Podcasts about wbcs

Get ahead with VETAHEAD and join Dr. Laila Proença™ on 15 minutes of ZooMed (exotic animal medicine) content.  Think all blood tubes are created equal?  Think again. Today,  we're diving into a study that settles one of reptile medicine's most overlooked debates — should you be using EDTA or heparin for CBCs in your bearded dragon patients?Turns out, heparin might be sabotaging your counts — lowering WBCs, wrecking cell morphology, and leaving you with unreadable smears (yikes). EDTA? It's the MVP you didn't know you needed. Join Dr. Proença for a deep dive into how one simple change can level up your diagnostics and prevent you from missing infections, inflammation, and more. Because even tiny dragons deserve accurate bloodwork. Listen now — your CBCs will thank you!Click here to get your VETAHEAD E-Magazine!⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Click here to receive a VETAHEAD Gift!⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Do you want to access more ZooMed (exotics) knowledge directly from specialists? Come with us and #jointhemovement #nospeciesleftbehind⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Head to VETAHEAD Website⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Join our VETAHEAD Community⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Follow @vetahead.vet on Instagram⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Subscribe to @vetahead channel on YouTube⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Follow @vetahead on Facebook⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Follow @vetahead on TikTok

A 70 year old man with a history of BPH, HTN and dyslipidemia presents with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. He denies GI upset and is taking fluids without difficulty. He denies sexual activity with others for the past three years. He is alert, oriented and appears slightly uncomfortable while seated. Abdominal and scrotal exam are WNL, there is no penile discharge and digital rectal exam reveals a tender, enlarged prostate. UA reveals positive leukocyte esterase and > 10 WBCs per HPF. With a working diagnosis of acute bacterial prostatitis, which of the following is the most appropriate antimicrobial option in this clinical scenario?  A. Ciprofloxacin PO x 10 days B. IM Ceftriaxone as a one-time dose with doxycycline PO BID X 10 days C. IV piperacillin with tazobactam for 5 days D. Nitrofurantoin PO BID x 5 days.  Visit fhea.com to learn more!

In this episode, we explore the role of probiotics in managing histamine levels and mast cell activation syndrome (MCAS), particularly in the context of rebuilding the gut microbiome. We discuss which probiotic strains could contribute to symptoms (in the short term) due to their histamine-producing properties, such as Lactobacillus casei and Lactobacillus reuteri, and we highlight beneficial strains that degrade histamine, including Lactobacillus plantarum. Topics: 1. Introduction to Histamine and Mast Cell Activation - Overview of histamine and mast cell activation syndrome (MCAS) - Understanding histamine production 2. Breakdown of White Blood Cells (WBCs) - Origin of WBCs from hematopoietic stem cells in the bone marrow - Categories of WBCs: granulocytes, monocytes, and lymphocytes 3. Examination of Granulocytes - Neutrophils: Role in bacterial infections - Eosinophils: Role in allergic reactions and parasitic infections - Basophils: Involvement in inflammatory and allergic responses through histamine release - Mast Cells: Similarities to basophils, maturation in tissues, and histamine release 4. Examination of Agranulocytes - Monocytes: Phagocytic function and differentiation into macrophages and dendritic cells - Lymphocytes: - T cells: Subtypes and their functions (helper T cells, cytotoxic T cells, regulatory T cells) - B cells: Antibody-mediated immunity - NK cells 5. Mast Cells vs. Basophils - Location and function comparison - Importance in histamine production 6. Mast Cell Activation Syndrome (MCAS) - Triggers of MCAS (infections, environmental exposures, dietary factors, genetic predispositions) - Focus on addressing root causes (lyme?, mold?, candida?, SIBO?, ...) 7. Probiotic Use in the Context of MCAS - Probiotics and pathogenic microbes in the context of mast cell activation 8. Example: Candida and Mast Cell Interaction - Recognition of Candida by mast cells through pattern recognition receptors (PRRs) - Activation pathways and release of histamine and other inflammatory mediators 9. Probiotics and Histamine Production - Probiotic strains that produce histamine - Lactobacillus casei, - Lactobacillus reuteri, - Lactobacillus bulgaricus... - Probiotic strains that do not produce histamine and/or degrade histamine - Bifidobacterium infantis, - Bifidobacterium longum, - Bifidobacterium bifidum, - Bifidobacterium breve, - Lactobacillus plantarum, - Lactobacillus rhamnosus, - Lactobacillus gasseri, - Lactobacillus salivarius Thank you to our episode sponsors: ⁠⁠⁠Liver Medic⁠⁠⁠⁠ Use code Chloe20 to save 20% on ⁠⁠⁠⁠⁠"Leaky Gut Repair"⁠⁠⁠⁠⁠ ⁠⁠⁠⁠⁠Brendan's YouTube Channel⁠⁠⁠⁠⁠ ⁠⁠⁠⁠⁠https://x.com/livermedic⁠⁠⁠⁠⁠ Tremetes, LLC Use code CHLOE15 to get 15% off Tremetes' Turkey Tail Thanks for tuning in! Get Chloe's Book Today! "⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠75 Gut-Healing Strategies & Biohacks⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠" Follow Chloe on Instagram ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠@synthesisofwellness⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ Follow Chloe on TikTok @chloe_c_porter Visit ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠synthesisofwellness.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ to purchase products, subscribe to our mailing list, and more! --- Support this podcast: https://podcasters.spotify.com/pod/show/chloe-porter6/support

Episode 164: More Than Just A HeadacheDr. Song presents a case of a subacute headache that required an extensive workup and multiple visits to the hospital and clinic to get a diagnosis. Dr. Arreaza added comments about common causes of subacute headaches.    Written by Zheng (David) Song, MD. Editing and comments by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the episode: We are happy to announce the class of 2027 of the Rio Bravo / Clinica Sierra Vista Family Medicine Residency Program. Our new group will be (in alphabetical order): Ahamed El Azzih Mohamad, Basiru Omisore, Kenechukwu Nweke, Mariano Rubio, Nariman Almnini, Patrick De Luna, Sheila Toro, and Syed Hasan. We welcome all of you. We hope you can enjoy 3 enriching and fulfilling years. During this episode, you will hear a conversation between Dr. Arreaza and Dr. Song. Some elements of the case have been modified or omitted to protect the patient's confidentiality. 1. Introduction to the case: Headache. A 40-year-old male with no significant PMH presents to the ED in a local hospital due to over a month history of headaches. Per the patient, headaches usually start from the bilateral temporal side as a tingling sensation, and it goes to the frontal part of the head and then moves up to the top of the head. 8 out of 10 severities were the worst. Pt reports sometimes hypersensitivity to outdoor sunlight but not indoor light. OTC ibuprofen was helpful for the headache, but the headache always came back after a few hours. The patient states that if he gets up too quickly, he feels slightly dizzy sometimes, but it is only for a short period of time. There was only one episode of double vision lasting a few seconds about 2 weeks ago but otherwise, the patient denies any other neurological symptom. He does not know the cause of the headache and denies any similar history of headaches in the past. The patient denies any vomiting, chest pain, shortness of breath, cough, abdominal pain, or joint pain. The patient further denies any recent traveling or sick contact. He does not take any chronic medication. The patient denies any previous surgical history. He does not smoke, drink, or use illicit drugs. What are your differential diagnoses at this moment? Primary care: Tension headache, migraines, chronic sinusitis, and more.2. Continuation of the case: Fever and immigrant.Upon further inquiries, the patient endorses frequent “low-grade fever” but he did not check his temperature. He denies any significant fatigue, night sweats, or weight loss. He migrated from Bolivia to the U.S. 12 years ago and has been working as a farm worker in California for the past 10 years. He is married. His wife and daughter are at home in Bolivia. He is currently living with friends. He is not sexually active at this moment and denies having any sexual partners. Differential diagnoses at this moment?  Tension headache, migraine, infections, autoimmune disease, neurocysticercosis. 3. Continuation of the case: Antibiotics and eosinophilia. As we kept asking for more information, the patient remembered he visited a clinic about four months ago for a dry cough and was told he had bronchitis and was given antibiotics and the cough got better after that. He went to another local hospital ED one month after that because the cough came back, now with occasional phlegm and at that time he also noticed two “bumps” on his face but nothing significant. After a CXR at the ED, the patient was diagnosed with community-acquired pneumonia and sent home with cough medication and another course of antibiotics. His cough improved after the second round of antibiotics. We later found on the medical record that the CXR showed “mild coarse perihilar interstitial infiltrates of unknown acuity”. His blood works at the ED showed WBC 15.2, with lymphocyte 21.2%, monocyte 10.1%, neutrophil 61.7%, eosinophil 5.9% (normally 1-4%), normal kidney, liver functions, and electrolytes, and prescribed with benzonatate 100mg TID and doxycycline 100mg bid for 10 days. He went to the same ED one month before he saw us for headache and fever (we reviewed his EMR, and temp was 99.8F at the ED). After normal CBC, CMP and chest x-ray. The patient was diagnosed with a viral illness and discharged home with ibuprofen 400mg q8h.Due to the ongoing symptoms of headache and fever, the patient went back to the same clinic he went to four months ago for a dry cough and requested a complete physical and blood work. The patient was told he had a viral condition and was sent home with oseltamivir (Tamiflu®) for five days. However, the provider did order some blood work for him. Differential diagnoses at this moment?  Patients with subacute meningitis typically have an unrelenting headache, stiff neck, low-grade fever, and lethargy for days to several weeks before they present for evaluation. Cranial nerve abnormalities and night sweats may be present. Common causative organisms include M. tuberculosis, C. neoformans, H. capsulatum, C. immitis, and T. pallidum. At his physical exam visit, the patient actually asked the provider specifically to check him for coccidiomycosis because of his job as a farm worker and he heard from his friends that the infection rate is pretty high in the Central Valley of California. His serum cocci serology panel showed positive IGG and IGM with CF titer of 1:128. His HIV, syphilis, HCV, HBV are all negative. The patient was told by that clinic to come to ED due to his history of headache, fever, and very high serum coccidiomycosis titer.  The senior and resident intern were on the night shift that night and we were contacted by the ED provider at around 9:30 pm for this patient. When reviewing his ED record, his vitals were totally normal at the ED, the preliminary ED non-contrast head CT showed no acute intracranial abnormality. A lumbar puncture was performed by the ED provider, which showed WBCs (505 - 71%N, 20%L, 7%M), RBC (1), glucose (19), and protein (200). CSF: High Leukocytes, low glucose, and high protein.On the physical exam, the patient was pleasant and cooperative, he was A&O x 4, he had a normal examination except for two brown healing small nodules on his forehead and left cheek and slight neck stiffness. At that point, we knew the patient most likely had fungal meningitis by cocci except for the predominant WBC in his CSF fluid was neutrophil not the more typical picture of lymphocyte dominant. And because of his very benign presentation and subacute history, we were not 100% sure if we had a strong reason to admit this patient. We thought this patient could be managed as an outpatient with oral fluconazole and referred to infectious disease and neurology. 4. Continuation of case: Admission to the hospital.Looking back, one thing that was overlooked while checking this patient in the ED was the LP opening pressure. Later, the open pressure was reported as 340mm H2O (very high). The good thing was, after speaking to the ED attending and our attending, the patient was admitted to the hospital and started on oral fluconazole.  Three hours after the admission, a rapid response was called on him. While the floor nurses were doing their check-in physical examination, the patient had a 5-minute episode of seizure-like activity which included bilateral tonic arm/hand movements, eye deviation to the left, LOC unresponsive to sternal rub, and the patient desaturated to 77%. He eventually regained consciousness after the seizure and pulse oximetry increased to 100% on room air. The patient was started on Keppra and seen by a neurologist the following day. His 12-hour EEG was normal, but his head MRI showed “diffuse thickening and nodularity of the basal meninges are seen demonstrating enhancement, suggesting chronic meningitis, possibly related to cocci. Other etiologies including sarcoidosis and TB meningitis and/or infiltration by metastatic process/lymphoma are not excluded. The ventricles are slightly prominent in size”. MRI of the cervical, thoracic, and lumbar spines also showed extensive diffuse leptomeningeal thickening, extensive meningitis, and nodular dural thickening. Also, his chest x-ray showed “some heterogeneity and remodeling of the distal half of the left clavicle. Metabolic bone disease, infectious etiology and/old trauma considered”. This could also be due to disseminated cocci infection. The infectious disease doctor saw this patient and recommended continuing with fluconazole, serial LPs until opening pressure is less than 250 mmH2O and neurosurgery consultation for possible VP shunt placement. The neurologist recommended the patient continue with Keppra indefinitely in the context of structural brain damage secondary to cocci meningitis.Take home points: Suspect cocci meningitis in patients with subacute headache associated with respiratory symptoms, new skin lesions, photophobia, neck stiffness, nausea, vomiting, eosinophilia, erythema nodosum (painful nodules on the anterior aspect of legs). Other symptoms to look for include arthralgias, particularly of the ankles, knees, and wrists.____________________Brief summary of coccidiomycosis. Etiology Coccidioidomycosis, commonly known as Valley fever, is caused by dimorphic soil-dwelling fungi of the genus Coccidioides (C. immitis and C. posadasii). They are indistinguishable in clinical presentation and routine laboratory test results.1, 2, 3, 5Epidemiology In the United States, endemic areas include the southern portion of the San Joaquin Valley of California and the south-central region of Arizona. However, infection may be acquired in other areas of the southwestern United States, including the southern coastal counties in California, southern Nevada, southwestern Utah, southern New Mexico, and western Texas (including the Rio Grande Valley). There are also cases in eastern Washington state and in northeastern Utah. Outside the United States, coccidioidomycosis is endemic to northern Mexico as well as to localized regions of Central and South America.1, 2Overall, the incidence within the United States increased substantially over the 1998-2019, most of that increase occurred in south-central Arizona and in the southern San Joaquin Valley of California. From 1998 to2019, reported cases in California increased from 719 to 9004.1, 6The risk of infection is increased by direct exposure to soil harboring Coccidioides. Past outbreaks have occurred in military trainees, archaeologists, construction or agricultural workers, people exposed to earthquakes or dust storms. However, in endemic areas, many cases of Coccidioides infection occur without obvious soil or dust exposure and are not associated with outbreaks. Change in population, climate change, urbanization and construction activities, and increased awareness and reporting, are possible contributing factors.1, 2, 5 Pathology In the soil, Coccidioides organisms exist as filamentous molds. Small structures called arthroconidia from the hyphae may become airborne for extended periods. Arthroconidia are usually 3-5 μm—small enough to evade bronchial tree mucosal mechanical defenses and reach deep into the lungs.1, 3Once inhaled by a susceptible host into the lung, the arthroconidia develop into spherules (theparasitic existence in a host), which are unique to Coccidioides. Endospores from ruptured spherules can themselves develop into spherules, thus propagating infection locally.1, 3, 5Although rare cases of solid organ donor-derived or fomite transmitted infections have been reported, coccidioidomycosis does not occur in person-to-person or zoonotic contagion, and transplacental infection in humans has never been documented.2, 5Cellular immunity plays a crucial role in the host's control of coccidioidomycosis. Among individuals with decreased cellular immunity, Coccidioides may spread locally or hematogenously after an initial symptomatic or asymptomatic pulmonary infection to extrathoracic organs.1, 3, 7Clinical manifestationThe majority of infected individuals (about 60%) are completely asymptomatic. Symptomatic persons (40% of cases) have symptoms that are related principally to pulmonary infection, including cough, dyspnea, and pleuritic chest pain. Some patients may also experience fever, headache (common finding in early-stage infection and does not represent meningitis), fatigue, night sweats, rash, myalgia.1, 2, 3, 5In most patients, primary pulmonary coccidioidomycosis usually resolves in weeks without sequelae and lifelong immunity to reinfection. However, some patients may develop chronic pulmonary complications, such as nodules or pulmonary cavities, or chronic fibrocavitary pneumonia. Some individuals with intense environmental exposure or profoundly suppressed cellular immunity (e.g., in patients with AIDS) may develop a primary pneumonia with diffuse reticulonodular pulmonary process in association with dyspnea and fever.1, 3, 5Fewer than 1% of infected individuals develop extrathoracic disseminated coccidioidal infection. Common sites for dissemination include joints and bones, skin and soft tissues, and meninges. One site or multiple anatomic foci may be affected. 1, 2, 3, 7It is estimated that coccidioidal meningitis, the most lethal complication of coccidioidomycosis, affects only 0.1% of all exposed individuals. Patients with coccidioidal meningitis usually present with a persistent headache (rather than a self-limited headache in some patients with primary pulmonary infection), with nausea and vomiting, and sometimes vision change. Some may also develop altered mental status and confusion. Meningismus such as nuchal rigidity, if present, is not severe.Hydrocephalus and cerebral infarction may develop in some cases. Papilledema is more commonly observed in pediatric patients.1, 3, 4, 5, 7When meningitis develops, most patients may not have any respiratory symptoms nor radiographic manifestation of pulmonary infection. However, a large number of these individuals also present with other extrathoracic lesions.7DiagnosisAlthough early diagnosis carries obvious benefits for patients and the health care systems as a whole (e.g., decreases patient anxiety, reduces the cost of expensive and invasive tests, removes the temptation for empirical antibacterial or antiviral treatments, and allows for early detection of complications), considerable diagnostic delays up to several weeks to months are common in both endemic areas and non-endemic areas.3, 7 Most symptomatic persons with coccidioidal infection present with primarily pulmonary symptoms and are often misdiagnosed as community-acquired bacterial pneumonia and treated with antibiotics. In endemic areas like south-central Arizona, previous studies found up to 29% of community-acquired pneumonia is caused by coccidioidomycosis. Healthcare providers thus should maintain a high clinical suspicion for coccidioidomycosis when evaluating persons with pneumonia who live in or have traveled to endemic areas recently. Elevated peripheral-blood eosinophilia of over 5%, hilar or mediastinal adenopathy on chest radiography, marked fatigue, and failure to improve with antibiotic therapy should prompt suspicion and testing for infection with coccidioidomycosis in endemic areas.1, 3, 5Serological testing plays an important role in establishing a diagnosis of coccidioidomycosis. Enzyme immunoassay (EIA) to detect IgM and IgG antibodies is highly sensitive and therefore commonly used as the screening tool. Immunodiffusion is more specific but less sensitive than enzyme immunoassay. It is used to confirm the diagnosis of positive EIA test results. Complement fixing (CF) test, which indirectly detects the presence of coccidioidal antibodies by testing the consumption of serum complement, are expressed as titers. Serial measurements of titers are of not only diagnostic but also prognostic value.1, 2, 3, 5Other methods, including culture, microscopic, or polymerase chain reaction (PCR) exam on tissue or respiratory specimens, are limited by their availability, sample obtaining and handling, or lack of sufficient evaluation.1, 2, 3, 5Cerebrospinal fluid (CSF) examination in coccidioidal meningitis usually demonstrates lymphocyte dominated elevation of leukocytes, although polymorphonuclear leukocyte dominance can also be seen in the early stage of the infection. Profound hypoglycorrhachia and elevated protein levels in CSF examination are also very common in coccidioidal meningitis.1, 7Although isolating Coccidioides from CSF or other CNS specimens are diagnostic for coccidioidal meningitis, in practice, diagnoses are often made based on the combination of clinical presentation, CSF examination that suggesting fungal infection, and positive Coccidioides antibodies found in CSF.7Imaging, especially enhanced magnetic resonance imaging (MRI), can help in diagnosing coccidioidal meningitis. Basilar leptomeningeal enhancement is a more common finding even though hydrocephalus, cerebral infarction, and vertebral artery aneurysm can also be seen.7TreatmentMost patients with focal primary pulmonary coccidioidomycosis do not require antifungal therapy. According to 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline, antifungal therapy should be considered in patients with concurrent immunosuppression that adversely affect cellular immunity (e.g., organ transplant patients, AIDS in HIV-infected patients, and patients receiving anti–tumor necrosis factor therapy) and those with significantly debilitating illness, extensive pulmonary involvement, with concurrent diabetes, pregnant women, or who are otherwise frail because of age or comorbidities. Some experts would also include African or Filipino ancestry as indications for treatment. Conversely, humoral immunity comprise splenectomy, hypocomplementemia, or neutrophil dysfunction syndromes are not major risk factors for this disease.1, 2, 3, 4, 5Triazole antifungals (fluconazole or itraconazole) are currently considered as the first-line medications used to treat most cases of coccidioidomycosis. Amphotericin B is reserved for only the most severe cases of dissemination and patients with coccidioidal meningitis in whom triazole antifungal therapy has failed. It is also the choice of therapy for coccidioidomycosis in pregnant women during the first trimester because of the possible teratogenic effect of high-dose triazole therapy during this period of time.1, 3, 4, 5Treating coccidioidal meningitis (CM) poses a special challenge because untreated meningitis is nearly always fatal. Lifelong therapy is recommended for CM because the majority 80% patients with CM experience relapse when therapy is stopped despite initial response to antifungal treatment. Shunting of CSF is required in cases of meningitis complicated by hydrocephalus.1, 3, 4, 5, 7Prevention Avoidance of direct contact with contaminated soil in endemic areas (e.g., respirator use by construction workers) may reduce disease risk, although clear evidence of its benefit is lacking.1, 5Some special population groups may benefit from prophylactic use of antifungals, such as those about to undergo allogeneic solid-organ transplantation or patients with a history of active coccidioidomycosis or a positive coccidioidal serology in whom therapy with tumor necrosis factor α antagonists is being initiated. The administration of prophylactic antifungals is not recommended for HIV-1-infected patients even if they live in an endemic region.1, 5Conclusion: Now we conclude episode number 164, “More than just a headache.” Dr. Song explained that a headache with an indolent course, accompanied by subacute respiratory symptoms, nausea, vomiting, photophobia, neck stiffness, and skin lesions can be secondary to Valley Fever. The Central Valley of California, as well as other areas with dry climate, are endemic and we need to keep this disease in our differential diagnosis.This week we thank Hector Arreaza and Zheng (David) Song. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Roos KL, Tyler KL. Acute Meningitis. McGraw Hill Medical. Published 2023. Accessed August 18, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192020493Information for Healthcare Professionals. Published 2023. Accessed August 18, 2023. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/health-professionals.html#printValley Fever (Coccidioidomycosis) a Training Manual for Primary Care Professionals. Accessed August 18, 2023. https://vfce.arizona.edu/sites/default/files/valleyfever_training_manual_2019_mar_final-references_different_colors.pdfAmpel NM. Coccidioidomycosis. Idsociety.org. Published July 27, 2016. Accessed August 18, 2023. https://www.idsociety.org/practice-guideline/coccidioidomycosis/Herrick KR, Trondle ME, Febles TT. Coccidioidomycosis (Valley Fever) in Primary Care. American Family Physician. 2020;101(4):221-228. Accessed August 18, 2023. https://www.aafp.org/pubs/afp/issues/2020/0215/p221.htmlValley Fever Statistics. Published 2023. Accessed August 18, 2023. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/statistics.htmlUpToDate. Uptodate.com. Published 2023. Accessed August 18, 2023. https://www.uptodate.com/contents/coccidioidal-meningitis?search=7%20Coccidioidal%20meningitis&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1Royalty-free music used for this episode: Tropicality by Gushito, downloaded on July 20, 2023, from  https://www.videvo.net/

