Podcasts about pjp

Send us a textIn this episode, Dr. Sheliza Halani interviews Dr. Nisha Andani (Infectious Diseases) about the latest guidelines regarding the epidemiology, clinical presentation, investigations, treatment and prevention of PJP. Support the show

Dr Cilia Nazef, Infectious diseases Fellow at the University of South Florida Morsani College of Medicine, explores how Pneumocystis jirovecii, a fungal infection typically affecting immunocompromised patients, can also affect patients suffering from hypercortisolism. Dr. Nazef begins by examining different cases of Pneumocystis jirovecii Pneumonia (PJP) in patients with Cushings disease. Next, she further explains the immunologic basis behind how the hypercortisol state induces immunosuppression. Dr. Nazef closes by examining the basis for PJP prophylaxis in Cushings disease patients, and the shortcomings of the current literature in advocating prophylaxis options.

Basic knowledge of the common CNS manifestations of rheumatologic diseases and sarcoidosis is important. In the context of many systemic inflammatory diseases, CNS disease may be a presenting feature or occur without systemic manifestations of the disease, making familiarity with these diseases even more important. In this episode, Kait Nevel, MD speaks with Jennifer A. McCombe, MD, author of the article “Neurologic Manifestations of Rheumatologic Disorders,” in the Continuum® August 2024 Autoimmune Neurology issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. McCombe is an associate professor in the Division of Neurology, Department of Medicine at the University of Alberta, Edmonton in Alberta, Canada. Additional Resources Read the article: Neurologic Manifestations of Rheumatologic Disorders Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Guest: @Div_Dubey Transcript Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology.  Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME.   Dr Nevel: Hello. This is Dr Kait Nevel. Today, I'm interviewing Dr Jennifer McCombe about her article on neurosarcoidosis and neurologic involvement of rheumatological disorders, which appears in the August 2024 Continuum issue on autoimmune neurology. Welcome to the podcast, and I would love to have you introduce yourself to the audience.   Dr McCombe: Well, thank you, and thank you for having me. As you said, my name is Jen McCombe. I'm a neurologist in Edmonton, Alberta, Canada, where I spend kind of a third of my time in teaching roles (I coordinate the undergraduate block for our medical school there), I spend about a third of my time in a neuroinflammatory clinic in Edmonton, Alberta, and then about a third of my time doing clinical research.   Dr Nevel: Wonderful. Well, thank you so much for being here today and for chatting with me about your article on this topic.   Dr McCombe: Thank you for having me.   Dr Nevel: To start off, can you share with the listeners a little bit about your career path?   Dr McCombe: Absolutely. Yeah. So, I've had, uh, a bit of a circuitous career path. I did my medical school in Queens (which is in Eastern Canada, in Kingston, Ontario) and then went back to Edmonton, Alberta, for my residency (in Canada, we have a five-year residency program, so a little bit different than the US), but finished my residency and then did a master's degree in Public Health at Johns Hopkins while completing clinical research in HIV, actually, and did this thing we call the Clinical Scholar Training Program – so, kind of like a fellowship, but a little bit more, you know, research and academic-based. So, when I first started, I was focused more on neuroinfectious diseases, and that's kind of what my career path looked like at the time - but, actually, shortly after I finished my residency program, I also had my first child, and he, unfortunately, developed opsoclonus-myoclonus syndrome, and at the time (this was in 2010), it was a rather rare condition, so, I ended up finding myself having to become a bit of a neuroinflammatory disease specialist at the same time. So, at that point, I transitioned into working in the neuroinflammatory clinic with some mentorship but was getting all of the kind of weird and wonderful referrals and diagnostic dilemmas from my colleagues who recognized I kind of developed some expertise, and so decided (actually, mid-career) to take a sabbatical, and in 2021, completed a fellowship in autoimmune neurology at the Mayo Clinic. So, I finished that quite recently and then went back, and now I'm feeling much more, I guess, confident, too. Sometimes, you wonder about, you know, the choices you're making. I recognize most of the conditions I'm dealing with don't have, in fact, any evidence for their treatment, and that was confirmed when I went to the Mayo Clinic and found that, really, it was just trying to gain an understanding of the disease process to make a rational choice to medications and treatments. So, now, I'm back and kind of trying to focus a little bit more on some clinical research in that area since I've kind of solidified that expertise.   Dr Nevel: Wow. Well, thank you for sharing with us your career path and how, you know, unexpected life events kind of changed your interests or molded your interests (changed kind of the things that you became expert in, you know), and being fluid in your career path and willing to kind of take a break and reassess and get additional training. That's really inspiring to, I think, to me, and probably to a lot of listeners, that you can always, you know, develop more expertise in the more niche area or additional area no matter where you are in your stage of life or career path.   Dr McCombe: Yeah.   Dr Nevel: So, can you tell us a little bit more about - you know, you shared with us kind of autoimmune inflammatory disorders and how you became interested in that, neurosarcoidosis, specifically (you know the article focuses on that), and what's your background in neurosarcoidosis, how you became interested in that specifically and in neurologic manifestations of rheumatologic disorders?   Dr McCombe: I started in our neuroinflammatory clinic over a decade ago, and, you know, at the time, a lot of the expertise in any of these neuroinflammatory disorders was quite spread out over the country, and so, as I kind to alluded to before, often some of the more complicated patients where there wasn't necessarily clear-cut evidence or even, you know, a fellowship path to get there, I would end up getting referrals for - and so, I developed quite a cohort of patients with central nervous system primarily, but other types of neuroinflammatory and autoimmune neurologic diseases, and part of that cohort was a rather large (and still growing) group of patients with neurosarcoidosis. And so, I kind of developed some practical expertise, although, as you can see in the article (and as I'm sure you all know), the approach to the treatment is extremely variable. One of the most telling things is when we were at the Mayo Clinic, one of my co-fellows actually pulled all of the neurologists in neuroinflammation at all of the Mayo Clinic sites and asked them, you know, what is your treatment approach to a patient with neurosarcoidosis, and I think got twelve completely different responses as to the medications chosen and the length of time for the tapers and things like that. So, you know, it is very much a part of neurologic disease treatment that we still really don't have great evidence for, and although we do have some kind of rational choices that we can make based on other types of evidence, so -   Dr Nevel: Yeah.   Dr McCombe: And I enjoy working with patients with these types of diseases where we can kind of work together to come up with a treatment plan that makes sense for them and also makes sense based on whatever evidence we do have at this time.   Dr Nevel: Yeah. So, moving on to the article a little bit, knowing that this is a area of neurology where there's a lot of, you know, maybe personal expertise and experience but not a ton of data or evidence to necessarily guide our standardization to our treatments and approach, what do you think is the most important clinical takeaway from your article for our listeners?   Dr McCombe: Well, I mentioned before I coordinate the neuro block for our undergraduate program here, so I've developed over the years (I've been doing that for a number of years) a curriculum that's all based on, kind of, that approach to - and I like to do it that way because it's very practical. I like the students to be able to basically take their class notes and then go to the emergency department on their first shift as a clerk and, you know, use their approach to headache that I've developed for them to kind of take a clinical history and examine a patient with that sort of problem. And so, similar to that, I tried to do an approach to, you know, a couple of the more common presentations that would make you think of a rheumatologic condition or neurosarcoidosis in looking at the approach to CNS vasculitis and the approach to, uh, pachymeningitis - and these are difficult differentials for lots of neurologists, because it really relies on a lot of medicine knowledge, and we graduate from our residencies slightly more confident in our medicine knowledge, because we get a lot of that in our residencies. But as neurologists, as we go through our careers, we get much more confident in our areas of specialty, and at least for myself and many of my colleagues, much less confident in other things like general medicine. And so, it's difficult, because you have to face your areas of potentially less confident knowledge and really think about that in the differential - and so, I think, you know, I put those two big “approach to” sections in there, because they're the most relevant for the conditions that I was covering. But, I think also what I would say to a learner or a more experienced neurologist who might be reading the article, kind of pick out the little things that you might add to your own kind of approach to - you know, when you see that person with an ataxia, remember that Sjogren syndrome is one of the things you might consider that could be a treatable cause, or you want to see a sensory neuronopathy, don't just think paraneoplastic – again, Sjogren syndrome. So, kind of pick out those little pearls and add them to your approach to that patient that we all see, and I think that would be my biggest takeaway.   Dr Nevel: Yeah. Thank you. So, kind of like, keep this information from the article in mind so that you keep rheumatologic disorders in mind as a possibility when you're approaching a patient with whatever neurologic symptoms they're presenting with. So, what do you think is challenging? You kind of already mentioned a little bit, you know, just that it stretches us maybe into the medicine arena and so maybe stretches our medical knowledge, especially as we become more subspecialized or focused in neurology - but what is challenging about identifying, diagnosing neurologic symptoms as being related or due to an underlying rheumatologic disorder?   Dr McCombe: Absolutely. Yeah. Well, as you said, you know, it forces us to kind of face that medicine stuff that we might not be as comfortable with, but I think what else is challenging is that, sometimes, those medical clues aren't there. For the rheumatologic disorders for the most part, they are. Sjogren's is potentially a little bit different in that, potentially, the symptoms are less obvious or a little bit more subtle. But, in particular, with neurosarcoidosis, there's a distinct proportion of the patients that won't, in fact, have any systemic complications of their underlying disease, and so, you have to think about it even when the clues aren't there. That's why you have to add it to those kind of differential diagnoses where it might be considered, because those systemic clues that we all rely on when we do our review of systems and we ask about rashes and joint pain and lung issues, and these sorts of things may not be there - and so, you still have to think about it even when it might be completely isolated to the central nervous system.   Dr Nevel: What is our understanding of why some patients with rheumatologic disorders develop neurologic involvement? Do we have an understanding? Do we know why some patients do and some patients don't? I know that's, you know, kind of, uh - that's a tough question, but that was something that I thought of as I was reading your article, like, why does this happen to some people?   Dr McCombe: Absolutely. I mean, I think, potentially, it's a little bit more clear for some of them, like rheumatoid arthritis, because, typically, if you develop a CNS complication of this, it's, in fact, just because you've had the disease for a very long time, and often, it's uncontrolled, and so you think about the disease “spreading” now to the central nervous system - but for other conditions, like neurosarcoidosis, it is much less clear, and even if you look at the epidemiologic patterns for that, it makes it even more muddied in that in some populations, it appears that they develop more central nervous system disease, whereas in others, less. And so, why that is the case and why certain individuals might develop this complication of these diseases I think is yet to be seen.   