herd immunity.Yeah, think of it like you're at a bowling alley, there's 12 lanes, 12 people the lane one person has the virus, they give it to lane two, lane two gives it to lane three, lane three gives it to somebody who has been vaccinated. It stops. Lanes 4, 5, 6, 7, 8, 9, 10, 11, 12 do not get this. So that's that's what the herd immunity is. I don't know what the it's based on R0 number, the number of exposed, I think I read someplace, it's if we can get 70% of the US either vaccinated or infected. It basically is wipes out this disease.I'll admit I've heard the same number but I don't know. I don't know the data behind it. But I have seen that quoted.Now you got me questioning data all the time. Now, you know, I'm looking at it's oh my gosh, I'm getting I actually I'm gonna take a break Eric and I worked with Eric today and I was like, dude, can we do a non COVID podcast? Can we do I don't really care what we talked about. Eric brought up, Mike Tyson looks like he's training again. And at 53 he looks like he could just wreck shop. So I'm like, let's talk boxing or something, anything but COVID right now, because the data is just bruhhh, all these non peer reviewed articles that then get chewed up and shredded by statisticians and other doctors. It's, it's hard. It's really hardIt is and it's confusing. And, you know, I think when it comes to all this COVID testing, you know, some of the things you got to remember, as a patient or someone who's looking to get tested, there's tons of tests available now, tons, and all of them have different sensitivities and specificities and because of that, their ability to tell you whether you do or don't have the disease or in the antibody testing, whether they whether you have or haven't been exposed. are gonna vary, right? And many of those tests were recalled already by the FDA and the FDA is starting to crack down on it because they, they sort of opened the gates a little too wide. And because we don't know yet the incidence and prevalence of the disease, it makes it a little more challenging to calculate those positive and negative predictive values. And we know that geography plays a role in this because the incidence changes, right? While it definitely is higher in Dallas than we initially thought, we haven't thankfully gotten anywhere near what the incidence is in New York where in some areas it's gotten over 20%. So the same test might might tell you different things depending on whether you did it in Dallas or whether you did it did it in New York.And you know, you said it best right there that if we do this when we get our tests in because you're an integral part of this, and you're gonna, you're gonna help us try and figure this out tests that we're looking at, will upload to the CDC to help them have real time history. We're gonna have a snapshot of our area, it would be so cool to we're all in this together kind of attitude. Well, let's bring the data in together. I did have a very interesting discussion which you and I have talked about with the manager at our surgery center today, Chris, and he was like, but what do you do if you start testing employees does do you have to shut up? I mean, then all of a sudden get into these ethical, theoretical, where do we go blah blah blah, like you just just go down rabbit holes. All I know is we got to start getting some data and we can start doing it between you and I we can get our patients involved we can get people coming in if you want to get a finger prick and find out if your IgG positive. I know I will feel more comfortable going to the hospital I know I'll feel more comfortable hugging my wife. If we're both IgG positive whether I'm wrong we're just going to learn over time but there's no way to test it.Right and and some of this, you know, information that we're going to gather now, you know, will be available later that we can look back at and reanalyze. So we've got a, we've got to build that data set. And that's kind of the pitch that I would make to our patients and the community at large. You know, if someone says to me right now, should I get tested for antibodies? You know, is there value to it? I would say there is you just have to understand what that value is. And right now, there's a little bit less of a value personally, although there's definitely some, like you just said, but there's a big community impact that we can we can have. Okay, so you always end up with some great little nugget. Say that one more time right now.So, as it stands right now, you'll have some information for yourself. I can't tell you if you're immune. We can tell you if you've been exposed, which is on the mind of many people. I had that illness two months ago, they tested me for flu, it was negative. But now that I know that I know more about COVID why couldn't I have had COVID at that time? This can answer that question. But it can't tell me if I'm immune. But on a population level, it can start telling us what that prevalence of disease is, it then can feed back and make our tests better. Because now we know what the prevalence is. It has ripple effects,This is usually the stuff that's discussed in an academic institution behind ivory tower. Now we're just like, we're all in it people let's all do this. That's, that's what's cool.Yeah, and, you know, two months from now, three months from now, whatever it is, when we find out what immunity means, and what what thresholds we need for immunity, we might be able to look back at this now and say, Well, we've got all these patients that are already tested, and this is the threshold in this test. Maybe these patients are immune and now we can go back and tell them that, you know, sort of remains to be seen, but I would say that there's value in antibody testing, you just have to understand what that value is and I would also suggest that and we've discussed this as part of the parameter that we're going to employ. If a patient has a positive test, you know, partially because we don't know yet how strong that positive predictive value is, and also because IgG starts during the illness, so we don't know if you're a had a disease person or have a disease person, we're going to get, we're going to have all those people get follow up testing immediately for PCR, because if your PCR test is positive, you're actually in the disease starting to get over it. And you're going to you're going to self quarantine, and we're going to let you know and you're not going to expose anyone. And now you're going to know that you had it. And that's going to help you later on, not just now.Yeah, yeah, I know that if I when these tests come in, and I and I get tested, and I'm IgM for instance, calling up the wife and kids and I'm saying see in about three weeks go get a hotel room. Not even coming not even coming home. So...And, you know, I'll go one step ahead of you there and sort of shift gears just a little bit on my soapbox. But, you know, we had discussed a couple recent articles, you know, offline here, one of them being that article in Spain that tested all the health healthcare workers and one of the hospitals where they had really strict PPE. And they found an incidence of the disease that was almost identical to the general incidence they have in population. And it's interesting, because we both we both came to the same conclusion, as did your favorite co host, that it wasn't that the incidence was lower. It was that PPE works. And you know, you can have your own opinions. And I'm not saying there's right or wrong about the economy and all these other things that are going on. But there are ways to meld both of those ideas together. And as we start getting out of our homes and reopening the economy, and we're more available and we have more face time with people, we shouldn't lose sight of that. And these principles that that are working to decrease transmission should still be employed.Yeah, a recent study came out where it looked at ER physicians in Utah and very similar, like the incidence was much lower than you would think. What we're doing works the hand washing the masks everything. So yeah, well, that's awesome. Well, I tell you what, this is a tough topic that nobody's talking about. I appreciate you taking the time to do the PowerPoint. You've got it sorted out in your brain to help thicker brains like me get it kind of figured out. Because when we started realizing that, yes, when I talk to my patients, this is the incident. Six months from now we can say, oh, look, as it turns out, Plano's at 15% or North Texas or whatever, we can say with a certain certainty, this is what it is then. So thanks for helping the companies that we're working with. Thanks for taking the time to do this. And yeah, this is an ever evolving thing. And I think that we're in it, we're part of it, and the beautiful people behind you, and you're seeing there, this is why we're doing a lot of this stuff. SoYeah, I agree. And I would encourage anyone watching these videos, to, to ask us questions. You know, we were, we're guessing based on what we're hearing and what we're seeing what it is, that's confusing, and we can help explain and, you know, disseminate the information there. But if there's specific questions, let us know. That's what we're here for.Absolutely. And as always, please like and share, go to Dr. Akerman's website, go to my website. We got our sponsor Atrantil. We know that a healthy gut leads to a healthy immune system so everyone stay safe. Dr. Akerman once again, thank you for a fantastic point five episode.Thank you.