I am not sure the term “unstoppable” is good enough for our guest Denise Meridith. Denise was born in Brooklyn NY and, in part, attributes her “get things done” attitude to her upbringing in New York. As a child she wanted to be a veterinarian, but such was not to be. Denise explains that colleges back then didn't consider women capable of assuming veterinarian positions. So, Denise got a BS degree in Wildlife Biology.   She then joined the U.S. Bureau of Land Management where, for 29 years, assumed a number of position including serving as the deputy director. We get to hear stories of her time with the bureau and how she moved around, something that was fairly common for government employees for awhile.   After serving with the bureau for more than 20 years Denise was offered “early retirement” due to the long time she served there. After retiring she became the CEO of Denise Meridith Consultants Inc (DMCI), a public and community relations firm. In 2019 she also became the CEO of The World's Best Connectors LLC, a virtual community for C-suite executives that helps other executives enhance their connections with family, employees, clients, government & the media. If running two companies weren't enough Denise also has formed a 501C3 nonprofit organization, Read to Kids US Inc to promote literacy and family bonding.   See what I mean about being unstoppable? Denise is quite engaging and I am sure you will discover that the time listening to our conversation goes by quickly and you may even wish to give this episode a second listen.   About the Guest:   Denise Meridith is a highly accomplished senior executive, entrepreneur and thought leader, with more than 40 years of success in government, technology, sports, and entertainment. When sexism denied her access to her childhood dream of becoming a veterinarian, she earned a BS in Wildlife Biology from Cornell University and became the first professional woman hired by the Federal Bureau of Land Management. During her 29 years with the Bureau, Meridith served in multiple states and, while Deputy Director in Washington, DC, she oversaw 200 offices, 10,000 employees and a $1.1 billion budget.   After early retirement from the Federal government and for the past 20 years, she has been CEO of Denise Meridith Consultants Inc (DMCI), a public and community relations firm. Since 2019, Meridith has also been CEO of The World's Best Connectors LLC, a virtual community for C-suite executives that helps other executives enhance their connections with family, employees, clients, government & the media. Recently she created a 501(c)3 non-profit Read to Kids US Inc to promote literacy and family bonding.   During the past 25 years in Arizona, Denise founded the Phoenix Black Chamber of Commerce, Linking Sports & Communities (a youth sports non-profit for 14 years), and was a Governor-appointed member of the original Arizona Sports & Tourism Board. She helped win approval for State Farm Stadium for the Arizona Cardinals.  In academia, she taught sports marketing for undergraduates at Arizona State University and business operations for executives at eCornell. As a freelance reporter, she has even written 1000 articles about small businesses. Denise Meridith has won many awards for business and community development in Arizona.   ** ** Ways to connect with Denise:   FREE OFFERS:   JOIN DENISE MERIDITH'S MAILING LIST   http://tinyurl.com/3ttt5rsu   Make your first New Year's Resolution Now: Schedule a 15-min call to see if Denise Meridith's Gen X & Baby Boomer Executives Regaining Your Mojo  counseling or masterminds starting in January are right for you https://calendly.com/dmci2021/mastering-the-metaverse   LEARN MORE ABOUT Denise Meridith:   By reading her self-biographies published on Amazon: o   Thoughts While Chillin'  https://www.amazon.com/dp/1791662323 o   The Day a Roof Rat Ate My Dishwasher https://www.amazon.com/dp/1729211127   Social Media:   Facebook:    http://www.facebook.com/denise.meridith.7 LinkedIn:     http://www.linkedin.com/in/denisemeridtih Twitter:  @MeridithDP2023       About the Host: Michael Hingson is a New York Times best-selling author, international lecturer, and Chief Vision Officer for accessiBe. Michael, blind since birth, survived the 9/11 attacks with the help of his guide dog Roselle. This story is the subject of his best-selling book, Thunder Dog.   Michael gives over 100 presentations around the world each year speaking to influential groups such as Exxon Mobile, AT&T, Federal Express, Scripps College, Rutgers University, Children's Hospital, and the American Red Cross just to name a few. He is Ambassador for the National Braille Literacy Campaign for the National Federation of the Blind and also serves as Ambassador for the American Humane Association's 2012 Hero Dog Awards.   https://michaelhingson.com https://www.facebook.com/michael.hingson.author.speaker/ https://twitter.com/mhingson https://www.youtube.com/user/mhingson https://www.linkedin.com/in/michaelhingson/   accessiBe Links https://accessibe.com/ https://www.youtube.com/c/accessiBe https://www.linkedin.com/company/accessibe/mycompany/   https://www.facebook.com/accessibe/       Thanks for listening!   Thanks so much for listening to our podcast! If you enjoyed this episode and think that others could benefit from listening, please share it using the social media buttons on this page. Do you have some feedback or questions about this episode? Leave a comment in the section below!   Subscribe to the podcast   If you would like to get automatic updates of new podcast episodes, you can subscribe to the podcast on Apple Podcasts or Stitcher. You can also subscribe in your favorite podcast app.   Leave us an Apple Podcasts review   Ratings and reviews from our listeners are extremely valuable to us and greatly appreciated. They help our podcast rank higher on Apple Podcasts, which exposes our show to more awesome listeners like you. If you have a minute, please leave an honest review on Apple Podcasts.     Transcription Notes: Michael Hingson ** 00:00 Access Cast and accessiBe Initiative presents Unstoppable Mindset. The podcast where inclusion, diversity and the unexpected meet. Hi, I'm Michael Hingson, Chief Vision Officer for accessiBe and the author of the number one New York Times bestselling book, Thunder dog, the story of a blind man, his guide dog and the triumph of trust. Thanks for joining me on my podcast as we explore our own blinding fears of inclusion unacceptance and our resistance to change. We will discover the idea that no matter the situation, or the people we encounter, our own fears, and prejudices often are our strongest barriers to moving forward. The unstoppable mindset podcast is sponsored by accessiBe, that's a c c e s s i capital B e. Visit www.accessibe.com to learn how you can make your website accessible for persons with disabilities. And to help make the internet fully inclusive by the year 2025. Glad you dropped by we're happy to meet you and to have you here with us.   Michael Hingson ** 01:21 Well, a pleasant hello to you wherever you happen to be. I am your host, Michael Hingson. And you are listening to unstoppable mindset. We're really glad you're with us. And today we get to talk to Denise Meridith, who has a really interesting story, a few factoids, and then we will just go from there. She as a child wanted to be a veterinarian, but had some sexist issues. And they wouldn't let her do it. I want to know about that. I think the world has changed in that regard. Some but nevertheless, when she was wanting to do it, it was different. She is the first female professional hired by the Bureau of Land Management. And that's fascinating. And she's got a lot of other things to talk about. So I don't think we're going to have any problem filling up an hour Denise. So I want to welcome you to unstoppable mindset. And thanks for being here.   Denise Meridith ** 02:13 Well, thank you, Michael. I appreciate being invited. Looking forward to it. Well,   Michael Hingson ** 02:18 why don't we start then, with you talking a little bit about the the early Denise the child and all that, you know, what, where you grew up and some of that kind of stuff. And what made you interested in being a veterinarian and you know, we can take it from there? Sure.   Denise Meridith ** 02:34 Well, I am born in Brooklyn, like so many people in New York City, a lot of people born in Brooklyn, and then they migrate different boroughs.   Michael Hingson ** 02:43 Where are the best bagels in Brooklyn? Well, I   Denise Meridith ** 02:47 didn't stay there long enough to find okay. Yeah.   Michael Hingson ** 02:53 Well, okay, we're the best bagels and Queens.   Denise Meridith ** 02:55 We had so many people grew up in New York City. Every block will have a good bagel. So yeah,   Michael Hingson ** 03:03 I know. That's why I asked the question, trying to be cute. It's just like I lived in Chicago for five years. I was born in Chicago moved out when I was five. And so I don't know when things like Garrett Popcorn started. But I know that whenever I go through Chicago, I do need to go to get popcorn in O'Hare. Or if I'm in the city that I'll go to one of the places downtown. We do. We do tend to do some of the things in the world buy our food. What can I say?   Denise Meridith ** 03:29 Yes. All right. If that's hotdogs, yeah, that would be asking you where to get their best hotdog in Chicago. Sure.   Michael Hingson ** 03:34 When they're in Chicago pizza, which is different than New York pizza, but that's okay, too. Yeah, they're both great. Ah, what a world anyway.   Denise Meridith ** 03:44 Yeah, so I sort of grew up in knots, whatever I did grew up in Queens, and I had what I call a Norman Rockwell childhood. If you seen his paintings and pictures, that's pretty much my childhood, but some Boxster ovaries, three houses, that type of thing. My dad had grown up on a ranch in Texas. So that's why he moved to Queens. You want more land around his house there. And so we had a big lot in our house became the center of attention in the neighborhood. We had the barbecues parties. We had a finished basement with a pool table and ping pong table and all that stuff. So we were at the center of things. My dad was a renaissance man, he believe it I didn't ride horses when he grew up. He thought horses would work. He couldn't understand why people rode horses for fun once he became an adult, so instead, he hears the musician. Big bands, he played in big bands,   Michael Hingson ** 04:41 what did he play   Denise Meridith ** 04:43 any horn and also the drums and also the guitar. Anything he can get his hands on? He was an Army and Army veteran. So I played an Army band as well. He was Avature tennis player, a poet, professional photographer, you name it. You did it. And then my mom was a community organizer. So church, PTA, anything that needed somebody in charge she was it. So when you merge those two together, you get me. So I liked a lot of pay for things. My mom, she belonged to the animal association or now Humane Society. So I had all kinds of pets growing up. So it's logical that I would want to be a vet. Because there's not too many professions in New York. It could be go to Broadway and I did take dancing lessons most of my life. But you could go to Broadway, you could be a doctor, you gotta be a lawyer or bid. That was pretty much it. So I picked the vet, because Cornell was in New York one. Yeah. Got vet schools and world. Yes. When I got up there, I found out that they weren't too keen on women being vets, they were just letting like one woman a year and into vet school. And pretty much to be that woman. I knew it was gonna be me, because there'll be somebody who pretty much grew up on a farm or something, or whose parent wasn't? Preferably who went to Cornell.   Michael Hingson ** 06:08 What was what was their logic? I mean, of course, I'm looking at it from today's standpoint, and today's point of view, but what was there was   Denise Meridith ** 06:19 physical physical, that went on weren't capable being that's the women, the few that I let them know, you had to be a small animal that they work with horses or anything like that. So which I thought was pretty ironic. Could you pick up all the women, cow girls and stuff? Yeah. Why? Why they would think women in fact, why went to Cornell, I had a lot of offers when I went to Cornell, was because I had the best equine contract program in the country. And I do like horses. So anyway, I got to do a lot of horse stuff there without being a vet, my roommate, actually was from a town, she just wanted to live in a dorm. So no breaks, all the kids go, you know, I guess what I do now biking, or vaping, or something. We would go horseback riding during breaks. So during lunch, or any kind of break, after school, we would go horseback riding. So it was pretty ideal setting for me growing up. And going to that point, the ideal part of it, of course, was what a lot of people don't know about the North. isn't that different from the south in a lot of ways and that I integrated junior high school, all white, you're in high school, I integrate it in a whole white high school. Cornell there were, like 75 African Americans in my entering class of 3000. So I had a lot of experience, being in the first study only our breaking glass ceilings. So that was my growing up. And my bed story how I got not to be a bit of what happened with that was, which was fortuitous, or actually more beneficial was that I wound up majoring in wildlife biology. Have any women but they didn't say they didn't want any women. So it was a lot different atmosphere there. So three women, three women graduated with degrees in wildlife biology.   Michael Hingson ** 08:23 What did you do with it? Then when you got that degree? My   Denise Meridith ** 08:27 first job was as a wildlife biologist, believe it or not? The Bureau of Land Management. So that was I got to be the first woman in that agency.   Michael Hingson ** 08:37 Were there a lot of challenges in getting that job? Or were you pretty well accepted? Right from the outset? Or what?   Denise Meridith ** 08:44 There was always going to be challenges. Yeah. Dave, and but essentially, and that was I interviewed earlier today. And it reminded me when you're a senior in college, now, you don't just go online, put in entries, but you would have to write write letters. So people remember that you had to write letters to them and agency companies asking to be considered. And I as a wildlife biologist, there are not a lot of options are state government. Maybe that's not likely because people die in place and the state government openings there.   Michael Hingson ** 09:21 So what was what year was it that you graduated?   Denise Meridith ** 09:25 I was graduated 73.   Michael Hingson ** 09:27 Okay. All right. All right. Yeah. Because I'm thinking of of things like it was much later than that was like 23 years later. Well, it was actually more than that. It was like 26 years. It was like 1999 my fourth guy Doug Linney became ill with glomerular nephritis and the, the emergency vet or actually the specialists that we took her to was a woman in in a veterinarian facility that was mostly women. So, clearly there was a lot of change. But anyway, that   Denise Meridith ** 10:03 Yeah, well, it's I would say it's all women. Now you've made pretty   Michael Hingson ** 10:07 hard, but very much a lot. It is. Yeah. Yeah. Yeah, it's   Denise Meridith ** 10:11 timing is everything. Yeah, that's hardly very few men anymore. I don't sure exactly why. But there are very few men anymore in that field. So I wrote my letters to places that would harm wildlife people. So Fish and Wildlife Service in a Forest Service and the Bureau of Land Management. The Park Service and Forest Service both told me they didn't hire women. That was pretty plain. And what's interesting now and I talked to younger people, sort of horrified. People could say that then it wasn't. It wasn't uncommon. It wasn't thought to be different, or rude or discriminatory or anything. They. And so now, you know, I wish I kept the letters. You didn't keep going wasn't anything different. Before, right, and forest service offered me a job as a secretary, they liked my degree from Cornell. They thought I'd make a pretty good secretary. So the Bureau of Land Management is the only one that said, okay, and probably I said, it's a perfect storm. Why I got that particular job. That job had been vacant for two years. They couldn't find anybody   Michael Hingson ** 11:21 to take it. So they figured what the heck, we'll give her a try.   Denise Meridith ** 11:24 Yeah, all right. Gotta have somebody in here sooner or later. So I took that job and which was in Las Vegas, of all things of all places. And it was turned out great with an office, small office 25 people or so in office, the average age was 27. Because nobody wanted to live in Vegas at that time. We had a if you can imagine. People that age in Vegas, we had a great time. We had a great time to that office. And it's a lot of fun. I was one of six wildlife biologists in the state. Because now people have seen all the movies and the shows and everything. But at that time, while kingdom was it, the only show it mentioned, you know, that wildlife Marlon Perkins. Yep. So he was an inspiration to me and everybody who went into the field and at that time, but there weren't many of us. So I had 10 million acres to play with by myself.   Michael Hingson ** 12:26 With a lot of fun and what was it you were to do with those 10 million acres?   Denise Meridith ** 12:30 Wildlife Biology it pretty much studying patterns and populations, identifying ingredient species, we need to do the preserve them. What the big change for me was I went to school in upstate New York. And my first job was in the desert of Nevada. Yes. Completely different wildlife. So I got to learn a lot about a lot of different wildlife. In fact, the main wildlife there was desert tortoises, and my favorite, yeah, they're nice. And pup fish and the old era. That's about it.   Michael Hingson ** 13:09 That's about it. Well, I had desert tortoises as pets growing up. And then we lived in Mission Viejo and California in 1982 through 1989. And my in laws lived, but 2025 miles away in San Clemente. And one day they were outside and a tortoise came walking up their driveway. And they advertise because they wanted to find it. They figured it was so Taurus that belonged to someone and nobody ever claimed it. And I said I would love it. So we named him et turtle because his face was like ET. And he lived with us for for a number of years. And then the gardener left the gate open and he got out but it was fun. He loved cantaloupe. He loved rose petals.   Denise Meridith ** 14:02 Yeah, yeah, they're interested in pets. I had one one time that also got out. And it's something you don't think about, you know, think about you know, you think of dogs running away. You don't think your Taurus is gonna run away but   Michael Hingson ** 14:17 curious. Yeah. Well, it happens Mukunda What do you do, but by the same token, it was fun when he was around with us. And he figured out that we had a screen door in the backyard that went into the house and wouldn't latch but he figured out he could use his front feet and open the door and come in. That's great. And what he liked to do is go live right in front of the refrigerator because the refrigerator was nice and warm and and that caused great consternation with our cat who couldn't figure out what he was so   Denise Meridith ** 14:55 that's good. Well, they're smarter than we think. They are. Yeah, Well, people are asking me today Well, earlier as if you will have a master's degree in public administration, and I said, Yeah, I have a people degree and an animal degree. Yeah. And believe me, the people agree as a lot harder. Oh, yeah. Animals wildlife would do fine on its own. Okay. The reason why we have wildlife biologists is to actually figure out what to do with about the people, much   Michael Hingson ** 15:28 more than the animals. You're right. Exactly. So you became a wildlife biologist? And how long did she do that?   Denise Meridith ** 15:36 I did that for a couple of years there in Vegas. And then what I figured out was that while being from New York, you know, I'm very decisive, or aggressive or assertive, is that biologists don't make decisions. They make recommendations, I figured that out. It was like, I could do a lot more for wildlife being in more decision making capacity. So I switched from wildlife biology to environmental science, because the environmental scientists are the ones that wrote the environmental assessments, and the rules and regs and all of that type of thing. And so I was able to do a lot more for wildlife, from that position than I did from being a bog biologist.   Michael Hingson ** 16:25 Was that also in Las Vegas? Yeah,   Denise Meridith ** 16:27 so I did that for two years. And then after that I was on the road I moved at that time, which is different now. Because I assumed government can't afford it. They wanted you to move every three or four years, just like the military. So you did. So that was four years time ago. Again, because still a bit. Some people think the good old days or the bad old days, depending on what side you're on. couldn't really get another job as a first woman. And most of the western areas, they're back east where I was hired in and our job was in Silver Spring, Maryland. So I hopped back after that, I hopped back and forth across the country. Guess where the best opportunities?   Michael Hingson ** 17:18 Were you've been in a number of positions where you're kind of the first or first woman to do it. What were what were some of the others? Yeah,   Denise Meridith ** 17:28 every job in the bureau after that pretty much was the first. No, I was the first the somebody but I was deputy for resources and New Mexico, Santa Fe, New Mexico. I was associate state director lesson number two person in California. That was great. I was the head person and eastern region, which covered 31 states, West that bordered on that nice for the Mississippi. And then I was the first in only woman. Personnel call a deputy director in the United States, for the Bureau of Land Management. And Washington, DC during the Clinton Administration. That's pretty much in charge. It's a political visit the directors political position. So the deputy is sort of the one that sort of runs things as us almost a CEO type of Ryan. Oh, and that I had 10,000 employees and billion dollar budget and 200 offices. So that was very exciting.   Michael Hingson ** 18:34 A little bit more expensive to live in DC than in Vegas. And but but I don't know, today, Vegas is getting pretty expensive.   Denise Meridith ** 18:41 Yeah, I guess it's funny because Vegas even then was relatively expensive to other parts of the Southwest. Luckily, I moved to DC, you know, so long ago, and then I kept my house and move away and don't move back. I was in DC a couple of times, luckily kept my house. So it was that the thing with the government. The other reason that government doesn't move you all over the place now is that they will buy your house. And I'm sure they can't afford to do that type of thing anymore. Yeah. If you? Yeah, if you didn't want to sell it, or you couldn't sell it, the government would buy it   Michael Hingson ** 19:16 and move you. Do you still have your house in DC now. Now? Yeah,   Denise Meridith ** 19:20 I kept it I'd be very well off. But oh, yeah, I left it. So I moved to LA. Well, it's interesting selling my house in DC I could afford two houses. In Phoenix. I didn't buy two houses. Probably should have done that too. But I how low the price of the housing was here. Yeah. And now since pass COVID Since everybody knows that figured out. It's a wonderful place to live. I think it had the highest rise in prices in the country. Well, Phoenix. This past year   Michael Hingson ** 19:54 gets pretty hot in the summer. Now I live in Victorville. So we're on the high desert weekend. had over 100 in the summer, but you get a lot more hot for longer periods of time than we do. We'll be in the high 90s Low hundreds or so. But Phoenix tends to get hotter.   Denise Meridith ** 20:12 Yeah. Why about saves that has no humidity whatsoever.   Michael Hingson ** 20:15 Right? Most cases where I am pretty much the same thing. Yeah.   Denise Meridith ** 20:20 So here are the ideal temperature is probably 100 100. And Summertime is fine. Yeah.   Michael Hingson ** 20:27 That's when it gets to 110 115. It's a little bit a little bit different.   Denise Meridith ** 20:32 And we haven't been having much of that. So I guess climate change. We haven't been having as much of that. lately.   Michael Hingson ** 20:38 You did this summer, though, right? This past summer.   Denise Meridith ** 20:41 This summer. Yeah. But it was like one stretch. Yeah.   Michael Hingson ** 20:47 It did make national news. You're right. But still,   Denise Meridith ** 20:49 it was just like, a week or two. And I will trade that for 11 months and perfect. Navi   Michael Hingson ** 20:56 I hear you.   Denise Meridith ** 20:59 So but yeah, Victorville that was in my my area, you know, and I was I had a California here. So high desert was pretty interesting. It's like two different countries. In Northern California and Southern California.   Michael Hingson ** 21:15 Well, in Southern California, the high desert is different than the Inland Empire somewhat and both different than right on the coast. So So what do you do? It's, it's, it's the way it is, but it was 26 this morning when I woke up. Yeah. Oh, not too bad. And it was high was 59. I was pretty impressed with it. It went up by 33 degrees. So that's pretty cool. Oh,   Denise Meridith ** 21:43 neat sense of the word. Yeah. And we were having a fit here. Because it was a high was like 59 or 68. We're ready to jump out windows here. It was. I don't know. And nothing is here. We complain about it being cold. But we don't have jackets. You know what I mean? We don't have Cokes? We don't have anything that would make it not fairly that bad, right.   Michael Hingson ** 22:12 For a while I lived in the Bay Area. And there were times up in Novato where we could get over 100. But typically, it wasn't too bad. So we didn't have an air conditioner in the summer.   Denise Meridith ** 22:22 Oh, wow. Okay. Yeah, I lived in Sacramento. The class difference. Yeah. Yeah, that was hot. But I would tell people, you know, they come visit. And of course, you have to take them to San Francisco. They're coming to visit you. They're really not coming to visit you. So I need to always forewarn them. Okay, San Francisco, it's got to be cool. The same? And still, everybody's surprised and they get the air for Cisco. And freeze.   Michael Hingson ** 22:48 Yeah. Yeah. Well, yeah. Like Mark Twain said, he said this. I spent a what a winter there one week in the summer or something like that. But yeah, well, so how long did you stay with the Bureau of Land Management in   Denise Meridith ** 23:02 29 years, I was with them. Oh, my gosh, yeah. And I left. After I left the DC current administration, when I was had the 200 offices. And even a 200 officers didn't bother me as much as the issue is in DC. I'm a very, like I said, sort of decisive kind of person, I like results. And DC is not designed for that. You know, it's not nobody's fault. It's just not designed to make decisions. So I wanted to go back where you could actually do things, have projects that are finished, etc. So after a couple of years, I moved to Arizona, where I am now. So I've been here for 28 years. And it was great when I moved back here as the state director, and I wound up designating for national monuments. So helping get the Arizona Trail doesn't made it I upgraded all the RV parks, a lot of campgrounds, etc, etc, etc. So I was able to do things. And I love that.   Michael Hingson ** 24:14 And then what did you do? And   Denise Meridith ** 24:16 so when I left Oh, they had an early out, which they don't do that anymore, you but they used to say, Okay, have they like every so many years they would say okay, you can leave if you have based on yours, not your age. So guess what, since I started two weeks out of college, I had a lot of years and no age, so I got to retire super super early in life. And what I did is Denise married a consultant Incorporated, which is a public and community relations firm. It's actually wound up doing a lot of the same things, tourism recreation. Thanks for the outdoors I helped. Also well thanks like I Have the get the stadium built the NFL stadium built here. Several other spring training stadiums designated not just a lot of parks and star help get them designated a lot of things like that. So I did, yeah, pretty similar types of work. Except I'm from the private industry president.   Michael Hingson ** 25:22 So what made you leave BLM and start your own company? Just because of the out the years? Yeah,   Denise Meridith ** 25:30 yeah. Hard to pass that up. Or retire at that age. So yeah, got that. And and you know, it's can make up what I used to preach to people, they didn't believe me, because people go, Oh, government, so boring, and bla bla bla bla bla bla, well, it ceases to be boring when you have a pension and health care. Right. So well,   Michael Hingson ** 25:55 I can make it as fun as you want at all. It's all about mental attitude to   Denise Meridith ** 26:00 Yeah. And I was less than working for the Bureau of Land Management, because what you had, it's all scientists. Right? So this geologists, it's science, people doing science, happiest people in the world, you know, so I really enjoyed. I enjoyed them, they were enjoying their work, I enjoyed them. It was just, to me a wonderful opportunity to work with people for that long, who enjoy their work. And it's not too many people who can say that anymore. But it was unusual that why in government with our agency.   Michael Hingson ** 26:38 So you what, what made you start the company, you just wanted to continue doing the same sorts of things. And that was the easiest way to do it. Or, yeah,   Denise Meridith ** 26:47 I probably should have stayed retired now. Now, I've enjoyed what I've done. But essentially, two weeks after retirement, the story was, well, two weeks after retirement. And I'm thinking boy, gee, I can do anything. How does this you know, it's sort of a shock when you're working all the time. And like, when I was in DC, I was on the road 75% of the time, so And Arizona, I travel a lot. Oh, I could do anything. So a friend of mine called and said, Well, why don't we go to the movies, and it was like the middle of the day. And I thought, oh my god, this is good. Go to the movies. So we went to see a movie very bad. Well, I know I shouldn't but and I came back and water was coming out my front door. I've sunburst blah, blah, blah. I spent the next five weeks in a hotel. And so the only thing I can think is that I was lost my mind. Because it had happy hour every night. When I invited somebody else to join, join me and happy hour, and they go, Oh, nice. What is great opening job opened up and I think I had too much wine. This great opening open up but heading up this nonprofit. You should take a look at that. And so I did. Some I retirement didn't last very long. So I ended up that nonprofit. And I've been doing something ever since.   Michael Hingson ** 28:15 Just what was that nonprofit?   