Podcasts about thought process behind

Session 31 A 55-y/o heavy smoker is shown to have a peripheral, well-circumscribed mass with popcorn-like calcifications in the RUL. What is the lesion likely composed of? Dr. Karen Shackelford from BoardVitals joins us once again as we delve into another case to prepare you for your Step 1 or Level 1 exam. Save 15% off their QBank by using the coupon code BOARDROUNDS. BoardVitals has a powerful QBank with comprehensive explanation and rationales behind all of their questions. Get up-to-date board review questions. You can avail of their 3 or 6-month plan and ask a clinician. Ask one of the physicians behind all of the questions. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:48] Question of the Week: A 55-year-old male with a 40-year history of smoking who undergoes a low-dose chest CT for lung cancer screening. Imaging results show a peripherally located, well-circumscribed 2-cm mass in his right upper lobe. It has a popcorn-like calcification. Which of the following describes the characteristics of this mass? (A) is composed predominantly of fattened cartilage (B) is composed of poorly differentiated neuroendocrine cells (C) is composed of significant glandular components (D) is caused by keratin production and intracellular desmosomes (E) is formed by caseating granuloma around the causative organism [03:00] Thought Process Behind the Correct Answer The correct answer here is Answer choice E refers to TB and this doesn't sound like TB as there are popcorn lesions with TB. Answer choice A would sound more or less of a benign tumor. B sounds like a malignant small cell lung cancer. C would make you think of adenocarcinoma. [03:00] Thought Process Answer choice A would sound more or less of a benign tumor. B sounds like a malignant small cell lung cancer. C would make you think of adenocarcinoma. Answer choice E refers to TB and this doesn't sound like TB as there are popcorn lesions with TB. The correct answer here is A. A well-circumscribed lung tumor with predominantly fattened cartilage is a hamartoma. A trick that helped me remember this back in medical school is that “popcorn isn’t bad.” It's the most common benign tumor of the lung. It usually contains connective tissue, fat, and cartilage. It's classically associated with popcorn-like calcifications on imaging. They are relatively large, well-demarcated and they rarely impinge on surrounding structures. For the management of pulmonary hamartoma, it would be more beneficial not to undergo surgery. The approach to those tumors is individualized unless it's diagnosed as a stable nodule. Karen stresses the importance of not overdiagnosing people. Once you figure out it's not causing any problems, you just leave it there. [06:08] Understanding the Other Answer Choices The poorly differentiated neuroendocrine cells is a small cell lung cancer. It's a really aggressive malignancy that is most common in smokers. They usually have irregular margins and has a really poor prognosis largely because it tends to metastasize. Significant glandular components are characteristic of adenocarcinoma. It's the most subtype of lung cancer. It has both solid and ground blast components on imaging. It's a pretty heterogenous-looking tumor. It's usually peripherally located. Keratin production and intracellular desmosomes are characteristic of squamous cell carcinoma. It's a common form of non-small cell lung cancer. It originates from epithelial cells along the airways. They're usually centrally located, often associated with the larger bronchi. Caseating granuloma is characteristic of pulmonary tuberculosis around the causative organism. It usually looks like a focal cavitary lesion often in upper lobes. The patients usually have a risk factor like travel to an area where TB is endemic. Or there's exposure to infected individuals or incarceration. Links: BoardVitals (coupon code BOARDROUNDS)

Session 29 Which of these neurotransmitters is mostly likely causing this patient’s galactorrhea and secondary amenorrhea? Where is it coming from? Dr. Karen Shackelford from BoardVitals. When you're looking to prepare for your Step 1 or Level 1 board exams, check out how BoardVitals can help you. You can find all their amazing QBanks for Step1, Level 1, or even any of your SHELF exams. Use the coupon code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:37] Question of the Week A 34-year-old woman presents with amenorrhea for six months (secondary amenorrhea). Her menstrual cycles have been regular until this episode. She has, most of her life, a period every 28 days with a menstrual period that lasted three days. Today, on exam, a white nipple discharge is noted. A test for urine hCG is negative. Which of the following neurotransmitters suppresses the release of the hormone responsible for her condition? (A) Dopamine (B) Insulin (C) Serotonin (D) Somatostatin (E) Vasopressin [Related episode: Why Is This Menstruating Patient So Sick?] [02:50] Thought Process Behind the Correct Answer The correct answer here is A. If you think about the treatment for prolactinoma, where prolactin is released from the anterior pituitary, bromocriptine and cabergoline are used to shrink the prolactinoma. They're both dopamine agonists. The patient's symptoms are suggestive of prolactinoma. It's not totally obvious though as there wasn't headaches or visual field issues mentioned. Nevertheless, prolactinoma is the most common of all pituitary adenomas. It's also the most common cause of galactorrhea. The clinical features include amenorrhea, galactorrhea, and infertility. The prolactin normally stimulates the mammary glands to produce milk and inhibits the secretion of gonadotropin-releasing hormone, which results in amenorrhea and infertility. With large tumors, like the compression of the optic chiasm that results in bitemporal hemianopsia. Dopamine is normally used to suppress and release the prolactin. When you're not breastfeeding after birth, this becomes an issue. [05:15] Understanding the Incorrect Answers Insulin is produced by the pancreas and it's necessary for the uptake and utilization of glucose. Serotonin agonist is available in several classes, used as antidepressants. They're used to treat migraines, but not for prolactinoma. Additionally, some antipsychotic agents interfere with prolactin. Somatostatin is a hormone secreted by the pancreas that inhibits secretion of insulin and glucagon. It reduces the activity to digest the system. It's not receptive to dopamine and not related to galactorrhea. Vasopressin is an antidiuretic hormone and it's not affected by dopamine agonist. [06:22] Key Takeaways The key concept is that prolactinoma is probably the most common type of pituitary tumor and is the most common cause of galactorrhea. The symptoms occur because prolactin stimulates the mammary glands and suppresses GnRH, causing amenorrhea and infertility. The dopamine agonist suppresses prolactin secretion and shrinks the prolactinoma. Links: BoardVitals (coupon code BOARDROUNDS to save 15% off)

Session 27 A patient with a history of arrhythmia is found to have atrial amyloid deposition on autopsy. Do you know what peptide is associated with this finding? Dr. Karen Shackelford joins us for another round of interesting questions to help you ace your boards. If you haven’t yet, check out BoardVitals and use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [02:14] Question of the Week The autopsy of the patient with a history of arrhythmia revealed amyloid deposition in the atria but no other amyloid was found in the ventricles. Which of the following peptides is associated with amyloid deposition in the atria? And what is that peptide's function? (A) Calcitonin and reduction of blood calcium concentration (B) Prolactin and gastric emptying (C) Acetylcholine and positive chronotropy to sinoatrial node (D) Immunoglobulin and cell-mediated immune response (E) Atrial natriuretic peptide and vasodilation [Related episode: Cardiac Electrophysiology—What is it?] [03:15] Thought Process Behind the Correct Answer The correct answer is E. An amyloid is a group of diverse extracellular proteins in variable amino acid sequences and they have common physical properties. Amyloid deposition and the extracellular deposition of the fibrils are composed of the subunit of varied serum proteins that form beta-pleated sheet configurations that lead to the histologic changes seen in amyloidosis. Isolated amyloidosis is found only in a single organ such as this cardiac amyloidosis. Alpha-atrial natriuretic peptide is responsible for deposition in this isolated cardiac amyloidosis. This is what's responsible for amyloid deposition in part. The incidence appears to be maybe part of the normal process of aging. In one autopsy series, 86% of the patients between the age of 81 and 90 had isolated atrial amyloidosis. It may lead to heart failure. Although diuretics are commonly given to patients with heart failure due to cardiac amyloidosis, beta-blockers, calcium channel blockers, and ace inhibitors may be harmful. [05:55] Understanding the Wrong Answer Choices Calcitonin is associated with isolated amyloidosis of the thyroid. Prolactin is associated with lactation found in amyloidosis that is isolated to the pituitary gland. Acetylcholine is the negative chronotropic sinoatrial node in the right vagus nerve. The stimulation of the nerve decreases the firing of the SA nodes, increasing potassium and decreasing sodium and calcium movement to the cell. Finally, immunoglobulin amyloid deposition is widespread and it's the result of its light chain immunoglobulin deposition. The point of the question was that isolated amyloidosis can affect many particular organs. This is different from more widespread amyloidosis related to immunoglobulin in terms of ideology and distribution. [07:10] The Big Takeaway Amyloid is not just that atrial natriuretic factor but you have to ask yourself where is it is as you're reading this question. Is it in the parathyroid for prolactin or widespread for the immunoglobulin or is it in the atrium for the atrial natriuretic peptide? [08:11] BoardVitals Check out BoardVitals for their Step 1 and Level 1 QBanks. Use the promo code BOARDROUNDS to save 15% off. This can be used for your SHELF exam QBanks as well. Links: BoardVitals

Session 26 A 20-year-old menstruating adult is tachycardic, somnolent, and hypotensive with GI symptoms and macular rash. What sort of organism do you suspect? As always, we're joined by Dr. Karen Shackelford from BoardVitals. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:35] Question of the Week A 20-year-old female patient presents 5th day of her menstrual period complaining about abdominal pain, vomiting, watery diarrhea, and myalgia for 12 hours. On exam, her temperature is 103.13 F. Her blood pressure is 80/60 mm/Hg. And her heart rate is 135 beats per minute. She is ill-appearing, somewhat somnolent, has hyperemic 02:04 and a generalized erythematous macular rash that involves her palms and soles. Which of the following best describes the cause of her illness? (A) Gram-negative diplococci (B) Gram-negative obligate intracellular bacteria (C) Gram-positive facultative anaerobic cocci (D) Single positive stranded RNA virus [Related episode: Biology Grab Bag of Questions for the MCAT] [02:50] Thought Process Behind the Correct Answer The correct answer here is C. The patient has toxic shock syndrome. It didn't mention in the question but she had an indwelling tampon. Highly absorbent tampons are the biggest risk factor. But interestingly, half of the women who develop toxic shock syndrome during the menstrual period are not using tampons actually. Related to the menstrual period, however, a toxic shock is usually the result of infection by Staphylococcus aureus. It releases endotoxins. But also, 05:33 axis is superantigen. And that's what triggers the syndrome. It triggers the activation of T-lymphocyte and they release massive amounts of cytokine. The post-immune response is limited in patients with toxic shock. Studies show that people who end with toxic shock, they failed to develop an antibody against the bacteria that usually developed in up to 95% of the population in childhood. The criteria for diagnosis include fever, chills, hypotension, and dermatologic findings. Evident multi-system organ involvement is at least 3 body systems and that counts the skin. In this patient's case, she had her circulatory system. She had hyperemia of her mucus membranes. The maculopapular rash would eventually desquamate after 1-2 weeks. She had nausea, vomiting, diarrhea in the GI system. Her mental status was somnolent. Some people have seizures from somnolence or encephalopathy that the other organ involvement may include intrinsic renal failure or prerenal failure. Myalgias are also sometimes resolved in elevated serum creatinine phosphokinase. hepatic dysfunction is also not uncommon. [07:50] The Treatment If there's foreign body removal, the treatment of any surgical wounds is the rapid administration of appropriate antibiotics. This includes Vancomycin and Clindamycin with the Penicillin that has B-lactamase inhibitor. [08:10] Understanding the Wrong Answer Choices You would probably suspect meningococcal meningitis but then you would have thought they would have given you a clue about the stiff neck. Rocky Mountain spotted fever for answer choice B would also be a good thought. The USMLE Step 1 is going to give you clues to the most typical case. For instance, with Rocky Mountain spotted fever, they would probably mention that the patient was in an endemic area. But they wouldn't necessarily say he was bitten by a mosquito. Finally, Dengue fever is the diagnosis for answer choice D. Remember that they're not going to hand-feed you every single detail. It's not always going to be that easy. [11:00] BoardVitals Check out BoardVitals' USMLE Step 1 QBank or their COMLEX Level 1 QBank. They have 1-month, 3-month, and 6-month packages. Every time you purchase, a vaccine is donated. If you get the 3-month or 6-month package, they offer the Ask a Clinician feature where you can respond to a question. Then one of the physicians from BoardVitals will respond to you as well. Use the promo code BOARDROUNDS to save 15% off. Links: BoardVitals (promo code: BOARDROUNDS to save 15% off)

