Podcasts about zofran

Cannabinoid Hyperemesis Syndrome (CHS), also known as "scromiting," is a debilitating condition characterized by severe nausea, vomiting, and abdominal pain that affects heavy cannabis users. Dr. Casey Grover explains this increasingly common syndrome caused by high-potency cannabis products, which paradoxically improves with hot showers and proves challenging to treat with conventional medications.• First identified in 2009 and named "scromiting" to reflect the combined screaming and vomiting patients experience• Cannabis potency has increased dramatically from 1% THC in the 1970s to 25-30% THC in today's products• Patients experience cyclical episodes of diffuse abdominal pain, nausea, and vomiting lasting 24-48 hours• Compulsive hot bathing is a hallmark symptom, with patients focusing hot water on their abdomen for relief• Standard anti-nausea medications like Zofran don't work well; psychiatric medications like Haldol often provide better relief• Many patients question the diagnosis because cannabis is thought to help nausea rather than cause it• Treatment requires cannabis cessation, though symptoms may persist for months after quitting• Multiple theories explain CHS, including nerve hypersensitivity and paradoxical stress responses from high-dose THCTo contact Dr. Grover: ammadeeasy@fastmail.com

This week on Second Helpings MJ fills Jackie in on how they have personally taken the Second Helpings lifestyle to heart, and Jackie is preppin' for the union of Friendsgiving and 4/20 on Sunday! Jackie reveals her plans for reeducation of the youth via Forrest Gump. Gayle King is now lord of space, and Jackie gives a rundown of the new season of "Black Mirror." MJ and Jackie are hackin' through "Hacks", and John Mulaney has a new live talk show on Netflix, and Jackie ponders why "The Accountant 2" got made. Jojo Siwa is doin' great despite the recent run in with a tattered leather jockstrap, which leads to a convo about pronouns, and Jackie gives a revew of "Warfare" and MJ asks for suggestions on what to see in theatre, and Adam pops in to help! Cameron Diaz shares some dirty secrets, Jackie gets spooked, AND MORE!!!Want even more Page 7? Support us on Patreon! Patreon.com/Page7Podcast  Subscribe to SiriusXM Podcasts+ to listen to new episodes of Page 7 ad-free.Start a free trial now on Apple Podcasts or by visiting siriusxm.com/podcastsplus.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

SOCK method quiz/cheatsheets/resources at: https://nursing.com/sock   In this raw and revealing episode, Jon Haws, RN, shares his personal journey from pharmacology nightmare to nursing confidence. With vulnerability and humor, Jon recounts his 3 AM study sessions surrounded by scattered flashcards and energy drinks, feeling like a failure as he struggled to memorize endless drug facts that wouldn't stick. When a simple clinical question about Zofran administration left him frozen, Jon discovered a breakthrough approach that transformed his nursing education. Through heartfelt storytelling and evidence-based insights, Jon introduces the SOCK Method (Side Effects, Organs, Classes/Considerations/Cards, Know) - a framework that replaces overwhelming memorization with meaningful connections and clinical reasoning. This episode features Jon's signature blend of nursing wisdom, personal struggle, and practical solutions, including a weekly study plan and Nurse Blake-inspired humor that will have you laughing through your pharmacology tears. Whether you're currently drowning in drug cards or looking to strengthen your medication knowledge, Jon's compassionate guidance offers a lifeline for every nursing student who's ever wondered: "Is there something wrong with me?" Join the nursing family that's putting on their SOCKs and walking confidently toward pharmacology mastery.

In this episode of "Ditch the Lab Coat, where we delve into health issues with a grounded, scientifically skeptical eye. This week's conversation is truly special as we sit down with two giants in the field of medicine: Dr. David Carr and Dr. Sumon Chakrabarti. Join us as we unpack the essentials of travel medicine. From crafting the ultimate travel medical kit to knowing when to panic about that mysterious fever after your Southeast Asian adventure, these experts bring humor, experience, and a wealth of knowledge to the table. Whether you're planning a family vacation or a solo expedition, this episode promises to equip you with the wisdom you need to travel smart. Get ready to learn about must-have medications, the truth about travel vaccines, and how to handle those daunting, "Is there a doctor on board?" moments on a plane. Sit back, relax, and let us turn you into the savvy traveler you've always wanted to be. Let's get into it! and prepare to have your preconceptions about medicine and holistic care turned upside down.Episode HighlightsTravel Kits Essentials: Dr. Carr and Dr. Chakrabarti shared their must-have items for medical travel kits, including antiemetics like Zofran for nausea and glue (Dermabond) for minor injuries. They also discussed the importance of carrying Imodium for emergencies but warned against using it as a solution for diarrhea with fever.Medical Travel Tips: They emphasized preparing for potential health issues depending on the destination, especially in places with known diseases, such as malaria in certain regions. Pepto Bismol was highlighted as an effective preventive measure for traveler's diarrhea.Vaccination Advice: Dr. Chakrabarti recommended vaccinations based on the destination, particularly focusing on hepatitis A, typhoid, and yellow fever in certain regions. They also discussed the malaria prophylaxis options available today, like Malarone.Emergency Situations on Airplanes: Dr. Carr shared his experiences responding to medical emergencies on flights, describing the airplane's medical kits as adequate but limited, emphasizing the importance of an EpiPen and defibrillator.Healthcare Access While Traveling: They talked about how healthcare access varies by destination and shared personal stories of needing medical attention abroad, such as Dr. Bonta's trip to the Amazon.Safety Precautions: Emphasized no pills and no powders, especially for teenagers on trips. They suggested considering Narcan kits due to the prevalence of opioids tainting other substances and the importance of preventative measures like condoms to avoid STDs in areas with higher rates.Returning Traveler's Fever: Both guests stressed the importance of not dismissing a fever on returning from a tropical trip, as this could signify a serious condition like malaria.Episode Timestamps04:13 - Travel medical essentials insights.09:32 - Emergency eye and ear care prep.10:51 - Ducorel: Cholera vaccine limitations.14:33 - Plane medical emergencies: doctor's role?18:21 - Vaccine recommendations for Caribbean travel.20:46 - Essential travel vaccines and malaria prevention.22:56 - Avoiding travel health mistakes.27:27 - Check fever after tropical travel.31:45 - Essential travel health tips.32:41 - Gratitude and safe travels.DISCLAMER >>>>>>    The Ditch Lab Coat podcast serves solely for general informational purposes and does not serve as a substitute for professional medical services such as medicine or nursing. It does not establish a doctor/patient relationship, and the use of information from the podcast or linked materials is at the user's own risk. The content does not aim to replace professional medical advice, diagnosis, or treatment, and users should promptly seek guidance from healthcare professionals for any medical conditions.   >>>>>> The expressed opinions belong solely to the hosts and guests, and they do not necessarily reflect the views or opinions of the Hospitals, Clinics, Universities, or any other organization associated with the host or guests.       Disclosures: Ditch The Lab Coat podcast is produced by (Podkind.co) and is independent of Dr. Bonta's teaching and research roles at McMaster University, Temerty Faculty of Medicine and Queens University. 

The Headlines: Drake Is About to Make Us Feel "Uneasy" – Read more People Are Selling "Bank Soil" For Good Luck In China – Read more Drake Is About to Make Us Feel "Uneasy" Drake is ready to… well, we don’t exactly know what. In an Instagram post, he said, “This next chapter may leave you feeling uneasy, but I hope you see my honesty as clarity not charity.” No word yet on what he’s hinting at—new music, beef with Kendrick Lamar, or maybe something else entirely. In the post, Drake reflected on his non-confrontational nature, saying he’s treated the rap game as a sport where his “pen won gold.” But now, he’s addressing the “unanswered texts” and teasing that something big is coming. The post included a photo of two Zofran tablets—a medication used to treat nausea and vomiting. Whether this is a reference to nerves or something deeper remains to be seen. Fans are speculating wildly, but for now, we’ll have to wait and see what Drake has up his sleeve.

A 29-year-old who is 8 weeks pregnant presents with a chief complaint of nausea and vomiting. She states, “I've been like this for three weeks. I don't know why this is called morning sickness since I feel sick to my stomach almost all the time”, reporting that she vomits 2-3 times nearly every day, stating, “I was worse 2-3 weeks ago, when I was throwing up 4-5 times a day. I figured out what food really bothers my stomach and cut those out.” A 24-h dietary recall reveals frequent low-fat meals and consistent sipping of liquids. She denies thirst or infrequent urination, and reports, “I'm just tired of feeling this way. I've missed so much work and can hardly keep up with my 3-year-old.”  Physical exam reveals the following; Alert, appears fatigued, with moist mucous membranes,  a 1 lb. weight loss since last visit 4 weeks ago, and minimal epigastric tenderness without rebound.   The NP considers advising on the following: A.  Initiate therapy with an oral  5HT-3 antagonist such as ondansetron (Zofran®).B.  Referral to high-risk for advise on further management.  C.  Advise on the use of daily dose of oral  vitamin B6  with doxylamine.  D. Increase fluid and fiber intake. Visit fhea.com to learn more!

Episode 181: Cannabinoid Hyperemesis SyndromeFuture Dr. Johnson explains the pathophysiology, assessment, and management of Cannabinoid Hyperemesis syndrome. Dr. Arreaza adds some insights on the topic.  Written by Tyler Johnson, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. 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.Definition Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic abdominal pain, vomiting, or nausea in older adolescents and adults who have chronic ϲаnոаbis use.The term “marijuana” is considered racist by some people. In the 1930s, American politicians popularized the term “marijuana” in the U.S. to portray the drug as a “Mexican vice” and to have a justification to persecute Mexican immigrants. Epidemiology The overall prevalence of cannabinoid hyperemesis syndrome is unknown due to a lack of definitive criteria or diagnostic tests. It occurs in a population that may not disclose substance use. One study conducted in 2015 in a United States urban emergency department not named, found one-third of patients with near-daily cannabis use met criteria for having had CНЅ in the prior six months.Why are rates of CHS increasing?Between 2005-2014 hospitalizations cyclic vomiting syndromes increased by 60 %. concurrent cannabis use in hospitalized patients increasing from 2 to 21 percent. 7 years after the commercialization of cannabis in Canada, the Canadian health services found a 13-fold increase in cyclic vomiting syndromesPotential correlations for the increase in CHS are increased legalization and commercialization of cannabis, higher tetrahydrocannabinol concentrations in cannabis products, and increased recognition of the syndrome.Legal status of Cannabis in the USCannabis is legal in 24 states: Alaska, Arizona, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, and Washington. It is also legal in Washington, D.C. Cannabis is approved for medical use in 38 states.Federal level: Cannabis is a Schedule I drug, under the Controlled Substance Act (added in 1970) in the group of Hallucinogenic or psychedelic substances. Tetra-hydro-cannabinol (THC, a “mind-altering substance in cannabis”) is on the same list. However, cannabidiol (CBD, derived from hemp or non-hemp plants) was removed from the Controlled Substances Act in 2018. CBD is FDA-approved (under the name of Epidiolex®) to treat rare seizure disorders. CBD is still on the list of controlled substances in some states. I see THC as a problem.THC increased concentration As recreational Cannabis becomes more normalized, innovators look to find new ways to differentiate their product and increasing THC has become a common way to perform this similar to alcohol content in the beer, wine, and liquor industry. An article by Yale School of Medicine titled “Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks” states, “In 1995, the average THC content in cannabis seized by the Drug Enforcement Administration was about 4%. By 2017, it had risen to 17% and continues to increase. Beyond the plant, a staggering array of other cannabis products with an even higher THC content like dabs, oils, and edibles are readily available—some as high as 90%.”Recently, cannabis-infused water started to be sold in some grocery stores.Pathophysiology of CHSIt is not entirely understood. Some suggest multifactorial involving cannabinoid metabolism, exposure dose and tolerance modifying receptor regulation, complex pharmacodynamics at Cannabinoid receptors, and even changes in genetics and cannabinoid variation in plants. CB1 receptors are involved in gastric secretion, sensation, motility, inflammation, and lipogenesis. The activation of CB1 and CB2 receptors has been suggested as the possible cause of CHS.Risk FactorsCHS can occur after acute or acute on chronic use but many report daily 3-5x cannabis use cannabis use over one year and many over at least two years. Median age 24 years. Interesting factsMedical visits for inhaled cannabis are more likely associated with CHS while edibles are more likely for acute psychiatric reactions.Also, CHS is a paradoxical effect since cannabis and cannabinoid receptor agonists are known antiemetics (as seen in nabilone and dronabinol (synthetic analogs of THC)) and prescribed by some physicians to combat chemotherapy effects.Clinical Features of CHSCyclical pattern with abdominal pain, severe nausea, and vomiting up to 30 episodes daily. Pain is intense and even referred to as “scromiting” due to its intense nature, causing patients to scream and vomit concurrently.Typically, it presents with 2 or more episodes over a 6-month period with no symptoms in between. It starts within 24 hours of last cannabis use (differentiating from cannabis withdrawal) and occurs at day or night. There is a gradual symptom resolution of nausea and vomiting after several days of cannabis cessation. Some patients had symptoms 2 days to 2 weeks after cessation. Diagnosis of CHSClinical diagnosisRule out neurological symptoms such as migraine headaches, acute abdomen, motion sickness, and medications, such as recent antibiotics and chemotherapy.Often the diagnosis is discovered with a thorough history reporting a decrease in symptoms with hot showers/baths.Management of CHS AcuteRehydrate with Fluids Dopamine Antagonists– Droperidol (0.625 or 1.25mg) /Haloperidol (0.05 to 0.1mg/kg with max dose of 5mg initially) favored over typical antiemetics like Zofran or Reglan.If needed, combine with an antiemetic like metoclopramide IM or ondansetron IV and consider patients' dehydration status likely requiring US-guided IV.Topical capsaicin cream 0.025 – 0.1% on the abdomen. Long term97% resolution of symptoms completely in a systematic review of patients who stopped cannabis use.Reinforce it may take several weeks of abstinence for symptoms to resolve and symptoms can worsen if cannabis is resumed. It is unknown if a reduction in use can prevent recurrence.Approaches in the clinicEducate patients on the etiology of their symptoms with complete cessation of cannabis use.Consider referral to counseling for cannabis use disorder and abstinence support for treatment-seeking cannabis users. Approach topics such as changing one's environment, seeking social support, and using self-help techniques to non-treatment-seeking individuals.Consider referring patients with polysubstance use and significant comorbidities to a supervised withdrawal management setting. Conclusion: Cannabis use is increasing with legalization and commercialization across the United States. With increased use, Cannabinoid hyperemesis syndrome incidence increases. Often it can be diagnosed with a thorough history including chronic cannabis consumption and symptomatic relief by showers. Physicians will need to develop counseling approaches to better understand CHS patients and how to approach an often-difficult topic.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:Angulo MI. Cannabinoid Hyperemesis Syndrome. JAMA. 2024;332(17):1496. doi:10.1001/jama.2024.9716. Link: https://jamanetwork.com/journals/jama/fullarticle/2824833#:~:text=Cannabinoid%20hyperemesis%20syndrome%20(CHS,last%20less%20than%201%20week.Backman, Isabella, Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks, Yale School of Medicine, August 30, 2023. https://medicine.yale.edu/news-article/not-your-grandmothers-marijuana-rising-thc-concentrations-in-cannabis-can-pose-devastating-health-risks/Buchanan, Jennie A and George Sam Wang, Cannabinoid Hyperemesis Syndrome, Up To Date, updated July 17, 2024. https://www.uptodate.com/contents/cannabinoid-hyperemesis-syndromeTheme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Today, The Frontier Psychatrists welcomes back my friend Ben Spielberg. He's been a reader for a long time and has contributed to the newsletter in the past. It was on Clinical Trial design, a perennial favorite around these parts.With only light edits, what follows is his work, narrated by me, for the Audio Version.I would invite you to the live class today on working as an out-of-network provider, but it sold out last night, so you'll have to wait for the next one. My prior article on Spravato is available here.The year is 2024. OpenAI has just launched its latest update to ChatGPT, promising more natural and less artificial-sounding language. Donald Trump has won the nomination for President of the United States. Another chain of ketamine clinics has engaged in a corporate reorganization. There is conflict in the Middle East. Are we sure that we're not living Groundhog's Day?I am the founder of Bespoke Treatment, an integrative mental health facility with multiple locations that has at times been referred to as a "ketamine clinic." I have also seen countless so-called "ketamine clinics" sell for pennies on the dollar and go bankrupt seemingly overnight. In this case, Numinus, a company that was publicly traded in Canada and owned a number of psychiatric clinics specializing in ketamine in the US and Canada, has sold its clinics to Stella (a company that has stealthily become one of the larger mental health providers in the country and is the first to bring the awesome SGB treatment to scale). It's not the first time this has happened. It's not the second, nor the third, nor even the fourth time this has happened. But yet, the common consensus is that ketamine clinics are a cheap, easy business with recurring revenue. So, what gives?Figure 1. A reddit user asking anesthesiologists if they should start a ketamine or Botox clinic for easy cash on the side. Does this make you feel gross? Should it?The Ketamine Clinic Model 101The most basic outline for a ketamine clinic is as follows: a provider rents an office space with, on average, five or so exam rooms. They buy equipment for infusions like a pump, catheter, needles, and syringes. They buy some comfortable recliner chairs. They hire a receptionist to answer phones, field patient questions, charge credit cards, and handle medical record requests. They hire a nurse to insert the IV, monitor vital signs, check blood pressure, juggle multiple patients at once, and make sure the ketamine is flowing into patients' veins unencumbered. Two SKUs are typically offered: ketamine infusions for mood, which last approximately 40 minutes, and ketamine infusions for pain, which last for up to 4 hours. Zofran is offered for nausea, and some clinics have fun add-ons like magnesium or NAD. An average mood infusion costs around $400-$500 in a medium cost-of-living area, while mood-infusions can run up to $700 in a higher cost-of-living area. Some clinics offer package discounts if patients buy six or more upfront, which helps with cash flow for the clinic (cash now is better than cash later, of course).A Note on Scope of PracticeThe first wave of ketamine clinics was started mainly by providers who were not mental health specialists. Instead, they were owned by anesthesiologists, ER physicians, and sometimes CRNAs. These providers were especially experienced with ketamine in hospital settings, as well as setting up infusions. Psychiatrists, on the other hand, do not usually order infusions in outpatient settings, and very few had actual hands-on experience with ketamine in practice. That being said, there are a number of variations to the model above: psychiatrist-owned ketamine clinics would often prefer to use intramuscular injections in lieu of infusions, but 2-3 injections would have to be given during a single session for mood and pain sessions were out of the question. Other ways to save costs might include having an EMT do the actual injections (this is highly state-dependent), asking nurses or MAs to work the front desk, or working a full-time regular doctor job. In contrast, your nurses run the actual ketamine services via standing orders, a written document that details routine and emergent instructions for the clinic.Some clinics offer full evaluations prior to rendering treatment, but many offer a simple brief screening on the phone to check for contraindications before scheduling a patient for their first session. The clinics owned by psychiatrists have historically been a bit more thorough in terms of the initial psychiatric evaluations, given that they can actually perform initial psychiatric evaluations within their respective scope of practice. Sometimes clinics may have therapists on-site who can render ketamine assisted therapy (meaning, therapy occurring concurrently) for an additional $100-$300. Otherwise, there is not much decision-making that goes on— other than deciding on medication dosages. Most infusions start off at .5mg/kg of body weight, which is by far the most evidence-based dosage. In practice, most clinics increase dosage every session because even though ketamine is considered to be a weight-based medicine for anesthesia, there is thought to be a “sweet spot” of dosage for everyone, if one can imagine an inverted U shape curved, where the ideal dosage for each patient is at the tippity-top of the inversion. Dosage increases are highly variable depending on the clinic: some have a maximum dosage, some will only increase a certain percentage, and some may even use standardized increments (e.g., only offering dosages in increments of 50mg). A typical series of infusions is 6-8 over 3-4 weeks, followed by boosters as needed.Fool's GoldAt first glance, the business model seems fantastic. As a cash business, there are no AR issues, no third party billing companies to deal with, and no prior authorizations to fight over. Sure, the cost is high, but it's not that high compared to many other healthcare services. Since the benefits fade over time, a ketamine clinic has built-in recurring revenue from patients every week, month, quarter, or year – it's like a subscription business! Ketamine is trendy and sexy; TV shows like White Lotus mention it, and ravers from the 90's recall it with great fondness. Unlike SSRIs and psychotherapy, ketamine works for depression fast. It's amongst the fastest treatments for depression that we have today, and there are a lot of depressed people. It can help someone out of debilitating depression in 40 minutes. It has none of the un-sexy side effects of SSRIs like sexual dysfunction, gastrointestinal discomfort, or uncontrollable sweating. Instead, it has sexy side effects: euphoria, hallucinations, and feelings of unity with the universe. Also, unlike SSRIs, it helps most people who try it. It really is an amazing treatment, and I often feel grateful that my clinic is able to offer it to patients in needFigure 2. Most business-savvy reddit user.Supply and Demand… or SomethingMood disorders disproportionately affect individuals who are of lower socioeconomic status compared to individuals with a lot of disposable income. Of course, wealthier individuals are no more immune to mental health disorders than anyone else, but the main target market that benefits most from ketamine just do not have the means to afford it. They don't have $3,000 to burn on yet another treatment that may or may not work. Often, the patients who could really use a series of ketamine infusions cannot scrounge enough money for a single infusion, let alone a whole series and prn boosters. However, there should be enough depressed people with cash to throw around out there… right?Wait, Isn't That A Horse Tranquilizer?Of course, ketamine clinics can find more patients via marketing and advertising. However, I've found that many medical doctors who see this population, like primary care providers, are not up to date with the research. When I first launched my company, I used to go door-to-door to medical buildings in Santa Monica with cookies to speak with them about advancements in interventional psychiatry. I cannot count the number of times that I was laughed out of each office; referring providers are risk-averse, and the perception of ketamine has traditionally been poor. Medical doctors would exclaim, “Of course people feel better; you're getting them high,” and lament that I was administering a drug thought to be highly addictive. Psychotherapists, who would also be fantastic referral partners, generally refer to psychiatry, but it's less common for them to refer to specific treatments. Nowadays, psychotherapists who are particularly invested in ketamine can sign up with venture-backed companies like Journey Clinical and render their own ketamine-assisted psychotherapy with some prescriber supervision. The issue is that despite the media attention, people with depression don't read innovative health newsletters, nor do they review papers in scientific journals. They rely on information from their psychiatrists, medication management providers, and psychotherapists. If they are not told that this is an option for them, they won't hear about it without ad spend. Oh yeah, and there is a major issue with ad spend: the word ketamine itself is a restricted drug term, and legitimate clinics routinely get banned from Google and Meta for mentioning it, which makes digital advertising more difficult than it would be for any other legitimate service.The Matthew Perry EffectKetamine is very desirable for some patients (unfortunately, sometimes the patients who want it most are frankly the worst candidates for it), but I'd wager that the majority of patients who need it are kind of scared of it. They want to feel good, they want relief from depression and trauma, but it's a weird thing to do a drug that is a horse tranquilizer and also an anesthetic in a reclining chair in a medical office that tricks your brain into feeling like you're dead for a little bit. It's kind of far off from acupuncture and more traditional alternative medicine. There is certainly a non-zero addictive potential that needs to be carefully weighed, it's not a particularly comfortable experience for many patients—especially those with a history of trauma—even if it helps after the experience is over. Additionally, the famous actor from the most famous show in the world, who was deemed to have a cause of death relating to ketamine, isn't exactly helping mass adoption. Overall, this just makes marketing and advertising even more expensive, because a) the majority of referring providers are skeptical, b) patients can't pay for it and c) patients who can pay for it are cautious.Disruptive Business ModelsIn the model I've described above, there are 3 sets of cost centers: rent, staff, and marketing. In some areas of the country, rent may be negligible, and in others, it is quite high. Like an owner-operated restaurant, if a clinic is owned by a company that is not a clinician, they have to find one and pay for one. Venture-backed companies like Mindbloom, Better U, and Joyous have also created entire businesses on the back of the COVID-era controlled substance waivers, whereby they send patients ketamine tablets and/or lozenges directly through the mail. Unlike the clinic model, they don't have rent to pay, and since national marketing campaigns are often cheaper than hyper-local brick and mortar campaigns, they are able to find new patients at lower acquisition costs compared to their clinic counterparts. Some patients do extensive research before treatment and only want to find IV clinics that offer specific dosages, but many are fine with the cheapest ketamine possible, and would prefer to pay as low as $150 for an entire month compared to $3,000.Figure 3. Did you sign up for a discounted ketamine subscription on Black Friday after purchasing a new flat-screen TV?Spravato: Coming In HotJohnson & Johnson's branded esketamine (note the prefix es) is on track to reach coveted “blockbuster status.” While it was FDA approved for Major Depressive Disorder in 2019, it took some time to catch on for a number of reasons including skepticism that the added es only added to pharma pockets and didn't actually work, health insurance companies taking time to decide on what their medical necessity criteria should be, and social isolation due to COVID-19 being a thing. My clinic has become one of the larger Spravato providers in the Los Angeles area, and while we still offer ketamine infusions, our infusion census has decreased by over 70%. The scenario is this: a patient with severe depression comes in to see us, they've heard about ketamine, but they find out that Spravato is covered by insurance for a $20 copay. Maybe ketamine has slightly better efficacy (which, in my opinion, is really just a function of being able to adjust dosage). Still, patients would prefer paying a lot less money to receive almost-the-same benefits.Death By A Thousand SticksThere are a number of other issues with the model that become problematic, especially at scale. Large medical distributors like McKesson and Henry Shein have instituted CYA policies, limiting ketamine sales to licensed anesthesiologists. Medical malpractice carriers alike have followed suit, requesting detailed addendums from providers regarding their ketamine training or flat-out refusing coverage for anyone who isn't an anesthesiologist. Since controlled substance manufacturing is directed by the DEA based on their own predictions, it's not uncommon for ketamine to go on shortage for weeks to months at a time. There are a myriad of problems with the model of point solutions which have been detailed here already, but in short, the old adage rings true: if all you have is a hammer, everything looks like a nail, and if all you have is ketamine, everything looks like a juicy vein. But while ketamine is a highly efficacious treatment, it's not the best treatment for everyone, and patients can become downright dysregulated after ketamine, which a clinic in this model just can't handle adequately at scale. And ultimately, methods to do everything cheaper don't work out that well. For example, putting multiple patients in one room may seem like a good idea, but it is ultimately not conducive to the actual ketamine experience. Any sort of vertical integration also adds an insurmountable amount of complexity, like starting to offer Spravato or TMS, because now they have to start accepting insurance, become in-network, manage billing and AR, and so on. Depending on location and the clinic set-up, they also require specialized providers onsite.Figure 4. Supply chain issues abound.Insurance IssuesSome patients try to be well-informed. They, rightly or otherwise, don't believe everything they hear from their providers, so they call up their health insurance companies and ask. They just call the phone number on the back of the card and ask the representative if ketamine infusions are covered. Undoubtedly, the representative says yes—even though many insurance companies have published guidelines that explicitly deny any coverage for ketamine for a mental health disorder. These patients come in frustrated, distrustful of their providers and reaffirms their belief that ketamine clinics are just cash grabs. Even if one manages to obtain a coveted insurance contract for ketamine, like Ketamine Wellness Centers had with the VA, it kickstarts cashflow and complexity issues that scale should sort out, but ultimately doesn't because of the aforementioned issues above.Overall, it is possible to have a successful ketamine clinic in 2024. Still, it isn't easy due to market conditions, the population served, and the ever-changing landscape of mental health treatment. While many successful clinics exist today, the wheels tend to start to fall off when scaling, where all of a sudden, a clinic's reach has surpassed its captive population. Otherwise, it becomes a series of continual cost-cutting until there is nothing left to cut… save for the business itself.Ben Spielberg is the Founder and Chief Executive Officer of Bespoke Treatment, a comprehensive mental health facility with offices in Los Angeles, CA, and Las Vegas, NV. He is also a PhD Candidate in Cognitive Neuroscience at Maastricht University.For more on psychiatric medications, buy my book Inessential Pharmacology. (amazon link).For pieces by other TFP contributors, follow:Alex Mendelsohn, Michelle Bernabe, RN, @Psych Fox, Carlene MacMillan, MD, David Carreon, M.D., Benjamin Lippmann, DO, Awais Aftab, Courtny Hopen BSN, HNB-BC, CRRN, Leon Macfayden and many others! The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

“The room's not moving, but you still feel like you're on a boat. It just feels terrible.” About 60 to 70% of all fibromyalgia patients also deal with dizziness, which shows up in two main ways: lightheadedness and vertigo. With lightheadedness, you'll typically experience a feeling like you might faint or pass out, whereas with vertigo, it feels like the world is moving even when you're holding still. For the past week, Tami has been dealing with an episode of bad vertigo, and she decided to use this as an opportunity to bring the topic to the podcast since, chances are, you've experienced dizziness too. Today, Tami is talking about the differences between lightheadedness and vertigo, the most common causes of lightheadedness in fibromyalgia patients, her recent experience with vertigo and how it compared to her first episode, the role of the vestibular system, conditions which cause vertigo, symptoms of BPPV (benign paroxysmal positional vertigo), Ménière Disease and unilateral vestibular hypofunction, how these conditions differ from each other, vestibular migraines and their connection to vertigo symptoms, medications such used to treat vertigo and their effects on patients, vestibular rehabilitation therapy and why it's essential for recovery, specific exercises used in vestibular rehabilitation to improve balance, how the Epley maneuver helps with BPPV-related vertigo, what research shows about the benefits of whole body vibration for treating vertigo, Tami's current medications (including Scopolamine (patch), Dramamine Less Drowsy (meclizine), Zofran (ondansetron), Phenergan (promethazine)), and more.     Note: This episode is not meant to be medical advice. Every person and every situation is unique. The information you learn in this episode should be shared and discussed with your own healthcare providers. To learn more about the resources mentioned in this episode, visit the show notes. For daily doses of hope, inspiration, and practical advice, join Tami on Facebook or Instagram. Need a good book to read? Download Tami's books for free. Ready to take back control of your life and health? Schedule a complimentary consultation with a Certified Fibromyalgia Coach®.