Denise Meridith ** 28:19 It was the Arizona Trail Association. You know, they were one of the longest trails in the United States. And it goes from border to border from the northern border, Arizona, New Mexico. And spectacular trail. Because Arizona is beautiful. So it's a very beautiful trail. But they were having problems getting it designated. Because yes, politics and I understand politics. I help them. Actually it was me and John McCain got together and helped get that trail designated. But I'm sort of a restless person. Sorry, I was only there for a year with them. I had my own Disney spirit consultants started anyway. So then I just did a variety of things. I like projects start finished start finish. Until about, you know pretty much on my own. until five years ago, I decided, well, why don't you get a whole group of people who like to do that. And that's when world's best connectors was started. So the current organization that I manage, and what it just made up of a bunch of folks like myself, they all have their own businesses. But we get together and people throw out ideas and we jump on them or not. We're consulting firm. If n were CEO, the CEO, we're not B to B or C it'd be all those things. We're CEO, the CEO, that what we do is help other executives what problems they come in, they need a tech person, they need a HR person, they need whatever come to us. We either have a person like that, or we can get them a person like that. So that's what we've done in the past five years   Michael Hingson ** 30:03 is disease murders consultants still functioning? So you have two companies? Yeah.   Denise Meridith ** 30:10 Well, I actually three, but we want if it gets too complicated, but no, I have a nonprofit to read to kids, us. I'm trying to get parents to read to the kids again, like they did in the old days. But the days for consultants where that comes in is, and really the reason that I met you really, at do a lot of conferencing and whatever. But I do coaching, professional coaching, or people, and particularly for Baby Boomers and Gen X, what I do is help them rediscover their mojo. That's what I call it. And so I think both of those groups pretty much had it made in the beginning of 2020. Yeah, they had figured it out. They were doing well, economy's doing well, it's all kinds of opportunities going. Everything looks fantastic. I as an example, was that in Miami for Super Bowl week with my group, a group from world's best connectors, and we were networking and going to a lot of special events, thinking of future partnerships, future contracts. And two weeks later, I come back COVID Close everything down. So and that happened to a lot of what happened, everybody but baby, I think Baby Boomers and Gen X is crooked, because it was more of a disappointment. He thought you had it figured out you could actually had everything made. And then when President says COVID stuff and pandemics over those people ran back to work. And guess what? Nobody only wants to came back. Nobody else was in the office. Yeah. Nobody else wanted to be in the office   Michael Hingson ** 31:57 and a bunch of them got COVID.   Denise Meridith ** 31:58 Yeah, so it was just, to me devastating for a lot of people in my age group. So what I do is, work with them. You can't go backwards, it's not going to change. It's not going to go back to what it was. What can we do to find your happiness? Again? A place in a position and a life that can make you happy again? Yeah, a lot of people don't notice that. Really? COVID gave them a second chance. Yes. Okay, you're gonna have another opportunity. Maybe they didn't even like that job. You know that they're complaining about low job anyway. So what can we do? They get you something that you do like or no job at all. That's delicate, and people have a hard time transitioning sometimes to retirement. And so I help people over those humps. That's what I tried to help you. So   Michael Hingson ** 32:55 you do a lot of coaching and helping people and so when I should explain to the folks listening out there that Denise and I met through PATA Palooza that people know what PATA Palooza is, we've talked about it a number of times on on unstoppable mindset. And for those who don't know PATA Palooza is a program that meets four times a year and the people who come are either podcasters interested in being podcasters, or want to be interviewed by podcasters. Pretty much. Those are the people that usually come. And Denise and I met there. And here we are.   Denise Meridith ** 33:29 Yeah, we had a, you know, I think a lot in common as far as the way we look at the world, and achieving things and being happy. So I yeah, I was very impressed with what you do what you've overcome. I do a lot of speeches. Well, now it's coming up on Black History Month. So for that Women's History Month back, but I get request, obviously. Because people want to know how, yeah, obviously, all these all these things could have been obstacles, not being a vet, that not, you know, getting certain jobs, they not getting promotions, all of that. You can look at that as an obstacle that it is, or you can figure out a way to overcome that. But   Michael Hingson ** 34:20 you But you made a choice, somewhere in your psyche, that you weren't going to let those kinds of things stop you and that you were going to continue to   Denise Meridith ** 34:28 move on. Exactly. And that's that's the only way to do it. Thanks for not gonna be equal, you know, and that's one thing that's sort of hard to take those true. Baby bonus. Well, what we see is what we see, what we see is what we get. So I if you think about I was a kid when Civil Rights Act was passed, and everybody thought everything was going to change. And it hasn't been something strange, but women can be better Now, you know, overall, they're still allowed to obstacle. So I worked with people, well, I not work with people, I hope to be a role model for people, and how not to give up. And, and I say, essentially, wonder closes, God opens another one to take it.   Michael Hingson ** 35:20 What's hot? What's ironic is so the same thing in a sense with the Americans with Disabilities Act, everybody thought everything was going to change, and it hasn't. Unemployment rates have dropped a little bit. But they're still incredibly high. Internet websites aren't accessible, for the most part. And we're not included in a lot of the conversations when you talk about diversity that doesn't generally include disabilities. So some of us like, like I and I've talked about it on the podcast here talk about inclusion, you either are inclusive, or you're not, there's no middle ground, you either are gonna be or you're not. But at the same time, the thing that we have, and continue to face is not included in a lot of the conversations. So I don't hear anybody talking about a disability history Awareness Month or anything like that, although there is a month dealing with disabilities, but it is not nearly as well discussed and mentioned and talked about, or included as other minorities, even though we're a larger minority than all of them.   Denise Meridith ** 36:24 Wow. And everybody has the potential to be in that group. And   Michael Hingson ** 36:29 everybody has the potential to be in that group. Every well. Well, of course, actually, in, in a technical sense, everybody is a member of that group, I believe that we've misinterpreted the definition of disability, and that disability is a characteristic that everyone has, it manifests in different ways like you can see, and your disability, at least one of your disabilities, is your light dependent, you know, the power goes out, what are you going to do, you gotta go off and try to find a light source. Thomas Edison fixed it mostly, but not totally. And so it still creeps in. So the bottom line is, everybody has a disability. You know, it's something that we, we we really should think more about, but there's a lot of fear. And people know that they can become a person with a physical disability or whatever. And so the fear keeps us from being really included, like we ought to be.   Denise Meridith ** 37:21 And I've always had empathy along those lines, whatever reason why parents whatever reason was, but I, when I became the director, the deputy director of the Bureau, Ada, just pretty much passed. Right. And so I hired a person to, you know, interpret that legislation for us and help people with that legislation. Or did that set off a firestorm? How couldn't you be wasting a position on that? Nobody cares about that, and nobody needs to know that. Anyway, so but I do what I do. Right. So So I went ahead. And in this case, she was a hearing impaired, but as soon as she got there, things changed people. Oh, I have a question. Oh, I don't understand this, oh, how can I do this better? And   Michael Hingson ** 38:19 of course, today, and of course, today, most people rightfully so would not be caught dead saying hearing impaired because people who are deaf or hard of hearing recognize impaired is, is a negative thing. And we're not even cared, you know, the, and that hasn't really translated into blindness, because so many people continue to say visually impaired, and it shouldn't be blind or low vision. Because why are we Why do you equate how much sight you have with whether you're impaired or not? And that's the issue that we're Why do you equate, whether you how much you hear is to whether you're impaired or not. That's the whole thing we have to change and it's just so hard to do, because it's so ingrained in society.   Denise Meridith ** 39:01 Yeah, that'll be GQ. T I A plus. As an example, you know, the it's just the getting across what we need to get credit. It's getting harder, not easier to talk to people about anything. All right. Unfortunately, it's getting harder. So but she went on to be pretty popular pretty, pretty much in demand. But I I'm doing right now, one of the projects that we're working on, and world's best connectors is business education for college athletes. So again, it sort of comes up. Most people when they think about the NCAA is ruling on name image and likeness, nio that kid's gonna get paid for playing. Like a football, man and men and footballs. That's the whole thing. And if you look at this statistic, that's where the money is. That's where it nio money is going, blah, blah, blah, man and football and so my group, we're looking at students overall. And our program is open to any student in any sport in any school. And I want people that want to go to the Olympics, I want Paralympic people, I want LGBTQ T people, I want any athlete. But again, that's different. People aren't saying that they're not thinking that at all. So we're going to be a little different that way. But I always have been different. But I think if anything, those other groups all need it more. Because right now 2% of NCAA athletes in college, become professional athletes. 2% Okay, 98% What are they gonna do afterwards? And, you know, college is not really prepared for them for that. It's no, but just they have different goals. Okay. And I don't begrudge them that they have different goals, different objectives. But what we're doing is teaching them how to create a business run a business. So they have something when they leave college, they leave our program with a business license. So they have something when they leave college, what they do with it after that, we up to them, but at least it gives them a chance and opportunity to be I say something besides a pitcher in a yearbook? Yeah.   Michael Hingson ** 41:25 Which is something that certainly makes sense to do.   Denise Meridith ** 41:30 So where it's called Project Nylo. And so I encourage people to look into it. It's pretty simple. It's www dot project. Nylo. And I l.com Pretty simple, but the O is for ownership. And what we do is want to put ownership in the NFL, on the side of the good. Oh, that's just something different. Okay, now, I was gonna say, but you know, the things why I like liked you when I met you. And why I like your program, is there's such a need for educating the public about things. And it's getting harder and harder to do that. On paper. You know, to me, that's the anti intellectual approach that's being taken to so many things. It makes it more difficult. So I appreciate what you're doing.   Michael Hingson ** 42:27 You have you have in your life I'm sure had. Well, you talk a lot about mentoring, and you've been mentored a number of people who are some of the people who have been your mentors?   Denise Meridith ** 42:40 Um, yeah, it's interesting. Obviously, I didn't have many women. I didn't have any women mentors in Bureau, I was it so I became the permanent woman, mentor, and the Bureau of Land Management. But I did have a lot of male mentors. And that's one thing I try to get across to people know not to make stereotypes of people judgments about people you never know. My first mentor and Bureau of Land Management was older Anglo guy, and I say older, we thought he was really old, because he was 55. He's like, 2020 to 21, and whatever. So and he was a sagebrush specialist, right? That was his site. So you wouldn't think, and it was Republican conservative, you could go down the line. And we hit it off perfectly, which you wouldn't think so you can't make judgments about people. And he really helped me in the beginning, because like I said, I dealt with wildlife in New York. And we were in Nevada, though, he taught me a lot of desert, survival skills that I needed the half, and really helped me understand the bureau and it's what it did and how it did. It sounds like that. So Jim Bruner was my first mentor there. But then I had others while I'm away at hasty was the director of California for like, 30 years. He was the bureau director in California. He was awesome. Oh, God said and he would say, I like women better they work harder. Here's a big guy, Marine veteran, you know, tough guy and buzz cut until he died, you know? And so to have someone like that, except you Yeah, you know, promote you as like Kevin a year on pet Pitbull. Right. But it was very helpful. So I've had people like that. JOHN MCCAIN, ARIZONA. So I had mainly just because of the nature of the work I was said, mainly male mentors, mainly Anglo male mentors. So I do Estelle people keep an open mind about things you can learn from everyone. And I've had great support.   Michael Hingson ** 45:05 Was your mom, a mentor to you? Yeah,   Denise Meridith ** 45:09 yeah, I talked about that your parents if you're lucky. I'd be the first mentor. So I described my dad and everything that he did. And my mom was community organizer, a very strong, liberated woman, so to speak. And so for both of them, I got a little bit from both of them that helped shape me. And I, and really, they're the ones said, you could do anything? Honestly, you bet. They didn't say that, you know, they were very supportive. The track the track to get to Cornell is no easy track. In New York, it starts my mother figured it out. It pretty much started when I graduated from elementary school. I was valedictorian there. And she knew you had to get into the right Junior High School to get into the right high school to get to Cornell. Okay, she was that far ahead. So I'm thinking, so that's why I integrated the junior high school. And it was all white. I think there was 20 people of color in that whole school. And then I integrated the high school that I went to as well. And yeah, that was no easy thing. But I keep your eye on the prize and what you want out of it, what you got, and then that high school was sort of a feeder type of high school for for now.   Michael Hingson ** 46:40 Here's an off the wall question. Going back to mentors for a second. You mentioned John McCain. How about Cindy McCain?   Denise Meridith ** 46:46 Cindy is wonderful. Yeah, people I don't know, maybe most people outside of Arizona don't realize or the southwest. It was a it was a couple. Yeah. He was very important. And his decision making. And just being an I love them both. There was such a strong couple. And she's carried on she's so she has   Michael Hingson ** 47:17 you know, he was the visible one. Pretty much in the news and all that but she is clearly continue to move. Move forward in is a vibrant force in her own right, which is great.   Denise Meridith ** 47:30 Yeah, and she has I'm gonna approach her about my program, too. But hey, you know, it's Yeah, yeah. And politics in general. You know, I just don't have many I care right now, are Republican and Democrat. I've been independent all my life. So it hasn't mattered, obviously. But, but the just, we need people that have conviction, you know, and make honest decisions, not based on, you know, contributions or anything like that.   Michael Hingson ** 48:05 Yeah, that's really the issue is having true convictions. And we just don't see that much of it. In the world in general, like we should know.   Denise Meridith ** 48:13 And, you know, who knows when we'll get there again. But it's very price people. He people never really knew what he was gonna vote, you know, how he's gonna vote, even though he was a conservative Republican. So you could guess some of it. But he did a lot of environmental work this Yeah, I know, as I was working with him on it, right. So that would shock people. They would not think that would happen. But there were   Michael Hingson ** 48:37 a few decisions he made. I thought were a little bit strange, but you know, but that's okay. You You do what you can, but clearly, he was a man of convictions and, and was was one of the good ones. Yeah,   Denise Meridith ** 48:53 he was also effective. And that's one thing. There you go. You know, well, I don't know if we have to leave effective politicians anymore. But he brought a lot of money to the state. He was very obviously supportive of the military. So veterans, he did a lot to help veterans. He did a lot of, to me. Very important things that involve getting money, you have to get money to do good things. And he did. had, you know, did a good job of doing that. But, you know, so a lot of politicians now you don't see them getting money for anyone but themselves in a lot of cases. Yeah. It's pretty sad.   Michael Hingson ** 49:32 Yeah, we don't have the role models that we used to have them true models that you can look up to in terms of ethics and everything else. Yeah.   Denise Meridith ** 49:42 Sandra Day O'Connor, another person we lost. I said another wonderful person. I met her obviously through my stuff with the Bureau of Land Management. But again, you know, people couldn't predict. Yeah, she voted accordingly, you could not predict or assume, you know that she was going to do this or do that. He evaluated every issue that came up and, and, you know, stuck to her guns with it. She was very important. She also what I liked about her is that she rarely promoted education. Right now, Arizona, I don't know, I didn't look this past year are pretty much been number 49 out of 50. States and education. And she was did a lot to try to rectify that by really pushing education. She thought that people choose, right. Don't know enough about government. Yeah, it's not taught anymore. People don't know how government works. How, what is public service? Now that is, I know, Bureau and other federal agencies have a hard time getting anyone anymore. And believe me, we need civil servants. We need public servants. So who are honest, and they're just to do a good job. We need   Michael Hingson ** 51:09 to get leaders and it isn't just civil servants. They need to, to understand and other civil servants we need to grow leaders to write.   Denise Meridith ** 51:21 And I just really, a lot of people been discouraged. Like, even aside, even the science, they can't do science anymore. Right. So scientists are not happy campers as there used to be. Yeah, it's gotten very politicized. Yeah, exactly. So I don't know. But I, my, what I've decided from here on I have a few years left, maybe just a few. But anyway, is to legacy, my legacy, hopefully, would be developing future leaders. So that's what I'm doing. That's why I'm doing like this education program. We're gonna create a whole new generation of business leaders, which will be nice people that in the past, or qualities have been overlooked athletes, people don't think about them, except how fast I can run or how high they can jump. Yeah. And when you think about it, that discipline there that they had to go through to be to where they are charismatic, a lot of them are charismatic leader type people. And, you know, we're missing all of that, by just, you know, throwing them out if they can't run out in the field anymore. Yeah. I'm hoping to give them some alternatives. In turn, they can take that business degree, go back home, hire people in their area, and their community back home with a business degree and have a family business. You know, it's it's multiple, as the effects multiply dramatically, I hope, what they were doing with this program,   Michael Hingson ** 53:00 you mentioned earlier, read to kids tell me a little bit more about that.   Denise Meridith ** 53:04 Yeah, that's, that's my fun project. But I feel one I've been writing since I was 10 years. Well, probably before, but since I wrote my first book when I was 10 years old, right, dreading it, too. I was pretty good artists. But I'm concerned that people aren't. I think reading is the crux of a lot of things. Decision making, you know, rationality, everything, but my angle on it is in the past, parents rented our kids, it was one moment, you know, bedtime stories. One moment, bedtime alone, if your child quietly do something together. Now, it's pretty much an ima ComiCon fan, so not knocking marvel in particular, but now it's, you know, syndicated on another TV, watch Marvel until this time because parents are very busy. I got a lot of different jobs. It's just, to me, that's something that's been lost. And when I read the kids, us the mascot is my dog, my miniature poodle, airy, and he has five books on Amazon. And the adventures of airy are about what he's doing as he grows up so to speak. So   Michael Hingson ** 54:30 every right Harry writes his own books. Yeah,   Denise Meridith ** 54:33 he does a good job. This book sell more than my Yes. So his first haircut our first target went to the doctor right those types of issues, though he helps kids overcome those fears that they might have. But to be the key is there. I'm what I might our model is to read to a kid three to six years old 15 minutes a day. So you take that 15 minutes read in 15 Min. So we have a lot of authors in our group, you can read those books, 15 minutes. And that's just 15 minutes, which doesn't seem long, but it's, you know, face to face. Total attention, working on something together, and it just doesn't happen much anymore. Know what to say. And when we go to book shows or whatever, and type of thing, and so all the people that go to these giant, you know, now they still have a few, I was glad to find out a few giant book fairs going on. And one in Tucson, I guess. 100,000 people go to that one. It's pretty incredible. But everybody that will come up to our booth say, oh, yeah, my mom used to read to me. It's passed along. Yeah, passed along. And these people that are coming up to you are very educated, erudite people, right. So that's what I hope to do. And luckily, I had a RT O'Hagan and I'll give a shout out to him. He, during pandemic, he bought Aires books, and distributed them to nurses and hospitals. So that they could go home and read to their kids. And so you get nice letters. Oh, it's first time. My kid read out loud. Or it's the first time that ghost I hope that nice books that people would get some lessons from them dedicate my talk about? Oh, you didn't know that your kid was afraid of such and such? Yeah. You didn't know the kid was being bullied at school? Or you didn't know these things? It? Yeah. So it could open up a lot of discussions. So it's the region kids got us is that site. And it's just a little thing I do on the side. But I'm hoping it has some impact on parents, grandparents in particular, I thought grandparents were really sort of left out during COVID. You know, they couldn't even see anybody and got separated from their grandkids. My books are various books, obviously, you can get them on Kindle. You can get them on online. And so it's something that you can do now what technology you can do over what we're doing zoom, right. You can read to hear grant kid on the other side of the country through zoom. So that's what I'm hoping. Right now. I appreciate your asking about it. So the little thing I do on the side but reallocates us that's as my heart. It's something that I really like to see happen.   Michael Hingson ** 57:36 So how does the program work? What do you do?   Denise Meridith ** 57:39 What we do is just write books there online. And what we had breach over it, or we'll have starting again this year, is go to schools, you know, go to school, go to libraries. You know, Eric goes, I take Gary. And he goes, and we have, you know, the books there. And parents. Yeah, by the books we read. We have readings for our office from our, you know, our group COMM And I read some of the kids there, and whatever. So it's just getting kids excited about reading again. And parents like it too.   Michael Hingson ** 58:16 Alright, so I get to that is that is really cool. What books have you written?   Denise Meridith ** 58:20 I just have to have my own. But anyway, so he has five, but I have   Michael Hingson ** 58:26 He's got four paws though. So he's got a porter, right?   58:30 That's true thoughts, while chillin and a C h i l l i n what no G is really covers my career from being born in Brooklyn, I guess, up into my career through the Bureau of Land Management. So it's funny when you write something like that, and you call it an autobiography, because when you're young, you don't think you're gonna live that long. And then it was like, Gee, wow, I guess I had some more living to do I should write something else. So the other book is the sequel to that and it's called the year roof rat ate my dishwasher. Which people go I'd say what Okay. Roof rats are I don't know that their I guess their data. Arizona. I don't know. Anyway, we have roof rats here. A lot of people have different kinds of pests than their areas but we have roof rats, and they eat there. They have big teeth. And not like normal rats. They have big teeth. They climb trees and they eat through pipes. They eat through all kinds of things. So literally, the story opens so that book the first story is about the My dishwasher stopped working. And I had the guy come to repair it and he opened stuff up but he like jumps back and scrapes I go whoa. And he goes look at a pipe. So the rat should eaten through the PCV pipe. And that's why my dishwasher what's not working. And so what I wanted to do with this book is it's very much about Arizona. So it's an Arizona Survival Guide is what I call it. Arizona is a very particular place with very unique problems like roof rats. And so I talk about as a business person, how to survive here in Arizona, what kinds of things to consider and look out for. And I tried to tell people, it's a great place to live. People know that already. But there are some things that are different here that you have to look out for Scorpio, roof rats, rattle steaks, black nose, yeah, 115 degree temperatures now one ban. But I tried to keep it very upbeat. And I also tried to acknowledge people here in Arizona that are doing very positive things like McCain, I mentioned in there, people who, because Arizona doesn't get any recognition really has a very strange reputation outside of Arizona. And I wanted to get across that is very normal place. With it's a purple state that much into that, but it's we have people all kinds and all religions and all people think there are people of color hair for some reason, because it sort of looks that way if you walk through parts of Scottsdale, but it's gonna be majority minority state a couple of years. So there are plenty of people of color here. And it's just a wonderful place to live. So my second book while it's out, it's about me and people. I never hear what they've accomplished. It's also i My love you but who? Arizona.   Michael Hingson ** 1:01:51 So do you see desert tortoises these days?   1:01:56 I hear are Phoenix not anymore? Because it's so built up? Yeah. But the thing is, Phoenix is also spread out, believe it or not, it's the biggest city now geographically in the country. surpassed LA. So now it's the biggest Yeah. And so around the edges, people live around the edges. So they see tortoises, but they also see coyotes and rattlesnakes. So I, you know, I had my years as a wildlife biologist, I don't need that anymore.   Michael Hingson ** 1:02:29 Well, if people want to reach out and contact you, how do they do that? Okay.   1:02:34 Pretty simple. You could get my website that's about me is Denise. Meridith.   Michael Hingson ** 1:02:41 Can you spell that, please? Yeah, I   Denise Meridith ** 1:02:43 was about to do that. Oh, great. Yeah, that's people fill it in correctly. So thats D e n i s e m e r i d i t h.com. Meridith is normally spelt with two E's, so I don't get much junk mail. But it's denisemeridith.com is my website. And you can sort of go from there links you to all things, world's best connectors is the wbcs.com. Again, and my ComiCon routine, but we're the WBCs that's what we pretend to be. But it's t h e w b c s.com. And that's the other site they can go to. And I really welcome people to go in and read to kids.us if you want to see airy, and hear about airy, and get some kids books, but I really want to encourage people to read to their children and read to their grandchildren. It's like a lot of stars, Michael. It's getting to be a lost art. And if   Michael Hingson ** 1:03:43 people go to our our show notes, and so on. You have some gifts that you're giving away. Yes,   Denise Meridith ** 1:03:49 yes, I have. It's called the we're talking about mentors, right. So it's called a mentors almanac. One of the gifts that I'm giving away in which you can, and what it is is 365 tips on how to be a great leader. And so I have a sort of a mantra every day that you can use, that you can use in helping you mentor other people, and also hopefully help yourself at the same time. And then people can call me and when they go to my site, they can get the phone number there too. And set up a call with me about coaching. Again, I have masterminds. I'm starting a mastermind here, probably the end of the month, so call me about that. And I also do personal coaching private coaching. And while I emphasize Gen X and baby boomers I you know, really executive coach for anyone. It's just those groups are pretty in need. Right now of that. I get it kids through my events, like world's best connectors through my events with the educational program. So I'm going to be helping kids. I'm not discriminating against younger people. I'm going to be helping them. But I coach, Baby Boomers and Gen X primarily. Cool.   Michael Hingson ** 1:05:10 Well, again, I want to thank you for being here. This has been a lot of fun. Can you believe it? We've been doing it over an hour now, which   Denise Meridith ** 1:05:18 I appreciate it. It's, well, I went I'm once I met you, I know this is gonna be great. I think we're gonna stay in touch and do a   Michael Hingson ** 1:05:26 lot of good things. Well, I sincerely hope so and definitely want to do that. So I want to thank you again. And thanks for listening wherever you are, we really appreciate it. Whether you're listening or watching on YouTube or some other podcast source would really appreciate it. If you give us a five star rating we value your ratings very highly. And of course, needless to say, Love five star rating. So please do that. Love your opinions, any thoughts that you have about what we did today and we appreciate your opinions. If you know of anyone who ought to be a guest on unstoppable mindset. Denise, you as well. Please let us know we're always looking for additional guests, people who we can have on to tell their stories and talk about what they'd like to talk about. If you wish to reach out to me you can do so by emailing me at Michael m i c h a e l h i, at accessiBe A C C E S S I B e.com. You can also go to our podcast webpage, www dot Michael hingson.com/podcast. And Michael Hingson is m i c h a e l h i n g s o n So www dot Michael hingson.com/podcasts. And again, love those ratings really appreciate it. And we definitely want to hear from you and get your thoughts. So, one last time, Denise, I want to thank you for being here and taking so much time to be with us.   Denise Meridith ** 1:06:57 Thank you, Michael and I wish you continued success.   **Michael Hingson ** 1:07:03 You have been listening to the Unstoppable Mindset podcast. Thanks for dropping by. I

