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S2D: The Symptom to Diagnosis Podcast - Episode 05: Cough, Fever and Respiratory Complaints
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S2D: The Symptom to Diagnosis Podcast - Episode 05: Cough, Fever and Respiratory Complaints
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Language: EN.
Segment:0 .
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we are back with episode 5 of the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. Each episode is divided into four parts. We begin each episode with a case, unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand, we then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge pertaining to the week's symptoms.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites. Our topic this week is cough, fever and respiratory complaints. Scott, you are the expert of the day though I'm honestly not sure I can call you an expert since you wrote an entire chapter on cough fever and respiratory complaints and neglected to include COVID.
DR. CIFU: Anyway, do you have a case to present to me?
DR. STERN: I do but that's not quite a fair criticism given that COVID wasn't on the planet when I wrote the chapter, but anyway, I thought we'd do something different for a change. And that is focus on respiratory complaints that weren't COVID. We do have a lot of information right now in the media and elsewhere about COVID. So I thought it'd be useful to describe our approach to patients who have respiratory complaints that are not COVID-related, sound okay?
DR. CIFU: Sounds good, I guess I'll buy that excuse.
DR. STERN: [laughs] Good 'cause that's all I've got. All right, so how's this? This is a patient I saw many years ago. He's a 72-year-old man who came in with cough and fever for about 10 days. He told the team that he'd been sick for about that period of time, started with a mild cough, it was not too productive and associated with some low grade fevers. He didn't pay too much attention initially but his cough and his fever persisted, and he even developed some more shortness of breath when he was walking around and climbing the stairs.
DR. STERN: At that point his wife got worried actually and she insisted he come in for an evaluation, which is probably why married men live longer than single men. His past medical history is remarkable only for some well-controlled hypertension to diabetes. His last glycohemoglobin was 7.6 and on physical exam he looked overall healthy, no acute distress, his temperature was 38.2, his respiratory rate was up a little bit to 20, his blood pressure was 147/84.
DR. STERN: His pulse was 95 and his room air saturation was 92%. His cardiac exams showed a regular rate, rhythm without murmur, gallop or rub. And his pulmonary exam though revealed diffused crackles in the lower two thirds bilaterally. And he had no peripheral edema. So that was this presentation. Adam, what do you think? What would you do here? What are you thinking?
DR. CIFU: Well, that's an interesting case. There are a couple of things which actually sort of throw me off on that one. So he's a 72-year-old guy, diabetes and hypertension but sounds like he's pretty healthy. And he sounds like if he were to have a pneumonia, let's say he would have, you know, he'd be at high risk for community acquired pneumonia, meaning he hasn't been in the hospital. I haven't heard risk factors for aspiration, you know, he's not an alcoholic, not someone with a seizure disorder.
DR. CIFU: But what confuses me a little bit is one, this has kind of been going on for a while, right? It's 10 days and often when I think about things like, you know, pneumococcal pneumonia, it's often very quick, mycoplasma or the atypicals is certainly a possibility. And of course, 72-year-olds can get that but I really think about mycoplasma, chlamydia, legionella as being, you know, a younger man's disease, certainly legionella disease being different.
DR. CIFU: The other thing which is striking is that he's pretty hypoxic, so given, you know, the slow kind of subacute nature, I may say, oh, you know, this is a viral bronchitis or even a bacterial bronchitis but you know, when then I hear that he's hypoxic, I'm going, wow, that's really more consistent with the pneumonia. And then his lung exam, you know, sounds strikingly abnormal.
DR. CIFU: And it doesn't sound like a focal lobar pneumonia, right? So, you know, what am I thinking at this point? Hey, I'm thinking the guy needs a chest X-ray and I'm thinking he needs a chest X-ray 'cause he's hypoxic and he's got an abnormal lung exam plus he's got a febrile illness, so the possibility that he's got pneumonia is fairly high. I think, as I think about differential diagnosis, I guess an atypical pneumonia is probably highest on the list for me and by that, I mean, as I said, things like chlamydia, legionella, mycoplasma, I guess I broaden things out a little bit to, you know, some stranger pneumonias, you know, does this guy keep birds and maybe he's got, you know, bird keepers' pneumonia, maybe he's recently run over a rabbit while he was mowing the lawn and has tularemia.