See all the Healthcasts at https://www.biobalancehealth.com/healthcast-blog I bet you have heard the idiom, “There is no free lunch”, or  “There is no medication without a side effect”, but did you know that medications that are prescribed by your doctor can have negative effects on your health that are never even discussed with you….so you should protect yourself by replacing the nutrients that your medications  remove from your body, and that must be replaced for you to be healthy. Statins -→ COQ 10 DEFICIENCY= fatigue and depression Beta Blockers -→ COQ-10 DEFICIENCY= fatigue and depression Oral contraceptives and oral estrogen/progestins-→ COQ-10 DEFICIENCY= fatigue and depression Antidepressants called SSRIs-→ COQ-10 DEFICIENCY= fatigue and depression Dosage: If you take any of these medications you need to take COQ10 200-400 mg/day every day! Thiazide Diuretics=HCTZ -→ Magnesium and Zinc Deficiency muscle spasms, prostate issues, constipation Take 50 mg of Zinc and 400-600 mg of Magnesium Glycinate a day to replace what is lost. NSAIDS (Motrin, Advil, Aleve, Ibuprofen, Meloxicam, Naproxen, Indomethecin, Daypro, Mefenamic acid, Voltaren)-→ malabsorption, depression, anxiety, and the vitamin and mineral deficiencies listed: Folic Acid Deficiency- Take Methyl- Folate 500 mg Iron Deficiency—Take Iron Bisglycinate (Ferrabsorb) Vitamin C deficiency—Take Vitamin C 500-1000 mg/day Amino acid deficiency—take Arginine +/- Ornithine. OR change your medication to Celebrex 200-400 BID  PPIs=Proton Pump Inhibitors (Omeprazole, Prilosec, Pantoprazole, Lansoprazole, Protonix) are taken for stomach ulcers, H. Pylori infection and gastric reflux PPIs Increase Homocysteine which increases your risk of stroke, MI, and Pulmonary embolism.  PPIs decrease the absorption of many nutrients.  They actually cause malabsorption of essential nutrients.   Replace these nutrients with supplements, but much of what you take won't be absorbed unless you take daily Probiotics:  B12 – take methyl B12 1000 mcg/day Folate – take as methyl folate 5,000mcg/day Vitamin D – take 5,000 IU/day Note: PPIs can even cause the growth of dangerous gut bacteria causing chronic Hemophilus. If you have chronic vaginitis that smells fishy, it could be your PPIs! If you have this stop the PPI, take Pepcid instead (histamine receptor blocker) or nothing and take probiotics to repair the damage the PPIs have caused. These nutrients need to be replaced to keep you healthy, however it is better for most patients to only take PPIs for 2 weeks at a time or substitute a histamine receptor blocker like: Pepcid, Zofran. Surgery It is not just the medications doctors prescribe for their patients; sometimes surgical procedures can cause chronic diseases through preventing nutritional nutrients to enter your body.   Removal of the gall bladder must be done, yet patients are not told what they can do to be healthy after the surgery. The gall bladder provides enzymes that help you breakdown foods, primarily fats and absorb fatty vitamins from your food and supplements.  If you have had your gallbladder removed you can become nutritionally deficient in A, D, E fat soluble vitamins, and you will promote the growth of abnormal gut bacteria and are at risk for leaky gut, Celiac disease, autoimmune diseases and malnutrition. Everyone who has their gallbladder removed should take digestive enzymes with every meal and take Probiotics daily. Bariatric Surgery for Obesity The last iatrogenic nutritional deficiency that I will discuss is Bariatric surgeries, all kinds that remove part of the stomach, or band the stomach or in any way physically makes the stomach smaller is related to nutritional deficiencies caused by malabsorption of vitamins and minerals.  The way to combat these deficiencies include taking: a probiotic daily digestive enzymes with every meal and all vitamins should be chewable or sublingual to be absorbed from the mucosa of the mouth  In Conclusion: Remember I am a physician, and my job is to promote wellness in my patients.  It is sometimes more important and lifesaving to take the above medications or have these surgeries, than to prevent a nutritional deficiency in the future.  We must follow those medical decisions with trouble shooting addition of nutritional supplementation to replace what these necessary medications and surgeries remove.  That is preventive medicine and why supplementation is often needed for our health.  

When Kay Kays was diagnosed with pancreatic cancer in 1994, she not only had few treatment options, but she had no way of knowing this would be the first of four such diagnoses; but she survived each one, the last in 2008, and is still going strong.  She is now able to do just about everything she could do prior to her initial diagnosis and continues the fight as a cancer research advocate.

Nausea is one of the most frequently reported side effects of GLP-1 agonist medications used in obesity treatment, such as Zepbound, Wegovy, Mounjaro, and Victoza. Although not everyone will experience it, the nature of these anti-obesity medications can often lead to nausea, caused by the slowing of gastric emptying.Anyone who has experienced nausea before, especially during pregnancies, will understand just how debilitating it can be, impacting your daily life and work. So, what level of nausea should you expect from weight loss medications? And how can we effectively manage this side effect? In this episode, I'm sharing practical strategies to mitigate nausea, advice on when to seek medical advice, and insights on using medications like Zofran to ease discomfort.Remember: This podcast provides general educational information. Always consult your doctor and medical team for personalized advice and guidance on any symptoms you're experiencing.ReferencesQuest Nutrition Cheese CrackersDevotion Nutrition HydroFLEX PacketsGHOST®Audio Stamps00:58 - Dr. Rentea explains why most anti-obesity medications contribute in some capacity to nausea and describes the nature and impact of this common side effect.06:05 - Dr. Rentea encourages us to be mindful of the types of foods consumed while on anti-obesity medications as certain foods can trigger nausea more than others.08:20 - We hear the importance of hydration in managing nausea and Dr. Rentea explains how cold drinks and electrolyte products can alleviate symptoms.13:05 - Dr. Rentea shares some general tips and changes you can make to your diet to help manage nausea.17:35 - Dr. Rentea stresses that vomiting is not normal and urges consulting a doctor if it occurs, as adjustments to eating habits or medication dosage may be necessary.Quotes“You need to be spacing out your food because most people will not be able to eat these bigger meals at once.” - Matthea Rentea MD“If you are avoiding fried stuff, greasy, or really high sugar foods, it's going to be really helpful.” - Matthea Rentea MD“Vomiting is never normal. You always need to talk to your doctor.” - Matthea Rentea MD“Electrolytes can oftentimes be helpful for nausea and headaches.” - Matthea Rentea MD“Something like Zofran, if you're not allergic, is just nice to have in your toolkit. But you need your physician to walk you through when and how to use it.” - Matthea Rentea MDAll of the information on this podcast is for general informational purposes only. Please talk to your physician and medical team about what is right for you. No medical advice is being on this podcast. If you live in Indiana or Illinois and want to work with doctor Matthea Rentea, you can find out more on www.RenteaClinic.com

Are you struggling with Hyperemesis Gravidarum and looking for solutions? Today, we're joined by dietitian Rebekah Matznick, who shares her personal experience with this condition. Rebekah is currently using a Zofran pump, which has significantly improved her current third pregnancy compared to her first two.In our conversation, we explore her challenging experiences with HG, explain what the Zofran pump is, how she uses it, the potential side effects of Zofran, advice for those dealing with Hyperemesis Garvidarum, and more. If you're searching for something that could make a world of difference during this difficult time, just as it has for Rebekah, join us!Resources:Did you miss Marissa's story dealing with Hyperemesis Gravidarum? Listen in here!If you want to connect with Rebekah, you can find her on Instagram and through her website!Find us over on Instagram @‌fitmamain30One of the biggest questions we get is what protein powder do you recommend? While there are many out there, not all are created equal. We always look for ones that are third-party tested, have no artificial ingredients, and have at least 20 grams or more of high-quality protein. So we are happy to be partnering with Just Ingredients to give you 10% off your order.And if you're looking for a vitamin that you can feel really good about giving to your kids (and they will actually try), then give Hiya a try. You can get 50% off and free shipping when you use this link.This podcast uses the following third-party services for analysis: Chartable - https://chartable.com/privacy

This is the 32nd episode in my drug name pronunciation series.  Today, we're talking about ondansetron (Zofran).  I divide both drug names into syllables, tell you which syllables to emphasize, and share my sources. The written pronunciations can be helpful, so you can see them below and in the show notes on thepharmacistsvoice.com.   Ondansetron = on-DAN-se-tron Emphasize DAN  Source:  USP Dictionary Online   Zofran = ZOE-fran Emphasize ZOE Source:  My experience as a pharmacist   Thank you for listening to episode 278 of The Pharmacist's Voice ® Podcast!   To read the FULL show notes, visit https://www.thepharmacistsvoice.com.  Click the Podcast tab, and select episode 278.   Subscribe to or follow The Pharmacist's Voice ® Podcast to get each new episode delivered to your podcast player and YouTube every time a new one comes out!     Apple Podcasts   https://apple.co/42yqXOG  Spotify  https://spoti.fi/3qAk3uY  Amazon/Audible  https://adbl.co/43tM45P YouTube https://bit.ly/43Rnrjt   Links from this episode USP Dictionary Online **Subscription-based resource USP Dictionary's (USAN) pronunciation guide (Free resource on the American Medical Association's website)  The Pharmacist's Voice ® Podcast Episode 276, pronunciation series episode 31 (tocilizumab-aazg) The Pharmacist's Voice ® Podcast Episode 274, pronunciation series episode 30 (citalopram and escitalopram) The Pharmacist's Voice ® Podcast Episode 272, pronunciation series episode 29 (losartan) The Pharmacist's Voice Podcast Episode 269, pronunciation series episode 28 (tirzepatide) The Pharmacist's Voice Podcast Episode 267, pronunciation series episode 27 (atorvastatin)  The Pharmacist's Voice Podcast Episode 265, pronunciation series episode 26 (omeprazole) The Pharmacist's Voice Podcast Episode 263, pronunciation series episode 25 (PDE-5 inhibitors) The Pharmacist's Voice Podcast Episode 259, pronunciation series episode 24 (ketorolac) The Pharmacist's Voice ® Podcast episode 254, pronunciation series episode 23 (Paxlovid) The Pharmacist's Voice ® Podcast episode 250, pronunciation series episode 22 (metformin/Glucophage) The Pharmacist's Voice Podcast ® episode 245, pronunciation series episode 21 (naltrexone/Vivitrol) The Pharmacist's Voice ® Podcast episode 240, pronunciation series episode 20 (levalbuterol) The Pharmacist's Voice ® Podcast episode 236, pronunciation series episode 19 (phentermine)  The Pharmacist's Voice ® Podcast episode 228, pronunciation series episode 18 (ezetimibe) The Pharmacist's Voice ® Podcast episode 219, pronunciation series episode 17 (semaglutide) The Pharmacist's Voice ® Podcast episode 215, pronunciation series episode 16 (mifepristone and misoprostol) The Pharmacist's Voice ® Podcast episode 211, pronunciation series episode 15 (Humira®) The Pharmacist's Voice ® Podcast episode 202, pronunciation series episode 14 (SMZ-TMP) The Pharmacist's Voice ® Podcast episode 198, pronunciation series episode 13 (carisoprodol) The Pharmacist's Voice ® Podcast episode 194, pronunciation series episode 12 (tianeptine) The Pharmacist's Voice ® Podcast episode 188, pronunciation series episode 11 (insulin icodec)  The Pharmacist's Voice ® Podcast episode 184, pronunciation series episode 10 (phenytoin and isotretinoin) The Pharmacist's Voice ® Podcast episode 180, pronunciation series episode 9 Apretude® (cabotegravir) The Pharmacist's Voice ® Podcast episode 177, pronunciation series episode 8 (metoprolol)  The Pharmacist's Voice ® Podcast episode 164, pronunciation series episode 7 (levetiracetam) The Pharmacist's Voice ® Podcast episode 159, pronunciation series episode 6 (talimogene laherparepvec or T-VEC)  The Pharmacist's Voice ® Podcast episode 155, pronunciation series episode 5 Trulicity® (dulaglutide)  The Pharmacist's Voice ® Podcast episode 148, pronunciation series episode 4 Besponsa® (inotuzumab ozogamicin) The Pharmacist's Voice ® Podcast episode 142, pronunciation series episode 3 Zolmitriptan and Zokinvy The Pharmacist's Voice ® Podcast episode 138, pronunciation series episode 2 Molnupiravir and Taltz The Pharmacist's Voice ® Podcast episode 134, pronunciation series episode 1 Eszopiclone and Qulipta

When people of any age experience side effects such as fatigue, irritability, anxiety, decreased libido, or joint pain, they may benefit from hormone replacement therapy.Susan, our longtime nurse at Basu Plastic Surgery, brought her passion and expertise with hormone replacement when she joined our practice in 2017. Since then, we've been able to help many patients not only look their best, but also feel their best.BioTE hormone replacement therapy transforms people mentally and physically by restoring energy and vitality. Susan walks us through the step-by-step process of starting BioTE with us, from your initial screening appointment to what it's like to get your first cycle.Susan answers the important questions about BioTE, including:How long do injections take and do they hurt?Is there any downtime?How different do you feel after?What labs are required?Will you notice a difference after one cycle?What are the advantages of going to an aesthetic practice for BioTE rather than going to a testosterone replacement clinic?LinksLearn more about BioTe Take a screenshot of this or any podcast episode with your phone and show it at your consultation or appointment to receive $50 off any service at Basu Plastic Surgery and Aesthetics.Basu Plastic Surgery and Aesthetics is located in Northwest Houston in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to https://www.basuplasticsurgery.com/podcastOn Instagram, follow Dr. Basu and the teamBehind the Double Doors is a production of The Axis

In this mailbag episode, Dr. Nathan Fox answers some of the top questions from our listeners. He answers questions regarding how culture influences labor and birth, placental abruption, fetal growth restriction, Group B strep, and taking Zofran in pregnancy.

Semaglutide, a medication commonly used to treat type 2 diabetes and obesity, has gained significant attention in recent years due to its effectiveness in helping patients achieve better blood sugar control and weight management. And most recently, clinical studies have shown that it also helps lower the risk of heart attack, stroke, and kidney disease.  But, some individuals who take semaglutide may experience nausea. In this podcast, we'll talk about why nausea happens with semaglutide and provide valuable insights on managing this side effect. Understanding why this happens and learning effective management strategies can significantly improve the overall experience for individuals taking semaglutide. Why does nausea happen with semaglutide? Nausea is a common side effect of many medications, including semaglutide (Ozempic, Wegovy). It's not clear why semaglutide may cause nausea, but it may have to do with the way the medication works.  Remember, semaglutide slows down how fast food leaves the stomach. Because of this, food stays in the stomach longer, which can lead to extra pressure inside the belly or can affect the nerves in the gut. This, in turn, may cause bothersome side effects like nausea and vomiting and other stomach-related side effects.  How long does nausea typically last? This depends. For most people, the nausea goes away as their body gets used to taking semaglutide. But remember, it can happen each time semaglutide doses are increased. How can you manage nausea from semaglutide? Take It Slow and be patient: When starting semaglutide, it's important to follow the prescribed dosage and administration instructions provided by your healthcare provider. Starting with a lower dose and gradually increasing it allows your body to adjust more easily, potentially reducing the intensity and frequency of nausea. In fact, studies show that people taking higher doses of semaglutide were more likely to experience nausea.  The typical starting dose of semaglutide is 0.25 mg weekly. The maximum dose of semaglutide for weight loss is 2.4 mg, and 2 mg weekly for type 2 diabetes. It's important to communicate the side effects you're experiencing with semaglutide. This way, they can decide if you should increase or stay on your current dose. Timing Matters: Take semaglutide at a time of day when you are less likely to be bothered by nausea. Although semaglutide is a long-acting medication, some people find it helpful to take the medication before bedtime so they sleep through the initial side effects.  Stay Hydrated: Nausea can often be exacerbated by dehydration. Ensure you drink enough water throughout the day, which can help alleviate feelings of queasiness.  The general rule is to take your weight in pounds and divide the number in half. This is about how many ounces of water you should drink daily. For example, a person who weighs 200 lbs should drink about 100 ounces or 3 liters of water daily. This is about five 20-ounce bottles of water daily.  Keep in mind: People living in hot climates or physically active should drink more water to replace the fluids lost through sweat. Dietary Changes: Sometimes, certain foods and drinks can trigger or worsen nausea. Avoid greasy or spicy meals, and opt for lighter, easily digestible foods. Small, frequent meals can also help manage nausea better than large, infrequent ones. It's also best to avoid caffeine if you're feeling nauseous. Try to avoid refined sugars, which are usually found in processed foods. These include packaged snacks, candy, soda, cakes, cookies, and cereals. These foods aren't filling and can cause nausea and lead to more weight gain. Focus on incorporating nutrient-rich whole foods like quinoa, beans, and sweet potato. These foods will help you feel full longer and don't cause nausea. Try ginger: Natural remedies like ginger can have anti-nausea effects. Consider sipping ginger tea or chewing a piece of raw ginger to alleviate nausea symptoms. Listen to your body: The most important thing to remember is that semaglutide makes you feel fuller faster and reduces your appetite. Because of this, it's important to listen to your body and engage with food differently than before.  You'll need to retrain how you approach snacks and meals. It will take time to learn how much you can eat before you feel full. But listening to your body will help you from overeating and avoid side effects like nausea.  As a general rule, it's important to start by reducing the size of your meals and the frequency of your snacks. You can do this by creating a meal you would typically eat and cutting the portion size in half. Try eating slowly and paying attention to how you feel to help you determine if you're full. If you're still hungry, you can slowly eat more food. Studies have shown that when you eat slower, you suppress ghrelin, a hormone that makes you feel hungry. Talk to Your Healthcare Provider: If nausea persists or becomes unbearable, it's crucial to communicate with your healthcare provider. They can adjust the dosage, provide additional prescription anti-nausea medications such as Zofran, or explore other weight loss options.  Thanks again for listening to The Peptide Podcast, we love having you as part of our community. If you love this podcast, please share it with your friends and family on social media, and have a happy, healthy week! Pro Tips We're huge advocates of using daily greens in your routine to help with gut, skin, nail, bone, and joint health. We take AG1 (athletic greens) every day. Not only does it have vitamins, minerals, and a diverse range of whole-food sourced ingredients, but it also has probiotics to promote a healthy gut microbiome and adaptogens to help with focus and mood balance. It's vegan, paleo, and keto-friendly.

It's that time again! Yes. Time for another captivating episode of The Gripe Session Podcast, where your hosts, our lovely Gripe Gals, bring you into their world of candid conversations and captivating stories from their daily lives. In this episode, Chika shares her recent experience with a potent over-the-counter sleep aid (we won't name names right now, you'll have to listen in to find out more!) and providing a unique perspective on the topic. This segues into a conversation on insights into pregnancy and morning sickness remedies, making it a treasure trove of advice for our listeners, including advocating for yourself with medical professionals. Shanea shares a brief update on her ongoing journey with her PT treatment for her pelvic tilt, with more updates promised in future episodes. As always, the conversation takes interesting turns touching on many other topics and spirited dialog that will leave you craving more. Don't miss out! 

Eric and pal of the pod, Sarah Squirm, talk about opening for parents weekend and how it's hard to make mom and dad laugh. Talks of SNL ensue and how it's great to collectively bomb as a cast and why people get the rush of stress on live television. This isn't TikTok, this isn't Instagram, THIS IS LIVE TELEVISION BABY! This episode is not sponsored by Zofran, but, it is the drug of choice. Also, they both agree on the biggest heckler at an outdoor comedy show: the sun.Rate and Review Bombing with Eric Andre here!Do you like listening to Bombing and want extended conversations with more bombing stories every week? Then check out Big Money Players Diamond, a new subscription available exclusively on Apple Podcasts, where you can get exclusive material from all my interviews for the show, plus 100% ad-free episodes every week. See omnystudio.com/listener for privacy information.

Dr. Andrew Jenzer joins us today as we kick off our series focused on medicine by doing a deep dive into cardiology and some of the most important aspects that all levels of residents and practicing surgeons need to know about. This episode and the ones that follow in the same vein are designed to maximize learning, and as such, we explore some of the most useful terms on the subject, safety precautions for medication, and related conditions and concerns. We delve into managing hypertension, issues with blood pressure, EKG interpretation, atrial fibrillation, and more, with Dr. Jenzer taking the time to approach these areas in theory and in practice. Towards the end of today's chat, Dr. Jenzer also gives some attention to the important ideas of cardiac risk, congestive heart failure, and cardiomyopathy, so make sure to stay tuned right to the end to catch all of that too!Key Points From This Episode:Introducing the electric system of the heart.  Five important technical terms and becoming familiar enough with them to communicate effectively around cardiac medications. Tips and recommendations for the basics of EKG interpretation. Extra care that is required when prescribing Zofran. An explanation and a few vital notes on atrial fibrillation.Different degrees of heart blocks and reasons for their occurrence.Final comments on the electrical concerns of the heart.Dr. Jenzer's thoughts on how this subject figures into study plans. Unpacking the hormones involved in cardiology.Assessing hypertension and the steps that can be taken in response. Defining and explaining ischemic cardiac disease, acute coronary syndrome, and more.Weighing the benefits of the use of various opioids, morphine, and Toradol.  How to go about defining cardiac risk and using “major adverse cardiac events.”  Classifications of congestive heart failure. An understanding of the different types of cardiomyopathy and how they impair the heart. Links Mentioned in Today's Episode:KLS Martin — https://www.klsmartin.com/en/Dr. Andrew Jenzer — https://surgery.duke.edu/profile/andrew-clark-jenzerRapid Interpretation of EKG's — https://www.amazon.com/Rapid-Interpretation-EKGs-Sixth-Dubin/dp/0912912065MDCalc — https://www.mdcalc.com/MACE Calculator — https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-eventsRCRI — https://www.mdcalc.com/calc/1739/revised-cardiac-risk-index-pre-operative-riskNSQIP — https://riskcalculator.facs.org/RiskCalculator/Everyday Oral Surgery Website — https://www.everydayoralsurgery.com/ Everyday Oral Surgery on Instagram — https://www.instagram.com/everydayoralsurgery/ Everyday Oral Surgery on Facebook — https://www.facebook.com/EverydayOralSurgery/Dr. Grant Stucki Email — grantstucki@gmail.comDr. Grant Stucki Phone — 720-441-6059

Hold onto your seats and get ready for a rollercoaster of an episode! In this highly anticipated installment of Not Well, Jim is back from his eventful trip to Italy, but his return is not without its challenges. As he deals with some post-travel stomach issues and excuses himself to purge, Bobby takes the opportunity to hilariously act as if he's podcasting solo once again, throwing sassy remarks left and right.But fear not, because once Jim rejoins the show, he regales us with the tales of his European adventures, complete with wild stories that will leave you in stitches. From encountering drugs at every turn (seriously, Europe knows how to party) to indulging in excesses that would make even the most seasoned partiers blush, Jim holds nothing back.Meanwhile, Bobby keeps the laughs coming as he dives into the intriguing world of online relationships and catfishing. A voicemail from a listener named OS6 sparks a discussion about open relationships and the potential dangers of virtual connections. Will they uncover a classic case of catfishing? Tune in to find out!And if that weren't enough, Bobby introduces a unique and humorous segment: wiener pics. Yes, you read that right. He playfully invites submissions from willing participants (ages 18 and older, of course) who want him to pass judgment on their husbands' privates. It's all in good fun and guaranteed to bring some laughs.With hilarious banter, outrageous anecdotes, and a touch of vulnerability, this episode of Not Well is a non-stop laugh riot. Jim's return from Italy takes us on a whirlwind journey through the highs and lows of European travel, while Bobby keeps us entertained with his quick wit and knack for storytelling.So sit back, relax, and prepare to laugh until your stomach hurts (hopefully not as much as Jim's). Don't forget to share your thoughts and feedback by reaching out to us at she'snotdoingsowell@gmail.com or messaging us on Instagram. We love hearing from our listeners!Stay tuned for the release of this uproarious episode, and in the meantime, catch up on all our previous episodes for more hilarious and relatable content. Get ready to laugh, cringe, and question your own life choices as we dive into the wild and unpredictable world of Not Well Podcast.Note: This episode contains discussions about drugs, excessive drinking, stomach issues, open relationships, and adult content. Listener discretion is advised.Don't miss out on the fun! Like, follow, listen, and share with your friends. Stay not well, stay entertained, and keep laughing with Not Well Podcast!#NotWellPodcast #EuropeanAdventures #CatfishTales #WienerJudgments #HilariousStories #PodcastHumor #TravelTales #ComedyPodcast #LaughRiot #StayNotWell #ListenerLove #SubscribeNow #ShareTheLaughs #FunnyPodcast #CringeComedy #RelatableContent #LaughUntilYouCry  Support the showAs always you can write us at nowellpodcast@gmail.com or call us at ‪(614) 721-5336‬ and tell us your Not Wells of the week InstagramTwitterBobby's Only FansHelp us continue to grow and create amazing content, like a live tour or just help fund some new headphones when needed. Any help is appreacited. https://www.buzzsprout.com/510487/subscribe#gaypodcast #podcast #gay #lgbtq #queerpodcast #lgbt #lgbtpodcast #lgbtqpodcast #gaypodcaster #queer#instagay #podcasts #podcasting #gaylife #pride #lesbian #bhfyp #gaycomedy #comedypodcast #comedy #nyc #614 #shesnotdoingsowell #wiltonmanor #notwell