Session 25 Dr. Karen Shackelford form BoardVitals joins us once again as we dig deep into a question about the hematopoietic and immune system. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:05] About BoardVitals If you're ready to prepare for your Step 1 or Level 1, go to BoardVitals. Their QBank system is set up to simulate the real USMLE Step 1 and COMLEX Level 1 exams. They have questions that are equally as hard to get you prepared for your exam. Use the promo code BOARDROUNDS to save 15% off when you purchase any of their products. [02:20] Question of the Week A 16-year-old male presents with a complaint of sore throat, fatigue and low-grade fever for three days. Exam reveals glossopharyngeal erythema with white exudates on his tonsils. He has enlarged posterior cervical lymph nodes and the posterior auricular lymph nodes are slightly enlarged. His spleen is palpable on abdominal exam. The throat culture is negative for strep and the monospot is positive. Which of the following findings are associated with the patient's diagnosis? (A) Atypical lymphocyte (B) Eosinophilia (C) Howell-Jolly bodies (D) Sickled erythrocytes (E) Target cells [Related episode: USMLE and COMLEX Prep: Glossopharyngeal Nerve Anatomy] [03:20] Thought Process Behind the Right Answer The correct answer here is A. The enlarged spleen could throw students off as it may make you think about Howell-Jolly bodies. But this is a case of classical mononucleosis with fever, exudative pharyngitis, the tender lymphadenopathy, particularly posterior in the cervical and posterior auricular nodes. Adenopathy in the anterior nodes and the atypical lymphocytosis are the hallmarks of classic infectious mononucleosis. The explanation to this question goes on to discuss the infection of the Epstein-Barr virus. It's a viral replication that begins in the oral pharyngeal epithelial cells with dissemination and infection of B-lymphocytes and the oropharyngeal lymphoid tissue. There is more Step 1 detail here. The infected B-lymphocytes produce antibodies to the viral antigens. But they also produce another type of antibody which could be heterophile antibodies that are not antibodies to the virus, but antibodies to other tissues. Active infection and the reinfection are regulated basically by the Epstein-Barr virus-specific T-lymphocyte. And atypical lymphocytes are activated. CDA plus T-cells and CD16 after killer cells appear in the blood at least 1-3 weeks after symptom onset. Fatigue can persist forever – 6 months or longer in 13% of patients. The splenic enlargement is a big caution for practitioners to remind their patients to avoid contact. The enlargement usually resolves after about 3 weeks. But even without contact, spontaneous splenic rupture is responsible throughout half of the cases. This usually occurs 2 weeks after symptom onset. [06:50] Understanding the Other Answer Choices Eosinophilia is usually associated with parasitic infection. The Howell-Jolly bodies were good distractor. They refer to the basophilic remnants of DNA. The circulating erythrocyte is usually removed in the spleen so they're found in patients who have either no spleen or 07:15. Sickled erythrocytes are associated with sickle cell disease. Target cells are associated with this disorder where the erythrocyte's cell surface is increased disproportionately to the cell volume. An example would be spherocytosis. Links: BoardVitals (Use the promo code BOARDROUNDS to save 15% off when you purchase any of their products.)

Session 24 We're joined by Dr. Karen Shackelford from BoardVitals as we talk about hepatitis and how antigens and antibodies appear and disappear during the course of infection. Please also check out Specialty Stories, a podcast dedicated to helping you figure out what specialty you want to practice. Listen to different physicians as I interview them about why they chose their specialty, what they like and don't like about it, and much more. Maximize your Step 1/Level 1 prep by checking out BoardVitals. Check out their 3 or 6-month plan where you get access to there over 1700-question QBank. Get detailed explanations and rationales for every question targeted to the Boards. Use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [02:20] Question of the Week A 45-year-old male presents a sudden onset of flu-like symptoms and yellowing eyes which he thought looks scary to him when he saw his reflection on the mirror. His past medical history reveals positive Hepatitis B infection and his lab's elevated ALT and AST levels. The consult suspects that he may not be superinfected with Hepatitis D. Hepatitis D virus can only propagate in the presence of Hepatitis B. The presence of which of the following components of Hepatitis B viral protein is necessary to allow Hepatitis D infection? (A) HpX (pX antigen) (B) Hepatitis B core antigen (HBcAg) (C) Hepatitis B surface antigen (D) Hepatitis B  e-antigen (E) Hepatitis B virus DNA polymerase [Related episode: What Does Academic Infectious Disease Look Like?] [03:35] Thought Process Behind the Correct Answer The correct answer here is C. Remember the actual viral structures. Hepatitis D envelops single-stranded RNA virus. It can't make its own surface antigens. So it requires Hepatitis B surface antigen. Hepatitis D can only be acquired either by co-infection or superinfection of an HPV carrier of co-infection. But this only resolves in 2% of the cases. HPV is a virulent pathogen.  Superinfection results in chronic hepatitis in over 90% of cases. Often, hepatitis with rapid progression of cirrhosis in about 80% of cases. But the influx of this type of viral infection has significantly declined since the development and widespread use of the Hepatitis B vaccine. However, this is still a problem in developing countries. In a lot of underdeveloped countries, it's passed on through migrants from more developed countries. It's therefore important for people to be aware of their Hepatitis B immunity and their potential for this really virulent superinfection. [Related episode: USMLE and COMLEX Prep: Tropical Medicine—Dengue Fever] [07:35] Understanding the Wrong Answer Choices Hepatitis pX is pX protein of Hepatitis B virus. It's implicated in viral transcription, replication, and increased risk of hepatocellular carcinoma through the expression of this X protein gene. The core antigen is the indicator of active viral replication. It's also a determinant of whether an individual is able to transmit the infection. But this is not the necessary component for the protein. Hepatitis B e-antigen can act as a marker of our replication infectivity but this isn't the necessary component either. Hepatitis B virus DNA polymerase is not necessary for HPV to replicate. HPV is the host hepatocyte, while the polymerase works to produce that complementary RNA. Links: BoardVitals  (Use the promo code BOARDROUNDS to save 15% off.) Specialty Stories

Session 23 We're joined by Dr. Karen Shackelford from BoardVitals as we tackle a neuro question this week. Maximize your Step 1/Level 1 prep by checking out BoardVitals. They have an amazing QBank that contains targeted questions. If you have a question about a question or explanation, for instance, simply click a button. This will allow you to ask a doctor and get a response within 24-48 hours. Use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:13] Question of the Week A patient has a decreased level of consciousness and they're testing the gag reflex. The elevation of the soft palate is symmetric when he touched the left side. But when he touched the right side, there's no response. Which of the following is true relating to this patient's condition? (A) The glossopharyngeal nerve carries efferent fibers that mediate the gag reflex. (B) The ideology of that absent reflex is a lesion of the right glossopharyngeal nerve. (C) The cause of the patient's absent reflex is a lesion of the left vagus nerve. (D) The reflex is mediated through the dorsal motor nucleus of the vagus. (E) Both the glossopharyngeal nerve and the vagus nerve are damaged on the right side. [Related episode: USMLE and COMLEX Prep: Glossopharyngeal Nerve Anatomy] [02:11] Thought Process Behind the Correct Answer The correct answer here is B. The motor limb is mediated by the vagus nerve. Sensory, however, is mediated by the glossopharyngeal nerve. The vagus nerve also carries some sensory fibers through the recurrent laryngeal. If the gag reflex is intact, the soft palate will rise symmetrically regardless of which side is touched. If both the glossopharyngeal and the vagus are damaged on one side, there is no response when touching the contralateral side. The soft palate will rise unilaterally on the side that's intact. Also, there won't be any response whenever you're testing the affected side of the lesion if both nerves are damaged. The vagus nerve is the only nerve damaged and there's a lesion on the single side of it. And the soft palate rises and pull to the intact side. Regardless of the pathway, this is something worth remembering. If the glossopharyngeal is only damaged on a single side, there's not going to be a response on either side when you test the reflex on the affected side. This is because you're not receiving the sensory impulse. Whenever you test the intact side, the palate will rise on both sides because the motor fibers of the vagus nerve are still intact. [06:40] Understanding the Other Answer Choices The afferent fibers of the glossopharyngeal nerve mediate the sensory component of the gag reflex. Hence, answer choice A is wrong. For C, if the left vagus nerve or the motor nerve was damaged on the left side resulting in an elevation of the soft palate on the right no matter which side was tested. In other words, this is the lateral lesion of vagus nerve. There's also the elevation of the soft palate to the contralateral side regardless of which side you're testing. For option D, this is also wrong because the reflex is mediated through the nucleus ambiguus. For E, if that were the case, then there would be no response at all when testing the right side or the side of the lesion. There would also be no response when testing the left side because the motor portion is damaged on the side of the lesion. Hence, there'd be an asymmetric elevation of the soft palate on the contralateral side. [08:45] BoardVitals Maximize your Step 1/Level 1 prep by checking out BoardVitals. They have an amazing QBank that contains targeted questions. If you have a question about a question or explanation, for instance, simply click a button. This will allow you to ask a doctor and get a response within 24-48 hours. Use the promo code BOARDROUNDS to save 15% off. Links: BoardVitals  (Use the promo code BOARDROUNDS to save 15% off.)