A 22-year-old woman presents with a chief complaint of a 4-day history of mild dysuria, described as, “It burns a bit when I urinate.” She denies fever, GI upset, urinary urgency and frequency. About 1 month ago, she entered a relationship with a male partner who is currently without symptoms. Clinical assessment reveals a friable cervix covered by a thick yellow discharge. Suprapubic, CVA and cervical motion tenderness are absent.  UA is positive for leukocytes and negative for nitrites, and microscopic examination of vaginal discharge reveals a large number of white blood cells (WBCs).  She is in no acute distress. Thie presentation is most consistent with: A.  Pelvic inflammatory diseaseB.  Lower urinary tract infectionC.  Genital herpesD. Chlamydia trachomatis cervicitis. ---Youtube: https://www.youtube.com/watch?v=7X1T771b9ac&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=54Visit fhea.com to learn more!

Visit: https://nursing.com/140meds to request your free copy of "140 Must Know Meds" Generic Name Enalapril Trade Name Vasotec Indication hypertension, management of CHF Action Block conversion of angiotensin I to angiotensin II, increases renin levels and decreases aldosterone leading to vasodilation Therapeutic Class Antihypertensives Pharmacologic Class ACE Inhibitor Nursing Considerations • May cause hypersensitivity (allergic) reactions and angioedema (swelling of face, lips, tongue, throat) • Can cause neutropenia – check WBCs regularly • Use cautiously with potassium supplements and potassium sparing diuretics. • Use cautiously with diuretic therapy • Administer 1 hour before meals • Monitor blood pressure often • Monitor weight and fluid status • Monitor renal profile • Monitor CBC frequently • Dry cough

Get a free nursing lab values cheat sheet at NURSING.com/63labs   What is the Lab Name for White Blood Cell (WBC) Lab Values? White Blood Cell   What is the Lab Abbreviation for White Blood Cell? WBC   What is White Blood Cell in terms of Nursing Labs? White blood cells (WBCs) are created in the bone marrow. Their primary function is to defend the body against infection. There are various types of WBCs which have different shapes and functions. Decreased WBC count is called Leukopenia and increased WBC count is called Leukocytosis.   What is the Normal Range for White Blood Cell? 4,500 – 10,000 cells/mcL   What are the Indications for White Blood Cell? Evaluate for infection   What would cause Increased Levels of White Blood Cell? Infection/inflammation Leukemic Neoplasia Trauma/stress Tissue necrosis Pregnancy Cushing Disease Asthma Allergic reaction   What would cause Decreased Levels of White Blood Cell? Systemic Lupus Erythematosus (SLE) Anemia Rheumatoid Arthritis (RA) Chemotherapy/radiation Overwhelming infections (WBCs are all used up)

Visit: https://nursing.com/140meds to request your free copy of "140 Must Know Meds" Generic Name Captopril Trade Name Capoten Indication Hypertension, management of CHF, decrease progression of DM neuropathy Action Block conversion of angiotensin I to angiotensin II, increases renin levels and decreases aldosterone leading to vasodilation Therapeutic Class Antihypertensives Pharmacologic Class ACE Inhibitor Nursing Considerations • Can cause neutropenia – check WBCs regularly • Use cautiously with potassium supplements and potassium sparing diuretics • Use cautiously with diuretic therapy • Administer 1 hour before meals • Monitor blood pressure often • Monitor weight and fluid status • Monitor renal profile • Monitor CBC frequently • May lead to Rhabdomyolysis • Dry cough

On today's show, Matt Robinson talks with Toronto Blue Jays play-by-play man Dan Shulman about the war of words between Alek Manoah and Alex Verdugo of the Boston Red Sox, a rocky first trip through the rotation, what's going on with Jose Berrios, Yusei Kikuchi getting off to a nice start, how the vibe around the clubhouse has changed after major roster moves during the offseason, whether Matt Chapman is likely to want to stay in Toronto when he hits free agency, whether this year's edition of the World Baseball Classic was bigger than previous WBCs and lots more.Check out the Tall Can Audio 1000 Playlist for all sorts of songs associated with the show over our first thousand episodes. Apple Music: https://music.apple.com/ca/playlist/tall-can-audio-1000/pl.u-pZ2ETYAq6vySpotify: https://open.spotify.com/playlist/2rZG14zZDmm70onDkGrv2a?si=yeSwQIUXTaW2XfUPUY50_wFollow TCA on Twitter: https://twitter.com/tallcanaudioFollow TCA on Instagram: https://instagram.com/tallcanaudio?igshid=YmMyMTA2M2Y= Follow TCA on Facebook: https://www.facebook.com/tallcanaudio

In this super HY podcast, I discuss a host of commonly tested adverse drug reactions around the blood elements (RBCs, WBCs, platelets). These things show up on almost every USMLE exam. It is a continuation of Episode 387 on the website. If you’re interested in helping with the transcription of my Step 1 podcasts, reach … Continue reading Divine Intervention Episode 433: Adverse Drug Reactions for The USMLE exams Part 2 (Step 1-3)

Stress may affect your white blood cells and your immune system—making you more susceptible to getting sick. Check this out. Dr. Berg's Keto and IF Lab: https://www.facebook.com/groups/drbergslab/ How to Bulletproof your Immune System FREE Course: https://bit.ly/39Ry3s2 FREE MINI-COURSE ➜ ➜ Take Dr. Berg's Free Keto Mini-Course! ADD YOUR SUCCESS STORY HERE: https://bit.ly/3z9TviS Find Your Body Type: https://www.drberg.com/body-type-quiz Talk to a Product Advisor to find the best product for you! Call 1-540-299-1557 with your questions about Dr. Berg's products. Product Advisors are available Monday through Friday 8 am - 6 pm and Saturday 9 am - 5 pm EST. At this time, we no longer offer Keto Consulting and our Product Advisors will only be advising on which product is best for you and advise on how to take them. Dr. Eric Berg DC Bio: Dr. Berg, 51 years of age is a chiropractor who specializes in weight loss through nutritional & natural methods. His private practice is located in Alexandria, Virginia. His clients include senior officials in the U.S. government & the Justice Department, ambassadors, medical doctors, high-level executives of prominent corporations, scientists, engineers, professors, and other clients from all walks of life. He is the author of The 7 Principles of Fat Burning. Dr. Berg's Website: http://bit.ly/37AV0fk Dr. Berg's Recipe Ideas: http://bit.ly/37FF6QR Dr. Berg's Reviews: http://bit.ly/3hkIvbb Dr. Berg's Shop: http://bit.ly/3mJcLxg Dr. Berg's Bio: http://bit.ly/3as2cfE Dr. Berg's Health Coach Training: http://bit.ly/3as2p2q Facebook: https://www.facebook.com/drericberg Messenger: https://www.messenger.com/t/drericberg Instagram: https://www.instagram.com/drericberg/ YouTube: http://bit.ly/37DXt8C Pinterest: https://www.pinterest.com/drericberg/

The TWiP team solves the case of the Woman Who Vomited Up a Worm, and discuss how malaria transmission intensity can modify the effectiveness of the RTS, S/AS01 vaccine in Africa. Hosts: Vincent Racaniello, Dickson Despommier, Daniel Griffin, and Christina Naula Subscribe (free): Apple Podcasts, Google Podcasts, RSS, email Links for this episode Malaria intensity modifies vaccine effectiveness (J Inf Dis) Letters read on TWiP 208 Become a patron of TWiP Case Study for TWiP 208 An adult female resident of Hawai'i presented to the emergency department (ED) with several days of fever, abdominal pain, urinary hesitancy, and generalized itchiness. white blood cell [WBC] count 14,000 cells/mL) without eosinophilia. Urinalysis suggested a urinary tract infection and she was treated for acute UTI and discharged home.  The following day she returned to the ED because of worsening abdominal pain, bilateral hip and leg pain, dizziness, diffuse hyperesthesia, and allodynia (Pain from stimuli which are not normally painful)  (worse on her feet and legs.) Urine culture from her initial ED visit grew normal urogenital flora. Her leukocytosis increased and she now had eosinophilia (WBC count 15,500 cells/mL; absolute eosinophil count 574). Laboratory evaluation was otherwise unremarkable. CT scans of the brain, abdomen, and pelvis were normal. She was hospitalized and her allodynia worsened despite treatment with analgesics. She also developed a sensation of “electric eels swimming through [her] body. Electromyography and nerve conduction studies were normal. The patient underwent a lumbar puncture and CSF examination was notable for eosinophilic meningitis with 138 WBCs and 13% eosinophils (absolute eosinophil count 18). Send your case diagnosis, questions and comments to twip@microbe.tv Music by Ronald Jenkees

Paul Murnane and Wayne Cabot have the top local stories from the WBCS newsroom, including a rise in the presence of the West Nile Virus in Queens, COVID testing guidelines for NYC public school student, and Rockland County's fight against Polio.

Download the cheat: https://bit.ly/50-meds  View the lesson: https://bit.ly/EnalaprilVasotecNursingConsiderations    Generic Name Enalapril Trade Name Vasotec Indication hypertension, management of CHF Action Block conversion of angiotensin I to angiotensin II, increases renin levels and decreases aldosterone leading to vasodilation Therapeutic Class Antihypertensives Pharmacologic Class ACE Inhibitor Nursing Considerations • May cause hypersensitivity (allergic) reactions and angioedema (swelling of face, lips, tongue, throat) • Can cause neutropenia – check WBCs regularly • Use cautiously with potassium supplements and potassium sparing diuretics. • Use cautiously with diuretic therapy • Administer 1 hour before meals • Monitor blood pressure often • Monitor weight and fluid status • Monitor renal profile • Monitor CBC frequently • Dry cough

Download the cheat: https://bit.ly/50-meds  View the lesson: https://bit.ly/CaptoprilCapotenNursingConsiderations    Generic Name Captopril Trade Name Capoten Indication Hypertension, management of CHF, decrease progression of DM neuropathy Action Block conversion of angiotensin I to angiotensin II, increases renin levels and decreases aldosterone leading to vasodilation Therapeutic Class Antihypertensives Pharmacologic Class ACE Inhibitor Nursing Considerations • Can cause neutropenia – check WBCs regularly • Use cautiously with potassium supplements and potassium sparing diuretics • Use cautiously with diuretic therapy • Administer 1 hour before meals • Monitor blood pressure often • Monitor weight and fluid status • Monitor renal profile • Monitor CBC frequently • May lead to Rhabdomyolysis • Dry cough

WBCS 880's Brad Heller chats with Seattle Mariners' manager Scott Servais on getting to play teams you don't face every season, Paul Sewald's impact on the rotation, and managing a roster with a lot of young talent

See all the Healthcasts at https://www.biobalancehealth.com/healthcast-blog/ 50% of men who receive Testosterone replacement therapy (TRT) have elevated Red Blood cell counts, and high Hemoglobin and Hematocrits. The numbers that are considered normal are usually normal for men at sea level, and an elevated H/H doesn't necessarily mean that a man will have any negative effects If you have lung problems, or disease: For those men who have COPD, Chronic Bronchitis, or asthma, high counts are an adaptation that help you live with a compromised ability to oxygenate your blood. You should not get your blood dumped because the high counts are keeping you alive!  If you live at high altitude or if you spend a large amount of time at high altitudes, then you don't necessarily need your blood phlebotomized because you need higher counts to live or vacation there. Men who live at high altitude have adapted to a lower oxygen level making more RBCs. If you are an extreme athlete, or you train excessively you may have high red blood counts to help you collect and distribute oxygen during your exercise. You won't have to remove blood unless this level remains a year after you stop excessive exercise. Why are doctors telling us to get phlebotomies (blood dumped) all the time? The problem with having a diagnosis of Erythrocytosis from TRT is that it is almost always confused with the disease called Polycythemia Vera (PCV).  PCV does carry with it a high risk of blood clots, strokes and heart attacks.  The two conditions are completely different, but ER doctors and surgeons only know that a high H/H is a sign of PCV, and PVC causes blood clotting…but they don't know that elevated H/H from TRT or adaptation to a disease doesn't cause the same medical problems as Polycythemia vera.. One of the ways we can separate the disease of PVC from the condition of Erythrocytosis: The CBC will show us the difference.  PVC his elevated RBCs, H/H, Platelets and WBCs…all of them are elevated.  Erythrocytosis only has an elevated RBC, and H/H. If your doctor gets excited about your elevated blood count, please tell him we have evaluated you for PVC and you don't have that, so you are not in danger for clotting or CVDx. Here are the differences between PCV and Erythrocytosis from TFT:   Polycythemia Vera Erythrocytosis Blood test: high RBC, High H/H and High platelets, High WBC Blood test: only high H/H and RBC Abnormal Platelets, increase clotting Normal Platelets, no increase clotting Genetics: + Jak 2 mutation Genetics: no mutation Cause is genetic requires blood dumping to lower all counts or hydroxyurea meds Causes: High Altitude, TRT, COPD, Familial cause Treatment: requires blood dumping to lower all counts or hydroxyurea meds Treatment not necessary to keep it below HCT of 50.  Some people do better with higher counts especially COPD, High Altitude Living, exercise at high altitude. A lot of Research that supports the theory that these patients are at risk for blood clots and coronary artery disease. No research paper that says high H/H from T causes CVDX, Stroke, or Blood clots. Abnormal platelet number and function cause the vascular diseases and clotting TFT is associated with normal platelet counts and functions. Jak 2 increases clotting factors and platelet production, and erythropoietin from the kidneys  and increases clotting. Way it works:  T directly stimulated the bone marrow to make more RBCs. No other blood products are elevated Remember: It is not T that causes high H/H to require blood dumping, it is the confused medical community that goes crazy when they see high H/H and cry malpractice!  In many cases we are dumping blood to appease the primary care doctors.  We ideally would like to keep a man's H/H below 20/55.   Other reasons for elevated H/H: Do you have COPD, Asthma or chronic bronchitis? Don't get your blood dumped. The high counts are helping you. Do you have, or have you had elevated platelet count with your elevated red blood cell count? If you have, please tell your primary or your BioBalance Health Nurse Practitioner you will be evaluated for PCV with a genetic test. Do you live for part of the year at high elevation? If yes, then it is not necessary to phlebotomize you to get your counts down because you need those RBCs. Do you eat high iron foods (liver, braunsweiger, pate, bone marrow, Deep green leafy veggies) ? If so of if you are taking iron, you can stop because you shouldn't need it while taking T, because the bone marrow is stimulated to make more red cells with T. Do men in your family die of CVDX before age 50? Then you might have PCV! Get an iron panel + a Jak 2 genetic test. Blood Phlebotomies: Men over 70, should only have 250 cc removed at one time and told not to exercise for a few days. Blood pressure and blood volume take longer to equilibrate after the age of 70. Make sure these patients have a lot of water and that they drink it and eat something after the phlebotomy.  Remember you just removed blood sugar, dropped their blood pressure, and dehydrated them by removing blood. They may be dizzy, but they have to sit until they are stable.   Blood tests for erythrocytosis/ PCV: CBC Iron panel Ferritin Jak-2 mutation Hereditary hemochromatosis

In this podcast, Dr. Kim Thielen, a nephrologist/kidney specialist with Minnesota Kidney Specialists joins us today to continue part 2 of our discussion on acute kidney injury, as we wade further "into the weeds"  discuss intrinsic renal disease. This episode will break down hallmark urinary findings and further subdivide intrinsic concerns into bland, nephrotic and nephritic, various causes, and treatment. Enjoy the podcast! Objectives:   Upon completion of this podcast, participants should be able to: State the 3 types of urinary analysis findings related to instrinic acute kidney injury. Describe etiology of presentation of each type of intrinsic acute kidney injury. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation. CME Evaluation (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker's outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. Thank-you for listening to the podcast. SHOW NOTES: *See the attachment for additional show information.  Intrinsic Kidney Injuries: Urinary analysis findings- Bland Urine: no protein - Nephrotic: protein - Nephritic: protein and blood Hallmark Urinary Findings: Casts - Tamm Horsfall Protein : Mucoprotein made by tubular epithelial cells that precipitate out and congeal    to form casts on whatever is in the cells at the time.  (i.e. RBCs, WBCs, tubular debris) Bland Urine States- Crystalline Induced Renal Injury: obstruction and infllamatory response       - Uric Acid Neuropathy (Most common)              - Cancers, lymphomas, etc.              - Drugs: acyclovir, methotrexate, protease inhibitors, etc.              - Toxins: Ethylene glycol - Bland Urine Disease states: results from injury to tubules, instertim or pre glomerular blodd vessels, not    the filters of the kidney       - Interstital Nephritis              - Hallmark: pyuria and WBC casts                      - Biopsy: inflammatory infiltrate              - Causes:  viral, PPIs, Adenover, mizalamin, etc., Checkpoint inhibitors       - Acute Tubular Necrosis              - Hallmark: tubular epithelial cell cast                      - Granular: (course or fine) diagnostic of ATN              - Biopsy: denuded dilated tubular cells              - Causes: #1: Ischemia;  toxins, drugs, contrast dye;  pigment injury. myoglobin              - What about contrast dye?                      - Categorized under ATN                      - Per Dr. Thielen, plays a role, but injury is not solely dependent on dye alone.       - Hepatorenal Syndrome: ischemic injury to the kidney due to unopposed vasocontstriction               - Ace inhibitors cause unopposed efferent vasoconstriction + nonsteroidals cause                 unposed afferent vasoconstriction = no glomerular perfusion pressure       - Multiple Myeloma              - Hallmark: Light chain cast nephropathy or myeloma kidney                      - Light chains precipitate  out causing obstruction, inflammatory response and causes                        tubular damage              - Presentation: older possibly with anemia, bone pain and elevated creatinine with a bland urine.              - Protein to creatinine ratio: + for protein (non albumin)              - Dipstick: (which measures for albumin and not light chains) will be negative for protein aka                 bland urine       - Hypertensive Nephrosclerosis              - Small vessel vascular disease                     - Blood vessels prematurely atherosclerosis causing glomerular drop out and scarring of the                        interstim       - Scleroderma                - Limited cutaneous systemic sclerosis                - Diffuse cutaneous systemic sclerosis: 60-80% have renal injury from disease state itself                           - FANA positive                           - Concern for Scleroderma Renal Crisis = medical emergency                                   - AKI, moderate to severe HTN and bland urine                                   - Uncontrolled accumulation of collage, thickens vascular walls, narrowing and renal                                       ischemia                          - Occurs in 10-15% of those with Diffuse Cutaneous Systemic sclerosis and happens early                              in disease                                     - Left untreated: renal failure in 1-2 months and death in 1 year                          - Treatment: ACE Inhibitor Nephrotic Urine States - Urine protein: albumin excretion greater than 3.5g in 24 hours - Nephrotic Syndrome:      - Present with 3 things (nephrotic range protein, hypoalbuminemia, peripheral edema)       - Hyperlipidemia: due to increased hepatic lipogenesis                - Increased risk of renal disease and arthroscleratic       - Venous thrombotic disease:                 - Loose proteins other than albumin and develop a hypercoagulale state                 - Renal and peripheral venous thrombosis      - Lipiduria (forms fatty casts,  looks like a latese cross under microscope)  -Pathophysiology or nephrotic syndrome    - Glomerular capillary wall           - 3 layers that work as a glomerular filtration and responsible in the filtration between blood and             urine                  - Fenestrated Capillary Enothelial cells (fenestrations allow plasma through to the basement                     membrane)                 - Glomerular Basement Membrane (maintains glomerular filtration barrier; negatively charged,                     repels albumin)                 - Epithelium: Podocytes (Have highly specialized foot processes that connect and form slit                     diaphragms; Slit diaphragm important for the efficient flow of small solute and water)          - Anything that messes with any of these layers: nephrotic proteinuria - Nephrotic Disease States:     - Biopsy: anyone with nephrotic proteinuria (besides diabetics)          1) Light microscopy: high overview          2) Immunofluorescens: looks for nephritic component and identif immunce complexes          3) Electron microscopy: (EM) helps look at the ultrastructure and better identify immune deposits    - Diabetic nephropathy           - Leading cause of kidney disease in U.S. and western society           - Responsible for 30-40% of all ESRD causes           - Hyperglycemia: produces inflammatory responses, oxidative stress, and injures the podocytes and             deposits that charge and affect the ability of the kidney to filter.     - Amyoidosis            - Organize into betapleted sheets and produce spikes of the capillary uniion and poke through the               GF membrane            - Easily identified by apple green birefringence on congo red            - Terminal illness            - Present with HTN, cardiac effects and elevated creatine  - Nephrotic Disease states based of histologic appearance      - Diagnosed by histologic appearance but does not determine the etiology      - Minimal Change Disease              - Fairly common              - Minimal change under light microscope              - EM: podocytes are abnormal, fused, no unique cell-cell junction              - Primary: Immune generated circulating facture;  alters the cytoskeleton of the podocytes       - Secondary               - Nonsteriodal - most common cause of secondary minimal change disease               - Gama interferon               - Hodgkin's lymphoma               - Allergy: 30% of minimal change have associate allergy (mechanism unknown)       - Presentation               - Sudden onset (days to weeks)               - Marked edema and hypoablbuminemia               - 60% have normal blood pressure,    82% have normal creatinine - Focal Segmental Glomerulosclerosis (FSGS) - primary and secondary         - Most common cause idopathic nephrotic syndrome in adults        - Primary glomerulonephritis in the US that causes ESRD        - Widespread podocyte injury     - Primary: circulating factor that messes with regulation of foot process and adhesion to the         glomerular basement membrane (afffect all podocytes)          - Present with nephrotic syndrome and rapid progression          - HTN and elevated creatinine    - Secondary: the visceral epithelial cells don't replicate          - Nephron loss or obesity or direct foot process injury          - Cannot replicate (podocytes), leads to decreased to podo denisty at specific areas (focal injury)          - 2/3 of all cases FSGS          - Present: with slowly increasing proteinuria and kidney impairment over time          - Causes: interferon, bisphosphonates, talc, anabolic steroids    - Genetics: gene mutations that encode for the slit diaphragms of the podocytes (affect all podocytes)            - Present in Childhood: full blown nephrotic and progress rapidly to ESRD Membranous Nephropathy - Most common cause of nephrotic syndrome in caucasion adults - 80% present with nephrotic but develops more slowly to ESRD - Primary: Major antigen identified      - antibody to trans-membrane receptor that is highly expressed on the glomerular podocyte - Secondary: Cancers (lung, breast, GI), Lupus, Thyroiditis, Hep B, Syphilis, Nonsteroidals, Monoclonal    Antibodies Nephritic Syndrome - Hematuria and proteinuria    - Hematuria: blood from kidney or outside the kidney             - Outside the kidney: look the same             - Inside the kidney: dysmorphic red cells    - Present:             - Renal impairment for days to weeks             - Edmatous, HTN and look critically ill              - Vasculitis, sinusitis, oral ulcers             - Pulmonary renal syndrome: short of breath or hemoptysis             - Skin changes: bruising , bleeding, purpura             - Myalgias and arthritis     - Urine:             - Hallmark: red blood cell casts (polymorphic red cells)             - dipstick + for blood             - elevated proteinuria    - Biopsy: nephritic and + urine Nephritic Disease States (based on immunofluorescence staining) - Pauci Immune Disease         - Ankle vasculitis, common         - A paucity (little amount) of immune complexes         - See black on imaging         - Lab work: check on ANCA and peripheral eosinophils - Anti-GBM Disease         - Renal limited, or classic pulmonary renal: Good Pasture's          - linear staining of the glomerular basement with anti IGG (looks like a ribbon on a package)          - Treat with cytotoxic agents - Immune Complex          - Starry sky pattern          - Glomerulus looks dotted with stars                - Stars = immune complex definition          - Diseases:  Lupus (FANA), Post Infectious GN, Membranous Proliferative GN  - IGA Nephropathy           - Most common cause of glomerulonephritis in the world          - Presentation:                 - Peak incidence is the 2nd and 3rd decades of life                - 40-50% gross hematuria with upper respiratory and GI illness          - Risk Factors for Progression:                - younger age or hypertension at time of presentation                - > 1g proteinuria                - Elevated creatinine at time of presentation Thanks for listening.

Our conversation today with John Fleming, Mid-Atlantic Regional Administrator for the US Small Business Administration is part of an ongoing partnership to talk about the agency's programs and services. John explained the Community Navigators and told us how they came out of the pandemic when it was realized that their services and website were difficult to navigate for small businesses seeking advice and information. The Community Navigator Pilot Program is an American Rescue Plan initiative designed to reduce barriers that underrepresented and underserved entrepreneurs often face in accessing the programs they need to recover, grow, or start their businesses. The program will provide a total of $100 million in funding to 51 organizations that will work with hundreds of local community groups to improve access to SBA and government resources for America's entrepreneurs.  The selected projects will cover diverse communities across the U.S. and Puerto Rico. Grantees will serve as “hubs” -- centralized, lead organizations, which will incorporate “spokes,” organizations that have built trust in their local communities and will be the ‘boots on the ground' that will connect small businesses to critical resources and assistance, including: financial assistance and access to capital contracting and procurement marketing, operations, business development, and exporting industry-specific training Locally, Shenandoah Community Capital Fund is one of these community navigators. We also discussed other "resource partners" such as Small Business Development Centers and SCORE. Locally, you can contact the Lord Fairfax (becoming Laurel Ridge) Small Business Development Center. John also talked about the Women's Business Centers which are a part a national network of entrepreneurship centers throughout the United States and its territories, which are designed to assist women in starting and growing small businesses. WBCs seek to "level the playing field" for women entrepreneurs, who still face unique obstacles in the business world. We discussed the impact getting government contracts can have for small businesses. John recommended that all small businesses check out sam.gov and register their business in the database.

See all the Healthcasts at https://www.biobalancehealth.com/healthcast-blog/ If you ever wondered if there was something other than anti-cancer chemicals, quarantine or vaccines to help protect you from cancer and viral illness, there is a safe, inexpensive and effective medical treatment.  Why haven't you heard of this wonder drug?  The FDA has blocked the US population from access to this immune stimulator in the middle of a pandemic!  I can't tell you why, except that it gave us a way to improve our immune status without other preventive treatments.  It is not dangerous so you can only imagine your own reasons for this action. ‘In this blog I am going to inform you of this option so your will know about it and possibly help drop the ban on compounding pharmacies from making this communicator protein.  I have included quotes from medical and scientific journals to support my information. At the end of the blog, I will list the sources for my information in case you question my information, you can look it up! “Thymosin alpha 1 is a peptide naturally occurring in the thymus that has long been recognized for modifying, enhancing, and restoring immune function. Thymosin alpha 1 has been utilized in the treatment of immunocompromised states and malignancies, as an enhancer of vaccine response, and as a means of curbing morbidity and mortality in sepsis and numerous infections “, World Journal of Virology 2020 Dec 15; 9: 67-78. This “bit of protein” is called a peptide, and it is just one of thousands of peptide communicators produced by the human body. When we are young and healthy these communicators are all working well in healthy mature adults, but as we age, we lose the ability to produce many of the peptides that keep us healthy, like Thymosin alpha 1. This is the reason that people over 60 get sick and die from infections that don't kill younger people. In the Journal of Virology this information was written in December of 2020, during the Covid Pandemic: Studies have postulated that thymosin alpha 1 could help improve the outcome in severely ill corona virus disease 2019 patients by repairing damage caused by overactivation of lymphocytic immunity and how thymosin alpha 1 could prevent the excessive activation of T cells. …. thymosin alpha 1 deserves further investigation into its antiviral properties and possible repurposing as a treatment against severe acute respiratory syndrome coronavirus-2. What does Thymosin Alpha 1 do? Thymosin alpha-1 (TA1) functions as a stimulator to the thymus gland.  This gland produces white blood cells including but not limited to T-Killer cells and T helper cells (CD4+/CD8+ T cells) those WBCs that kill viruses, bacteria, fungus, and cancer cells.  The thymus gland is located behind the “breastbone” and is largest when we are born and shrinks as we age.  As it gets smaller, our immunity to everything decreases which is why older people get more severe infections and take longer to heal, and why older people need stronger vaccinations than younger people to get the same effect. TA1 has many functions other than increasing the number of T cells, it also increases their killing ability and modulates the T cells, so they respond to both abnormally directed immune responses (autoimmune diseases) and stimulates the activity of T cells against infections. TA1 decreases inflammation and is effective in treating pancreatitis and Hepatitis C. Regarding viruses TA1 decreases viral replication, therefore limits both the infections, communicability, and the severity of all viral infections. For cancer patients this peptide is amazing at limiting both incidence and growth of cancers. It is unparalleled in its activity against cancer recurrence. ..thymosin alpha 1 works via two main mechanisms: Either stimulating the immune system or employing its anti-proliferative activities on tumor cells. The protective action of thymosin alpha 1 against oxidative damage because of its effect on liver superoxide dismutase and glutathione peroxidase has been explored by Armutcu et al [26]. I have given TA1 to patients who have small tumors or failure of cancer treatment, when there is no more treatment left for them, to stimulate their own immune system to kill cancer cells. There are basically 3 other ways to kill cancer.  Surgically remove it, kill it with chemicals that also kill beneficial cells in your body (chemotherapy), or radiate the area of cancer.  However mainstream medicine rarely uses the fourth most effective and least dangerous method of stimulating the natural immune system and preventing and killing cancer. One of the unused methods of killing cancer cells is prescribing TA1 which stimulates your own immune system to kill cancer cells. This fact is rarely discussed by doctors, but it is a fact that everyone produces cancer cells in their bodies daily and when they are young and healthy their own immune system kills those cancer cells. When we are young, cancer is rare because our immune cells are activated by TA1 produced in our own thymus glands.  As we age, our thymus shrinks, our TA1 decreases and some of these abnormal cells are missed and not killed, which allows these cells to grow and proliferate into what we call cancer.  The true cause of cancer is the loss of normal immunity (TA1) to kill cancer cells. Due to the action of thymosin alpha 1 on other cell types, it is used as a therapeutic agent for diseases with evident immune dysfunction [4]. Clinical trials with thymosin alpha 1 for diseases like DiGeorge syndrome, non-small cell lung cancer, hepatocellular carcinoma, hepatitis B and C, HIV, and melanoma have been conducted and yielded promising results.  FDA approved the orphan drug thymalfasin (Zadaxin) for treatment of malignant melanoma, chronic active hepatitis B, DiGeorge anomaly with immune defects, and hepatocellular carcinoma due to its immunomodulatory and anti-tumor effect. These diseases are the ones approved by the FDA for treatment with Thymosin alpha 1, in the form of the pharmaceutical called Thymalfasin, however they have ignored the elephant in the room: Thyomsin alpha 1 is effective against cancer, and preventing cancer recurrence, autoimmune diseases, viruses, parasites and bacterial infections.  Why isn't it used in the US to stimulate our own thymus to act like it did when we were younger?  I can't understand it! When we needed this compounded drug the most—in the middle of a pandemic, the FDA prevented all the compounding pharmacies from making it!  This could have been an answer for those people who could not or would not get vaccinated, but in the beginning of the pandemic, production was shut down! Thymosin alpha 1 works and there is a lot of research to back this up, but it is unattainable in the US since Covid started.  I had several patients with recurrent cancer on this peptide for years before the pandemic, and it prevented a recurrence. These patients got their medication from compounding pharmacies, and it had to be discontinued because no compounding pharmacy was allowed to make it.  Why? Both patients, who had. exhausted their mainstream medical options for their cancer, are now experiencing a recurrence of their cancer without being able to get this drug. With all this proof and knowledge about the power of Thymosin alpha1, to prevent and treat viral illnesses and cancer, why have you never heard of it, especially at a time of pandemic when this peptide could do so much good to prevent and treat the virus that is causing our pandemic, especially for those people with immune dysfunction, cancer, autoimmune diseases, and immune senescence of aging? First, the government enacted an FDA letter to all doctors threatening discipline for doctors and healthcare workers who recommended “unproven” therapies for the Covid virus. Included in this new law, rule, is to silence anyone saying to their patients that Vitamin D (which has now been proven to protect against Covid), Quercetin which has supporting evidence in the medical literature to prevent the recommendation of doctors to patients from suggesting these methods of preventing supplements to our patients. If anyone can explain why our own government is working against us (both patients and doctors who are working to save lives), and using our tax dollars to do it, please tell me. I always thought being a doctor in America meant being able to use any safe and effective means that I know works effectively, to treat my patients.  Doctors were effectively gagged by the FDA letter sent in December 2020, from telling my patients about preventive medicine practices that stimulate the immune system and protect us from infection.  Now I have lost respect for the government who treats us all like we are uneducated and sheep who will follow whatever they tell us. They use the one size fits all in a decade when the practice of medicine is becoming more aware of the individuality of patients especially in the melting pot of the US.  Drugs are ridiculously expensive and unaffordable except for the very rich.  We often use compounding pharmacies for alternatives to this price burden for patients and offer inexpensive alternatives that patients can afford.  I am listing the medical references that support my information.  I don't generally do this but I believe it is important to support my blog. References: World Journal of Virology: Thymosin alpha 1: A comprehensive review of the literature, 2020 Dec 15; 9: 67-78. Regulatory Focus, webpage, FDA Targets Remdesevir , Thymosin Alpha In Compounding ,concerns, posted Feb 24 2021 by Kari Oakes. American Journal Health System Pharmacy. May 15, 2001;58(10):878-885.

Thank you for joining us for our 2nd Cabral HouseCall of the weekend! I'm looking forward to sharing with you some of our community's questions that have come in over the past few weeks… Let's get started!    Simon: Hi Dr Cabral, I am looking to improve my immune defenses against a 'certain virus' and am concerned that my white blood cell count is sub-optimal (4,000/ul) despite my otherwise good health. I suspect this may be a hangover from having VERY low WBC levels after contracting dengue fever 5 years ago. Is increasing my WBC something I should be exploring and what can I do to get my count up?   Lorena: Thank you so much for all you do for your community! Not sure if you remember but I asked here a few weeks ago regarding my elevated heart rate at night according to my Oura ring and that I started to experience a lot of neurological symptoms (similar to MCAS) such as anxiety, heart palpitations and pseudoseizures at the same time. You mentioned that I should check my cortisol levels at night (which I did and was slightly elevated in the PM and low in the AM). I'm a Vata level 1 and 2 IHP so I literally ran all of the labs that you can imagine as I was very confused as to what was going on. Hormones, heavy metals, stool, OAT, neurotransmitters + more. Everything was fine except some candida/mould overgrowth as well as elevated toxic metals. I started the CBO again (last one was over a year ago) + heavy metal detox + 21 day detox all at the same time lol. Anyways, I haven't felt any neurological symptoms after just a couple of days of starting these protocols. I can't figure out how this would have happened. Surely 2 days worth of protocols is not enough to stop these symptoms (very happy though). Any idea why?   Lorena: Hi Doc, me again! I forgot to mention that I also ran a precision allergy test by Precision Point Diagnostics because they test IgE, IgG, IgG4 and complement (C3d) from blood serum. It's much more expensive so not very affordable for a lot of people. Anyways, a lot of things came up and I also eliminated the ones in the red section of my IgE and IgG (vanilla, banana & more) at the same time that I started all the protocols. A lot of them showed in the IgE section and these were foods that I was consuming on a daily basis when I was having all of those symptoms. Do you think it might have been the removal of these foods that caused the relief of symptoms so quickly? If so, it's crazy how consuming foods you're sensitive to from an IgE and IgG perspective can do to you! I always thought this wasn't a big deal but it clearly is.    Nina: Hi doctor Cabral, I get very lightheaded every time I bend down to pick up something. Do you know why this is happening? I do have a low blood pressure, so maybe that could have something to do with it, but I really want to know if there's anything else that could be causing it. I also always feel cold, especially in my extremities. Just to give you some background, I'm a 44 year old female, no kids, vegan and pretty active. Thanks so much for your answer, I really appreciate your help! Nina   Farrel: Hello, Dr Cabral. I trust you and your family are in great health. Listening to older episodes and about two years ago on a House call segment you were asked about Tongkat Ali and it's use for athletes and men in their 30's. You went on to say there's a product your team will be launching around September 2020 called Libido Booster. I purchase from the site and I've never seen it. Has the launch been put on hold or it won't be released? Keep up great work.   Andjela: Hello Dr!! Thanks for your information! Love following you on Instagram. I had covid (delta) in October 2021, and now 3 months later experiencing hair loss. So are many of my relatives who all had it at the same time. Any suggestions on remedies?   Danielle: Hello Dr. Cabral,Thank you so much for sharing your knowledge in functional medicine. I've read your book twice and have no doubt I'll read it again. I listen to this podcast daily and am awaiting the arrival of the minerals and metals test. My question is related to IIH. (I understand the medical advice disclaimer) Are there any natural ways to reduce pressure in the head? I do not want a LP. How else can I reduce excess fluid? I do take L-Lysine and well as a long list of other supplements daily. I'm also taking Goduchi and Triphala as herbal support and am on 2 pharmaceuticals as well, which Id love to come off of, safely, of course. Thanks so much for your time. Thank you for tuning into this weekend's Cabral HouseCalls and be sure to check back tomorrow for our Mindset & Motivation Monday show to get your week started off right! - - - Show Notes & Resources:  http://StephenCabral.com/2214 - - - Dr. Cabral's New Book, The Rain Barrel Effect https://amzn.to/2H0W7Ge - - - Join the Community & Get Your Questions Answered: http://CabralSupportGroup.com - - -  Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Stress, Sleep & Hormones Test (Run your adrenal & hormone levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels)

HOUR 1 Important Nutrients for Immune Support-Silver-- Carolyn Dean MD ND  In May 2018 we introduced Pico Silver, our 20ppm concentration of stabilized silver ions in solution to our customers around the world and the results have actually exceeded our expectations! In fact, Pico Silver has become one of our customer's most favorite immune boosting formulas.  You see, when you introduce stabilized ions of minerals into your body incredible things begin to happen. And, as the benefits of silver are well documented in medical literature, the benefits of a stabilized, ionic form of silver in Pico Silver make those same results even more powerful and immediate!  It can be confidently declared and scientifically proven that the silver ion is far safer than antibiotics or any other antimicrobial ever created. It's still the go-to formula for healing even severe skin burns and preventing infection. In this regard, allopathic medicine knows that the characteristics of the silver ion far exceed the capabilities of patented antibiotics. Also, antibiotics cannot keep up with bacterial organisms' ability to mutate, nor do antibiotics work against viruses. In addition, antibiotics have many side effects, such as yeast infections. This is because antibiotics travel deep into the intestinal tract, where they kill the good bacteria along with the bad. It is also known and documented that taking antibiotics over a long period of time weakens the body's immune system.  Here are some more fun facts about Pico Silver:  Silver As A Nutrient  Silver can be considered as a necessary nutrient in the body because it is systematically concentrated in the body to a much higher level than occurs in nature. Since most minerals have been proved to be depleted from our soil and water, the same can be said for silver.  White Blood Cells and Silver  It has been shown by various bodies of research on yeast overgrowth that infectious organisms have gained the upper hand and overwhelm our ability to keep them under control. Silver ions weaponize white blood cells (WBCs) to do their work. Silver assists the WBCs and the immune system to attack infectious organisms.  Characteristics of Silver  Silver has the highest electrical conductivity of any metal.  Silver ions are highly effective and the body's response is nearly instantaneous.  The silver ion is an integral and important part of the body's immune system response to infections and disease.  The DNA of the body is already pre-programmed to utilize silver to fight infections and disease.  Silver ions are absorbed into the bloodstream and transported to all of the tissues of the body and stored on the surface of white blood cells.  The silver ion is bonded to the surface of adult stem cells and causes dedifferentiation of the adult stem cells into the embryonic state leading to tissue regeneration.  New, healthy tissue growth is at least five to six times faster utilizing silver in wound treatment when contrasted with non-silver-treatment.  The silver ion aids the body's ability to “find” the focal point of treatment, through the body's cell signaling mechanisms – its electrical conductivity.  The silver ion aids the body's ability to “digest” the pathogen.  The silver ion aids the body in the correction of the associated complex metabolic consequences associated with long-term infectious states.  The effects of the silver ion in anti-aging approaches is very promising although clinical research has not been fully funded.  The silver ion has a beneficial effect upon co-infections simultaneously.  The silver ion will readily pass the blood-brain barrier, allowing for interface and intervention with neurological diseases such as ALS, MS, polio, spinal meningitis, and viral encephalitis.  The silver ion increases the Red Blood Cell count.  The silver ion is known to negatively affect bacteria through: lethal oxidation, an “intermolecular electron transfer,” resulting in electrocution; a binding and chelating to essential pathogen receptor sites, which defeats the pathogen's mechanisms of invasion into host cells; an ion non-dependent heightened catalytic action; and cleavage, which fragments (and thereby destroys) essential pathogen/proteinaceous structures.  Once the silver ion ruptures a bacterial staph infection or certain fungal infections, the remaining silver ion particles begin to act as an antidote to the resulting poisons lessening the Herxheimer reaction.  The silver ion has a very high therapeutic value because there is no known lethal dose for silver ions.  Our customers are raving about the benefits of our Pico Silver. Here is one of numerous examples from Joan, a long-time customer.   Years of happy marriage to a "smoker" created in me a chronic dry smoker's cough, back to back sinus infections spanning several decades and even now 7 years as a widow, I still hack as if I was the smoker. I began to add Pico Silver to my daily routine and I found myself just adding a teaspoon here and there throughout the day...not really aiming towards anything specific...but specific things magically happened: 1. Bleeding gums from rigorous brushing stopped. 2. My morning hacking sessions (rib banging)went from dry to extremely wet, where I let go of a lot of lingering mucus in my lungs which is now being expectorated appropriately. 3. I am normally do not sweat, but I began to sweat ... which kept my body temperature from spiking hot to cold, and back...I just felt great. 4. I no longer have ankle swelling in the heat which has been my norm. 5. I seemed to be able to actually control my bladder when caught short...with a mental command and it obeys. 6. Lastly, my taste buds woke up...everything is just delicious and I'm satisfied with smaller quantities. And I have lost 2 lbs without doing anything but adding Pico Silver throughout my day to my sea-salted water. This I attribute to the increased neurological impulses that Dr. Dean says silver amplifies as it works alongside ReMag and ReMyte! Thank you so much, Dr. Dean. Joan, Ontario, Canada About Dr. Carolyn Dean    Dr. Carolyn Dean MD ND has been featured on national media for over 30 years offering practical strategies to improve health, vitality, and well-being the natural way. As a medical doctor, naturopath, certified clinical nutritionist and master of many modalities including acupuncture and homeopathy, Dr. Carolyn Dean MD ND has authored over 33 books and 100 publications including The Magnesium Miracle, 3rd Edition, Hormone Balance, Future Health Now Encyclopedia and Heart Health. Please note that the information and opinions expressed on these broadcasts are not designed to constitute advice or recommendations as to any disease, ailment, or physical condition. You should not act or rely upon any information contained in these broadcasts without seeking the advice of your personal physician. If you have any questions about the information or opinions expressed during these broadcasts, please contact your doctor.  Video Version: https://youtu.be/uH7r8sEtQns Disclosure: Dr. Dean does have a financial interest in the sale of all the Completement Formulas. Call in and Chat with Dr. Dean during Live Show with Video Stream: Call 646-558-8656   ID: 8836953587 press #.  To Ask a Question press *9 to raise your hand  Dr. Dean takes questions via email. Please write questions@drcarolyndeanlive.com We will be glad to respond to your email  Learn more about Dr. Carolyn here: https://drcarolyndeanlive.com   Chatline on Station: http://bit.ly/Dreamvisions7Radio_Network

HOUR 2 Important Nutrients for Immune Support-Silver-- Carolyn Dean MD ND  In May 2018 we introduced Pico Silver, our 20ppm concentration of stabilized silver ions in solution to our customers around the world and the results have actually exceeded our expectations! In fact, Pico Silver has become one of our customer's most favorite immune boosting formulas.  You see, when you introduce stabilized ions of minerals into your body incredible things begin to happen. And, as the benefits of silver are well documented in medical literature, the benefits of a stabilized, ionic form of silver in Pico Silver make those same results even more powerful and immediate!  It can be confidently declared and scientifically proven that the silver ion is far safer than antibiotics or any other antimicrobial ever created. It's still the go-to formula for healing even severe skin burns and preventing infection. In this regard, allopathic medicine knows that the characteristics of the silver ion far exceed the capabilities of patented antibiotics. Also, antibiotics cannot keep up with bacterial organisms' ability to mutate, nor do antibiotics work against viruses. In addition, antibiotics have many side effects, such as yeast infections. This is because antibiotics travel deep into the intestinal tract, where they kill the good bacteria along with the bad. It is also known and documented that taking antibiotics over a long period of time weakens the body's immune system.  Here are some more fun facts about Pico Silver:  Silver As A Nutrient  Silver can be considered as a necessary nutrient in the body because it is systematically concentrated in the body to a much higher level than occurs in nature. Since most minerals have been proved to be depleted from our soil and water, the same can be said for silver.  White Blood Cells and Silver  It has been shown by various bodies of research on yeast overgrowth that infectious organisms have gained the upper hand and overwhelm our ability to keep them under control. Silver ions weaponize white blood cells (WBCs) to do their work. Silver assists the WBCs and the immune system to attack infectious organisms.  Characteristics of Silver  Silver has the highest electrical conductivity of any metal.  Silver ions are highly effective and the body's response is nearly instantaneous.  The silver ion is an integral and important part of the body's immune system response to infections and disease.  The DNA of the body is already pre-programmed to utilize silver to fight infections and disease.  Silver ions are absorbed into the bloodstream and transported to all of the tissues of the body and stored on the surface of white blood cells.  The silver ion is bonded to the surface of adult stem cells and causes dedifferentiation of the adult stem cells into the embryonic state leading to tissue regeneration.  New, healthy tissue growth is at least five to six times faster utilizing silver in wound treatment when contrasted with non-silver-treatment.  The silver ion aids the body's ability to “find” the focal point of treatment, through the body's cell signaling mechanisms – its electrical conductivity.  The silver ion aids the body's ability to “digest” the pathogen.  The silver ion aids the body in the correction of the associated complex metabolic consequences associated with long-term infectious states.  The effects of the silver ion in anti-aging approaches is very promising although clinical research has not been fully funded.  The silver ion has a beneficial effect upon co-infections simultaneously.  The silver ion will readily pass the blood-brain barrier, allowing for interface and intervention with neurological diseases such as ALS, MS, polio, spinal meningitis, and viral encephalitis.  The silver ion increases the Red Blood Cell count.  The silver ion is known to negatively affect bacteria through: lethal oxidation, an “intermolecular electron transfer,” resulting in electrocution; a binding and chelating to essential pathogen receptor sites, which defeats the pathogen's mechanisms of invasion into host cells; an ion non-dependent heightened catalytic action; and cleavage, which fragments (and thereby destroys) essential pathogen/proteinaceous structures.  Once the silver ion ruptures a bacterial staph infection or certain fungal infections, the remaining silver ion particles begin to act as an antidote to the resulting poisons lessening the Herxheimer reaction.  The silver ion has a very high therapeutic value because there is no known lethal dose for silver ions.  Our customers are raving about the benefits of our Pico Silver. Here is one of numerous examples from Joan, a long-time customer.   Years of happy marriage to a "smoker" created in me a chronic dry smoker's cough, back to back sinus infections spanning several decades and even now 7 years as a widow, I still hack as if I was the smoker. I began to add Pico Silver to my daily routine and I found myself just adding a teaspoon here and there throughout the day...not really aiming towards anything specific...but specific things magically happened: 1. Bleeding gums from rigorous brushing stopped. 2. My morning hacking sessions (rib banging)went from dry to extremely wet, where I let go of a lot of lingering mucus in my lungs which is now being expectorated appropriately. 3. I am normally do not sweat, but I began to sweat ... which kept my body temperature from spiking hot to cold, and back...I just felt great. 4. I no longer have ankle swelling in the heat which has been my norm. 5. I seemed to be able to actually control my bladder when caught short...with a mental command and it obeys. 6. Lastly, my taste buds woke up...everything is just delicious and I'm satisfied with smaller quantities. And I have lost 2 lbs without doing anything but adding Pico Silver throughout my day to my sea-salted water. This I attribute to the increased neurological impulses that Dr. Dean says silver amplifies as it works alongside ReMag and ReMyte! Thank you so much, Dr. Dean. Joan, Ontario, Canada About Dr. Carolyn Dean    Dr. Carolyn Dean MD ND has been featured on national media for over 30 years offering practical strategies to improve health, vitality, and well-being the natural way. As a medical doctor, naturopath, certified clinical nutritionist and master of many modalities including acupuncture and homeopathy, Dr. Carolyn Dean MD ND has authored over 33 books and 100 publications including The Magnesium Miracle, 3rd Edition, Hormone Balance, Future Health Now Encyclopedia and Heart Health. Please note that the information and opinions expressed on these broadcasts are not designed to constitute advice or recommendations as to any disease, ailment, or physical condition. You should not act or rely upon any information contained in these broadcasts without seeking the advice of your personal physician. If you have any questions about the information or opinions expressed during these broadcasts, please contact your doctor.  Video Version: https://youtu.be/uH7r8sEtQns Disclosure: Dr. Dean does have a financial interest in the sale of all the Completement Formulas. Call in and Chat with Dr. Dean during Live Show with Video Stream: Call 646-558-8656   ID: 8836953587 press #.  To Ask a Question press *9 to raise your hand  Dr. Dean takes questions via email. Please write questions@drcarolyndeanlive.com We will be glad to respond to your email  Learn more about Dr. Carolyn here: https://drcarolyndeanlive.com   Chatline on Station: http://bit.ly/Dreamvisions7Radio_Network

In honor of Breast Cancer Awareness month,  Linda Short,  PR Chair & volunteer coordinator at WBCS  is here to tell her story of working with Wisconsin Breast Cancer Show House and  the amazing work and events this organization does to to raise money for cancer research.WBCS is a nonprofit, all-volunteer organization that supports early stage breast cancer & prostate cancer research at the Medical College of Wisconsin. Linda Short is a survivor of breast cancer and is dedicated to volunteer and charitable work for her community. Linda's passion to help the community goes far beyond WBCS working as a Milwaukee Public School teacher, a volunteer for a local nature center, a water fitness class coach for older adults and a supporter for breast cancer and prostate cancer survivors. Tune in to hear all about Linda's story, WBCS events, how to get involved,  what a show house is + behind the scenes show house info and so much more all on this episode of Tell Them You Mean Business.

Benazepril, also known as Lotensin, is an antihypertensive agent. It works by competitively inhibiting the conversion of angiotensin I to angiotensin II. The onset of action is between 1-2 hours. When treating hypertension the treatment range is between 10-40 mg PO qd-bid. When first initiating, start at 10 mg PO qd with a max of 80 mg per day. There is black box warning for fetal toxicity. Common side effects are cough, fatigue, dizziness, hypotension, and hyperuricemia. Benazepril should be stopped ASAP if the patient is pregnant due to risks of fetal injury and fetal death. Sone monitoring parameters are blood pressure, BUN, Cr, electrolytes, and WBCs.After sitting down or lying down for a period of time, avoid getting up to fast to avoid orthostatic hypotension. Go to DrugCardsDaily.com for episode show notes which consist of the drug summary, quiz, and link to the drug card for FREE! Please SUBSCRIBE, FOLLOW, and RATE on Spotify, Apple Podcasts, or wherever your favorite place to listen to podcasts are. The main goal is to go over the Top 200 Drugs with the occasional drug of interest. Also, if you'd like to say hello, suggest a drug, or leave some feedback I'd really appreciate hearing from you! Leave a voice message at anchor.fm/drugcardsdaily or find me on twitter @drugcardsdaily --- Send in a voice message: https://anchor.fm/drugcardsdaily/message

Contributor:  Sam Killian, MD Educational Pearls: Patients with cirrhosis and ascites are frequently evaluated for spontaneous bacterial peritonitis, an infection of the ascites fluid that is not from a surgically treated source Fever, abdominal pain, and altered mental status should all raise clinical suspicion in a patient with ascites Fluid from paracentesis may show increased WBCS (polys and neutrophils), high LDH, high amylase, and decreased glucose Outcomes are very poor in these patients with 30-40% of these patients continue to renal failure with 60-80% in-hospital mortality Typically treat with a third generation cephalosporin or ampicillin+gentamicin References Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med. 2018;36(4):689-698. doi:10.1016/j.ajem.2017.12.047 MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018;10(3):e2253. Published 2018 Mar 1. doi:10.7759/cureus.2253 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.  Donate to EMM today!