Why are expectations about being a woman—specifically a mother—so unrealistic? Mother, author, and New York Times opinion writer Jessica Grose has a lot to say on this subject. Her latest book, Screaming on the Inside: The Unsustainability of American Motherhood, is inspired by her own shortcomings as a mother. She interviewed hundreds of women as part of the research process while writing the book. In it, Jessica shines a light on the current state of motherhood, and the historical context around the impossible standards for American mothers. In honor of Mother's Day, Jessica and I sit down to discuss the narrative and messaging to parents that “they're doing it wrong.” Jessica urges parents to learn to trust their instincts and to show up to parenting as their authentic, imperfect selves. Join me every Monday for a new episode of Beyond the Prescription.You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.Please be sure to like, rate, review — and enjoy — the show!Transcript of the podcast is here![00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride and this is Beyond the Prescription, the show where I talk to my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for more than 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, to find out, are they okay, and for you to imagine, and potentially get healthier from the inside out. [00:00:45] You can subscribe to my weekly newsletter at lucymcbride.substack.com and to the show at Apple Podcasts, Spotify, or wherever you find your podcasts. So let's get into it and go beyond the prescription. [00:01:01] Dr. McBride: Today I'm interviewing Jessica Grose. She is a mother, she is an author, and she is a New York Times opinion writer who writes a lot about parenting. Her most recent book is called Screaming on the Inside: The Unsustainability of American Motherhood. I was immediately drawn to this book because it was inspired by Jess's own perceived shortcomings as a mother, something I think a lot of us women can relate to. The book combines in-depth interviews with mothers and a historical context on motherhood to help explain why our expectations about being a mom are so unrealistic.[00:01:37] I think there's a narrative that a lot of us women and mothers absorb that if we only read the right book, if we only had the right parenting expert on speed dial, that we could be the perfect mother when it's not that simple, and frankly, we need to be better able to trust our instincts to know that by showing up, by being a good person and by leading with empathy and curiosity about who our kids are that we are good enough. Jess, I'm thrilled to have you today. Thank you so much for joining me.[00:02:07] Jess: Thank you for having me. I just wanted to mention, we actually recently dropped the on parenting. I will still talk about parenting. I think my last column was about parenting related issues, but I wanted to have a chance to broaden my aperture a little bit, write about all sorts of issues, mostly cultural, but it's been exciting and I'm really looking forward to this year.[00:02:30] I mean, an example of that was I just did a big piece about midlife and millennials at midlife. I am one. I am an ancient millennial. I just turned 41.[00:02:39] Dr. McBride: What's the newsletter called now?[00:02:41] Jess: It's just my name, just Jessica Grose.[00:02:43] Dr. McBride: Okay, awesome. How cool is that though, Jessica, that you got to move from being a reporter, which I know you loved to giving your Opinion. I mean, anyone who knows me will tell you that. I love data. I love analysis. I love pouring through primary sources. I also have a few opinions and I love delivering them.[00:03:04] Jess: Well, I don't think that my approach has actually changed really radically. I do what I like to think of as reported opinion. It's unusual for me to just riff on an idea without including data or including interviews. Occasionally I will actually, my next column is just about Brook Shields' new documentary. And so that's more just thoughts about what it's like to grow up in the public eye for a kid. And it's unsurprisingly not great. It was really difficult for her to develop a sense of an identity. But typically I still do a lot of reporting. What it allows me to do is draw more aggressive conclusions from that reporting. And anyone who knows me in real life knows I have a lot of opinions, so it feels really nice to share them.[00:02:52] Dr. McBride: Well, I think that's right. It's the same thing in medicine. I have a lot of opinions, but it's rooted in my understanding of the medical literature and the understanding of the patient in front of me. So I'm never going to just say, do this because I said so. The fun is taking the data and the data in your case on motherhood and the historical context around it, and then giving parents and mothers permission to be less perfect than their Instagram highlights might suggest they should be.[00:04:23] Jess: Yeah, I mean I had just the genesis of the book was really just in having so many questions about where ideas that I had about motherhood came from. Because when you start to unpack them, they sound crazy. So one example that I often give is I was very sick during my first pregnancy. I had hyperemesis, so I was throwing up constantly. I could not keep food down. I got incredibly depressed and anxious. I honestly think in large part because I had hyperemesis, just as you cover, the body mind connection is very deep. Not being able to nourish yourself, it's tough to feel good in any way. And I had the question, why is there even the expectation that one should feel good during pregnancy?[00:05:16] Because I've known a lot of pregnant people in my life, and most of them do not feel great. Maybe they have moments where, during the second trimester, they're not enormous yet. They're feeling a baby kick. They're not sick anymore. Maybe you've got like two months of feeling pretty good, but often, there are many ways in which you can feel not your best self, and so every chapter of the book started with a question about an ideal that when you think about it for more than five minutes, makes absolutely no sense.[00:05:49] Dr. McBride: Yeah, it's interesting about the hyperemesis, and I heard you say in an interview that you leaned into the toilet, that was your lean in. So I had a patient recently in my office who is pregnant with her second child. She's in her second trimester, and so, so sick, like on her knees, in her bedroom. She's a congressional staffer and can't even really go to work most days because she's so sick. And she went to her gynecologist and she was explaining how sick she was to her gynecologist, her obstetrician, and my patient asked the question, “can I take Zofran or something for this nausea?” And the doctor said to her, and the patient's crying telling me this story, she said, “well, if you really can't function, I guess you can take some Zofran.”[00:06:31] That's a tough standard to hold ourselves to. If you're in the fetal position, then you can treat yourself to a medication that's exceedingly safe, particularly in the second trimester. Why are women so conditioned to suffering and why are we depriving them of the permission to experience highs and lows of pregnancy and motherhood, I don't know.[00:06:55] Jess: Well, we're working against thousands of years of conditioning, right? I mean, the idea that mothers shouldn't be martyrs and sacrifice themselves, put themselves last in every situation. That is in all of our in some ways all of our religious texts of the major religions, it is there if you want to pick it up. I mean, in terms of pregnancy and the benefit risk analysis, I think particularly in the United States, and Emily Oster is obviously the guru on this topic, we have just over-rotated on risks and perceived risks because statistically speaking, many of the things we think of as scary and we shouldn't do them, are not damaging really at all, except in extremely unusual circumstances. [00:07:45] And so I think medication is one of those things, and particularly things that are seen to be non-essential. And it's always a question, well, it's like, well, non-essential for whom, and one of the big mental health related medications, it's even more for, where it's like Prozac in particular is that there's so many studies on SSRIs in pregnancy. So, so, so many and perinatal psychiatrists will tell you that the risk profile for those drugs is pretty good. Everybody needs to make that calculation for themselves. I am not pro or anti-drug. I'm pro making an accurate risk benefit assessment in every individual[00:08:31] Dr. McBride: You sound like my friend Emily Oster, and you sound like, and you sound like me, because Emily's a good friend and she was on the podcast and we've talked extensively about the level of scrutiny that we expect women to look at these risks with is exceedingly high. Eating blue vein cheese during pregnancy, having a thimble full of wine. Those carry risks, but so do being anxious and being depressed.[00:08:59] Jess: So does getting in your car every day, which [00:08:00] is probably the most dangerous thing that you do as a pregnant woman. That's typical. But we don't think of it that way because of complicated reasons. And I do think it's affecting not just how we feel in our own bodies and how we experience the pregnancy and postpartum period, but I think it's affecting how we parent and it's making us more anxious parents than we need to be. And to me, the joy of being a mother is watching my kids become who they are and watching them go out into the world and navigate it. And excessive anxiety about things that have risks but low risks really impedes relationship building that joy of watching them become their own people.[00:09:50] And that just makes me incredibly sad because it should be joyful. Not all the time. That's a big part of my book. Parenting is not joyful all the time, but there are parts that are incredibly joyful and validating. And so I think having too aggressive a feeling about risks and a scary world out there impedes the joy that we could feel.[00:10:15] Dr. McBride: Yeah, I think we learned in Covid that people in general do a pretty bad job of assessing risk. And then thinking about risk benefit ratios, we tend to overestimate risk when we're thinking about our children and we think about women.[00:10:31] Jess: Yes, and I don't blame anyone because the avalanche of information that all of us are getting all of the time, no one can parse that. You don't know who to trust. I feel lucky that I gave birth to my older daughter in 2012 when the social media ecosystem was not—I guess I would describe it as broken today. There were problems with it, but it wasn't, there just was less social media. There were no Instagram stories. TikTok didn't exist. It was not what it is today, and I made a concerted effort knowing myself that I tried and really didn't look for parenting information online. I did not follow any parenting as much as I could. I had one book, and the only book was the Mayo Clinic's Guide to Your Baby's First Year. And if I had a question, I would ask my pediatrician or I would ask my mom, and that's unfair to expect everybody to do because my mom is also a retired physician.[00:11:31] Dr. McBride: You have an advantage.[00:11:33] Jess: I have a home court advantage in terms of trustworthy, you know, people in my life. But I think paring down that is one thing I tell parents all the time. Pick a few trusted sources and just try to block everything else out because otherwise you're gonna drive yourself bananas.[00:11:53] Dr. McBride: I think it's great advice, because of all the information coming at us like a open fire hose, and because there's so much fear-based messaging and because we're predisposed to being more anxious about our children and society has made women more anxious about themselves for whatever reason. How do you guide people on deciding who to trust and who not to trust? What's the anatomy of trust in your mind?[00:12:16] Jess: So, I mean, number one, and again, expertise does not always equal trust, but always look at the credentials. Look at their credentials. See as much as you can. If they have a particular narrative on any topic that they are trying to push, see if they have any conflicts of interest in terms of payment through a certain company. All of the things that… it's sort of a journalistic way to look at the sources that you trust. And then the sort of X-factor is more just vibes. Are they making you feel bad about yourself? That's huge. So many advice givers on social media are invested in negativity.[00:13:01] Actually, there was just a great article in Vox about this, not specifically targeted at mothers, but saying, because negativity plays better in the algorithms telling you that you're doing it wrong will rise to the top and that's just not how I wanna be talked to about my parenting. Like, “you're doing it wrong and this is the right way to do it.” Well, piss off! My spirit is very contrarian. And so if anyone is telling me like, you're doing it wrong, I have just an immediate gut [reaction]—I'll do what I want. I've talked to so many people through my reporting days that they have the opposite reaction, which is like, I must be doing it wrong and I feel terrible. So if something's making you feel terrible, listen to that voice.[00:13:45] Dr. McBride: I think women walk around with that narrative on their own. They don't need help in many cases. I think so much of our messaging to women the historical context around this is about you're doing it wrong. You could be better. You're not enough. Your kids are messy, your kids are loud, your kids are emotional, your kids are this. And then of course we feel anxious. Of course we feel like we're not good enough. And so we have this narrative often that is, we are not doing it right, we're doing it wrong. And that is a narrative that dies hard for so many people and does inform the way they show up in my office as patients with insomnia, alcohol overuse, distress and malaise. The pressures we put on the American mother are enormous, and it's not like it is in other countries. Other wealthy countries don't have the level of scrutiny on mothers like we do in this country.[00:14:41] Jess: And I think there's been cross-cultural studies done on this, and parents in our peer nations actually look to experts less for advice because they feel more supported in their own communities and they  feel more confident in their own instincts. And I think that there's a lot of complicated reasons why that is. [00:15:01] Dr. McBride: Could you talk about why you think that is?[00:15:03] Jess: Well, I mean, I think, you know, they orient their entire societies around children being more part of the day-to-day and having children behave as children do is just understood. It's not demonized. It's not, you're not worried all the time, that's everybody's gonna give you nasty looks in a restaurant.[00:15:29] It's like children are just sort of more welcomed as a baseline. And I do think that. There's a relationship—it's not a one-to-one relationship—but there's a relationship between that attitude and having more child-centered public policy. So everything from paid leave, which we are the only wealthy country in the world, that doesn't provide it for our citizens. More subsidized child care to things like even urban design, having more parks and green spaces, having more walkable areas for, and areas for children to exist and play and be more a part of society. [00:16:10] I did a piece about this adorable Japanese show that's on Netflix called Old Enough, and when I was researching that piece, the show depicts toddlers, really little kids going on their first errands alone, which, just would never happen for a million reasons in the United States. But part of the reason that it is easier for Japanese children to be more independent is because of the built environment in Japan. And there's a great article in Slate about that. So, those are things that are sort of subterranean. We don't even see them. We don't think about them. We obviously are not all so well traveled that we know what the built environment looks like in Japan, but those are some of the reasons that I think American parents do feel such a sense of scrutiny and need and desire to seem perfect or keep their kids perfectly in line when they're out in public.[00:17:11] Dr. McBride: Do you think there's something to the idea of women in America not trusting their instincts as much, or not being allowed to trust their instincts? I mean, what I see since I became a parent, and it's the same problem in the wedding industry, is that there's a whole professional industry around parenting. I'm so glad I got married in 2000 and not today because we didn't have one of these produced proposal moments. It was just a casual moment in the woods. Similarly, when I was a parent for the first time, I didn't have Instagram and all the parenting gurus out there. I just had to trust my instincts. But I think because we professionalize these phenomena, women can start to feel less than, or like they have to read this book and then they'll be okay when actually we are born to be parents if we want to be. So I don't know if there's something about that, but it does feel to me like we often don't give ourselves permission to just listen to our intuition.[00:18:19] Jess: Yeah, I think the sort of commercialization of everything is connected to the fact that there are no sort of communal supports and rituals. So, for example, in many countries after you give birth, Somebody from the National Health Systems will come and visit you. A nurse will come to your house and… [00:18:37] Dr. McBride: Can you imagine that happening in the us?[00:18:40] Jess: I cannot, I would have loved that. They will come to your house free of charge. They will make sure you're doing okay. They'll make sure the baby's doing okay. They'll help you with nursing. They'll do all of that built in support in that way. There are mothers groups that will be organized through the community and I think when you don't have that, then figuring out how to solve your problems is an individual issue, and then you feel isolated and that leads to that sort of stress and anxiety and desire for individual solutions that ultimately might not help us feel good or feel accepted. And so it all sort of is so connected to so many different aspects of how we raise children in this country.[00:19:32] Dr. McBride: I also wonder what you think of the idea of caution as a virtue we saw in the pandemic that we really moralized human behavior. If you didn't get vaccinated, certainly you were sort of deemed a pariah of society. If you didn't mask long enough, diligently enough, there was something wrong with you.And I think when we looked at the data on Covid and kids, at least when I looked at the data, it was clear that kids, healthy kids tended to do generally pretty well with the virus, which is not to say that we wanted kids to get covid. It's not to say that kids haven't tragically died from covid, but there's something about the moralization of motherhood and behavior and children in this country that is, to me, seems unique. I don't know what you think about that.[00:20:27] Jess: I think that's right. There's just this pervasive attitude. It's like if anything goes wrong, it is your fault, it's your responsibility, it's your fault. You should, you have to be there to pick up the pieces. No one's there to help you. You should have done X, Y, and Z differently, but it's not working.[00:20:44] Dr. McBride: It's not working because Jessica kids get covid. Kids do stupid stuff on the playground to each other. Kids are messy and imperfect and so are we. And so this notion that caution as a virtue is inherently flawed because there's only so much you can be cautious about and risk is ubiquitous.[00:21:04] Jess: Yeah, I think a lot about the fact that my older daughter broke her arm during Covid. She broke her arm in May 2021, and it was because she was playing soccer in our courtyard and she fell. And there was nothing that was… we were lucky enough to mostly remain healthy during that time, but it was just like I was literally a hundred feet away from her. Things happen in children's lives. I didn't feel guilty. I felt bad for her. Obviously seeing child in pain stinks. It was a thoroughly un-fun experience for all involved, but I didn't feel responsible for it. I, but it occurred to me as I basically witnessed it happen. It was just like, there's nothing I can do. She's biting it and her arm looks really messed up. [Unless we] start placing her in bubble wrap and never letting her leave the house, this was unavoidable.[00:22:09] Dr. McBride: That's right. I just had a thought as we were talking about risks to kids. I was remembering the article you just wrote for the New York Times about the reporting on the CDC data on adolescent mental health. And I thought it was such a great article because in my office I have parents and older teens as patients who are having mental health challenges, whether it's anxiety, depression, substance use disorders, eating disorders. I also have a fair amount of parents who are anxious about the headlines alone and anxious about the data. And then I have fair amount of teens who feel like, “oh my God, this is inevitable that I am a mentally ill person because this is what everybody's talking about.” And so what I loved about your article is that you are trying to take away the catastrophization, if that's a word… [00:23:03] Jess: Yeah.[00:23:04] Dr. McBride: You're the the writer! and to frame the data and recognize let's look at the facts and look at the way the data was collected and the timeframe. And then let's also recognize the historical context around over worrying perhaps about girls having emotional health, not to dismiss the fact that kids are suffering, not to dismiss that kids are losing their lives to mental health problems, but rather to recognize the biases we have culturally that make us kind of mentally masturbate, if you will, on girls having feelings. So can you talk about that a little bit more because I thought it was brilliant.[00:23:40] Jess: Yeah. Oh, thank you. It was a struggle to write because I really wanted to be very careful and not… the fact that suicidal ideation is up, the fact that suicides are up is awful. Full stop. We need to help those kids. Any kid dying before they're 18 is a tragedy. That is awful. And my heart absolutely breaks for parents whose kids are really struggling, you know, exactly as you say, with eating disorders, substance use, self-harm is up, cutting all, of that. So. I never want to seem like I am diminishing the seriousness or pain of that.[00:24:24] At the same time, since I was a teenager… I graduated from high school in the year 2000. All we've had since the year 2000 is more awareness and more discussion of mental health, and I just don't want teenagers in particular, who, and being, because being a teenager is really hard. I remember being a teenager and you could not pay me to go back there. I don't want them to pathologize the normal ups and downs this period of rapid change. And I don't want them to necessarily label themselves as, oh, I'm an anxious person. I'm a depressed person. I am X, Y, and Z. Well, it's like, maybe, but maybe you're just having strong feelings and that's part of life, and that's part of being a person and you're learning how to handle them and you can handle them.[00:25:24] You can handle these big feelings and you don't need to necessarily label yourself as having a broken brain, which is how a philosopher that I quoted describes it. She calls it the broken brain hypothesis. Oh, my brain is broken and it needs fixing. And is that narrative helpful for all teens? And I would argue, no. I am the daughter of a psychiatrist. I am pro psychiatry. I am pro psychology. I am pro therapy. But at the same time, does turning inward help everybody all the time? I think most teenagers could benefit from just as they say on the internet, touching grass, not turning inward, turning outward to their communities, to their friends, to their own habits. [00:26:20] One thing that I had in an earlier draft, which I didn't include and I think is under discussed, there is good data on the fact that teens are sleeping less than they used to, and that is huge. They might just need more sleep. They're just tired and cranky and I mean, I've, there's been, especially when I was a new mom, there were numerous times where I really thought I was losing my mind and I was just completely exhausted.[00:26:48] Dr. McBride I think it's such a good point, not only do we tend to pathologize normal human emotions, which is distinctly not to dismiss the harms of depression, anxiety and substance use. We also tend to make things more complicated than they sometimes are. Sometimes the solution to my patient's angst and alcohol overuse in the evenings when she gets home from work and poor sleep and hot flashes is, she just needs to eat lunch. Same thing with what you're talking about. It's not gonna solve everyone's problems, but sleep is an essential part of the human brain and bodily function. So I think you're right. Sleep is huge.[00:27:33] Jess: But also, I mean in terms of my researching for this piece, my attitude towards all of the ideas around this is yes, and it's not, I don't agree with that. Screens are an issue. They're absolutely an issue. That's part of this. It's how we parent and over parent possibly. I think that's part of it too. It's more just to say, I wanted to take. The temperature down a few degrees because I don't think really panicky headlines are helpful to anyone, honestly, on almost any subject. I think that's making everybody more anxious. And so I just wanted to say, can we talk about different ideas? Can we look at this from a different angle?[00:28:18] Jess: And I have a dog in this fight. I have two girls, one of whom is entering middle school in the fall. I want her to feel confident and empowered, and I want her to feel like she can take charge of her own emotional life, and I will admit that this is one of the few times where my reporting has really changed the way I think about parenting.[00:28:43] Dr. McBride: It's so interesting. I want to talk a little bit more about the taking the temperature down phenomenon, because like Emily Oster, I have been writing, I mean not to the extent she has been, but about fear getting ahead of the headlines about pediatric risk, of covid, about the excessive amount, in my opinion, of rumination, about covid risks in the vaccine era at the expense of thinking about health in a broader way.[00:29:20] And I'm talking to women in particular. I'm talking to everybody, but I think women as the ones who are largely the primary caregivers for kids and women who are, the ones that I see, at least in my office, tend to be more anxious about risk, not universal, but there's utility in doing that and trying to take the temperature down.[00:29:42] There's also a fair amount of backlash to that narrative. People don't necessarily want to hear that it's okay if your kid gets covid because by the way they will anyway, and it's not going to necessarily do them long-term damage because that's what the data show us. There's some currency there about. The vigilance and the anxiety. It feels like having its own life, its own place, and that is what's concerning to me that, that it's really hard to let go of. Do you see that? Does that make sense to you? I know that because Emily Oster and I have discussed how we have to go into hiding when we put out these articles for The Atlantic.[00:30:22] She wrote the article that your kids going on vacation or flying on an airplane is like the same risk as their grandparents or something like that, and she had to go into like witness protection program because people were so angry that she was trying to help people manage risk and calibrate it to the actual threat.[00:30:38] Jess: Yeah, but I'm sure she at the same time, she also had a lot of people thanking her. I mean, it's easy to think about the backlash.[00:30:45] Dr. McBride: I think that's right, but I also think that, I just wonder where that anger is coming from. [00:30:52] Jess: Well, I do think that there is something to, and I'm not saying that this is a conscious feeling, but if you are not worrying about your kid, you're not a good mother. And that has to be part of the equation. And it goes back to if anything goes wrong, it's your fault. And so your worrying will prevent anything from going wrong. But you know, that's not how life works. There's terrible unlucky things that happen and that's part of un unfortunately, that is the downside of living a full life, because if you just avoid anything that is, you know, has a potential risk and even at a potential emotional risk, I think you're gonna be missing out on most of the good parts of life.[00:31:36] Host: I think that's right. I think because motherhood is intrinsically stressful, I think we can start to associate stress with mothering, where if you're a good mother, by any definition, It's despite being anxious, it's despite being stressed, like I know that I'm doing my best mothering, which, you know, I'm not winning mother of the year anytime soon. But I feel like I'm in my best moments when I'm not [00:31:00] leading with fear or anxiety when I'm like just straight talking. But I think it's easy, like just for anybody, to, anyone who's used to like achieving or. You know, trying to do well, and we're all trying to do well as parents to associate the anxiety itself with the outcome.[00:32:19] Jess: Right. But I think, and this is actually, I've been thinking about this a lot lately because I see a move in parenting advice towards giving people scripts. And my attitude towards most parenting advice is like anything that helps you get through the day in one piece, great. But I do wonder if we are overthinking the importance of every single word we say to our children and worrying that if you say one wrong thing wrong, I'm putting that in air quotes because who knows what even is the right thing for your individual child. It could have catastrophic blowback, and to me it's a risk of being inauthentic with your children if you are relying on some sort of words that didn't come from you or your brain, it teaches your kid that you're also not really human yourself. I think it's important for your kids to see you as a human. Obviously, they should never feel responsible for your emotional wellbeing, but they should know that you're not perfect. That's good for them.[00:33:36] And I've written articles where I try to give people scripts when I think it's helpful, so I'm not knocking it overall, but I do wonder what we're losing if we're not just trying to speak honestly as ourselves, because are we pretending that we all want the same outcomes for our children? Like what does that even mean? What is a good outcome? I think all the time about What do you want for your kid in the world? We don't all agree because everybody's different and everybody has different values. So, I just think the challenge for all of us is to sort of live an authentic self as we are also parents. We are not some new kind of person.[00:34:17] Dr. McBride: That's right.[00:34:18] Jess: We're still just people.[00:34:20] Dr. McBride: I'd love to ask you about you as a parent right now and what are your particular struggles? Are their particular narratives you have in your mind that you're trying to undo, and how are you looking to be a healthier parent for your kids?[00:34:39] Jess: My kids are at a great ages. They're in first grade and fifth grade, and so we're out of that diapers and toddler tantrums phase, which I found. I love babies. I really liked having babies. I struggled with that one. That age between one and two. I think that was the hardest for me as a mother just sheer exhaustion, but with my older daughter who will enter middle school, something that I'm proud of is completely removing myself from any of her friendship drama. And I never got involved in terms of like talking to anyone. Of course not. But I would… she would tell me something. I would not react to her, but later I would be stewing about it. And I have just been like, stay out of it. Do not get emotionally involved because there will be a new drama tomorrow and some other girl is gonna say something to some other girl and obviously if it were a bullying situation, that would be different.[00:35:44] But just having been a middle school girl, this is very familiar to me. And so when it first started happening kind of at the beginning of fifth grade, I was upset. I was upset, man, it stinks to watch your kid be in this mean girl business. And I don't think she was probably totally innocent and it either, who knows? I wasn't there. I shouldn't be there. And I always let her deal with it herself. I never got involved with it, but I would get really upset. When she wasn't around. And so I think it's a parenting win for me to just have let that just be like, I'm not getting emotionally involved with this. It's only gonna get worse in the next couple of years. I assume maybe I'll get better, who knows? But having been a teenage girl, this is just the beginning. And so I think training myself to not get too involved in any way.[00:36:38] Dr. McBride: It's really healthy. And what's particularly healthy when I hear you talk about it, that you recognize your daughter may have had a role in it. You're not assuming innocence just because she's your offspring, and you're also recognizing there are harms of, you know, the dynamics that you would hopefully pick up on.[00:35:53] But you're right, they have to kind of navigate these things themselves.[00:36:59] Jess: They have to, and they have to learn how to deal with people they're not getting along with. That's life. That's the workplace that's going to go into, there's nothing I can do. Absolutely I can be there for her when she comes and tells me she's upset about something and if she asks me for advice. I'll give it to her. She seems to want no part of my advice about anything… [00:37:18] Dr. McBride: Welcome to the club. Welcome to the club, my friend.[00:37:21] Jess: but I found it very distressing when she first would start telling me about the beginnings of these sort of… it's so familiar. I'm sure you found it familiar when your kids started going through it.[00:37:34] Dr. McBride: A hundred percent.[00:37:35] Jess: And so it's been, now that she's almost at the end of fifth grade, I feel like I think we both have a better handle on it, let's put it that way.[00:37:44] Dr. McBride: My last newsletter subject was about this after I interviewed Lisa Damour for my podcast. I love Lisa. She's, oh my gosh, I could just listen to her voice all day long.[00:37:53] Jess: She has a very soothing voice. That's true.[00:37:55] Dr. McBride: And I wrote a substack piece about how hard it is to do this, but how essential it is for us and for our children to try not to ride the rollercoaster of their emotions. Because first of all, they want us to, and that that's a little bit of a currency. I mean, they don't want us to really, but they're, they get their mojo from riling us up. But if we can have a little bit of a distance or space from their everyday minute to minute, Emotions. It's good for both parties[00:38:26] Jess: It is, and again, it's like when I said that reporting, that piece really changed how I thought about parenting. I already felt this way to an extent, but I think not allowing our children to deal with their own problems is so bad for them. It's bad for us and it's bad for them, and we can't just, as my children get older, I want them to feel a sense of agency in their own lives. I want them to be really self-sufficient. It's really important to me. I think it's really important for them. And so, I already thought that, but there are certain things that I have vowed to do a little differently solely based on the reporting about teen mental health, just because I really do think allowing them as much independence, again, emotional and physical independence as makes sense for them as an individual child.[00:39:28] All kids are different. All kids have different abilities. They have different desires. They have different things that they're ready for at different times. I mean, it's so wild to look at my children. And their classmates because you can see all of these kids are normal kids and they have such a range of physical size, emotional maturity, intellectual, cognitive differences that are, again, all within the range of normal, all beautiful in their own ways. And so every parent has sort of a different way to do it, but I think really giving our kids independence is so important for them.[00:40:08] Dr. McBride: Thank you so much for joining me. Thank you for shining a light on American motherhood and giving us a more nuanced view of how it actually is and for bringing data and facts and context to it. So I really appreciate your work and I'm so grateful you joined me.[00:40:24] Jess: Oh, thank you so much for having me.[00:40:29] Dr. McBrideThank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on apple podcasts, spotify or wherever you find your podcasts. I'd be thrilled if you like this episode to rate and review jt. And if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on the show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.  Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

In our 171st episode of Beyond the Bump, Dr Timmy is back in the poddy pod!! And he's here to talk about pregnancy myths versus facts. We hope you enjoy!!! When I'm pregnant, I can't: Drink coffee Eat soft serves Eat sushi? And I can't eat seafood because of the mercury Eat deli meats and soft cheese Eat runny eggs and/or eggs in general Pineapples can cause miscarriages so I should avoid them in pregnancy Avoiding foods during pregnancy leads to a greater risk of bub being allergic to that food I can have tiny bits of alcohol when I'm pregnant If I take Ondansetron or Zofran during pregnancy it increases the risk of my child being born with a cleft lip/palate Ultrasounds are bad for the baby I have to sleep on my side, not on my back during pregnancy Your baby's gender is impacted by the time in the cycle that you have sex Nausea is worse if you're having a girl There are different cravings during pregnancy based on gender? Sweet it's a girl. Savoury if it's a boy Carrying low means you're having a boy A faster heart rate is likely to be a girl and a slower one a boy Heartburn means your bub has lots of hair It's a good sign if I have nausea at the start of my pregnancy I should not do high intensity exercise during my pregnancy Hot baths, saunas and spas are dangerous when I'm pregnant I should be weighted at every antenatal appointment Can I do laser hair removal when pregnant? What about Botox and/or other cosmetic procedures? Can I dye or bleach my hair? Can I smoke/vape during pregnancy?   Resource links Quit Centre - Pregnancy and Maternal Health   Beyond the Bump is a podcast brought to you by Jayde Couldwell and Sophie Pearce! A podcast targeted at mums, just like you! A place to have real conversations with honest and authentic people.   Follow us on Instagram at @beyondthebump.podcast to stay up to date with behind the scenes and future episodes.    This episode of Beyond the Bump is brought to you by Le Purée: If you are interested in trying out Le Purees nutrient-dense meals and smoothies or you would like to gift a pregnant or postpartum mama, you can select from both a la cart and subscription!  Head to www.lepuree.com.au and use code BTB10 for $10 off!

Continuing the drug box discussion, the crew discussed the clinical math, preparation, and dosages of various drugs including Zofran, Epi, and Dilaudid. This is a great episode to watch on our YouTube channel. Med UPDATES: The new ADULT dosing is to mix 2 grams (2000 mg) in 100 ml of D5 and administer that dose over 10 minutes and Push Dose Epi can be given up to 50 mcg per dose prn.

Welcome back to the Lighthouse Podcast! Chris and Christy have the privilege of talking with Joshua Elder today. It's so great to have Josh on the podcast representing his profession as a Clinical Pharmacy Specialist. It's the first time Chris and Christy have talked with someone in this profession. He lives in Kentucky with his wife and two daughters, who are six and four years old. In his free time, he volunteers as a counselor at a pediatric oncology camp and loves to travel. In the episode today, you will hear about the role of an Oncology Pharmacist and why it's essential. You will also learn practical information about supportive care medications like Zofran, Bactrim, and more. Last but not least, you will listen to some specific side effects to look out for. In conclusion, Josh shares how his role is in a lot of larger hospitals. If you are unsure you have access to a Clinical Pharmacy Specialist, ask your medical team about it. Follow Lighthouse on Social Media: Facebook: https://www.facebook.com/lighthousefamilyretreat Instagram: http://instagram.com/lighthousefr

In this episode, Bryan explains that he is expecting his new baby soon, tells a story about needing some Zofran, and shares his love for the sun. Life Level 1 is a general topic podcast about life from the humorous perspective of Bryan and his broad, Kristen. Bryan has a background in video game development and Kristen has a background in life. The thoughts and opinions expressed on this podcast are those of the individual contributors alone and are not a reflection of their employers.

The radiation oncologist sends Natasha to a psycho-oncologist (did you know that was a thing?) because her antidepressants aren't working, making self-care too hard. This forces her to confront the mental health struggles caused by the abrupt end of her time in Malawi, the surprise end of her 25-year marriage, and a cancer diagnosis all happening at the same time. Missing her old pre-cancer life, but not necessarily the marriage, she is engulfed in sadness and nostalgia but chooses to still show up. ==A special thank you to Doctors Without Borders for listening to the show and sending good thoughts to Natasha!

Download the cheat: https://bit.ly/50-meds  View the lesson:     Generic Name ondansetron Trade Name Zofran Indication nausea/vomiting Action blocks effects of serotonin on vagal nerve and CNS Therapeutic Class antiemetic Pharmacologic Class 5-HT3 antagonist Nursing Considerations • administer slowly over 2-5 minutes – fatal QT prolongation and VTach, respiratory arrest • may cause headache, constipation, diarrhea, dry mouth • asses nausea and vomiting • assess for extrapyramidal symptoms • monitor liver function tests

Does every child who is vomiting need Zofran? What is the “best” thing to do for a vomiting child and how do we set our PO challenge for success? What do we do when things don't go as planned? Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC  

Claire and Skye give some relationship advice to some assholes on the internet. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

Thanks to the incredible cold cap technology, Desert Essence shampoo, and seldomly using a brush, after six rounds of chemo Natasha still has her hair. Meanwhile, everything else is falling apart. Plans to celebrate at a fancy restaurant are wrecked when her date gets COVID and none of her friends can go. An insurance snafu just 2 days before her last chemo causes her to run out of Zofran and getting a refill requires some creativity. Natasha has another MRI to see if the chemo worked, and realizes only after reading the results alone that if it had been bad news she would have been in a dark place without support. As she reflects on chemo, she shares what could have been done differently. Links The End of Chemo, brought to you by DigniCaps cold caps (they didn't sponsor us but probably should now) Shop Desert Essence shampoos https://www.desertessence.com/hair-care/shampoo Links Support the Breast Cancer Stories podcast https://www.breastcancerstoriespodcast.com/donate Subscribe to our newsletter here: https://breastcancerstories.substack.com/subscribe About Breast Cancer Stories Breast Cancer Stories follows Natasha Curry, a palliative care nurse practitioner at San Francisco General Hospital, through her experience of going from being a nurse to a patient after being diagnosed with breast cancer. Natasha was in Malawi on a Doctors Without Borders mission in 2021 when her husband of 25 years announced in a text message that he was leaving. She returned home, fell into bed for a few weeks, and eventually pulled herself together and went back to work. A few months later when she discovered an almond-sized lump in her armpit, she did everything she tells her patients not to do and dismissed it, or wrote it off as a “fat lump." Months went by before Natasha finally got a mammogram, but radiology saw nothing in either breast. It was the armpit lump that caught their attention. Next step was an ultrasound, where the lump was clearly visible. One painful biopsy later, Natasha found out she had cancer; in one life-changing moment, the nurse became the patient. This podcast is about what happens when you have breast cancer, told in real time. Host and Executive Producer: Eva Sheie Co-Host: Kristen Vengler Editor and Audio Engineer: Daniel Croeser Theme Music: Them Highs and Lows, Bird of Figment (https://music.apple.com/us/artist/bird-of-figment/1434663902) Production Assistant: Mary Ellen Clarkson Cover Art Designer: Shawn Hiatt Breast Cancer Stories is a production of The Axis. (http://www.theaxis.io/) PROUDLY MADE IN AUSTIN, TEXAS

With five sessions down, Natasha feels less like a nurse and more like a patient. Her final chemo treatment is next Wednesday, and the planned end-of-chemo celebration feels fake because surgery and radiation are still ahead. Because food tastes even worse than before, she lives off rice and beans. To keep the weight loss from further eroding her self esteem, she downloads an app to send her daily affirmations. Links Support the Breast Cancer Stories podcast https://www.breastcancerstoriespodcast.com/donate Subscribe to our newsletter here: http://eepurl.com/hX12YD About Breast Cancer Stories Breast Cancer Stories follows Natasha Curry, a palliative care nurse practitioner at San Francisco General Hospital, through her experience of going from being a nurse to a patient after being diagnosed with breast cancer. Natasha was in Malawi on a Doctors Without Borders mission in 2021 when her husband of 25 years announced in a text message that he was leaving. She returned home, fell into bed for a few weeks, and eventually pulled herself together and went back to work. A few months later when she discovered an almond-sized lump in her armpit, she did everything she tells her patients not to do and dismissed it, or wrote it off as a “fat lump." Months went by before Natasha finally got a mammogram, but radiology saw nothing in either breast. It was the armpit lump that caught their attention. Next step was an ultrasound, where the lump was clearly visible. One painful biopsy later, Natasha found out she had cancer; in one life-changing moment, the nurse became the patient. This podcast is about what happens when you have breast cancer, told in real time. Host and Executive Producer: Eva Sheie Co-Host: Kristen Vengler Editor and Audio Engineer: Daniel Croeser Theme Music: Them Highs and Lows, Bird of Figment (https://music.apple.com/us/artist/bird-of-figment/1434663902) Production Assistant: Mary Ellen Clarkson Cover Art Designer: Shawn Hiatt Breast Cancer Stories is a production of The Axis. (http://www.theaxis.io/) PROUDLY MADE IN AUSTIN, TEXAS