COVID-19 Files: Ep. 4.5

Gut Check Project

Play Episode Listen Later Apr 17, 2020 64:57

Hey, what's up everybody? Here we are on our COVID files 4.5. That means a point five we have our recurring super smart guests, my friend and colleague, Dr. Stuart Ackerman. Dr. Ackerman, would you please introduce yourself?Sure, Ken. Thanks for having me again. It's my name's Stuart Ackerman. I'm a gastroenterologist with digestive health associates of Texas. And we're glad that I'm here again to discuss more COVID type stuff.So on Dr. Ackerman and I did a COVID 3.5 Episode three and a half episode where we looked into the role of COVID in the digestive tract. Today, we're going to look at some journals and discuss the role of COVID-19 testing specifically the role of antibodies, and you're going to be hearing a lot about this. And so a lot of the shows that we're doing, we're a little ahead of the media. So that's what I'm really happy about is that every time we do a show, and then later the media kind of catches up, so. The one thing I do want to address and if you're watching this on YouTube, Dr. Ackerman, you've changed your look a little bit. I mean, you had this very beautiful luscious beard, you know Wolverine like and it's a little different is that because you're getting all the notoriety from the show or what's going on?Yeah, some sacrifices have to be made. So, as part of my practice, you know, although there's some restrictions because of COVID on doing procedures and seeing patients in person, I still I still have a significant number of emergency and urgent procedures that needs to be done and part of the protocol as recommended by all of our societies is that you've got to wear PPE these protective equipment and some of that is an N95 mask and an N95 mask when it goes over your your mouth and your nose, it doesn't fit to securely if you've got luscious locks like I did. So sacrifices needed to be made.So Dr. Ackerman did this really cool video where he's basically explained the whole process of this, and how certain sacrifices have to be made. So I suggest everybody go to his website. What is your website?It's www.stuartakermanmd.com Stuart Akerman dot comYou posted the video on your website, I hope.Yeah, it's posted on my blog on the website.That's awesome. I love the video. It's so cool. All right. So when you and I were discussing about doing this, and what I like is that you and I talk all the time. And we discuss journals and we do stuff and we kind of debate a little bit and we poke each other and you were you were discussing that, you know, hey, we should do a show on this. Do you want to do like a point counterpoint kind of thing where we should debate and I laughed because I immediately thought of airplane the movie from 1980 you're way too young for this but the airplane.I've done I've googled it.They were doing point CounterPoint. And you know, the whole point of the show is to be so obscenely on either end where the one guy so, a CRNA Jack Kerry that I'm not sure if you know him. Have you met jack? So jack would always laugh, he would use that quote whenever something would happen in the in our endoscopy center. If maybe the scopes weren't ready or a patient showed up late or something got off track, he would always say the same thing which I started thinking about about this. In the point counterpoint in airplane, the CounterPoint guy was like, they bought the ticket, they knew what they were getting into, I say, let him crash. This is not going to be quite like that. Because I think you and I will end up in the same spot ultimately when we're discussing this. So that's kind of where I thought where you and I were hoping to have a kind of a point CounterPoint. But I think we're gonna end up in the same spot. You kind of agree?Yeah, I agree. I think that it's, it's good to sort of flush out both sides of the argument so that you're more well rounded in your discussion. And I think that's kind of how we approach it, you know, that, we're we're looking at the same data. We're drawing our own conclusions, and sort of coming out on both sides of the argument. I think that's, that's good for any kind of evidence based discussion.Totally. And what we're going to talk about today is something that is super important, because it is how do we get the economy back on track? How do we use testing to do it? And we're going to take a look at the evidence based approach to this. And in fact, this is coming so fast that this morning I woke up, and I saw a couple different articles that that came out this morning. One of them was an article on a homeless shelter in Boston. And what they decided to do is do PCR testing on everyone in the homeless shelter, and what they found was that 36% of the people were positive at that moment, and we're gonna discuss what that moment means. So 33% were positive, but only 7.5% admitted to having a cough and only .7 even had a fever. The conclusion was in this article was holy cow, we need to do mass testing so that we can see who's really been infected. And then almost on cue, a New York Times article came out today, where it was a journalist that he opens with a with a classic Mark Moran. I'm a comedy fan Mark Moran line, where the the journalist says, "I know a guy. And because I know a guy and the connections I have, I was able to get my hands on a rapid antibody test. And I took the test, and I was negative. The problem is, I'm not sure it was a valid test." I'm like, this could not have been in a better time this guy did this. And that's what we're going to talk about today. You and I know guys.Yeah, we know people and this is the national and international discussion. Now if you've at all been watching the news, or reading papers or going on Reddit, you know that Italy, Spain, the United States to some degree, they're all discussing this idea of how do we figure out who has immunity? Is there a way for us to figure out who can safely come out of their homes, go back to work, and sort of jumpstart the economy again and jumpstart life? And it sounds dystopian. It sounds like it could be a great idea, it could be a terrible idea and anything in between. But what we don't have is we don't we don't necessarily know the details yet. And I think that's, that's what gets everyone confused, because there's no shortage of media outlets touting this as you know, the next great idea, but is it? I don't know. Well, we're gonna we're gonna get into that I there was an article written by I don't remember who wrote this, but it was just this just happened in the last couple days about ending the lockdown. And they interviewed a Harvard epidemiologist, and he said, well any of the lockdowns are going to be an effort with trial and error. There is no scientific evidence to this, he's like the best I can say this is we're all in a life raft. I'm not sure how we get to shore yet. What we're going to talk about is possibly how to get to shore. Because if you think about it, governments around the world, they need to triangulate the health of the people, the freedom of the population, and there's no scientific consensus. So what I wanted to do today with you, because you're a super smart guy, much smarter than me, let's kick some science. Let's go over some articles, and then play the pros and cons of each side of it. So I'll throw it back in your court. Where do you want to start with this?So I think, you know, we, we have a few articles that we definitely want to discuss as the basis for the arguments about immunity. I think before we jump into it, just to get a better sense for our viewers, we need to explain some of the terminology and the differences between the testing methods to understand what best to use to acutely diagnose someone with COVID-19 versus how do we tell that they're no longer infected, they're no longer sick and whether or not or at least to start that discussion of whether or not they have immunity.Absolutely. So let's start with what is the standard test being done when somebody shows up with a fever to an emergency room?So the standard testing when you're trying to figure out is this person currently infected and sick or...not sick, we know they're sick they're there is something called PCR testing. So in PCR testing, we actually will try to replicate the virus, right? The implication being that you gotta have virus in order to replicate it. So a negative test means there's nothing there to replicate. And therefore, you might have a fever, you might have some chills, you might have a cough, but you don't have COVID-19. On the flip side to that, if you start replicating virus, the virus has to be there. By definition, if a virus is there, you have viral infection. So PCR testing has been considered the gold standard for diagnosis of COVID-19 at this point.And let's talk about the what we did talk about on our last show the kind of pros and cons of that, because what we're learning. And what is fascinating is we're here today, what is the date? April, April 16, to April 16 2020. I mean, we may be eating crow tomorrow, because everybody, this is all changing. But what we're learning now is that a lot of people, I was listening, I don't remember who the virologist was, but he was describing the actual process. If you've had this swab done, it's not very comfortable, they get in there they try and get the cells that try and do this...it...there is some sampling error issues with this and possibly it's not in the back of the throat. We discussed how possibly could be in the stool. So there are some limitations to that particular PCR testing, and a lot of the studies we're going to refer to look at comparison to PCR.Correct. And so with this study is that in order to mitigate that risk for false negatives, they'll swab multiple areas and multiple sites to try to decrease that risk of missing a potentially positive person just because of sampling error.It's funny you say that because now after our last episode, and I'm pretty sure that they listened to our episode and this is why they did this because...I can only assume I can only assume that, that there's a Chinese doctor that saying that we should probably swab the anus and those that have recovered to determine if they have PCR positive. So before somebody is released from the hospital swab their anus,Yeah, right, I think fewer people are going to go to the hospital. We probably shouldn't publicize that.Um, you know, so the PCR testing now explain what the antibody testing is.So, when we talk about antibody response, and you might have heard a lot about this, you know, the buzz words are IGM and IGG. These are the two immunoglobulins that we talked about with infection. And once you have an infection in order to mount a response, that's really what we're talking about. And IGM is the immunoglobulin that comes up first. That's kind of the, the acute fighter for you to try to get the infection under control. And then once you're sort of getting to a point where you're starting to go towards recovery, you start creating idg and idg are more like your your memory, right? That's what that's what reminds your body and how to fight something. So when we talk about vaccinations, where we're actually providing immunity to people, what we really are doing is either providing directly IGG or giving what's called a live attenuated virus a small kind of stunted virus so that your body will see it react and create its own IGG. If I have encapsulate this in one sentence so that you remember the difference between IGM and IGG? I would say that IGM is what wins the battle for you. But IGG is what wins the war.I love that. I've never heard it. Did you...did you just, I mean, Is this yours?Yeah, that's a shower thought.I love that. You're exactly right. So, a lot of people if you've ever been checked for epstein barr virus, which is a very common thing. epstein barr virus will usually have an IGM and an IGG and people will realize that most of us are IGG positive, we've been exposed, which means you saw the virus and you carry these antibodies throughout your life. That is a I love the battle war thing that is awesome.I just think it's an easy way to remember it. And you know, similarly, you know, if you go to have a new patient visit at a primary care doctor and they say to you, well, have you been vaccinated for hep B? Have you been vaccinated for varicella, which is chickenpox. You're like, I don't know, I don't have that little card from when I was five years old. They're going to run some blood tests. And those blood tests are just checking for the varicella IGG and that and certain Hepatitis B IGG is because if you've got them, you're you're good. And if you don't you need either vaccination or boosters, right, because sometimes you might be immune, but that immunity can wane.We're seeing that with varicella. So we're seeing people actually, co host Eric Rieger developed shingles. Oh, wow. And it happens. It's happening to a lot of 40 year olds, a reoccurrence of varicalla, it's happening and so that we got into a long discussion about that when him and I were in Hawaii because he were in Hawaii, and he had a bad shingles outbreak which sort of limits going to the beach. Yeah.But it was all it was all kind of related to that. So yeah, that is a great explanation IGM wins the war. So basically, your your innate immunity The virus comes in your body reacts to it cytokines, they send white blood cells, they kill whatever, hopefully they kill whatever it is. And then they take it back to memory cells that say, look, next time this guy invades the house, make sure that we kill it before it causes any damage like it did this time. And that is initially they go, okay, we're going to send out some early troops, IGM, just in case it's out there, just look for this guy, they get a card, they have a picture, and they go out and then they mobilize the IGG which says you guys are our reserves that you will remember this picture, hopefully for the rest of your life. And if this invader comes back, you go out and handle it.Yeah. And you know, now that now that we understand that I think we can we can jump into some of these articles. And I think...yeah sorry.I was thinking...before we get into the deep aspects of these these other articles, I I was very impressed with when I threw out the Macaque study at you, and you're like, yeah, did you really read it? I'm like I read the abstract. This is a great example of what I did scientifically poorly, which was I read the abstract, and I've been quoting this article. And then you're like, yeah, read the whole article. So in the abstract, and not to sabotage where you were going, but I just want to do this that this is why we need to dive deep into the journals, because in the abstract, they described recently has been reported that discharged patients in China and elsewhere were testing positive after recovering. However, it remains unclear whether the convalescing patients have a risk of relapse or reinfection. So what they did is they gave COVID-19 to Macaque monkeys, they don't say how many they don't discuss anything. What they say is after the symptoms were alleviated, and the specific antibody tested positively, that positively the half of the infected monkeys were re-challenged half of the infected notably neither viral loads in nasal pharyngeal and anal swabs along timeline nor viral replication in all primary tissue at five days post infection was found in reexposed monkeys. And then you said to me yesterday, why don't you read the rest of the article?Right? Because if you I mean, we'll get into this in a little more detail in a couple minutes. But, you know, sort of a spoiler. This is the study. This is the study that's been quoted as the basis for immunity testing and talking about giving people immunity cards because it it's a it's a solid proof that immunity exists and you can't get reinfected. And if you read the abstract and you listen to all the pundits, you would think they they herded every monkey they had in China and created a cohort of thousands. In reality, when you read the study, they had four monkeys. They reinfected half.They reinfected two. So, not to say that the data is not valid, but you know, you have to have it with a grain of salt the size of the Rock of Gibraltar, you know? Yeah. So after I read it, I was like, oh, man, he wasn't kidding. And then they reinfected the two. And then they sacrificed them. And they call them adult Macaques. So then I went down a rabbit hole, typical Google rabbit hole. As it turns out, Macaques can live 20 to 30 years. The average age of these adults were three to five years. SoRight younger, you know, theoretically healthier,Theoretically healthier, much younger, preteens or teen style adults. And I get it that we don't want to sacrifice a whole bunch of macaque monkeys. I'd rather not sacrifice any animal or anything and have some sort of other way to test this. But this is just a great example of the media using this article me using the article and other you know, when Eric and I were talking on another episode I was bringing this up, I'm so thank you for pointing that out to me because that has to be you have to look at the articles and that's what we're going to do today is let's let's dive so I'm gonna throw it in you wherever you want to go with it, run with it, and I'll try and keep up.Alright, so before we hit that study, and we definitely want to talk about that because it's the it's the basis for the whole argument. There's there was a study or data set really published by the Chinese CDC, about the Wuhan experience, and I think it's good just to just to hear the numbers. So basically...Is it this one? Correct.Okay, great. Yeah. So this is the viewpoint characteristic of and important lessons from the Coronavirus 2019 outbreak in China is the title of the article.Yeah. and these and these numbers are current as of February which is at the end of the curve in Wuhan so they are completely valid numbers, you know, that they published. So they had 72,314 cases of COVID-19. And, you know, 62% of those were confirmed with some sort of testing. You know, a lot of those numbers came from people who just had the right clinical syndrome because, you know, much like us, they didn't have enough testing to go around, they weren't able to get all the testing at the same time. So, you know, some of those numbers are the people who were admitted and treated and may have been on ventilators but didn't have a confirmed diagnosis. But it seemed pretty likely that that that they were sick with COVID-19 and 3% of them were in advanced age of over 87. An 87%, though, fell into that 30 to 79 age range, with only 8% of the confirmed cases being younger than 30. So, you know most people fell into that fat part of the age distribution, with a very small percentage of them being on opposite ends of the young or old spectrum. Of the disease and this is where it gets really important. 81% of the cases were mild, right? So you might have had some sniffles, you might have not felt so great. But you didn't end up right, we get worried, right? We talk about ventilator shortages, we talk about, you know, overrunning the capacity of the hospitals. But the vast majority, four out of five, didn't really have much symptoms, if any. Severe cases-14% right, those are your hospitalized patients. And critical the ones that are new upper ventilators are 5%. So you know, if you break down the numbers, it's a very, it's not insignificant, but I think much like is the case in general we sensationalized the worst cases, and we got to be careful about falling into that trap.You know, just for that. I mean, right before we hopped on the call here, I had a friend call me because his father is very sick with COVID-19. So when we say that 80% of the people don't get sick If you're if you have a personal relationship, or it's you, that's 100% of the most important thing that's going on. And that's what's scary is the high infectivity rate of this. And in this in this article, the thing that stuck out to me was COVID-19 rapidly spread from a single city to the entire country in 30 days. And now we have a worldwide pandemic. So even though it's a small, the majority of people will have mild symptoms. But when you take into the account of the people that do get sick, that's how come we're taking it so seriously, but where you're going is how do we get that 80% back to work?Right. Right. And and also just having that knowledge that you know, we'd much prefer you don't get sick, but if you do, don't panic.Yeah. Yeah, everything is everything in the media right now is really bad. I've been talking to a lot of people. The New York Times article, the thing I didn't get into Was that the guy actually thought for sure he had COVID. Because a month before he had the classic symptoms, high fever, whole nine yards tested negative for the flu, and his antibody test was negative. So is it a valid test or not? And there's a lot of people that are like, you know what, I got sick in January, I got sick before we start talking about it here in the US. Has it been around? Has it been, basically, did it come to the US sooner? So who knows where this is all, we're all gonna sort this out.Right. And the case fatality rate in Wuhan was 2.3%. So 2.3% of the confirmed cases, you know, passed away, but 50% of those were critically ill patients. So it does sort of pass through that the sicker you are, the more serious it is.Yeah. And then that's coming out of China. And we have all this new data showing the people that do do worse, and we're starting to you know, partion everybody out. We know that the Italians have a much higher death rate. And then if you look at their demographic, they're older and all this other stuff. It's, we're learning. We're learning that in New Orleans here in the US, we're having a higher fatality rate higher, sicker rate, because of multiple different reasons. And you can start to predict where you're going to need more healthcare resources based on these based on these demographics,right. I mean, there were there were two specific issues that came up in New Orleans that may parallel the Italian subset in that it was a high density area with you know, Mardi Gras going on. And, you know, a lot of the case fatalities happened in a nursing home population, people had advanced disease living in close quarters, you know, so, this this may not be a new paradigm, it may actually be the same paradigm playing out in a specific way. Your audio is out. Sorry, what's your what's your take? What's your summary of this article then?So my summary of this article is that there's a really high number of people who got infected pretty quickly. This is a high infectivity virus. But of those, the vast majority of them did not get that sick, thankfully. But of the ones that did get sick, there are significant number who became critically ill and some who unfortunately even died. So it is serious. We do have to take it seriously and maintain social distancing and do all the things we can to flatten that curve. But if you do get sick, there there for most, you will you will see the other side okay.Yeah. So the other articles that you chose to talk about how does this play into this one?So the second article is answering the question of what is the true denominator? Right? How many people actually are infected, right? We're talking about these rates of infection. But the problem is in just about every spot in the world, we're choosing to because of limited resources, we're choosing to test people who are high risk- the patients who come in with significant symptoms, right? It's not just simply that you show up and say, hey, I've been coughing for a few days, I want to get checked for COVID. If you do that, you're gonna get turned around and told to go home and self quarantine, right? The ones who are sick, having trouble breathing, high fevers, those are the ones that are getting tested. So unfortunately, we're creating our own sample error. And this is this is playing out the world over so the natural follow up question is, what's the true denominator how many people actually are infected and they there's a study called the estimates of undetected rate among SARS CoV2 infected using testing data from Iceland. And they chose to look at Iceland in particular, because they have a sort of a dual phase program. They have the same exact setup as we all do, where they're testing nationally high risk individuals through their national university hospital system. But most of the population again, so they do throw in there, there still is a little bit of sampling bias, but most of the population is eligible for voluntary testing from a private company called deCODE genetics. So because they have a much larger sampling size, this became a good spot to try and figure out what that true denominator is. You know, like I said, there are some limitations because even though most people did fall into the ability to get or eligibility to get tested through this private company, they didn't get everybody. But they did get some nice demographic data. 44% of the people who went and got voluntarily tested had some mild sort of cold or flu symptoms. So these were not asymptomatic individuals by and far, many were, but not all. And based on their data, the results of both the national testing and the private testing 88.7 to 93.6% of infections are undetected infections. They're the ones that we don't know about.Say that one more time. Slowly.Yeah, so they created a range, they didn't have an exact number, but somewhere between 89 to 94% of all true infections. were being undetected to sort of flip that around the other way-we're only diagnosing about 6% of the true infections. So we're, we're leaving a lot on the table by design.Yeah. And so and I have to believe these guys. Now I know that your undergraduate degree was in economics, correct?Yeah, among others,Among others. Well, I got the biggest kick out of reading this article because looking at the math that they're doing, this is basically my insecurity nightmare. I'm like, I'm not walking around whenever I'm like really stressed, I don't have nightmares about being naked. I have nightmares about trying to take a calculus test or something. These stats are stunning. I mean, it almost looks like artwork, what they're doing, so I have to believe them that they're right. Because, it's pretty crazy.Yeah, it took me a little bit to read it and make sure that I understood what the numbers meant. And that and as we discussed it, the the first time around when we're talking about this article, I actually overstated what they were trying to say. Because I misunderstood some of the numbers. So after reading it two, three or four times, it made a little more sense to me. So...Well, I'm glad it made sense to you because it just I just looked at this and it just looks like I'm, I'm, I feel like I'm on goodwill hunting with that chalkboard and trying to solve the, whatever equation it is these things are they did a lot of math on this to extrapolate this to a nationwide thing, which means they had that they had the test. They showed how many people were being missed, and then they extrapolated it to their census.Right, and just to explain what I mean by numerator and denominator in this situation. So the numerator or the number above the line are the number of people who have COVID infection. The denominator is the population, right? So one point of bias in a study like this, that you have to understand whenever you're reading this, is you have volunteers by people who said I'm going to go get tested. You might have plenty of people who said, I'm fine. I'm not getting tested. I don't want to know.I'm not getting paid. So why should I drive over?Yeah, exactly. Maybe I'm gonna get exposed because I'm hanging out with all these people. So the true denominator, the population might be underrepresented. So even though we're saying that 6% of the people are the true and 94% are being undetected, might actually be a smaller number. But I think what you can take away from this is that we're only seeing the drop in the bucket. The question is, how much is that drop?So we have to figure out how much of the population has already been exposed. Because what it comes down to is what this study is telling us.Right.Yeah. So how do we get to the denominator here? What are some different ways to do it?So probably one way to do it, which hasn't been done yet, but is under discussion is random testing, right? Because if here you're saying the selection bias is in that only certain people are coming to you...well, maybe if you go to them, you'll be able to get a better sense of a smattering or a cross section of the population. And this has been one of the discussions now in the media, about in the United States, in particular about certain counties, getting access to testing, and setting up random testing protocols. And some of the discussion has been about mobile command centers, right, going out to people so that you decrease that selection bias.So if you're going to do something like that, it has to be a test that is easy has to be a test that is sensitive and more important to be...Gotta be cheap.Yeah.Gotta be cheap.It's gotta be cheap. You have to have a certain level of sensitivity and specificity. Can you explain to everybody what sensitivity and specificity is?Sure. So harking back to my medical school days, I remember this little, this little memory game that you play to try to remember the difference between sensitivity and specificity. And we call it spin and snout. So when you talk about sensitivity, sensitivity is the number or the percentage of ruling out the disease, whereas specificity is ruling in the disease right, so we want to talk about it. In other words, or another part of that is, if you have a positive test, do you actually have it? What are the chances that that that's a true positive, and you actually are infected? And on the flip side to that, if you have negative exam, how confident are you that you don't have it and we didn't miss the fact that you have it?Yeah. If you want an update on this, I went to Peter Attia MDs website and he does a whole thing on how to get people back up to speed with this epidemiology and in stats kind of terms, because it is confusing, but bottom line is, if you have a high sensitivity, high specificity, it's a good test.Right. Is what it comes down to.Yeah, any screening test you want to have, you want to know that it's picking up the right people and casting away the right people and not telling people incorrectly that they have something. And also not letting us lose the ones who truly have who we don't know.Yeah, so think about this: if we do a test, and it says that I am positive for the antibody, meaning that i have IGG, and it is a false positive, then I go around the world thinking I'm, I'm bulletproof, and I could be infecting people. And then I put myself at risk. If we take a test, and it is a false negative, then we're putting people in saying you don't have this yet, go back in your home, keep quarantine, you can't go back to work and all this other stuff. And that's kind of what we're going to get into right now.Right. The risk of it is it's the antithesis of social distancing.Yeah, yeah. So you pulled up another article, or this is the diagnostic value and dynamic variants of serum antibody, Coronavirus disease. What was your take on this article?So it's an interesting article for sure, but I would caution that when you read it, kind of similar to the monkey article, which we'll discuss next, the numbers are small. And you always have to be careful whenever you're trying to interpret data in a small data set, because the smaller it is, the higher the risk of bias, the unintentional but but bias in the numbers. So it was the first published data that compared the PCR testing, versus well, rather, they took a bunch of patients who were all being tested for COVID with PCR, and the ones who tested negative and therefore were known to not have COVID right? We might walk around thinking we don't have COVID. But we don't know whether we do or don't since people can be asymptomatic for so long. These are patients who we know don't have COVID and use them as the control group compared to the PCR positive patients who are known to have COVID. And what they did is they then looked at those patients, and tested IGM and IGG to know who makes it how much and whether or not that can happen in the control group as well, to say it another way: if I'm infected with COVID, and I make IGM and IGG, but somehow someone in the non COVID group does it as well, how valid is that to know that I'm immune?Yeah.Right? The idea is that only the people who have been exposed and therefore can protect themselves should generate that immunity or should we should be using that as a marker for the immunity so a couple interesting things are that some people that's an important point did not make IGG. And on the on the control side, three people did make IGG. However, a big caveat in that is that they made it a much lower titer. So they had a they made some IGG but less IGG than those people who were exposed to or had active viral replication. So another point I'll make is that this is a it's a very interesting article, and it's been discussed a lot. It's a journal pre proof article. So it does mean that it hasn't been published yet. But the journal has accepted it for publication. It's already been through peer review. So this is still a very legitimate publication. So there were in the two in the two sides, there were 43 patients with PCR positive confirmed COVID-19 and compared to their control group of 33 patients who were these rule out patients, patients who came in they, they thought they were sick and potentially had COVID, but the PCRs were never positive. And another good point I would make is, these patients have multiple testing points. They were tested at multiple times. So to decrease...Multiple times in the same location, though right? Nasopharyngeal swabbing.Right. So so they're trying to control for that. Well, what if there, we missed it the first time, right? So then they're going to repeat it again a few days, which gives you a trend over over time. So but but I agree, the point being that it was all nasopharyngeal swabs, I think oral too nasal and oral, yeah. So limited to one type. So you can still you still have that bias of did you not do it adequately? You would hope it's only and they don't mention this, whether it was or not, that's it only a certain few people who are doing the testing, so that you're controlling for variables of maybe some who do it better than others. And maybe get better sampling. So they don't mention that but because it was all done in one site, you have to assume for the moment that there's only a few people who are doing the testing, so they know what they're doing. The sensitivity, I'm sorry.Oh, I was just gonna say what I found interesting in this is this suspected infected patients were discharged from the hospital once the results of two time molecular tests in 24 hours were negative. So basically, in my interpretation of this understanding, now, the limitations of the testing, they may have sent people out that were not PCR positive, that could later develop IGG and IGM. So when you get into the sensitivity and specificity of this, it is this is this is as good as we can get. But it may change as we gather more data.Right. Right. So the sensitivity specificity for IGM and IGG to diagnose an infection was 48% and 88.9% of sensitivity. So IGM was 48 and IGG was 88.9 and 100% and 90.9% specificity, right? So, in other words, if you had IGM, that meant that you had the infection because it's an acute marker that would only happen if you've been acutely infected. But if you didn't have IGM, it did not mean that you weren't infected. Right? So just to sort of wrap your head around that it's really really good as a marker if you have it, but if you don't have it doesn't give you a whole lot of confidence.I love how we're doing this because the media just glosses over it and just confuses people. My patients are calling me all day long asking all these questions.Yeah, it's important to understand what it is right and the media doesn't kind of give you a primer to explain the background of what they're talking about. They just give you a two minute soundbite and you're sort of left on your own to interpret it. Exactly. Sorry to interrupt go on. No no problem at all. So they found that as you would expect, given that IGM comes first and then IGG follows IGM titers would rise and then they'd fall because as you get over the acute infection, you no longer need your IGM. But the IGG titer would rise until they were 100% in those people that produced IGG, right, so the ones that were making IGG made them. It was always higher, for whatever reason, and this, this is not clearly explained, but the titers of IGG were always higher than the titers of IGM. I think it's just something to sort of keep in the back in your mind just because we don't yet know what titers means. So it's just getting all the data you can and trying to figure out what it means going forward is important. The IGG positivity rate was over 90 was up to 90%. And it didn't really change it once...from the time that you were virus positive with PCR to your post infectious viral negative state. But the titer of IGG was almost double once you pass the infection, which that starts giving you that glimmer of hope about immunity, right. Because as you're fighting the infection, it's not as important to remember, you need someone who's actively on the front line. And that's where your IGG IGM helps you. But once you're done, you want to you want to remember that you want to be stone cold, you want to know that if you get any kind of exposure again, your body is ready to jump into action.I mean, this is just getting back to your analogy, what you have are some special, we've got special ops that have a picture of something and they say when this thing shows up, kill it before it does anything. And all they do is wait. That's what the IGG is doing is waiting for the possibility of seeing that and they just get after it.Right. So just to sort of talked about the the the sort of underside of this, three of the 33 patients in the control group are IGG positive, right. So that that makes you step back just a little bit in saying that, well, if you got the IGG, you're good, right? But the important thing is that the titers were lower. So they talk about the the units, the units of positivity for this assay, were 1010 units per milliliter, and those that were in the control group had no one higher than 15. So they were sort of a low kind of weak positive compared to those in the active group, who all had much higher at least twice the normal titers. So that might be an important piece of information, right that not only figuring out who is IGG but how much maybe there's a threshold value that confers immunity. 27 of the known COVID patients has IGG testing during the infection, three of them didn't make any IGM or IGG, so whoever didn't make IGG also didn't make IGM. It's interesting because the way I look at this is probably different than almost everybody who reads this article. I'm sure everyone who looks at it and it's valid is gonna say certain people don't make it. What I look at it is that's kind of an amazing thought. 10% of the people didn't make IGM or IGG and still fought off the virus somehow. So there's some sort of mechanism of secondary mechanism to be able to successfully defeat the virus beyond this, the typical virology that we know about.Well, I okay, so point CounterPoint. What if they're catching this person at a point in time where the IGM is dipped down and the IGG is coming up? So you're going to have two overlapping...Right you're in a window right?You're in a window. So did they check them at the wrong time?Right. That's a great thought. The catch is they did this at least three times separated over several days, going all the way out to 28 days post infection. So I suppose it's possible, but given what we know about the curves of IGM and IGG, even if you think maybe you were shifted over in time, you should have caught it somewhere. And maybe you don't get one maybe maybe you only get one, maybe you don't get both. We should have seen something.So what you're describing is that people that had an innate immunity, but they did not develop the adaptive immunity. In other words, their body's initial response may have been effective enough, but they did not develop. So those people, the question is, can they be reinfected? Will they have a possibility of the virus, having a resurgence and come back and hit them again? Interesting.Yeah. So that's the discussion. The discussion is do these people have immunity now, right? If you're making the supposition that you need IGG to have immunity, and these people can't make IGG, are they subject to reinfection? I would argue it goes even deeper. We're trying to get serum right draw blood from people who have had infection, to look at IGG titers to understand how much is needed for immunity. How much is enough? I would want to know about the serum of these people. What makes it different? Is there something is there a different way that we could be looking at this to confer immunity? Is there something else that maybe can work in concert?Hmm. So here you have the subset of people which is a significant amount and it's small study 10%. Right. So a subset of people that survived did not produce the antibodies, and going forward and some sort of weird society where we have to have immunity passports to go around. Peter Attia was talking about when you get bracelets for people to show I'm this I'm that which is gets a little bit big brother-ish and it gets real scary thinking about that. But there could be a subset of people that will not produce antibodies, but their innate immunity prevents them from getting infected. And we can't withhold them from going to work. We can't stop them. That's a fascinating observation. I did not see it that way. I was I was of everybody else that read this article and just went 10% didn't produce it. So...Yeah, but it's going back to what you said. I mean, this is this is why you gotta analyze articles and you got to have multiple people looking at it because people can read articles and have the same data and draw completely different conclusions.Much like everything else.Much like life. Let's, let's jump into the sort of article the day before we start talking about the pros and cons of these immunity badges or licenses. The we want to talk about the the Macaque monkey study. And...What's the only reason why I threw that out first not to describe it, but it just shows why you have to pay attention and read the articles yourself and have two different people interpreting it differently. Right. So it's a very small study. It is pre-publication, and it has not been peer reviewed. So it is being touted as kind of the be all and end all for the discussion about immunity. But it is a very much in the pubescent stages of research.It's fascinating because I heard Dr. Fousey on a CNN news thing. We believe that because of the macaque monkey study, and then I heard Dr. Hotez go on Joe Rogan. He said we're we're sure that we can develop immunity because there was a macaque monkey study and everybody just keeps saying the macaque monkey study the macaque monkey study. I don't think there's another one out there. I tried to look I didn't find one. This is the one that I found.Yeah, no, I did the same. And, you know, like I said, it's it's fascinating but has to be taken with a big grain of salt. So let's, let's jump into it. Yeah. The whole reason why they did this study, it was prompted by reports of patients who have been discharged and considered cleared from virus and then they were coming back with reinfection or raising that question of is this a relapse or reinfection? You know the difference being relapse, that you have the same infection you did and you just got sick again, versus reinfection that you actually got sick a second time. And it implies that there's no immunity.Big difference. So they followed four rhesus monkeys. And they infected all four of them. They actually gave them inoculations of the SARS CoV2 virus and they developed a lot of those typical symptoms that we're seeing in people around the world. Once they the symptoms were alleviated, and the viral replication as judged by, as you said, respiratory and animal swabs and PCR had all subsided, all appropriate antibodies, so IGM and IGG and there's actually a whole bunch of other ones we didn't even touch on. They were all there, right? So they sort of validated the subset of the four monkeys by saying these all created everything appropriately and therefore, we can look at them for some information. They euthanized one of the monkeys from the start. And they basically took various organs and tested the organ tissue to see if they would be PCR positive and they found evidence of viral replication all over the body: nose, pharynx lung, gut, spinal cord, heart, skeletal muscle and bladder all displayed PCR positive COVID at the time of infection. Two of the Monkey so now you're down to three monkeys. Two of the monkeys were then re challenged, where they inoculated them a second time with SARS CoV2. So again, this is talking about reinfection, not reactivation. All the monkeys. So all three monkeys were then tested for viral load. And none of them were found to be PCR positive. So the one monkey who was left as a control and the two monkeys who were re inoculated, none of them had PCR positive disease at this point. They then took one of those reinfected monkeys euthanized that monkey as well did the same kind of testing, looking at all those different organs and trying to see if they were PCR positive and found that they were negative in the tissueIn all of the tissue and that's pretty shocking how disseminated that virus was in the first one. So that's impressive.Yeah. So very interesting data very interesting information throws out a lot of very positive possibilities here now for infection and the ability to fight off reoccurrence. But, gotta gotta to be very skeptical, right? I mean, for monkeys, you know, they all displayed antibodies. And from the last study we looked at, we know that that's not true, right? If you have those 43 patients, you know, sort of looking at that and say, if I only took four of them, and looked at those four people, and they all made antibodies, I draw conclusions from the study. Well, I guess everyone makes antibodies, but we know that's not true.Yeah, that is a that's a very interesting analysis on a study that's being thrown around in the media like crazy. Nobody's talking about that. And if you read their abstract, I'll say it one more time, like I did. It seems like they had 1000 monkeys. So great job on interpreting that and getting into the details and you know, having the time during Passover and stuff to go into detail like that, because...Yeah, I mean I just got a cup of coffee, got some matza just sat down and went through all these studies.Well, you're better than me because it's it's like drinking out of a firehose, I try to sort through which ones I'm going to take a deep dive in. And I like doing this with you. I like doing these point five episodes where we do do deep dives. And, and you challenged me to look at some of these studies. So I had a long interview yesterday with Matt Atwood, who's the CEO of a company that has access to rapid point of care IGG, IGM testing, where they actually have the ability to take a finger prick like a glucose stick, and then you can see if you're IGM positive, IGG positive. And it's interesting because you had also sent me that study and he sent it to me about the Laredo was it El Paso or Laredo?Laredo yeah...Laredo. Yeah. Why don't you go ahead and tell everybody about what kind of a fiasco that was?Well, the short version is best intentions for sure. The city of Laredo ordered, I think half a million testing kits to try and stimulate their economy, right? They wanted to...Just to clarify, it was half a million dollars for 20,000 kits. So they spent half a million dollars.Oh, thank you. And they basically wanted to go out and test everyone and see if they could figure out who's IGG positive and say that those people can go back to work and sort of get Main Street running again. And it turned out that the kits were not quite up to snuff. And unfortunately, it was a bit of a loss for the city of Laredo.So people are asking like, well, how is this happening? And I just want to just clarify this a little bit. It's what happened in China is exactly what President Trump is doing here. When they realized that they were behind the curve on this, and they needed masks and gloves and testing kits, China went to facilities like toy manufacturers, and they went to different manufacturing companies and said, you're going to stop production on that. Here's your parts to make masks, here's your parts to make test kits. And here's how you're going to do it, figure it out. So these were not already pre designed medical locations. They were doing what the government told them to do. And then they made a bunch of these things. They shipped them out, the US bought a bunch. And then we realized...a lot of these things are not effective, and they shipped them back, discussed possibly suing this and so then China had to step it up and be like, well, we can't just force you to do this. Well, as it turns out, there's a bunch of that stuff still floating around in the US. And there are some companies that are saying, well, I'll just repackage it and sell it. And that's kind of what happened to these guys. So for instance, our group, I got an email from somebody in our group that said, we have access to these IGG kits. And I looked into it and as it turns out, I, we contacted the manufacturered for company and they're like, yeah, we got a bunch of those kits that are not valid because they're not certified. So a company out of Houston bought us. And then they contacted our group and offered to sell it for dirt cheap. And it's, you get what you pay for, I guess.Yeah, I mean, it definitely was a great deal. They were super cheap, but...couldn't really do much with them unfortunately.And then from as doctors, imagine, if we tested people with an unreliable test, and we said look, the we all you and I carry liability all the time, but at least we can say this test was FDA shown to be this the sensitivity specificity, so there is a 95% chance that the information I'm going to give you as correct, you're going to assume and I'm going to assume that there's a slight possibility that it could be wrong. If you're positive, then what we're going to do is send you for another more distinct test, which costs a lot more money, it's going to be serum and that's kind of where I think this needs to go. You do mass screening, like we did with well, quite honestly, HIV, I remember we did the rapid HIV and then you do the the Elisa test or whatever it was afterwards to try and really determine what's going on. So we have these people that if we can screen them and get the IGG IGM and then do a secondary test and prove that they're that they have antibody. Then now the next discussion is alright, Dr. Akerman. We've got IGG people running around with their badge saying I can work I can do things. What are the limitations of that?Well, I think there's there's some issues that are...and I want to be clear, I, I agree that we need to figure something out. And this opens up a world of possibilities. But we're in the infancy because there's a lot of questions that haven't been answered. So first of all, do we know are there specific titers that confer immunity? Because if there are, a simple little blood test that just says yay or nay might not be enough, right, we have to make sure that all the manufacturers are assessing at the same level to call that positive. Right? If we know that you need titers of 20, let's say, and you have a test that calls it positive at 10. Right? You're creating a ton of false positive results. So you got to be really, really careful about that. And, you know, again, we haven't answered that question just yet. Is there the possibility of reinfection? So what does immunity mean? Right, we have all this data now coming out of South Korea because they've had over 100 people come back who were discharged from hospitals being told that they've cleared infections and that they're no longer sick. And they've actually come back and have retested positive by PCR. But what does that mean? Does that mean that they've gotten the infection again? Does that mean that maybe they were kicked out too quickly? Maybe that their viral loads had dropped? Or they simply had sampling error. Right. When they got tested the day before, maybe they just didn't pick it up in the right spot.Exactly. So the other articles that you talked about bringing that up, but it is fascinating, because this is just case reports coming out of South Korea. And everybody that looks at this nobody wants to believe that you can get reinfected like like that is like the the that is a doomsday prediction. So we're going to say, look, the macaque monkey study which you've kind of already said take it with a grain of salt, the size of Gibraltar and then this the IGG so it's the good news is looking at SARS CoV from 2003...they those people have been looked at years later a decade later, and they've maintained their immunity. Now, I challenge that there are some possibilities that these tests, although they're COVID-19 specific, what if some of these people test positive because they have IGG to SARS CoC? That was right. That was an argument that a PhD brought to me. Because he did...I was on the I was on a zoom call yesterday with a virologist who did the original research on that and he's like, doing this he's like, well, we're seeing that some people can develop antibodies which made a mistake that being said, I don't know that these fingerpricks there was a article that just came out today, that detection of SARS CoV2. They found the binding protein to be specific so the test you can still do a test specific for SARS CoV2. And I'm not sure if these IGG IGM are can actually do determine that. So more studies are gonna have to be kind of vetted for this.Yeah. And I think that, you know, it begs the larger question, what do you do with those false positive results, especially if you don't know that they're falsely positive? Right? Again, like you mentioned earlier, patient could be walking around thinking that they're bulletproof. And it turns out, not only are they not bulletproof, they might now get the infection and pass it along to everyone. It becomes part of the larger discussion about herd immunity, right? Because if we're getting all these people that now are immune, and we're putting those people out in the population, then the people that they're coming across are not as at risk. Right, but we don't know what that critical number is to create that herd immunity.Yeah, absolutely. There's a lot to discuss and clearly you and I can get together and try and vet some of this stuff as the literature comes out. I appreciate you taking the time to do that. Unfortunately, it's starting my telemedicine time right now. But where can people find you Dr. Akerman?The easiest way is to check out my website. There's a lot of information about my practice there and I've been trying to update my blog with useful information. And that's at www.stuartakermanmd.com.Yeah, so clearly this is a super smart guy watch his videos he actually has a pretty good sense of humor and has some pretty interesting stuff and his the videos you're sending me your kids which we will not discuss today was pretty pretty funny also so quarantine in the Akerman house should be a some sort of big brother type thing where it's just funny it's hilariousYeah, we're thinking of pitching it to the networks in the near future.Alright buddy, I appreciate you taking the time so go to stuartakermanmd.com You can reach me at on Instagram at kbmdhealth and kbmdhealth.com for the website. We are currently oh good news, we now have brought a leak on our website. So BrocElite, Atrantil, and CBD. We're having some pretty good results with that we can get into that later but today was much more of an academic discussion. Thank you so much, Dr. Akerman for joining now I got to get to the real job.Thanks Ken. Have a great day.Alright buddy. Have a great day.

Movies, Emoticons and Storytellers: Things to Avoid When Writing Your PCR

EMS | Board & Collar

Play Episode Listen Later Aug 16, 2019 5:56

How many times have you heard the horror stories about those individuals behind in finishing their patient care reports (PCRs)? Typically, these individuals are not behind by one or two but sometimes, ten, twenty or even more. Ugh. How can anyone recall the patient interaction from ten days prior? That's absolutely impossible (sorry for the editorial comment). While most states have rules for timely completion, the question remains as to how well this is policed and to be honest, why must something as important as report writing be put on the back burner? Yes, I know, your organization runs call after call but timely report writing is part of the patient care process and it is your responsibility to get them completed. In this episode of The QMC Board & Collar we'll take a quick look at how to avoid life's simple distractions that will hopefully, help you get those PCRs completed on time.Written by: C. HumphreyPresented by: G. Harvat

movies writing storytellers emoticons pcrs

Technology: Is it Working for Your Organization?

EMS | Board & Collar

Play Episode Listen Later Aug 13, 2019 6:25

Efficient processing of patient care reports (PCRs) are paramount to ensure reimbursement and a sound cash flow for your organization. Is your processing system/billing office current with today's technology to always be in step with payers? This edition of The QMC Board & Collar takes a look at technology, your billing office and efficient processing of claims. Written by: C. HumphreyPresented by: G. Harvat

technology efficient pcrs

My Buddy, My Pal - A Team Approach to PCR Completion

EMS | Board & Collar

Play Episode Listen Later Jul 23, 2019 4:04

Yep, it's never easy getting the crews to get their PCRs completed in a timely fashion. Usually, this task falls with the medic in the back of the rig who carries out the lion's share of the care. With any organization, this can be a daunting task after a busy shift. We explore "the buddy system" in this edition of The QMC Board & Collar.Written by: C. HumphreyPresented by: G. Harvat

buddy completion team approach pcrs

Episode #10 Is Face-to-Face Contact Still Relevant for Networking REIs? An Interview with Jason Franasiak, MD

Inside Reproductive Health Podcast

Play Episode Listen Later Feb 27, 2019 23:01

In this episode, Griffin talks to Dr. Jason Franasiak. Dr. Franasiak works with RMA of New Jersey, and he has joined Griffin to discuss the importance of professional networking. Even during his fellowship, Dr. Franasiak became an active member of professional organizations, and today he sits on committees for a variety of organizations, including ASRM and PCRS. Follow Dr. Franasiak on Twitter at @jasonfranasiakmd.

new jersey networking relevant reis face to face rma asrm pcrs

11: The Gift of Sharing Positivity after an Acceptance

Premed Diaries

Play Episode Listen Later Dec 17, 2018 38:03

Session 11 When being a premed is a struggle and there are times you don’t think you are going to make it, remember you can do it. Humor and hustle will get us by. [01:15] Caller of the Week: "Just a little foreword to this rant because being a premed sucks and lot of it sucks and it's hard and it's so lonely. I just want to express some sincere gratitude to both Drs. Gray for all the efforts in making this whole premed experience a little bit more bearable - humble, grateful, excited that this might just spread a little bit of positivity. Initial Interest in Biomedical Engineering When I went to college, I wanted to be a biomedical engineer. I didn't really know what they did but it was probably cool, right? Prosthetics or drugs or whatever nanotubes... I was 17, I just thought I could be part of that. I could graduate in four years, get a job, maybe a Master's but probably not. No big deal - but not medicine. I didn't have anyone in my family in science or medicine but I saw their type. They always talk about grades, how easy everything was. They always documented how many hours they were in the library or Instagram and I wasn't about that "gunner" stuff. Anyway, I dropped out of engineering after about two weeks. It turned out I'm not good at math and I don't like it at all. Not my thing. Thinking Through What to Take But going into the whole chemistry, PhD, the big pharma was a good second bet. Sure it was a bit more school but at least PhD programs in my area, they were funded. I didn't have to worry about loans. I don't really have financial support from my folks. Nothing against them but it's just not my scenario. It was kind of big topic in me choosing these things. But orgo was my favorite class, biochemistry was a close second. I even tolerated PChem pretty well. It was still math but it was about something. It wasn't just numbers on a page and I like that. So I did the thing people do. I got a lab tech job that would help me pay rent. My PI was making these peptide drugs that would convince to cure cancer or Alzheimer's or dengue fever or whatever. I did more blocks and more PCRs than I could count... “I was part of the team... but the whole time, I had this feeling that something was missing here.” I was just grateful to be there. I was part of the team... but the whole time, I had this feeling that something was missing here. It wasn't cutthroat. But the part of the work that I enjoyed the most was this prospect of making a therapy that could save someone. But I got sad, maybe it was selfish, knowing that I'd never meet this person. I would just be at the vent where I couldn't take their hand or high five their kids...but that was the road I was convinced that I was supposed to go on - get a job, settle down, have family, have my 2.5 kids in a white picket fence - the American Dream. Going Labless and Jobless Fast-forward to the week before my Junior year began, I keep doing the chemistry lab nerds thing and then I got an email from my PI that essentially says someone who worked before you came back from being abroad. She started this project so we got to let you go. Now, I'm labless, I'm jobless, I'm pissed off. How am I going to pay rent? I go on a run. I come home. I sing all my feelings out in the shower. And I emailed many chemistry professors as possible to add to my CV and get a job and get into a good grad school. But little did I know that I was going to be premed buddy that day. From Jobless to Having a Job on the Same Day! That afternoon, I got a call from my dad about my mom... I visited them. It wasn't anything serious, probably heartburn. But she's okay. The doc and ED was the second nonprimary care doctor I've ever met. The first was a cardiothoracic surgeon who gave my dad a bypass. But I've never seen a doctor like him before. He was chatting with families between rooms. He was high fiving patients in the hall. I think he's a total rockstar in the midst of all this chaos. I just remember thinking it was pretty different from what I thought those kids tearing textbook pages so other people couldn't have it. It was pretty different from that image in my hear that I thought they were like. Then there's this guy with a computer following the doctor around. So I asked him and the doctor said to me it was his scribe who writes his notes so he can spend his time seeing patients, what he was trained to do, instead of sitting behind the computer. For him, it was like paid shadowing and he's going to medical school next year. Me, not really caring about medical school or not, I just thought this was a job and since I was jobless six hours ago, I asked if they needed more scribes. So I got a job but I really didn't know much about shadowing but looks like I could get paid and I could learn at the same time...ultimately, it was a pretty good ending to my otherwise pretty rough day. An Interest in Premed At that point, I totally caught this medicine bug that all my premed friends couldn't shut up about. This was the stuff that I was missing from lab... at the end of the day, I could see an immediate positive impact that these doctors have with others and I was inspired by that. Caring someone of an ailment is super dope, but at the very least, the physician can empathize, they can educate these people. To me, it was this perfect marriage of continued education and expertise and just being a human being and I like that. So I kept scribing and I ended up in my premed office... but I still didn't have my MCAT or done some shadowing or volunteering. But I told her I've been a scribe for two weeks. In retrospect, I wasn't prepared and I wasn't expecting someone to tell me I'd get into an Ivy League school. I just wanted some direction. I didn't have any family who had done this before. "I didn't really have a template to go forward but I didn't get any encouragement or direction from this lady. She just said pretty quickly, 'you're not going to get in.'" "You're not that bright," she said. "Physicians are good in biology and you're not. I recommend sales or finance." She then went off-tangent... and then she forgot who I was and just moved on to the next person. Finding His Own Encouragement and Getting into Medical School I guess I just had to find my own encouragement. So like I did when I lost my lab job, I went on a run. And some of my friends were talking about podcasting and that's how I stumbled upon this, the Medical School HQ Podcast. And it's just very nice to have that weekly dose of positivity, hearing these stories of a 40 something single parent of four who went against all odds and got into medical school. And I thought that at least one person who had a story at least somewhat similar to mine, let alone all these people who had so many more challenges that I had. "If one person was able to do it, then there's no reason that I couldn't as well." So I joined that pretty cutthroat premed crowd but I still had this mantra of collaboration, not competition. That was still the goal. I kept scribing my junior and senior year. I joined a master's program. I moved to Manhattan. I did some quality work. I joined a second lab, I hated it, I left after six months. I got married. I joined the third lab. I love the third lab. There now, published a couple of things, you shake a couple hands, you shadow a bit, volunteer for a bit... and got into an MD school last week. The first thing that went through my mind other than sobbing to my wife, been calling everyone who had picked up in the middle of the day during the week, was just to stick it to that random one advisor that I had met five years ago. And I just wanted to tell her that if I get 25 rejections today doesn't matter. I got in and you were wrong. But I didn't do that. Instead, I wanted to spread the thing that got me this far in the first place, spreading a little bit of positivity in the light of "oh, look at this small amount of adversity that I've come around and look who came from it." Instead of sticking it to the advisor. I know Dr. Gray has been digesting a lot of Gary Vee, he's this entrepreneur. Something he always says is "happiness is the ROI, the return on investment of life." And this constant negativity from this three-letter forum that shall not be named or these classmates who are stealing textbooks, just the cutthroat nature of this field makes this process so challenging but it doesn't have to be that way. So I hope I can just spread a little encouragement to you all who maybe just got a D on a test or your peer just called it super easy and they didn't study for it and they got an A. Or if you're planning a wedding. That's challenging. If you lost a family member, if you have a kid or three, or you're taking your unplanned gap year, if you have to apply more than once, or if you just had some jaded premed advisor tell you that you should go and become a used car salesman. Keep hustling because it does improve gratitude. Be thankful for the opportunity you have and you all got this! [14:45] Congratulations! This caller has a very good sense of humor and it's infectious. Congratulations on your admission to medical school! Who could blame you for wanting to stick it to your advisor. It's just sad when you think about how somebody like you, if you had listened to that premed advisor and gone in finance. You could have regretted not pursuing this the whole rest of your life. And what a shame that would have been! You obviously got a lot of hustle and hearing how you picked yourself off after having hurdles and things thrown against you and get right back onto the next thing. You have so much drive and ambition. Clearly, that is why you're where you are now. I love how you go for a run, how you sing in the shower... those are great coping strategies. You have an incredible story from losing your job, going for a run, singing in the shower, and this whole series of things happening with your mother in the emergency room, and six hours later, you had a new job which propelled you to end up going to medical school. That is an incredible story! It just goes to show that with that loss of a job, you could've just decided that maybe work and go into finance. Or you might have just completely changed course and decide to leave science. [17:05] Collaboration, Not Competition It's also cool how you were inspired by that emergency room doc. Yes, not all premeds are that gunner type. It's miserable to be around people who all they want to talk about is their grades, how many hours they were in the library, and making other people feel uncomfortable. It's not who we are, it's not who we want to be, it's not who we should be. As you pointed out in your entry, Ryan who is the host of The Premed Years podcast always talks about collaboration, not competition. And that's exactly what the premed community should be. "Collaboration, not competition -- and that's exactly what the premed community should be." Unfortunately, not everybody is like that. But it's great that you got the opportunity to be in the emergency room. Obviously, it wasn't a good reason you were there because your mom was not feeling well. But the fact you got to see this ER doc high-fiving patients inspired you and made you realize that not all premed students are like that. [19:00] Making a Difference as a Physician It's true. Once you get the medicine bug, you can't get rid of it. It's neat that you got that bug and just stuck with it. It's also amazing how you said about the way in which physicians can be there. Even if they can't cure a person, they can always have a positive impact. I think that's why many of us want to be physicians. "You can make a positive impact even if, at the end of the day, you can't cure anyone." As a neurologist, I am unable to cure a lot of people. But I feel very strongly that my job is not to cure people. That's not why I became a doctor, but I became a doctor to make a difference. You can absolutely make a difference in whatever field of medicine you choose [23:17] Spreading Some Positivity Whether you're having a terrible day or struggling through all sorts of things, we help one another by being there and supporting one another and by being grateful. It's hard not to feel just the weight of the amount of negativity that can come from other people. So anytime there is some positivity, it's wonderful that you spread it around. "Grades don't define an applicant by any means." Certainly, you don't tell a person what their chances are getting into medical school. If any of you have had similar unfortunate experiences with an advisor, listen to our caller's wise words and just keep on pushing, keep hustling, and don't let that drag you down. Don't let that make it impossible for you to see yourself as a physician and to keep on a path you're fighting. [26:15] Feedback on Episode 10 "I was actually going to call myself to make an entry about this because it's been in my mind a lot. Keeping it short, I am a 31-year-old who is applying for medical school now. I'm married and not a day goes by without me thinking about it. And it's nice to know that I'm not alone in this and I do agree that being a woman does carry a different perspective into what having kids in the next few years is going to be like. My husband is very supportive too but I know that some things will have to be done by me and not him. So I worry about that a lot and I did get a lot of comments when I decided to. I'm a career changer too and I got a lot of comments and I started to share that I was going to apply for medical school from family just them worrying asking when we're going to have kids if I'm going back to school now. I guess I just learned to listen to them and not take it to heart. What I realized, and I've been on the premed track for the last four years, I actually went back to doing another undergrad to get better marks that are more competitive. And so for the last four years, I have just been thinking about this and working towards being a competitive applicant and what I realized is that I want to be a mom just as bad as I want to be a doctor. It just happened that they're going to have to happen at the same time because of my age. I pretty much have the next ten years to do both. And so I just learned to accept that. What I did start to do, and I would have some suggestions for the caller. I just started to go try seeing other moms who were doctors. I just thought that seeing women who are doing this on a daily basis, using social media to that purpose, and so I started following a lot of doctor moms on Instagram. There is #mamasinmedicine on Instagram and you can find just amazing posts of women who are doing those. I just figured that if I see it enough, my brain would just get the message that it's possible. "Everybody has a different journey that they figured it out in the end." There's also another blog called Mothers in Medicine. The blog features a lot of women who are in different stages of medicine where they all share their journey. There's also YouTuber called Jenny Le and she is a mother of a two-year-old now and she was applying for residency when she was pregnant. This has just been my coping medicine of soaking these energies in and reading about how they make it happen so that I am ready to just be confident in myself and my husband and I's capacity to make it work and just going for it. It's really nice to know that I'm not alone in this and to hear the caller just telling her story is so much of what goes through my head everyday. So know that you're not alone either. If she feels like that it is something she wants badly as she wants to be a mom, just go for it as I'm going for it. I try to also think of that picture and think of 20 years from now when this is all over and our kids are teenagers and we're doctors and we're going to look back and just see that we're proud of ourselves then our kids will be so proud of us. And we'll set as an example. I don't want to a job that I'm not excited about. I realized that's not what I want that's why I'm going into medicine and to make a difference in people's lives. I feel that'show my life is going to have meaning. So I'm going for it and I hope that she does too." "20 years from now, I'm going to thank me for making this decision and it's all I can hope for. As I said, I want to be a mom as badly as I want to be a doctor." [36:05] Be a Part of this Community! Please call 1-833-MYDIARY and leave us a diary entry. Share with us your triumphs as well as down moments. Tell us what you feel. We'de love to hear all about it! Press 1 to leave a diary entry and press 5 to leave your feedback on a previous episode (just be sure to tell us which episode you’re talking about.) Links: PMD 10: The Worry of Being an Older Premed Who Wants Kids The Premed Years Podcast MedEd Media Network Follow #mamasinmedicine on Instagram Mothers in Medicine Jenny Le’s YouTube channel

SBA Area 5 | Randy Marchiafava | Episode 9

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Play Episode Listen Later Jun 14, 2018 33:29

SBA | Area V | Randy MarchiafavaRandy Marchiafava (New Orleans) discusses the many roles of PCRs, strategic approaches to government contracting, the power of FedBizOpps, and some lesser known SBA resources.

SBA Area 4 | Phil MacLean | Episode 10

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Play Episode Listen Later Jun 14, 2018 28:32

SBA | Area IV | Phil MacLeanPhil MacLean (OH) discusses important differences between OSDBUs, Small Business Specialists, and PCRs; procurement review; agency points of contact; researching historical awards, internal source lists, and subcontracting listings

SBA Area 4 | Phil MacLean | Episode 10

small business sba maclean smallbiz govcon pcrs

Play Episode Listen Later Jun 14, 2018 28:32

SBA Area 5 | Randy Marchiafava | Episode 9