Session 22 Today, we tackle a pathophysiology question related to pancreatitis. Once again, we're joined by Dr. Karen Shackelford from BoardVitals. Check out their QBanks containing 1,700+ questions for Step1/Level 1. Use the promo code BOARDROUNDS to save 15% off. [01:50] Question of the Week A 45-year-old male presents to the hospital with abdominal pain and vomiting. He began to experience a dull pain in the epigastrium two days prior to admission that has progressively worsened. The pain radiates to his back. He's had several episodes of bilious non-bloody vomiting. He has no prior medical conditions. And he takes no medications. He has a 20-pack per history of tobacco and drinks 6-10 beers daily. The vital signs vary, has a temperature of 100 degrees Fahrenheit, and a heart rate of 102 beats per minute. He appears uncomfortable. On exam, his abdomen is soft and mildly distended, with marked right upper quadrant in epigastric tenderness to palpation. There is no rebound or guarding. He has hypoactive bowel sounds and no palpable masses or hepatosplenomegaly are appreciated. Laboratory studies through the hemoglobin of 12.8 g/dL, leukocytes 14,500 cells per mm3, with 81% PMNs and 16% lymphocytes. Platelet count is 178,000 and total bilirubin is 1gm/dL with the direct bilirubin of 0.4 g/dL. Alkaline phosphatase is 90 IU/L and aspartate aminotransferase (AST) is 88, alanine aminotransferase is 78, and serum amylase is 1,447 IU/L. What is one of the pathophysiological mechanisms of this patient's condition? (A) Pancreatic duct obstruction due to a stone (B) Activation of pancreatic stellate cells (C) Viral infection (D) Intraductal stone formation (E) Toxic fatty acids in pancreatic microcirculation [04:00] Thought Process Behind the Correct Answer Hemoglobin is normally low. White blood cells are minimally elevated. Platelets are normal. Bilirubin is a little bit elevated. Alkaline phosphatase is slightly elevated as well as the aspartate aminotransferase (AST), alanine aminotransferase and amylase. The condition of the patient is actually pancreatitis. The lipase is also slightly elevated which is more specific for pancreatitis and amylase which can be released by other cells as well. The most common cause of pancreatitis is gallstone pancreatitis but this guy has a history of pretty heavy drinking. The second most common cause of pancreatitis is related to alcohol. It's not clear though exactly how they're related but most chronic alcoholics do not end up with chronic alcoholic pancreatitis. But there may also be other risk factors to be considered here. One of the mechanisms is the hyperactivation of the pancreatic stellate cells. These cells that get activated by alcohol as well as by acetaldehyde. They regulate the deposition and the degradation of the pancreatic extracellular matrix protein. They secrete the matrix proteins and metalloproteinases that degrade the matrix proteins. So they regulate all the extracellular matrix proteins in the pancreas. Whenever they're overactivated by phenol and acetaldehyde, the metabolite of ethanol, the matrix becomes fibrotic. That's one of the mechanisms of chronic pancreatitis. Another interesting thing is that the stellate cells also express ADH and whenever overactivated, it seems to perpetuate a cycle of autocrine reactivation. So it's self-perpetuated. Another mechanism of alcoholic pancreatitis is that the alcohol is metabolized by both oxidative and non-oxidative mechanisms. There are changes in acinar cells that increase the activation of intracellular digestive enzymes. Hence, there's an autodigestive component. There is a transient decrease in pancreatic blood flow that results from the action of ethanol. 10:17 There's also an increase in ductal permeability related to alcohol use. It then makes it possible for these improperly activated enzymes to leak out of the duct into the surrounding tissue which just adds to the inflammation and fibrosis. Any of those mechanisms could be asked on the USMLE. [11:00] Understanding the Other Answer Choices It's not completely known what causes pancreatitis. After an obstruction, there's an increase in pancreatic pressure. Studies showed that the flow of biliary salts itself does not cause pancreatitis. This patient doesn't have a previous history given the biliary colic. Bilirubin is relatively normal and patients with a stone obstruction usually have a direct hyperbilirubinemia. The viral infection mumps and Kawasaki virus have been implicated in some sporadic cases of pancreatitis. But this is unusual and this patient doesn't have a history of it. Intraductal stone formation is what causes pancreatitis in patients who have hypercalcemia due to hyperparathyroidism or some other conditions. They usually have additional features mentioned in the history that are associated with hypercalcemia. These may include constipation or kidney "stones, bones, groans, and moans." Finally, fatty acid deposition with ensuing inflammation is the mechanism of pancreatitis in patients who have familial hyperlipidemia. They have those really high triglycerides. They would usually have other features mentioned like xanthelasma or early atherosclerosis or family history. Links: BoardVitals (Use the promo code BOARDROUNDS to save 15% off.)