Partners in cancer care – who are advanced practice providers? In the first episode of ASCO Education's podcast series on Advanced Practice Providers (APPs), co-hosts Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guest speaker, Wendy Vogel (Harborside/APSHO), discuss who advanced practice providers are, share an overview of what they do, and why they are important to oncology care teams. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org   TRANSCRIPT Todd Pickard: Hello everyone, and welcome to the ASCO Education Podcast, episode number one of the 'Advanced Practice Providers' series, 'APPs 101: What and Who Are Advanced Practice Providers?' I'd like to introduce my co-host for this series, Dr. Stephanie Williams. My name is Todd Pickard. I'm an advanced practice provider, I'm a PA, and I work at MD Anderson Cancer Center in Houston, Texas. I'm also the Executive Director of Advanced Practice and my clinical practice is in urology. Dr. Williams, how about you introduce yourself? Dr. Stephanie Williams: Thanks, Todd, and thanks for this opportunity to present this incredibly important topic. I am currently retired from clinical practice. I had been in practice for over 35 years both in an academic setting, a private practice, and more recently in a large institutional, multi-specialty institutional type of practice. My primary clinical care has been in stem cell transplants and cellular therapy. And we have used APPs, both PAs and NPs for a couple of decades in our particular area. Todd Pickard: Great, thanks for that. I'd also like to introduce you to our guest panelist today, Wendy Vogel from Harborside, who is a certified oncology nurse practitioner with over 20 years of clinical experience and expertise. We're excited to be chatting with Wendy today about the basics of advanced practice providers and who they are. This will be an introduction for the rest of the upcoming episodes of APP Podcasts. Wendy, why don't you tell us a little bit about yourself and your practice. Wendy Vogel: Thanks, Todd. It is a pleasure to be here. I appreciate you asking me to talk. I am an oncology nurse practitioner as you said. I do a high-risk cancer clinic and do that a couple of days a month. And I am also the executive director of APSHO, the Advanced Practitioner Society for Hematology and Oncology. Todd Pickard: Great! We're looking forward to a robust and informative discussion today between the three of us. So, I'd like to get started with some basics. Wendy, do you want to always start with a definition of advanced practice registered nurse? Wendy Vogel: Okay, great question! So, APRNs or advanced practice registered nurse include nurse practitioners. It can include clinical nurse specialists, nurse anesthetists, and nurse midwives. And generally, APRNs hold at least a master's degree in addition to some initial nursing education as a registered nurse. Some APRNs have doctorates like the DNP or Doctorate of Nursing Practice. But licensure for APRNs generally falls under the State Board of Nursing.   So, we're also required to have a board certification, usually as some sort of generalist as in family medicine, pediatrics, geriatrics, women or acute care. But in oncology, many APRNs also carry oncology certification. Todd Pickard: Excellent! Thanks for that. I'll go ahead and add to the conversation by defining physician assistant. So, physician assistants are individuals who are trained in the medical model and are licensed to practice medicine in team-based settings with physicians. Very much like advanced practice registered nurses, we come from a variety of backgrounds, and our education model is really focused on thinking about the patient the same way that our physician colleagues do. We're trained in really taking a very broad look at patient care, and our education as a generalist model. PAs are certified by the National Commission on Certification of Physician Assistants, which is one national certification that includes all of the content areas in which we will practice. Dr. Stephanie Williams: For those out there who don't know, what are the differences between a physician assistant and an APRN? Or are there differences in practical terms, in terms of how we practice our field? Wendy Vogel: That is a great question, Stephanie, thanks for asking that. We function very much the same. The main difference is just in our educational background, where nurse practitioners come from a nursing background and the nursing model of care, and I'll let Todd speak to where PAs come from, but basically, our functions are very much the same. Todd Pickard: I very much agree. If you are in a clinical setting, and for some reason, Wendy or myself failed to identify who we are, you wouldn't really detect a distinction between the care either of us provide, because we are there in that provider setting and we're really there to assess the conditions you have like appropriate history in physical examination, think through differential diagnosis or a workup, create a diagnosis and then a therapeutic plan and also to educate you as the patient or to make an appropriate referral. So, really, when APPs, PAs, and NPs work side by side, there's really not a lot of difference in what people detect in what we're doing and how we're doing things. But there are some educational differences, which are pretty minimal. So, for example, one small difference is that PAs include surgical assisting as part of our core fundamental training, and our APRN colleagues generally don't. So, in my institution, we do have nurse practitioners that go to the OR and do assisting, but in order to get there, they did a Registered Nursing First Assist Program, it's a certification. So, they learn those fundamentals of sterile technique and surgical technique. So, in essence, there's really not a whole lot of difference. Dr. Stephanie Williams: I think what I was struck with about the difference was the history and the fact that PAs came out of the Mobile Army Surgical Hospitals. To me, that was just fascinating. I think Duke was the first graduating class. Wendy Vogel: You know, the role of the APRN has really changed drastically. It began in the 1960s, because there were not enough primary care providers, particularly for children in the urban and rural areas of the US, and the first nurse practitioner program was in 1965, at the University of Colorado. So, gosh! Have we come a long way since then, both the PA role or the NP role. When was the first PA role, Todd, when was that? Todd Pickard: We were born at the same time in 1965, we just happened to be at Duke University and y'all were in Colorado. You know, I think that the most important thing about working with advanced practice providers is that you look to work with somebody who has the competencies, the skills, interpersonal communication, and the pertinent experiences because honestly, I know fantastic APRNs, I know fantastic PAs, and I know some of either profession that really just don't quite fit a particular role. And so, there is some kind of mythology around PAs and APRNs, and who should work where, like PAs should be more procedural and more in surgery, and nurse practitioners should be more in medicine in the hospital. And really, there's nothing in our training that defines that per se, I think it's just a natural progression of we're over 50 now, so our professions are middle-aged. And we're starting to really have our feet underneath us. And I think people who've worked with PAs or NPs really understand, it's about the individuals and what they bring to the table. It's not really about the initials behind our names, because honestly, that's not what makes me do good work. It's not that I have the PA or NP behind my name. It's my commitment and dedication to my patients and supporting the rest of my team. Wendy Vogel: I think Stephanie, that's why we use the term advanced practitioner, advanced practitioner provider because it doesn't single out either one of us because we are functioning in the same manner. It's easier to say than say, PAs and NPs, so we just say, APPs. Todd Pickard: Yeah. And it doesn't mean that we don't identify as individual professions, because we do. I mean, I'm a PA, but I am part of a larger group. And part of that larger group is identifying as advanced practice provider because, at my institution, there are over 1000 of us, and we are a community of providers, and that's the way that we sense how we function within the team and within the institution. And so, it's really about that kind of joint interprofessional work. And speaking of work, Wendy, tell us a little bit about what are typical things that advanced practice providers do? Wendy Vogel: It might be easier to say what we don't do. I've got a list. Do you want to hear my list? Todd Pickard: Yeah, lay it on us. Wendy Vogel: Okay, here you go. Staff and peer education, survivorship care, palliative care, hospice care, pain management, acute care clinics, case management, research, cancer patient navigator, genetic services, lung nodule clinics, quality improvement. We're writers, we're authors, we're speakers, we mentor, and we do all kinds of public education. We can have clinical roles with faculty and professional organizations. We do procedures like bone marrows, paracentesis and suturing, and all that kind of stuff. We do a lot with all the other things like diagnosing, all the things you said earlier, diagnosing, ordering lab tests, ordering chemotherapy, etc. Todd Pickard: I think what's amazing about advanced practice providers is the flexibility we have to fill in gaps on teams or in service lines, no matter what that is. You know, I like to say and I'm sure everybody thinks that they originated this, but I feel that advanced practice providers are the stem cells of the team because we differentiate into whatever is necessary. At my institution, we recently had a gap in how our peer-to-peers were handled. Many times, you order an MRI or a PET scan, and the payer will, the day of or the day before, say, ‘Oh, I need to talk to somebody.' How that gets to the clinical team and when the clinical team has time to do that, it's really hard to coordinate. So, we created a team of advanced practice providers who spend one day a week doing the regular clinical roles, but then the rest of the time, they are dedicated to facilitating these peer-to-peer conversations. They have over a 95% success rate. And the payers, the medical directors, have actually gotten to know them. And so, they'll say, ‘Hey, I want to talk to so and so because she's fantastic and knows our program, and it's really easy to have these conversations.' And so, patients are taken care of and these business needs are taken care of, and then our clinical teams can really focus on what they're there for, which is to see those patients in and out every day. So, that's the power of advanced practice, its flexibility, filling in gaps; we can bend and morph to whatever we need to do because one of the things that's in our DNA is part of PA and advanced practice RN, we're here to serve, we're problem solvers or doers, too. When we see something, we pick it up and take care of it. That's just in our nature. Stephanie, tell us a little bit about your experience working with an advanced practice provider, is what Wendy and I are saying ringing true, or what's your experience? Dr. Stephanie Williams: Oh, absolutely! As I look back on my career, I'm not certain that I could have accomplished much of what I did, without my team members and advanced practice providers, both PAs and NPs. We also use them in an inpatient setting. And I can't remember Wendy mentioned that to take care of our stem cell transplant patients, because of residency, our requirements were removed from our services, and they became the go-to's to taking care of the patients. It actually improved the continuity of care that the patients received because they would see the same person throughout their 4 to 6-week course in the hospital, they also helped run our graft versus host clinics. I hate that term physician extender because they're really part of our health care team. We are all healthcare professionals working together, as Todd beautifully mentioned, for a common goal to help that patient who's right there in front of us. And not only that, from a kind of selfish viewpoint, they help with a lot of the work, doing the notes, so that we could all split up the work and all get out on time and all have at least some work-life balance. And I think that's a very important part of any team is that we can each find our own work-life balance within the team. So, I feel that they're a very important part of the oncology healthcare team. And I would recommend that everyone who wants to take care of patients, incorporate them into their team. Wendy Vogel: Can I say something right here that you mentioned that I'm so glad you did, which was physician extender. That is a dirty, dirty word in the AP world now because we don't know what part we're extending, that is not what we do. And also, we don't want to be called mid-level providers because – you can't see but I'm pointing from my chest to my belly - I don't treat just the mid-level, nor do I treat in mid-level care. I give superior care. I just give different care. And I give care on a team. And the last one is a non-physician provider. That is also a no-no because I wouldn't describe a teacher as a non-fireman, nor would I describe you, Stephanie, as a non-nurse practitioner. So, I don't want to be a non-physician provider either. Todd Pickard: It is an interesting phenomenon that even after 50 years, so many different places, whether it's the Joint Commission, or the Centers for Medicaid and Medicare Services, whether it's a state legislator, an individual state, an individual institution like Memorial Sloan Kettering or an MD Anderson or a Moffitt, everybody comes up with these different terms. And it's so interesting to me. Physicians are either physicians, doctor, sometimes they're called providers. But as a PA, who's an advanced practice provider, those are the two things that resonate with me: either call me PA or call me advanced practice provider. All these other names seem to just be, it's an alphabet soup, and it really doesn't carry any meaning because some places just come up with these strange terms. And I agree, physician extenders has been the one that always has amused me the most because it reminds me of hamburger helper. Am I some noodles that you add to the main meal so that you can extend that meal out and serve more people? I think what Wendy and I are really trying to get at, I know this has been with a little bit tongue in cheek, but we are part of the team. We work with physicians in a collaborative team-based setting, just like we all work with social workers and schedulers and business people and pharmacists and physical therapists. I think the main message here is that oncology care and taking care of patients with cancer is a team effort because it is a ginormous lift. It's a ginormous responsibility and our patients deserve a full team that works collaboratively and works well and has them in our focus like a laser, and I know that's what APPs do. Dr. Stephanie Williams: I think that's well said, Todd. What I enjoyed in the clinic in particular, was sitting down and discussing patient issues and problems with my APPs. And we worked together to try to figure out how to resolve issues that would come up. But we also learned from each other, you're never too old to learn something from people. I just felt the interaction, the interpersonal interaction was also very satisfying as well. Wendy Vogel: I think that the job satisfaction that comes from being a team player and working together is so much higher and that we're going to experience so much less burnout when we're working together each to the fullest scope of our practice. Todd Pickard: So, Wendy, one of the things that people ask a lot about when they work with advanced practice providers is, ‘Well, gosh! How do I know that they have this training or this experience or this competency?' And then the question arises about certification. So, let's talk a little bit about certification and what that means and what it doesn't mean. So, tell me, are advanced practice providers certified? And are they required to get a variety of certifications throughout their career? Let's talk a little bit about that. Why don't you open up the dialog. Wendy Vogel: Okay, happy to! So, to be able to practice in the United States, I have to have a board certification. And it can vary from state to state, but generally, it has to be either a family nurse practitioner certification, acute care nurse practitioner, geriatrics, women's health, pediatrics, there are about five. So, you are generally certified as one of those. There are a few oncology certifications across the US, board certifications to be able to practice at the state level, but not all states recognize those. So, most of us are educated in a more generalist area, have that certification as a generalist, and then can go on to get an additional certification. So, many nurse practitioners in oncology will also get an advanced oncology nurse practitioner certification. So, that's a little bit different. It's not required to practice. But it does give people a sense that, ‘Hey, she really knows what she's doing in oncology.' Todd Pickard: The PA profession has one national certification, and it is a generalist certification. It's probably similar to USMLE, where you really are thinking about medicine in its entirety. So, whether that be cardiology, orthopedics, family medicine, internal medicine, geriatric, psychiatry, or ophthalmology. I mean it's everything – and oncology is included as well. And that certification really is the entree into getting licensure within the states. It's basically that last examination that you take before you can get that license just to make sure that you have the basic knowledge and fundamentals to practice. And so, I always respond to this kind of question about certification, I say, ‘Well, is it really the experience and the onboarding and the training that one gets on the job and the mentoring and the coaching that one gets from our physician colleagues and other advanced practice providers that brings them the most value? Or is it going through an examination, where basically you're responding to a certain amount of information, and you either pass it or you don't, and you can get a certification? I'm not saying there's not value in that, but I'm also making the argument that if you are working with your APPs well, and they have good mentors, and they have good resources, they're going to be excellent clinicians. And having an additional certification may or may not make some huge difference. Many times I see people use it as a differentiator for privileges or something. It's really an external kind of a pressure or a desire, it doesn't really have anything to do with patient care. I mean, Wendy what has your experience been around that need for additional certification? Wendy Vogel: I've seen it used in practices to merit bonuses, which isn't really fair when a PA does not have that opportunity to have a specialty certification per se. So, I've seen it used negatively. I'm a great believer that any additional education that you can get is beneficial. However, I will say just like you said, if you are getting your mentoring, you have good practice, you're doing continuing education, then it's essentially the same thing. To be able to have an oncology certification, I had to practice for a year and I had to take a test that really measured what I should know after one year. And that's what a certification was for that. Is it beneficial, do I want it? Yeah, I want it. Do I have to have it to practice? No. Todd Pickard: I think that is a great way to segue to having a brief conversation about how you bring APPs in? I mean, just at a very high level, should people expect for an APP to come in right out of school and just hit the ground running without any additional investment? And I could ask the same question about a resident or a fellow who completes an oncology training program. Do you just put those people to work? Maybe that's an older model, and now really mentorship and that additional facilitated work is, I think, critical. So, I'll start with Stephanie, tell us a little bit about what's your experience been with advanced practice providers, or even young physicians as they enter the workforce? What's the role of onboarding or mentoring program? Dr. Stephanie Williams: So, it's important. We had a set process for bringing on our new APPs and it pretty much followed the guidelines from the American Society of Cellular Transplantation in terms of the knowledge base that they would need to know. So, it was a checklist. And we would also have them do modules from ASCO's oncology modules, as well looking at primarily hematologic malignancies, so they could get a background there. And then we would slowly bring them on board. Usually, they would start taking care of autologous patients, a certain subset of patients, and then move on to the more complicated patients. We did the same clinic, whether they were clinic or inpatient APPs. So, it took us about three to four months to onboard our APPs. In terms of a fellow becoming an attending physician, I'd like to say that there's specific onboarding there. Unfortunately, sometimes they're just, ‘Okay, these are your clinic days, this is when you start.' I mean, you're right Todd, we really need to work more on onboarding people. So, that one, they like their jobs, they're not frustrated, and they want to stay and continue to work in this field. I see many times after two or three years, if they're not onboarded properly, they just get frustrated and want to move on to a different area. Wendy Vogel: We know that most of the advanced practitioners who come into oncology don't have an oncology background, PA or NP.  They just don't, and we don't get a lot of that in school. So, it takes months, it would probably, I dare say, take 12 months of full-time practice to feel comfortable in the role. But how many practices particularly in the area that I've practiced in you get this AP, and you throw them in there, and in four weeks, you're supposed to be seeing patients. How can you make those decisions when you haven't been properly mentored? So, absolutely important to have a long onboarding time till that APP feels comfortable. Todd Pickard: Yeah, I think that it is critically important that we set up all of our team members for success, whether they be physicians, or PAs, or nurse practitioners or nurses, or pharmacists, and I think that is the role of onboarding and mentoring, having people who will invest time and energy in what you're trying to accomplish. You know, Wendy is spot on. Advanced practice providers have specific types of training within their educational program. As a PA, my focus in oncology was to screen for and detect it. So, to understand when a patient presents with a mass or some symptoms that may make you think that, oh gosh, maybe they've got acute leukemia or something else and looking at those white counts and, and understanding. But that transition from identifying and screening and diagnosing cancers is very different than how do you care for specific types of tumors and specific disciplines, whether it be radiation oncology, surgical oncology, medical oncology, cancer prevention. There's a lot that folks need to be brought up to speed about the standards of what do we do in this practice and how do we care for these types of cancers? And that really is the role for the onboarding and mentoring. You know, you may be lucky, you might get an advanced practice provider who used to work at a big academic cancer center in the same field, whether it be breast medical oncology or GI, and yeah, that's a much easier task. That person probably really needs mentoring about the local culture, how we get things done, what are the resources, and which hospitals do we refer to. But for the most part, working with an advanced practice provider means that you've got a PA or an NP, who has a strong foundation in medical practice. They know how to care for patients, they know how to diagnose, they know how to do assessments, they know how to critically think, they know how to find resources, and they know how to educate. But they may not know how long does a robotic radical prostatectomy patient going to be in the hospital? And how long does it take to recover and what are some of the things you need to be considering in  their discharge and their postoperative period? That is very detailed information about the practice and the local resources. Every advanced practice provider is going to need to have that kind of details shared with them through mentorship, and a lot of it is just how do we team with each other? What are the roles and responsibilities? Who does what? How do we have backup behaviors to cover folks? So, a lot of this really is just deciding, ‘Okay, we've got a team. Who's doing what? How do they work together and how do we back each other up?' Because at the end of the day, it's all about the team supporting each other and that's what I love about advanced practice. Wendy Vogel: Very well said, yes. I had an AP student yesterday in clinic, who told me - I was asking about her education in oncology and what she got - and she said, ‘Well, so for lymphoma, we treat with R-CHOP. So, a student, of course, raised their hand and said, ‘What's R-CHOP? She's like, ‘Well, the letters don't really line up with what the names of the drugs are, so, just remember R-CHOP for the boards.' So there you go. That's kind of what a lot of our education was like specific to oncology. And again, I'm a little tongue in cheek there also. But Todd, are you going to tell everybody about the ASCO Onboarding tool that's now available? Todd Pickard: Absolutely! ASCO has done a really great job of trying to explore what advanced practice is, and how teams work together. All of us are part of the ASCO Advanced Practice Task Force. One of the things we did was really to look at what are some best practices around onboarding, orientation, scope of practice, and team-based cancer care, and we created a resource that is available on the ASCO website, and I think that it is a great place to start, particularly for practices, physicians, or other hospital systems that don't have a lot of experience with advanced practice. It's a  great reference, it talks about the difference between orientation and onboarding. It gives you examples of what those look like. It talks about what are the competencies and competency-based examinations. So, how you assess people as they're going through the onboarding period. It has tons of references, because ASCO has done a lot of great research in this field, around collaborative practice and how patients experience it, and how folks work on teams, and what do those outcomes look like. So, I highly recommend it. Wendy, thank you for bringing that up. It's almost like you knew to suggest that. Well, this has been a really, really good conversation. I'm wondering, what are some of those pearls of wisdom that we could all provide to the folks listening? So, Stephanie, what are some of your observations that, you know, maybe we haven't just thought about, in your experience working as a physician with advanced practice providers? Dr. Stephanie Williams: One, it's important to integrate them into the team, and, as Wendy mentioned, to mentor them – mentor anybody correctly, in order for them to feel that they're contributing the most that they can to the care of the patient. I think there are other issues that we'll get into later and in different podcasts that come up that make physicians hesitant to have nurse practitioners or physician assistants. Some of those are financial, and I think we'll discuss those at a later time. But really, that shouldn't keep you from employing these particular individuals for your team. It really is a very rewarding type of practice to have. You're not alone. You're collaborating with other providers. I think it's just one of the great things that we do in oncology. Todd Pickard: I wanted to share a moment as a PA, advanced practice provider, when I most felt grateful for the opportunity to work as an advanced practice provider. My clinical practice has been in urology for the past 24 years for the main part. I've had a few little other experiences, but mainly urology, and I'll never forget a patient who was a middle-aged lady who had been working with transitional cell bladder cancer. It was superficial. So, the treatment for that is BCG and repeat cystoscopies and surveillance. And I walked into the room and I was going to give her BCG installation, and she was so angry. I wanted to know what was going on. I thought, gosh, should I make her wait too long or something else? So, I asked her, I said, ‘How are you doing today? You seem to be not feeling well.' And she said, ‘Well, I'm just so tired of this. I don't understand why y'all don't just fix me. Why don't y'all just get this right? Why do I have to keep coming back?' And as I looked at the medical record, this patient had had superficial bladder cancer for years. And I thought, ‘Has nobody ever really kind of sat down and mapped this out for her?' So, I asked her to get off the examining table, and I pulled the little paper forward, so I had someplace to draw. And I drew a big square and I said, ‘This is a field, just think of any big field anywhere near you. And it's full of weeds.' And I drew some weeds on there. And I said, ‘You know we can pull them out and we can pluck them, and we can put some weed killer in that field,' I said,  ‘do you think that if you come back in three months and there will be any weeds on that field?' She said, ‘Of course, there will be. There are always weeds because they always come back. It's very hard to get rid of.' And I said, ‘Well, this field is your bladder. And the type of cancer you have are like these weeds, and we have to constantly look for them, remove them, and then put this treatment down, that's why you come.' And she started crying. And I thought, ‘Well, I've blown it.' Because this was in the first couple of years of working as a PA in urology. And I said, ‘I'm so sorry. I really apologize.' She said, ‘Don't you dare apologize to me.' I said, ‘Man, I've really blown it now.' She said, ‘Todd, I've had this disease now for this many years. This is the first time I've ever fully understood what's happening to me. I am so grateful to you.' I will never forget this patient. I will never forget this experience. And I'm extraordinarily proud. It's not because I'm the smartest person in the world. I just happened to investigate, take the time, and I drew it out. I explained it in the simplest of terms because I wanted her to understand. And then whenever she came back, she always wanted to see me. So, it was great. I really developed a really lovely relationship with this patient. It was very rewarding. Wendy, can you think of a story that you have about an advanced practice provider that makes you particularly happy or where some big lesson was learned? Wendy Vogel: Yeah. I love your analogy. That's a great analogy. I think that part of what I love to do is similar to you, Todd, in that I like to make things understandable because I consider myself an East Tennessee southern simple person, I want to understand things in the language that I understand. So, I like using a language that a patient understands. I think if I was to say about some of the proudest things, or what makes me so excited about oncology is what we've seen in our lifetime. So, Todd, you and I practice probably about the same number of years and we could say we remember when Zofran came out, and how that revolutionized chemotherapy nausea and vomiting – Stephanie's nodding here, too. We all know that. And then wow! When we found out that we could maybe cure CML, that we're having patients live normal lives in our lifetime, that we've seen non-small cell lung cancer patients living past a year that are metastatic – Oh my gosh! This is such an exciting field and we learn something every day. There's new drugs, there's new treatments, there's new hope, every single day, and that's what makes me proud to be a part of that. Todd Pickard: Yeah, I think that oncology and the work that we get to do as a team is so incredibly rewarding. It's challenging, and we have losses, but we also have wins, and those wins are amazing, and transformative, not only for us but for our patients. So, some final pearls of wisdom. I'll share and then Wendy, I'll turn it over to you. One thing that I really want to convey to folks is to know about the state that you work in and what are the practice acts for advanced practice providers. Because, unlike our physician colleagues who have a very standard scope of practice across the country, advanced practice can drastically change from state to state and place to place even from institution to institution. So, be aware of that, so that you can build your team-based practice around what are the constraints, what is the scope of practice, and you can comply with that. It just takes a little bit of pre-work at the beginning. It's not daunting. These things are written in English. We're all smart folks. We can understand them and we can build our teams in the right way. So, just keep that in the back of their mind. It is not an obstacle. It's the instruction manual of how to build your team. That's all it is if you just think about it simplistically like that. So, Wendy, what's one or two things that you would say you really want our listeners to understand about advanced practice? Wendy Vogel: I loved what you said, Todd, both of our PA Associations and our Nurse Practitioner Associations have that information online, so it's very easy to find. But I think I would say, don't be afraid to stand up for yourself as an advanced practitioner or as a physician who wants an advanced practitioner. Don't be afraid to stand up for yourself and your scope of practice, know what you can do, know what you can't do, know and demand the respect that you deserve. I would always say that just don't forget that ‘no' is the first step to a ‘yes,' and keep on trying. Todd Pickard: I think we can all appreciate that sentiment, whether we be a PA an NP or a physician. Many times, we're advocating for our patients within our systems or our practices or with our payers or insurance providers. And yeah, sometimes you start from a place of ‘no' and then you work until you get to that ‘yes', or at least a compromise, if you can get to a 'maybe,' that's a good place too. Stephanie, any particular last words of wisdom or wrap us up with our conclusion? Dr. Stephanie Williams: Thanks, Todd and Wendy, for sharing your insights today. It's always a pleasure chatting with you both. Stay tuned for upcoming episodes where we plan to dig deeper into the various types of APPs, how they are trained, what a day in the life looks like for an oncology APP, their scope of practice, and the importance of team-based care, especially in oncology. Thank you to the listeners as well. Until next time. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive education center at education.asco.org.   The purpose of this podcast is to educate and inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product , service, organization, activity or therapy should not be construed as an ASCO endorsement.  

Watch the oral arguments at the Arizona Court of Appeals: https://thekushkronicles.com/news/watch-dcs-vs-the-amma/  2:10 Hyperemesis gravidarum is persistent, extreme nausea and vomiting while pregnant.   4:25 Read more about Zofran side effects and warnings for pregnant women: https://www.healthline.com/health/pregnancy/zofran-pregnancy  18:56 Read more about Julie Gunnigle and be sure to vote in your local elections: https://coppercourier.com/story/julie-gunnigle-running-maricopa-county-attorney-special-election/  22:55 We're happy to say that Lindsay has since found a job for $20/hour.  33:57 Donate to Lindsay's GoFundMe here: https://www.gofundme.com/f/help-battle-the-department-of-child-safety

CONTENT WARNING: Discussion of Suicidal Thoughts In this episode of Becoming Moms, Dr. Sterling discusses nausea in pregnancy - one of the most debilitating symptoms. As both an ObGyn and mom who has been there, who better to break down the treatment options with realistic expectations? From ginger chews and sea bands to prescription medications, tune in to learn about the potential side effects of each option and how to navigate finding the treatment that is right for you. If you've experienced nausea in the past or are currently navigating it, you are not alone. Sterling Parents - listen over on the private podcast to hear a deep dive into the prescription medication, Zofran. Resources: Sterling Parents Membership - https://sterlingparents.com/ (Sterling Parents) The Best FREE Pregnancy Class - https://thebestpregnancyclass.com/ (4 Ways EW Registration Page (thebestpregnancyclass.com)) Selfcare Rituals for Pregnancy Guide - https://www.thesterlinglife.com/pregnancyselfcare (https://www.thesterlinglife.com/pregnancyselfcare ) Host: Dr. Christine Sterling, Board Certified ObGyn & Founder of Sterling Parents Membership Music: Good For You by THBDhttps://soundcloud.com/thbdsultan ( https://soundcloud.com/thbdsultan) Creative Commons — Attribution 3.0 Unported— CC BY 3.0 Free Download / Stream:http://bit.ly/2PgU6Mu ( http://bit.ly/2PgU6Mu) Music promoted by Audio Libraryhttps://youtu.be/-K_YSjqKgvQ ( https://youtu.be/-K_YSjqKgvQ)

Episode 2093 - On this Sunday School episode, Vinnie Tortorich and Gina Grad talk food poisoning, Guns N' Roses, travel tips for motion sickness and combating nausea, and more. Https://www.vinnietortorich.com/2022/05/combating-nausea-motion-sickness-episode-2093 PLEASE SUPPORT OUR SPONSORS COMBATING NAUSEA Gina had terrible food poisoning last week. She always cooks her meat so that she can't even worry whether it's fully cooked. Vinnie's had food poisoning and salmonella before. He was on the ground with salmonella, so dehydrated. Vinnie likes to travel, but he gets unbelievably nauseous from motion sickness in cars and on planes and boats, and even after spinning around a couple of times. He doesn't love Dramamine, but he doesn't want to stop traveling.  The little bracelets didn't work -- neither the electric nor the accupressure.  Now Vinnie uses scopace -- he was prescribed this by a doctor. He loves it, in part, because he can drive after landing. They don't make it anymore, but you can still get it once it's prescribed at compound pharmacies. This is very different than Zofran which is what you use when you're already throwing up. PURCHASE BEYOND IMPOSSIBLE The documentary launched this week on January 11! Order it TODAY! This is Vinnie's third documentary in just over three years. Get it now on Apple TV (iTunes) and/or Amazon Video! Link to the film on Apple TV (iTunes):  Share this link with friends, too! Link to the film on Amazon Video: It's also now available on Amazon (USA only for now)!  Visit my new Documentaries HQ to find my films everywhere: REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY 2 (2021) Visit my new Documentaries HQ to find my films everywhere: Please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY (2019) Visit my new Documentaries HQ to find my films everywhere: Please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter!