Dr Nevel: Yeah, that's always the crux of things if we can figure out the why, then maybe we could prevent it, right?   Dr McCombe: Million-dollar question always.   Dr Nevel: Always. So, what do you find the most intriguing about neurologic involvement of rheumatologic disorders?   Dr McCombe: Well, I think one of the things that, really, I mean, for neurosarcoidosis in particular, so many patients do so well, and that's what I really like about it. You know, you see patients who present with an incredible burden of disease radiologically, and yet, don't look nearly as sick as they should when they're sitting in front of you. And then, you start them on therapies and some of them do so well, and even those with relatively devastating deficits, or moderate disease who do have neurologic symptoms, have a remarkable improvement in their neurologic symptoms with treatment. And so, that's always something that's quite rewarding when you get to see these patients in follow-up, and they're generally quite thankful because they're doing so well. And it's different from many of the neurologic diseases that we treat. I mean, in autoimmune neurology, we're lucky because we do have a number of diseases that are quite treatable and patients can have wonderful outcomes. But, you know, it's always scary when we see patients with devastating neurologic signs and it's great to see improvement with treatment. And so, that really draws me to it.   Dr Nevel: Yeah, absolutely. That's really rewarding when you're able to help somebody get better in such a profound way.   Dr McCombe: Mm hmm.   Dr Nevel: What is one common misconception about neurologic manifestations of rheumatologic disorders? Or what do you think is not well understood by treating clinicians?   Dr McCombe: I think probably one of the things I see the most is, sometimes, an undertreatment of the patient. And so, I see patients who, you know, other clinicians may have seen and have made the diagnosis, and perhaps it's a lack of confidence in the diagnosis and so they kind of want somebody else with a subspecialty to kind of confirm the diagnosis, but that treatment hasn't been initiated despite pathological confirmation on biopsy of another tissue. And these patients, like I alluded to before, they do well, but you need to treat them and you need to treat them adequately, and when their symptoms are quite impairing, you need to treat them adequately now. And so I think, sometimes, that delay in starting a second-line therapy and relying on steroids for too long - those sorts of things can really expose a patient to a lot of different side effects and to a lot of different complications that they may not have had, too. So, that's why I spent some time focusing on the treatment, because I think just gaining a little bit of comfort with some of these more common second-line medications is a good thing, because starting those early, I think, makes sense because you can really save the patient a lot. And then, the other thing, too, is that when you're using steroids, think about all of the systemic things that you're causing - think about the increased risk of infection and the fact that you need to prophylax for certain infections, think about bone health, think about protecting the lining of someone's stomach - so not only kind of thinking about your disease in isolation and what you need to do for treatment, but that you need to ensure that you're appropriately prescribing the patient all of the things they need to do to protect themselves during these times.   Dr Nevel: Yeah. I think that's so important. And I'm glad that you brought that up, because I think, unfortunately, many of us have seen a patient who ended up having PJP pneumonia (or something like that) because they weren't put on antibiotic coverage for prolonged steroid use or, you know, bone health - all of that is really important to think about. So, this may be entering a territory where there's no, you know, great evidence, but you mentioned, you know, starting kind of that maintenance or second-line agent - when do you decide to do that in patients? And maybe we can focus (since it gets a little broad), but, you know, in a patient with neurosarcoidosis, let's say - when you're starting the steroids, when do you decide, okay, this person is also going to need a maintenance therapy? Is that something that you do at the beginning when you're starting the steroids, or is that something that you think about later on depending on how their course goes?   Dr McCombe: Yeah. In my practice, I do it at the outset - again, because I'm quite focused on, you know, as soon as I get them on it, getting people off steroids - and so I start essentially almost all of my patients on it unless there's some other contraindication or complication to their disease. And because I deal with central nervous system complications in the vast majority of my patients, I'm starting a TNF-a inhibitor as well as methotrexate, and that's because I see a lot of patients with cord disease and significant brain disease, and so I want to treat them kind of more aggressively from the outset. And so, typically, they'll be on steroids, um, a TNF-a inhibitor, as well as methotrexate, and then I just back off, actually, as they do well. And so, I try to taper the steroids quite quickly over the course of just a number of weeks, or kind of two to three months at most. I maintain the TNF-a inhibitor, and then in some patients, depending on how they're doing, I might eventually stop the methotrexate. Some patients tolerate it so well that we don't for a number of months - other patients want to try to minimize their medications as quick as they can. So, that's my personal practice. In the province where I live, we don't have to worry about access to these medications, and so I understand that that might be an issue in some centers where people practice and have different access and different funding. Of course, I live in a country where we have universal healthcare, and in our province, I have very good access to these medications and they're funded from my patients regardless of socioeconomic status, and so I have the luxury of making these choices and I understand that other people might not, but that's my personal practice and I find it works quite well in the vast majority of patients.   Dr Nevel: Yeah. And you bring up a really good point that, you know, access to some of these medications for patients with CNS manifestations of sarcoidosis, neurosarcoidosis, sometimes can be challenging to treating the patient with medications that you feel like would be best for them. But that's wonderful that you don't have those access issues where you live. How long do you typically continue the TNF-a inhibitor in patients, since you mentioned, you know, tapering off the steroids, tapering off the methotrexate, potentially depending on patient tolerance and course. What's your approach to the TNF-a inhibitor?   Dr McCombe: Yeah, so, of course I follow them clinically, and then radiologically as well, and it's really satisfying if you can see the resolution of their symptoms as well as resolution of the abnormalities and the MRI, so I let that guide me a little bit. But, in most patients, I keep them on therapy for about one to two years, and then at that point, see if I can cease it in some patients. And I, again, continue to follow them radiologically and clinically after I cease it so that I can ensure that I'm catching their disease more quickly if it does come back and then can just reinitiate therapy, but in lots of patients you're able to stop the medication and they have persisting, kind of, disease freedom after that, and so they don't need to be on anything.   Dr Nevel: Yeah, great. And I'm almost hesitant to focus so much on neurosarcoidosis. (It was the rheumatologic manifestation that you talked about the most in your article.) I'm going to put in a plug for everybody to read your article so that they can read about neurologic manifestations of rheumatoid arthritis, Sjogren's, lupus, Behcet's - many more things. But focusing on neurosarcoidosis, it can be difficult in my experience to definitively diagnose, and people who have neurosarcoidosis particularly, and people who don't seem to have any systemic manifestations or, you know, imaging findings consistent with sarcoidosis - can you share your approach with us? And you outlined this in your article nicely, too, but your personal approach to patients with suspected neurosarcoidosis, and how you make that clinical decision to treat somebody with possible neurosarcoidosis, somebody who maybe you're not able to get pathologic evidence on?   Dr McCombe: Absolutely. Yeah, those ones are difficult. And, you know, whenever possible (as I mentioned in my article), I think pathological evidence of a diagnosis is important, because then when you find yourself a year down the road and a treatment path and you have uncertainty, it's much more difficult to consider continuing medications that can have quite a number of side effects when you're not absolutely certain about that diagnosis. But, in some patients, you know, I've had patients who might have nondiagnostic biopsies (if you attempt to do a biopsy), or they have disease in a site that really just isn't amenable to biopsy, or they have some other reason they can't have a biopsy. So, how I approach that is that, you know, if you think about possible neurosarcoidosis similar to any other nondiagnosed, you know, blow out-like lesion (for lack of a better term) in the CNS, if it's steroid-responsive, I think that kind of going down a path of treating it as a steroid-responsive lesion is kind of the approach that I take - so the diagnosis in the chart might be possible neurosarcoidosis, but in the back of my mind, I'm just thinking of kind of a steroid-responsive nondiagnostic or idiopathic lesion. So, I then follow that up typically with something like methotrexate (so, a more broader- spectrum immunosuppressant-type medication), and if the methotrexate is able to maintain the response that the steroids initiated, then eventually get them off the steroids. And so, you know, if I think about my patients that I've treated in the past, if they have a diagnosis of possible neurosarcoidosis, I probably don't start a TNF-a inhibitor as quickly in them, because in the back of my mind, I'm always wondering what type of inflammatory lesion this is, but that steroid responsiveness really helps me decide to start a second-line or maintenance therapy and then, typically, in those patients, as I mentioned, I'll start something like methotrexate a little bit more soon.   Dr Nevel: Yeah, great. Thanks for sharing that with us. So, what do you think comes next in this field? What excites you? Where do you think our next kind of development or understanding or breakthrough, whether it's diagnostic or treatment-wise?   Dr McCombe: I think, in the field, you know, any immunologic diseases, we've been really gaining a much better understanding of pathophysiology, and that's honestly what excites me the most, when you can know precisely what part of the immune system is at play here (whether it's, you know, complement-mediated or antibody-mediated) and then being able to then rationally choose medications based on a really clear understanding of the disease is something that I think is kind of novel in a way. For so many years, we would use kind of big broad-spectrum immunosuppression - even in multiple sclerosis, still, we use medications that, historically, we've found to be helpful - but we don't have a great understanding sometimes of why the medicines work. So, kind of going at it from the other way, where we're actually determining what is the exact pathophysiology of disease and then making a rational approach to a therapy, or choosing a therapy based on that, I think is what excites me the most, and I think we'll gain a better understanding of even a broader swath of diseases and be able to make those choices more often. That's what I like about this field.   Dr Nevel: Great. Well, thank you so much for sharing that - and looking forward to the future in this area of neurology. And thanks so much for talking with me today and sharing your story and your expertise and knowledge.   Dr McCombe: Well, thank you for having me. It's been fun.   Dr Nevel: And I encourage all the listeners to read your article. Again, today, I've been interviewing Dr Jennifer McCombe, whose article on neurosarcoidosis and neurologic involvement of rheumatologic disorders appears in the most recent issue of Continuum on autoimmune neurology. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today.   Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at Continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Dr. Jackie Sherbuk, Assistant Professor of Medicine at the USF Morsani College of Medicine, presents this case-based review of the opportunistic infectious syndromes associated with HIV-AIDS. The speaker covers PJP prophylaxis and treatment, HIV pulmonary disease, and cryptococcal meningitis. Dr. Sherbuk also discusses IRIS (Immune Response Inflammatory Syndrome) and its effect on the AIDS patient when antiretrovirals are started. Lastly, Dr. Sherbuk covers HIV esophageal disorders, Histoplasmosis, Coccidioidomycosis, and Mycobacterium avian-complex-related syndromes.