DR. CIFU: I don't, you know-- you said this was 10 years ago. We used to see a lot of pneumocystis so I guess that's a possibility, 72-year-old married guy, of course it could be, though he'd be at lower risk, I guess now pretty much everybody is screened for HIV. So I got to say maybe either way I'd screen this guy and I think that's kind of where I am at this point.
DR. STERN: All right, so that's very good and very thoughtful and I didn't mention the fact he has 5,000 birds in his house. No, he doesn't have any birds, and he expresses no interest in hunting rabbits but we did get a chest X-ray, which actually showed bilateral diffuse infiltrates. His cardiac silhouette was normal and he had no pleural effusion. So as you integrate that in your thinking, what would you be thinking?
DR. CIFU: Yeah, you know, as soon as I stopped talking, I thought one other thing I should have said is that to think about non-infectious causes, you know, we're talking about cough, fever and respiratory complaints today, you know, this isn't a bad presentation for a heart failure, right? Except that the guys is febrile. Now that I see this X-ray with a normal heart size with no pleural effusions, I think that makes heart failure fall even further down on the list.
DR. CIFU: So now I think I'm at the point where I would say atypical pneumonia is like absolutely a possibility here, pneumocystis, actually a possibility here. So I think I would want, you know, legionella antigen on this guy, I'd want an HIV test on this guy. I guess I'd also want a CD4 count on this guy because even if he was HIV positive, to really think about pneumocystis, you'd want a low CD4 count. That would be obviously a great surprise to me, to the patient, to his spouse.
DR. CIFU: But I think that has to be in the differential diagnosis. I think that's about as far as my differential goes.
DR. STERN: Well, that's really wonderful. So we saw his chest X-ray and he really did have diffuse infiltrate, which is different than multilobar infiltrates, and really does raise the question of some sort of viral pneumonia or pneumocystis pneumonia of that sort. It was not flu season. And so we did send off in addition to starting him on community acquired pneumonia therapy, we sent off an HIV and a CD4 count as well as the legionella antigen.
DR. STERN: Now the urinary legionella antigen was negative but low and behold, his HIV test was positive. His CD4 count was 120. And that meant that this was very likely to be pneumocystis although you can't make that diagnosis clinically, the literature says that if you try to make that diagnosis clinically based even on an HIV and a low CD4 count, you're wrong half the time because HIV patients often have multiple pathogens.
DR. STERN: And so he was bronched and he actually did have pneumocystis pneumonia much to the surprise of everyone involved. Only showing that of course sexual histories are not very reliable.
DR. CIFU: I should've mentioned and you mentioned it there. You know, I did not talk about viral pneumonia, which I guess serves me right for giving you a hard time about COVID to begin with. And it's probably my fault how I talk about these things 'cause usually in my mind, when I think about atypical pneumonias, I often group viral pneumonias in with that but sure if this was flu season, boy, you know, influenza pneumonia could be exactly like this.
DR. CIFU: You know, maybe I would have expected more kind of classic flu symptoms to begin with but you don't have to. So thanks for adding that.
DR. STERN: Sure.
DR. CIFU: So Scott, let's move on before we get back to what I guess will really be, you know, management of this case. Can you give us your five key points about diagnosing cough, fever and respiratory complaint?
DR. STERN: Actually I can, the first point is actually obvious but I'm just going to emphasize it 'cause in the clinics, sometimes this isn't done and that is you have to actually figure out who are the patients who have a high likelihood of pneumonia and who are going to benefit from antibiotics from the much larger group of patients that just have a bronchitis or URI who should be managed symptomatically. And the test of choice when you're going to actually look, if you decide that you're going to look and we'll talk in a minute about who to look at, is a chest X-ray.
DR. STERN: It's not a white blood count, it's not other tests. When you wonder about pneumonia, you go to a chest X-ray.
DR. CIFU: I'm just going to add, that sounds, it's an obvious point to make, it sounds like "Pssh, you can never make a mistake there." But you got to put yourself into an urgent care where you know, man, during cough and you know, cold and flu season, you may see a dozen people in a day with kind of upper respiratory symptoms. And most of those patients don't need a chest X-ray and so you'd have to stop on each one of them, right?
DR. CIFU: And you have to think, is this just another cold? Where honestly, I think the person wasted their time coming in to see me or is this someone I need to take more seriously and actually explore, you know, the differential diagnosis. And do I need to test this person?
DR. STERN: Well, that's a perfect preamble to what I'm about to say. So how do you then make that distinction of who gets that chest X-ray? And there are several features that might help you decide this person needs a chest X-ray but you can organize them. So first, do they have symptoms that actually suggest pneumonia? A high fever is not typically seen with the viral bronchitis, shaking chills, shortness of breath.
DR. STERN: Most of the viruses that cause bronchitis won't make you short of breath, chest pain or altered mental status. Any of those symptoms should make you think about pneumonia and a chest X-ray. And of course there are signs that should absolutely make you think about pneumonia, abnormal vital signs, abnormal lung findings, such as crackles, bronchophony or decreased breath sounds. And of course, tachypnea and hypoxia, any of those signs, should say absolutely they need a chest X-ray.
DR. STERN: And the other category of things that might make you consider getting a chest X-ray, not in every case but often, are people who have risk factors for pneumonia and aren't going to tolerate very well if they get pneumonia and you missed the diagnosis. So elderly, frail patients, patients with heart failure, patients with COPD, patients with immunocompromised, they're not going to do well if you miss the pneumonia.
DR. STERN: And so you must have a much lower threshold for obtaining a chest X-ray in those patients.
DR. CIFU: I really like that, you know, I think if you compare the two of our practice patterns, I'm probably more of an under tester, a pathological under tester, and you're probably more of a pathological over tester. And so I worry a lot about doing tests that I'm like, I don't need that but it is important that person who's sick, you know, someone with for instance COPD to say this person was 30 with exactly this presentation, I would not get a chest X-ray, but I'm going to get a chest X-ray in this person, because if this person has pneumonia and I miss it, they need to be intubated 24 hours later.
DR. STERN: Exactly, exactly. So my next key point deals with the patient, the evaluations of patients in whom the chest X-ray shows an infiltrate / pneumonia. And here we need to do something that's unusual for some of us, which is we have to think to diagnose those patients who have community acquired pneumonia versus those patients who come from the community but have some other form of pneumonia. And I'm going to get to this later but I actually hate the term community acquired pneumonia because buried in this group of patients who have come in from the community with pneumonia are patients who have aspiration pneumonia, are patients who have tuberculous pneumonia, are patients like this who have pneumocystis pneumonia.
DR. STERN: And so we actually have to think about what type of pneumonia this is so that we can get the right testing done and so that we can deliver the right therapies.
DR. CIFU: Right, in fact, you could say that anybody who doesn't develop pneumonia in the hospital has community acquired pneumonia, right? But that doesn't mean that all those people have pneumococcus atypical pneumonia or viral pneumonia, right? Can have anything.
DR. STERN: Right. It's a terrible use of nomenclature, unfortunately. And so we have to look at the clues to see what are other types of pneumonia that might be likely in those clues can really be grouped into either clinical clues or radiographic clues. So clinical clues might suggest tuberculosis, for instance, a person who comes from an endemic country or has HIV. Our clinical clues might suggest pneumocystis if you knew the patient had HIV and a low CD4 count.
DR. STERN: Clinical clues might suggest the aspiration and the person who like you mentioned was an alcoholic or a drug addict or has trouble swallowing because of a prior stroke. Radiographic clues can be helpful, for instance, if I see an upper lobe pneumonia, I'm absolutely going to think about tuberculosis 'cause secondary TB tends to reactivate in the lungs in the upper lobe. If I see diffuse infiltrates, I'm thinking about pneumocystis, if I see an abscess, I can think about Staph pneumonias and anaerobic pneumonia.
DR. STERN: So we have to use that combination of clinical features and radiographic features. So we can intelligently decide if other testing is needed and if additional therapies need to be added in addition to our standard therapies for community acquired pneumonia.
DR. CIFU: Perfect, perfect. Okay, let's get back to the case.
DR. STERN: So you know, we diagnose pneumocystis pneumonia. We put him on Bactrim and steroids because he was hypoxic after his bronch came back positive and he did well fortunately, you know, he was started on HAART and did well, I don't know what happened with the relationship with him and his wife afterwards. I imagine that was a stressful conversation but overall he did fine clinically fortunately.
DR. CIFU: Do you know if the wife tested negative as well?
DR. STERN: She did test negative. Yeah, absolutely. And it's interesting, you know, I think we often expect with pneumocystis that patients are going to come in with tattoos on their forehead that say HIV. And that's not the case. So, as you know, pneumocystis used to be the common presenting complaint before we screened people for HIV. And so it still happens.
DR. CIFU: Absolutely. I think what's also interesting about this or just maybe bears, you know, highlighting, is that HIV has changed so much since when we first trained that, you know, everybody was young men basically and it was young men, either men who have sex with men or people with hemophilia or people who had IV drug use now it's everybody. And I always you know, quote that-- So in my practice I take care of five people with HIV.
DR. CIFU: They are all over 70 and what I do with them is I manage their hypertension and diabetes, you know.
DR. STERN: That is remarkable, that's a different world.
DR. CIFU: It's a different world.
DR. STERN: I think we were as afraid of HIV then as people are of COVID now. Back in the old days before we knew this was, how this virus was spread, we used to walk into rooms gloved, gowned, masked, who knew.
DR. CIFU: Right, no it's absolutely true. I mean, neither of us are old enough to say that we are at the, you know, closing parentheses of our career.
DR. STERN: Right.
DR. CIFU: But you could probably place yourself time-wise perfectly, you know, had you started practicing in 1980 and were stopping practicing in 2020, to say I've come in with an infectious disease pandemic and left with another one.
DR. STERN: It's an interesting point. You could almost make a book out of that one.
DR. CIFU: That'd be a depressing career. Okay, so let's move on now to fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge. Scott, do you want to start us off with fingerprints?
DR. STERN: I do, shockingly and very interestingly, a high fever of over 38.3 or 101 Fahrenheit is very suggestive of a serious infection, such as pneumonia in the elderly where the likelihood ratio is 4.7. One study actually showed that the rate of serious infections that required hospitalizations or were life-threatening increased in patients with a high fever in the younger ones only 29% had serious life-threatening infections but was 91% of patients who had high fevers of those patients who are 60 to 79.
DR. STERN: And if you looked at patients who are over 80, who had high fevers, 96% of them had serious life-threatening infections, only 4% of folks over 80, who had high fevers, didn't have serious life-threatening infection. So you better take it seriously when the elderly get very hot.
DR. CIFU: So did you just make the point that old people with high fevers are sick?
DR. STERN: I did.
DR. CIFU: Good thanks, I was just checking.
DR. STERN: Pretty profound, was that? Thank you very much. I really appreciate that.
DR. CIFU: So, my fingerprint very, very short and it's not absolutely a fingerprint because the likelihood ratio is not above 10 but it's pretty close. So egophony is very suggestive of pneumonia. So egophony has a likelihood ratio of 8.6 for pneumonia. So if you are examining someone's lungs, you hear bronchial breath sounds, you perform egophony on that person.
DR. CIFU: And the person has egophony. You would say, huh-huh! This person almost certainly has a pneumonia. The other time we see egophony, which is probably why this isn't higher is people have effusions at the borderline, sort of at the top of the effusion between effusion and normal lungs. You usually hear egophony there, that's one of the tools I use to figure out if someone has an effusion, and so that's probably what throws off the likelihood ratio a little bit here.
DR. STERN: You show your age with that one 'cause we used to use that to decide when to do a thoracentesis.
DR. CIFU: That's right.
DR. STERN: Nobody does that anymore.
DR. CIFU: You're right.
DR. STERN: All right, should we go to misconceptions?
DR. CIFU: Let's do it.
DR. STERN: Okay, so if my last fingerprint wasn't profound about fever, surely you're going to find this profound and that is that normal temperatures don't rule out pneumonia in the elderly. So we should be worried when they have high fevers but we should not be reassured by normal temperatures. Actually studies show that the elderly typically run temperatures almost a full degree centigrade lower than younger patients and therefore, should be considered to be febrile if their temperatures are even over at 37.5 or they're up 1.3 degrees centigrade over baseline or they have altered mental status.
DR. STERN: I thought this was really interesting 'cause for years I've had patients come in and say, you know, 98.9 is a fever for me and I've always thought, oh, come on that can't be true. But actually the literature supports that that is true. If they're normally cold, then they're hotter, they're hotter. Go ahead what do you have to say about that one?
DR. CIFU: [chuckles] I think that's a great point. And I think it is something that I often teach, right, is that the elderly often don't mount fevers and it really probably underlines your previous point that when you do see a fever, you should be worried. So no fever shouldn't reassure you and a high fever should scare you.
DR. STERN: Perfect.
DR. CIFU: So my point and I think you really talked about this when you talked about the case, is that a normal chest exam does not rule out pneumonia. So the sensitivity of a chest exam for pneumonia even in good hands is about 75%, okay. So that means if you're seeing somebody and you think that they have pneumonia and you listen to them and you don't hear anything, that person still needs a chest X-ray 'cause you're going to be wrong 25% of the time.
DR. CIFU: The converse of that is if you get that X-ray, okay, and the X-ray's normal and the person has normal vital signs that person is fine. That's got about a 95% sensitivity of ruling out pneumonia. Okay, so that person's okay. And they can go home and maybe close follow-up if you're worried about them.
DR. STERN: Sure, perfect. All right, so let's turn to pet peeves. I'm going to take the first crack at this and not surprisingly, my first pet peeve is not taking an adequate history. We've spent a lot of time talking about temperatures but the temperature curve can be very helpful. Flu tends to have a temperature curve that it develops abruptly and then tapers over three to four days. Pneumonia can do that but pneumonia can also develop over days.
DR. STERN: Post viral pneumonias often occur where patients get a high fever, get better and then two days later start spiking fevers again. All of this is often lost in a poor history where all the history that's taken is I've had a fever for a week. No, I actually want to know how it started on day 1, day 2, day 3 and follow it through because there's valuable information there.
DR. CIFU: And I think if we do want to throw in COVID here, we can say that COVID is confusing because you know, often those people, the people who really get sick with it often look like they've got influenza, right? They get sick immediately, they get better for a little while before, you know, really crashing day 7, day 8, day 9. And so that may mimic, you know, influenza within an influenza related pneumonia but here are completely different process.
DR. STERN: Right and fortunately now the lab testing has become very available.
DR. CIFU: Absolutely, absolutely. So my first pet peeve is just decreased breath sounds. I just hate it when people tell me that like, what the hell does that mean? To me it means you didn't listen, okay? Or maybe you listened through sort of a puffy polar tech jacket or something like that, you know, what decreased breath sounds should mean is that the person has a pleural effusion, so I can't hear, maybe the person is morbidly obese so there's a lot of space between you and the lungs or maybe they have really bad emphysema and so they're just not moving a lot of air.
DR. CIFU: And so actually decreased breath sounds can really mean something if you use it to mean something, but if you just use it like, "Terrible, during the physical exam, I can't hear anything." The number of times I've gotten reports that a patient of mine from home, who somebody has gone into the house and listened to them and reports decreased breath sounds. I was like, well that helps me not at all.
DR. STERN: We do sound a bit like old fogeys.
DR. CIFU: We are.
DR. STERN: We use the stethoscope, what's with that? All right, so my second pet peeve I've already mentioned, which is I really dislike the term community acquired pneumonia, I know it's not going anywhere but I want to encourage everyone who's listening to really think about patients when they come in from the community before applying that term and making sure that it truly seems like a community acquired pneumonia and not one of the other pneumonias that we've talked about.
DR. CIFU: Okay, pet peeve number two for me is examining the chest over the clothes. Okay, getting to Scott's 'old fogey' moniker. So I think I would actually start by admitting we all listen to the chest over clothes, right. Many of my patients who come in for their yearly physical exam, they don't need a yearly physical exam. Right? They need me to check their blood pressure, they need to talk to me, they need me to maybe draw some labs if there's something I'm following but I don't need to listen to that person's heart or lungs.
DR. CIFU: And I'll actually listen to that person's lungs often through a T-shirt because I'm not listening for anything. I'm just trying to make, you know, the how to know, improve my therapeutic alliance with the patient. But if someone comes in and you're concerned that there's something going on in their lungs, whether it's heart failure, whether it's pneumonia, whether it's a pleural effusion, that people needs to take their clothes off, they need to put a gown on and you need to listen, not just in, you know, at the basis in the back, but you need to listen to all the quadrants, you need to listen to them up front, you need to really do a lung exam before you can say this lung exam is normal.
DR. STERN: I agree actually my pet peeve just works off of that, which is to remember to examine people from side to side and work your way down. You mentioned decreased breath sounds as you know sometimes pneumonia is really a change from side to side, rather than crackles on one particular side. And so if you don't do that carefully, you're absolutely going to miss it. You can even have increased breath sounds if there's increased transmission from a consolidation and again, you'll miss it without a good exam.
DR. CIFU: True. Did you just throw in a third pet peeve there?
DR. STERN: I think I did actually.
DR. CIFU: I got it. So let's move on to clinical pearls. We'll go from the dark to the light here. Scott, you want to start?
DR. STERN: Yes, so I want to talk about rigors briefly. So patients often say that they're chilled, meaning they feel cold, but occasionally they physically shake, which is the definition of rigors. And you should take that seriously. So if someone tells me they were chilled, I actually asked them were you physically shaking would I have seen you. 28% of patients who've had shaking chills actually have bacteremia compared to 5% of people who just had mild chills.
DR. STERN: So if you hear that physically shaking chills, boy, you should be alarmed.
DR. CIFU: I like that. And it probably actually feeds into my pearl, which underlines some of the things you've said in the past that if you think someone has pneumonia, really sit back and get a good history to see if you can figure out what kind of pneumonia they have. It's not only fun and it's what makes, you know, medicine a pleasure to practice but also may really help the patient because you're going to get the results of that history and physical back well before you're going to get any lab tests, right?
DR. CIFU: So think about it, is there a stereotypical presentation? You talked about the presentation for influenza-related pneumonia. You know, we always talk about pneumococcal pneumonia, which often starts with a true bed shaking chill, right, followed by the rusty sputum. Are there associated symptoms? You know, we think a lot about atypical pneumonias, specifically legionella often be associated with some GI distress worth looking for.
DR. CIFU: Are there exposures? You know, we talked about the birds, we talked about the bunnies, you know, lots of things that could kick people off. Has the person just been camping in the Southwest or caving in the Midwest or I don't know, just playing with pigeons out in Chicago or something like that.
DR. STERN: One of my favorite pastimes.
DR. CIFU: Absolutely, and those things may help you because you might actually identify an actual bug or you might be able to say, huh, this is a community dweller who's presenting with something other than a classic community acquired pneumonia.
DR. STERN: Perfect. My clinical pearl that was next, I have already mentioned, which is again having a low threshold to get a chest X-ray in patients with emphysema. I can't tell you how often these patients have pneumonia that's difficult to detect and as we've already said, they don't do well if you miss it.
DR. CIFU: Good and my last one to wrap things up here is the patients with pneumonia and a pleural effusion. So you thought that patient might have pneumonia, you get an X-ray, they do have pneumonia they also have a pleural effusion. That person needs a thoracentesis. And you do a thoracentesis to exclude both an empyema or a complicated parapneumonic effusion both of which require surgical drainage. Because if you don't go in there and evacuate that complicated parapneumonic effusion, that person can end up with really bad pleural disease, which will impair their lung function for years forward.
DR. STERN: That's great.
DR. CIFU: So we hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable. As a reminder, our textbook, Symptom to Diagnosis: An Evidence-Based Guide takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places and also available and fully searchable via the Access Medicine website available worldwide from McGraw Hill and also available on your iPhone or other handheld device.
DR. STERN: Thank you very much.
DR. CIFU: Thank you. The music for the S2D Podcast is courtesy of Dr. Maylyn Martinez.