Olga and her husband were having the vacation of a lifetime. They hooked up a teardrop trailer to their Subaru in NJ and headed out west. The planned to explore the gorgeous landscapes of the Washington State parks before jumping on ferry to Alaska. On July 19, 2021, at a campground in Deception Pass State Park on the Washington State Peninsula, things started to unravel. Olga had a brain stem stroke. She felt tingling up and down one side of her body and could not stop vomiting. She felt it was a stroke. Her husband called 911 and they made it out of the woods to a fire house. The EMT said she wasn't having a stroke. The ambulance that arrived said she wasn't having a stroke. The ER staff said she wasn't having a stroke. The neurologist said she probable wasn't having a stroke and specifically discouraged the tPA that could have solved the problem And no one sent her to the more advanced hospitals in Seattle for stroke treatment. The window for tPA came and went. This whole time, Olga was having a stroke. Olga shares her story in this conversation. If you don't see the audio player below, visit http://Strokecast.com/Olga   Click here for a machine-generated transcript. Who is Olga Wright? Olga is a married mother, grandmother, and recently retired educator. She lives in central New Jersey, where she practices extreme gardening. She and her husband recently returned from a six-month, 24,000-mile road trip to Alaska and back, with their ultra-light, solar-powered camper. Her goal is to educate the public and medical professionals at all levels to recognize nausea, vomiting, and tingling as stroke symptoms so that no one else is misdiagnosed as she was. Olga can be reached at olgawrightstrokestory@gmail.com Deception Pass Deception Pass State Park is a gorgeous corner of the state. It's filled with hiking trails (including accessible trails), lakes, salt water shoreline, and campgrounds. It's also just an amazingly beautiful part of the state. It seems remote but it's also within just a couple hours of Seattle to the Southeast and 90 minutes from Canada to the north. It's easy to see why Olga and her husband chose to camp there. Zofran and the Brain Zofran is a medication I was not familiar with, and it's what finally got Olga's vomiting under control. It's typically used to help treat nausea associated with chemotherapy. In Olga's case, it was used to treat a malfunctioning brain that was sending the signal of, "OKAY! Everyone out the way you came in!" even though there was nothing left. The brain tries to protect us in lots of ways. Sometimes those threats are real and sometimes they are not. In Olga's case, her dying brain stem knew something was wrong but didn't know what. It went to an early reflex for poison and just kept trying the expulsion solution because it didn't know what else to do. Meanwhile, Olga's higher level brain functions were still working and trying to seek medical treatment for the stroke. And this conflict is an illustration that the brain is not one, cohesive unit. It's different parts grabbing different pieces of data and attempting to execute a solution based on the tools at its disposal. The brain does not always work as a single unit. But back to Zofran. One of the interesting things I learned while reading about it is that Serotonin, one of the brain's "happy" chemicals is also responsible for the vomiting function/command. Zofran works by suppressing Serotonin. And that makes me wonder how its use as an antiemetic impacts things like depression. I suppose that will be a future research project. Swedish ARU The reason Olga and I connected is that she spent her inpatient rehab time at Swedish Medical Center. It's the same place I lived for the month following my stroke. You can learn more about the Acute Rehab Unit here. Olga was lucky enough to work with OT Emilee who told her about the Strokecast. Emilee was also one of my OTs 4 years before Olga made it there. I interviewed Emilee in episode 20. You can hear that conversation here: http://Strokecast.com/Emilee I've stayed engaged with members of my rehab team over the years. I've also met other folks on the stroke team at Swedish. Here are some other interviews I've done with the team at Swedish: http://strokecast.com/Swedish Licensing for PT and OT The pandemic has brought a dramatic increase in the availability of telemedicine. This is great because a lot of follow up appointments really don't need to be in person. I'd much rather do a 15 minute video appointment versus a 15 minute in person appointment I have to travel to and back from. In Olga's case, it almost worked out for Outpatient PT. She would be able to continue her travels after leaving the hospital and get therapy on the road via the internet! It's a great idea, but it didn't work. Not because of technology or willingness, but because of state level bureaucracy. A Washington licensed physical therapist cannot legally treat a patient who happens to be in Alaska or whatever other state Olga happened to be travelling through. Hack of the week Walking is one of the best ways to drive recovery. At certain points, walking 100 feet may be the most you can do. At other points, a mile or two may be achievable. Regardless of the distance, walking as much as you can helps to drive recovery. The most important thing, though, is to do it safely. Olga uses traction cleats for all her hiking activities. Traction cleats are basically snow chains for your feet. Even if there's no snow, they help traverse the wilds with less slipping and falling. You can find an assortment on Amazon here: https://strokecast.com/Hack/TractionCleats *. A walker or cane can be great in a city environment, but they are less usable on the trail. What is usable whether hiking in Alaska or going down to the corner bodega is a pair of trekking poles. These are much taller than a cane. As you use them they give many folks plenty of stability and an upper body work out. You can find them on Amazon at http://strokecast./com/Hack/TrekkingPoles *. Links Where do we go from here? Connect with Olga via email at OlgaWrightstrokestory@Gmail.com Share this episode with the road trip lover or medical professional in your life by giving them the link http://Strokecast.com/Olga Subscribe to the free Strokecast newsletter for more updates at http://Strokecast.com/News Don't get best…get better.

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Jetlag, Nausea, and Diarrhea are Largely Optional, published by Thomas Kwa on March 21, 2022 on LessWrong. Many people I know are aware of drugs for basic ailments, but don't bother using them because they're too much trouble to carry around. But using a pill organizer basically eliminates this overhead. For me, having a pill organizer has dramatically reduced the negative effects of insomnia, jetlag, nausea, diarrhea, headaches, etc., and significantly increased my operational capacity. In total, it has probably increased my productivity by over 3% over the last few months, and also increased my quality of life substantially. (But note that I think most people won't get such a large benefit). Just using the alertness adjustment drugs to curb jetlag saves me about 3 hours of productive time each way on critical trips. Here are the exact steps I followed, which take less than an hour and cost about $30: Get a 10-slot pill organizer (4 for $10 on Amazon). Not the same as a weekly pill organizer. Get a few basic pills from your local drugstore, supermarket, Amazon, whatever. I suggest the following: ibuprofen 200mg (Motrin, Advil) for pain, fever, etc. [1] caffeine 100mg, optionally with l-theanine loperamide/simethicone 2mg (anti-diarrhea) dimenhydrinate (Dramamine, anti-nausea) [2] melatonin 0.3mg (mild sleep aid) doxylamine 25mg (Unisom, sleep aid to be used sparingly) [3] This gives you 4 slots left for whatever other drugs you benefit from or are prescribed, maybe things like aspirin 81mg (in case of heart attack, also another option for pain) modafinil 200mg or armodafinil 150mg (suppresses sleep drive). Note that this dosage is way too much if you don't have narcolepsy. stimulants e.g. amphetamines, nicotine anti-anxiety meds [4] allergy meds (if these are antihistamines they could double as other things) electrolyte pills: sodium, potassium, magnesium Put the pills in the medication organizer, and label each compartment with the medication and dosage, using a permanent marker. You can erase the labels with alcohol wipes if needed. Carry it around in your backpack or purse. If those particular drugs don't work for you, try others that do the same thing. Our civilization has invented these multiple times and there's a good chance at least one works for your particular body. In December, I lost my pill organizer. In the few days it took me to order a new one, the following things happened: I had to stay up late to finish work, which threw my sleep schedule off. Without melatonin my sleep was out of phase for a few days, losing me about 10 hours of work. I had mild food poisoning and had diarrhea for much longer than necessary, which was very unpleasant and lost me ~3 hours of work. Someone asked if I had ibuprofen. They probably had a headache or period cramps or something for hours, or had to walk to a store. Either way, they suffered for at least an hour. All six of the basic substances listed are over the counter, have fairly low abuse potential, and have few harmful interactions (other than, say, caffeine increases wakefulness and doxylamine decreases wakefulness). However, I highly recommend doing basic research into the substances you're using (e.g. reading the wikipedia page), especially if you're customizing. Notes [1]: One could also add acetaminophen (Tylenol); ibuprofen has an anti-inflammatory effect which acetaminophen does not have but taking it too often can cause GI bleeding or kidney damage. [2]: A doctor I know suggests replacing this with ondansetron (Zofran, anti-nausea/vomiting) which requires a prescription but has almost no side effects, and is probably safe during pregnancy too. [3]: Hypnotics (sleep drugs like Unisom) are not recommended as an intervention to improve sleep in the long term compared to other interventions like melatonin, CBT...

Link to original articleWelcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Jetlag, Nausea, and Diarrhea are Largely Optional, published by Thomas Kwa on March 21, 2022 on LessWrong. Many people I know are aware of drugs for basic ailments, but don't bother using them because they're too much trouble to carry around. But using a pill organizer basically eliminates this overhead. For me, having a pill organizer has dramatically reduced the negative effects of insomnia, jetlag, nausea, diarrhea, headaches, etc., and significantly increased my operational capacity. In total, it has probably increased my productivity by over 3% over the last few months, and also increased my quality of life substantially. (But note that I think most people won't get such a large benefit). Just using the alertness adjustment drugs to curb jetlag saves me about 3 hours of productive time each way on critical trips. Here are the exact steps I followed, which take less than an hour and cost about $30: Get a 10-slot pill organizer (4 for $10 on Amazon). Not the same as a weekly pill organizer. Get a few basic pills from your local drugstore, supermarket, Amazon, whatever. I suggest the following: ibuprofen 200mg (Motrin, Advil) for pain, fever, etc. [1] caffeine 100mg, optionally with l-theanine loperamide/simethicone 2mg (anti-diarrhea) dimenhydrinate (Dramamine, anti-nausea) [2] melatonin 0.3mg (mild sleep aid) doxylamine 25mg (Unisom, sleep aid to be used sparingly) [3] This gives you 4 slots left for whatever other drugs you benefit from or are prescribed, maybe things like aspirin 81mg (in case of heart attack, also another option for pain) modafinil 200mg or armodafinil 150mg (suppresses sleep drive). Note that this dosage is way too much if you don't have narcolepsy. stimulants e.g. amphetamines, nicotine anti-anxiety meds [4] allergy meds (if these are antihistamines they could double as other things) electrolyte pills: sodium, potassium, magnesium Put the pills in the medication organizer, and label each compartment with the medication and dosage, using a permanent marker. You can erase the labels with alcohol wipes if needed. Carry it around in your backpack or purse. If those particular drugs don't work for you, try others that do the same thing. Our civilization has invented these multiple times and there's a good chance at least one works for your particular body. In December, I lost my pill organizer. In the few days it took me to order a new one, the following things happened: I had to stay up late to finish work, which threw my sleep schedule off. Without melatonin my sleep was out of phase for a few days, losing me about 10 hours of work. I had mild food poisoning and had diarrhea for much longer than necessary, which was very unpleasant and lost me ~3 hours of work. Someone asked if I had ibuprofen. They probably had a headache or period cramps or something for hours, or had to walk to a store. Either way, they suffered for at least an hour. All six of the basic substances listed are over the counter, have fairly low abuse potential, and have few harmful interactions (other than, say, caffeine increases wakefulness and doxylamine decreases wakefulness). However, I highly recommend doing basic research into the substances you're using (e.g. reading the wikipedia page), especially if you're customizing. Notes [1]: One could also add acetaminophen (Tylenol); ibuprofen has an anti-inflammatory effect which acetaminophen does not have but taking it too often can cause GI bleeding or kidney damage. [2]: A doctor I know suggests replacing this with ondansetron (Zofran, anti-nausea/vomiting) which requires a prescription but has almost no side effects, and is probably safe during pregnancy too. [3]: Hypnotics (sleep drugs like Unisom) are not recommended as an intervention to improve sleep in the long term compared to other interventions like melatonin, CBT...

0:33 Learn more about the Happy Mom School: https://www.modernmilk.com/happy-mom-school-1    08:01 The FDA has issued a safety warning in 2014 on “serious risks” for pregnant women taking Zofran. Read more: https://www.lieffcabraser.com/injury/drugs/zofran/#:~:text=The%20National%20Law%20Journal%20reported,cleft%20lip%20and%20cleft%20palate.    27:18 The stigma of cannabis sprouted from the war on drugs, and harsh laws that were put in place to punish users. Learn more from Forbes: https://www.forbes.com/sites/emilyearlenbaugh/2021/12/30/study-finds-cannabis-stigma-is-higher-in-countries-with-more-punitive-cannabis-laws/?sh=7e06ff587830    31:16 Rikki mentions her clone, which is a cutting off of a cannabis plant that will then grow into a plant itself when correctly cared for.

Sometimes I feel like Oscar the Grouch, and today is no different. Today I'm going on a (lighthearted) rant about some shit that's annoying me. Lighthearted is the emphasis here my dudes. DISCLAIMER Colorful words may be used. don't be alarmed. NEWSLETTER https://view.flodesk.com/pages/61525a85337f1c2aacf52f6d Etsy Shop is open! https://www.etsy.com/shop/CGBPrints FIND ME ON ALL THE THINGS Patreon - https://www.patreon.com/cindyguentertbaldo YouTube - https://youtube.com/c/CindyGuentertBaldo Instagram - https://www.instagram.com/llamaletters/ Discord - https://discord.gg/Rwpp7Ww Pinterest - https://www.pinterest.com/llamaletters/ Website - www.cindyguentertbaldo.com STUFF I MENTIONED Work Planner Setup - https://youtu.be/4dM7YsxI2jo Maintenance Phase Celery Juice - https://maintenancephase.wixsite.com/home/episodes/episode/4cfde6d6/celery-juice Livestream (puke story) - https://youtu.be/mdCd5fS3iZU Inquiries - cindy@cindyguentertbaldo.com   TRANSCRIPTION Hello friends. Welcome back to the uncurated life podcast today. I'm glad you're here because I need someone to listen to some shit. That's annoying me. My name is Cindy Guentert-Baldo welcome. If this is your first time here. And do you like what you hear then? I hope you subscribe. We've got new episodes every Monday.   And if this is not your first time here, I hope that you like what you hear and you stick around because that makes me happy quick. And before I get into the episode, I do want to let you know, in case you didn't know already that this week on the 11th, November 11th, 2021 in my Etsy shop, I will be offering a limited run of 2022 calendars, their wall calendars.   They have a mixture of. My fuckery flowers from both series, then old series series one in the new series series two. These will be limited because I can only get so many of them before I lose it. So make sure you head on over there to pick up a calendar or three, they make excellent gifts, blah, blah, blah.   But anyway, I want to make sure to remind you of that because the there'll be dropping on the. If you are on my newsletter, you will get the heads up when they go live. And if you are a patron, your access comes tomorrow, November 10th. So just make sure that if there's something that you're interested in, I don't know how quickly they're going to sell out.   I've never done this before. So you may want to keep your eye on. Anyway, let's get into this because marketing also annoys me. So I've just got a handful of things that annoy me. I told you when I did my like I'm back episode, that I wanted to both handle some spicy topics and some light-hearted topics and talk about things I love and blah, blah, blah.   Well, a combination of lighthearted and spicy is some shit that's annoying me. And I've got a whole list of things that run the. And I just thought I would let you know to see if a they annoy you and B if they don't, you can always yell at me on Instagram at llamaletters, let me know in the stories. So let's just get into it because I love talking about shit that annoys me, apparently that I wonder if there's a personality test that tells you that I don't know.   First of all, is celery juice. I am so tired of seeing on Instagram. I am tired of seeing influencers talk about it. I am tired of seeing it in YouTube videos. I'm tired of it. If you want to have a deep dive on how bunk the whole celery juice thing is now that it's bad for you. It's not, but it's not like it's magical either.   Then listen to the maintenance phase episode on celery juice. They do a great job. I'll leave at link in, the show notes. If you haven't listened to that podcast, a 10 out of 10 recommend. However, my big hatred of celery juice comes from two sort of areas. The first one being like, what the fuck is wrong with just eating celery?   Like I don't even like celery all that much. I like it in soup. I don't really like it on its own. It's too stringy for me, but. There's like a segment of people who think that you have to juice it for it to be good for you, but doesn't that just remove all the fiber? I don't get it. Secondly, a lot of the celery juice, like the people who are enchanted with it kind of use the same language around wellness culture that I find to be really toxic.   And that's going to show up later on this list, but also in some later podcasts, but a lot of it has to do with like the idea of like, Hearing your chronic illnesses and detoxifying yourself. And I'm just going to say that whenever anybody suggests some new trendy thing to cure chronic illness, especially genetic chronic illness, which is what I have, it feels remarkably abelist and it feels really like, uh, I was going to say naive, but I don't think that's the right word.   Just sorta sort of. I don't know, bogus, like fucking no, dude, I have genetic kidney disease, celery juice won't help me. And secondly, anytime somebody tells me they're doing a cleanse or drinking the juice to flux out, flush out the toxins as somebody with failing kidneys. I want to slap them because you know what flushes your toxins, your liver and your kidneys.   So if they're functioning, they're doing it for. You don't need magic juice to do that. And if you're like me and have failing kidneys, Magic juice is not going to flush my toxins. You know what? Well, dialysis, sorry. I did say this was shit that annoys me. So sorry. Celery juice, but I am, I am moving on from you.   Number two, raisins in cookies. Now I know there are some of you who love a good fucking oatmeal raisin cookie, but for me, raisins and cookies are. The most disappointing thing that can ever happen. And the reason that this is like on my mind right now is recently I got surprised the other day thinking I was going to have a delicious oatmeal chocolate chip cookie.   And it was an oatmeal raisin cookie. And I'm sorry, that is not the business. I like raisins. I have nothing against raisins, but not in cookies and raisin bran. Fuck. Yeah, leave my cookies alone. Hashtag. Number three. And this one is actually very, very much relevant to me right now, because I have had to make so many doctor's appointments for both myself and my kid because of my chronic illnesses that have already talked about.   And because my kid has some health problems, we're trying to nail down, hold music. Now I would be fine if a company had like a serious XM station or something, or some kind of. Radio station. I don't know something where the music rotates, but when it's the same song over and over and over and over and over and over again.   And you're on hold for like eleventy million years. It's it makes my brains leak out my ears, like an ice pick to my temple and it's awful. And like, I understand that that's probably less expensive for a company than doing like a radio station, but dear God, dear. Oh. Oh, my God, I just can't. I can't it's it's grading.   Thankfully, at least one of the people that I had to call had the option for you to save your place in line and hang up and they'd call you back. And as much as I hate my phone and ignore it, I tried that and it actually worked. Most of the time I haven't trusted it, but I did try it and it worked. So I may go with that because that might save me from turning into Jack Torrance in Stanley Kubrick's the shining and having all work and no play makes Cindy adult boy, number four, I wrote this out and then the day I wrote this out, it was wrong.   So I'm still gonna tell you it, but. I was kind of shown up by it. And that is that they made the strawberry SAE refreshers at Starbucks seasonal. I have fallen for that with extra water and extra ice because it's too sweet for me. And then they disappeared because it was seasonal, but I don't think it's seasonal now.   I think it might just have been because of supply shortages because they came back. So I don't know. So that may not be accurate. So right now I'm annoyed by the fact that I was wrong.   Next is my seasonal allergies. I thought they would disappear when I removed, when I moved to Denver, because I never had them until I moved to Napa. And Napa is a micro climate and it is known among locals that when you move to Napa, you tend to get allergies, even if you never had them before. And like, everybody I know in Napa would have like the most miserable seasonal allergy situations.   I thought I would be rid of them when I moved, but apparently Napa just like imprinted them on me because I got to Denver and I still have them and it fucking sucks. And I just, I, it annoys me and this is a, should I annoys me? That annoys me podcast. I'm just saying. The fact that my Claritin only takes the edge off.   And the fact that anytime you sneeze or have a runny nose right now in the age of COVID, that everybody looks at you, like you're carrying the plague. And it's like, dude, I have fucking allergies. Like it just it's, it's one of those little things that like, I hated I've always hated, but with COVID it has just gotten more annoying and sure.   It's not as annoying as having COVID, but like, this is annoying shit. This is not catastrophic shit. Right. Speaking of COVID. The next thing that's annoying me is that I bought one of those home COVID tests because one of my kids had some symptoms after somebody at school had gotten exposed and I gave them the test and the test was negative and I was supposed to give them another test in 36 hours.   And I couldn't find it. This annoys me. I still can't find half of the shit in my house because we just moved and I put some stuff away. And now I don't know where anything is. And I know that that will be solved when I start organizing. And now that we live in a bigger house, there's just so many more places for shit to be.   I spent way longer than I needed to looking for the broom the other day, because we have too many closets and I know it's a first world problem, but like it's fucking annoying and referencing that I also can't find my AirPods and I really want them and could use them. I've been doing a lot of things recently where it would have been helpful to have my.   And I don't want to replace them because they're expensive. And on top of that, like I know that the moment I replaced them, they're going to come out with new ones. It's just, I have them there. They work perfectly fine and I just cannot figure out where the fuck they are. And I'm really annoyed by that on a completely unrelated note.   I am very annoyed by my new potassium. So as people who. I have chronic illness or people who take a lot of medications can probably understand. One of the things that can get really annoying is when you've been taking a medication for a long time, and then you change pharmacies or you change healthcare systems, or you change something and the brand manufacturer of your medication.   Especially if you're on generics and so like a different generic company, because there's all sorts of companies that make some of these medications, especially the ones that have lots of generics. I'm not talking about insulin because insulin doesn't have generics. And that's an entire thing that goes beyond annoyance into white, hot rage as this wife of a type one diabetic says, but for me, my potassium.   Has changed. I just, when I made, made the move, we swapped from the Kaiser system to a different healthcare system. And now I'm getting my prescriptions filled at Walgreens and the brand or the generic brand that is making my potassium is different. And for some reason, this new potassium, my gigantic fucking potassium pills that have take three times a day melt in my mouth.   Not in my hand, they start to dissolve the moment they hit my mouth. They kind of crumble when I dropped them into my pill minder, so that there's already little bits of potassium to dissolve into my mouth. And it is bitter and terrible. And I have chronically low potassium, which is really strange for someone in kidney failure.   Like I am, but because of that, I have to take, I have to eat Tassie and rich foods and take hella potassium. And the real thing that makes me sad is that the options that I have. To swap to, instead of this melt in your mouth, not in your hands, potassium are like infusions, which according to my sister, feel like molten lava in your veins or the liquid, which is even gnarlier.   So I'm stuck with it. And it's really goddamn annoying, especially since those pills are so big. I gag on them every time I swallow them and I have to do it three times a day. I am lucky that I haven't barfed on myself. Well, because of that, I have barfed on myself recently. That's an entirely different story.   Number nine is something that has been annoying me for a long time. And I am sort of subjecting myself to it and it still annoys me, but it's my fault because I'm subjecting myself to it. And that is discs for planners. It's helpful to have the disks for my work planner. I can take pages out and write on them.   It's cuter than. Using, um, a three ring binder and I wanted letter sized paper and having like a Filofax type situation for that size. It's harder to find. I love the cover. I love everything about my work planner, but the discs are really pissing me off because even though they're helpful for removing things and whatnot, random shit keeps popping off.   And every time it happens, I curse myself for putting myself in this situation because this is why I don't like this. But I'm gonna keep using them. And so I probably should shut up about it, but this is my podcast. I'm going to do what I want. Right. Number 10, back to the barfing. Nausea is getting worse and worse for me.   It happens when you get further into kidney disease. My sister warned me to keep a extra trashcan with a roll of bags in it, near the toilet for all of those times when it takes you over. And I wish I had known that. After I puked all over myself, I'll make sure to link the plan with me where I tell that story.   If you're really interested in it in the show notes, however, my nausea is getting worse and worse and the Zofran has stopped completely helping and instead just taking the edge off. And I know it's just going to get worse until I get a transplant. I hate being nauseous. You guys, I hate it so much.   Number 11 trader Joe's is discontinuing their curtains from what I was told when I was there the other day. And I just decided I liked them. So I'm bummed. I know this is like the most white girl thing to say about my trader Joe's product. That was discontinued. Trust me. I worked there for 12 years. I had to hear it all, but dammit, this crew Johns are good.   And then finally, the thing that's annoying me the most in the preview. If it's something you're interested in, please let me know in the stories at Lama letters. If you want to make episodes on it, because I'm really thinking about doing it. And that is talking about toxic wellness culture and deprogramming myself from some diet culture.   I have a kid who is dealing with some disordered eating right now, and it is really causing me to take a look at some of the things that I do. And it's annoying the shit out of me. And more than annoying me that I haven't set a better example. But on top of that, I've had some comments over the years, but recently I've had a few more of people being very well intentioned, but completely dismissing my experience as somebody with chronic illness.   And it's just making me more and more annoyed to the point of rage about toxic wellness culture. So if you are interested in hearing a podcast about that, please. Anyway, those are some things that I, that annoy me. I know this is not the most positive episode, but fucks shut. Sometimes shit annoys you. And sometimes you want to get off your chest and sometimes you get surprised by raisins and cookies, and sometimes you puke on yourself and we got to talk about those things.   If you want to share with me something just random, that's been annoying you lately. Let me know in the Instagram stories, just post at llamaletters and tell me about it because I'm curious to see, but the random shit that's annoying. You. Because it's fun for me. Don't forget to check out the Etsy shop on the 11th.   If you're interested in calendars and don't forget to thank my patrons. If you ever see one bop and about because they make these episodes possible. So thank you, patrons, www.patreon.com/cindyguentertbaldo. If you would like to find out more, you know, who doesn't annoy me, you all, and I'm glad that you're here.   So thanks for hanging out next week. I won't be quite as annoyed potential. But until next time, until that next annoying or not annoying time, stay safe because it'll annoy me. If you're not safe and peace out.

On today's episode of Mass Tort News LegalCast, I sat down with Dena Young and John Albanese of the law firm of Berger Montague. Dena is Senior Counsel in the firm's Philadelphia office with significant experience in the mass tort space, involving dangerous and defective medical devices, pharmaceutical, and consumer products including Talcum Powder, Transvaginal Mesh, Roundup, Risperdal, Viagra, Zofran, and Xarelto. She discusses her work on the Allergan BIOCELL textured breast implant products liability litigation, and explains how she recognized an opportunity to help victims when other lawyers shied away from doing so. For Dena, her work is a passion project that allows her to connect on a very personal level with her clients. John is an associate in the firm's Minneapolis office. Like Dena he got his start with mass torts at an early stage in his career. John talks with me about the positive work culture at Berger Montague, where every single team member's voice matters. John is fueled by his passion for the practice of law and his desire to help his clients seek justice. As always, please remember to subscribe and follow us on social media. Enjoy the show. LinkedIn: https://www.linkedin.com/company/mass-tort-news Twitter: https://www.twitter.com/masstortnewsorg Facebook: https://www.facebook.com/masstortnews.org

Ondansetron (brand name Zofran) is a very common medication you'll see in the clinical setting, on your care plans, and sprinkled throughout nursing school exams. In this episode, we'll go through ondansetron using the Straight A Nursing DRRUGS framework. Click here for show notes and links! https://www.straightanursingstudent.com/episode163/

Contributor:  Jared Scott, MD Educational Pearls: Around 30 patients with cannabinoid hyperemesis syndrome (CHS) randomized treatment in three arms with 8mg Zofran, Haldol 0.05 mg/kg, and Haldol 0.1 mg/kg Haldol arms performed better on all measures compared to Zofran Extrapyramidal symptoms were significantly higher in the Haldol group than Zofran, especially the high-dose Haldol group References Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021 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!

Other antiemetics exist that aren't Zofran - what?! Listen in to find out what they are and how to safely use them.

Dr. Harbut, PGY-4 Anesthesiology Resident at the University of Kentucky, discusses options for patients with severe PONV, more than just Zofran.

“Hi, my name is Dave and I suffer from Masklophobia.” “Hi Dave!” Dave makes absolutely no progress on his phobia in Episode 7 as he claims that all 2 of his issues stem from Halloween. Jason makes a great impression on his new boss. And both agree that a new holiday – “Falladay” should be implemented across the board. 

Follow Christina on Instagram! @thecanncierge Visit her website: thecanncierge.com In this episode, Christina shares her personal experience with cannabis and how she began working in the industry. Lindsey and Christina get into research, the lack of scientifically sound studies, how Christina handles the spread of misinformation and unwelcome comments, plus so much more! Thanks for tuning in- new episodes every Sunday.   3:40 Cold start dabs are done with a rig and banger, but instead of heating your banger before you put your dab in, you heat a pre-loaded nail. 7:49 Israel has become a leader in cannabis research! We encourage you to check out the many studies available online. Read this article to learn more:  https://www.greenentrepreneur.com/article/332807 8:38 UC San Diego received $4.7 million to fund cannabis research. Pretty amazing, huh?! Read more about what the funding will support: https://wholistic.org/news/uc-san-diego-receives-4-7m-gift-for-medical-cannabis-research/#:~:text=The%20%244.7%20million%20gift%20to,research%20in%20the%20United%20States. 21:46 There have been studies that link Zofran to birth defects. They include The Anderson Study, a study from the New England Journal of Medicine, and a CDC and Sloan Epidemiology Report. 23:13 Interested in the Grow Sciences rosin pen Lindsey mentions? Find it here: https://growsciences.com/rosin/  25:20 Lindsey and Christina reference Puffco- a brand that makes a popular smart rig. Find it here: https://www.puffco.com/products/the-peak 26:12 Christina discusses chemotypes and how they will change the way we classify cannabis. We recommend keeping up with Christina on her website and social media to stay updated on her developing research! In the meantime, here's a helpful article: https://www.cannabisbusinesstimes.com/article/chemotype-classification-how-science-is-changing-the-way-the-industry-describes-cannabis-varieties/#:~:text=This%20chemotype%20refers%20to%20cannabis,mystery%20within%20the%20cannabis%20market. 26:28 Sun-grown and indoor-grown cannabis both have pros and cons. While they may smell and look different, both can produce desirable traits! Here's some more info: https://ecocannabis.net/indoor-vs-outdoor-cannabis-for-potency-terpenes-and-flavor-which-is-better/ 29:45 Lindsey mentions Cannabombz uses full-spectrum CBD. Contrary to CBD isolate, full-spectrum includes all of the compounds in the plant, providing greater benefits.

On this weeks podcast is Danea. A mother of two from California, USA. Her two Hyperemesis experiences were 11 years apart, and her second pregnancy was a complete surprise after failed IVF attempts with her new husband. Whilst they both had children from a previous relationship they were desperate to have a child together.Danea's second pregnancy took place right at the height of the Global Pandemic, and whilst she remembers being able to get through her first pregnancy with the help of medication, this second pregnancy was so so different.Finally fitted with a Zofran Pump and a PICC Line, Danea was hopeful that she would start to feel better, and yet her Hyperemesis plagued her right up until labour.Numerous problems, dismissals and the ordeal from the Zofran pump falling out several times, by the 32 week mark Danea was done. It was all too much. But she had to fight through until she went in to labour and of course now is enduring the problems of HG and the aftermath. NB: Danea speaks about a warning from her Doctor to minimise taking Zofran. This is common but please be assured that the studies the Doctor was referring to have shown a minimal increase in cleft palate and the benefits in the opinion of HG Charities and Campaigners like myself certainly outweigh the risks. For more information on Ondansetron/Zofran and this minimal risk please visit the HER Foundation or the Pregnancy Sickness Support website.

Contributor: Don Stader, MD Educational Pearls: Majority of patients experience side effects while taking opioids Most common include nausea/vomiting, puriitis, constipation; more severe and less common include respiratory depression, addiction and overdose Opiates can cause nausea, but ondansetron (Zofran) is the wrong treatment because it’s not antidopaminergic. Instead consider using metoclopramide (Reglan), olanzapine (Zyprexa), or haloperidol (Haldol) Itching from opiates isn’t histamine mediated so hydroxyzine (Atarax) and diphenhydramine (Benadryl) aren’t effective - oddly ondansetron may help with itching. Constipation is best treated with promotility agents like Senna, rather than stool softeners References Rogers E, Mehta S, Shengelia R, Reid MC. Four Strategies for Managing Opioid-Induced Side Effects in Older Adults. Clin Geriatr. 2013 Apr;21(4):  PMID: 25949094; PMCID: PMC4418642. Farmer AD, Holt CB, Downes TJ, Ruggeri E, Del Vecchio S, De Giorgio R. Pathophysiology, diagnosis, and management of opioid-induced constipation. Lancet Gastroenterol Hepatol. 2018 Mar;3(3):203-212. doi: 10.1016/S2468-1253(18)30008-6. PMID: 29870734. Summarized by Jackson Roos, 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. 