The boys slip one under the radar with a special redux episode covering... Well, you'll just have to listen to find out! That being said, don't expect the plot any time soon. The fellas are not super eager to talk about this one. But they ARE excited to talk about: The artist formerly known as Texas, 'Dillo Dollars, French necromancy, PJP, Boom Sauce, Prilk and Chekhov's Hot Dog.

It's time for a bumper edition of the PJP takeover as Ning brings onboard Lez & 80's thrash aficionado Gaz to look at one of the aforementioned genre's seminal albums,  Reign In Blood by cuddly metalheads Slayer.   Even the usual Jukeboxpod host would struggle to downplay the reverence of the big hitters ‘Angel of Death' & ‘Raining Blood' on this effort but how's the rest of the material hold up nearly 40 years on?  The guys cover all aspects of the album and conduct a major internal discussion over track listing & song running times, heavy metal heaven indeed

The guys recap their vacations and Max talks about playing the non-rev game // The latest PJP drama (recorded prior to the release of JC's rebuttal video) // We've both performed go-arounds recently, Dylan and Max both reflect // Mailbag: Clarity Aloft vs. Bose Proflight, More jumpseat headset observations, EVTOL thoughts // Flight Advice: #1 - College student asks for advice on applying for internships. #2 - Should I sign a training contract in a cadet program? Advanced Aircrew Academy's Blog Join us in supporting the Pilot Mental Health Campaign by making adonating. Listener Rick S will match 21.Five listeners donations up to $1000! 21Five's Youtube Channel Connect with us on LinkedIn Our sponsors: Harvey Watt, offers the only true Loss of Medical License Insurance available to individuals and small groups. Because Harvey Watt manages most airlines' plans, they can assist you in identifying the right coverage to supplement your airline's plan. Many buy coverage to supplement the loss of retirement benefits while grounded. Visit harveywatt.com to learn more! Advanced Aircrew Academy enables flight operations to fulfill their training needs in the most efficient and affordable way—anywhere, at any time. We do this by providing high-quality professional pilot, flight attendant, flight coordinator, maintenance, and line service training modules delivered via the web using a world-class online aviation training system. Visit aircrewacademy.com to learn more! Tim Pope is a CERTIFIED FINANCIAL PLANNER™ and a pilot. His financial planning practice provides services to aviation professionals and aviation 401k plans. Tim helps clients pursue their financial goals by defining them, organizing & optimizing resources, planning, implementing, and monitoring their financial plan. Visit https://link.21fivepodcast.com/timothy-pope to learn more. Check out Tim's new podcast: The Pilot Money Podcast Employee Compensation Software That Answers "What's the Going Rate?" The AirComp Calculator™ is business aviation's only online compensation analysis system. It can provide precise compensation ranges for 14 business aviation positions in six aircraft classes at over 50 locations throughout the United States in seconds. VAERUS MEANS RIGHT, TRUE, AND REAL.Buy or sell an aircraft the right way, using a true partner, to make your dream of flight real. Connect with Brooks at Vaerus Jet Sales | Learn more about the DC-3 Referral Program Do you have feedback, suggestions, or a great aviation story to share? Email us info@21fivepodcast.com Check out our Instagram feed @21FivePodcast for more great content and to see our collection of aviation license plates. The statements made in this show are our own opinions and do not reflect, nor were they under any direction of any of our employers.

This week, Marianna sits down with John Faragon to talk about OI Prophylaxis, which stands for Opportunistic Infection Prophylaxis or prevention in HIV. Join us as we discuss new DHHS guidelines, PJP, and more. --Help us track the number of listeners our episode gets by filling out this brief form!  (https://www.e2NECA.org/?r=AXR6258)-- Episode Resources: Prevention guidelines: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-newHIV Drug Resistance Database: https://hivdb.stanford.edu/HIV Assist: https://www.hivassist.com/IAS-USA Drug Resistance Mutations: https://www.iasusa.org/2022/09/23/2022-update-of-hiv-drug-resistance-mutations-now-available/National Clinician Consultation Center (NCCC): https://nccc.ucsf.edu/--Want to chat? Email us at podcast@necaaetc.org with comments or ideas for new episodes. Check out our free online courses: www.necaaetc.org/rise-coursesDownload our HIV mobile apps:Google Play Store: https://play.google.com/store/apps/developer?id=John+Faragon&hl=en_US&gl=USApple App Store: https://apps.apple.com/us/developer/virologyed-consultants-llc/id1216837691

Dr. Jack Cush Reviews the news and journal reports on CVA, TKA, PJP, ADA, and more!

Hello and welcome back to the oasis podcast! Follow @oasispodcast on twitter and @oasispod on instagram Support patreon.com/oasispod Check out the full interview with James Hargreaves here - https://youtu.be/nRoYJa9FABI Check out Silvertone Hills here - @silvertonehills  https://www.youtube.com/@silvertonehills Check out PJP's full cover of Easy Now here - https://youtu.be/nX4WItURfuk

Democrats padded their midterm elections win tally this week with another victory in Georgia's runoff election to fill the state's second Senate seat. When neither incumbent Raphael Warnock nor challenger Herschel Walker garnered 50% of the vote in November, that set Georgia's voters on an accelerated runoff schedule. One of the strangest races in this year's senatorial elections got even stranger with former football star Walker making comments about werewolves and vampires and dodging additional accusations of allegedly encouraging former girlfriends to get abortions. Although Reverend Warnock won convincingly enough to have the race called mere hours after polls closed, Walker still managed to garner 48.6% of the votes cast. Jessica welcomes journalist Greg Bluestein from the Atlanta Journal-Constitution back to PJP to discuss the runoff, how Warnock won, why Walker lost, why Republicans still voted en masse for a candidate as flawed as Walker, and why Brian Kemp beat Stacy Abrams so convincingly in the Georgia governor's race.

After an earth-shattering term that ended federal protection for abortion in the last term, the 6-3 Supreme Court GOP majority is flexing its power in the new 2022-2023 term. Jessica welcomes the PJP producer and co-host Joe Armstrong back to discuss upcoming cases about redistricting and voting rights, a 1st Amendment case that deals with Andy Warhol (you read that right), a pair of cases that address affirmative action, yet another religious rights and discrimination case, and a doozy of a case with colossal implications that deals with what what is referred to as the independent legislature doctrine. And there is a new justice on the bench, with Ketanji Brown Jackson displaying a keen legal mind in the first oral arguments of the new session.

A panel of judges on the 4th United States Circuit Court of appeals this week reversed a decision by a trial judge that barred the election board in North Carolina from looking into whether Rep. Madison Cawthorn was eligible to hold public office after taking part in the Washington rally that preceded the January 6th, 2021 insurrection at the Capitol. Cawthorn last week lost his primary election and will not appear on the ballot for reelection in November, but the precedent - based on a section of the 14th Amendment that dates to just after the Civil War - has far-reaching implications for other lawmakers who may have participated in the "Stop the Steal" riot. In this episode of PJP, Jessica explains why this crucial clarification goes far beyond the soon-to-be former Congressman Cawthorn.