Session 21 Today, we’ve got some interesting case of a 14-year-old male with some malaise and abdominal pain. Once again, we're joined by Dr. Karen Shackelford of BoardVitals. Check out the resources they have to offer. Use the promo code BOARDROUNDS to save 15% off upon purchasing a QBank. Also, they have an Ask a Clinician feature where clicking a button gives you access to a physician who will help you through specific questions or content. This feature comes with their 3-month and 6-month plan. This podcast is part of the Meded Media network where we help premeds and medical students as they journey towards becoming great physicians. [02:15] Question of the Week A 14-year-old male is evaluated for malaise and abdominal pain. He reports passing dark urine this morning. His past medical history is significant for Streptococcal pharyngitis ten days ago, for which he received Amoxicillin. Today, his vital signs are within normal limits, except for an elevated blood pressure of 145/95 mmHg. Examination reveals spatial edema with pronounced periorbital swelling. He has 1+ pedal edema bilaterally. Abdominal exam reveals mild, diffuse tenderness without rebound or guarding. Laboratory studies are unremarkable except for a serum creatinine of 2 mg/dL. What is the common finding associated with the patient's condition? (A) Hypovolemia (B) Polyuria (C) Red blood cell cast (D) Hypokalemia [03:30] Thought Process Behind the Answers The correct answer here is C. Basically, the patient has glomerulonephritis. This is characterized by red blood cell casts that are almost pathognomonic for glomerulonephritis. Poststreptococcal glomerulonephritis is not common but also not unusual. The history of streptococcal pharyngitis should lead to that conclusion. Other symptoms of glomerulonephritis include white blood cell casts, hematuria, and proteinuria. But for this question, you have to hone in on the glomerulonephritis. Other findings in the urine sediment include granular casts. Dysmorphic red blood cells are strongly associated with glomerulonephritis and proteinuria. This is clinically manifested by a slow and progressive rise in serum creatinine and fluid hypertension, peripheral or periorbital edema, and sometimes, hypercoagulability. Rhabdomyolysis may come to mind but it wasn't really an option among the choices. This could happen on the boards. There might be systemic manifestations of some underlying disease process associated with glomerulonephritis. There's a group of immunologically triggered disorders that result primarily or characterized by glomerular inflammation. It can also manifest the proliferation of glomerular tissues that damage that basement membrane, mesangium, or the capillary endothelium. [07:15] Understanding the Other Answer Choices Glomerulonephritis is associated with hypervolemia. In this case, you have the proteinuria. But with the edema, you should immediately be able to figure out that it wasn't associated with hypovolemia. The patient had pedal edema and periorbital edema. It is also important to mention that there are three primary mechanisms of glomerular inflammation. And what distinguishes a nephrotic syndrome from glomerulonephritis is the inflammation as a mechanism of damaging the glomerular apparatus. This might come in the boards that the mechanisms are either immune complex deposition as in this case. Anti-glomerular basement disease is associated with Wegener's granulomatosis, eosinophilic granulomatosis with polyangiitis, or microscopic polyangiitis. The other mechanism is the antineutrophil cytoplasmic autoantibody (ANCA) or small vessel vasculitis. It causes damage to the glomerular filtration barrier. This results in the leakage of plasma proteins and inflammatory cells into the renal tubule. Patients may even have pulmonary edema in some cases. The hypertension results from retaining salt and water. The patient has a rising creatinine and so hyperkalemia is more likely to happen. So this is an easy one to rule out. Polyuria is associated with diabetes and causes diabetic ketoacidosis. This isn't that uncommon. Further laboratory testing is needed to determine the ideology. Typically on post-streptococcal glomerulonephritis, it is self-limited. A fair amount doesn't progress to renal failure. But testing is needed to determine the ideology on other cases whether it's long-lasting or the significant decline in glomerular filtration rate. There is usually a raise in serum complement levels, anti-neutrophilic cytoplasmic autoantibodies, antiglomerular basement membrane autoantibodies, antinuclear antibodies, anti-double stranded DNA. The treatment is just supported in these cases or treatment of the underlying disorder if there is one that you can determine from these other tests. Links: Meded Media BoardVitals

Session 15 This week, we're joined by Dr. Karen Shackelford from BoardVitals. If you're looking for more prep with your USMLE Step 1 or COMLEX Level 1 training, visit BoardVitals and check out their QBanks for Step 1 and Level 1. Sign up for either 3 months, 6 months, or even 1 month. Your signup will have a vaccine donated through the #GiveVax program. If you sign up for the 3 months and 6 months, you'll get access to Ask a Clinician, where you can connect with the BoardVitals medical experts to answer your content questions. Use the promo code BOARDROUNDS to save 15% off of your purchase. [02:17] About Dr. Karen Shackelford Karen is a former ER clinician. She did her residency in medical school at the University of Mississippi. She eventually moved to Pennsylvania and began working remotely with BoardVitals as a contributor and editor. [03:20] Question of the Week A 35-year-old female patient returned 10 days ago from a mission trip to Nigeria. He was evaluated in the clinic a week ago, complaining of a high fever. She had a rash on the axilla, face, and extremities. The symptoms she had experienced were similar to some she had two years earlier after returning from the same mission trip. Those symptoms resolved with only symptomatic treatment. Today, her husband took her to the emergency department reporting that her fever had resolved two days ago. But she began to complain about abdominal pain and then she appeared very lethargic. On exam, her skin is cool and blocky. She had circumoral sinuses. Her pulse is weak and rapid. And her blood pressure is 80/60 mm Hg. She has a diffused confluent rash and her liver 2 cm below the costal margin. Laboratory studies are significant for a platelet count of 70,000 cells/mL. White blood cell count is 2,000 cells/mL with predominant lymphocytosis. Her serum aminotransferase is elevated. Which of the following is most likely caused by these severe symptoms? (A) Has bacterial super infection (B) Inoculation with a larger viral load (C) Antigenic drift (D) Different viral serotype change [05:08] Thought Process Behind the Answer Antigenic drift is characterized by small changes in the viral structure. It denotes spontaneous changes in the viral type. This is how viruses avoid getting destroyed by vaccines. Serotype is defined as a serologically different strain of microorganism with slight structural differences. They're classified together and have the same type of immune response. But just with a slight variation in their effect on the immune system. The correct answer here is D. The patient, in this case, is her second infection with Dengue Virus but with a different serotype. There are four serotypes of that virus. It's not atypical for somebody to have a mild case that resolves or even asymptomatic initial infection. At that time, the virus presents to a naive immune system. The second time around, it triggers a more significant immune response instead of immunity because of the antigenic differences that the virus responds to. A lot of these viruses are becoming more common in areas that people routinely travel to. A severe viral infection can resolve in hemorrhagic fever and epistaxis, hepatomegaly, circulatory shock. And it resolves through increased capillary permeability because the immune system is having a fluoric response to this second exposure to a slightly different serotype. [10:05] Third Infection If she had a third infection with Dengue Virus, it could be another viral serotype which can be potentially harmful. Although you might have some measure of immunity against the same one. When somebody comes into the office in the Emergency Department with a history of travel to the tropics and they have fibromyalgia, lethargy, and a rash, there are several things that could be wrong with them. Check on Chikungunya fever or dengue fever. They should be considered. But the one that is potentially fatal is dengue. The person could seem to recover. The fever could resolve. They could also become progressively ill and have circulatory collapse several days later. Hence, they should be monitored closely after an episode. The tests for these two are not readily available in those hospitals. So close monitoring should be done if they're coming with acute high fibromyalgia, lethargy, and rash after a trip to the tropics. [11:50] Potential Questions Both fevers are viral and both transmitted by the Aedes mosquito. There's not a vaccine and not a specific treatment. It's just supported. In most cases, the initial infection is asymptomatic or mild asymptomatic. Increased formation in immune complex so she has a pretty flourid response to dengue fever would be the primary mechanism behind it. Again, no specific treatment. Links: BoardVitals (promo code BOARDROUNDS to save 15% off)

Session 07 We often associate biochemistry with undergrad, but biochemistry is present in many specialties! Let’s dive into the types of biochem questions you may see! We're joined once again by Dr. Andrea Paul from Board Vitals as we help you prepare for your first board exam so you have what it takes to score high and match into your specialty of choice. Use the promo code BOARDROUNDS to save 15% on your QBank purchase. [03:30] Why Biochemistry? Biochemistry is more applicable to some specialties than others. But just basic genetics and metabolic diseases, for instance, are seen in many specialties. Biochemistry comes into play especially when you talk about metabolic diseases. Hence, it's a commonly tested subject on the exam, more than the other basic science components. [04:41] Question for this Week: A healthy married couple has a child who develops clinical symptoms of what you suspect to be a rare disease. Genetic testing revealed the patient's mother carries the mutated gene, but the father is not a carrier. However, the father's brother had the same disease, which has also occurred in one of his sisters' sons. This pattern is characteristic of which of the following diseases? Note from Andrea: The question is drawing you a pedigree. You can jot down a little diagram of pedigree for yourself as you're going through it. You have to figure out the pattern from the pedigree but know which diseases of the options fit that pattern of inheritance. Answer choices: (A) G6PD (B) Cystic fibrosis (C) Phenylketonuria (PKU) (D) Alpha-1 antitrypsin deficiency (E) Tay-Sachs Disease [05:50] The Thought Process Behind the Answer Once you've drawn that pedigree and determined what the inheritance pattern is, you can go through each option and cross out what doesn't fit or jot down what pattern each one has. In this case, the couple is healthy and not showing any disease. But the one child does and the father is not a carrier. This gives you another hint. So if he's not a carrier, how is that possible if the child is showing the disease? Then you're seeing that it's present in the father's brother and one of the sisters' sons. Here, you can see a distinctive pattern where this is not an autosomal recessive type pattern. This leads you to a dominant X-linked route. As you draw this out, you will start to see the pattern where the children follow up to them. The mother is a carrier, the father is not. And the child has the disease. It's likely that the child is a male because they're receiving only an X from the mom. So this would be an X-linked pattern. Now, you would only see one that follows that X-linked disease – G6PD Looking at patterns and pedigrees can really help you. Another algorithm Andrea found helpful is to ask: does the child with the disease have a parent with a disease. If no, then you're skipping a lot of things. You're left here with X-linked recessive which is 50% more common than a male child. Therefore, it's an X-linked recessive disease. [11:02] Tips and Tricks to Help You Memorize and Understand Better Most students are using mnemonics to remember all of the X-linked recessive diseases. This is most common for autosomal recessive or autosomal dominant. There's no way to think through them in a way that doesn't require memorization. The names of the disease don't really help in this case. All this being said, Andrea recommends using mnemonics. You can also use visual mnemonics you can look at or silly drawings to help you remember stuff. [12:37] Other Possible Questions Probably, if the question talked about a food that this person that this person may develop symptoms with, then you could probably