Walk down the 4 pathways that lead to vomiting,  learn to organize types of nausea, how vomiting reflex and nausea threshold works, and explore how to choose between antiemetics.  The PDF Handout Website: medmechanix.com The Ginger Study Recommended Resources

Halo Infinite continues to burn in the flames of incompetence as another lead developer exits the project, fans react less than reasonably to CD Projekt Red's delay of Cyberpunk 2077, and EA finally get's hit with an $11 Million fine over their greed in handling lootboxes in Europe. Also, Corey doesn't know what Zofran does. Let's get it!Follow us on Twitter: ScrubVerse | AntiChris | Corey aka "Tornado Jones"Subscribe to us on YouTube and Twitch! - MegaVisions TwitchYoutubeOpening: "ScrubVerse Theme - Wily" by KubalukaClosing: "Toadwise" by MazedudeMusic Provided by OCRemixNews:Halo Infinite continues to be on firehttps://www.gfinityesports.com/article/2103/halo-infinite-budget-rumoured-to-be-the-most-expensive-video-game-everhttps://twitter.com/jasonschreier/status/1321494790098354177[read in Incognito mode] https://www.bloomberg.com/news/articles/2020-10-28/microsoft-s-new-halo-game-loses-top-director-after-project-delayhttps://twitter.com/jasonschreier/status/1321499369976352769Cyberpunk 2077 goes into hibernation for another monthhttps://twitter.com/CyberpunkGame/status/1321128432370176002https://twistedvoxel.com/cyberpunk-2077-aiming-90-metacritic-score/http://biznes.pap.pl/en/news/all/info/2997307,highlights:-cd-projekt-video-games-on-cyberpunk-2077-delayhttps://twitter.com/jasonschreier/status/1321857302115151873EA fined $11.6M over lootboxes as Dutch Courts side with gambling authorityhttps://www.gamesindustry.biz/articles/2020-10-29-ea-fined-10m-over-loot-boxes-as-dutch-court-sides-with-gambling-authority

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Michael Greiwe on the show to discuss telemedicine.  Dr. Michael Greiwe is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. In this episode, we discuss: -The benefits of telemedicine for both the patient and provider -Choosing the right telemedicine platform for your practice -How to meet patient privacy and compliance requirements -Practical tips for a seamless telehealth visit -And so much more!   Resources: Ortho Live Website Michael Greiwe LinkedIn Michael Greiwe Twitter Email: mikegreiwe@ortholive.com   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.    For more information on Dr. Greiwe: Dr. Michael Greiwe, M.D., is a surgeon by day and tech guru by night. He is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. Dr. Greiwe is a nationally recognized expert on how telemedicine technology is changing the practice of medicine. TV news stations and podcasts across America have interviewed him about the future of telemedicine and how to use it to improve the patient experience. He attended the University of Notre Dame, where he won the prestigious Knute Rockne Award for excellence in academics and athletics. He completed his Founder and CEO of OrthoLive orthopaedic surgery training at the University of Cincinnati Department of and SpringHealthLive Orthopaedic Surgery and Sports Medicine. In 2010, Dr. Greiwe completed his fellowship in shoulder, elbow and sports medicine at Columbia University, training with the head team physician for the New York Yankees, Dr. Christopher Ahmad.   Read the full transcript below: Karen Litzy (00:01): Hey Dr. Greiwe, welcome to the podcast. I am so happy to have you on today to talk all about telemedicine. Michael Greiwe (00:08): Oh, thanks so much, Karen. I'm glad to be here. I really appreciate you having me on the show. Karen Litzy (00:11): Yeah. So for any of the long time listeners of this podcast, you know that back in March and April, when the covid pandemic hit, we talked a lot about tele-health. But I think it's great to sort of revisit that now that we're a couple of months in and perhaps more people are using telehealth at this time, then were back then. But what I want to know is Dr. Greiwe, did you just start using telehealth when the pandemic hit or were you more of an early adopter? Michael Greiwe (00:42): Yeah, thanks for the question. I kind of carrying out with sort of like an early adopter. You know, I started using telemedicine back when it really wasn't cool, I guess. It was like back in the 2016 time period. And I knew it was great for my patients cause they live pretty far away. I had patients that live like two or three hours away and they would drive and try to meet me. And then you know, I'd only see them for 15 minutes. I felt really bad about that. So I started using telemedicine and it's been a great thing for my practice. And then of course, you know, recent things changed everything and it's now exploded. Karen Litzy (01:16): Right. And like I said, in your bio is that you're an orthopedic surgeon. So one question that I think is probably good that you probably get asked all the time is how in the heck do you see someone for an orthopedic condition when you can't put your hands on them and kind of feel what's going on? Michael Greiwe (01:37): Yeah, that's a great question. I get it all the time. And it's one of those things where, you know, for me, and I'm sure for you as a physical therapist, you know, so much when you hear about the history of that patient. So like the history gives you probably 80 to 90% of what you need. And then the rest is sort of verifying things through, you know, a physical exam and there's certain things on video that you can kind of catch. So like if I have somebody with the rotator cuff problem, I can watch their arm move. And I just know that the rotator cuff is bothering them. And then I'll maybe order like an MRI or something along those lines sort of confirm. But ultimately for me, it's more about like, you know, I may have to see this patient in the office at a certain point in time, but I don't always have to do that. It's kind of like depends on what the history gives me. Karen Litzy (02:22): Yeah. And I agreed from a physical therapy standpoint. I get that question all the time is, well, how can you do physical therapy on someone if you can't, if you're not in the same room. And again, it comes down to listening to the patient. Like they will tell you everything you need to help treat them to help diagnose them. If you just listen in the beginning and then you can tailor your program accordingly. Now of course, like you said, there are times where you have to see the person in person, right. And sometimes that's the same with PT. So I think oftentimes when people think about tele-health, they just paint with a very broad stroke and they think, well, how can you do that? So what do you say to people who sort of have that mentality of all or nothing? Michael Greiwe (03:13): Yeah. I think if they experience it for their, you know, themselves, they can sort of see that, okay. You know, this really works and it works because, you know, if you have somebody on the other side that's engaging you and asking the right questions, you're going to eventually come to the right answer. You know, I've had patients with a frozen shoulder and I'm sure you've treated patients with frozen shoulder. It sort of have classic signs and symptoms. Sometimes the history isn't like exactly, they're just sort of out, well, you know, my shoulder has been hurting and it kind of came on over the last several months and now I can't really move my arm as well as I used to. Or maybe you might not hear that. You just hear like, well, it hurts all over all the time, but if you kind of ask some leading questions, you have the right examiner, you can find out the answer. And so I think that's really, the key is having the right person on the other side of the screen, you know, asking the right questions. I'm sure you do the same in your practice with physical therapy. Karen Litzy (04:06): Yeah, absolutely. And you know, when we're talking about our different practices and our businesses because of the COVID pandemic, a lot of places had to shut down there in person I'm in New York city. So talk about being shut down. So we were shut down quite early. Now other parts of the country are flaring up and there's a lot of uncertainty here. So when it comes to tele-health and our business, how can tele-health help our practices grow and help our businesses grow? Michael Greiwe (04:41): That's a great question. I think it's something that people are sort of finding out more and more about right now. I mean, there's so many ways to be able to utilize telemedicine in our practices to help it grow. I mean, first of all right now as an orthopedic surgeon, I see patients from around my area because of COVID in the situation we're in right now, they don't want to come into the office, you know, so they're looking online and they find, Oh, Dr. Greiwe has got an open slot to be able to be seen via telemedicine. So we're kind of advertising that at ortho Cinc, where I practice to say, Hey, anybody that might want to come in for telemedicine appointment, you can. And it just gives me access a lot better than it normally would to be able to see patients. And then I think there's other ways too. Michael Greiwe (05:25): So for instance you know, for physical therapists, you might work with employers for instance, or workplaces that need a physical therapist and you put like an iPad there to say, if you need a physical therapist, here's how I can help you, you know, call me or whatever through this device. And so there's just so many ways for us to do that inside ortho, specifically postoperative recheck appointments, they open up slots of time that, you know, you typically wouldn't have because it's a lot more efficient to see someone via telemedicine than it is in person. And you know, also there's a lot of downtime kind of between surgeries for us too, so that downtime can be utilized for telemedicine too. So there's a lot of ways we can sort of generate you know, revenue through that and kind of open up our practice a little bit more. Karen Litzy (06:13): And, what I found is I can actually help more people. Michael Greiwe (06:17): Oh yeah, absolutely. Because you could probably have group visits too. Right. You could have you know, on those group visits or are you talking about just sort of more you know, area? Yeah. Karen Litzy (06:29): Like you were saying before we went on is sometimes you have people have to drive two to three hours to see you. Right. You know, that's really, that can be really difficult. So imagine if you have, you know, this really aching shoulder pain and you have to drive two hours. Michael Greiwe (06:45): Right. Absolutely. You're absolutely right. I think what helps, what helps you is, you know, with telemedicine, you've got the reach to be able to see somebody that's five hours away or even across the country that's heard about you or, you know, maybe they know that you have certain techniques that they like. I sort of developed like a posterior shoulder replacement where it's kind of a muscle sparing approach to the shoulder. And so I have people come from like California, Texas, Montana, you know, and now I can kind of see them postoperatively and preoperatively with telemedicine. So it's a really nice, it's a nice tool from that standpoint too. Karen Litzy (07:19): Yeah. That's great. Yeah. So you could see them preoperatively, if they're across the country, they come in, you do the surgery and then you can then see them postoperative. So they don't have to stick around by you for six weeks. Michael Greiwe (07:33): Right. So I'll have him stay for the first week and then we'll have the incision to make sure everything's looking good. Take x-rays and then they'll go back home and then I'll check in with them every four or five weeks, they'll be doing physical therapy kind of in their local area. Or of course I could refer them to you to remote therapy, but yeah. So that's how they do it currently is they go back home, they work and they get their motion back. And then we'll check in again, virtual. Karen Litzy (07:57): Now how about prescribing medications? Is that something that you can do via tele? How does that work? Michael Greiwe (08:03): Yeah, it still works pretty well via telemedicine, but I don't really do any like schedule three narcotics, you know, things like that. We don't do, but you know, anti-inflammatories, you know you know, if somebody has had some nausea like Zofran or, you know, things of that nature are pretty easy to prescribe and we still prescribe and have the same prescribing practice that we do in person, it's just, I get a little bit more wary and I think it's prudent to be more wary about, you know, narcotic prescriptions and things like that, especially in the world that we live in right now. We've gotta be very careful about that. So, we're super careful with that, but I think most of the other prescriptions are totally they're okay to do. Karen Litzy (08:46): And how about this is a question that I get sometimes is what about privacy and compliance and making sure that meeting all those standards. So how can we ensure that we're doing that as a healthcare practitioner on tele-health? Michael Greiwe (09:04): That's a great question. I think, you know, it is very important, obviously. So HIPAA compliance is what it's sort of called as you know, and it's what everybody's sort of, doesn't like to have to worry about, but it's very important for our patients, right? I mean, it's, people are very much in tune with their privacy. Data privacy is becoming like a really big thing right now, but really people's healthcare privacy and their you know, their medical privacy is very, very important. So the telehealth platform that you choose, you have to make sure that that is HIPAA compliant. And that means end to end encryption. That means like the data that starts out, you know, it's carried through the internet and it's encrypted and then wherever it's housed, it's also encrypted there too, so that no one can sort of get to that information. I think that's really critical, very important for our patients and most of the platforms they will advertise whether or not they're HIPAA compliant. And you want to know kind of how many you know, what type of bit encryption they are and things like that when you look at platforms. Karen Litzy (10:06): What was that last thing you said? Michael Greiwe (10:09): Yeah, it's sort of like, as the information is traveling across the internet there's sort of, you know, bytes of information, right? And so the amount of encryption can be sort of leveled up so that, you know, basically you can have like 64 bit encryption, or you could have 264 bit encryption there's certain levels. And so it takes, it's like a string of numbers. And so that string of numbers is how much it would take to crack the code essentially. So 256 bit encryption is like, you know, a massive amount of code breaking has to happen to catch that while it's traveling through, you know, the inner web. Karen Litzy (10:50): Well, no, that's really good because I think that's something that if people are choosing a platform, it's definitely something that as a provider you want to be looking at. Michael Greiwe (11:00): Absolutely. It's very important, you know, and most providers are pretty in tune with that, but right now, like, you know, they're allowing telemedicine to occur on FaceTime and some other platforms. Karen Litzy (11:12): Now FaceTime is not HIPAA compliant. Michael Greiwe (11:17): Yeah. So we don't want to really be using that right now. And there are some providers out there that are doing it, maybe just for ease of use and because the pandemic it's happened. But ultimately what we really need to make sure is that we don't use those platforms. Those platforms are not safe, not secure. Karen Litzy (11:35): Are there any other sort of things that you want to watch out for when you're let's say, well, first we'll start with looking at different tele-health platforms. So what are the things that you want to be looking for? And if you have any advice on a do's and don'ts, while you're actually in your tele-health session, I know some of them seem like, should be common sense, but you never know. So let's go with, what should you look at first? What should you be looking at in your telehealth platform? Michael Greiwe (12:11): It's a great question. I think the first thing that's really important for patients is making sure that, you know, the HIPAA compliance there, we covered that, right? So HIPAA compliance, probably number one, number two is, does this platform allow you to, you know, keep a schedule? So one of the most frustrating things as a provider of telemedicine is, and this is what I found out many, many years ago is that there is no schedule. You know, you have to send the invitation to the patient. The patient sort of says, yes, I'd like to do this. And then, you know, they link up eventually, but what you really want us to be able to schedule the appointments, that way you can move from one person to the next, and you're not really leaving a screen and trying to come back and forth just from an efficiency standpoint. Michael Greiwe (12:53): It's not very efficient to do that. Another thing that's important, I think is being able to chat with your patient. Sometimes it's important to be able to have a conversation. And it's also important to answer questions. And so being able to have kind of a text based chat that's secure as well, that might be, you know, maybe they can send you a picture. Maybe you can send them a video. Maybe you can send them sort of a document that gives them some exercises or what have you. And that's really important too. But I think one of the other things I was gonna mention is consenting. A lot of platforms don't have consent and of course that's part of the law. You have to consent that patient for telemedicine before you have a visit in most of the States, I think 45 of the States, you have to have a consent. So very important for the consent process to happen also. And that allows you to have a legal telemedicine appointment. Karen Litzy (13:44): And that consent process. Can that be in your initial paperwork? So if you're onboarding someone and, you have, I mean, we've all been to the doctor's office, you have to fill out a million different forms, right? So same thing with PT. So can that consent to tele-health be in that onboarding or does it have to be every time you connect for a telehealth visit, do they have to consent every single time? Michael Greiwe (14:11): That's a great question. And it's really just a onetime consent, so it doesn't have to be, you know, every time. So if they just come to your office first time, you're going to maybe have him sign some paperwork that says consent to telemedicine, and that's fine. You're good to go. But in the case where you have a new patient, it's very important to make sure that you have that consent process. And so for us and what we do at ortho live and spring health live, we just have them sign off one time that they agree to telemedicine. And then we assume every time they visit the platform, they know what they're doing and they've already agreed to it. Karen Litzy (14:44): Yeah. Yeah. Cause I have woo. You just gave me a little sigh of relief cause I have it again as part of my onboarding paperwork that people are consenting to their telehealth visits, but I don't do it every single time for each visit. Michael Greiwe (15:00): Right. Then I think it's just sorta like the billing practices in your practice too. And that people sign off that they're okay with billing and that they just do it once they're not signing it every time that they come back, it applies similarly to telemedicine. Karen Litzy (15:12): Got it. Got it. Okay. So those are the things you want to look at when you're kind of shopping around for a platform. Now let's talk about some things that you want to have in mind as the healthcare practitioner during your telehealth visit with your patient on the other end. Michael Greiwe (15:30): Yeah. It's a really good question. So the first thing is if you're going to use a phone, you know, and sometimes you're using a phone because you might be on the go or maybe your platform only allows you to have a phone it's really important to make sure that you don't like hold the phone, like right underneath your nose. Because it sort of gives you like kind of the up the nose shot a little bit. So I always tell people, you know, prop your phone up in front of you, like on your keyboard, maybe that's a really good place for it. Or if you're using a laptop, obviously like your face is kind of directly in front of that camera. And it just gives you more of a conversational type of appearance to your patient rather than you're not like talking straight down to them. Michael Greiwe (16:06): I think that's important. The other thing to sort of test out is just make sure that like, you know, when you move your right arm, like your right arm is like going up in the correct location in the camera. So you're not off to the side, you know of the camera when you're trying to show them kind of what you expect, I imagine for physical therapy and you can answer this, you know, too, I imagine for physical therapy that you may have to be seen, like your full body may need to be seen at some point in time. Karen Litzy (16:33): Yeah. Yeah. You definitely need like a decent amount of space so that you can lay down on the ground. You can come up to kneeling, you're standing you're so yeah, for physical therapy, you do need a good amount of space. So it comes down to finding those spaces, whether it's in your home or your office, where you can kind of get the right angle and good lighting. Michael Greiwe (16:54): Right. That's great. I think that's really important. You know, for your listeners on the physical therapy and for us, it's also being able to screen share too. If you can screen share, then you can show x-rays MRIs, things like that. And just getting tests sent out. Like I know for my practice, you know, we had a lot of physicians go live as soon as COVID hit and nobody had practiced. And so it was disaster on the first day, it was like, you know, it was like Groundhog day. And like no one knew what they were doing. And I was running around different pods trying to help everybody. But it's important to practice just like we would never go to surgery, not practicing what we're doing, you know, you practice to on your side to make sure that everything's working properly, your camera, your audio and all of that. Karen Litzy (17:36): Yeah. Do a couple dry runs with friends and family, make sure it's working well. Yeah, that's excellent advice. And now what do let's say, physicians or therapists what do they need to do now to kind of quickly adapt to this telehealth? Because from like, I look at, it's such old hat now, but I've been doing it since March. So now you have other parts of the country who are sort of trailed behind New York city. So they're in lockdown maybe for the first time and they really need to start adapting quickly. So what advice do you give to those practitioners? Michael Greiwe (18:12): Well, you know, providers of medical services always have a hard time with change, right? I think that's like one of the tenants of being a type a personality, the personality that ends up getting into medical practices or, you know, we're very particular. So we don't like to change. That's the first thing to recognize. And, and so there's going to be bumps in the road and they're just going to be hurdles. And I think it's really important to just understand like, Hey, you got to sort of roll with the punches a little bit, understand is not usually too difficult. We just need to kind of figure out what your plan of attack is going to be. Are you going to see tele-health patients in the morning and then see your regular, you know business in the afternoon, if you're completely shut down, how are you going to adapt to that? How are you going to get the word out? Are you going to be able to market this really, really important for you to make sure you kind of figure all that out on paper before just sorta like saying, yeah, I'm going to buy this telehealth cloud from when we get rolling, you know, it's like let's plan an attack and how we're going to be seen and how we're going to be able to see patients. I think that's really, really important. Karen Litzy (19:12): Yeah. Makes sense. And now let's talk about the platforms. Let's talk about the platforms that you're involved with and how you got involved. So there's ortho live and spring health live, right? So how are you an orthopedic surgeon with all of the work that surrounds that and then sort of this tech person entrepreneur on the side. So you must have some spectacular time management skills. Michael Greiwe (19:44): Well, I've got a very forgiving wife. I know that that's number one. But you know, it is like a it's a wonderful thing for me because I really enjoy doing kind of creative things. Things that might help my patients and telemedicine was one of those things I think really was, was a great thing for my patients ultimately. But for me, telemedicine was a way for my patients to be helped in a way that we couldn't really help them through anything else. And so there wasn't a great solution. So I decided to found ortho live about three years ago, that was 2016. And it was only because I was looking around to try to find a solution for patients and for providers that was really efficient and that worked really smoothly. But what I found was that really didn't exist and it was really hard to find the right solution. Michael Greiwe (20:32): And so I decided to create it after speaking with a CEO of a telemedicine company out in the California area, he kind of runs a lot of the video for MD live and some of the other larger companies. And he said, Mike, you know, this is a great idea. You ought to kind of through on your vision to do this for orthopedics. And so I did that with ortho live and it's been really successful and I kind of knew what we needed. We just, you know, we didn't have the efficiency in a way to be able to see patients in a streamlined fashion. So we created that within orthopedics, which I knew very well. And then we kind of branched out and now we're offering services to other specialties and subspecialties as well with spring health live. Karen Litzy (21:11): And within these platforms, do you have ways to do objective measurements within these platforms? Cause I know some do some don't so how does this, how does this work let's say from an orthopedic standpoint. Michael Greiwe (21:27): Yeah. So I mean, if you want true objective measurements we have to kind of integrate with braces and things like that. So, you know, we're like a smartphone application. And so we do have API APIs that can integrate and take in information like that. It's not something that, you know, orthopedic surgeons really use on a daily basis. I would see that more for physical therapists. So we kind of have the ability to integrate with you know, applications that give you range of motion and actual discrete data. I think that's really important because it does give you some actual feedback on a day to day basis, how a patient's doing. But from an ortho standpoint, we don't really need those, like the discrete data points we just sorta need to see, okay, well, how was that patient performing? Michael Greiwe (22:09): Are they having difficulties still, you know, moving their knee, let's see you bend your knee. And if it's not really going as well as we want, we know we need to up the physical therapy, we need some more intensity there. And it's more of a good stall for us. Less on the discrete hard numbers, but with therapy, I feel like it is really important to have that feedback to say on a day to day basis that patient's not doing well, how can we help them? Do we need to intervene sooner? So maybe that's what you're getting at, but, but yeah, we have the ability to kind of feed that information back into our platform. Karen Litzy (22:39): Yeah. Yeah. That's cool. Because a lot of times it's, you know, you could say, well, if 180 degrees of shoulder elevation is considered full, it looks like maybe they're at 75% or they're at 50%. So, but it's hard to get those, like you said, very discrete numbers because we can't measure it. Right. So having the ability to kind of integrate applications to be able to do that, I think is it can be really helpful. Although I, yeah, I guess sort of postsurgical when the patient is perhaps limited to X amount of degrees of movement, I think is where that comes in really handy. Michael Greiwe (23:21): Right. Right. And we have them sort of stand kind of at the side and like watch for inflection and things like that. So I think we get, you know, to within probably five to 10 degrees, but if you're looking for exact degrees, that's where those programs, which, you know, you can strap like an iPhone to your leg now and like move your knee. And it measures range of motion through like some little track pads and things like that. And there's ways to, to really effectively get that, that motion and understand what's happening with the patient and recovery, which is nice. And so we've allowed the ability to integrate those types of applications to our platform, which is cool. Karen Litzy (23:56): Yeah. That's really cool. I was working with some developers based in Israel who have an app for gait. And so you put it in your pocket and what it does is it can tell you the excursion of your hip range of motion from flexion through extension pairing side to side, your stance time steps per minute all sorts of stuff. I think there's up to like seven or eight discrete measurements, which is super cool. So again, in times like this, this is where the technology 10 years ago didn't exist. Michael Greiwe (24:33): Yes. A hundred percent. Karen Litzy (24:36): Having that now is allowing healthcare professionals to continue to help their patients during this pandemic. Michael Greiwe (24:46): No question. I was speaking with a group that has some special socks that like will measure stride length and things like that. So they know when a person may be like, you know, unsteady with their gait when they might be a fall risk which I think is a great, it's a great thing. And so, you know, understanding when patients may need some therapy to try to help with balance is critical. I mean, falls are a multibillion dollar issue in the United States today. And if we kind of cut down on falls, it's a great, great opportunity. And so we're, I think we're leveraging little things like, you know, from a data standpoint to be able to improve population health. I think it's great. Yeah. Karen Litzy (25:26): And where do you see telemedicine moving in the future? The pandemics over is everybody just gonna wrap it up and call it quits? Or what, where do you see that moving towards in the future? Michael Greiwe (25:39): No, I think telemedicine is here to stay Karen, I think you know, so-called genies out of the bottle, you know, there's a lot of great things that have happened with telemedicine recently. I think it's here to stay. We're gonna end up seeing telemedicine continue to spike. It was on the rise. Even before the pandemic, we were seeing multi millions of patients that were being seen every year. It was doubling every year. And now it's like, I mean, I think it's gone up by 10 X. So there's going to be a lot more telemedicine, I think, in people's future. Karen Litzy (26:10): Yeah. And as we were discussing before we came on the air hopefully the providers of insurance will also agree with that and say, we are going to continue paying for these because look at the advantages it's giving look at the money we're saving because of this. Cause like you said, if you can have a telemedicine visit with someone and it prevents a fall, which is a multibillion dollar industry, would you rather pay the $2-300? Whatever it, I don't know how much it is or have that person hospitalized for hundreds of thousands. Michael Greiwe (26:48): You're absolutely right. And so if there's any, you know, any of the insurance industry listening is very, very critical that we continue with telemedicine for their patients. And it's so beneficial, not only in protecting them during this time period, you know, we definitely don't want to let them go out of the house or 70 year old patients that are potentially sick and I'll really you know, it's for their safety and it's also for the benefit of the patient. I mean, it's way more convenient for them. And so I think without a doubt, it is so important to make sure that our legislature continues to support telemedicine and telemedicine billing. Karen Litzy (27:25): Absolutely fingers crossed fingers crossed that that happened. So I'm with you on that. Alright. Now, before we start to wrap things up, is there anything that we didn't cover or anything that you want the listeners to sort of walk away with from our discussion on telemedicine? Michael Greiwe (27:43): Oh, I think the main thing is, is that, you know, there's a lot of great people out there trying to provide health care. And many of them are trying this, you know, as a new you know, thing for them in their practices. And I think supporting them in that is important. I think everybody inside their local community is really trying to do things via telemedicine now and they weren't doing that before. And so being flexible, I think with those providers, I think is important, but I also think that telemedicine is here to stay. It's one of these things where there's so much benefit on both the provider and the patient's end that it'll just continue to be here and be a part of society and medical care going forward. Karen Litzy (28:20): Yeah, absolutely. And now I have one question left and it's a question I ask everyone, and that's given where you are now in your life and in your career. What advice would you give to yourself as a fresh medical school graduate? Michael Greiwe (28:36): That's a good question. I love this question. I think for me, I was such a you know, a worrier, like I was, I was always worried about, you know, what was I going to be good enough? Was I going to be smart enough? And you know, I always knew that I believed in myself, but I didn't trust myself back in those days enough to know that I was going to be okay. And I think the thing to remember is like, you know, you went into this medical profession for a reason you want to take good care of patients. You got to believe that, you know, you're a hard worker and you're going to continue to do as best you can to take good care of people. And you're not, you know, even a few fail it's okay. I think failure is it's okay to fail. I think that's another thing that I would tell myself to, because I was so worried about failing that I wasn't willing to like branch out and take risks. But I've learned that now. And I think if I could go back, I'd tell myself, don't worry about failure. Just you're gonna be fine. Just keep working hard. Karen Litzy (29:36): Great, excellent advice. And now where can people find out more about you more about ortho and spring health live? Michael Greiwe (29:43): Great. Yeah. Well, they can actually look at our website. So our website is www.ortholive.com and then www.springhealthlive.com. So for me, I can be reached at mikegreiwe@ortholive.com. That's my email address and I'll be happy to respond. Karen Litzy (30:08): Perfect. And just so everyone knows, we'll have all of those links in the show notes under this episode at podcast.healthywealthysmart.com. So Dr. Greiwe, we thank you so much for coming on. And, and like I said, I've spoken about tele-health before, but it was way back when this started. So it's great to get more information out there for people to know that it's not just something that we're doing during the COVID pandemic, but that this is something that can be incorporated into your practice. It can help your business, help your patients. So thank you so much. Michael Greiwe (30:43): Oh, thank you, Karen. I was glad to be here. Appreciate it Karen Litzy (30:45): Anytime. And everyone. Thanks so much for tuning in, have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Today’s show is about an important topic that isn’t talked about very often. We’ve all heard of morning sickness, but there is a much more severe condition called hyperemesis gravidarum. It brings all-day nausea and vomiting and can result in significant physical and emotional effects. Lauren Harris is a married mother of three kids who lives in western Massachusetts. She’s a licensed mental health counselor who owns the Center for Perinatal Wellness. Lauren is also the Western Massachusetts Regional Coordinator for Postpartum Support International. In today’s show, Lauren shares her story of hyperemesis gravidarum (HG) through three separate pregnancies. We’ll hear how she learned of her condition and dealt with for a very long time with little support. Lauren also shares about her struggles with postpartum anxiety, along with how her experiences propelled her into the field of perinatal mental health. Show Highlights: Lauren’s story of her surprise pregnancy at age 22 with her daughter, Natalie, now 13 At eight weeks, Lauren was hit with incredible nausea that kept her vomiting up to 12 times each day; she was unable to keep food/liquids down, but was told it was “normal.” There were four separate times that Lauren was hospitalized for IV fluids due to dehydration; she lost 40 pounds during the first 20 weeks of her pregnancy. She was frustrated that no one took her seriously, and she couldn’t work or function each day, which put a financial strain on their family. Late in her pregnancy, she was prescribed Zofran, which was the only thing that would help. Her parents helped pay the out-of-pocket cost at $90 per pill; Lauren had to take three pills daily for several weeks. What it felt like to be told that her extreme sickness was “normal” Why Lauren had the conversation with her mother about terminating her pregnancy How HG affected Lauren’s work as a mental health counselor How Lauren met the emotional challenges to keep going day by day After a 23-hour induction, her perfectly healthy baby girl was born, weighing 8 lbs. 11 oz. Why the birth was followed by a D & C because of a hemorrhage Four years later, Lauren was pregnant with her second child; she had similar nausea and vomiting but felt much more supported by her medical team With her third pregnancy, she took more care with rest and hydration but experienced much more postpartum anxiety The irony was that as the HG improved with each pregnancy, the anxiety issues became worse How Lauren coped by using therapy and medication Why Lauren was propelled into perinatal mental health work by her personal experiences Lauren’s practice has three clinicians now but is looking to expand soon because the need is so great What Lauren learned about HG and herself Resources: Email Lauren: lauren@laureneharris.com Lauren’s practice: www.cpw.care Find the Center for Perinatal Wellness on Facebook  