Jaime Perales, PhD, presents statistics, screening tools and useful resources for primary care providers for Alzheimer’s disease. The KIDs list is presented. Question of the month: Fever and Cough.Introduction: KIDs List and Cognitive Impairment in the ElderlyBy Hector Arreaza, MDToday is May 3, 2021.  In family medicine, we believe in caring for patients “from the cradle to the grave.” During this introduction, we want to inform first of the KIDs list[1] and then some updates on cognitive impairment screening in older adults[2].First, KIDs stand for Key Potentially Inappropriate Drugs in Pediatrics. It is a list of medications that are potentially inappropriate in children. It contains 67 drugs with their risks, recommendations, strength of recommendation and quality of evidence. Common meds include anti-infectives, antipsychotics, dopamine antagonists and GI agents. 85% of these meds require a prescription, and are taken by mouth, or used by parenteral route or even for external use. For example: Mineral oil, oral, carries the risk of lipid pneumonitis, recommended to avoid in patients younger than 1 year old, this recommendation is strong with low quality of evidence. For all the “abuelas” (Spanish for grandmothers) out there, listen to this: Camphor carries a risk of seizures, the recommendation is “use with caution in children.” However, the recommendation is weak and quality of evidence is low, but the concern is enough to include it on the list, in other words, use “vi-vah-pore-oo” with caution in children. I recommend you look up the KIDs list and use your clinical judgment to incorporate it into your practice. From childhood, now we go to the elderly. On February 25, 2020, the USPSTF posted their final recommendation statement regarding screening for cognitive impairment in older adults. This is a Grade I recommendation (Insufficient Evidence). It means that more research is needed to recommend for or against it. This is the same recommendation given in 2014. An article published in JAMA on the same date, Feb 25, 2020, reports that screening instruments can adequately detect cognitive impairment, however there is no evidence that this screening improves patient or caregiver outcomes or causes harm. It is still uncertain if early detection of cognitive impairment is important to provide interventions for patients or caregivers with significant clinical benefits.Jaime Perales, PhD, will present some statistics on Alzheimer’s disease, he will explain some useful tools to screen for cognitive impairment and address the issue of Alzheimer’s disease at the primary care level. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.  Question of the Month: Fever and CoughWritten by Hector Arreaza, MD, read by Claudia Carranza, MD, and Valerie Civelli, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. He has no surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition? Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!____________________________Screening for Alzheimer’s. With Jaime Perales Puchalt, PhD, and Hector Arreaza, MD Jaime Perales Puchalt is an Assistant Professor in the Department of Neurology. His main areas of interest include dementia among minorities and populations of Latin American origin in the Americas. He currently spearheads the Latino Alzheimer's education efforts at the University of Kansas Alzheimer’s Disease Center (KU ADC) and the Latino Cohort in which he recruits and conducts clinical dementia assessments of English and Spanish speaking Latinos. He has also led the integration of the Spanish National Alzheimer's Coordinating Center Unified Data Set 3.0 into REDCap. Together with Dr. Vidoni, Dr. Perales developed Envejecimiento Digno, a curriculum to increase Alzheimer's disease awareness among individual Latino community with different literacy levels.  Dr. Perales completed his MS in Psychology at the University of València, and his MPH in Public Health and PhD in Biomedicine at the University Pompeu Fabra, Barcelona. He started his research career at the University of València, where he collaborated in several stress-related projects among breast cancer patients, Latin American immigrants and caregivers of schizophrenia patients. Dr. Perales co-managed a four-year European Commission-funded multi-country study on healthy aging (COURAGE in Europe) at the Parc Sanitari Sant Joan de Déu. He also spent one year as a visiting researcher at the Institute of Public Health, University of Cambridge conducting dementia-related epidemiological research and collaborating in successful aging literature reviews. At Juntos: Center for Advancing Latino Health (KU), he contributed to the cultural and linguistic adaptation of several smoking cessation interventions for Latinos[3].Questions discussed during this episode:  Incidence and prevalence of dementia in the US: under-diagnosis, death risk, caregiver, Recommendations on screening for dementia by national organizations: American Academy of Neurology, examining models of dementia care (page 22), USPSTF, grade I, no evidence, screening early improves outcomes; ARDADBest evidence-based tools for screening for dementia: MMSE, MoCA (better for MCI), AD8, MiniCog. Useful resources for primary care providers: Alzheimer’s Association: Unidos Podemos (soap opera), NIH Caring for a person with Alzheimer’s Disease, Course: USDHHS,  Any other information you would like to provide us: The course, Jul 23, 2021, and Sep 3, 2021. Conclusion.Now we conclude our episode number 50 “Screening for Alzheimer’s Disease”. You heard from our experts the importance of assessing and treating your patients with Alzheimer’s Disease. We hope you can find all the resources mentioned during our interview with Jaime Perales, make sure you check our episode notes to find the links or just Google them, they are readily available online. Do not forget to send us your answer to the question of the month: What are your top 3 differential diagnosis and acute management of a 69-year-old male with new onset of fever, cough, shortness of breath, and right lower lobe consolidation. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ariana Lundquist, Jaime Perales, Claudia Carranza, and Valerie Civelli. Audio edition: Suraj Amrutia. See you next week! References and resources mentioned during this episode:Meyers RS, Hellinga RC, Hoff DS. The KIDs List: Medications That Are Potentially Inappropriate in Children. Am Fam Physician. 2021 Mar 15;103(6):330. PMID: 33719376. https://www.aafp.org/afp/2021/0315/p330.html Cognitive Impairment in Older Adults: Screening, February 25, 2020. U.S. Preventive Services Task Force.  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening Patnode CD, Perdue LA, Rossom RC, et al. Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(8):764–785. doi:10.1001/jama.2019.22258.  https://jamanetwork.com/journals/jama/article-abstract/2761650 KU Medical Center, The Univeristy of Kansas, Core Faculty, https://www.kumc.edu/ku-adc/core-faculty/jaime-perales-puchalt-phd.html 2021 Alzheimer’s Disease Facts and Figures, Special Report on Race, Ethnicity and Alzheimer's in America, published by the Alzheimer’s Association, Chicago, Illinois, USA.  https://www.alz.org/media/documents/alzheimers-facts-and-figures.pdf Examining Models of Dementia Care: Final Report, U.S. Department of Health & Human Services, September 1, 2016, https://aspe.hhs.gov/pdf-report/examining-models-dementia-care-final-report ¡Unidos Podemos! (Fotonovela, Spanish), Alzheimer’s Association, http://www.alz.org/espanol/downloads/Novella_spanish_081213.pdf Together We Can! (Picture Novel, English), Alzheimer’s Association, http://www.alz.org/espanol/downloads/Novella_english_081213.pdf Alzheimer’s Disease, Caring for a Person with Alzheimer's Disease: Your Easy-to-Use Guide, U.S. Department of Health & Human Services, National Institute on Aging, https://order.nia.nih.gov/sites/default/files/2019-03/Caring_for_a_person_with_AD_508_0.pdf 

Episode 49: Dementia in Primary Care. Dr Ryan Townley explains what to do when a patient reports “memory problems”, including labs, imaging, and more. Question of the month: Fever and Cough.Introduction: DementiaBy Hector Arreaza, MDToday is April 26, 2021.Dementia is an umbrella term that includes many conditions that have in common a cognitive decline affecting ADLs. It is an acquired condition that presents after the brain is fully developed. As our population ages, the topic of dementia has become more pertinent. Recently we had an introduction about the link between poor sleep and dementia, episode 42. The next two episodes will be about dementia.Today we would like to discuss further this relevant topic. We talked with Dr Ryan Townley, who is an assistant professor in the Department of Neurology at the University of Kansas Medical Center, and the director of the Cognitive and Behavioral Neurology Fellowship. We will discuss dementia screening, how to evaluate our patients who report “memory problems”, including additional testing and imaging, when to send to a neurologist or neuropsychologist, and some things we can do for prevention of dementia. This episode is not intended to be a comprehensive lecture about dementia, but it may motivate you to keep learning about this topic. I hope you enjoy it.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.  Question of the MonthWritten by Hector Arreaza, MD, read by Terrance McGill, MDThis is a 69-yo male patient, with controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but smokes recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!____________________________Dementia in Primary Care. With Ryan Townley, MD, and Hector Arreaza, MD.Ryan Townley, M.D., is an assistant professor in the Department of Neurology at the University of Kansas Medical Center and is the director of the Cognitive and Behavioral Neurology Fellowship. He is also the Alzheimer's Clinical Trials Consortium Associate Director and Primary Investigator at the University of Kansas Alzheimer's Disease Center. Dr. Townley is certified by the American Board of Psychiatry and Neurology. He joined the KU Medical Center faculty in August 2019. Prior to medical school, he earned a bachelor of science in neurobiology from the University of Kansas. He graduated from the University of Kansas School of Medicine, where he earned the 2013 Dewey K. Ziegler Award for Excellence in Neurology presented by the KU Department of Neurology and was honored with the American Academy of Neurology's Outstanding Neurology Medical Student Award. He then completed his neurology residency, an internal medicine internship, and a two-year cognitive behavioral fellowship at the Mayo Clinic School of Graduate Medical Education. He is the author of many publications and has presented more than two dozen lectures and posters nationally and around the world. His clinical and research interests include atypical Alzheimer's diseases, normal pressure hydrocephalus, frontotemporal lobar degeneration and dementia with Lewy bodies. He also has interests in patient, resident and medical student education, and preventative health against neurodegenerative disease.Questions discussed during this episode:What to do when someone complains of "memory problems" in primary care?When should a primary care doctor refer a patient to Neurology for evaluation of dementia?Dementia vs Normal aging. What are the types of dementia?When should a primary care doctor start medications for Alzheimer's disease? First-line pharmacologic treatment of Alzheimer's disease. Prevention of Alzheimer's disease:    Resources mentioned in this episode:AD8 Dementia Screening Interview: It is a tool given to an informant (ideally) or to the patient. It can be self-administered or administered by someone in clinic or by phone.AD8 in English: https://www.alz.org/media/Documents/ad8-dementia-screening.pdfAD8 in Spanish: https://championsforhealth.org/wp-content/uploads/2017/01/AD8-Screening-Spanish.pdf Mini-Cog: It is a 3-minute instrument that can increase detection of cognitive impairment in older adults. It can be used effectively after brief training in both healthcare and community settings. It consists of two components, a 3-item recall test for memory and a simply scored clock drawing test. It does not substitute for a complete diagnostic workup.Mini-Cog in English: http://mini-cog.com/wp-content/uploads/2018/03/Standardized-English-Mini-Cog-1-19-16-EN_v1-low-1.pdfMini-Cog in Spanish: http://mini-cog.com/wp-content/uploads/2018/03/SPANISH-Mini-Cog.pdf Montreal Cognitive Assessment (MoCA): Dementia screening tool, no longer free, it requires training and certification. Available in several languages: https://www.mocatest.org/ Saint Louis University Mental Status Examination (SLUMS): Screening tool for dementia, training advised and available for free, available in Epic.Training video: https://www.youtube.com/watch?v=z4ctoWU-qzwSLUMS in English: https://health.mo.gov/seniors/hcbs/hcbsmanual/pdf/4.00appendix8slumsform.pdfSLUMS in Spanish: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/spanish-pr.pdf Short Test of Mental Status, The University of Oklahoma Health Science Center, https://www.ouhsc.edu/age/Brief_Cog_Screen/documents/STMS.pdfDementia prevention, intervention, and care: 2020 report of the Lancet Commission, The Lancet, Vol 396, Issue 10248, P413-446, AUGUST 08, 2020. https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext Dementia Update Course: July 23, 2021, and September 3, 2021. Register at: https://www.eeds.com/portal_live_events.aspx?ConferenceID=634196____________________________ Conclusion.Now we conclude our episode number 49 “Dementia in Primary Care”, Dr Ryan Townley explained different tools we have to assess patients with “memory problems” and explained some interesting concepts in the assessment of cognitive impairment. Talking about dementia, don’t forget to answer our question of the month. Send us your top 3 differential diagnosis and acute management of a 69-year-old male with fever, cough, tachycardia, and right lower lobe consolidation. Send your answer before May 7, 2021, and win a prize! Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ryan Townley, Ariana Lundquist, and Terrance McGill. Audio edition: Suraj Amrutia. See you next week! 

Episode 48: Acute Low Back Pain. Stephanie and Veronica explain common causes of acute low back pain, including lumbar strain, disc herniation, and spondylosis; spontaneous human combustion; question of the month about pneumonia. Introduction: Spontaneous Human CombustionBy Hector Arreaza, MDToday is April 19, 2021.  I’ve been trying to keep this podcast very academic and clinically relevant, with a touch of humor but very professional. I hope after this intro, you do not stop listening to us. Recently I was playing a trivia game at a friend’s house. The question was: How many spontaneous human combustion cases have been published in medical journals between 1600 and 1900? What would be your answer? I did not know the answer, but it woke up my curiosity.I did what’s expected of a normal PCP, exactly, I looked it up in Up-to-Date. The only reference to “spontaneous combustion”, I found was on the article about long-term supplemental oxygen therapy (LTOT). “Facial and upper airway burns are an infrequent complication of LTOT, but can be severe and potentially life-threatening. The main cause of burns is exposure to open flames while wearing supplemental oxygen. However, spontaneous combustion may occur with exposure to a spark source rather than an open flame. Certain factors may contribute to the risk of combustion in the absence of open flames, such as facial hair and use of hair products containing oils or alcohol.” This “spontaneous combustion” does not match the definition given the non-medical community.Spontaneous human combustion, also known as preternatural combustion, refers to a rare episode where the complete body, or significant parts of it, are reduced to ashes with no apparent source of ignition. Other items around the body of the victim are intact, making people believe that the fire originated from inside the body. This phenomenon has been described in fictional movies, documentaries, books, novels, and even medical journals. In 1984, Nickell and Fischer[3] investigated cases from the last 3 centuries. They concluded that in those cases of presumed “spontaneous human combustion” possible sources of ignition were ignored on the reports. A common characteristic among victims of spontaneous combustion was intoxication with alcohol or other substances.More recently, the American Burn Association looked into this topic and published in 2012[2] an article titled “Spontaneous Human Combustion in the Light of the 21st Century”. They state that a literature search retrieved 12 case reports between 2000 and 2012. They concluded that the so-call “spontaneous human combustion” is a reality, however, it is not exactly how people think it is. People are not just sitting around and get consumed alive in flames. The term “fat wick burns” was suggested to provide a more exact definition. The article explains that the burn victim must die for the body fat to start melting, then a break in the skin allows melted fat to impregnate clothes and produce a wick effect that allows fire to be on for a long time causing a complete carbonization of tissues. In case you are curious, the number of spontaneous human combustion cases published in medical journals between 1600 and 1900 is ninety-six (96). Citation needed.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. __________________________Question of the Month: Cough and FeverWritten by Hector Arreaza, MD, read by Jacqueline Uy, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!____________________________Acute Low Back Pain. By Stephanie Rubio, MS3, and Veronica Phung, MS3. Acute low back pain definition and statistics.  Eighty percent (80%) of Americans will experience back pain at some point in their lifetime.  Low back pain is the 5th most common reason for all doctor visits in the US. Most cases of low back pain are acute and 90% resolve within 1 month. Recurrence rate for back pain is high at 35% to 75%.  Acute back pain is defined as pain in the lumbar area for less than 3 months. The sources of low back pain are extensive. We would like to discuss some of the more common causes and important considerations when a patient presents with acute low back pain.  With such an extensive differential for acute low back pain, we want to briefly discuss three common causes: lumbar strain, disc herniation, and degenerative arthritis of the spine; AND three causes that require special attention: cauda equina, malignancy, and prostatitis.     Lumbar strainLumbar strain is the most common cause of acute low back pain in adults. Presentation can be acute or sub-acute after an injury or strenuous activity such as moving heavy furniture. Paraspinal muscles are typically the source of pain and can be unilateral or bilateral with or without radiation down the leg. Pain increases after immobility and specific movements depending on strain location. Patient will have a negative straight leg test.  Treatment: Patient education is key for treatment. It includes explaining that acute back pain is often benign in nature and reassurance. Advise your patients to stay active; to avoid twisting and bending, particularly when lifting; and to return to normal activities as soon as possible.  NSAIDs or muscle relaxants will help the pain process. Muscle relaxants combined with NSAIDs may have additive benefit for reducing pain. “Moderate evidence suggests that no one NSAID is superior, and switching to a different NSAID may be considered if the first is ineffective.” In clinic: Ibuprofen and Naproxen are our “go-to” medications. Acetaminophen is also an option.  “Moderate-quality evidence supports that non-benzodiazepine muscle relaxants (such as cyclobenzaprine, tizanidine, and metaxalone) are beneficial in the treatment of acute low back pain in the first seven to 14 days with effects for up to 28 days. However, muscle relaxants do not affect disability status. Make sure you warn your patient about drowsiness, dizziness, and nausea. Diazepam and Soma (carisoprodol) have the potential for abuse, so use them cautiously and for a short period only.  We also have to mention the controversial opioids. Due to the opioid epidemic, prescribe opioids only for patients with severe acute low back pain for a short period; however, there is little evidence of benefit when compared to NSAIDs.  Epidural steroid injections are not so beneficial for isolated acute low back pain, they may be helpful for radicular pain that does not respond to two to six weeks of noninvasive treatment. Transforaminal injections appear to have more favorable short- and long-term benefit than traditional interlaminar injections. Ok, we are done with lumbar strain. Disc herniationDisc herniation may also be acute or subacute with a variety of pathologies involving the displacement of disc material into the spinal cord or nerve roots. Presentation: Sudden injury could precipitate pain such as a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg and it is made worse when hips are flexed such as sitting. Radicular pain in the dermatome of the compressed nerve root is common. Herniation at L5-S1 is the most common location, and it would present as a loss of sensation on the dorsolateral thigh, lower leg, and dorsal foot. Patients can also have motor deficits on the lateral side of the foot which can cause a problem in tilting the sole of the foot away from the midline or difficulty toe walking. Use neurologic deficits to determine the location of herniation.Radicular pain and radiculopathy are not the same. Radicular pain is a single symptom (pain) that follows the distribution of a nerve root. Radiculopathy is a group of symptoms including, paresthesia, hypoesthesia, motor dysfunction and pain. Symptoms may be the result of compression of more than one nerve root.Nerve RootDermatomal areaMyotomal areaReflexive changesL1Inguinal regionHip flexors L2Anterior mid-thighHip flexors L3Distal anterior thighHip flexors and knee extensorsDiminished or absent patellar reflexL4Medial lower leg/footKnee extensors and ankle dorsiflexorsDiminished or absent patellar reflexL5Lateral leg/footHallux extension and ankle plantar flexorsDiminished or absent Achilles reflex S1Lateral side of footAnkle plantar flexors and evertorsDiminished or absent Achilles reflex (Source: Physio-pedia.com, https://www.physio-pedia.com/Lumbar_Radiculopathy)  Treatment: Please tell patients to keep moving as much as possible. Bed rest is not helpful and may prolong the pain process. NSAIDs should be used to decrease inflammation. Neurosurgery consultation may be needed for large herniation, especially if there is spinal canal compression, causing severe or progressive motor deficit. Use of steroids may be beneficial, but the available evidence suggests limited or no benefit. I’ve seen prednisone prescribed by neurosurgeons frequently when surgery is being delayed. If used, prednisone (60 to 80 mg daily) for five to seven days for patients who do not respond well to analgesics and activity modification. This is followed by a rapid taper to discontinuation over the following 7 to 14 days.Degenerative arthritisSpondylosis is more common in patients with advanced age. Osteophyte impingement of a nerve root can cause radicular symptoms following the nerve’s dermatome distribution as well. Presentation: Onset tends to be more insidious and posture dependent. For example, extension of the lumbar spine, like standing or walking upright causes pain. Symptoms are related to posture, patient may mention leaning on the shopping cart alleviates the pain.Neurogenic claudication is typical of spinal stenosis: pain, numbness, tingling, cramping, weakness of the lower back and extremities; which are exacerbated by walking or exertion, worse walking downhill, not worsened by biking. Neurogenic claudication is not to be confused with vascular intermittent claudication, which is pain, cramping, and tightness on the lower extremities relieved by rest, NOT relieved by walking flexed with a shopping cart. Treatment: Conservative physical therapy is an appropriate treatment. Cycling exercises can be recommended to keep your patients moving because hip flexed activities do not induce pain.  Consider a pain management clinic referral for treatment of foraminal stenosis with steroid injections. From personal experience, I can tell you, those shots really work! However, the response is not 100% effective in all patients. You do not send patients to pain management just because they are requesting chronic opioids. You send them for real treatment of pain with procedures. Cauda equina syndrome: This condition should always be considered due to the seriousness of the consequences. Symptoms may present as saddle anesthesia, loss of anal sphincter tone, and major motor weakness. Decompression should be performed within 72 hours to avoid permanent damage. Clinical suspicion is low if patient denies problems with bowel or bladder control. The most common symptom is actually neurogenic bladder, evidenced by acute urinary retention or incontinence.  Malignancy: Cancer is a serious cause of back pain. Your patient may complain of a dull, throbbing pain that progresses slowly and increases with recumbency or cough. Non-radiating pain is worse at night. More common in patients over 50 and history of cancer in the past.Genital organs: Prostatitis can cause referred low back pain. Expect to find evidence of infection in the history. So, a prostate exam and a genital exam may be needed in older males with acute or chronic low back pain.  Females may also have referred low back pain in the setting of pelvic inflammatory disease and endometriosis. So, a pelvic exam may be needed, based on your clinical judgment.     Overview of Acute Low Back Pain:   Patients with acute LBP without any red flags such as: infections, fever, or weight loss should start conservative therapy for up to 6 weeks with NSAIDS and/or muscle relaxants. Localized cold therapy for direct injury first to constrict blood vessels, reduce swelling, decrease inflammation and potentiate a numbing effect. Then heat therapy can be used after inflammation has subsided. Reevaluate in 1-3 weeks, if significant pain or neurologic complications persist or if there is no improvement in pain. If there is spinal pathology detected, then surgical evaluation is needed. Advise patients to stay active. Physical therapy may prevent recurrence. Studies showed that early physical therapy, after primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. However, it is still unclear which patients with LBP should get referred to physical therapy.Depending on severity of pain and presentation of the patient, diagnostic studies such as MRI and labs can be ordered if findings are suggestive of serious pathology, such as bilateral radicular signs, urinary retention, saddle anesthesia or suspicion of a high-risk mechanism (cancer, hematoma, abscess), presence of fever, night sweats, nocturnal pain, older patients, and more.For prevention, remember proper lifting techniques should be used when moving heavy objects. Bend at the knees with a straight back and use the leg muscles to lift instead of bending at the waist to prevent injury. Maintaining a healthy weight is important for back health.Back-strengthening and stretching exercises at least 2 days a week help prevent back pain. exercise by using the proper equipment and techniques. Remember motion is lotion. Encourage patients to keep moving even as patients progress in age. Because you know you’re getting old when your back goes out more than you do.____________________________Conclusion: Now we conclude our episode number 48 “Acute Low Back Pain”. Veronica and Stephanie did a great job explaining three common causes: Lumbar strain, disc herniation, and spondylosis. Be aware of signs of cauda equine syndrome, malignancy and prostate in men and pelvic organs in women. Initial imaging and labs are not needed in most patients, but make sure to order an MRI and labs depending on the presence of red flags. Don’t forget to send us your answer to the question of the month: What are your top 3 differential diagnoses and explain the acute management of a 69-year-old male with fever, cough, tachycardia, right lower lobe consolidation, and negative COVID-19 test.Remember, even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Stephanie Garcia, Veronica Phung, and Jacqueline Uy. Audio edition: Suraj Amrutia. See you next week!   References:Tiep, Brian L, MD; Rick Carter, PhD, MBA; Long-term supplemental oxygen therapy, Up-to-Date, Last updated: May 08, 2019. https://www.uptodate.com/contents/long-term-supplemental-oxygen-therapy. Accessed on March 25, 2021.  Virve Koljonen, MD, PhD, Nicolas Kluger, MD, Spontaneous Human Combustion in the Light of the 21st Century, Journal of Burn Care & Research, Volume 33, Issue 3, May-June 2012, Pages e102–e108, https://doi.org/10.1097/BCR.0b013e318239c5d7 Nickell, Joe; Fischer, John F. (March 1984). "Spontaneous Human Combustion". The Fire and Arson Investigator. 34 (3). Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012 Feb 15;85(4):343-50. PMID: 22335313. https://www.aafp.org/afp/2012/0215/p343.html. Lumbar Radiculopathy, Physiopedia, https://www.physio-pedia.com/Lumbar_Radiculopathy, accessed on April 9, 2021.  Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976). 2012 Dec 1;37(25):2114-21. doi: 10.1097/BRS.0b013e31825d32f5. PMID: 22614792. https://pubmed.ncbi.nlm.nih.gov/22614792/  