In this episode from the series “Key Decisions in HIV Care,” Cristina Mussini, MD, and William R. Short, MD, MPH, AAHIVS, discuss important considerations for ART with opportunistic infections, including: When to start ART with pneumocystis pneumonia including discussion of the ACTG 5164 study of immediate vs delayed ART with opportunistic infectionsEACS, DHHS, and IAS-USA guideline recommendations for starting ART in the setting of most opportunistic infectionsConsiderations for the administration of ART to patients who are unable to swallow or critically ill and intubatedTreatment of Kaposi sarcoma and considerations for starting ART to avoid drug–drug interactions with Kaposi sarcoma treatmentConsiderations for starting ART with cytomegalovirus and the risk for IRIS from cytomegalovirusDiscussion of treatment of cytomegalovirus and overlapping toxicities between its treatment and ARTWhen to start ART with cryptococcal meningitis and the data to support delayed treatment initiation with this particular opportunistic infectionEACS, DHHS, and IAS-USA guideline recommendations for starting ART in the setting of cryptococcal meningitis specificallyTreatment of cryptococcal meningitis and managing drug–drug interactions between ART and antifungal therapyPresenters:Cristina Mussini, MDHead of Department of Infectious Diseases and Tropical MedicineFull Professor of Infectious DiseasesInfectious Diseases Clinics University HospitalUniversity of Modena and Reggio EmiliaReggio Emilia, Italy William R. Short, MD, MPH, AAHIVSAssociate Professor of MedicineDivision of Infectious DiseasesDepartment of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania Content based on an online CME program supported by educational grants from Gilead Sciences, Inc.; Janssen Therapeutics, Division of Janssen Products, LP; and ViiV Healthcare.Follow along with the slides at:https://bit.ly/3uktrm1Link to full program:https://bit.ly/3q2DlGd

In this episode we cover the rare but important driver of your patients respiratory failure:  Pneumocystis Jiroveci Pneumonia. Come listen to why you should always delineate HIV status, how to approach patient workup and treatment via an invasive and non invasive manner, and why heatwaves is just a sick song.

Joe Armstrong makes his first appearance of 2022 on PJP this week, and he and Jessica discuss three of the biggest current legal topics. First, former Alaska Governor Sarah Palin took the stand in her defamation suit against the New York Times this week. How did she do? [ANSWER: Not great.] We also recently learned that although Donald Trump may or may not have been flushing official documents down a White House toilet, he most definitely improperly took some top secret documents with him when he left for Mar-a-Lago in Florida. Lastly, the Supreme Court this week ruled in Alabama's favor when it came to a recent challenge to congressional redistricting despite a violation of the Voting Rights Act, and Jessica shares some theories about how this "shadow docket" decision may be related to SCOTUS' recent YOLO energy.

Thank you to the first sponsor of the show - the Church Of Phizodernica! Mention the promo code "PJP" upon admission for a years worth of boosters (actual number of doses unknown). This episode is all about fear. It does not do us any good to fight fear with more fear. "Darkness cannot drive out darkness; only light can do that." - MLK Jr. For any questions, comments, or if you'd like to join me for a conversation reach out to plaidjacketphilosopher@gmail.com. Please rate, review, subscribe, and mention it to a friend if you are enjoying it! https://linktr.ee/plaidjacketphilosopher

An interview with Dr. Leslie Fecher from the University of Michigan Health System, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She reviews considerations for the use of steroids to manage immune-related adverse events in patients treated with immune checkpoint inhibitor therapy in the final episode of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines   TRANSCRIPT SPEAKER 1: 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, at asco.org/podcasts. My name is Brittany Harvey, and today we're continuing our series on the management of immune related adverse events. I am joined by Dr. Leslie Fecher from the University of Michigan Health System in Ann Arbor, Michigan, author on "Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy. ASCO Guideline Update" and "Management of Immune Related Adverse Events in Patients Treated with Chimeric Antigen Receptor T Cell Therapy, ASCO Guideline." And today we're focusing on considerations for the use of steroids to manage immune related adverse events in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Fecher. LESLIE FECHER: Thank you, Brittany, for this invitation. BRITTANY HARVEY: Great. Then I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with a publication of the guidelines in the Journal of Clinical Oncology. Dr. Fecher, do you have any relevant disclosures that are related to these guidelines? LESLIE FECHER: The details of my disclosures are included in the manuscript, but I'd just like to note that I have received research funding, specifically in the form of clinical trial funding, from companies that do manufacture these immunotherapies. BRITTANY HARVEY: Thank you. Then getting into the content, so steroids are valuable agents in the management of immunotherapy related adverse events. So first, what should clinicians consider pretreatment with steroids? LESLIE FECHER: So I think one of the first things is obviously going back to the traditional history and physical exam, and making sure you understand any preexisting comorbid conditions, such as diabetes, high blood pressure, preexisting cataracts or glaucoma, infections, osteopenia or osteoporosis. It's always good to try and optimize things before getting started on steroids. Additionally, it's typically considered very reasonable to check hepatitis B and C serologies prior to starting immunotherapy treatment. And also consideration of assessment for tuberculosis, if there are specific risk factors, understanding if somebody already carries a diagnosis of HIV, and Understanding the status of that in advanced would be relevant. BRITTANY HARVEY: Those are important considerations. Then in addition to that, how should opportunistic infections be prevented? LESLIE FECHER: So one of the most common infections that we tend to try and prevent is pneumocystis jirovecii pneumonia, or PJP, previously known as PCP pneumonia. And this is one of the more common things that we recommend prevention for. So in patients who have received the equivalent of prednisone dosing of 20 milligrams per day for four or more weeks, or greater than 30 milligrams per day for three weeks or more, that's when it would reasonably be indicated. There are obviously specific institutional guidelines for the preferred regimen, but I think that's important to consider. The role of viral prophylaxis as well as antifungal prophylaxis is a bit less clear, but is something to be considered, especially depending on the duration of the steroid course. And whether or not in the setting of herpes zoster, for example, if the patient has had issues with zoster in the past. BRITTANY HARVEY: OK. and then the use of these steroids is to treat immunotherapy related adverse events. But what are the key recommendations for monitoring both the short term and long term adverse effects from steroids? LESLIE FECHER: So I think being aware of the side effects as well as making sure that the patients and the family members or loved ones that are helping them are aware of them as well. From a short term standpoint, typically we recommend things such as GI prophylaxis, with either a proton pump inhibitor or a histamine 2 antagonist, to reduce or prevent gastric ulcers or duodenal ulcers or gastritis. Given some of the long term effects, such as bone loss as well as steroid myopathies, we encourage exercise as well as physical therapy in some circumstances. But really one of the most important things is to make sure that you're constantly both assessing and eliciting from the patient and family members for any other side effects. So often, common acute short term side effects can be increased risk of infection. So making sure you're asking about it. They may not have the typical manifestations of infection, such as fevers or chills. Insomnia or difficulty with anxiety, irritability, skin changes for sure, or high blood pressure. And then obviously being aware that laboratory evaluation for glucose intolerance is important as well. BRITTANY HARVEY: Definitely. Those are important points for clinicians, patients, and caregivers. So then we've had some of the other authors on this guideline talk about tapering steroids. So what are those recommendations on how clinicians should taper steroids? LESLIE FECHER: So tapering is an art in and of itself in my opinion, and there's lots of different ways to do it. Some general concepts are you want to really try and understand what the side effect is that you are managing, because that will require frequent reassessment. And so when we talk about reassessing patients during the treatment of their toxicities, the management of the toxicities, in my opinion, is almost as important as the management of the immunotherapy itself. And so patients still need to be seen, still need to be assessed, still need blood work done. And so reassessment for the toxicity that you're managing, given that we can see rebounding of symptoms. So for example, if they were getting treated for diarrhea or colitis, having a really good understanding of what their baseline bowel movements were, how bad they got, and then a constant reassessment and making sure that the patient, as well as the family, knows that this should not come back again, if you will, in the midst of the taper. I think the other things to be aware of is that I tend to always reassess before giving the next decrease in dose of the steroids rather than having an automatic decrease. Because again, patients sometimes will follow those, even if their symptoms recur. So ensuring that there's that, again, reassessment. When we're on oral steroids, some of the general concepts we say is that the course should be at least usually about four weeks total, sometimes as long as six weeks or even longer, depending on the toxicity. And we think about, on average, decreasing from a prednisone or prednisolone amount roughly 10 milligrams every three to seven days, depending on the side effect that you're managing. The longer the taper, the slower you might need to go, depending at the end. And also being aware of the risk of adrenal insufficiency towards the end of a long steroid course is also an important thing to assess for. BRITTANY HARVEY: Great. I appreciate you reviewing those considerations. So then in your view, Dr. Fecher, how will these recommendations for the use of steroids in the management of immune related adverse effects impact both clinicians and patients? LESLIE FECHER: I think it will bring ongoing awareness to the physician and their team, as well as the patient and their team. I think that this is obviously really important that everybody is involved and aware. And I use the term engagement from a patient and family member standpoint. It's really critical to have an understanding of the side effects, have an understanding of the prednisone management. And explaining that not only to the physician team and nurses and other people involved in their care, but when patients call in, that they know to look out for rebounding of their symptoms and to report them immediately, as that can impact steroid tapering. I think, again, the awareness and engagement is going to ensure that patients get the best care and best results. BRITTANY HARVEY: Absolutely, and thanks for highlighting both that awareness and engagement. So thank you so much for your work on these guidelines, and for taking the time to speak with me today, Dr. Fecher. LESLIE FECHER: Thank you so much, Brittany. I appreciate your time. 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/supportive care 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.