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses. Every year, the ASCO Annual Meeting brings together attendees from around the globe to learn about the latest research in the treatment and care of people with cancer. This year, attendees from 138 countries worldwide gathered virtually for the ASCO20 Virtual Scientific Program, held Friday, May 29 through Sunday, May 31. In the annual Research Round Up podcast series, Cancer.Net Associate Editors answer the question, “What was the most exciting or practice-changing research in your field presented at the ASCO20 Virtual Scientific Program?” In this episode, 3 editors discuss new research in the fields of breast cancer, sarcoma, and palliative and supportive care. First, Dr. Norah Lynn Henry will discuss 3 studies that exploring treatment options for different types of breast cancer. Dr. Henry is an Associate Professor in the University of Michigan's Division of Hematology/Oncology in the Department of Internal Medicine and is the Breast Oncology Disease Lead at the Rogel Cancer Center. She is also the Cancer.Net Associate Editor for Breast Cancer. View Dr. Henry’s disclosures at Cancer.Net. Dr. Henry: I'm Dr. Lynn Henry, one of the breast cancer experts from the Rogel Cancer Center at the University of Michigan. I would like to share with you a few of the research highlights related to breast cancer from the ASCO 2020 Virtual Scientific Program. I do not have any relationships to disclose related to any of these studies. There were many exciting trials presented at this conference for all types of breast cancer. Today I will highlight 3 key studies that will likely change how we treat patients with breast cancer. Before I start talking about the trials themselves, I'm going to give a very brief overview of the types of breast cancer. Then I will talk about an important study that looked at the use of surgery and radiation in patients whose cancer is metastatic or has already spread to other sites of the body at the time they are diagnosed with breast cancer. Then I will highlight some research that was presented on triple negative and HER2-positive metastatic breast cancer. As a brief review, there are multiple kinds of breast cancer. Some breast cancers are called hormone receptor positive or estrogen receptor positive and are stimulated to grow by estrogen. We treat those cancers with anti-estrogen treatments to block estrogen or to lower estrogen levels. Other breast cancers are called HER2-positive. These are often more aggressive cancers, but because they have extra copies of the HER2 receptor, they often respond to treatments that block HER2. Finally, there are breast cancers that don't have any hormone receptors or HER2 receptors. These are called triple-negative breast cancer and are also often very aggressive cancers. The first clinical trial I'm going to discuss was a relatively large trial conducted by the ECOG-ACRIN cooperative group. Of patients newly diagnosed with breast cancer, about 6% are actually found to have cancer in other sites in their body such as in the bone, liver, or lung, as well as in the breast. This is called de novo metastatic breast cancer. The goal of this trial was to determine whether patients in this situation should have surgery and radiation to treat the cancer in their breast in addition to drug treatment, or whether they should just have drug treatment for their cancer. In this trial, patients with de novo metastatic breast cancer of any type were treated with appropriate drug therapy for 4 to 8 months. The approximately 250 patients whose cancers improved with treatment were randomized to either have breast surgery and, if appropriate, radiation therapy, and then resume drug therapy or to just continue drug therapy the entire time. Overall, there was no difference in how long patients survived whether they had removal of the breast mass or not. In addition, the quality of life in the 2 groups of patients also appeared to be similar. These results confirm studies that have been conducted in other countries around the world and importantly examined whether surgery is appropriate in patients who are treated with modern therapies. It appears that surgery is not needed in most patients. This is important information for patients with de novo metastatic breast cancer who are trying to decide whether or not to have breast surgery as part of their treatment. The next trial is called KEYNOTE-355 and examined the use of an immunotherapy drug pembrolizumab, also called Keytruda, in patients with triple-negative metastatic breast cancer. Immunotherapy is a treatment type that allows a patient's own immune system to help treat her cancer. We already have the FDA approved option of using a similar immunotherapy medication called atezolizumab, also called Tecentriq, in combination with a specific chemotherapy drug for patients whose cancer express PDL1. In this new KEYNOTE trial, pembrolizumab was combined with 1 of 3 possible chemotherapy options in patients with previously untreated metastatic triple-negative breast cancer. In this trial, in patients whose tumors had an increased amount of PDL1 on the cells and in the surrounding tissue, the addition of pembrolizumab to chemotherapy made it less likely for the cancer to progress compared to chemotherapy alone. Although this treatment combination is not yet FDA approved, all the drugs that were tested are already approved for use in other situations. These results are exciting because they will likely lead to new treatment options for patients with this type of breast cancer which can be quite challenging to treat. Finally, I will highlight new results from the clinical trial called HER2CLIMB. This is a large phase 3 trial examining a new drug called tucatinib that is a pill that is designed to turn off the HER2 receptor. Patients who enrolled on this trial had previously been treated with multiple different treatments for HER2-positive metastatic breast cancer. All enrolled patients were treated with the anti-HER2 antibody drug trastuzumab, also called Herceptin, as well as a chemotherapy drug called capecitabine or Xeloda. In addition, two-thirds received the new drug tucatinib and one-third receive placebo. We learned about 6 months ago that this drug combination was pretty well tolerated by patients. And what is exciting about this trial is the patients who were treated with tucatinib had a longer time until their cancer progressed and lived longer compared to those who took placebo. As a result of this trial, the drug was approved by the U.S. Food and Drug Administration in spring 2020. Because of the type of drug that it is, tucatinib is thought to treat cancer both outside and inside of the brain. This is important because many patients with HER2-positive breast cancer have the cancer spread to their brain. In fact, almost half of the patients enrolled in the trial had a history of metastases in the brain and many had active growing cancer in their brain at the time of trial enrollment. Importantly those patients with cancer in their brain obtained a similar benefit from the drug compared to those who didn't. Over half of patients with active cancer in their brain had at least a partial shrinkage of the cancer in their brain as seen on brain MRI when treated with tucatinib in addition to the other drugs, which demonstrates that tucatinib can get into the brain to treat the cancer. On average, patients with active cancer in their brain were more likely to live an average of 8 months longer as a result of taking tucatinib. This represents an exciting new treatment option for patients with HER2-positive breast cancer whose cancer has spread to their brain, and importantly this treatment is already available for patients. Overall, there's a lot of exciting research going on across all the different subsets of breast cancer. As you can see, the results of these and many other important clinical trials were reported at the recent ASCO Annual Meeting and there are many more clinical trials ongoing that will hopefully result in the approval of multiple new effective treatments for breast cancer. In addition, there's research going on that is examining the impact of treatment on patients with breast cancer and trying to improve the lives of those living with breast cancer. Clinical trials are critical to the development of these new treatments. Well, that's it for this quick summary of this important research from the ASCO 2020 Virtual Scientific Meeting. Overall, we continue on a fast track in breast cancer with many new and exciting therapies being actively studied and research helping support our patients do better than ever before. Stay tuned to Cancer.Net for future updates from upcoming cancer conferences. Thank you very much. ASCO:Thank you, Dr. Henry. Next, Dr. Vicki Keedy will discuss an international study that compared different treatment options for Ewing sarcoma, as well as new research in using immunotherapy to treat sarcomas. Dr. Keedy is an Assistant Professor of Medicine in the Division of Hematology/Oncology and the Clinical Director of the Sarcoma Program at the Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center. She is also the Cancer.Net Associate Editor for Sarcoma. View Dr. Keedy’s disclosures at Cancer.Net. Dr. Keedy: Hello, my name is Vicki Keedy, and I am the clinical director for Sarcoma at the Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center. I am pleased to discuss with you some of the exciting research findings in the management of patients with sarcomas presented at this year's ASCO Annual Meeting. I have no direct conflict of interest, but my institution does participate in some of the trials using some of the immunotherapy agents discussed below. Sarcomas are a class of cancers made of many different types of connective tissue tumors. Thus, there is significant variety in the types of abstracts presented, making narrowing them down a difficult task. First, I will discuss a study that establishes the standard first-line treatment for patients with Ewing sarcoma. And then, I will finish by summarizing a few abstracts on the use of immunotherapy in various sarcomas. Ewing sarcoma is a type of sarcoma that can start in either the bones or soft tissue, tends to occur in children and younger adults, but can present at any age. It is characterized by small, round blue cells and is considered sensitive to chemotherapy. Regimens using multiple chemotherapy agents are considered the standard first-line treatment. However, there's variation in the exact regimen with considerable differences between the treatments most commonly used in the United States versus that used in many European sarcoma centers. EURO EWING 2012, presented by Dr. Bernadette Brennan compared these 2 most common regimens to determine whether 1 is better in regards to improving survival but also to evaluate differences in toxicity. In this trial, 640 patients in 10 different European countries with newly-diagnosed localized or metastatic Ewing sarcoma were randomized to receive either the regimen called VIDE, most commonly used in Europe, or the regimen called interval-compressed VDC/IE, most commonly used in the United States. VIDE consists of four drugs - vincristine, ifosfamide, doxorubicin, and etoposide - given together every 3 weeks prior to surgery. This is then followed by additional chemotherapy of a similar regimen post-surgery. VDC/IE consists of 2 different regimens alternating an every 2-week cycle. These are vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide, and these are received both before and after surgery. The results of this study showed an improved survival for patients who received VDC/IE that was both clinically and statistically significant. Its benefits seem to hold true for patients with both localized and metastatic disease regardless of age. Additionally, VDC/IE appeared to be less toxic with fewer episodes of neutropenic fever and fewer severe treatment-related toxic events, while also allowing patients to complete their treatment approximately 3 months earlier than patients receiving the VIDE regimen. This study demonstrates the importance of cytotoxic chemotherapy for patients with Ewing sarcoma and establishes interval-compressed VDC/IE as the standard of care. Moving on to the next topic of immunotherapy and sarcoma, many of the abstracts presented this year related to use of those concepts in patients with various types of sarcoma. Due to the biology of sarcoma, the immune system is generally not able to recognize and attack sarcoma cells. Thus, this approach by itself has not shown much benefit in most sarcomas. However, as I mentioned, there are many types of sarcomas, and they do not all behave the same. We have seen signals of benefits in certain subtypes. Many of the abstracts presented this year evaluated immunotherapy in some of these specific subtypes or attempted to use it in combination with other treatments such as chemotherapy or radiation. Unfortunately, these studies were relatively small or did not compare the immunotherapy to a standard treatment, making it very difficult to make definitive statements about the results. But they do give us more insights into which types of sarcomas might benefit from this approach. These abstracts confirmed responses in undifferentiated pleomorphic sarcoma, synovial sarcoma, alveolar soft part sarcoma, in angiosarcoma, and Kaposi's sarcoma. There's still much work to be done to determine whether an immunotherapy approach is better than already approved treatments for these types of sarcomas, and it is essential to validate these results by treating patients with immunotherapy agents in the context of the clinical trial. I thank you for your time and hope you found this discussion helpful. I look forward to discussing more exciting results next year. ASCO:Thank you, Dr. Keedy. Next, Dr. Kavitha Ramchandran will discuss several aspects of research in supportive and palliative care that was presented at ASCO20. This type of care focuses on managing the symptoms and side effects of cancer and its treatment. It also includes support to help reduce the financial, emotional, and social effects of cancer. Dr. Ramchandran is the Clinical Associate Professor of Medicine in the Division of Oncology at Stanford University, and the Medical Director of Palliative Medicine at the Stanford Cancer Institute. She is also the Cancer.Net Associate Editor for Palliative Care. View Dr. Ramchandran’s disclosures at Cancer.Net. Dr. Ramchandran: Hi. It's wonderful to be here with you all today. My name is Kavitha Ramchandran, and I'm a clinical associate professor at Stanford University in oncology and palliative medicine and also have the pleasure of being the Associate Editor for Palliative Care on ASCO's patient education website, Cancer.Net. And I do not have any conflicts of interest to disclose related to the research that we'll be discussing today. ASCO 2020 was a wonderful year in terms of palliative care education and research, and I am excited to share some of the highlights from that meeting with you all. We'll be talking about a few key research studies, and we'll be discussing a couple of different things. One, what are some of the novel approaches to symptom management in palliative care? Two, how do we actually assess risk in terms of our patients and how can we better stratify patients in terms of what type of treatments are best for them, and are there novel tools we can use? Three, how can we improve care by integrating palliative care early and often, both through a primary palliative care approach as well as a specialist palliative care approach? With that, let's go ahead and get started. So in terms of symptoms, we had a really great discussion by Dr. Roeland from Mass General on several abstracts. The couple of abstracts that we're going to focus on here, one looked at armodafinil, which is a stimulant that has been often used for cancer fatigue. And the second was looking at cannabis compounds that have been thought about in thinking about nausea and folks who are suffering from nausea due to chemotherapy. So our investigators that looked at armodafinil looked at armodafinil in patients who had glioma, and they wanted to see that if they used armodafinil in these patients, whether or not they would have an improvement in their fatigue. Now in the past, we know that there have been a number of studies that have looked at different types of treatments for fatigue, everything from steroids, to stimulants, to herbs, and what we found is that, consistently, stimulants have not been shown to improve fatigue. The things that have been shown to improve fatigue in small studies include steroids as well as American ginseng. Unfortunately, this was yet another negative study, and what we see here is that armodafinil did not improve fatigue and in fact, at the dose of 250 milligrams, might have increased insomnia or trouble sleeping. And so with that, I think we would make the assumption that we probably need to rethink our approach with stimulants in cancer-related fatigue and, for the majority of our patients, would make the decision that stimulants may not be the best course to improve fatigue. On a positive note, we did look at patients who were receiving chemotherapy, and, in an Australian study, what they looked at was whether the addition of a THC plus CBD compound - now, this was both THC and CBD 1-to-1 - could improve nausea. And what they found is that, for these patients who all received the normal prophylaxis-- so they got Zofran. They got a D2 receptor antagonist, such as Compazine. If you added the THC-CBD compound, those patients actually had better nausea control, which was fantastic. However, they did also have some side effects from the THC-CBD, including dizziness, sedation, and disorientation. Yet despite these side effects, the patients really felt better, and so they were likely to continue using the cannabis. And they would actually choose to continue using the cannabis. Moving on to a different note, there were a variety of different studies that looked at risk assessment, and can we actually identify which patients would benefit most from which intervention? And there was a couple of different types of studies here. One looked at the utilization of patient-reported outcomes to see whether or not we can identify patients who may be at more at risk for poor outcomes. We know Ethan Basch published, a couple years ago, a landmark study that showed that if you integrated patient reported outcomes, also known as PROs, routinely into cancer care, you could improve survival. So basically, if you looked at symptoms, evaluated those symptoms, and treated those symptoms early and often, people lived longer and lived better. Now, can we use this data that patients give us through questionnaires on a regular basis, can we use this data in other ways? And we actually had a few studies here that looked at patients who had metastatic disease. And Dr. Batra et al. from Calgary looked at 1,300-plus patients, and what they found was that patients who had fewer symptoms tended to do better. And it seems like a kind of obvious point. If you have more symptoms, you might do worse, but I think the routine assessment of symptoms in patients and utilizing those symptoms is not done. So if we know that patients who have fewer symptoms might do better, may be able to use that data to see whether or not those patients might need more support or to use that data to see if those patients may not be the best patients for a clinical trial. Maybe we need to do symptom control first. So it does help us to risk-stratify and understand that patients that have more symptoms tend to have a shorter survival. Patients that have fewer symptoms tend to have a better survival. Additionally, we have some really interesting data from Dr. Supriya Mohile at the University of Rochester looking at the use of a different type of assessment called the geriatric assessment for patients who are older. Now, we know that the geriatric assessment can identify patients who are at high risk for things like falls or cognitive changes or dementia, but what we don't necessarily know is whether if we routinely use the geriatric assessment, it helps us with our cancer treatment. And what they did in the study is they actually randomized patients to do the geriatric assessment. And in 1 arm, they showed the geriatric assessment to the oncologist, and in the other arm, they did not. And what they found is when they showed the geriatric assessment to the oncologist, the patient actually received treatment that was probably better for them based on the findings of their geriatric assessment. So patients who were more frail or who had more findings that would require an assessment and treatment had those things done. So if they needed a fall assessment, that got done. If they needed some neuropsych testing for their dementia, that got done. And for those patients, the oncologist often would choose to give a slightly lower dose of treatment to prevent further adverse effects. So what they found is that if you did a geriatric assessment routinely for older patients, you could appropriately provide for those needs and actually give them the treatment that is correct for them, preventing adverse events, preventing higher-grade toxicities, and ensuring that those patients got the best care. And then finally, coming to our last group of trials, we had a really great discussion from Amber Barnato from the Dartmouth Research Institute. So it looked at variety of clinical trials of early palliative care integration as well as integrating palliative care through primary palliative care intervention. Now, what's the difference here? So primary palliative care intervention is when you teach clinicians, like your oncologist, to do palliative care themselves. So that's when they prescribe an opioid for pain, or that's when they do a goals of care discussion as part of routine advance care planning. Now, specialist palliative care interventions look a little different, and that's often when you have someone who's board-certified in palliative care and hospice, and they come in and do another consultation. And this would be akin to having a cardiologist come help your primary care doctor take care of your hypertension. This would be pulling in another team. So that's the difference between primary and specialist palliative care. So what we saw here is that there were 2 different types of interventions that were both really interesting. Now 1 was done in University of Pennsylvania, where they actually looked at several thousands of patients who had their oncologists get a little nudge through an email that said, "You know what? Your patients coming in this week might be at a little bit of a higher risk for a poor outcome, at a higher risk for mortality. And when that happens, it might be good to do some advance care planning." So that these oncologists that got this email nudge, they were more likely to do the right thing by their patients. They were more likely to do an advance directive, and they were more likely to ensure that these patients had their goals of care documented and their prognosis documents within their charts. So something as simple as a mortality prediction done through a computational tool and an email to those oncologists could really improve getting the basics done for patients, such as getting their advance directive done. Additionally, when we think about, now, specialist palliative care intervention, Dr. Barnato actually made a really beautiful point. She actually looked at a couple of different studies, 1 done by Tom Smith looking at integrating palliative care in phase 1 populations and the other by Dr. Areej El-Jawahri looking at integrating palliative care into the acute leukemia patient population. And both of these studies were really excellent studies that showed quality of life improvement with early integration of palliative care. And that is fantastic, and it supports the work that was led by Jennifer Temel in 2010, where she saw that if you integrated palliative care early and often, those patients had better quality of life, those caregivers did better, and those patients live longer. And these studies continue to support the fact that early integration of palliative care improves quality of life for patients from a variety of different walks, whether it's phase 1 or acute leukemia. But what Amber Barnato pointed out was that palliative care also does something really different. What palliative care does is it also improves the way that we communicate across systems, and what she said, and I think it's important to point out, is that we don't often account for that in our metrics. We don't often point out that when a palliative care doctor talks to an oncologist, it decreases the anxiety of the oncologist. It makes the oncologist deliver better care. It actually changes the infrastructure of how we deliver care in the system, and that improves quality in ways that goes beyond the biopsychosocial model of just quality of life for patients but really changes the paradigm of how we deliver care across the system. And that we not only need to measure quality of life for patients but really look at some of these system changes that palliative care really helps to propagate and think about how that could be measured ongoing. So it's been another great year for research. We're really excited about what our colleagues are doing out there in palliative care and supportive care and both in improving systems, improving risk assessments, and improving symptoms. We look forward to another year of research in ASCO 2021. Thank you so much for having me here today to talk to you a little bit about what we learned from our colleagues and friends. ASCO: Thank you, Dr. Ramchandran. Learn more about the research presented at the ASCO20 Virtual Scientific Program at www.cancer.net/blog, and subscribe to Cancer.Net podcasts on Apple Podcasts or Google Play for additional episodes in the Research Round Up series, released throughout the summer. This Cancer.Net podcast is part of the ASCO Podcast Network. This collection of 9 programs offers insight into the world of cancer care, covering a range of educational, inspirational, and scientific content. You can find all 9 shows, including this one, at podcast.asco.org.  Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/donate.

GI Meds. Nausea, Zofran, ondansetron. Free quiz & full course at https://Simplenursing.com/nursing-school  Pharmacology Master Class - 100 videos not on YouTube - Try it for Free!    Pharmacology Master Class - Try it for Free: https://Simplenursing.com/nursing-school  100 videos not on YouTube    FREE Access to new app + 1,000 videos not on youtube!  https://Simplenursing.com/nursing-school   NCLEX FREE TRIAL:  https://simplenursing.com/NCLEX   STAY IN TOUCH

Pink Sheet reporters and editor discuss the potential effects of virtual advisory committees, should they be scheduled, as well as the coronavirus implications of the new first generic for Proventil HFA, and the FDA getting pulled into a Zofran product liability suit.

In this podcast, Dr. Greg Peterson, a emergency medicine physician with Ridgeview Medical Center, discusses opioid use disorder, treatments for opioid withdrawal, and the use of medical assisted therapy (MAT) for the ongoing opioid crisis. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: State at least 3 facts of where we (the United States) are at with the opioid epidemic today. Describe the components of medical assisted therapy (MAT). Assess the potential expansion of using medical assisted therapy (MAT) into the emergency department. CME credit is only offered to Ridgeview Providers 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 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Medical Assisted Therapy (MAT) for Opiates" (**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.)  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.”    FACULTY DISCLOSURE ANNOUNCEMENT  It is our 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. 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. SHOW NOTES: In this podcast, we are discussing opioid use disorder, treatment of opioid withdrawal, and medical assisted therapy for the current opioid crisis that is ongoing. CHAPTER 1: The CDC noted that in 2016, a little over 2 million Americans suffer with OUD (opioid use disorder). In that same year there are around 42,000 deaths related to the opioid misuse. Interestingly, about 135,000 new heroin users after misusing mediations in 2015. Essentially, over 100 deaths daily are related to this epidemic. The stats are staggering and unfortunate. The direct medical costs in 2016 were $12.2 billion. Indirect societal costs $9.2 billion. Total societal costs area somewhere around $80 billion. Interestingly, less than 5% of morphine equivalents come from the ED.  MAT is a longer-term strategy for treating patients along with counseling and psychosocial support to assist those for the propensity of misuse.  Withdrawal is treatment of acute phase sxs (n/v/d/piloerection) along with some of the more prolonged phase sxs of withdrawal include: anhedonia, depression, insomnia, decreased appetite which can last months or longer. COWS or Common Opioid Withdrawal Symptoms is a scoring tool that allows the clinician to better assess where the patient is within their withdrawal state. The scoring system is based on 0-4/5. 4 and 5 obviously being more concerning for severe withdrawal sxs. Common sxs include: HR, dilated pupils, diaphoresis, anxiety/irritability, restlessness, joint or bone pain, GI upset, tremors, runny nose, yawning, and gooseflesh skin. Usually less than 5 - no withdrawal.  5-12 your are starting to withdrawal; 13-24 moderate withdrawal; over 24 - badness. CHAPTER 2: The options for treatment of pt with withdrawal can include: opioid agonist - such as methadone or buprenorphine or non-opioid medications such as: alpha-adrenergic medications - including: clonidine, antiemetics (like Zofran). Studies show these treatment options are effective for treating the withdrawal. The medications for typical MAT use and withdrawal are the opioid agonist Methadone and Buprenorphine.  Buprenorphine is partial mu agonist and is thought of as a safer medical treatment option for withdrawal and MAT. The literature notes that their is "ceiling effect" for euphoria with the use of Buprenorphine. Typically dispensed as a tablet, sublingual film, depot injection, subcutaneous (sc patches) along with implantable.  Buprenorphrine is compounded with Naloxone (trade name Suboxone) with is thought to be safer and less prone to abuse. If given, a person is till using opioids Suboxone can precipitate withdrawal sxs.  Withdrawal sxs are based on shorter vs longer acting opioids. Norco or Percocet are shorter time periods to withdrawal in comparison to Methadone which can take several weeks before pts experience sxs. The Drug Addiction Treatment Act of 2000, or DATA 2000, requires clinicians to have a valid license, DEA#, and complete an 8-hour training course covering Buprenorphine and OUD treatment management. "Warm Hand Off" is generally the PCP or ED physician and addiction specialist having a discussion directly with the patient about the next steps in their care management. "Cold Hand Off" is streamlined referral system where social work is assisting the patient by providing resources or helping with the setup of next appointment. CHAPTER 3: Vivitrol comes in a 380mg dose of naltrexone that is given as an IM depot injection monthly for opioid medical assisted therapy. The literature seems to report that MAT combined with psychosocial management is more effective than just the psychosocial therapy.  The psychosocial model by itself has a low success rate, in comparison to combined therapy.  Some studies have included that therapy + Suboxone vs solo therapy with Suboxone did not show a difference in the rates of success. Dr. Peterson notes that proposing MAT to a medical group or hospital is complex. It requires close collaboration with addiction specialists, therapy, and social work for the continued coordination of care. Optimally, the thought is short follow-up 24-48 hrs after discharge from the clinic or Ed to addiction specialist. CITED LITERATURE: Cisewksi, DH, Santos, S, Koyfman, A, & Long, B. (2019 Jan). Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. Am J Emerg Med,37(1). pp. 143-150. doi: 10.1016/j.ajem.2018.10.013. Epub 2018 Oct 11. Duber HC, Barata, IA, Cloe-Ena, E, Liang SY, Ketcham, E, Macias-Konstantopoulos, W, Ryan, SA, Stavros, M, & Whiteside, LK. (2018, Oct.). Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Ann Emerg Med, 72(4). pp. 420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. D'Onofrio G, O'Connor, PG, Pantalon, MV, Chawarski, MC, Busch, SH, Owens, PH, Bernstein, SL & Fiellin, DA. (2015, Apr 28). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA, 313(16). pp. 1636-44. doi: 10.1001/jama.2015.3474.  Schuckit MA (2016, July 28).  Treatment of opioid-use disorders. N Eng J Med, 375 pp.357-368.  doi: 10.1056/NEJMra1604339. Sigmon SC, Bisaga, A, Nunes EV, O'Conner PG, Kosten T & Woody G. (2012, May). Opioid detoxification and naltrexone induction strategies: Recommendations for clinical practice. Am J Drug Alcohol Abuse, 38(3). pp.187-99. doi:10.3109/00952990.2011.653426. Epub 2012 Mar 12. Samuels EA, D'Onofrio, GD, Huntley K, Levin S, Schuur JD, Bart G, Hawk K, Tai B, Campbell CI & Venkatesh AK. (2019, Mar). A quality framework for emergency department treatment of opioid use disorder. Ann Emerg Med, 73(3). pp.237-247. doi:10.1016/j.annemergmed.2018.08.439. Epub 2018 Oct 11.

Ashlie: (00:18) Welcome back to another episode of tactical living by LEO Warriors. I'm your host, Ashlie Walton Clint: And I'm your co-host Clint Walton. Ashlie: In today's episode, I want to talk about how finding commodity in the most unlikely of places can really change your outlook on things. So just sit back, relax and enjoy today's content. Clinton, I were afforded the opportunity to enjoy a two and a half day fishing trip with a boat full of police officers this past weekend. We are still exhausted. We're actually finding it a little difficult to get back into our normal work routine that we're used to, but something I was thinking about. Ashlie: (01:09) It's a moment that happened on the boat that I'll probably never forget. Clint and I have gone fishing several times and I've never once gotten sick when we're in the middle of the ocean. Actually, the only time was when we took a cruise, coincidentally enough, but bobbing up and down in the middle of the ocean on a smaller boat has never been an issue for me. We were a little bit worried on this trip because there were several people that we've never gone out with before and we were worried that they were going to get sick. Something happened that first night and the captain told me that this was a slow rocking boat and that the experience was a little bit different than most of the other boats that we've been on and almost immediately getting onto that boat. I knew that I didn't feel right Ashlie: (02:10) We had this amazing raffle. There was some really cool prizes and I think that that energy sort of took my mind off of feeling sick. We ate a fish taco and as soon as I ate it, it was one of those things where you know when you're going to get food poisoning, you just don't quite feel right about what's being introduced into your body. Your body is literally not accepting it. Maybe you eat it anyways. You eat the whole thing, you eat some of it. Well, that's what happened to me. As I'm telling you this, I'm recounting it. I literally am feeling nauseous. Just thinking about the fact of ever eating a fish taco again. I don't know if there was something wrong with this fish taco or what the deal was, but that sort of set it off for me and ever since Ashlie: (02:59) In that moment, I just tried to make myself sick because I knew that was the only thing that was going to make me feel better. Sorry if that's a little graphic, but that's how it is on the boat.   Ashlie: (03:11) so we go out to the back of the boat. Mind you, I'm the only girl surrounded by a bunch of men, men who are like egging you on to get sick to be honest with you. And I wasn't quite there. I tried to like think of things to make myself sick. Clint: (03:29) It's funny that you're talking about this because I remember standing back there with you and I see just one of my partners run out from the galley and just puke over the side Ashlie: (03:41) And that's what I'm getting at. So we're on the side of the boat and one of cleanse old partners. He is notorious for getting sick on these trips all the time. So when he comes out there I'm like, okay cool. Like he's going to puke and if I just watch him puke it's gonna make me sick and then like I'll be fine. So I'm waiting for it to happen. And then another one at cleanse partners comes and all three of us are like hanging over the rails. K they're about to get sick, but I'm just waiting for them to get sick so that I can like do my thing and be done with it. Ashlie: (04:19) And then one of the other guys on the boat comes and stands behind all of us. He might've had a little bit too much to drink. He is literally ageing all three of us on to get sick. Like just telling us just to let it go and like you'll be fine after like come on guys. Like he couldn't wait for us to just get sick. And Ashlie: (04:43) I'm sure that, I'm sure that out of like the pure enjoyment of that, like the rest of the boat, well I didn't even pay attention to them but I'm thinking about it now. They, they must've been laughing their asses off just watching this take place and so we all were staring at each other like it was the weirdest thing because I remember it's pitch dark. There is a light on the boat so that's the only light we can use to see one another in all three of us are like looking over at one another and for me I'm like Shit, I'm actually like the last person in the very back of the boat. Maybe this wasn't the best place for me to stand because the other two are next to me, like directly to my left and I just hear, I just hear just going off just telling us to just like go, go, go. Ashlie: (05:32) And then finally the guy in the middle starts to throw up and I'm like, okay, great. Like, well I'm just going to watch him. I'm literally just staring at him, trying to throw up. But the guy is in the back like jumping with excitement like so, so happy that that this guy is just puking all over the side of the boat. And then I'm looking at guy number one and he's staring at me and could tell he's like trying to hold it back and like maybe he was also waiting for me to get sick. But having already in back of me, it was so funny that like my nausea went away. Like I still didn't feel good but like that whole terribly, you know like the whole saliva build up in your mouth sort of deal like that went away just out of pure humor. Ashlie: (06:20) And then finally guy number one pukes and then other guy is going crazy. Like it's some big party and then they're all looking at me like waiting for me to just puke. And I was just like just, I was just too into this guy and his excitement for what was happening that that just didn't happen for me at that time. And something happened in that moment of like the, the most pure vulnerability. Like, if you've never been out on a boat when you feel sick, like it's probably difficult to understand. But that is the worst feeling I think I've ever experienced physically in my entire life is to be sick on a boat. Like you want nothing more than to just like shoot me now, let it be done with like, cause there's nothing you can do. The boat's not gonna turn around. Like a helicopter isn't coming to save you. Ashlie: (07:12) Like you're going to have to tough this out. And mind you, this was just on a Thursday. We weren't coming home until Sunday, so I still felt sick and I didn't, I didn't get the opportunity to throw up that night. So I went to bed and luckily the next morning I was able to like get sick and then I felt completely fine for the rest of the trip. But the relationship between me and guy one and guy two throughout that entire trip, it seemed to be a little bit more connected. And I think that stems from being in this place of literally we just felt like we were dying or at the very least we wanted to die because of how miserable it faults. But as sadistic as that sounds, there's this sort of comfort that came along with that because everybody else on the boat was completely supportive and understanding because even those that didn't feel sick to their stomach but still felt a little off, like they understood what we were all going through and it wasn't a matter of like, Oh, poor Ashlie, you're a girl. Ashlie: (08:19) Like never once did I feel that. But it helped to create this inner bond between us. And there was a firefighter on the boat that we had met for the first time and he was so kind to everybody on the boat and he had brought some Zofran. It's a very, very strong anti-nausea medication. They actually use it for chemotherapy patients. And he had offered one of those to me and to some other people on the boat. And it just, it really helped to set that foundation for us, setting off into the unknown as we traveled in the middle of the night to go fishing and to enjoy our time together. And I think that that type of environment, not only us getting sick, but just seeing the way that everybody was interacting with one another, it helps to create an even better trip than we thought it was going to be. Clint: (09:16) And I think the big thing with that is, you know, we all checked in on one another. Those who got sick, those who weren't sick, it was just that brotherhood and sisterhood of wanting to make sure everyone's okay because we all wanted each other to have a fun time and seeing people sick like that. It's a miserable feeling and you don't want anyone to not enjoy their time because of it. Ashlie: (09:45) It's true. If I could think of one thing that I would never want anybody to experience even more so than the physical pain of an injury that I've felt or surgeries that I felt like the worst is being sick like that in the middle of the ocean. So of course like you would never want that to happen to anybody that you're sharing space with, especially in a confined space like you are when we were on the boat. Ashlie: (10:11) But even the commodity of being next to each other while we were fishing, it's, it's definitely, it's definitely a craft, right? To be able to fish alongside other fishermen on a boat. It's not just like you pop your line in the water and then you'd just go with it. It takes them some teamwork and I felt that that teamwork started to build more and more as we were on the boat, the longer and longer we were on the boat and people got the hang of it. And as you sit there, if you've never been fishing on a boat like this before, when when you're fishing, you literally have to start rotating in order to make sure that your aligns don't get tangled with one another's. And if you're not paying attention, which yes it happened, then your line can easily cross and create a huge mess. Ashlie: (11:00) Or if you're really not paying attention and you decide to drop your line against the current where everybody else's lions are going, you can literally tangle the entire boat's lines by that one. Careless mistake. And being able to chime in with one another and just say like, Hey, don't drop your line there. Like nobody got mad at that. Everybody was, was in the same mood. Everybody was there to have a good time and really just build on that relationship with one another. And I can't wait to go out again. I can't wait to see these people again. Especially some of the ones that we had the opportunity to meet for the very first time. Clint: (11:40) And what was cool about this trip too is you know the people that you're talking about. Have we met for the first time, they were great guys and I really enjoyed fishing with them and they enjoyed fishing with us and we were able to create that bonding with them. So to further ourselves in that world and, and friendships, new friendships with them is just a great feeling. Ashlie: (12:08) It is. And it's not like you're meeting up at a concert to meet some new people. The dynamics of a deep sea fishing trip like this really helped to instill that bond even further, even upon first meeting. Clint: (12:21) Yeah, and I mean, we literally lived on the boat with him for two and a half days. I mean, you can't get in tighter quarters in that. Ashlie: (12:32) And what I want to stress to you today is the importance of just being open, being open to the opportunity of creating bonds, even in the most unlikely of places. It's so easy for us to be waiting in line for our coffee and staring at our cell phones. But what would happen if you put your phone away and started to engage with the person behind you in line? These are the types of things that I think we're losing connection with, with humanity in general, and by being able to just be more alert and more cohesive with the fundamentals of being a human being and having that human connection with one another, then you're really able to enjoy your Tactical Living. Balance. Optimize. Tactics.  Hit that subscribe button so that you don't miss a day of the added value that I am dedicated to sharing with you weekly.  Let's Connect!  Facebook  Instagram  Email: ashliewalton555@gmail.com  LinkedIn  Website: www.leowarriors.com and www.leowarrior.com