remove some answer choices out. For example, G6PD is one of those diseases. If it's cystic fibrosis, they could ask what microbe commonly infects patients with this disorder. Or they could ask a treatment for that disorder. [14:00] Other Patterns Students Should Know About One pattern would be X-linked dominant. In this case, you would not see skipping of generations unlike what's in the above question. You would also see male and female as affected equally since the disease of the X chromosomes is dominant. So you think of diseases like X-linked dominant Alport syndrome or hypophosphatemic rickets. Another interesting inheritance pattern is mitochondrial where males and females are affected equally. It would skip generations but it is only transmitted from an affected female because mitochondrial diseases come from the maternal side always. And you would see a different pattern and all of the offspring would be affected – something you wouldn't see in the other types. Autosomal dominant, you would also see male and female as affected and not skipping generations. For instance, if two parents without the disease have a child with the disease, you'd think that the only way this could be autosomal dominant is there's a new mutation or there's some type of reduced penetrants or maybe the parent has the gene but just phenotypically normal. Otherwise, you would see this in every offspring because it's a dominant disease. Autosomal recessive is the opposite where you see skipping of generations. For example, if you have a couple both carrying the gene without any signs of disease, there would be 25% the child is born with two normal genes from the parents, 50% chance that they have one normal and one abnormal gene, and 25% that they would receive both. Since it's recessive that's the only case where you would see disease such as cystic fibrosis, thalassemia, sickle cell anemia, or PKU (of which some are shown in the answer choices above). Spinal muscular atrophy would be a more popular disease here, which my daughter has but me and my wife don't have, which makes us both carriers. This is going to be more popular to start talking about it on medical school and the boards because it's one of the first diseases out there that will be cured with gene therapy. [17:45] Board Vitals If you're interested in the QBank and how Board Vitals can help you prepare the best way you can for your Step 1 or Level 1, check out their site and use the promo code BOARDROUNDS to save 15% off of your QBank purchase. Links: Board Vitals (promo code: BOARDROUNDS)

My Guest this week is Adam Wiggins, the cofounder of Ink & Switch — an independent industrial research lab working on digital tools for creativity and productivity.   The topic of the conversation is the future of product-focused R&D, the Hollywood Model of work in tech, Ink & Switch’s unique organizational structure, and whether it can be extended to other areas of research.   Links Adam Wiggins’ Home Page Adam on Twitter Ink & Switch's Home Page A presentation on Ink & Switch's Structure Sloan Review Article on Applying Hollywood Model to R&D (Paywalled)   Transcript   How the idea came about Ben:  How did you come up with this idea? Like wait what what originated that I'm just really interested in the thought process behind there Adam: sure, you know, I think me and my partner's we come out of the sort of the startup kind of school of thought on Innovation, I think. There's a lot of way to think about there's the more academic research minded approach to Innovation. There's made which get a bigger companies. So yeah, we come out of very much from the yeah. I don't know what you want to call it ad Jolene startup y combinator or whatever that you know mix of elements is which is really about build a thing really quickly get it in front of customers minimal viable product innovate, but at least my thinking is that the startup model has been so successful in the last let's say decade. Particularly with the kind of mass production of the startup that you get through groups like y combinator such that I feel like the problems the space of problems that can be solved with that kind of, you know group of 25 25 year old Founders spending three months to build a thing not say it's let's say saturated. Yeah to some degree in that maybe the more interesting problems are like bigger or longer in scope. And so then we thought about okay. Well, what's a what's a model that is more possible for going after bigger things. And that's when I kind of fell down the rabbit hole of researching these Industrial Research Labs. I know that you spent a lot of time on as well, you know, these big famous examples like Bell labs and Xerox Parc and arpa and so forth. And of course many other examples when we thought okay, well, You know, we're not at the we're not in a position to you know, be setting up a multimillion-dollar research arm of a government or commercial institution. But what can we do on a smaller scale with a small Grant and it's kind of a scrappy band and people and that's kind of what led us to the Incan switch approach.    The Thought Process Behind the Model Ben: can you go one step further where it's  you have the constraint that you can't do  a straight-up corporate research lab, but I think there are a lot of unique ideas in terms of a model that are sort of just unique and. In that like how did you cope that Lee idea that like, okay, we're going to like have our principles. We're going to pull in people temporarily. We're going to  build this network that that seems sort of to come out of the blue. So what was what was the thought process behind that? Adam: Well, maybe it came out of the constraint of do it with very little money. And so part of that is we're trying to work on a big problem. Hopefully and I can talk about that if you want, but the in terms of the the model that we're using we came at it from do it with very little money and that in turn leads to okay. Your big costs are usually sort of like office space and then the people right, but if we can do these really short term projects, we called the Hollywood model and I can explain about that if you want the basically we have like a four or six or eight week project. You can bring in some experts on a freelance basis and you don't necessarily need to commit to paying salary is over the longer term and you couple that with no office. We have an all distributed team. We're not asking people they don't need to pick up. Move somewhere to even temporarily to work on a project. Right? And so we what we can offer them as a lot of flexibility. And so the I think there's certain there's benefits for the people to participate in these projects join, but from the lab point of view again, it was we were embracing this constraint of do it really really cheap. Yeah and that basically boiled down to very short projects people on a freelance basis only no office and that that's kind of what what led us there, but I think there actually is a lot. Benefits to doing things that way there's some big downsides as well but there's some benefits as well. So the constraint led us to the model you might say got a desire to work on a big problem in the same with a longer time Horizon like you would for a you know, a classic R&D lab, but trying to do that with a lot less money. Let us to this kind of short-term project model. The Hollywood Model in Tech Ben:  There are three things that I want to take into from that the three things are going to be  how the Hollywood model works and sort of the difference between the Hollywood model in Tech versus in Hollywood  and then like those those pros and cons and then it feels like there's a tension between working on a really big long term projects via very short term sort of Sprint demos. So. So let's let's start with the Hollywood model because in Hollywood I like after after I learned about. You doing that I sort of dug into it and it's it seems like the Hollywood model Works partially because all of Hollywood is set up so that even the best people work on this temporary basis. Whereas in Tech, it feels like you sort of have to get people who are in very special life situations in order to get the best people. So like, how do you how do you juggle that? Adam: Yeah, yeah, that is those are really good point. Well just to I guess briefly explain. The Hollywood model is please the idea. There is I actually lived in Los Angeles for a time and have a lot of friends who are trying to break into that industry and got a little exposure to that. I don't pretend to be an expert but and you can read about this online as well, which is that most movies are made by forming a an entity usually an LLC for the duration of the movie Project. You know, I might be a year or two. Here's whatever the shooting time is and everyone from the director or the camera people the whole cast the entire crew are all hired as essentially short-term contractors for whatever the duration of time their services are needed. But even someone like director who's there throughout. It's essentially a one or two-year gig for him it yeah, and everyone's fired right things right expanded and it's and it's an interesting accounting model because it means the sort of earnings from the movie in the and how that connects to the studio. And then the way the studio is invest is almost more like maybe Venture Capital invest in startups to some degree. So that's that's my understanding of it. So we kind of borrowed this idea for saying okay part of what we like about this is you get a situation. Any given person and a cameraman a crew member a member of the cast doesn't isn't guaranteed some long-term employment. They don't sign on for an indefinite thing. They sign up for the duration of the project. Right and the end everyone leaves. But what you see is that the same directors tend to hire the same crew the same. You probably noticed this most dramatically in directors that bring the same actors on to the same onto their future films because if working with them before worked, why wouldn't you bring them back? Right and so it's but it's it inverts the model of instead of we're going to keep working together by default. It's more every time a project ends. We're all going to disperse but the things that work will kind of bring back together again and just inverting the model in a subtle way. I. Produces better teams over the long term. But yeah, you get this sort of loose network of people who work and collaborate together to have more of an independent contractor gig mindset and I think that was yeah it was inspired by that and like you said, can we bring that to kind of Technology Innovation?    How do you incentivize the hollywood model? Ben: Most people in Tech don't do that. So, how do you sort of generate? How do you get the best people to come along for that model? Adam: That was definitely a big unknown going into it and certainly could have been a showstopper. I was surprised to discover how many great people we were able to get on board maybe because we have an interesting Mission maybe because me and some of the other. Core people in the team have you know just good networks good career Capital. Yeah, but actually it's that more people are in between spaces and you might guess so quite a lot to work with us on projects. Certainly. There's just people who are straight. You know, they made freelancing or some kind of independent Contracting be their business, right so that those folks are to work with a lot of folks that do open source things, you know, we work a lot of people from the DAT Community, for example, a lot of folks there. They actually do make a livelihood through some degree of freelancing in this space. So that's an easy one. But more common I think is you think of that. Yeah full-time salaried software engineer or product design or what have you and they. You know, maybe they do a new job every few years, but they're expecting a full employment salary HR benefits, you know the lunch on campus and the you know, the massages and you know yoga classes and so I was worried that trying to you know compete to get Talent like that when all we have to offer these very short term projects would be difficult. But as it turned out a lot of people are in some kind of in-between space. We're really interesting. Project with an interesting team good sort of in between things maybe a palate cleanser in a lot of cases turned out to be quite interesting. So we got a lot of people who are you know, they're basically looking for their next full-time gig but then they see what we have to offer and they go oh, you know, that's actually quite interesting and they can keep looking for the next job while they're working with us or whatever. Yeah their Habits Like do this thing is like an in-between thing onto the way that are to their next. Employment or we have situations like, you know one person we were able to get on the team with someone who is on Parental. Leave from their startup and so basically wanted to be like getting the mental stimulation of a project but couldn't really go into the office due to needing to take care of an infant, right? Um, and so by working with us was able to get some nice in that case part-time work and some mental stimulation and a chance to build some skills in the short term in a way that was compatible with. Needing to be home to for childcare. So the a lot of cases like that. I think so it granted, you know people that are looking for full-time gigs. We can't give them the best offer in the world. But there's a surprising number of people that are willing to take a weird interesting kind of cool learning oriented project in between there. May be more conventional jobs. Building from scratch with the Hollywood Model? Ben: Yeah. Because one of the things that I'm constantly thinking about what I'm asking these questions is how do we have more things using the same model in the world? Because I think it's a really cool model that not many people are using and so it's like what like could there be a world where there are people who just go from like one to the other and then would be an interesting shift in the industry to be a little more gig oriented or Independent. Contractor oriented versus the sort of the full-time job expectation that folks have now. Yeah and another sort of difference between I think Hollywood and Tech is that Hollywood you're always sort of Reinventing things from scratch. Whereas in tech there is code and and things that sort of get passed on and built on top of . Do you do you run into any problems with that or is it just because like every every experiment is sort of its own its own thing. You don't you don't have that problem. Adam: Yeah, the building on what came before is obviously really important for a lot of our projects. We were pretty all over the place in terms of platforms. And that was on purpose we built a bunch. Projects on the iOS platform we bought built from on the Microsoft Surface platform. We've done in various different web Technologies, including electron and classic web apps and so in many cases there is not a direct, you know, even if we had written a library to do the thing we needed in the other thing. We actually couldn't bring that over in that kind of build it all from scratch each time or or the the mic slate of it. I think is part of what makes it creative or forced to rethink things and not just rely on the. Previous assumptions that said. You know for certain tracks to research you might call it a big one for us is this world of like CR DTS and essentially like getting a lot of the value of getting a lot of capabilities that you expect from cloud Solutions real time collaboration Google Docs style of being able to do that and more peer-to-peer or less centralized oriented environment. And so we in an earlier project. We built a library called Auto merge just in JavaScript and it was being plugged into our electron app and. And in future projects, we wanted to build on top of that and we have done a number of subsequent projects some of which were but obviously they needed to like use the JavaScript runtime in some ways. So if we were doing another electron project, yes, you can do that but that and then another case, you know, we wanted to go with tablet thing. All right. Well that limits us because we can't use that library in other places. And in one case is we chose to build for example in the Chrome OS platform because we can get a tablet there and partially because we already had this investment in kind of. Script ecosystem through these libraries. But yeah again that comes with comes with trade-offs to some degree. So so we're always trying to balance build on what we made before. But also we're really willing to kind of start over or do the blank canvas because we really feel like at this. Level of early Innovation. What matters is the learning and what lessons you learn from past projects and you could often rebuild things in a fraction of the time in some cases we have actually done that is rebuilt an entire project sort of like feature complete from what on a completely different platform. But if you can skip past all the false turns and you know Discovery process and to build what you where you ended up it's often something that can be done in just a tiny fraction of the time or cost Knowledge Transfer in the Ink&Switch Model Ben: Got it. And  do you have a way of transferring learning between  different groups of temporary people that things like would be one tricky piece. Adam: Absolutely. Well an important thing here is we do have core lab members both. We have some principal investigators who are people that are around long-term and are the people that drive our projects and their, you know, carry a lot of those learnings both the Practical ones, but also like culture. Cultural elements and then a lot of the folks we work with they'll come back to work for a future project. But yeah, absolutely every given project is a new combination of people some existing people in the lab. They carry forward some of those learnings and then some people who are new and so we've had to do we tried a variety of approaches to kind of. Do a mental download or crash course and you know, none of it's perfect. Right because so much knowledge. Is that even though we take a lot of time to do a big retrospective at the end of our projects try to write out both raw notes, but also like a summarize here's what we learn from this project even with that and sharing that information with new people so much of what you learn is like tacit knowledge. It's somehow, you know more in your gut than in your head. And so to some degree we do count on the people that are more standing numbers that go project project in some cases. We do have to relearn small lessons each time. And again that that somewhat is a you know, if you start over from scratch and you kind of start from the same premises then you often discover some of the same same learnings. I think that's okay as long as we get a little faster each. Each time and then yeah combine that with learning documents and I don't know for example, we're actually the point now we have enough projects under our belt. We actually have a deck that is like here's all our past projects and kind of a really quick crash course summary, at least here's what they're called and least when people reference. Oh, yeah. That's the way we did things on Project number five right was called this and you can be like at least have some context for that. And so short answer is we haven't solved the problem but here's some things that at least have helped with that. Yeah, and how many projects have you done in total? Yeah. Well depends on exactly how you count. But when it comes to what we consider the sort of the full list called formal projects, which is we spend some time kind of wandering around in a in a period of time to call pre-infusion named after the the espresso machine for the sort of record time. You put in the water to kind of warm up the grounds. So the version of that and once we have basically a process where once principal investigator finds a project with egg, I think there's a really promising area and we should fund this. Okay. Now we're going to go actually hire experts that are specific to this area. We're going to commit to doing this for again six weeks or eight weeks something on that order. There's a project brief we present basically present that to our board to basically give like a thumbs up thumbs down. I'm so if you count stuff that has been through that whole process we've now done 10 projects cool. That's over the course of about three years. Ink&Switch Speed vs. Startup Speed Ben: Yeah, that's that's really good compared to. Like I start up where you do one project and takes three years. Adam:  I need to maybe feels sometimes it feels slow to me. But honestly, we spend as much time trying to figure out what it is that we want to do as actually doing it and then suspend a really good bit of time again trying to retrospect pull out the learnings actually figure out. What did we learn? You know, we usually come out with strong feelings and strong Instinct for kind of this work. This didn't work. We'd like to continue this. There's more to research here. This is really promising. This was a dead end but actually takes quite a bit of time to really digest that and turn it into something and then kind of the context shift of okay. Now, let me reorient and switch gears to a new project is really a whole skill, too. To be doing such a rapid turnover, I think and I think we've gotten decent at it over the last few years, but I think you get a lot better if you wanted to keep at it. Ink&Switch's Mission and Reconciling Long Term Thinking with Short Term Projects Ben: Yeah. And I've actually like to step back real fast to the bookmark in terms of  a the big picture long-term thinking like what is in your mind the real Mission here and B. How do you square these? Like, how do you. Generate  a long-term result from a whole bunch of short term projects. Adam:  right. Yeah, really cool problem. Absolutely. Yeah. Yeah and one again, I don't pretend to have answers to we're still in the middle of this experiment will see if it actually actually works. Yeah, let me start by just briefly summarizing our our mission or a theme. I like to think of it a little bit right like typically these and these great examples of successful Industrial Research Labs, you know for Bell Labs or theme was this Universal connectivity that has Bell had this growing Communications Network and they wanted to like solve all the problems that had to do with trying to tie together an entire nation with Communications technology or Xerox Parc. Of course, they had this office of the future idea. It's. How many papers and copier what is it going to be? I think you need a theme that is pretty broad. But still you're not just doing a bunch of random stuff that people there, you know think it's cool or interesting new technologies. It's tied together in some way. So for us our theme or a research area is Computing for productivity and creativity. Sort of what the digital tools that let us do things like write or paint or do science or make art are going to look like in future and we were particularly drawn to this and. And our investors were drawn to this because so much of the brain power and money and general Innovation horsepower in Silicon Valley certainly the tech industry broadly and even to some degree in Academia computer interaction research and so on it really pointed what I would call consumer technology. Right, it does social media It's Entertainment. It's games. It's shopping. Yeah, and and that's really a phenomenon just the last five or ten years, right the successful smartphones the fact that sort of computing has become so ubiquitous and mass-market its health and fitness trackers yet wearable, and you know, that's all great, but. I think that the more inspiring uses the more interesting uses of computers for me personally. I things that are about creativity there about self-improvement there about productivity and when you look at what the state of I'm going to look like a spreadsheet, right if you look at Excel in 1995 and you compare that to Google Sheets in 2018 the kind of looks the same. Yep, you know, it's at a Google Sheets as real-time collaboration, which is great. Don't get me wrong. But basically the same kind of program, right? Yeah. And I think you can say that same thing for many different categories Photoshop or presentation software note-taking software that sort of thing. There's some Innovation to give me to go get me wrong, but it just feels very out of balance how much again of that Innovation horsepower of our industry broad. They could go into Super Side. So for us the theme is around all right. We look forward five or ten years to what we're using to be productive or created with computers. What does it look like and you know, the reality is desktop operating systems or more and more kind of advanced mode because that's not where apple or Microsoft revenue is anywhere. But at the same time I don't think it's you know, touch platform particularly, you know are built around phones and consumer Technologies and sort of the pro uses of them tend to be kind of attack on afterthought. And so it sort of feels like we're in a weird dead end which is like what are we going to be doing 10 years from now to yeah do a science paper or write a book or make a master thesis or write a film script? It's hard to picture and but actually picturing it is that's that's sort of our the job of our research here. Ben:  and  that is a really long term project because you sort of need to go  back down the mountain a little bit to figure out what the what the other mountain is. Adam: Absolutely. Yeah the local Maxima of some kind and so maybe you need to yeah be a little. Out of the out of the box and go away from basically make things worse before they get better. Aside on AI Enabled Creativity Tools Ben: Yeah, just aside on that. Have you been paying attention to any of the sort of like a I enabled creativity tools? This is just been on my mind because Neurosis is coming up and there's some people who have been doing some like pretty cool stuff in terms of like. Enhance creativity tools were like maybe you start typing and then it starts completing the sentence