Episode 47: Hearing Carotid Lung.  Dr Civelli explains the updates on screening for lung cancer, hearing loss and carotid artery stenosis; Kafiya explains the use of bupropion and naltrexone in methamphetamine abuse, question of the month pneumonia.Introduction: Methamphetamine useBy Kafiya Arte, MS4, and Ariana Lundquist, MD.Today is April 12, 2021.Bakersfield, California, has a methamphetamine (meth) epidemic currently ravaging this area. We as health care workers believe we can spot somebody addicted to meth from a mile away by their characteristic “older-than-stated-age” appearance and obvious “meth mouth”. However, the actual scope of the epidemic is much larger. It’s not just people who are experiencing homelessness that are addicted to, and dying from, meth.  I saw while volunteering at a needle exchange at Weill Park, people getting out of nice-looking cars wearing clean, pressed clothes with sharps containers full of used needles ready to exchange. One man even had a teacup poodle in tow. It’s clear that meth can affect anybody.  Between May 10 and June 10, 2014, 31.8% of randomly selected patients in the ED of Kern Medical admitted to having used methamphetamine at least once in their life. It’s not just the individual who addicted to meth who is affected. 36.1% of children removed from their home by child protective services in Kern County during the month of May 2014 were cases that involved methamphetamine[1]. Meth accounted for nearly 75% of all drugs seized by the Bakersfield Police Department[2]. Statewide, meth kills more Californians than any single opioid alone[3]. Amphetamine overdose deaths have increased 212% from 777 in 2012 to 2,427 in 2018 in California. In 2020, Kern County had more than double the rate of deaths related to overdose of psychostimulants, of which meth was the dominant drug, compared to the state of California (20.48/100k residents versus 8.21/100k residents, respectively)[3]. This devastating problem, unfortunately, does not have a currently FDA-approved drug to treat it. A promising study called Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. Bupropion decreases the dysphoria of meth withdrawal that drives continued use; while naltrexone decreases cravings, therefore preventing relapse, as it does with alcohol use disorder.  A total of 403 participants with nearly daily meth use were included in the two-stage randomized, double blind trial conducted at 8 different sites from May 23, 2017 to July 25, 2019. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  The results of the study showed a 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. A response was defined as at least three meth negative urine samples out of four samples obtained at the end of each of the two stages.  The trial concluded that although the response rate among participants that received naltrexone and bupropion was low, it was higher than that among participants who received placebo. Although the ADAPT-2 trial did not provide any recommendations that can be adapted to clinical practice, it serves as a starting point for further research of the additive or synergistic effects of bupropion and naltrexone in the treatment of meth use disorder.  Hopefully, it will also serve as a catalyst for more pioneering research regarding the legitimization of meth use disorder as a treatable disease with major medical, psychiatric, socioeconomic and legal consequences. Clinicians should stay up to date with research regarding meth use disorder such as ADAPT-2, as it is our duty to understand the health crises that affect our patients on a daily basis, and the tools we can use to treat them.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ________________________________Question of the MonthWritten by Hector Arreaza, MD, read by Jennifer Thoene, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!     Hearing Carotid LungBy Valerie Civelli, MD, and Ariana Lundquist, MDScreening for hearing loss in older adultsHearing loss definition: To answer this, let’s first talk Hertz and Decibels. Many studies and guidelines define mild hearing loss as the inability to hear frequencies associated with speech processing under 25 dB and moderate hearing loss as the inability to hear those frequencies under 40 dB[5].  The most important range for speech processing is typically 500 to 4000 Hz. To check hearing, we often use pure-tone audiometry, which is the most standard quantitative measurement; however, this is not a perfect test. There is often discordance between objectively measured deficits and subjective perceptions of hearing problems. In one study, 1 in 5 persons who reported hearing loss had a normal hearing test result, while 6% of those with severe hearing loss detected on audiometry did not report feeling that they had hearing loss.[6]  I wonder if their significant other would agree with the 6% who self-reported no hearing loss but failed the hearing test?  That would be a great study! Risk factors for hearing loss: The #1 risk factor for hearing loss is increasing age. Hearing loss increases with age after 50 attributable to normal degeneration of hair cells in the ear.  This leads to the most common cause of hearing loss in older adults: Presbycusis.  Presbycusis is your diagnosis for patients with gradual, worsening of perceived high-frequency tones. Insufficient evidence for screening: If the patient reports hearing loss, you should order a hearing test. However, on March 23, 2021, for asymptomatic adults 50 years or older, the US Preventive Services Task Force (USPSTF) published a statement that re-confirmed the 2012 recommendations. That is, current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults without symptoms. This statement aligns with the AAFP and is referenced in their practice guidelines. This recommendation applies to asymptomatic older adults (age >50 years) who have not noticed any issues with their hearing. It excludes adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.Screening for Carotid Artery StenosisDo not screen: For the general adult population without symptoms of carotid artery stenosis, do not screen. This is a Grade D recommendation for all adults without a history of stroke or neurologic signs or symptoms of a transient ischemic attack. This is a re-endorsement statement made in Feb of this year, 2021, recommitting to 2014 statements.  The evidence continues to show that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. The USPSTF has made other recommendations related to stroke prevention and cardiovascular health. These include: Screening for high blood pressure in adultsScreening for abdominal aortic aneurysmInterventions for tobacco smoking cessation in adults, including pregnant personsInterventions to promote a healthy diet and physical activity for the prevention of cardiovascular disease:In adults with cardiovascular risk factorsIn adults without known cardiovascular risk factorsAspirin use to prevent cardiovascular disease and colorectal cancerStatin use for the primary prevention of cardiovascular disease in adultsLung Cancer Screening Grade B recommendation: On March 9, 2021, there are updated Grade B recommendations by the USPSTF.  For patients 50-80 years old, with a 20 pack-year history of smoking and still smoke or quit within 15 years, annual screening with low dose CT is now recommended.Stop screening when a person has not smoked for 15 year, or has a condition that substantially limits life expectancy or limits their ability to undergo curative lung surgeryThe USPSTF modified guidelines so we are screening earlier and with lower pack years.  It used to be recommended to do low dose Chest CT at age 55-80, but it’s now at 50-80.  Also, pack-years was 30 but it’s now at 20 pack-years that we should screen for lung cancer.  So, screen sooner at 50, and at lower threshold of 20. Screen for lung cancer in male and female patients.Conclusion: Now we conclude our episode number 47 “Hearing Carotid Lung”. Dr Civelli gave us an update on USPSTF screening in asymptomatic adults. For hearing loss, there is insufficient evidence to give a recommendation. For carotid artery stenosis, there is a grade D, meaning do not screen. And for lung cancer screening, it is a grade B recommendations, meaning screen your patients. Don’t forget to order a low dose CT of chest in patients of ANY sex, OLDER than 50 years, WITH a 20 pack/year smoking history, and currently smoking or quit less than 15 years ago. That’s a mouthful, but once you start following the guideline, it gets easier to recall.Remember, even without trying, every night you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Jennifer Thoene, Valerie Civelli, Kafiya Arte, Arianna Lundquist, Jacqueline Uy, and voluntarily unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! _____________________References:The Impact of Methamphetamine in Kern County: 2014, Update September 2014, Kern County Mental Health Department, https://transforminglocalcommunities.com/wp-content/uploads/2018/05/tlc-the-impact-of-meth-in-kern-county-2014-update.pdf Klein, Kerry, To Bakersfield Cops, Concern For Opioids Grows - But Meth Is Still King. Valley Public Radio News, NPR for Central California. May 1, 2019, https://www.kvpr.org/post/bakersfield-cops-concern-opioids-grows-meth-still-king#stream/0 California Opioid Overdose Surveillance Dashboard, California Department of Public Heallh, https://skylab.cdph.ca.gov/ODdash/, accessed on March 27, 2021. Klein, Kerry, Meth Is Making A Comeback In California – And It’s Hitting The San Joaquin Valley Hard. Valley Public Radio News, NPR for Central California. June 28, 2019, https://www.kvpr.org/post/meth-making-comeback-california-and-it-s-hitting-san-joaquin-valley-hard#stream/0 Feltner C, Wallace IF, Kistler CE, et al. Screening for Hearing Loss in Older Adults: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Mar. (Evidence Synthesis, No. 200.) Chapter 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK569275/   US Preventive Services Task Force. Screening for Hearing Loss in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(12):1196–1201. doi:10.1001/jama.2021.2566. https://jamanetwork.com/journals/jama/fullarticle/2777723.    Screening for Hearing Loss in Older Adults, March 23, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening#fullrecommendationstart Screening for Asymptomatic Carotid Artery Stenosis, February 02, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening. Lung Cancer: Screening, March 09, 2021, US Preventive Services Task Force, https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening.    

It's here!!! Radio voice of the New York Mets on WBCS 880 AM, Wayne Randazzo, host of The Chris Rose Rotation on Jomboy Baseball Media, Chris Rose, and our good friend Jacob Resnick of SNY join Tim for a Simply Amazin' Opening Day Extravaganza!  Learn more about your ad choices. Visit megaphone.fm/adchoices

There’s a common misconception that you need to run expensive advanced biomedical tests to fix your health. Over the years we’ve found just the opposite, that you can learn much of what you need to know from basic blood chemistry. Perhaps the best example is the information gained from a Complete Blood Count (CBC) with Differential. As the most common blood test, it is widely used to assess general health status, screen for disorders, and to evaluate nutritional status. On this podcast, NBT Scientific Director Megan Hall and I are talking about leukocytes, also known as white blood cells (WBCs), as critical elements of the CBC blood test. Megan discusses the various types of leukocytes and what it means when your count is outside the reference range. We talk about what leukocytes tell you about your nutritional status, why some people “never get sick” as well as signs you’ve got chronic inflammation or physiological stress. Megan also discusses how to use this information to determine the next steps in your health journey. Here’s the outline of this interview with Megan Hall: [00:01:04] Forum post: Chronically Low White Blood Cell Count. Get access when you support us on Patreon. [00:01:45] Leukocytes = White Blood Cells (WBCs) found on CBC with differential blood test. [00:02:58] Different types of white blood cells. [00:04:18] Phagocytosis video. [00:06:10] Absolute vs relative counts of WBCs. [00:09:15] Optimal range of WBCs in relation to all-cause mortality. [00:11:25] Baltimore Longitudinal Study on Aging: Ruggiero, Carmelinda, et al. "White blood cell count and mortality in the Baltimore Longitudinal Study of Aging." Journal of the American College of Cardiology 49.18 (2007): 1841-1850.  [00:12:57] Study: Shah, Anoop Dinesh, et al. "White cell count in the normal range and short-term and long-term mortality: international comparisons of electronic health record cohorts in England and New Zealand." BMJ open 7.2 (2017): e013100.  [00:15:30] bloodsmart.ai. [00:18:00] Why WBCs might be high: Leukocytosis. [00:18:45] Paper: WBCs are predictive of all cause mortality: Crowell, Richard J., and Jonathan M. Samet. "Invited commentary: why does the white blood cell count predict mortality?." American Journal of Epidemiology 142.5 (1995): 499-501.  [00:20:00] Podcast: Air Pollution Is a Cause of Endothelial Injury, Systemic Inflammation and Cardiovascular Disease, with Arden Pope, PhD. [00:21:57] Association of leukocytosis with metabolic syndrome; Study: Babio, Nancy, et al. "White blood cell counts as risk markers of developing metabolic syndrome and its components in the PREDIMED study." PloS one 8.3 (2013): e58354. [00:22:15] Megan's outline for this podcast. [00:22:41] What to do if you have elevated WBC counts. [00:22:54] Impact of stress; Studies: 1. Nishitani, Naoko, and Hisataka Sakakibara. "Association of psychological stress response of fatigue with white blood cell count in male daytime workers." Industrial health 52.6 (2014): 531-534. and 2. Jasinska, Anna J., et al. "Immunosuppressive effect and global dysregulation of blood transcriptome in response to psychosocial stress in vervet monkeys (Chlorocebus sabaeus)." Scientific reports 10.1 (2020): 1-12.  [00:23:32] Dr. Simon Marshall and Lesley Paterson; Podcast: How to Manage Stress, with Simon Marshall, PhD. [00:24:08] Reasons WBC counts might be low; Leukopenia. [00:27:57] "I never get sick". [00:30:40] What to do if your WBCs are low. [00:30:56] Effects of low energy availability: Studies: 1. Johannsen, Neil M., et al. "Effect of different doses of aerobic exercise on total white blood cell (WBC) and WBC subfraction number in postmenopausal women: results from DREW." PloS one 7.2 (2012): e31319. and 2. Sarin, Heikki V., et al. "Molecular pathways mediating immunosuppression in response to prolonged intensive physical training, low-energy availability, and intensive weight loss." Frontiers in immunology 10 (2019): 907.  [00:31:44] Articles by Megan on energy availability and underfueling: 1. Why Your Ketogenic Diet Isn’t Working Part One: Underfueling and Overtraining; 2. How to Prevent Weight Loss (or Gain Muscle) on a Therapeutic Ketogenic Diet; 3. What We Eat and How We Train Part 1: Coach and Ketogenic Diet Researcher, Megan Roberts; 4. How to Carbo Load the Right Way [00:31:52] Podcast: How to Identify and Treat Relative Energy Deficiency in Sport (RED-S), with Nicky Keay. [00:33:03] Ranges may slightly differ by ethnicity; 1. Haddy, Theresa B., Sohail R. Rana, and Oswaldo Castro. "Benign ethnic neutropenia: what is a normal absolute neutrophil count?." Journal of Laboratory and Clinical Medicine 133.1 (1999): 15-22; 2. Palmblad, Jan, and Petter Höglund. "Ethnic benign neutropenia: a phenomenon finds an explanation." Pediatric blood & cancer 65.12 (2018): e27361; 3. Grann, Victor R., et al. "Neutropenia in 6 ethnic groups from the Caribbean and the US." Cancer: Interdisciplinary International Journal of the American Cancer Society 113.4 (2008): 854-860.  [00:34:39] Absolute Neutrophil to absolute Lymphocyte Ratio (NLR) as indicator of systemic inflammation; Studies: 1. Gürağaç, Ali, and Zafer Demirer. "The neutrophil-to-lymphocyte ratio in clinical practice." Canadian Urological Association Journal 10.3-4 (2016): 141-2; 2. Fest, Jesse, et al. "The neutrophil-to-lymphocyte ratio is associated with mortality in the general population: The Rotterdam Study." European journal of epidemiology 34.5 (2019): 463-470.  [00:36:19] Elevated NLR associated with poor outcomes in COVID-19 patients. Studies: 1. Yang, Ai-Ping, et al. "The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients." International immunopharmacology (2020): 106504; 2. Ciccullo, Arturo, et al. "Neutrophil-to-lymphocyte ratio and clinical outcome in COVID-19: a report from the Italian front line." International Journal of Antimicrobial Agents (2020); 3. Liu, Jingyuan, et al. "Neutrophil-to-lymphocyte ratio predicts critical illness patients with 2019 coronavirus disease in the early stage." Journal of Translational Medicine 18 (2020): 1-12.  [00:37:41] NLR predicts mortality in medical inpatients: Isaac, Vivian, et al. "Elevated neutrophil to lymphocyte ratio predicts mortality in medical inpatients with multiple chronic conditions." Medicine 95.23 (2016).  [00:38:21] What to do if NLR is out of range. [00:39:23] NLR on bloodsmart.ai (found on the Marker Detail View page). [00:40:01] NLR as a marker of physiological stress: 1. Onsrud, M., and E. Thorsby. "Influence of in vivo hydrocortisone on some human blood lymphocyte subpopulations: I. Effect on natural killer cell activity." Scandinavian journal of immunology 13.6 (1981): 573-579; 2. PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC. [00:41:59] Schedule a 15-minute Starter Session.

See all the Healthcast at https://www.biobalancehealth.com/healthcast-blog/ We all have a blood type, either O, A, B or AB.  The original blood type was O, and it is the most common blood type in the world.  The other types are mutations that we have carried with us through our genetics….but what does blood type really mean?  Here is a tiny bit of basic science.  Our red blood cells carry a glycoprotein “antigen “ stuck to the outside of the Red blood cell.  It is this antigen that provides the “Type” of blood.  Antigens include A antigen, B antigen.  Those people with O blood type don't have any antigens on their RBCs, and AB people have 2 antigens. When it comes to getting sick, we have a very complicated immune system of White blood cells that recognize foreign invaders that can make us sick, like viruses and bacteria, and mobilize special white blood cells from our thymus gland and other lymph nodes to attack and kill the virus before it makes us sick.  This is called cellular immunity.  Our white blood cells are like an army that provides a pre-emptory strike to kill the invaders it recognizes as foreign.  The ability of our body to recognize foreign substances or particles, from “self” is the key to preventing our WBCs from attacking and killing our own red blood cells or attacking our own joints like Rheumatoid arthritis.  All living things have the ability to discern “foreign” glycoproteins from their own tissues, to protect themselves from disease, and infection.  When people lose the ability to determine the difference between their own tissue and foreign tissue, they develop disease.  An example of diseases where the immune system attacks its own tissues include autoimmune diseases like rheumatoid arthritis and MS.  An example of the immune system failing to recognize foreign or abnormal cells is cancer.  Cancer cells are not normal and have different proteins on their cell walls and they are produced  in everyone all day long, but a normal immune  system recognizes them as foreign (abnormal ) and the  WBCs attack and destroy them.  Disease occurs when a person loses the ability to recognize these cells as foreign, and the cells are left alone, and they grow and become “cancer”.  Cancer is in reality an immune problem. Our blood type is based on antigens that are attached to our RBCs. We recognize our own Blood type as “self” and a different blood type as foreign, and our WBCs attack the “foreign” RBCs.  We do not attack our own blood type cells.  So, the antigen A is recognized as self to A blood type people and antigen B is recognized as self to blood type B people. O blood type has no ABO antigens on their cell wall.  Our own immune cells, our white blood cells,  recognize our own blood type antigens as belonging to our body and do not attack.   For example, the A antigen is recognized as “self” to a person with A blood type, and therefore the immune system does not attack our own RBCs that have A antigen. if  an A person is given B blood  then their WBCs  attack the foreign B RBCs, B blood cells are destroyed and the patient can die.  When transfusing blood doctors give blood of the same type or O blood.  O blood has no ABO antigen on the cell wall, and can be given to any blood type, because they have no antigen to trigger the  immune response.   This is why O blood type people are called “Universal Donors”.  Your blood type obviously is the determent of how we recognize foreign tissue in our body and therefore determines whether we recognize other cells as “not ours”.  In addition, Blood type is also inherited along with other generic susceptibilities to diseases, so it can also be an inexpensive test of genetic susceptibility to diseases. How does this Blood type work in disease and cancer?  If an A person develops a cancer that resembles the A antigen, that person will not kill these cancer cells. B people also will be blind to cancer cells that look like the B antigen.  ABs have a double problem, being blind to both A-like and B like cancer cells.  However, half the world is blood type O and they kill both the cells that look like A and B cells. The Diseases that are more common for a particular blood type are listed at the bottom of the page, but a few examples of the association between blood type and disease is based on research from many researchers in the world.  There is a lot of research on the subject of diseases and Blood Types.  One study in Britain has found that people with the O blood Type peoples are have the highest risk of having a blood clot generally and has a stronger tie to blood clots in women on oral Birth Control Pills.  This blood type fact would help doctors especially OBGYNs decide3 whether to use this type of birth control or something else like an IUD. Heart disease, and atherosclerosis are very common in the US and the O blood type has been found to be protective against this disease, even if a patient has high cholesterol and inflammation.  It does NOT mean that NO ONE with O blood type will have a heart attack, but that it is a lower risk for O blood type people. Our last example of the relationship between blood type and disease is the risk for autoimmune diseases.  These include Rheumatoid arthritis, Lupus, MS, fibromyalgia, and sarcoidosis.  B Blood type puts a person at higher risk of developing this type of disease.

HOUR 1All About Silver-- Carolyn Dean MD NDThere is widespread controversy about the use of colloidal silver. Is it safe, is it effective, how do I know what product to trust? On tonight’s radio show, Dr. Carolyn Dean talks about the relationship between the body’s immune system and the natural element of silver. Silver can be considered as a necessary nutrient in the body because it is systematically concentrated in the body to a much higher level than occurs in nature. Since most minerals have been proved to be depleted from our soil and water, the same can be said for silver. Silver ions weaponize white blood cells (WBCs) to do their work. Silver assists the WBCs and the immune system to attack infectious organisms. And what is also known various bodies of research on yeast overgrowth is infectious organisms have gained the upper hand and overwhelm our ability to keep them under control. In fact, it can be confidently declared and scientifically proven that the silver ion is far safer than antibiotics or any other antimicrobial ever created. The characteristics of the silver ion far exceed the capabilities of patented antibiotics, which cannot keep up with bacterial organisms’ ability to mutate, nor do antibiotics work against viruses. In addition, antibiotics have many side effects, such as yeast infections. This is because antibiotics travel deep into the intestinal tract, where they kill the good bacteria along with the bad. It is also known and documented that taking antibiotics over a long time period weakens the body’s immune system. Along with its impressive function as an antimicrobial, consider these other characteristics of Pico Silver: · Silver has the highest electrical conductivity of any metal. · Silver ions are highly effective and the body’s response is nearly instantaneous. · The silver ion is an integral and important part of the body’s immune system response to infections and disease. · The DNA of the body is already pre-programmed to utilize silver to fight infections and disease. · Silver ions are absorbed into the bloodstream and transported to all of the tissues of the body and stored on the surface of white blood cells. · The silver ion is bonded to the surface of adult stem cells and causes dedifferentiation of the adult stem cells into the embryonic state leading to tissue regeneration. · New, healthy tissue growth is at least five to six times faster utilizing silver in wound treatment when contrasted with non-silver-treatment. · The silver ion aids the body’s ability to “find” the focal point of treatment, through the body’s cell signaling mechanisms – its electrical conductivity. · The silver ion aids the body’s ability to “digest” the pathogen. · The silver ion aids the body in the correction of the associated complex metabolic consequences associated with long-term infectious states. · The effects of the silver ion in anti-aging approaches is very promising although clinical research has not been fully funded. · The silver ion has a beneficial effect upon co-infections simultaneously. · The silver ion will readily pass the blood-brain barrier, allowing for interface and intervention with neurological diseases such as ALS, MS, polio, spinal meningitis, and viral encephalitis. · The silver ion increases the Red Blood Cell count. · The silver ion is known to negatively affect bacteria through: lethal oxidation, an “intermolecular electron transfer,” resulting in electrocution; a binding and chelating to essential pathogen receptor sites, which defeats the pathogen’s mechanisms of invasion into host cells; an ion non-dependent heightened catalytic action; and cleavage, which fragments (and thereby destroys) essential pathogen/proteinaceous structures. · Once the silver ion ruptures a bacterial staph infection or certain fungal infections, the remaining silver ion particles begin to act as an antidote to the resulting poisons lessening the Herxheimer reaction. · The silver ion has a very high therapeutic value because there is no known lethal dose for silver ions. With all that cellular power, you would expect the testimonials to be profound and pervasive, and indeed, they have been! Enjoy this testimonial from one of our dog-loving customers who used Pico Silver in a critical situation: Fred, our French Bulldog got loose and was hit by a car. We rushed him to the vet and they set his leg and placed in a cast with very specific instructions on how to care for his leg and keep his cast dry. We followed the directions to the letter but within 10 days his wound became septic and the vet wanted to amputate his leg. Fortunately, my buddy Gregg rushed over to my house with Pico Silver. We swabbed his leg hourly and added the solution to his drinking water. Within 3 days his wound was healed and the vet withdrew his recommendation to amputate. Thank you so much Dr. Dean for this product. We now have several bottles on hand. Perry K, Hudson, NC Call in and Chat with Dr. Dean during Live Show with Video Stream: Call 646-558-8656 ID: 8836953587 press #.  To Ask a Question press *9 to raise your hand Dr. Dean takes questions via email. Please write questions@drcarolyndeanlive.com We will be glad to respond to your email Learn more about Dr. Carolyn here: https://drcarolyndeanlive.com

HOUR 2 All About Silver-- Carolyn Dean MD NDThere is widespread controversy about the use of colloidal silver. Is it safe, is it effective, how do I know what product to trust?On tonight’s radio show, Dr. Carolyn Dean talks about the relationship between the body’s immune system and the natural element of silver.Silver can be considered as a necessary nutrient in the body because it is systematically concentrated in the body to a much higher level than occurs in nature. Since most minerals have been proved to be depleted from our soil and water, the same can be said for silver. Silver ions weaponize white blood cells (WBCs) to do their work. Silver assists the WBCs and the immune system to attack infectious organisms. And what is also known various bodies of research on yeast overgrowth is infectious organisms have gained the upper hand and overwhelm our ability to keep them under control.In fact, it can be confidently declared and scientifically proven that the silver ion is far safer than antibiotics or any other antimicrobial ever created. The characteristics of the silver ion far exceed the capabilities of patented antibiotics, which cannot keep up with bacterial organisms’ ability to mutate, nor do antibiotics work against viruses. In addition, antibiotics have many side effects, such as yeast infections. This is because antibiotics travel deep into the intestinal tract, where they kill the good bacteria along with the bad. It is also known and documented that taking antibiotics over a long time period weakens the body’s immune system.Along with its impressive function as an antimicrobial, consider these other characteristics of Pico Silver:· Silver has the highest electrical conductivity of any metal.· Silver ions are highly effective and the body’s response is nearly instantaneous.· The silver ion is an integral and important part of the body’s immune system response to infections and disease.· The DNA of the body is already pre-programmed to utilize silver to fight infections and disease.· Silver ions are absorbed into the bloodstream and transported to all of the tissues of the body and stored on the surface of white blood cells.· The silver ion is bonded to the surface of adult stem cells and causes dedifferentiation of the adult stem cells into the embryonic state leading to tissue regeneration.· New, healthy tissue growth is at least five to six times faster utilizing silver in wound treatment when contrasted with non-silver-treatment.· The silver ion aids the body’s ability to “find” the focal point of treatment, through the body’s cell signaling mechanisms – its electrical conductivity.· The silver ion aids the body’s ability to “digest” the pathogen.· The silver ion aids the body in the correction of the associated complex metabolic consequences associated with long-term infectious states.· The effects of the silver ion in anti-aging approaches is very promising although clinical research has not been fully funded.· The silver ion has a beneficial effect upon co-infections simultaneously.· The silver ion will readily pass the blood-brain barrier, allowing for interface and intervention with neurological diseases such as ALS, MS, polio, spinal meningitis, and viral encephalitis.· The silver ion increases the Red Blood Cell count.· The silver ion is known to negatively affect bacteria through: lethal oxidation, an “intermolecular electron transfer,” resulting in electrocution; a binding and chelating to essential pathogen receptor sites, which defeats the pathogen’s mechanisms of invasion into host cells; an ion non-dependent heightened catalytic action; and cleavage, which fragments (and thereby destroys) essential pathogen/proteinaceous structures.· Once the silver ion ruptures a bacterial staph infection or certain fungal infections, the remaining silver ion particles begin to act as an antidote to the resulting poisons lessening the Herxheimer reaction.· The silver ion has a very high therapeutic value because there is no known lethal dose for silver ions.With all that cellular power, you would expect the testimonials to be profound and pervasive, and indeed, they have been! Enjoy this testimonial from one of our dog-loving customers who used Pico Silver in a critical situation:Fred, our French Bulldog got loose and was hit by a car. We rushed him to the vet and they set his leg and placed in a cast with very specific instructions on how to care for his leg and keep his cast dry. We followed the directions to the letter but within 10 days his wound became septic and the vet wanted to amputate his leg. Fortunately, my buddy Gregg rushed over to my house with Pico Silver. We swabbed his leg hourly and added the solution to his drinking water. Within 3 days his wound was healed and the vet withdrew his recommendation to amputate. Thank you so much Dr. Dean for this product. We now have several bottles on hand.Perry K, Hudson, NCCall in and Chat with Dr. Dean during Live Show with Video Stream: Call 646-558-8656 ID: 8836953587 press #.  To Ask a Question press *9 to raise your handDr. Dean takes questions via email. Please write questions@drcarolyndeanlive.comWe will be glad to respond to your emailLearn more about Dr. Carolyn here: https://drcarolyndeanlive.com

Talk to a Dr. Berg Keto Consultant today and get the help you need on your journey (free consultation). Call 1-540-299-1557 with your questions about Keto, Intermittent Fasting or the use of Dr. Berg products. Consultants are available Monday through Friday from 8:30 am to 9 pm EST. Saturday & Sunday 9 am to 5 pm EST. USA Only. Take Dr. Berg's Free Keto Mini-Course! In this podcast, we're going to talk about how stress affects the immune system. When we're talking about stress, we're talking about the hormone cortisol. Cortisol has a purpose of suppressing white blood cells. Your white blood cells are basically the army of your immune system. Cortisol suppresses that function. Stress activates cortisol. There are two types of stress: 1. Acute stress 2. Chronic stress Chronic stress is the type of stress that's behind so many health problems. When you chronically elevate cortisol, you could create cortisol resistance. This is very similar to insulin resistance. The amount of cortisol may even appear normal in your blood. But, the cells are not sensitive to cortisol anymore, and cortisol is no longer working. This means it's not going to have a good effect on the immune system. It may create a spike in the white blood cells, which could increase your risk for all sorts of issues. Or, it could cause you to lose your immune protection and make you more susceptible to getting sick. Before you get sick, there is almost always something that happens. It's some type of factor that lowers your immune system. It could be a combination of stress and a nutrient deficiency, or it could be stress itself. A virus can also cause a nutrient deficiency. It can even block vitamin D. This can cause the infection to stay. Dr. Eric Berg DC Bio: Dr. Berg, 51 years of age is a chiropractor who specializes in weight loss through nutritional & natural methods. His private practice is located in Alexandria, Virginia. His clients include senior officials in the U.S. government & the Justice Department, ambassadors, medical doctors, high-level executives of prominent corporations, scientists, engineers, professors, and other clients from all walks of life. He is the author of The 7 Principles of Fat Burning. FACEBOOK: fb.me/DrEricBerg?utm_source=Podcast TWITTER: http://twitter.com/DrBergDC?utm_source=Podcast YOUTUBE: http://www.youtube.com/user/drericberg123?utm_source=Podcast DR. BERG'S SHOP: https://shop.drberg.com/?utm_source=Podcast MESSENGER: https://www.messenger.com/t/drericberg?utm_source=Podcast DR. BERG'S VIDEO BLOG: https://www.drberg.com/blog?utm_source=Podcast

In the latest episode of Simply Amazin', one-half of the Mets' dynamic play-by-play duo on WCBS 880, Wayne Randazzo, joins the show to discuss Luis Rojas' steady hand through his ascension into the manager's chair and his current even-keeled approach to the uncertain future of the 2020 season due to the COVID-19 pandemic. Replacing Noah Syndergaard's production in the rotation is another topic of discussion, and, yes, there's some Howie talk.