An interview with Dr. Loretta Nastoupil from MD Anderson Cancer Center, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She discusses the identification, evaluation, and management of hematologic toxicities in patients receiving ICPis, including hemolytic anemia among others in Part 10 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines   TRANSCRIPT [MUSIC PLAYING] SPEAKER: 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, at ASCO.org/podcasts. My name is Brittany Harvey. And today, we're continuing our series on the management of immune-related adverse events. I am joined by Dr. Loretta Nastoupil from the University of Texas M.D. Anderson Cancer Center in Houston, Texas, author on Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy, ASCO Guideline Update, and Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy ASCO Guideline. And today, we're focusing on hematologic toxicities in patients treated with immune-checkpoint inhibitor therapy. Thank you for being here, Dr. Nastoupil. LORETTA NASTOUPIL: Thanks, Brittany. I'm happy to be here. BRITTANY HARVEY: Great. Then first I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Nastoupil, do you have any relevant disclosures that are related to these guidelines? LORETTA NASTOUPIL: Yes, Brittany. So I have received honorarium for participation in advisory boards from the following companies, including BMS/Celgene, Genentech, Janssen, Novartis, Merck, MorphoSys TG Therapeutics, and Takeda. And I've also received research funding support from BMS/Celgene, Gilead Kite, Genentech, Janssen, Novartis and Takeda. BRITTANY HARVEY: I thank you for those disclosures. Then let's get into what we're here today to talk about. So what are the immune-related hematologic toxicities addressed in this guideline? LORETTA NASTOUPIL: So it's important to recognize that hematologic toxicities that are immune-related as a result of immune therapy are infrequent occurrences. So it's important to recognize when they do occur and some of the unique workups given that they are so infrequent. So probably one of the most common is hemolytic anemia. It's important to recognize that these are cancer patients. And they may have multiple reasons for the development of acute or new onset anemia, but recognizing if they're on either checkpoint inhibitors or immune therapies, it's important to recognize that it might be spurred on as a result of immune-mediated anemia. We advise in terms of history and workup to consider whether or not they've been exposed to new drugs, whether or not they've had a recent insect or snakebite exposure. The recommended workup includes a CBC with also a peripheral blood smear to look for evidence of hemolysis or macroketosis. In addition, other hemolytic anemia workup includes evaluation for LDH, haptoglobin, reticulocyte count, bilirubin, and free hemoglobin. Other potential diagnoses on the differential include DIC, so a panel, including coags, PT, INR, and PTT, exploring autoimmune serologies, PNH screening, evaluation for infection such as viral or bacterial causes of hemolysis, and also consideration for bone marrow failure syndrome, including evaluation for potentially reversible causes, such as B12, folate, copper, parvovirus, iron, thyroid, infection, et cetera. G6PD level is helpful in the evaluation, as well as exploration as I mentioned of potentially new drugs that might be linked, including ribavirin, rifampin, dapsone, interferon, some of the antibiotics, such as cephalosporins, penicillins, NSAIDs, ciprofloxacin, for instance, et cetera. So as part of the workup, if we have excluded alternative causes and we think that the immune-checkpoint inhibitor might be the underlying cause of the autoimmune hemolytic anemia, then generally we will continue unless they have grade 2 or higher toxicity, which is generally a hemoglobin less than 10. In which case, we would recommend to hold the immune-checkpoint inhibitor, again, with significant anemia. So those with grade 2 or higher, you might consider initiating corticosteroids, including 1.5 to 1 milligram per kilogram per day until improvement. For grade 3 or higher-- so this is more severe anemia So hemoglobin is less than 8. Generally, we're recommending permanent discontinuation of the checkpoint inhibitor and potentially higher doses, including up to 2 milligrams per kilogram per day of prednisone or corticosteroid equivalent to speed up the recovery. In regards to transfusion requirements or consideration, we are suggesting you evaluate or consider your local or regional guidelines. We generally do not transfuse for a target hemoglobin greater than seven to eight. And we also recommend supplementation with folic acid. BRITTANY HARVEY: Great. And then beyond those recommendations for hemolytic anemia, what are the key recommendations for identification, evaluation, and management of acquired thrombotic thrombocytopenia purpura? LORETTA NASTOUPIL: Sure. So fortunately, TTP is quite rare, but, again, something that is worth exploring. Some of the challenges are in the clinical syndrome. And that it can mimic some of the other toxicities that are covered in other sections, particularly the neurotoxicity section. But essentially, for patients who have pretty dramatic change in platelet count, again, they may have additional clinical sequelae such as neurologic toxicity or adverse events. It's important to recognize that TTP might be an underlying cause, again, for patients who are on immune-checkpoint inhibitors. This is where a hematology consult early in the clinical course would be particularly of importance to recognize it and potentially to minimize offending agents. Drug exposure is always important, because many of these patients might have other drugs, in addition to their immune-checkpoint inhibitors, such as chemotherapy, sirolimus, tacrolimus, antibiotics et cetera. And so exploring offending agents is important. An ADAMTS13 level, an inhibitor titer, would be important to send if you're considering TTP, in addition to evaluating the peripheral smear, and the hemolytic anemia workup, as I just mentioned, including LDH, haptoglobin and reticulocyte count. Exploring infectious etiology, including CMV titers or serology, would be particularly helpful, an additional clinical evaluation, such as brain imaging with CT or MRI, echocardiogram, and EKG would be of help. For all grades of TTP, again, even with a clinical suspicion for the diagnosis, in addition to hematology consult, we recommend stabilizing the patient. That might require care in an acute care setting, making sure that they have adequate organ function and that this is stabilized. For grade 1 or higher, we recommend holding the immune-checkpoint inhibitor. And you might consider, again, initiation of corticosteroids with 0.5 to 1 milligram per kilogram per day of prednisone or an equivalent. For grade 3 or higher, we would, again, in addition to holding the checkpoint inhibitor and in conjunction with your hematology colleagues, you might initiate a therapeutic plasma exchange. Again, in accordance with existing guidelines, you may consider higher doses of steroids, including methylprednisolone 1 gram IV daily for three days. You could consider some additional supportive agents, such as rituximab or pembrolizumab if the ADAMTS13 level is less than 10 or less than 10% of normal and an inhibitor or elevated ADAMTS13 IgG has been detected. BRITTANY HARVEY: I appreciate you going through the details for TTP. So then, additionally, this guideline addresses aplastic anemia. So what are the key recommendations for identification, evaluation, and management of aplastic anemia? LORETTA NASTOUPIL: Yeah. So fortunately, again, these are quite rare situations. So with aplastic anemia, similar to what we've discussed in terms of workup of anemia, globally, it's important to explore potentially causes of, again, bone marrow failure syndrome. And aplastic anemia is one of those such causes. Exploration of a bone marrow biopsy in conjunction, again, with your hematology consult would be critically important, and exploring potentially reversible causes, again, such as deficiencies and important nutrients, viral etiologies, in addition to parvovirus, CMV, HHV-6 is important to consider and rule out. But I think the end of the day, a bone marrow biopsy and aspirate is going to be the most helpful assessment to ensure that aplastic anemia has been considered and worked up. In regards to management of aplastic anemia, we're going to hold the immune-checkpoint inhibitor. You may need to provide additional support such as growth factors. And close follow-up, I think is the most critical aspect of this. Sometimes we initiate patients on corticosteroids. We hold the checkpoint inhibitor. And then we may monitor them less frequently. Oftentimes, these patients with high malignancies are going to need to be followed very closely, sometimes weekly or multiple times a week. So in regards to management of aplastic anemia that might be immune mediated as a result of immune-checkpoint inhibitors and in conjunction with your hematology and colleagues, consideration of management might include administration of horse ATG and cyclosporine, but again transfusion support, growth factor support, even consideration for HLA typing and evaluation first. Stem cell transplantation might be appropriate, particularly for a young patient with minimal comorbidities. For grade 3 or higher, in addition to these considerations, we're going to hold the checkpoint inhibitor and monitor weekly for improvement. If no response, you might consider repeating immune suppression with Rabbit ATG plus cyclosporine or cyclophosphamide. And for refractory patients, consider eltrombopag plus best supportive care. BRITTANY HARVEY: Great. Thank you. Those are important notes on the management of aplastic anemia. So then, additionally, what are the key recommendations for the identification, evaluation, and management of lymphopenia? LORETTA NASTOUPIL: Yeah. I think one of the challenges with lymphopenia, it's common for patients who've had cancer-directed therapy, particularly things like chemotherapy. And so understanding whether or not this is a new onset after exposure to checkpoint inhibitors is one of the critical aspects, in addition to considering alternative causes. But for patients in which we do think the lymphopenia is a result of the immune-checkpoint inhibitor, we're not generally advising discontinuation or holding of the immune-checkpoint inhibitor, but it is important to consider best supportive measures, including whether or not patients might benefit from monitoring for reactivation of certain viral etiologies, including CMV and HHV-6, for instance, in addition to potential consideration for prophylactic strategies, such as PJP prophylaxis. Also, zoster reactivation might be something that these patients might indeed be at risk for. So as opposed to holding your checkpoint inhibitor and initiating things like corticosteroids, if we have excluded alternative causes and think lymphopenia is a result of the immune-checkpoint inhibitor or as immune mediated, ensuring that they are receiving best supportive care to mitigate some of their toxicity that may result as the result of the lymphopenia. BRITTANY HARVEY: Understood. And it's important to note for clinicians that management is different from a lot of the management of the other hematologic toxicities. So then the last hematologic toxicity that was addressed in this guideline was acquired hemophilia A. So what are those key recommendations? LORETTA NASTOUPIL: Acquired hemophilia A, again, fortunately is very rare and uncommon, but this is one situation where engagement of a hematologist, who is an expert in management of hemophilia, will be critical. So that would potentially be step one. In terms of laboratory assessment, that would be helpful, in addition to your CBC, where you're assessing things like platelet count, coagulation workup, including fibrinogen, PT, PTT, INR, that would be informative. Patients with acquired hemophilia A will likely have a prolonged activated PTT with a normal PT. So that might be one of the clues. Imaging would be helpful to ensure the patients don't have any signs of spontaneous bleeding or hematoma basis, such as MRI, CT, or ultrasound, if particularly they have any localizing symptoms. Medication review to look for alternative causes would always be helpful. And determination of the Bethesda unit level of inhibitor would be critical. In regards to management, we would hold the checkpoint inhibitor, initiate corticosteroids, transfusion support as indicated, and you want to treat the underlying acquired hemophilia with conjunction of a hematologist. For grade 2 or higher, this may require factor replacement. And the choice is usually based on the Bethesda unit of the titer. Administration of prednisone, in addition to rituximab 375 milligrams per meter squared weekly for four weeks or cyclophosphamide dosed at 1 to 2 milligrams per kilogram per day may be patient specific. And, again, that decision should be made in conjunction with your hematology consult. Prednisone, rituximab, and cyclophosphamide should be given for a minimum of five weeks. And factors should be prescribed to increase the level, particularly during bleeding episodes. And, again, the choice of the factor is based on the presence or absence of an inhibitor. For grade 3 or higher, we advise to permanently discontinue the immune-checkpoint inhibitor. These patients generally will be admitted for stabilization. They do require factor replacement. Bypassing agents may also be required, including factor VII. Caution should be taken in elderly patients and those with coronary artery disease. Corticosteroids, rituximab, and cyclophosphamide should also be considered, transfusion support, if they're having active bleeding. And if worsening or no improvement, you could consider adding cyclosporine or immune suppression to try and stabilize these patients. Again, acquired hemophilia A requires special clinical and laboratory expertise. This would require consult and potentially even transfer to a specialized center, and consultation with a hemophilia center should be initiated as soon as this is considered or confirmed. BRITTANY HARVEY: That's a great summary of these recommendations. The expert panel and you clearly put in a lot of work into these recommendations. So then in your view, how will these recommendations for the management of hematologic toxicities impact both clinicians and patients? LORETTA NASTOUPIL: I think the most important thing are disseminating this information. I think ASCO plays a critical role in helping clinicians first recognize some of the toxicities that are different from what we have traditionally seen with chemotherapy and may have different management strategies. So guidelines, such as this, are critically helpful. Podcasts, such as this, are incredibly helpful to get the information out, recognizing that all of us authors are more than willing to provide additional guidance and are willing to be contacted in this situation where someone's facing one of these unique and rare toxicities and would like some additional guidance in terms of further management. Hematologic toxicities are sometimes hard to distinguish or maybe potentially hard to recognize, given many of these patients may have been on prior chemotherapy agents, and anemia or thrombocytopenia may not be unusual, but recognizing if it's new or more severe than what has been seen previously and that, at least, consideration of an immune-mediated hematologic toxicity, be considered, because the management might be unique. And so I hope that we've outlined today some of the hematologic toxicities that are rare that may be seen with immune therapy and some of the strategies to work up alternative diagnoses and management if it is indeed immune-mediated toxicity. BRITTANY HARVEY: Definitely. And I really appreciate you going through these rare but very important toxicities. So thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Nastoupil. LORETTA NASTOUPIL: Thanks, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune-related adverse events. To read the full guideline, go to www.ASCO.org/supportive care guidlines. 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. [MUSIC PLAYING]