for you and and or like you sort of like draw like a green blob and it fills in a mountain and then you sort of like just adjust it. Have you been paying any attention to those tools at all? Adam: Yeah. Absolutely. Some of the follow sir pokes on Twitter that post really interesting things in that vein that hasn't been an area of research for us partially because maybe we're a little contrarian and we like to kind of look where. You are looking and I feel like Ai, and that kind of Realm of things is very well. Or I should say a lot of people are interested in that that said yeah, I think to me one of the most interesting cases with that is usually we talk about with like generative design or things like. Sot great Target Range Loop last year by an architect who basically uses various kind of solvers we plug in like here's the criteria we have for like a building face, you know, we need the window has to be under the, you know can't because of the material dimensions and the legal things and whatever it can't be here's the constraints on it. But here's what we want out of the design. You can plug that in and the computer will give you sort of every possible permutation. And so it's a pretty natural step to go from there to then having some kind of. Algorithm whether it be here a stick or something more learning oriented, which is then try to figure out from that superset of every possible design satisfies the constraint which of them are actually sort of the best in some sense or fit what we said that we like before where we use, you know, the client or the market or whatever it is you're looking for. So I think there's a lot of potential there as I think it was more of an assistive device. I get a little skeptical when it gets into the like let's get the computers to do our thinking for us. Yeah realm of things. I would say, you know, I think you see with the fit and of the sort of auto complete version of this, but but yeah, but then but then maybe I you know, I love that artisanal Craftsman, you know, some kind of unique vibe that humans bring to the table and so yeah tools as. Assisting us and helping us and working in tandem with us and I think yeah, there's one probably a lot of potential for a eye on that that said that's not an area where researching. Ben: Yeah. I just I wanted to make sure that was on your radar because like that's that's something that I pay a lot of attention to him very excited about. More Reconciling Long Term and Short Term Ben: Yeah, and so for the long-term Vision,  the thing that I always worry about in the modern world is that we are so focused on  what can you do in a couple months these little Sprint's that if there's a long-term thing you just wouldn't be able to get there with a bunch of little projects. So I'm really interested in like how you resolve that conflict. Adam: Yeah, well you could say it's one of the biggest Innovations in Innovation, which I know is the area your study medication to get into this iterative mindset this what he called agile whether you call it. Yeah, iterative that the idea of kind of breaking it down into small discrete steps rather than thinking in terms of like I don't know we're going to go to the moon and let's spend the decade doing that. But instead think of and I didn't even see that difference in something like the space program right the way that the modern. Space exploration stuff that's going on is much more in terms of these little ratcheting steps where one thing gets you the next rather than that one big Mega project. It's going to take a really long time the super high risk and super high beta so I in general. I think that's a really good sort of shift that's happened. But yes, it does come at the expense of sometimes there are jumps you can or need to make that are not necessarily smaller steps. And so I certainly don't propose to have the answer to that. But at least for what we're doing the way I think of it is, you know, starting with a pretty Grand Vision or a big Vision or a long time Horizon. If nothing else and trying to force yourself first and foremost into the bigger thinking right? But then going from there to okay, if that's you know, where we want to go. What is the first step in that direction? What is the thing that can give us learning that will help us get there and one of the metaphors I always love to use for I guess research in general or any kind of Discovery oriented process is the other Lewis and Clark expedition, you know, this was commissioned by the Thomas Jefferson was president at the time and it to me was really crazy to read about. Holly you know they hadn't explored the interior of the continent they believe there might still be willing - running around and actually one of the things Thomas Jefferson Wander from the he's like, I really loved a, you know get a while you're out there they just had no idea they knew that the Pacific Ocean was on the other side that had ships go around there. But other than that it was this dark interior to the continent, but they sat out you know that expedition set out with the goal of reaching the Pacific Ocean and find out. What's on the way right and they did they took their best guess of what they might encounter on the way and put together Provisions in the team to try to get there. But then the individual sort of you might wait, you might call the iterative decisions. They need to make along the way to be go up this mountain rage. And we divert this way to be cut across this River. Do we do we follow this for a while do we try to befriend these tribes people who run away etcetera. Those are the sort of the iterative steps for the important thing is keeping in mind that long-term strategic goal. Um and defining that goal in such a way that it doesn't say go west, you know, it's not a set of directions to get there because you can't know that you have to start with here's what our vision is. Let's connect the two coasts of this country and then we're going to take whatever whatever iterative steps seem to be most promising to lead us in that direction. Also realizing that sometimes the most iterative step leads us in a way even away from our goal. So hopefully that's what we're trying to do it in can switch is picking individual projects. We hope carve off a piece of the bigger thing that we think will increase our learning or build our Network or just somehow illuminate some part of the this problem that we want to we want to understand better again, what is the future of you know, productive and creative Computing and then hopefully over time those will add up in the trick is not to get lost for me. I think the trick is not to get too lost in. Detail of the project right? And that's where the Hollywood model is. So important because you got to end the project and step away to truly have perspective on it and to truly return to looking at the bigger thing and that's what you don't get in my experience working in a startup that has operations and customers and revenue that you know goals. He need to hit us according to those things which are absolutely you know, the right way to run a business but then. Keeping that that that bigger picture view and that longer term mindset is very difficult. If not impossible in that setting. So that's our approach. Anyways, see how about in longer term? Loops around Loops: The Explicitly Temporary Nature of the Whole Lab Ben:  and in terms of of your approach and ending things is it true that you're actually going to  at the end of a certain amount of time. You're going to step back and look reevaluate the whole. Is it like you're sort of doing like loops loops around Loops Adam:  indeed? Yes. So individual projects have this sort of you know, we'll end it and and step back and evaluate thing. And then yeah, the whole thing is basically, you know, we have a fixed Grant when that's how it's out and right and it's up to us to deliver invest to investors the learning you might call the intellectual property. We're not patenting things or whatever, but the. See protect the things that offer commercial potential and could potentially be funded as startups. Basically. Yeah, that's you know, that's that's what we'll do. And actually that will happen next year. Wow. And when that does happen will hopefully do you know will do the same process? Like you said that the the bigger loop on the smaller Loop which that we've done on the smaller Loops which is retrospect at the end write down everything we've learned and then we do go ahead and let the team. Part of that may be when you've done put all this hard work and getting a team together, but my experience is that if there's really some great opportunity there. You'll recall us it in some new form. What Comes out of the Lab? Ben:  I can see it's  going multiple ways. Where you. You ended and then you could either say  there's another five-year research thing in this or there's some number of sort of more traditional startups to come out of that to try to capture that value are those sort of the the two options. What what do you see as the possibilities that come out of this? Adam: Yeah, those are those are both pretty key outcomes and they're not mutually exclusive right so it could be that we say, all right, great, you know we generated sort of five interesting startup options one of them. You know an investor decided to pick that up and you know, maybe take a team that is based on some of the people in the lab that worked on that and those folks are going to go and essentially work on commercializing that or making a go to market around that but then some other set of people who were involved in things and want to come back to this. He's promising tracks research and we're going to take another grant that has another time duration, I think. The obviously money is your ultimately all of them in limiting factor it yeah in any organization, but but I like the time boxes. Well, I think we use again we use that for our short-term projects and and some degree. We used it for the lab overall. I think thinking that it's like that Star Trek, you know, what is it or three-year Mission our five-year Mission, whatever it is. It's something about the time box that kind of creates clarity. Yeah, maybe in some is and yeah, you might decide to do another time box another chunk of time. In other chapter actually investors do this as well. If you look at something like the way that Venture struck funds are structured they often have sort of multiple. Entities which are you know, it's fun one fun to fund three. Yeah, right and those different funds can have different kind of buy-ins by different partners. They have different companies in their portfolio, even though there is like a continuous. I don't know if you want to call a brand or culture or whatever the ties them all together and I think that approach of like having these natural chapter breaks time or money based chapter breaks in any work is like a really useful and valuable thing for. Productivity and I don't know making the most of the time. Human Timescales - 4-5 Years Ben:  I completely by that. I have this theory that human lives are kind of divided up in like these roughly five year chunks. We're like that's that's the amount of time that you can do the sort of the exact same thing for the most time and if you if you like if you don't have. You can reevaluate every five years but it's like you look at like school. It's like you really like maybe it's like five years plus or minus like to but beyond that it's really hard to like sustained. Intense and tension on the same thing. So that makes that makes a lot of sense   Adam: agree with that. I would actually throw out 4 years as a number which does I think Max match the school thing it also matches the vesting schedules are usually the original vesting schedule and most startups is a four-year window. And if I'm not mistaken, I think that is the median length of marriages think there's something around. Well, you know, maybe it's something around, you know, there's renewal in our work life is what we're talking about here. But there's also renewal in a personal life, right? And if you're yeah if your employee at a company. Maybe something around for years as a feels like the right Tour of Duty. No not say you can't take on another Tour of Duty and maybe with the new role or different responsibilities, but there's something about that that seems like a natural like you said sustained attention, and I think there's something to goes about as well as inventing. Or Reinventing yourself your own personal identity and maybe not connects to you. Marry. Someone for years goes by you're both new people. Maybe those two people aren't compatible anymore. Yeah. I don't know. Maybe that's figure that's reaching a little bit far. I mean the other yeah Investors, Grants, and Structuring Lab Financing to Align Incentives Ben: that makes a lot of sense and you mentioned investors a couple of times but then also that it's a grant so  how did you something something that I'm always interested in is sort of like how to. He's up. So the incentives are all aligned between the people like putting in the money the people doing the work and people setting the