Join Yvonne Brandenburg, RVT, VTS SAIM and Jordan Porter RVT, LVT, VTS SAIM as we talk about: White Blood Cell Basics; what WBCs do and what to look for when WBCs are too high or too low.    Question of the Week How many of you do differentials in your clinics, and what are some of your favorite resources? Leave a comment at https://imfpp.org/episode25   Resources We Mentioned in the Show  IMFPP https://www.internalmedicineforpetparents.com/hematology.html Idexx hematology book:  https://www.amazon.com/gp/product/1893441687/ Small Animal Internal Medicine for Veterinary Technicians and Nurses https://imfpp.org/saimbook  E-Clin Path http://eclinpath.com/hematology/morphologic-features/white-blood-cells/     Thanks so much for tuning in. Join us again next week for another episode!  Get Access to the Technician Treasure Trove  Sign up at https://imfpp.org/treasuretrove    Thanks for listening!  – Yvonne and Jordan 

"People do business with people they know."It's the 25th anniversary of the Women's Business Council Southwest! To talk about the importance of the organization as well as why women really need to network, Chanel is joined by Debbie Hurst, president and CEO of WBCS, and Sharon Evans, owner and CEO of CFJ Manufacturing.What does the Women's Business Council Southwest do? Why is diversity so important, not just in employees but also suppliers? How can a strong network benefit you more than some certifications or training programs?To learn more:Women's Business Council - Southwest (WBCS): https://www.wbcsouthwest.orgServing North Central Texas, Arkansas, Oklahoma, and New Mexico, the Women's Business Council - Southwest (WBCS) is headquartered in the heart of the Dallas/Fort Worth Metroplex, with a satellite office in Austin, Texas. If a women-owned business is headquartered within this four-state region, WBCS is responsible for facilitating their certification.Women’s Business Enterprise National Council (WBENC): https://www.wbenc.orgThe Women’s Business Enterprise National Council (WBENC) is the largest certifier of women-owned businesses in the U.S. and a leading advocate for women business owners and entrepreneurs.Sharon Evans of Collections Fine Jewelry & CFJ Manufacturing:cfjmfg.com

"People do business with people they know."It's the 25th anniversary of the Women's Business Council Southwest! To talk about the importance of the organization as well as why women really need to network, Chanel is joined by Debbie Hurst, president and CEO of WBCS, and Sharon Evans, owner and CEO of CFJ Manufacturing.What does the Women's Business Council Southwest do? Why is diversity so important, not just in employees but also suppliers? How can a strong network benefit you more than some certifications or training programs?To learn more:Women's Business Council - Southwest (WBCS): https://www.wbcsouthwest.orgServing North Central Texas, Arkansas, Oklahoma, and New Mexico, the Women's Business Council - Southwest (WBCS) is headquartered in the heart of the Dallas/Fort Worth Metroplex, with a satellite office in Austin, Texas. If a women-owned business is headquartered within this four-state region, WBCS is responsible for facilitating their certification.Women’s Business Enterprise National Council (WBENC): https://www.wbenc.orgThe Women’s Business Enterprise National Council (WBENC) is the largest certifier of women-owned businesses in the U.S. and a leading advocate for women business owners and entrepreneurs.Sharon Evans of Collections Fine Jewelry & CFJ Manufacturing:cfjmfg.com

An overview of septic arthritis. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3 Download One Comment Tags: Infectious Diseases, Orthopedics Show Notes Episode Produced by Audrey Bree Tse, MD Background Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails) WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion Why do we care?  irreversible loss of function in up to 10% & mortality rate as high as 11% Cartilage destruction can occur in a matter of hours Complications include bacteremia, sepsis, and endocarditis Etiology Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis Organisms:  Staph: staph aureus (most co...

An overview of septic arthritis. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3 Download Leave a Comment Tags: Infectious Diseases, Orthopedics Show Notes Episode Produced by Audrey Bree Tse, MD Background Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails) WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion Why do we care?  irreversible loss of function in up to 10% & mortality rate as high as 11% Cartilage destruction can occur in a matter of hours Complications include bacteremia, sepsis, and endocarditis Etiology Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis Organisms:  Staph: staph aureus (most common),

Talk to a Dr. Berg Keto Consultant today and get the help you need on your journey (free consultation). Call 1-540-299-1557 with your questions about Keto, Intermittent Fasting, or the use of Dr. Berg products. Consultants are available Monday through Friday from 8:30 am to 9 pm EST. Saturday & Sunday 9 am to 5 pm EST. USA Only. Take Dr. Berg's Free Keto Mini-Course! Dr. Berg talks about why dietary sugar prolongs your sickness, especially infection. If too much sugar/glucose competes with vitamin C, the insulin receptors absorb both glucose and vitamin C. Vitamin C is needed for the immune system to do its job. WBCs also store more vitamin C than any other cell. The WBCs also have more insulin receptors than any other cell. When you consume sugar you shut down the WBCs, esp. the phagocyte, which is there to help clean things up. Dr. Berg's Podcast: http://bit.ly/2WKUKTE Dr. Eric Berg DC Bio: Dr. Berg, 51 years of age is a chiropractor who specializes in weight loss through nutritional & natural methods. His private practice is located in Alexandria, Virginia. His clients include senior officials in the U.S. government & the Justice Department, ambassadors, medical doctors, high-level executives of prominent corporations, scientists, engineers, professors, and other clients from all walks of life. He is the author of The 7 Principles of Fat Burning. ABOUT DR. BERG: https://bit.ly/2FwSQQT DR. BERG'S STORY: https://bit.ly/2RwY5GP DR. BERG'S SHOP: https://bit.ly/2RN11yv DR. BERG'S VIDEO BLOG: https://bit.ly/2AZYyHt DR. BERG'S HEALTH COACHING TRAINING: https://bit.ly/2SZlH3o Follow us on FACEBOOK: https://www.messenger.com/t/drericberg TWITTER: https://twitter.com/DrBergDC YOUTUBE: https://www.youtube.com/user/drericberg123 Send a Message to Dr. Berg and his team: https://www.messenger.com/t/drericberg

Talk to a Dr. Berg Keto Consultant today and get the help you need on your journey (free consultation). Call 1-540-299-1557 with your questions about Keto, Intermittent Fasting, or the use of Dr. Berg products. Consultants are available Monday through Friday from 8:30 am to 9 pm EST. Saturday & Sunday 9 am to 5 pm EST. USA Only. Take Dr. Berg's Free Keto Mini-Course! Intermittent Fasting Basics: https://www.messenger.com/t/drericberg How to do Intermittent Fasting: https://bit.ly/2yxcwPx What Topics are You Mostly Interested In: https://bit.ly/2R2NgYh Dr. Berg talks about if intermittent fasting is safe for your adrenals. It's a normal process and function for cortisol to counter a low blood sugar level. So when you do intermittent fasting, your blood sugars drop and cortisol, the adrenal hormone kicks in to prevent this. So it's a normal function for cortisol to do this just as cortisol also increases your WBCs and inflammation during infection and injury. So it's not that these things stress the adrenal, it's just a part of the normal process of the purpose of cortisol. You may need to fix your insulin resistance AS WELL AS your adrenal separately. Dr. Eric Berg DC Bio: Dr. Berg, 51 years of age is a chiropractor who specializes in weight loss through nutritional & natural methods. His private practice is located in Alexandria, Virginia. His clients include senior officials in the U.S. government & the Justice Department, ambassadors, medical doctors, high-level executives of prominent corporations, scientists, engineers, professors, and other clients from all walks of life. He is the author of The 7 Principles of Fat Burning. ABOUT DR. BERG: https://bit.ly/2FwSQQT DR. BERG'S STORY: https://bit.ly/2RwY5GP DR. BERG'S SHOP: https://bit.ly/2RN11yv DR. BERG'S VIDEO BLOG: https://bit.ly/2AZYyHt DR. BERG'S HEALTH COACHING TRAINING: https://bit.ly/2SZlH3o Follow us on FACEBOOK: https://www.messenger.com/t/drericberg TWITTER: https://twitter.com/DrBergDC YOUTUBE: https://www.youtube.com/user/drericberg123 Send a Message to Dr. Berg and his team: https://www.messenger.com/t/drericberg

Doctor Bryan Walsh is back with us today, discussing the diagnostic benefits of a simple blood chemistry.  He says the results of common and inexpensive lab panels can be mined for meaningful health information, potentially saving patients a lot of time and money on testing – that is, if you know what these blood markers actually mean (and your average doctor probably doesn’t). Fortunately for us, Bryan knows and loves to teach. In this podcast, he shares a bit about his own journey - what led him to study these basic blood markers, and what now inspires him to teach others.  If you like this episode, visit Bryan’s Metabolic Fitness Pro website, where he continues to develop new educational material for health practitioners and other avid learners. Here’s the outline of this interview with Bryan Walsh: [00:00:58] Bryan's WellnessFX videos. [00:02:07] Textbook: Fischbach's A Manual of Laboratory and Diagnostic Tests 10th Edition. [00:04:27] Albumin. [00:05:58] Study: Allen, Larry A., and Christopher B. Granger. "Risk assessment in the genomic era: Are we missing the low-hanging fruit?." American heart journal 157.5 (2009): 799. [00:06:36] Podcast: How to Understand Glucose Regulation with Dr. Bryan Walsh. [00:06:49] Organic Acids Test. Podcast: How to Measure Your Metabolism with Organic Acids with Dr. William Shaw, PhD. [00:07:33] Blood has to be the first place you go. [00:08:13] Reference ranges. [00:08:40] A lab determines a bell-shaped curve for the population of a given region; the reference range might then be +/- 2 standard deviations. [00:10:21] Vitamin D. [00:13:41] Functional reference ranges. [00:14:30] Harry Eidenier, PhD, widely considered to be the Grandfather of Functional Blood Chemistry analysis. [00:18:26] Total cholesterol. [00:19:18] Bilirubin: A metabolic breakdown byproduct of red blood cell destruction. [00:21:22] Study: Ong, Kwok-Leung, et al. "The relationship between total bilirubin levels and total mortality in older adults: the United States National Health and Nutrition Examination Survey (NHANES) 1999-2004." PloS one 9.4 (2014): e94479. [00:24:19] Insulin and c-peptide. [00:25:07] GGT Studies: Long, Y., et al. "Gamma-glutamyltransferase predicts increased risk of mortality: A systematic review and meta-analysis of prospective observational studies." Free radical research 48.6 (2014): 716-728. and Koenig, Gerald, and Stephanie Seneff. "Gamma-glutamyltransferase: a predictive biomarker of cellular antioxidant inadequacy and disease risk." Disease markers 2015 (2015). [00:25:52] Podcast: How to Measure Hormones, with Mark Newman, 8-OHdG. [00:27:57] GlycoMark, adiponectin. [00:28:39] HDL cholesterol 2.65mmol/L (in US, 102 mg/dL). [00:29:35] Study: Rosenson, Robert S., et al. "Dysfunctional HDL and atherosclerotic cardiovascular disease." Nature reviews cardiology 13.1 (2016): 48-60. [00:30:43] HDL - Above 75-80 could indicate dysfunction in the body (e.g., cancer, autoimmunity, liver dysfunction). [00:32:14] Study: Iannello, S., et al. "Low fasting serum triglyceride level as a precocious marker of autoimmune disorders." MedGenMed: Medscape general medicine 5.3 (2003): 20-20. [00:34:20] Undereating as a possible cause of low triglycerides. [00:35:17] Complete Blood Count (CBC) and haemoglobin. [00:36:19] Red blood cells (RBCs), white blood cells (WBCs) and platelets. [00:36:52] Mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC). [00:37:40] CBC indicates ability to carry oxygen around the body. [00:38:18] B12, folate, iron, copper and zinc deficiencies. [00:38:55] Red cell distribution and mortality studies:  Patel, Kushang V., et al. "Red cell distribution width and mortality in older adults: a meta-analysis." Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences 65.3 (2009): 258-265. and Lippi, Giuseppe, et al. "Relation between red blood cell distribution width and inflammatory biomarkers in a large cohort of unselected outpatients." Archives of pathology & laboratory medicine 133.4 (2009): 628-632. [00:41:37] Causes of low RBC count: Production, destruction and loss. [00:43:22] First, look at the MCV. [00:45:19] Normal RDW: low RBC probably due to destruction or loss. [00:45:38] Occult blood stool test to determine if there is a GI bleed (loss). [00:45:49] Reticulocytes: an underrated blood marker. [00:46:33] Erythropoietin (EPO). [00:49:30] HbA1C. [00:51:42] Estimation of RBC lifespan from the reticulocyte count: RBC survival (days) = 100/[Reticulocytes (percent) / RLS (days)], where RLS = 1.0, 1.5, 2.0 and 2.5 days at hematocrits of 45, 35, 25, and 15 percent, respectively. [00:53:17] Bryan and Tommy in a box. [00:54:16] Fatty Liver Index. Study: Bedogni, Giorgio, et al. "The Fatty Liver Index: a simple and accurate predictor of hepatic steatosis in the general population." BMC gastroenterology6.1 (2006): 33. [00:55:58] Website: Metabolic Fitness Pro. [00:57:46] Relying on protocols without knowing the physiology. [00:58:18] Website: Drwalsh.com. [00:58:32] Glucose course: Everything you ever wanted to know about glucose regulation. Detox course: Everything you wanted to know about detoxification.  

This week, newly crowned World Barista Champion Dale Harris and long-time coach, friend, and all-around troublemaker Pete Williams take the lead on No. 93 to share stories about the lead up to this year’s WBC and the somewhat unexpected result. This one is definitely longer than usual, but for good reason – there’s lots to cover, despite the relatively short amount of time they had to prepare between the UK and WBCs. Together, they chat through ideas left behind, their (dys-)functional working relationship, “the Harris process”, the goals they worked diligently toward during their eight weeks of preparation, and more – including (for those who know where to find this sort of thing) the answer to the question that everyone has been asking. Yes, that one.   www.nuovasimonelli.it/en  

This week, newly crowned World Barista Champion Dale Harris and long-time coach, friend, and all-around troublemaker Pete Williams take the lead on No. 93 to share stories about the lead up to this year’s WBC and the somewhat unexpected result. This one is definitely longer than usual, but for good reason – there’s lots to cover, despite the relatively short amount of time they had to prepare between the UK and WBCs. Together, they chat through ideas left behind, their (dys-)functional working relationship, “the Harris process”, the goals they worked diligently toward during their eight weeks of preparation, and more – including (for those who know where to find this sort of thing) the answer to the question that everyone has been asking. Yes, that one.   www.nuovasimonelli.it/en

In 2014, the CDC reported that UTI antibiotic treatment was avoidable at least 39% of the time. Why? Over-diagnosis and treatment results from the fact that asymptomatic bacteriuria is very common in all age groups, urine cultures are frequently ordered without an appropriate indication, and urinalysis results are often misinterpreted. Think of the last time you prescribed antibiotics to a patient for suspected UTI – what convinced you that they had a UTI? Was it their story? Their exam? Or was it the urine dip results the nurse handed to you before you saw them? Does a patient’s indwelling catheter distort the urinalysis? How many WBCs/hpf is enough WBCs to call it a UTI? Can culture results be trusted if there are epithelial cells in the specimen? Can a “dirty” urine in an obtunded elderly patient help guide management?... The post Episode 94 UTI Myths and Misconceptions appeared first on Emergency Medicine Cases.

It's another landmark Episode of the The People's Podcast and the 35th edition of the show hits on a different type of March Madness: The 2017 World Baseball Classic. Jay talks about the incredible energy of the WBC, particularly of the Latin American teams, in what is by far the coolest of the three WBCs. Plus, he tries his hand at Spanish and gets a quick word on Jim Boeheim's whining about missing the NCAA Tourney and letting MSU's name slide out of his mouth while doing so and Jay gives his Final Four prediction. ::: Leave a FIVE Star Rating & a Review on iTunes & Stitcher Radio ::: To Support the People's Podcast or become a sponsor: patreon.com/jscradio

When should you commit to getting urine? When can you wait? When should you forgo testing altogether? When do I get urine? Symptoms – either typical dysuria, urgency, frequency in a verbal child, or non-descript abdominal pain or vomiting in a well appearing child. Fever – but first look for an obvious alternative source, especially viral signs or symptoms. No obvious source? Risk stratify before “just getting a urine”. In a low risk child, with obviously very vigilant parents, who is well appearing, you may choose not to test now, and ensure close follow up. Bag or cath? The short answer is: always cath, never bag. (Pros and cons in audio) What is the definition of a UTI? According to the current clinical practice guideline by the AAP, the standard definition of a urinary tract infection is the presence of BOTH pyuria AND at least 50 000 colonies per mL of a single uropathogen. Making the diagnosis in the ED: The presence of WBCs with a threshold of 5 or greater WBCs per HPF is required. What else goes into the urinalysis that may be helpful? Pearl: nitrites are poorly sensitive in children.  It takes 4 hours for nitrites to form, and most children this age do no hold their urine. Pearl: the enhanced urinalysis is the addition of a gram stain.  A positive gram stain has a LR+ of 87 in infants less than 60 days, according to a study by Dayan et al. in Pediatric Emergency Care. When can I just call it pyelonephritis? In an adult, we look for UTI plus evidence of focal upper tract involvement, like CVA tenderness to percussion or systemic signs like nausea, vomiting, or fever.  It is usually straightforward. It’s for this reason that the literature uses the term “febrile UTI” for children.  Fever is very sensitive, but not specific in children. The ill-appearing child has pyelonephritis.   The well-appearing child likely has a “febrile UTI”, without upper involvement.  However, undetected upper tract involvement may be made in retrospect via imaging, if done. How should I treat UTIs? For simple lower tract disease, treat for at least 7 days.  There is no evidence to support 7 versus 10 versus 14 days.  My advice: use 7-10 days as your range for simple febrile UTI in children. Pyelonephritis should be treated for a longer duration.  Treat pyelonephritis for 10-14 days. What should we give them? Sulfamethoxazole and trimethoprim (Bactrim) is falling out of favor, mostly because isolates in many communities are resistant.  There is an association of Stevens-Johnson Syndrome (SJS) with Bactrim use.  This may be confounded by its prior popularity; any antibiotic can cause SJS, but there are more case reports with Bactrim. Cephalexin (Keflex): 25 mg/kg dose, either BID or TID.  It is easy on the stomach, rarely interacts with other meds, has high efficacy against E. coli, and most importantly, cephalexin has good parenchymal penetration. Nitrofurantoin is often used in pregnant women, because the drug tends to concentrate locally in the urine.  However, blood and tissue concentrations are weak.  It may be ineffective if there is some sub-clinical upper tract involvement. Cefdinir is a 3rd generation cephalosporin available by mouth, given at 14 mg/kg in either one dose daily or divided BID, up to max of 600 mg.  This may be an option for an older child who has pyelonephritis, but is well enough to go home. Whom should we admit? The first thing to consider is age.  Any infant younger than 2 months should be admitted for a febrile UTI.  Their immune systems and physiologic reserve are just not sufficient to localize and fight off infections reliably. The truth is, for serious bacterial illness like pneumonia, UTI, or severe soft tissue infections, be careful with any infant less than 4-6 months of age. Of course, the unwell child – whatever his age – he should be admitted.  Think about poor feeding, irritability, dehydration – in that case, just go with your gut and call it pyelonephritis, and admit. What is the age cut-off for a urine culture? In adults, we think of urine culture only for high-risk populations, such as pregnant women, the immunocompromised, those with renal abnormalities, the neurologically impaired, or the critically ill, to name a few. In children, it’s a little simpler.  Do it for everyone. Who is everyone? Think of the urine rule of 10s: 10% of young febrile children will have a UTI 10% of UAs will show no evidence of pyuria Routine urine culture in all children with suspected or confirmed UTI up to about age 10 What do I do then with urine culture results? From a quality improvement and safety perspective, consider making this a regular assignment to a qualified clinician. Check once in 24-48 hours to find possible growth of a single uropathogen with at least 50 000 CFU/mL.  Look at the record to see that the child is one some antibiotic, or the reason why he may not.  Call the family if needed. A second check at 48-72 hours may be needed to verify speciation and sensitivities. The culture check, although tedious, is important to catch those small children who did not present with pyuria and who may need antibiotics, or to verify that the right agent is given. Ok, so your UA is negative…now what? The culture is cooking, but you are not convinced.  Below is the differential diagnosis for common causes of pyuria in children:   What kind of follow-up should the child get? The younger the child, the more we worry about missing a decompensation.  Encourage the parents to call the child's primary care clinician for a re-check in a few days, and to discuss whether or not further work-up such as imaging is indicated.  As always, strict return to ED precautions are helpful. Who needs imaging? A more accurate question is: what is an important anomaly to detect? Vesiculo-ureteral reflux – a loose ureteropelvic junction causes upstream reflux when the bladder constricts. Uretero-pelvic junction obstruction – in older children or young adults with hematuria, UTI, abdominal mass, or pain.  Infants born with UPJ obstruction have congenital hydronephrosis. Ureterocoele – a cystic mass in the bladder.  It is not malignant, but can cause ureteral dilation, and hydronephrosis.  Treatment is surgical. Ectopic ureter – either a duplication of the draining system, or an abnormal connection, such as the epidydimis or cervix. Posterior urethral valves – occur only in boys, and they are a bit of a misnomer.  The most common type of congenital bladder outlet obstruction, posterior urethral valves are just extra folds of membrane in the lumen of the prostatic urethra.  Usually ablation by cystoscopy does the trick. Urachal remnant – a leftover from fetal development, and an abnormal connection between the bladder and the umbilicus.  Look for an “always wet” belly button in an infant, or an umbilical mass with pain and fever in an older child. Imaging of choice as an outpatient? Renal and bladder ultrasound (RBUS) after the first UTI is recommended (although incompletely followed in practice). If the RBUS is positive, or with the second UTI, DMSA scan to evaluate possible renal scarring. So, with all of this testing – are we over doing it? Like anything, it’s a balance.  A few tips to avoid iatrogenia by way of a summary. If a child over 3 months of age is well, has no comorbidities, has a low grade fever "in the 38s" (38-38.9 °C) without a source, especially if less than 24 hours, you are very safe to do watchful waiting at home. More to the point, an otherwise well child with an obvious upper respiratory tract infection has a source of his fever. If your little patient has risk factors for UTI, or you are otherwise concerned, send the UA and send the culture.  You can opt out of the culture by middle school in the otherwise healthy child. And finally, deputize parents to carry the ball from here – the child needs ongoing primary care and his pediatrician may elect to do some screening.  Don’t promise or prime them for it – rather, encourage the conversation. BONUS: Suprapubic aspiration (details in podcast audio; video below) BONUS BONUS: Infant Clean Catch Technique Step One: feed the baby, wait twenty minutes.     Step Two: clean the genitals with soap and warm water and dry with gauze.  Have your sterile urine container open and at the ready.     Step Three: one person holds the baby under his armpits with his legs dangling.  The other person gently taps the bladder (100 taps/min), then massages the lower back for 30 seconds.     Step Four: Clean Catch! (can also repeat process)   References Bonsu BK, Shuler L, Sawicki L, Dorst P, Cohen DM. Susceptibility of recent bacterial isolates to cefdinir and selected antibiotics among children with urinary tract infections. Acad Emerg Med. 2006 Jan;13(1):76-81. Coulthard MG, Lambert HJ, Vernon SJ, Hunter EW, Keir MJ, Matthews JN. Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits. Arch Dis Child. 2014 Apr;99(4):342-7. Dayan PS et al.  Test characteristics of the urine Gram stain in infants

On this LIVE from the WBC the gang is joined by Claire Brosius to talk about her experiences GMing Ticket to Ride at the WBCs.   Thanks for listening!

We continue our TableTop week with an interview from the archives Bruce interviewed TC Petty about Vivajava:the coffee game:the dice game.   Thanks for listening!

The CIAO Study is a multicenter observational study currently underway in 66 European medical institutions over the course of a six-month study period (January-June 2012). This preliminary report overviews the findings of the first half of the study, which includes all data from the first three months of the six-month study period. Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 912 patients with a mean age of 54.4 years (range 4-98) were enrolled in the study during the first three-month period. 47.7% of the patients were women and 52.3% were men. Among these patients, 83.3% were affected by community-acquired IAIs while the remaining 16.7% presented with healthcare-associated infections. Intraperitoneal specimens were collected from 64.2% of the enrolled patients, and from these samples, 825 microorganisms were collectively identified. The overall mortality rate was 6.4% (58/912). According to univariate statistical analysis of the data, critical clinical condition of the patient upon hospital admission (defined by severe sepsis and septic shock) as well as healthcare-associated infections, non-appendicular origin, generalized peritonitis, and serious comorbidities such as malignancy and severe cardiovascular disease were all significant risk factors for patient mortality. White Blood Cell counts (WBCs) greater than 12,000 or less than 4,000 and core body temperatures exceeding 38 degrees C or less than 36 degrees C by the third post-operative day were statistically significant indicators of patient mortality.