Opening Track - Swangin' On Westheimer x Don ToliverClosing Track - Praise God x Kanye West Ft. Baby Keem and Travis $cottRedd turned 29OT turned 33PJ turned 32Jay turns 23 in a couple of daysand Tre turns 28 a week laterSo it's only right we celebrate it!Most of S5 birthdays happen in the fall (Sept-Oct) so you know its big energy in the room......and balanced lolBrief discussion about Facebook and IG going down.Birthday week Recap from Red, Otis and PJP throws up at the SpotDave Chapelle and the LGBTQ+ backlashR Kelly and Elvis discussionsDallas shooting at school and bullying 18 Former NBA players arrested on health insurance fraud.

Stichwortzettel: Ballerman, Mallorca, Fancy essen gehen, Fuß eingeschlafen, Paranoid, mit der Axt in den Fuß, Schmerzempfinden, Parkemed vs. Aushalten, Top 3 der schlimmsten Foltermethoden, Zeitreise Mittelalter, Gladiator*innen der Neuzeit, Neues Spiel; Meanwhile on Facebook: dumme Facebook-Post suchen, alte gegen neue Werbung, Ilkcan infiltriert Fachhochschule. Wenn nichts für Sie dabei war, tut es dem ganzen Team von Peace Joy And Pancakes außerordentlich leid! Wir hoffen, dass wir Sie mit den Themen der nächsten Episode erreichen können! Mit freundlichen Grüßen PjP

Hey hey! This week I wasn't able to put in the appropriate time to record a new episode thanks to a family health issue and a record-setting heat wave rolling through locally. Next week I will be back with a new episode but this week I'm giving a replay of PJP#32. I apologize to those of you who've been following for a while, but to those of you who haven't listened back - this was one of my favorite episodes to record. We discuss "Cancel Culture" vs "Headline Culture" and why they both should be challenged.  For any questions, comments, or if you'd like to join me for a conversation reach out to plaidjacketphilosopher@gmail.com. Please rate, review, subscribe, and mention it to a friend if you are enjoying it! https://linktr.ee/plaidjacketphilosopher

Hear Me, See Me. Podcast. Paul Jones, Paul Jones Project.I first met Paul Jones when he asked me to be a guest on his Paul Jones Project after being recommend by my good friend Neil Moody.I really enjoyed it and said that " you've shown me yours so let me show you mine " so he agreed to be a guest on Hear Me, See Me Podcast. He is funny, entertaining and his positivity is infectious. I thoroughly enjoyed our chat and even though I was suffering from a deadly case of Man Flu ( I miraculously recovered ) I came off our chat with a real lift, such is his nature of his personality.Paul started his PJP video series during the pandemic to give people a lift and as an antidote to the depressing situation we were in and he helped so many people in and out of the industry alike.We are determined to collaborate after lockdown and he really will be an fantastic addition to the Haircuts4Homeless family.Please enjoy.Instagram : https://www.instagram.com/pauljoneshair/Website : https://www.pauljonescreative.com/Haircuts4Homeless : https://www.haircuts4homeless.com/Produced by : https://svnty6production.com/Artwork by : https://www.dvsyart.com/Support this show http://supporter.acast.com/hear-me-see-me. See acast.com/privacy for privacy and opt-out information.

 HOPA Now is the official podcast of the Hematology/Oncology/Pharmacy Association, an organization dedicated to supporting pharmacy practitioners and promoting the advancement of Hematology/Oncology/Pharmacy to optimize the care of individuals impacted by cancer.   These educational podcasts are part of our BCOP Preparatory and Recertification Course, which is designed to prepare oncology pharmacists preparing to sit for the BCOP Certification Exam, as well as meet the BPS requirement to complete a BCOP Preparatory/Recertification Review Course.   In this episode of HOPA Now, Dr. Samantha Reiss details the standard care for glioblastoma, the most aggressive form of brain tumors. She highlights main considerations surrounding the use of temozolomide, TTFs, and bevacizumab, and touches on the more controversial topics of treating elderly patients and retreatment care options for recurrent glioblastoma. She concludes with an overview of anaplastic gliomas in patients who harbor the 1P19q codeletion and those who don’t.   In this episode you will learn:   Central Nervous System Malignancies: Top 10 Clinical Pearls Standard of care for glioblastoma, the most aggressive form of brain tumors Considerations when determining if temozolomide is an absolute standard of care for patients with MGMT unmethylated tumors Supportive care for the upfront treatment of glioblastoma and options for PJP prophylaxis The role of the medical device tumor treating fields (TTF) in the upfront treatment of glioblastomas Controversial talking points regarding the treatment of glioblastomas in elderly patients The role of bevacizumab as a treatment of glioblastoma and toxicities to monitor for Recurrent glioblastoma considerations and retreatment care options Goals for the treatment of low-grade gliomas and the role of chemotherapy in this setting Anaplastic gliomas in patients who harbor the 1P19q codeletion and those who don’t   Mentioned in This Episode: HOPA   Quotes:   “This trial showed an overall improvement in survival from 12.1 months with radiation alone compared to 14.6 months with radiation plus temozolomide and the survival benefit lasted through the five-year follow-up.” — Dr. Samantha Reiss   “Chemotherapy-induced nausea and vomiting from temozolomide therapy is dose-dependent and standard emetic prophylaxis should be considered for all patients.” — Dr. Samantha Reiss   “The addition of tumor treating fields improved progression free-survival and overall survival in this patient population.” — Dr. Samantha Reiss   “Timing of radiation therapy should be considered to speed the progression and possibility of late neurotoxicity that patients can experience after brain radiation.” — Dr. Samantha Reiss  

Chief at Vanderbilt, Blake Funke, teaches us about PJP in non-HIV patients, the novel "downhill" esophageal varices and the in's and out's of parapneumonic pleural effusions! DISCLAIMER: This podcast is made by and for our internal medicine residents to enhance our educational experience. The content, while edited by residents, is not verified by host or speakers and we are not content experts on these topics. The content provided by this podcast is not intended and should not construe as medical advice and should not be used to diagnose or treat any medical condition. All opinions represented are our own and not representative of our university medical center.

In this episode, we cover ICU level Pneumocystic Jirovicii Pneumonia (previously known as Pneumocystic Carinii Pneumonia). Suggested approach: HIV +(ve) vs HIV -(ve) Invasive vs Non invasive diagnostic strategy Treatment w. Septra vs other line therapies

The gang discusses their emotional maturities, PJP fans, and bizarre weed stories. Email your questions to: askpajamapants@gmail.comOr call and leave us a voice mail at: 201.972.5262Follow us!Robert Iler: https://www.instagram.com/pajamapantspodcastKassem Gharaibeh: https://www.instagram.com/gmessakJamie-Lynn Sigler : https://www.instagram.com/jamielynnsigler

GeeDee Carey and Amy Beauchamp of Pandora's Jar Paranormal stop by one of PJP's active case site locations they have coined the "Halloween House" in Los Angeles County. At the active site, they enjoy some afternoon tea and nosh with home owners Pamela and Don, and discuss residential investigations / treatment challenges with all the paranormal layers that present at this unique location. Pamela and Don share their past paranormal experiences and pull all the strands of family life on the daily where unbelievable supernatural occurrences are a regular thing in their residence and where ever they happen to find themselves. Pamela is also the newest member of the PJP Team. Pandora's Jar Paranormal has spent two years working with this beautiful and compassionate family at their residence to make sense of all the layers of paranormal activity at their property. Join us to find out what makes this residence so special! *Pandora's Jar Paranormal episodes cover controversial topics and mature themes that intersect with the supernatural world. There is a fair amount of salty language. **Music by MonkeyMind Music Group

The alien Adam Cartier has landed on PJP again. Joe and Adam discuss a variety of topics from current events to philosophies of life. tune in and enjoy. --- Send in a voice message: https://anchor.fm/planetjoepod/message Support this podcast: https://anchor.fm/planetjoepod/support

Host Patterson Watkins takes you through the logistics of becoming a locavore! Locavore - a person whose diet consists mostly of locally grown or produced foodIf we breakdown the cycle of food starting with the farmer TO processor TO distributor TO chef/grocer TO the people - we can track how far an ingredient has to travel in order to be consumed. By keeping that cycle within our own communities it decreases ‘energy’ spending. Learn all about eating local.

Host Patterson Watkins breaks down the duality of the context around plant based diets! Should you avoid eating meat for animal rights reasons? Should you eat plant based meals to have smoother bowel movements? Let's break it all down like your colon breaking down a salad!

Feel the Bern... Bernie Sanders that is. This pod pod is all about the Bern. Joe talks politics and examines Bernie Sanders' recent speech. Whatever your political views are, you are encouraged to stay on PJP and listen. Also, support and vote for Bernie: BernieSanders.com PlanetJoePod.com | Facebook | Instagram | Twitter | Patreon | Youtube | PlanetJoeDesign.com --- Send in a voice message: https://anchor.fm/planetjoepod/message Support this podcast: https://anchor.fm/planetjoepod/support

Patterson Watkins, independent chef and food guru, host of the Left Handed Spatula a podcast from PJP. This episode features brief clips of Mike McGrath's TED Talk on composting. One of the biggest buzz words in the food service industry is "composting" in the midst of the food waste epidemic. Learn with PJP!

It's a shame that perfectly good produce goes to waste because of cosmetic and superficial judgement. Host Patterson Watkins talk about the brutal truth of food waste and how you can play your part. It's time to give ugly produce a chance, who are we to judge?

Planet Joe Pod - Podcast debut. This is Joe's first episode of PJP. in this episode Joe tells you about himself and his plans for this podcast.Oh, its also his birthday :-) PlanetJoePod.com --- Send in a voice message: https://anchor.fm/planetjoepod/message Support this podcast: https://anchor.fm/planetjoepod/support

In this Episode join us and learn about Thrombotic microangiopathies with KC, CMV retinitis with Chelsea, and PJP with Pierce!Sadly but excitedly, this was my last podcast for you all! It has been an absolute pleasure. I look forward to what your new hosts have to bring to you!This podcast is powered by Pinecast.

This episode dives into the idea of self expression, such a distinct thing in today's world of smartphones and internet culture!! What exactly sets us apart from humans of the past? And what does our future look like? With all this uncertainty in the world, self expression seems like the only way out. PJP says GO FOR IT! art by: @tnvnez Featuring: "Live Fully Now" excerpt by Alan Watts (youtube.com/watch?v=HdqVF7-8wng) "Desert Dreams" AS☀LAS, Prod. Nochi "Leafy Greens" AS☀LAS

Hey there, Shenanites! In this episode, Seth tries to spoil things, but Adam and Sam stop him. Also! We talk about the genesis of Levelhead early access, beefy switch magic, and the PJP rite of passage. To paraphrase Leonard Bernstein: all you need for greatness is a plan and not quite enough time. Want to meet up with us? We have a GDC meet-up on March 18 at 4:30p! Keep an eye on the Twitters for updates and more info. Plus, get your tickets for Shenanicon 2019 at http://meet.bscotch.net! Questions answered (abbreviated): - ANGRY MUFFIN: Will the Veeru be making an appearance in LeveLHead? - Dapvoo Doopokool: Would you ever consider doing a behind the scenes look at making the podcast? - Beekie Boppaboop: What’s one small thing that you’ve done or gotten that’s made your life much better? - Cpt. Jazz: Adam, according to your LinkedIn page, one of the societies you were a part of back in uni was "Chicago Men's A Cappella." Care to give us a sample of what went down up there? - CreatorRedA: Have you ever gotten a business card from someone that you actually used? On a related note, what are your opinions on self promotion? - Mopait Flatunk: Does Seth still stream on the weekends? Is there an archive of the videos somewhere? - Cerator: I‘ve heard about this memory palace technique you explained, but haven’t tried it. Do you think it could also work twice? Would you have to choose a different route when memorizing another list of things to prevent mixing up those two lists? Does this also work for lists that change on a daily basis like grocery lists? To stay up to date with all of our buttery goodness subscribe to the podcast on Apple podcasts (apple.co/1LxNEnk). If you want to get more involved in the Butterscotch community, hop into our DISCORD server at discord.gg/bscotch and say hello! Submit questions at https://www.bscotch.net/podcast, disclose all of your secrets to podcast@bscotch.net, and send letters, gifts, and tasty treats to http://bit.ly/bscotchmailbox. Finally, if you’d like to support the show and buy some coffee FOR Butterscotch, head over to http://moneygrab.bscotch.net.

Take a walk with us, through our past spaces—all so different yet similar and, of course, fascinating! We discuss how our hometowns have influenced us, the spaces we feel most comfortable/uncomfortable and where we feel most inspired. Here at PJP, we know the importance of recognizing the self and how our environments shape our personalities/moods/perceptions, etc. Join is as we journey through spacetime and discover ourselves! Video by @tnvnez Poem and music by @lilstargirl Featuring: “Bad Cops, Bad Charities” by Playradioplay! “Realiti” by Grimes “Not So Different” by Willow Smith #pjppodcast #tucson #douglasaz #phoenix #arizona #southwest #soundcloud #applepodcasts #creativecollective #recording #anthology #art #poetry #womenpoets #womenartists #photography #directing #experimental #videography #bordercommunity #usmexicoborder #immigration #sociology #socioeconomics #geography #ethnography #environmentalstudies #spaceexploration #exploration #selfdiscovery #identitypolitics #selfie

The topic of discussion: #IAMBELOVED, #Elevate18, #PJP, #MillennialWomen, #MillennialGathering, #Empowerment, #NextLevel, #walkbyfaith #northwestindiana #indianabloggers #indianacreators, #speaker #love #motivation #success #inspiration #music #business #writer, #lifestyle, #blogger, #leadership #entrepreneur #work #health #faith, #body, #peace, #spiritual, #god, #mind, #healthy, #transformation, #author, #soul, #wbfpodcast ________________________________________ Meet Alexandria S. Norton (@alexandria_norton): Alexandria S. Norton is one of America's rising millennial leaders. She is a highly sought after speaker who has been established as one of today's voices for young women. In our episode we covered her mission and why she started I Am Beloved. We talk about her walk with God and ministry in the church. She is a mover and shaker traveling all over to spread the message of God's word while empowering women in the process. IAMBELOVED is an organization whose mission is to encourage, enlighten, and empower women to walk confidently in Christ. We understand the hardships of being a young woman in society today and we are here to motivate and teach women how to value themselves, be bold, and not cling to any negative examples. We are here to help each woman grow and flourish in who God has called them to be. Tune in to this week's episode to hear why she walks by faith. ________________________________________ She's on social media: Instagram : https://www.instagram.com/alexandria_norton/ Facebook: https://www.facebook.com/iambelovedofficial/ --- Support this podcast: https://anchor.fm/jasmine-a-stith/support

I've only ever worn one piece of jewelry in my entire life — a silver owl ring. I mentioned a little bit about how I used it in Ep 52 : Spirit Guides, Sigils and Sign Language. This is the story of (partly) how it became so magical. It was blessed by the spirit of Pope John Paul II. Posthumously. HOST LINKS - SLADE ROBERSON Slade's Books & Courses Get an intuitive reading with Slade Automatic Intuition BECOME A PATRON https://www.patreon.com/shiftyourspirits Edit your pledge on Patreon TRANSCRIPT There is a picture of the ring on my blog. https://sladeroberson.com/blog/owlring In the episode on Spirit Guides and Sign Language, where I talked about projective and receptive energy, I promised to come back and tell this story. I’ve only ever worn one piece of jewelry in my entire life for more than like a day. I have this silver owl ring. It's like something worn by one of those guys who wears denim shirts and pants together, possibly a little Native American ancestry, probably also wearing some turquoise somewhere. Maybe a belt buckle. Have you ever seen a man wearing one of those Indian chief’s head rings? Do you know what I’m talking about? Well, my owl would be right beside it in the same jewelry tray. Now, obviously, owls are my totem, so that was a big reason why I have it in the first place. I had gone on a buying trip for this New Age store I worked at called the New Moon Gallery. Shout out to my friend Alisa who is hopefully listening right now and just started to squeal. She and I were together looking at mostly women’s jewelry for the store when I ran across this owl ring and had to buy it for myself. Not even for the store. And I wasn’t even sure I would ever wear it. It was kind of an ironic purchase in the moment. I took a quick pic with my phone just so you can see exactly what I’m talking about. It’s a carved, or casted maybe, silver ring that takes up the entire digit of one of my fingers. When I found it, it was too big for my ring finger and I took to wearing it on my index fingers. Which is why it became a part of the whole projective / receptive hand magic that I talked about on that other episode. As you’ll see in this awful pic, it has tarnished in my drawer because I stopped wearing it about seven years ago when I started lifting weights a lot. Since then, my hands are literally beefier — I didn’t know that had happened — and the tarnish makes it a little easier to see the carving detail, so I just took the pic as is. You can see it on the corresponding blog post for this episode. If you have been a Shift Your Spirits blog reader for a long time, you may remember my black and white author photo, where you can actually see it on my finger. I have my hand on my chin and that was my author pic for like ten years. So, a few years after buying that ring and hardly even knowing why considering I didn’t wear jewelry, when I started communicating with spirit guides, and trying to get back my power and a sense of direction, I started to wear that ring. I was also coding a lot and the weight of my index finger because of the ring helped me type. A QUICK DISCLAIMER ABOUT THE STORY I’M ABOUT TO TELL YOU: I am not even remotely Catholic, so I will likely butcher some details related to that. I don’t care. Of course you could say this is communication from a saint, and there have to be miracles associated with someone to become beatified. But I consider this about a connection to an individual soul, and also a member of a soul family. To be honest, his conservative statements against recognizing same sex unions are to be expected given his job, but they obviously piss me off and I completely disagree. But then I believe he was the head of one of the largest terrorist organizations on the planet. So, I don’t know what to do with the politics and the religion of the situation… Let’s just say that’s politics. I’m just going to leave it out as not really part of this story. I believe in a vague way, admittedly that I don’t fully understand, that I am connected to Mother Mary as an ascended master, that I attract others who are connected to her, regardless of religion, and that Pope John Paul II is a figure within this network of entities. I went through an intense period of researching Marian visitations. If you read books about people to whom the Virgin Mary makes appearances, of course you’ll find lots of young women, but there is a theme of her appearing or speaking to spiritual men of different faiths. It’s like a “control group” that transcends religion. If I can say this humbly, I feel a resonance with that. During all my Mary Visitation Research, I had heard this rumor somewhere that PJP II was a Marian cultist, and that a lot of the other cardinals did not want him to be pope because of this. He supposedly had some nuns secretly embroider this vest for him that said, in Latin, “I am hers” and he wore it during his inauguration. Like his predecessor, John Paul II dispensed with the traditional Papal coronation and instead received ecclesiastical investiture with a simplified Papal inauguration on 22 October 1978. During his inauguration, when the cardinals were to kneel before him to take their vows and kiss his ring, he stood up as this one Polish prelate Stefan Cardinal Wyszyński knelt down, stopped him from kissing the ring, and simply hugged him He also broke with tradition by addressing the crowd at all, in Italian, and he did declare that he accepted the responsibility of becoming pope "in a spirit of obedience to the Lord and total faithfulness to Mary, our most Holy Mother." When he died, I was sitting in a Border’s bookstore cafe — the one where I would go to visit Refuse to Choose. April 2, 2005, almost a year before I decided to move back to Chattanooga and about a year and half from launching Shift Your Spirits. I was still just blindly following these weird messages and signs and synchronicities I was receiving. I overheard this guy at a nearby table, excitedly talking about how he had impulsively decided was to jump on a plane and go to view the pope laid out in state. He was giddy with this bizarre impulse, telling his friend about the spontaneity and how he felt spiritually moved or guided to do this. Almost a week later, I think, it’s been a long time, I was in the Border’s cafe working again, writing, tinkering with code, building websites for clients, only this time I was there very late in the evening. It felt like a dream because my dreams always take place at dusk. There’s a quality to the light. And that guy was back, talking to two friends this time, same table just beside me. I listened to his breathless story about flying to Rome, getting straight into a cab, immediately standing in line, but for almost a whole day, being one of the last people they allowed through, to view the pope laid out in state, and the surreal experience of being back in a cab and back on a plane and flying home before realizing, really processing, what he felt. It all took like a day and a half. I learned later, by the way, that over a million people stood in line to see the pope laid out in state this way. This guy—I’ll never know his name—said felt strangely electrified and numb, but like he had to be there, and that all the people he would subsequently meet in life would receive some of the grace of PJP II directly. He said, he knew that sounded crazy and almost arrogant. He apologized for not being able to articulate what he meant about carrying that energy and giving it to others. At that point, I interrupted him. It wasn’t too weird, I’d caught his eye several times. Energetically and physically, I was part of both conversations, he knew that. His friends left when he started talking to me so he joined me at my table and continued to gush about his experience and the emotions and energy coursing through him. And I told him about Mary and my experiences with her and how bizarre it even was and how I wanted to tell someone about it. I asked this guy about receiving PJP’s energy. I said I thought I could actually feel it. They were getting ready to close the Borders at that point and we started walking outside together and he asked me: “Do you have a ring?” And I took off my owl ring, which I had started to wear and handed it to him. He stared at it and played with it and mumbled something over it, like a prayer or a spell. And then he handed it back to me. His eyes were shining with tears. He embarrassedly wiped them away. We walked a little further into the parking lot. The parting was strange. He said “I’m not quite sure what to do with myself, now.” I said “Me either." “We have to do something with this.” he said. “I’m going to. Promise me you will.” I said, “I will. I promise” And I did. At least, I think I did. I think this is it. All of this last thirteen years since I met him. Soon after that meeting, I received a more specific message from Mother Mary — the concept for Shift Your Spirits. Really, just the title. And that it was a blog and I was supposed to share my stories on it. The summer I started Shift Your Spirits, I dreamt a few times about PJP II. Back when I was having dreams I was at this Congress of Souls. It was this open air space that resembled the sanctuary where I have gone to Beltane Gatherings for decades, but of course, it was shifted in that dream dimension kind of way. Pope John Paul II was there giving a speech, but it was in Italian, and I couldn’t hear him. In the dream, I struggled as if it were a sound volume issue, not language … I was straining to hear him. I keep straining to hear those message and to translate what I think they’re about.

Dr. Pasikhova discusses the history of the Pneumocystis pathogen, its epidemiology, and how it is transmitted to patients. She also discusses the pathophysiology of the infection in the context of the immunocompromised cancer patient. The role of steroids in the aquisition of PJP infection is touched upon. Lastly, Dr. Pasikhova describes prophylaxis against Pneumocystis, including specific agents and their usual doses.

In this episode, Tracey is joined by Zacks Stock Strategist, Editor of the Tactical Trader and the Follow the Money Trader, Kevin Cook. The stock market is in the midst of a pullback. There’s so much going on in the stock market right now, that Tracey and Kevin recorded two episodes of the podcast. This is Part 2 of their discussion on what you should do now that stocks are selling off. In this episode, Kevin and Tracey discuss what the technicians and big money managers are saying about the stock market and how much further it may have to fall. Some numbers being thrown out, such as S&P 500 at 1300, are pretty darn scary. Street sentiment is obviously very bearish. But Kevin has noticed that recently several big money managers have gotten even more bearish, including Guggenheim Partners Global Chief Investment Officer, Scott Minerd. Minerd is usually middle of the road and is not a perma-bear. So what does that mean? Kevin has also run across some interesting trends in the S&P 500 this year. He explains the difference between the equal weight S&P 500 index and the market weight index (SPY) and the significance of the equal weight S&P 500 hitting February 2014 lows while the market weight index is barely at October lows. Tracey tracks the Russell 2000 small cap index for clues about market trends. The small caps have been a disaster in 2016. Does she see any signs that the small caps have bottomed? Kevin and Tracey like to use ETFs when there is a lot of volatility and these market conditions are no exception. Kevin likes the healthcare stocks. His favorite ETF in that sector is the Powershares Dynamic Pharmaceutical ETF (PJP), which combines big cap biotechs with big cap mainstream drug stocks. To play the small caps, Tracey says you can always invest in the general iShares Russell 2000 ETF (IWM). But she also likes the more niche ETFs, Vanguard Small-Cap Value ETF (VBR) and Vanguard Small-Cap Growth ETF (VBK). She discusses which one of those is her favorite and why. I bet you can guess. Find out all you need to know about this market sell off from Zacks experts, Tracey and Kevin, on Part 2 of this week’s podcast. SPDR SP 500: http://www.zacks.com/funds/etf/SPY/profile?cid=cs-soundcloud-ft-pod POWERSHARES DYNAMIC PHARMACEUTICALS PORT: http://www.zacks.com/funds/etf/PJP/profile?cid=cs-soundcloud-ft-pod ISHARES RUSSELL 2000 ETF: http://www.zacks.com/funds/etf/IWM/profile?cid=cs-soundcloud-ft-pod VANGUARD SMALL-CAP VALUE ETF: http://www.zacks.com/funds/etf/VBR/profile?cid=cs-soundcloud-ft-pod VANGUARD SMALL-CAP GROWTH ETF: http://www.zacks.com/funds/etf/VBK/profile?cid=cs-soundcloud-ft-pod Follow us on StockTwits: stocktwits.com/ZacksResearch Follow us on Twitter: twitter.com/ZacksResearch Like us on Facebook: www.facebook.com/ZacksInvestmentResearch

Inside/Out: Looking at Prisoner Realignment with the Poetic Justice Project on “Art of Peace” A collaboration of formerly incarcerated writers, artists, musicians, and actors. Featured guests will be Deborah Tobola, Artistic Director, Jorge Manly Gil, program manager and actor, and Whitney Elliott, actor. Poetic Justice Project is creating original theater examining crime, punishment and redemption. PJP has been performing across the state, and its participants have a recidivism rate of less than 2%. PJP is a program of the William James Association, a 501(c) non-profit organization.   www.poeticjusticeproject.org