direction and so like how did you structure that? How did you think about sort of coming up with that structure? Adam: Yeah, I've used maybe investors and Grant sort of a little Loosely there again, the model we have is a little different. So when I you know went to pitch the private investors on what we were going to do with this, I basically said look. Me and my partner's we had been successful in the past producing commercial Innovations. We want to look now at something that's a little bigger a little longer term and wouldn't necessarily fit as cleanly into some of the existing funding models including things like the way that the academic research is funded and certainly Venture funding and so take a little gamble on us. Give us a pics. Amount of money a very small amount of money by some perspectives to deliver not profits, but rather to deliver again this kind of concept of learning intellectual property in the loose sense not in the legal sense, but in the sense of intellectual Capital, maybe might be another way to put it and more explicitly. Yeah spin out potential right but the but but no no commitment to make any of these things. It's just we've evaluated all of these opportunities. Here's what we think the most promising ones are and that includes both. Let's call it the validated findings. We think there's a promising opportunity here at technology. That's right to you know, serve serve some marketing users well, but also some things that we got negative findings on we said well look we think there's a really interesting Market of users to serve right here the technology that would be needed kind of isn't ready yet and still five years out or maybe the market is actually tough for an early not very good for sort of early adopter type products and so in some way that would be valuable to. There's as well to have this information on why actually is it is not wise to invest in a particular Market a particular product opportunity. So that was that was what we asked for and promised to deliver and obviously we're still in the middle of this experiment so I can't speak to the whether they're happy with the results. But at least that's the that's the deal that we set up.   Tension between Open Knowledge Sharing and Value Capture Ben:  I just I love the idea of investment not. Necessarily with a monetary return and it's like I wish there were more people who would think that way and. In terms  of incentives. There's also always the question about value capture. So you you do a really good job of putting out into the world just like all like the things that you're working on and so it's like you have all those the great articles and like the code. Do you  hold anything back specifically for for investors? So that because I mean it would make sense, right because you need to capture value at some point. So it's like there's there's got to be some Advantage. So like how do you think about that? Adam: Yeah. I don't have a great answer for you on that, you know, certainly again, you know, there's conventional conventional ideas there around yet Trade Secrets or patents or that sort of thing, but I kind of. Personally, I'm a little bit more of a believer in the maybe comes back to that tacit knowledge we talked about earlier, which is you can in a way. I feel like it's almost misleading to think that if you have the entire project is open source that somehow you have everything there is to know I feel like the code is more of an artifact or an output. Yeah of what you learn and the team of people that made that and the knowledge they have in their minds and and again in. To some degree in there. There are sort of hearts and souls. Yeah is actually what you would need to make that thing successful. Right? And I think a lot of Open Source people who work on open source for a living rely on that some degree, which is you can make a project that is useful and works well on its own but the person who made that and has all the knowledge about it. They have a they have a well of. They have a lot of the resources that are really valuable to the project. And so it's worth your while to for example go hire them. And so that's that's the that's the way I think that we think about in The Way We pitched it to investors. If I were to do this again, I might try to look for something a little more concrete than that a little more tangible than that. The other part of it that I think is. Pretty key. Is that the networking? Yeah, and so you could say okay. There's the knowledge of the people who worked on in their heads. It may be that that kind of ties together. But there's the knowledge we transferred directly by like here's a here's a document that tells you everything we learned about this area where we think the opportunities are but then it's also by the way, we had a bunch of people to work on this some of whom are now in some cases where we were pushing the envelope on a particular Niche e sub technology. We end up with people on the team who are in many cases of the world's experts or we're in touch with the few experts in the world on a particular topic and we have act we have that network access. And so if someone wants to go and make a company they have a very easy way to get in touch with those people not the really impossible for someone else to take that. Bundle of information or take even a code based on GitHub and pick through the contributors list try to figure out who worked on it and go contact them. You know, I think that's possible Right, but I think it's quite different. You would be the pretty substantial disadvantage. There's someone that actually had the worm Network and the existing working collaboration. Extending the Ink&Switch Model to Different Domains Ben: Yes, the I like that and in terms of using the model in different places. Have you thought about how well this applies to  other really big themes the things that you're working on our nice because it's primarily software like the capital costs are pretty low. You don't need like a lab or equipment. Do you think that there's a way to get it to work for maybe in biology or other places where  there's higher friction. Adam: Yeah, I think the fact that we are in essentially purely in the realm of the virtual is part of what makes the sort of low cost. By all remote team and not asking people to relocate that's what as part of what makes that possible. We do have some cost. We've certainly purchased it quite a bit of computing Hardware over the course of the of the course of the lab and ship those to whoever needs it. But that said, you know, we can do that. I think this model would best apply to something that was more in the realm of knowledge development and not in the realm of you have to get your hands physically on something. Whether that's a DNA sequencer or a hardware development or something of that nature, but on the other hand as certainly as cameras get a more of the quickest and high-speed internet connections get better and certainly we've learned a lot of little tricks over the time. I think we were talking about the start of the call there about. Our use of document cameras is basically screen screen sharing for tablets doesn't work great because you can't see what the users hands are doing. So we learned pretty quickly that you got to invest in document cameras or something like that in order to be able to kind of effectively demo to your teammates. One of the quick or as a kind of a sidebar but related to that is one of the learnings we had in making the distributed team thing work is you do have to get together in person periodically so we can to support early team Summits got it. Making Watercooler Talk and Serendipity  Work with a Distributed Team Ben:  I was actually literally just thinking about that because one of the things that I always hear about. Great research places like whether it's like Bell Labs or DARPA is sort of like the the water cooler talk or the fact that you can just sort of like walk down the hall and like really casually hop into someone's office. And that's the problem with distributed teams that I haven't seen anybody saw well, so so you just do that by bringing everybody together every once in a while. Do you think that generates enough? Adam: Yeah. I mean the to your right like. That problem is very big for us. And there's there's a number of benefits we get from the distributed team, but there's also a number of problems. We haven't solved and so I'm not sure how this would balance against the sort of the spending the same amount of money on a much shorter term thing where people could be more in person because that water cooler talk you get some of with a slack or whatever but. It's just not the same as being co-located. So yeah, the the one of the mitigating things we have that I think is works pretty well as about about quarterly or so. We got everyone together and it's actually kind of fun because because we don't have to go any place in particular. There's no central office. We try to pick a different city each time someplace that's creative and inspiring we tend to like interesting Bohemian Vibe, you know in some cases urban city Center's been in some cases more historic places or more in nature. Ideally someplace close to International Airport that it wouldn't fly into and for really a fraction. I mean offices are so expensive. Yeah, and so our fraction of the price of maintaining an office. Actually fly everyone to some pretty interesting place once a once a quarter and so for a week, we have like a really intense period where we're all together in the same physical space and we're working together. We're also getting the human bonds more that casual conversation and we tend to use that time for like a lot of design sketching and kind of informal hackathons are also some bigger picture. Let's talk about the some of the longer term things lift our gaze a little bit and that helps a lot. Again, it is not as is demonstrably not as good as being co-located all the time, but it gets you I don't know 30 to 40 percent of the way there for, you know a fraction of the cost. So yeah over the over the longer term again, I don't know how that would Stack Up Against. Collocated team, but that's one good thing to getting product review so far. Where to find out more Ben:  I see that we're coming up on time and I want to be very respectful of your time.  I'm going to make sure people know about the website and your Twitter. Is there anything else any other places online that people should learn more about and can switch to learn more about you and what you're working on. Adam: Ya know the the website and the Twitter is basically what we got right now. We've been really quiet in the beginning here not because you know, I'm a big believer in that, you know that science approach of Open Access and you know, it's about sharing what you've learned so that humanity and can build on each other's learnings that said it, you know, it's a lot of work to to package up your ideas, especially when they're weird and fringy like ours are in a way that's consumable to the outside world. So we're trying to do a lot more of that. All right now and I think you're starting to see that little bit to our to our Twitter account where in including publishing some of our back catalogue of internal memos and sketches and things which again very itchy things you got to be really into whatever the particular thing is to find find interest in our internal memo on something as well as taking more time to put together demo videos and longer articles that try to try to capture some of the things we've learned some of the philosophies that we have some of the technologies that were. So yeah, there's she spots a great Thinking About  Extending The Model Ben: So freaking cool.  the. That I'm doing is just putting together the ideas and  trying to almost make a more generic description of what you're doing so  say like, oh, what would this look like if it goes into biology or it goes into something? What would this look like for nanotech? could you do the distributed team  using University resources? Right? Like could you partner with a whole bunch of universities and  have someone in different places and they just like go in and use the lab when you need to I don't know like that's  one Bay action item based on learning about this is like oh, yeah. I think I think it could work. Adam: That sounds great. Well, if you figure something out, I'd love to hear about it. I will absolutely keep you in the loop. Ben: awesome. Cool. Well, I really appreciate this.  I'm just super excited because these new models and  I think that you're really onto something. so I really appreciate you  bringing me in and going into the nitty gritties. Adam: Well, thanks very much. Like I said, it's still an experiment will we get to see? But I feel like I feel like they're more Innovation models than just kind of start up. Corporate R&D lab and Academia. Yeah, and if you believe like I do that technology has the potential to be an enhancement for Humanity then you know Finding finding new ways to innovate and a new types of problems and you new shapes of problems potentially has a pretty high high leverage impact the world.