Author: Jared Scott, MD Educational Pearls: Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis) When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0) References Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

I.Couldn't.Stop.It.If.My.Life.Depended.On.It. Kristen is back to talk about her birth story with Georgie. After suffering a miscarriage, a subchorionic hemorrhage and a 30+ hour first labor she was ready for another baby. She found out she was pregnant just before Christmas, but she couldn't tell anyone. The sack was small and they were not able to see a heartbeat. They told her it might be a blighted ovum and to come back in a few weeks. At 8 weeks, they were able to see the heart flicker and celebrated with all. She was so sick. She took Zofran, but the only thing that helped was Sour stuff like Chick-Fil-A lemonade and Starbuck's Iced Passion Tea Unsweetened and protein and fat. She lived on chicken nuggets and sausage, egg and cheese sandwiches. At 22 weeks she started suffering from symphysis pubis dysfunction (SPD) Desperate to go into labor, she started to call Hawthorne's Pizza to order the famous "inducer." As she went to dial, her water broke at 39 weeks and 5 days gestation. Immediately she was sailed into active labor with "cavewoman" like noises. She got to the hospital and delivered all within 2 hours. She even went from 4 cms dilated to a baby in her arms in 45 minutes. It can happen people! Kristen's favorite baby product is Quick Zip Crib Sheets and she recommends a baby carrier for baby wearing especially for #2. Use code BIRTHSTORYPODCAST for 15% off QuickZip Sheets!!! Thank me later. BIRTH STORY PODCAST INSTAGRAM: https://www.instagram.com/birthstorypodcast BIRTH STORY PODCAST FACEBOOK: https://www.facebook.com/birthstorypodcast LOOKING FOR A DOULA IN CHARLOTTE, NC? HIRE MyDoulaHeidi

Welcome back to our weekend Cabral HouseCall shows! This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track! Check out today's questions:  Meghan: Hi Dr. Cabral- I love listening to your podcasts while I work out, especially the recent ones on Ayurveda. They keep me motivated and excited to make healthy choices throughout my week. I recently enjoyed your podcast on the 7 foods you eat daily and can't live without. Your discussions on food have helped me fine tune my diet (like eating oats and berries more frequently!). In your podcast you mentioned that you'd like to hear if there was something your listeners eat on a regular basis and can't live without. I eat a granny smith apple almost everyday. I'm prone to constipation so it's really important that I get the right type and amount of fiber everyday. I don't know what it is about an apple but it truly does keep the doctor away for me! That along with plenty of water of course. I'm curious to know your thoughts on that since I haven't heard you talk much about the benefits of apples (I recently started listening within the last few months). Is it merely the fiber content or something else too? Or maybe I just found something that works well for my body!  Misty: Hello! I’ve been listening to Stephen Cabral’s podcasts and I applied in October to go to school for integrative health but I’m nervous that the school is so new that I may not get the education I need. I am a registered nurse with a background in Intensive Care and post recovery from surgical procedures. I ultimately want to own my own health “center” with nutrition classes (for profit & community volunteer education for the less affluent), include a “fast food” section for healthy dieters, exercise center (local teachers for yoga/weight lifting/etc), and a homeopathy shop with local vendor items and aromatherapy.  I am, as of now, going to Maryland University of Integrative Health (MUIH) for the Masters in Nutrition and Integrative Health. Do you or Stephen know of this school? It’s regionally accredited but I want to make sure I am getting what I pay for, it’s pretty expensive. They over post graduate certifications in aromatherapy, Chinese medicine, and yoga which I intend to obtain when I’m done. Please help! I need some advice. Sincerely, Misty  Andrea: Hello! quick question! I started the SEED CYCLING that Dr. Cabral mentioned and advised. I was wondering how long I could expect to do the cycling before seeing changes in my menstrual cycle...? I know it depends on the person and that there are too many variables to conclude as to when any one woman will see its effects- but I am a 26yr old female, 130lbs, very healthy other than having no menstrual period for 2yrs. I have done the cycling for one month thus far and will continue it indefinitely. Any answers would be helpful! I'm grateful for your all!!!! Thank you in advance, Andrea  Darrow: Hey. I am a firefighter working shifts day and night. I am reading your "A Man's Guide To Muscle and Strength". Great book. I am a vata pitta body type, more vata. Was wondering how I should go about training given my work schedule. Sometimes we have major calls that calls for hours of strenuous work in smoke filled environments. Or nights where we're out working. Should I still try to train on those days or count that as a strength day. I've friends I train with in the construction industry who are working hard everyday who have similar concerns. Keep up good work. Also what do you recommend if one has been briefly exposed to smoke inhalation. What immediate measures he can do to minimise any potential damage? Thank you.  Halle: Hi! Was just looking to see if there was a podcast from you guys about acid reflux and natural ways to diminish the symptoms. Thanks!  Tyffany: I'm on day 7 of the 21-day Detox and had a failed lunch. I am in the military and had only dining hall fare to choose from. Will picking up right where I left off be ok or do I need to do something special to start over?  Laura: Hi Dr. Cabral! I’m scheduled to have double jaw surgery (4-6 hours procedure) at the end of February 2019. I’ll have finished your CBO protocol by the end of January 2019 and will do your CBO Finisher Heal & Seal for one month before my surgery. I have some questions. 1. What would you recommend I do before my surgery in order to prepare I am ready? Any supplements I should be taking or natural remedies? I’ll be on your CBO Finisher but is there anything else I should incorporate?  2. For this surgery, I will be prescribed a lot of medication. I have to use an anti-nausea patch and Zofran (anti-nausea medication) before/during surgery. Afterwards, I know FOR SURE I will have to take antibiotics, nasal sprays (like Afrin, Simple Saline Spray, Decongestion Spray) and then possibly Oxycodone, Ibuprofen, Prescription Joint Medication, Mucinex, Tylenol, and Benadryl. As you can see a lot of medication! What do you recommend I do after surgery so that I can make sure my gut isn’t completely ruined after going through your whole CBO protocol? What supplements of yours do you recommend?  3. Any supplements/natural remedies you also recommend after surgery to help heal or to help with pain? I want to try and use as little medication as possible, but I just don’t know how bad I’m going to feel after.  Just so you know, I’ll have to be on an all liquid diet for 10 weeks after surgery! Thanks so much for all you do! Really appreciate it!  Darrel: Hey Dr. Cabral. I am of African descent and have to shave my face regularly. I do so using a depilatory shaving powder called SoftSheen-Carson Magic. Listening your podcasts and reading Rain Barrel Effect has me wondering whether there are any major toxic drawbacks from using it. Searches on EWG website proved futile. If it is negative can you suggest alternative options. I cannot use razors because they cause ingrown hairs. Thank you, keep up great work. Thank you for tuning into today's Cabral HouseCall and be sure to check back tomorrow where we answer more of our community’s questions!  - - - Show Notes & Resources: http://StephenCabral.com/1086 - - - Get Your Question Answered: http://StephenCabral.com/askcabral   - - - 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 Supplements: > “The Dr. Cabral Daily Protocol” (This is what Dr. Cabral does every day!) - - - > Dr. Cabral Detox  (The fastest way to get well, lose weight, and feel great!) - - - > Daily Nutritional Support Shake  (#1 “All-in-One recommendation in my practice) - - - > Daily Fruit & Vegetables Blend  (22 organic fruit & vegetables “greens powder”) - - - > CBD Oil  (Full-spectrum, 3rd part-tested & organically grown) - - - > Candida/Bacterial Overgrowth, Leaky Gut, Parasite & Speciality Supplement Packages - - - > See All Supplements: https://equilibriumnutrition.com/collections/supplements  - - -   Dr. Cabral’s Most Popular At-Home Lab Tests: > Hair Tissue Mineral Analysis (Test for mineral imbalances & heavy metal toxicity) - - - > Organic Acids Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Thyroid + Adrenal + Hormone Test  (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Adrenal + Hormone Test (Run your adrenal & hormone levels) - - - > Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Omega-3 Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - > Stool Test (Use this test to uncover any bacterial, h. Pylori, or parasite overgrowth) - - - > Genetic Test (Use the #1 lab test to unlocking your DNA and what it means in terms of wellness, weight loss & anti-aging) - - - > Dr. Cabral’s “Big 5” Lab Tests (This package includes the 5 labs Dr. Cabral recommends all people run in his private practice) - - - > View all Functional Medicine lab tests (View all Functional Medicine lab tests you can do right at home for you and your family!)

Communicating with Patients about Financial Toxicity: Dr. Ryan Nipp Welcome to the ASCO Daily News podcast. I'm Alex Carolan, and joining me today is Dr. Ryan Nipp, a gastrointestinal oncologist and health services researcher at the Massachusetts General Hospital Cancer Center. Dr. Nipp, welcome to the podcast. Thank you. Thank you so much for the opportunity. Of course. Financial toxicity is a big factor in how patients with cancer approach treatment. Dr. Nipp, how do you talk to your patients about this issue? It's a great question. I think there are a number of ways to somewhat, you know, bring up this topic in clinic with patients. I don't know that there's one correct way. I think it somewhat depends on the person, depends on the patient and how well you know the patients, somewhat depends on when the topic may come up and how it comes up. So, often, when we meet patients for the first time, we have a multidisciplinary discussion about the treatment plan, the options, and potential side effects, and side effects related to the cancer and the cancer therapies. And that's where I've started taking the opportunity to say, how are things going? Any issues with nausea, pain, bowel issues? And at that point-- also, kind of bring up the thought of sometimes therapies can be expensive. Sometimes when people get sick, they have to take time away from work. Has any of this affected you up to this point-- and kind of just opening up the idea to are there any issues. At other times, they'll be issues that come up throughout treatment where someone's having trouble with insurance covers or co-pays or getting to clinic on time or finding a ride. And so that will be another opportunity where people kind of offer you this opportunity to bring up the idea and at least start to discuss it and see if it's a problem. And, you know, for the most part, people welcome the question. A lot of the time, people are like, no, I'm doing fine, but thank you for asking. But for those certain people where it is a problem, I find that it's a huge problem. And they're incredibly relieved to hear about it and have the opportunity to talk about it. That's good to know. And with that in mind, how do you create treatment plans while taking financial toxicity into consideration? Yeah. This is a little bit difficult. I don't know that there's any correct answer. I think that you have to be mindful. It's just like you would with any other toxicity that you're dealing with. If you know a therapy is going to cause nausea, you have nausea medicines. If you know a therapy may have cardiac side effects, you think about discussing that with the patient, letting them know the risks, you know, what are the percentages and the potential that this could happen to them. And just so that people know that down the road it's not a surprise if and when something happens, you almost have that obligation to bring it up. And that's the way I've started to categorize financial toxicity in my mind as well. It's another side effect that could come up at some point. If it hasn't come up yet, it may come up at some point. And you don't want to surprise patients with it. I think that's one of the big issues right now with financial burden that patients encounter throughout their care or that they're just worried about it. It's just this unknown of you hear about the financial toxicity of cancer. And it's so scary when you've got a new diagnosis. There's so many things that you're dealing with as far as symptoms, and job, and family, and how are you going to handle this, and just coping with so many other things. And this is another thing, just the uncertainty of what things may cost-- co-pays. Do they have insurance? Can you get time away from work to do this? And so I think it is just something to bring up that it could happen down the road, that this does happen to some people. And then that kind of brings you to the point of what options are available for people if and when that does happen. Similar to where if you had nausea or diarrhea that people may be experiencing, you can say, if and when that happens, we've got resources available. And here's what we have available at our institution. And, increasingly, there are more options available to help patients. And so I think that's something that clinicians, you know, throughout the clinic, you know different clinicians-- social work, financial navigation, MDs, nurse practitioners, physician assistants-- can help with, just kind of getting familiar with what the institution may have, may not have, what's out there in the country as far as other resources and things going on to help. Right. How does financial toxicity affect patient quality of life and treatment outcomes? Yeah. That's where I think a lot of the research has been growing in recent years is kind of describing that this is a huge problem for patients. I don't think it's all patients. But definitely, for those patients where a financial burden or financial toxicity is an issue, it is a major issue. It has shown in multiple studies now to negatively correlate with patients' quality of life. And then interestingly, if you think about, you know, the financial toxicity and financial burden that patients may be experiencing, it would make sense that that might impact how patients may adhere to certain medications. Might patients, if they're experiencing financial burdens, not want to pay for their Zofran or pay for other medications that might help them with side-effects of treatment. And then that point, you know, if you're not adhering to certain medications that you may or may not have needed, then that's a barrier to getting adequate symptom control, supportive care, and then ultimately could affect outcomes related to cancer therapy if you're also not able to adhere to your chemotherapy regimen or schedule and having to, you know, miss trips or missed visits-- another way that it can impact patient outcomes. And there have been studies showing associations with financial burden and adherence to medications and, if you take it even further, to potentially affecting patient survival. In what ways can oncologists ease patient burden through advocacy or financial navigation programs? I think advocacy is a good way to put it, meaning that you are kind of their advocate at this point, where, as a clinician, you may or may not. That's one of the barriers right now within the world of oncology, that we may not actually even know that our patients are struggling with financial burden or we may not know how much their copay is. We don't understand what their insurance may or may not cover or what certain drugs might cost. And so it's going to be somewhat of a learning curve with all of us as far as, you know, I've seen patients with this before. I have understood that this medication can be expensive. Or I understand that this medication is needing to be frequently refilled. And so this may, you know, add to the cost of your care. So you're their advocate. Knowing that you've had experience with this before, it might actually, you know, behoove them to be thinking about this could become expensive and just to let them know about that, that it could be coming down the road. And then that gets into, well, what are we going to do about it if and when the financial burden, you know, hits or becomes a problem. And that's where there's more and more research that's needed. I think there's a lot of research underway looking at financial navigation programs, financial counselors. Social work has been really helpful at our institution. I often go to other clinicians, the nurse practitioners or mid-level practitioners, that are helping us in clinic that have done this more than, you know, others and have seen this before. And are there programs available as far as getting reimbursements or some way to help patients with their co-pays? We've done a little bit of research here at Mass General as far as helping with patients to stay enrolled on cancer clinical trials to, you know, somewhat as far as the travel and lodging that's related to the frequent visits associated with clinical trials. Could you reimburse for some of the travel on lodging and help, you know, alleviate some of the financial burden? And that's one strategy. Again, how sustainable and how scalable that strategy is in question. But at least, you know, there's people out there thinking about it. I understand there's, you know, a good number of start-ups. There's multiple advocacy groups, online communities, that are thinking very hard about this. And how can we do more research and better understand the problem in order to intervene upon the problem? What role can research play to help patients and oncologists stand on the same page regarding the effects of financial toxicity on their treatment? Yes. I think this is a very important point. I think getting patients and clinicians on the same page regarding the financial toxicity has been an issue in the recent years where more and more research is showing this is a problem. And I think it is now getting to the front lines as far as clinicians, oncologists, their staff, their faculty are understanding that we need to be thinking about this as a problem. And that's one huge hurdle, at least identifying this as a problem and naming it. And, now, I think the next step for research is to start trying to intervene, trying to think of creative ways to do something about this. Are there apps? Are there financial navigation programs as we've mentioned-- social work, implementing social work earlier in the course, or having ways of identifying, you know, what a drug or combination therapy is going to cost for a patient and letting them know up front? You know, these are the options available if there are options, if there's multiple chemotherapy strategies or multiple nausea medicines that are out there that could work equally effective. Is there a way to then discuss that with patients in a way that says this may cause this? This may cost this. This is what this schedule looks like. You'll be coming in weekly versus bi-weekly. And this is what the drug costs and may affect your job or your work life and how your family might need to be helpful at certain times. And similar to the way we deal with other toxicities where we trade off if somebody has renal issues or other blood problems where certain treatments may not be the best idea for them, we think creatively about ways to get people the best treatment possible for them. And I think that's going to be a lot of the research in the next few years is looking at how can we intervene upon the problem of financial toxicity. And it's actually really exciting that this movement has taken off. We've now named the problem. It's become mainstream and gotten a lot more attention. And I think, now, the next step is for all of us in the research community and in the clinician community to start thinking about creative ways to help with the problem. Again, my guest today has been Dr. Ryan Nipp. Thank you for joining us. Thank you so much for the opportunity. It's always my pleasure. And to our listeners, thank you for tuning into the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate and review us on Apple podcast.

In this episode, we sat down for a laid back conversation with Kate Spinner - a local mom and CrossFit box owner. She shares her journey to motherhood, baby Luke's birth story. And we had a lot of fun discussing fitness - prenatal, postpartum, and after a miscarriage, and chatting about that mompreneur life. We hope you enjoy this interview! 3:30 – Candace What’s Up 5:55 – Anna What’s Up 7:15 – Kate What’s Up 8:32 – Kate’s Introduction 11:20 – First Miscarriage – Early Term Miscarriage 12:35 – Keeping Baby Hope’s Memory Alive 16:50 – Second Miscarriage/Stillbirth 17:10 – Getting pregnant with Luke Mindset – fear of pregnancy after miscarriages 19:10 – How she felt during pregnancy Zofran, Progesterone shots 21:27 – Birth story C-section, NICU stay 25:25 – The journey back to fitness Working out while pregnant Each person is different Subchorionic hematoma 35:28 – Fitness in the postpartum period Diastasis Recti, Birthfit Functional Progressions 37:20 – Mompreneur Life Kate’s desire to get back into competing 46:10 – I Am Stronger – nonprofit Kate runs – www.iamstronger.org Free girls class on Saturdays Girls Only Fall Camp 48:40 – Progesterone in 3rdpregnancy because of pre-term labor details 51:25 – Rainbow babies 52:55 – How do you feel you’re Delivering Strength? 55:10 – How can our listeners find you? cocacrossfit.com iamstronger.org katerawlings.com Delivering Strength: Find Us Online Website – www.deliveringstrength.com Facebook – www.facebook.com/deliveringstrength Instagram – www.instagram.com/deliveringstrength Facebook Community – www.facebook.com/groups/DeliveringStrength/   If you have show topics or guests that you’d like to recommend to us, please feel free to send us a message through our website or send us an email at info@deliveringstrength.com. Find Dr. Candace Gesicki, DC at Cleveland Chiropractic & Integrative Health Center or Birthfit Cleveland. 

There are certain things in medicine which simply can't be taught by reading a textbook. Not everything follows an algorithm. About one year ago I had an 80 year old patient who kept complaining of nausea and abdominal pain after having a cholecystectomy. The surgeons kept telling her this was normal following this type of procedure and prescribed Zofran. Well, she eventually came into my ER and she didn't look to good. She became septic. We followed the septic protocol - but she ended up dying. Today, I want to share a very important lesson I learned... - If you haven't already - consider subscribing to our YouTube here: http://www.youtube.com/subscription_center?add_user=paboards - You can also follow Medgeeks founder's youtube here: http://www.youtube.com/c/andrewreidvlog - Follow us on Instagram here: https://www.instagram.com/medgeeksinc and https://www.instagram.com/pance_panre_usmle_review/ - Ace your exams: https://learn.physicianassistantboards.com/collections - Have questions about this podcast? Email gray@physicianassistantboards.com - This podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast, video, or blog.

It’s very common to have nausea and vomiting in early pregnancy. But there are times when it’s not that simple. Some women progress to Hyperemesis Gravidarum which can be a serious condition. Learn what’s normal, what’s not and how it’s treated!

Author: Arthur Lessen M.D. Educational Pearls: Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades.   Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised. When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic.   References:  https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm  

Join Dr Mike in the PediaCast Studio for more news parents can use! This week we cover Zofran & birth defects, swaddling babies & sudden death (SIDS), the full moon’s effect on behavior, taxi and Uber safety, and pop stars & bad food. Dr Sam Weisz also stops by to talk about Sugar Bugs, dental care and cavity prevention.

Zofran is an anti-vomiting anti-nausea medication prescribed to pregnant woman, which has been proven to cause serious birth defects and in some cases hurt the expectant mother.

The post Ondansetron (Zofran) appeared first on NURSING.com.

What should you do if Zofran or the other prescription medications aren't enough to combat the nausea and vomiting of pregnancy? What if you're not eating or drinking and no one in your town knows how to treat Hyperemesis Gravidarum? What are you options? In this episode, I talked to Katie when she found herself in this exact scenario. She found that marijuana was more helpful and allowed her to eat and take care of her child than the prescription drug Zofran. In this episode: Mental effects of HG and malnutrition Zofran made Katie feel like she was on drugs Immediate relief that lasted for hours The options: edibles, tinctures, smoking, vapor CPS and mandatory testing in the hospital Link to article discussing the dilemma of eating vs. illicit cannabis More information about HG and Medical Marijuana

I've been there before. Panicking in the bathroom, wishing it wasn't true. It's a hard question to try to answer because nothing I say is going to make you feel magically better. If you're already sick then more than likely it's going to continue to some extent. But learning what works best for you and fighting it everyday could mean the difference between hospitalization and infection, or staying home. If you haven't done it already, I highly suggest you get a Doctor's appointment, the soonest available. Ask for medication and start taking it round the clock right away. If you haven't gotten sick yet, you could just have it on hand until it starts. For some people it's violent from the start. Keeping yourself out of a bad cycle of dehydration and vomiting and not eating is the overall goal. Medication to ask about: Zofran: (prescription) (ondansetron) Anti-emetic (it helps control the vomiting) Unisom: (Over the counter) (doxylamine) anti-histamine (helps control the nausea) Diclectin: (prescription) (Pyridoxine/doxylamine) which is unisom and B6 together in a time release capsule. Phenergan: (prescription) (Promethazine), (I.V., suppositories, pill) Reglan: (prescription) (Metoclopramide) dopamine-receptor antagonist. It can help with nausea and vomiting by helping with gastric emptying. It's often given to people with GERD. However, one adverse effect to watch out for is called tardive dyskinesia. It can also make you feel tired, restless and anxious. Gabapentin: (prescription) (Neurontin) anticonvulsant and analgesic, usually given to control seizure disorders or neurological pain. This is still being trialed and is not commonly prescribed. Adverse effects for pregnancy are unknown. Dealing with constipation as a side effect of medication, notably Zofran. You can ask your doctor for a stool softener to be proactive and try to prevent constipation from happening. You can also try milk of magnesia or another kind of magnesium pill or liquid. That can help in numerous ways, including getting some much needed magnesium. If you're already constipated, I would suggest doing more than that to try to get ahead of the problem. Glycerin suppositories (can be found in more drug stores in the U.S.) Enemas (like Fleets brand enema): It comes in a self contained package with saline. One time use. Willard water Saline warm water Magnesium oil: You can make it yourself. It's actually not an oil but a solution of equal parts magnesium chloride and filtered water. What would you tell someone with HG who just found out they were pregnant?  

I wasn't always this obsessed with figuring out the why behind Hyperemesis Gravidarum. It took me a long time just to figure out that what I had when I was pregnant even had a name and was "a real thing". And then for awhile, I bought all the lies:  that it meant the baby was healthier, that the baby could get everything it needed from me, even if I wasn't eating or I was eating junk food and, the biggest one, that there's nothing I could do about it. Don't get me wrong, there's no simple answer for most people. But as science has advanced (especially since I took genetics in college) we have a better understanding of genetics. We no longer are doomed by our genes, but can effect change on our genes. We can turn genes on and off. So even if there is a genetic component to HG, that doesn't mean we can't have an affect on them through our nutrition and exposure to our environment. I'll give you an example from my own life. When I was 9 years old, I developed asthma. I started coughing and wheezing and no one could figure out why, so they took me to the ER. They decided I had asthma and was allergic to wheat dust. And I lived in Kansas on a wheat farm. So, I took a lot of medicine. I never left the house without an inhaler. I wore a mask during wheat harvest and I coped. I wasn't severe. It went up and down with the seasons and exposure, but I was fine. I was manageable. I moved away to college and it was the same thing. Up and down, don't leave the house without an inhaler. I was an asthmatic and I believed I always would be. All throughout my pregnancies and moving all around the country, I kept that albuterol inhaler nearby. It wasn't until right before I got pregnant for the fifth time, that I had a paradigm shift. Or the start of one. I made an appointment with a new doctor as we had just moved to the area. She asked me if I'd be willing to change my diet. I thought that was weird, because I had asthma. Why would I need to change my diet? She gave me a prescription for medication, a list of supplements I should look into taking and some foods I should consider excluding. I took her advice. Not all right away. Especially because a month or so later, I found out I was pregnant for the fifth time. Having had a terrible time with my fourth pregnancy, I immediately went to the first OB appointment I could get and got a prescription for Zofran and took that and Unisom as soon as the nausea started. That was the beginning of the end for me, though because it was being attached to those drugs and the words of my doctor echoing in my head that made me say, "Why? Why do I have to take medication at all?" It didn't seem right to me. I've learned a lot since then. I've changed a lot since then. I'm still learning and changing and growing. But here's the best part. I am no longer taking asthma medication. I still have an inhaler in my medicine cabinet. I don't consider myself CURED,  but I do consider myself recovered. And this experience, as well as talking to many other women who have changed their own health, has made dig deeper into the why of Hyperemesis Gravidarum. I don't believe it's normal. I don't believe it's healthy. And I don't believe it's not fixable. I don't believe I needed to suffer like I did and it pains me that so many women are still suffering so much just to have a baby. And I do believe that in finding out what is causing Hyperemesis Gravidarum, we can help countless women take back their health. Not just during pregnancy, but for the rest of their life. References in the podcast: Gelbvieh cattle (They're handsome beasts aren't they?) Unisom -I didn't mention vitamin B6, because I could never keep it down. But the unisom helped. (I would notice if I didn't take it.) What's your experience with Hyperemesis Gravidarum been like?

Dr. Stephanie Harman, Director of Palliative Care at Stanford University Medical Center, reviews nausea in the context of cancer, as well as the range of treatment options to manage it.

Dr. Stephanie Harman, Director of Palliative Care at Stanford University Medical Center, reviews nausea in the context of cancer, as well as the range of treatment options to manage it.

Mary Rose's labor went so fast she wouldn't have had time for medication if she wanted it. She went from “let's do this” to “your baby's here” in only 20 minutes of pushing! After struggling through a violently ill pregnancy, she got the beautiful birth she dreamed of.Hyperemesis gravidarum made the first 20 or so weeks of Mary Rose's pregnancy a nightmare.  It's more than just morning sickness. Hyperemesis refers to extreme nausea and vomiting during pregnancy. She couldn't keep anything down and eventually had to go for in-person liquid infusions after losing an unsettling amount of weight. But after that phase passed, she was able to have a normal pregnancy and a birth that went more smoothly than she could've anticipated.In this Episode, You'll Learn About:What hyperemesis gravidarum is and how it affected Mary RoseHow her care team could have done more to support her conditionWhether or not Zofran helped with her nausea and vomitingHow infusions helped her feel betterWhy she chose a doctor who didn't have the best bedside mannerWhat she expected labor to look like versus what really happenedHow she used breathwork to cope with her contractionsWhy she's grateful to have worked with a doulaHow quickly she was in and out of the hospitalWhat her experience was like with placenta encapsulation--Full website notes: drnicolerankins.com/episode234Check out The Birth Preparation CourseRegister for the class How to Create a Birth Plan the Right WayOur Sponsors:* Check out ByHeart and use my code DRNICOLE for 10% off your first order! - https://byheart.com/podcast* Check out Mabbly : https://lactationnetwork.com/* Check out Warner Bros: https://www.warnerbros.com/movies/the-color-purpleAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy