WEBVTT - Ep 177 Toxic Shock Syndrome: A shock to the system

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<v Speaker 1>Heyl.

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<v Speaker 2>I'm Autumn. I'm a longtime listener, and I am really

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<v Speaker 2>excited to share my story. So when I was eighteen,

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<v Speaker 2>I was hanging out with my boyfriend at the time

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<v Speaker 2>at his house and now was on the last day

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<v Speaker 2>of my period. So I was wearing a side light tampon.

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<v Speaker 2>It was about ten PM and I was at that

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<v Speaker 2>eight hour limit of my tampon. But he did not

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<v Speaker 2>have a trashkin in his bathroom, and I was also

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<v Speaker 2>really scared of his mom, and I did not want

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<v Speaker 2>to venture to the kitchen trash and so I figured

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<v Speaker 2>that I would just change it when I got home.

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<v Speaker 2>My midnight curfew came around, I went home, I changed

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<v Speaker 2>my tampon, then I went to sleep. Welcoup at eight

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<v Speaker 2>am to change my tampon again. But now I was

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<v Speaker 2>feeling a little bit woozy and I had this like

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<v Speaker 2>itchy red palm. Wresh for a bit of contexts on

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<v Speaker 2>this next part. I also have a condition called hereditaria

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<v Speaker 2>and duodema, which can often look and feel like an

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<v Speaker 2>allergic reaction even though it's not. So I figured that

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<v Speaker 2>I might have been having an ha a tack in

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<v Speaker 2>my hands, and so I used a dose of my

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<v Speaker 2>HAE medication. Then I went back to sleep. You could

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<v Speaker 2>equate it to maybe in a non HAE patient, if

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<v Speaker 2>you wake up you feel some allergic discomfort, and then

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<v Speaker 2>you take advantage ellly something. I woke up again at noon,

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<v Speaker 2>as teenagers do on the weekend, and I just felt

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<v Speaker 2>so nauseous, and I was light headed and feverish and

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<v Speaker 2>just overall real critty. I crawled down the stairs with

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<v Speaker 2>a blanket and I laid on the couch to watch TV,

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<v Speaker 2>and I kind of tracked up my symptoms to just

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<v Speaker 2>random illness, and I figured that I'd be better tomorrow.

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<v Speaker 2>I've had this bad track record ever since I was

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<v Speaker 2>little of having these wild and just incredibly harsh bouts

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<v Speaker 2>of strip throat, often bad enough to go to the

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<v Speaker 2>emergency room, and they would happen so suddenly and make

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<v Speaker 2>me so sick that I could just be on Depth's

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<v Speaker 2>doorstep today and then just be fine tomorrow if I

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<v Speaker 2>had AU of course, and I'd also struggled with these

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<v Speaker 2>just seemingly endless infections of staff and strip bacteria on

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<v Speaker 2>my skin, in my ears and in my eyes for

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<v Speaker 2>just about my whole life, and me and my parents

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<v Speaker 2>thought that this illness was just one of those situations,

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<v Speaker 2>or at least the blue because it was January, and

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<v Speaker 2>we really didn't think much of it until my hand

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<v Speaker 2>rash was so bad that I could no longer hold

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<v Speaker 2>my gayor aide, and it really wouldn't matter anyway, because

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<v Speaker 2>I could not keep my gatheror aid down. And it

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<v Speaker 2>got to the point where I vomited and I threw

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<v Speaker 2>up down my front and on the couch and I

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<v Speaker 2>could not even like move to not throw up on myself.

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<v Speaker 2>And that was when we went to the er. It

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<v Speaker 2>was about four PM when we got to the r

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<v Speaker 2>and then about seven PM, which was just eighteen hours

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<v Speaker 2>after removing tampon zero, I was in the ICU with

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<v Speaker 2>a blood pressure at fifty to over twenty eight, a

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<v Speaker 2>scorch and fever and then either racing heart heart rate

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<v Speaker 2>or a slowing heart rate I really cannot remember, and

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<v Speaker 2>then the gradual shutdown of my bone, marrow, kidneys, and lungs,

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<v Speaker 2>and it was obvious I was in septic shock, but

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<v Speaker 2>no one could figure out why. And then in my

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<v Speaker 2>feverish hase, I remembered all of the warnings about toxic

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<v Speaker 2>shock syndrome on tampon boxes, and I told my doctors

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<v Speaker 2>about what had happened with the tampa and the trash can.

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<v Speaker 2>Toxic shock syndrome really wasn't on anyone's radar, and nobody

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<v Speaker 2>working in that hospital had ever actually seen toxic shock

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<v Speaker 2>syndrome in person before. That's what I ended up happening

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<v Speaker 2>five days of hospitalization, my first ever perfect examined CAP.

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<v Speaker 2>There's awful and enough lines and anbiotics take down a horse.

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<v Speaker 2>I was discharged thanks to early intervention, quick thinking, and

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<v Speaker 2>then a hospital staff intent on sliver the mystery. I'm

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<v Speaker 2>still alive today and I'm lucky to have not lost

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<v Speaker 2>any limbs or organs do the tissue death. The worst

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<v Speaker 2>that I personally have in recovery was about a year

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<v Speaker 2>of being immune compromised and having to selute off all

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<v Speaker 2>of the skin for my palms and souls and mucus

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<v Speaker 2>membranes to the cell depth, which is just about the

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<v Speaker 2>grossest mental imas you can muster. But I guess it's

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<v Speaker 2>the price of being alive. And now that that's ten

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<v Speaker 2>years later, I'm really open about menstruation and what we

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<v Speaker 2>can do to prevent TSS and who might be more

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<v Speaker 2>susceptible to contract in TSS, and I love to talk

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<v Speaker 2>about the need for free access to menster products and

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<v Speaker 2>access disposal methods in all bathrooms, public and private. And

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<v Speaker 2>as a person who now works with teens, I love

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<v Speaker 2>putting my experience and advice to use in the hope

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<v Speaker 2>that young people, even if they never have a run

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<v Speaker 2>in with TSS, will not treat menstruation as a taboo topic,

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<v Speaker 2>because I'm living proof on how treating things as taboo

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<v Speaker 2>can just be a little bit hoppy, sometimes.

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<v Speaker 3>Absolutely terrifying.

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<v Speaker 1>Yeah. Yeah, And to be the one who has to

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<v Speaker 1>tell your doctors, by the way, could it be this yet?

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<v Speaker 3>This be toxic shocks? Oh my gosh, I mean it

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<v Speaker 3>just is like yeah. And then especially because I feel

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<v Speaker 3>like there's that sense of I don't want to tell

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<v Speaker 3>someone their like their job or be like, you know,

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<v Speaker 3>I don't want to be like, oh, yeah, I was

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<v Speaker 3>on I was on web md and this is what

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<v Speaker 3>I think. But like it's it's real, right, I have

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<v Speaker 3>to speak up and advocate.

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<v Speaker 1>And yeah, I'm a huge fan of people telling me

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<v Speaker 1>what they found on WebMD. It's very helpful.

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<v Speaker 3>I love that.

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<v Speaker 2>I love that.

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<v Speaker 3>Well, Autumn, thank you so much for sharing your story

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<v Speaker 3>with us.

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<v Speaker 1>Thank you, and we're so glad that you're okay.

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<v Speaker 3>Yes, yes, hi.

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<v Speaker 1>I'm Aaron Welsh and I'm Erin Allman Updike.

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<v Speaker 3>And this is this podcast will kill you.

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<v Speaker 1>Welcome to Toxic Shock.

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<v Speaker 3>Toxic Shock. Yeah, I'm this is I feel like one

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<v Speaker 3>of those I know we'll get so much more into

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<v Speaker 3>the weeds, but I feel like this is one of

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<v Speaker 3>those diseases where awareness around it is so much higher

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<v Speaker 3>than the incidence of it. But it also that means

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<v Speaker 3>there's like it's a double edged sword, right, Like there's

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<v Speaker 3>mean that there's more fear around it, but also we

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<v Speaker 3>can recognize it when we well yeah, okay, that's fair.

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<v Speaker 3>We're more likely to recognize it and it happens.

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<v Speaker 1>Yeah, I have I have so many questions for you,

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<v Speaker 1>Aarin about like how we first saw this and like

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<v Speaker 1>all of the I saw little bits and pieces of

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<v Speaker 1>what happened in the late seventies early eighties, and like

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<v Speaker 1>I I just have so many questions still and I'm

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<v Speaker 1>I'm really excited.

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<v Speaker 3>Do you want me to go first?

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<v Speaker 1>But kind of, but.

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<v Speaker 3>We could give it a go.

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<v Speaker 1>It would be fun on the fly.

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<v Speaker 3>Oh, on the fly. Well, I guess before we get

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<v Speaker 3>into literally any part of this, it's quarantine time. What

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<v Speaker 3>are we drinking this week?

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<v Speaker 1>We're drinking shock tactics. I could hear the pause, like

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<v Speaker 1>is it shocked? What was he just went over there.

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<v Speaker 3>We literally just talked about it. A shock tactic. Shock tactic, Yeah,

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<v Speaker 3>and it's it's we're doing. Honestly, we're doing like a

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<v Speaker 3>make your own quarantini if you want. But the standard

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<v Speaker 3>recipe is a plus syberrita version. So good, so good.

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<v Speaker 3>It's sour cherry syrup, like sour cherries. They're the best.

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<v Speaker 1>Yeah. Aaron before this was like where am I going

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<v Speaker 1>to get sour cherries? Gosh, They're not in season on

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<v Speaker 1>my tree yet, and I'm like, they're frozen.

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<v Speaker 3>Go to this frozen section. I do love, I mean yeah,

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<v Speaker 3>and I feel like my my trees produce enough to

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<v Speaker 3>make one cobbler type.

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<v Speaker 1>Keep getting better. Before we moved from when we moved

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<v Speaker 1>like from Illinois back out to California, the tree that

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<v Speaker 1>year had the best year ever and we had so

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<v Speaker 1>many still in the freezer by the time we moved

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<v Speaker 1>that I made a huge slab pie the dry that

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<v Speaker 1>all that we ate I think we gave something to you.

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<v Speaker 3>Thank you. Yeah, so sour cherries, sour cherry, and then

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<v Speaker 3>you can take the sour cherry syrup, add some club

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<v Speaker 3>soda and a little bit of lime and it's like refreshing, delight.

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<v Speaker 1>So delicious, so delish.

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<v Speaker 3>And we'll post the full recipe for that placed Brita.

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<v Speaker 3>And then you can make your own quarantine on our

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<v Speaker 3>website This Podcast will Kill You dot Com and on

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<v Speaker 3>all of our social media channels. If you're not following us,

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<v Speaker 3>you should. You should also follow exactly right on YouTube

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<v Speaker 3>so you can see the full video of this and

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<v Speaker 3>a lot of our other newer episodes.

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<v Speaker 1>Yeah, quite exciting stuff, it is.

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<v Speaker 2>It is.

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<v Speaker 1>Also you can check out our website if you haven't

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<v Speaker 1>done that already. It's called this Podcast will Kill You

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<v Speaker 1>dot Com and on it you can find such incredible things,

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<v Speaker 1>our episodes, links to Bloodmobile who does the music, our

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<v Speaker 1>Goodreads list, a bookshop dot org affiliate account, Patreon page.

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<v Speaker 3>The list goes on, This goes on.

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<v Speaker 1>Check it out. If you haven't already rated, reviewed, and subscribed,

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<v Speaker 1>you can do that. We'd love it.

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<v Speaker 3>Tiered Toxic shock shock syndrome syndrome. Okay, Okay, I'm gonna

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<v Speaker 3>have you go first because I feel like it'll help

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<v Speaker 3>me tell my story better. It's like the way we

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<v Speaker 3>do the way we.

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<v Speaker 1>Do it, yeah, right after a quick break. Toxic shock

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<v Speaker 1>syndrome or TSS is a disease. It's called a syndrome

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<v Speaker 1>because it was like just a collection of signs and

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<v Speaker 1>symptoms before we knew what caused it. But now we

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<v Speaker 1>know exactly what causes it, and it's caused by a

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<v Speaker 1>toxin or rather a group of toxins that are produced

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<v Speaker 1>by two old time friends of the podcast, that is

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<v Speaker 1>Staphylococcus aureus or Streptococcus pyogenies or group bastro. Okay, so Eric, I.

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<v Speaker 4>Was like, I have a question already off the bat

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<v Speaker 4>I thought about as I was putting the stick other

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<v Speaker 4>I was like, I should probably check in with Aaron

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<v Speaker 4>and see if she's doing the history of like staff

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<v Speaker 4>TSS or strap TSS.

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<v Speaker 1>But then I was like, I don't care. I'm going

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<v Speaker 1>to do both.

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<v Speaker 3>Great, Okay, great, I think I'm doing staff TSS.

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<v Speaker 1>That's what I assumed because that is more related to

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<v Speaker 1>like menstrual TSS, which we'll talk in a lot of

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<v Speaker 1>detail about, but we're going to talk about both. So

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<v Speaker 1>there's staff associated toxic shock and then there's strep associated

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<v Speaker 1>toxic shock.

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<v Speaker 3>Okay, real quick, this is just a minor question that

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<v Speaker 3>should we give it to me? It should? Yeah, toxic

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<v Speaker 3>shock it's no longer called toxic shock syndrome because it's

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<v Speaker 3>not a syndrome or.

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<v Speaker 1>Is it totally is still called toxic syndrome. Yeah, yeah, okay, yeah,

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<v Speaker 1>it's just that's how it got its name. And yeah,

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<v Speaker 1>but it's still called that.

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<v Speaker 3>Okay, yeah, Well I thought because you said that, because

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<v Speaker 3>it's it's we know what causes it, we know all

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<v Speaker 3>of this, that it was initially called a syndrome, and

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<v Speaker 3>now now.

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<v Speaker 1>It's just that, like some people who are into semantics

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<v Speaker 1>are like, it's not that accurate anymore.

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<v Speaker 3>But like it's still right, okay, okay, yeah, there are

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<v Speaker 3>more important things to worry about them, right, aren't there? Yeah?

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<v Speaker 1>I think so, like toxic shock, toxic shock syndrome, disease, whatever.

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<v Speaker 1>So toxic shock it's caused by toxins released by staff

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<v Speaker 1>or strap and these are both gram positive really cute

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<v Speaker 1>little ball shaped bacteria and the most famous of the

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<v Speaker 1>two is staff TSS, and that's because that is the

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<v Speaker 1>one that is more strongly associated with menstrel and tampons

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<v Speaker 1>with menstruation and tampons.

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<v Speaker 3>Yeah, you just mean like infamy or do you mean

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<v Speaker 3>like sheer number of cases.

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<v Speaker 1>I mean infamy, not sheer number of cases, as we'll

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<v Speaker 1>get into later. Okay, but we're going to kind of

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<v Speaker 1>talk about all of these because the mechanism is really

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<v Speaker 1>quite similar in all of these instances, whether it's menstrual

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<v Speaker 1>associated toxic shock or non menstrual toxic shock, whether it's

0:13:16.760 --> 0:13:19.920
<v Speaker 1>STAFF or strep that produce that toxin. There are some

0:13:20.120 --> 0:13:23.640
<v Speaker 1>differences in like the kinds of symptoms that we see

0:13:23.679 --> 0:13:25.559
<v Speaker 1>whether it's STAFF or strep. But I'm going to kind

0:13:25.559 --> 0:13:29.320
<v Speaker 1>of just focus on the similarities. Okay, Yeah, So in

0:13:29.360 --> 0:13:31.760
<v Speaker 1>any case, like I said, it really is a kind

0:13:31.760 --> 0:13:35.480
<v Speaker 1>of clinical definition how we find toxic shock, and so

0:13:35.520 --> 0:13:38.240
<v Speaker 1>it's a set of signs and symptoms that we're looking for.

0:13:38.280 --> 0:13:42.000
<v Speaker 1>There's not one diagnostic test that says you have toxic shock.

0:13:42.800 --> 0:13:45.160
<v Speaker 1>So let's go over what those symptoms kind of look like,

0:13:45.240 --> 0:13:48.000
<v Speaker 1>how it manifests, because that's how we get to how

0:13:48.000 --> 0:13:53.040
<v Speaker 1>we diagnose it right. So in toxic shock, people generally

0:13:53.080 --> 0:13:56.040
<v Speaker 1>start with a fever, and this might not be the

0:13:56.080 --> 0:13:58.520
<v Speaker 1>first symptom, but it is a very very common and

0:13:58.559 --> 0:14:01.199
<v Speaker 1>important symptom. And that fever tends to be quite high.

0:14:01.240 --> 0:14:03.559
<v Speaker 1>So we're looking at like one hundred and two fahrenheit

0:14:03.720 --> 0:14:06.760
<v Speaker 1>or higher. That's thirty eight point nine celsius or higher.

0:14:06.960 --> 0:14:07.320
<v Speaker 3>Okay.

0:14:07.920 --> 0:14:11.080
<v Speaker 1>The shock part of it means that there's also hypotension

0:14:11.200 --> 0:14:15.520
<v Speaker 1>or low blood pressure, because that's part of shock. Why

0:14:17.000 --> 0:14:17.760
<v Speaker 1>why does that happen?

0:14:17.840 --> 0:14:20.280
<v Speaker 3>Oh, we'll get there, Okay, Okay, we're just going through

0:14:20.280 --> 0:14:20.720
<v Speaker 3>the symptoms.

0:14:20.720 --> 0:14:22.600
<v Speaker 1>We're going through the symptory. This is how we know

0:14:22.720 --> 0:14:26.560
<v Speaker 1>signs and symptoms. You also, especially in the case of

0:14:26.680 --> 0:14:31.600
<v Speaker 1>staphylococcle toxic shock, we'll see a rash and this tends

0:14:31.640 --> 0:14:34.840
<v Speaker 1>to be like a diffuse kind of splotchy red rash.

0:14:34.920 --> 0:14:39.480
<v Speaker 1>Sometimes it's described as like sunburn like. And then we'll

0:14:39.520 --> 0:14:43.760
<v Speaker 1>also see evidence either laboratory evidence like when we're looking

0:14:43.800 --> 0:14:48.240
<v Speaker 1>at your lab results or symptom evidence of multi organ

0:14:48.400 --> 0:14:52.480
<v Speaker 1>involvement on the way towards organ failure. And so this

0:14:52.520 --> 0:14:56.080
<v Speaker 1>could be involvement of your kidneys, it could be your liver,

0:14:56.680 --> 0:14:59.080
<v Speaker 1>it could be your muscular skeletal system, which we might

0:14:59.120 --> 0:15:02.760
<v Speaker 1>see with like PA or with laboratory findings. It can

0:15:02.800 --> 0:15:06.720
<v Speaker 1>be neurologic manifestations. It can be literally any organ system

0:15:06.760 --> 0:15:09.840
<v Speaker 1>that's affected. And usually to meet the criteria you have

0:15:09.920 --> 0:15:12.720
<v Speaker 1>to have at least two organ systems, like evidence of

0:15:12.800 --> 0:15:16.880
<v Speaker 1>damage and at least two organ systems. Okay, When it's

0:15:17.120 --> 0:15:23.920
<v Speaker 1>streptococcal toxic shock, almost always you will find some kind

0:15:24.040 --> 0:15:29.760
<v Speaker 1>of initial infection, some kind of initial invasive infection like

0:15:30.040 --> 0:15:35.320
<v Speaker 1>a necrotizing fasciitis or a cellulitis, okay, or evidence of

0:15:35.360 --> 0:15:40.480
<v Speaker 1>a bloodstream infection, so growing this streptococcal bacteria in your bloodstream. Yeah,

0:15:41.480 --> 0:15:47.080
<v Speaker 1>with staff you might not. Very often you do not

0:15:47.360 --> 0:15:50.840
<v Speaker 1>see an initial infection like a cellulitis or something that

0:15:51.000 --> 0:15:55.200
<v Speaker 1>kind of precipitates this. And with staff, only about five

0:15:55.320 --> 0:15:59.040
<v Speaker 1>percent of blood cultures are positive for staff aureus in

0:15:59.120 --> 0:16:02.000
<v Speaker 1>toxic shock, compared to like sixty to eighty percent of

0:16:02.000 --> 0:16:06.280
<v Speaker 1>blood cultures being positive and strepto cockle toxic shock. Okay, okay,

0:16:06.400 --> 0:16:07.920
<v Speaker 1>does that make cop Yes? Yeah.

0:16:07.960 --> 0:16:15.120
<v Speaker 3>A couple questions okay, sorry. Number one timeline of these

0:16:15.720 --> 0:16:17.960
<v Speaker 3>of these signs and symptoms, like does it start with

0:16:18.000 --> 0:16:20.640
<v Speaker 3>a fever, Like, at what point does it go from

0:16:21.280 --> 0:16:24.880
<v Speaker 3>you know, not so great feeling bad rash to shock,

0:16:25.000 --> 0:16:26.120
<v Speaker 3>multi organ involvement.

0:16:26.400 --> 0:16:28.480
<v Speaker 1>It's such a good question. I don't there's not a

0:16:28.520 --> 0:16:30.440
<v Speaker 1>good I don't have a good number for you, okay,

0:16:30.920 --> 0:16:32.760
<v Speaker 1>in part because it's going to differ, you know, if

0:16:32.760 --> 0:16:35.920
<v Speaker 1>we're talking strept to coco versus stapholcockle. Right, Like, if

0:16:36.000 --> 0:16:39.080
<v Speaker 1>it's an infection, how quickly does it go downhill? It

0:16:39.120 --> 0:16:42.640
<v Speaker 1>really depends on the infection with strepto cockle toxic shock,

0:16:42.680 --> 0:16:45.920
<v Speaker 1>which very often might not have you know, evidence of

0:16:46.000 --> 0:16:51.080
<v Speaker 1>an infection necessarily because there's not necessarily evidence of infection,

0:16:51.160 --> 0:16:54.440
<v Speaker 1>we don't have this like traditional incubation period where you like, oh,

0:16:54.560 --> 0:16:57.520
<v Speaker 1>might have this amount of time or how long does

0:16:57.560 --> 0:17:01.120
<v Speaker 1>it take? But what I will say is that once

0:17:01.160 --> 0:17:03.520
<v Speaker 1>this has started to develop, so once you see this

0:17:03.680 --> 0:17:06.480
<v Speaker 1>evidence of like fever and the blood pressure starting to

0:17:06.920 --> 0:17:10.800
<v Speaker 1>go down, this process can happen very rapidly, so you

0:17:10.840 --> 0:17:13.879
<v Speaker 1>can see signs of organ damage and rapidly worsening clinical

0:17:13.880 --> 0:17:16.040
<v Speaker 1>status within like twenty four to forty eight hours.

0:17:16.320 --> 0:17:22.440
<v Speaker 3>Okay, that's very fast. Interrating. Another question then, so related

0:17:22.480 --> 0:17:27.119
<v Speaker 3>to the blood cultures, Yeah, Ken, you also screen for

0:17:27.240 --> 0:17:30.720
<v Speaker 3>the toxins themselves, Like, is that the way that question

0:17:31.000 --> 0:17:31.679
<v Speaker 3>look for this?

0:17:32.400 --> 0:17:37.240
<v Speaker 1>You? So you could if you if you had the

0:17:37.280 --> 0:17:39.080
<v Speaker 1>capability to do that. So if you had like the

0:17:39.160 --> 0:17:42.920
<v Speaker 1>right PCR based testing or whatever it is, you might

0:17:43.280 --> 0:17:45.800
<v Speaker 1>you might a not have that capacity, or you might

0:17:45.880 --> 0:17:48.560
<v Speaker 1>not think too because if you can't, like, if you

0:17:48.560 --> 0:17:52.359
<v Speaker 1>haven't detected any bacteria, then how do you know what

0:17:52.600 --> 0:17:56.480
<v Speaker 1>toxins to look for and that kind of thing. So, yeah,

0:17:56.520 --> 0:17:57.840
<v Speaker 1>so I don't have a great answer for that. But

0:17:57.920 --> 0:18:01.400
<v Speaker 1>what is really important, because we don't have a great

0:18:01.520 --> 0:18:04.440
<v Speaker 1>test for it, is that we do have to show

0:18:04.480 --> 0:18:08.800
<v Speaker 1>that there's no other infection, right, So part of the definition,

0:18:09.080 --> 0:18:12.280
<v Speaker 1>especially for staphylococcle toxic shock, is that you have to

0:18:12.320 --> 0:18:16.520
<v Speaker 1>show that there's no rocky Mountain spotted fever, there's no liptosperosis,

0:18:16.600 --> 0:18:19.479
<v Speaker 1>it's not actually measles, it's not meningitis. Like you have

0:18:19.560 --> 0:18:24.000
<v Speaker 1>to rule out all others before you can say that

0:18:24.040 --> 0:18:27.080
<v Speaker 1>this is toxic shock. But here's where it gets even

0:18:27.080 --> 0:18:30.200
<v Speaker 1>more interesting, especially when we talk later about the epidemiology

0:18:31.040 --> 0:18:35.040
<v Speaker 1>part of the case definitions in the literature and per

0:18:35.080 --> 0:18:39.600
<v Speaker 1>the CDC for stapholoccle toxic shock, is that one to

0:18:39.680 --> 0:18:44.920
<v Speaker 1>two weeks after this initial presentation, people develop a new

0:18:45.040 --> 0:18:49.760
<v Speaker 1>kind of rash where the palms and soles of your

0:18:49.920 --> 0:18:52.720
<v Speaker 1>hands and feet just kind of the skin rubs off.

0:18:52.760 --> 0:18:58.040
<v Speaker 1>It's called the desquamating rash. But that means that that

0:18:58.119 --> 0:19:03.439
<v Speaker 1>definition can only be met retrospectively, right, right, And so

0:19:03.920 --> 0:19:07.119
<v Speaker 1>it's a complicating factor and probably leads to part of

0:19:07.200 --> 0:19:10.959
<v Speaker 1>why we likely see an underreporting of toxic shock because

0:19:11.480 --> 0:19:14.480
<v Speaker 1>these are like kind of messy criteria, right, and a

0:19:14.520 --> 0:19:17.560
<v Speaker 1>lot of other things could potentially fit into this, and

0:19:17.640 --> 0:19:20.600
<v Speaker 1>so we don't have great numbers. That's a spoiler alert

0:19:20.720 --> 0:19:21.919
<v Speaker 1>for the future.

0:19:22.000 --> 0:19:25.639
<v Speaker 3>Say, yeah, hey, shocking, Wow, I really didn't mean to

0:19:25.680 --> 0:19:32.720
<v Speaker 3>do that. Okay. So staph oreus is often a like

0:19:32.800 --> 0:19:35.920
<v Speaker 3>a part of our biome, like it's part of our

0:19:36.080 --> 0:19:39.399
<v Speaker 3>our microbiome is strip piogenies.

0:19:39.520 --> 0:19:41.440
<v Speaker 1>Oh, it can be definitely, it can be Okay, I

0:19:41.480 --> 0:19:43.800
<v Speaker 1>can't get yeah, in like your throat or your nose

0:19:43.920 --> 0:19:44.520
<v Speaker 1>or something like that.

0:19:44.560 --> 0:19:46.520
<v Speaker 3>It can be interesting.

0:19:46.560 --> 0:19:49.080
<v Speaker 1>Staff is definitely like it is our friends. Staff lives

0:19:49.080 --> 0:19:52.360
<v Speaker 1>on probably almost all of us. Yeah, so how does

0:19:52.400 --> 0:19:54.200
<v Speaker 1>this actually happen? How do you get from like, I

0:19:54.240 --> 0:19:57.080
<v Speaker 1>don't know, staff just living on you to toxic shock, Well,

0:19:57.480 --> 0:20:01.000
<v Speaker 1>let me tell you. Uh, it can happen either from

0:20:01.320 --> 0:20:02.400
<v Speaker 1>an infection.

0:20:02.880 --> 0:20:03.080
<v Speaker 2>Right.

0:20:03.640 --> 0:20:07.960
<v Speaker 1>Often we see toxic shock, like I said, with streptococcus,

0:20:07.960 --> 0:20:10.800
<v Speaker 1>it's you know, a necrotizing fasciitis or some kind of

0:20:10.880 --> 0:20:15.760
<v Speaker 1>infection that leads to an invasive infection with staff. It's

0:20:16.000 --> 0:20:20.720
<v Speaker 1>often seen in the post operative setting. So it could

0:20:20.720 --> 0:20:24.360
<v Speaker 1>be like a wound or an incision after an operation

0:20:24.840 --> 0:20:27.680
<v Speaker 1>because staff is just everywhere. If it happens to get

0:20:27.680 --> 0:20:31.640
<v Speaker 1>in there and multiply, or if you happen to be colonized,

0:20:31.800 --> 0:20:36.120
<v Speaker 1>let's say in the vagina, and then you have an

0:20:36.240 --> 0:20:43.960
<v Speaker 1>overgrowth of this particular strain of these bacteria that produced

0:20:43.960 --> 0:20:49.400
<v Speaker 1>a particular kind of toxin. And there's multiple different versions

0:20:49.400 --> 0:20:52.760
<v Speaker 1>of this toxin. The one that is again most infamous,

0:20:53.119 --> 0:20:55.440
<v Speaker 1>and you'll talk about later, Aaron, Well, I don't know

0:20:55.480 --> 0:20:57.520
<v Speaker 1>if you'll talk about the toxin, but the most infamous

0:20:57.760 --> 0:21:00.760
<v Speaker 1>cause of toxic shock is caused by a toxin called

0:21:00.840 --> 0:21:06.760
<v Speaker 1>t SST one, a toxic shock syndrome toxin really clever, straightforward.

0:21:07.800 --> 0:21:10.720
<v Speaker 1>But all of these toxins that cause toxic shock are

0:21:10.760 --> 0:21:15.080
<v Speaker 1>called super antigens. And we talked about this idea of

0:21:15.080 --> 0:21:19.159
<v Speaker 1>a superanergen. Actually, in our scarlet fever episode, which you

0:21:19.200 --> 0:21:22.640
<v Speaker 1>may remember, scarlet fever is caused by strut piogeny, right,

0:21:24.200 --> 0:21:29.960
<v Speaker 1>a specific strain of strup piogenies. So superanigens are proteins.

0:21:30.720 --> 0:21:35.720
<v Speaker 1>These toxins are proteins that bacteria can make and excrete

0:21:36.680 --> 0:21:41.080
<v Speaker 1>that when they get into our body trigger an overwhelming

0:21:41.280 --> 0:21:46.280
<v Speaker 1>immune response, this idea of like a cytokine storm that

0:21:46.320 --> 0:21:48.959
<v Speaker 1>we've talked about here and there on the podcast. And

0:21:49.119 --> 0:21:55.040
<v Speaker 1>this overwhelming immune response itself, in combination with direct damage

0:21:55.080 --> 0:21:58.800
<v Speaker 1>that these toxins are causing, just like ripping through our cells,

0:21:59.520 --> 0:22:02.439
<v Speaker 1>is what ends up causing all of the symptoms that

0:22:02.480 --> 0:22:06.359
<v Speaker 1>we see in association with toxic shock. The fevers, leaky

0:22:06.440 --> 0:22:11.120
<v Speaker 1>blood vessels that lead to hypotension, dropping blood pressure, all

0:22:11.160 --> 0:22:13.480
<v Speaker 1>of the damage that we see to our organs rather

0:22:13.640 --> 0:22:16.359
<v Speaker 1>whether that's damaged directly to the tissues of the organs

0:22:16.400 --> 0:22:19.280
<v Speaker 1>themselves or damage to the blood vessels that are feeding

0:22:19.359 --> 0:22:23.200
<v Speaker 1>those organs, right, and all of this is what results

0:22:23.240 --> 0:22:26.359
<v Speaker 1>in the damage that we see and the shock part

0:22:26.400 --> 0:22:27.600
<v Speaker 1>of toxic shock syndrome.

0:22:27.960 --> 0:22:33.160
<v Speaker 3>Okay, And so it's not really about okay, like the

0:22:33.200 --> 0:22:37.720
<v Speaker 3>toxin itself is not acting in this way. It's our

0:22:37.880 --> 0:22:42.800
<v Speaker 3>immune system responding to this toxin, and so it doesn't

0:22:42.840 --> 0:22:46.160
<v Speaker 3>have to be like like I'm just trying to figure

0:22:46.160 --> 0:22:49.080
<v Speaker 3>out why this toxin exists, and I'm assuming it's like

0:22:49.359 --> 0:22:52.560
<v Speaker 3>is it competition with other microbes? Like what's going on?

0:22:52.600 --> 0:22:53.439
<v Speaker 3>Do you know the answer?

0:22:53.640 --> 0:22:56.520
<v Speaker 1>I don't, but it's such an interesting questionnaire in Yeah,

0:22:56.520 --> 0:22:59.240
<v Speaker 1>I didn't look into that, like the evolutionary history or

0:22:59.280 --> 0:23:02.320
<v Speaker 1>anything of these types of toxin, right, but it's really

0:23:02.359 --> 0:23:03.160
<v Speaker 1>really really weird.

0:23:03.200 --> 0:23:03.440
<v Speaker 3>I can.

0:23:03.480 --> 0:23:05.200
<v Speaker 1>Do you want a little more detail, Yeah, I do.

0:23:05.280 --> 0:23:07.000
<v Speaker 3>I would love a little more detail. Thank you.

0:23:08.119 --> 0:23:12.400
<v Speaker 1>It's really really interesting and weird how these toxins work

0:23:12.480 --> 0:23:15.920
<v Speaker 1>and the question of like why do they exist? It's

0:23:16.000 --> 0:23:20.720
<v Speaker 1>so so interesting because here's what they basically do. We're

0:23:20.760 --> 0:23:22.560
<v Speaker 1>going to step back a minute to talk about like

0:23:22.720 --> 0:23:24.400
<v Speaker 1>what is a typical immune response.

0:23:24.960 --> 0:23:25.120
<v Speaker 4>Right.

0:23:26.000 --> 0:23:29.520
<v Speaker 1>We get exposed to various toxins or antigens like all

0:23:29.560 --> 0:23:33.159
<v Speaker 1>the time, right, And in our typical immune response, we

0:23:33.240 --> 0:23:36.520
<v Speaker 1>have these cells that these cells that go around and

0:23:36.600 --> 0:23:41.560
<v Speaker 1>find these antigens, right, antigen presenting cells. They usually process

0:23:41.600 --> 0:23:43.720
<v Speaker 1>them in some way. And we've talked a lot about

0:23:43.720 --> 0:23:45.840
<v Speaker 1>our immune response and this podcast before and we've kind

0:23:45.840 --> 0:23:48.440
<v Speaker 1>of glossed over this part because it's just what they do, right.

0:23:48.520 --> 0:23:50.520
<v Speaker 1>They kind of take them in and they like break

0:23:50.520 --> 0:23:52.120
<v Speaker 1>them up and they're like beep it abop, let's find

0:23:52.119 --> 0:23:55.520
<v Speaker 1>the part. And then they present those antigens to our

0:23:55.600 --> 0:23:58.960
<v Speaker 1>T cells, who then decide what kind of response to

0:23:59.040 --> 0:24:02.199
<v Speaker 1>engage in. Do we do inflammatory stuff, do we do

0:24:02.240 --> 0:24:06.800
<v Speaker 1>antibody stuff? Whatever? Okay, So these anigen presenting cells are

0:24:06.880 --> 0:24:10.480
<v Speaker 1>like a mediator. They're the ones who take all the

0:24:10.520 --> 0:24:13.760
<v Speaker 1>anigens and they decide, like which parts do we show

0:24:13.840 --> 0:24:17.520
<v Speaker 1>to T cells? Like how are we gonna start this process?

0:24:17.800 --> 0:24:20.320
<v Speaker 3>Right, they're making these decisions exactly.

0:24:20.320 --> 0:24:24.840
<v Speaker 1>They're organizing, sorting through things. What super anigens are doing

0:24:24.960 --> 0:24:30.960
<v Speaker 1>is bypassing this process super anigens, they themselves go directly

0:24:31.080 --> 0:24:33.879
<v Speaker 1>to the T cells, grab a hold of these T

0:24:34.080 --> 0:24:37.080
<v Speaker 1>cells and then grab a hold of these anigen presenting

0:24:37.119 --> 0:24:41.040
<v Speaker 1>cells and bind them together, like bridge them, and they're like,

0:24:41.240 --> 0:24:45.040
<v Speaker 1>let's get this party started. And that causes this massive

0:24:45.119 --> 0:24:47.720
<v Speaker 1>immune response. And I was trying, Aaron, because you're so

0:24:47.800 --> 0:24:49.479
<v Speaker 1>good at analogies.

0:24:49.520 --> 0:24:53.399
<v Speaker 3>Noy, the number of times that we've been like this

0:24:53.480 --> 0:24:56.600
<v Speaker 3>analogy doesn't need to exist. This analogy has been taken

0:24:56.640 --> 0:24:57.280
<v Speaker 3>too far.

0:24:57.440 --> 0:24:59.960
<v Speaker 1>You know, but I love that. Okay, So I try

0:25:00.800 --> 0:25:04.760
<v Speaker 1>so hard to come up with analogies for this. Here's

0:25:04.760 --> 0:25:07.480
<v Speaker 1>the best one that I could come up with. It's

0:25:07.560 --> 0:25:11.960
<v Speaker 1>so bad, Okay. Super indigens are like the loudest guy

0:25:12.280 --> 0:25:14.679
<v Speaker 1>at the party, like the one that you didn't really

0:25:14.720 --> 0:25:16.879
<v Speaker 1>mean to invite or like didn't actually want to come in,

0:25:17.320 --> 0:25:20.680
<v Speaker 1>made it straight to the DJ booth somehow, and then

0:25:20.760 --> 0:25:23.280
<v Speaker 1>like opened all the doors and everyone's just rushing in.

0:25:23.320 --> 0:25:26.880
<v Speaker 1>The bouncers didn't catch him something like that's my analogy.

0:25:26.920 --> 0:25:27.400
<v Speaker 3>Oh my god.

0:25:27.400 --> 0:25:27.680
<v Speaker 2>Okay.

0:25:27.720 --> 0:25:30.199
<v Speaker 3>So it's like it's like those high school parties, you know,

0:25:30.320 --> 0:25:31.920
<v Speaker 3>or it's like just a few of us, and then,

0:25:32.160 --> 0:25:35.960
<v Speaker 3>unbeknownst to the host, her friends have invited all of

0:25:36.000 --> 0:25:39.639
<v Speaker 3>their whole school brothers other friends and yeah, and they

0:25:39.760 --> 0:25:40.560
<v Speaker 3>just run through the doors.

0:25:40.600 --> 0:25:41.879
<v Speaker 1>Okay, just run through the doors.

0:25:42.040 --> 0:25:42.280
<v Speaker 3>Wow.

0:25:42.280 --> 0:25:46.200
<v Speaker 1>So it's this overwhelming, way too expansive immune response.

0:25:47.080 --> 0:25:50.679
<v Speaker 3>Do you I'm stressed about it because those those scenes

0:25:50.680 --> 0:25:52.600
<v Speaker 3>and movies always stressed me out because I'm like, you're

0:25:52.640 --> 0:25:55.960
<v Speaker 3>gonna hurt the house, Like what about this? What's killing

0:25:56.040 --> 0:25:56.640
<v Speaker 3>on the carpet?

0:25:57.880 --> 0:26:00.119
<v Speaker 1>Like every teen movie you've ever seen, but.

0:26:00.160 --> 0:26:03.720
<v Speaker 3>I was not jol in high school. If you can't imagine.

0:26:03.640 --> 0:26:05.400
<v Speaker 1>I think I went to my first high school party

0:26:05.400 --> 0:26:06.679
<v Speaker 1>when I was definitely in college.

0:26:06.840 --> 0:26:11.240
<v Speaker 3>So I was being like, are you using coasters? Do

0:26:11.280 --> 0:26:13.160
<v Speaker 3>you need a coaster? I've got I've got a little

0:26:13.240 --> 0:26:17.919
<v Speaker 3>basket of them. Wasn't even my house, but I was

0:26:18.000 --> 0:26:19.879
<v Speaker 3>right the wood.

0:26:20.000 --> 0:26:22.760
<v Speaker 1>Yeah.

0:26:22.800 --> 0:26:25.919
<v Speaker 3>Anyway, so I can see why super antigens would be

0:26:25.920 --> 0:26:27.000
<v Speaker 3>a real pain, a.

0:26:27.040 --> 0:26:30.000
<v Speaker 1>Real pain, right, And to give you more of like

0:26:30.040 --> 0:26:32.800
<v Speaker 1>a numeric sense of this, to see how much these

0:26:32.800 --> 0:26:39.360
<v Speaker 1>superanigens are overdoing it. Regular antigens like just your typical

0:26:39.400 --> 0:26:43.000
<v Speaker 1>ones activate about point zero one percent of our T

0:26:43.160 --> 0:26:44.320
<v Speaker 1>cells on average.

0:26:44.520 --> 0:26:47.080
<v Speaker 3>Okay, point zero one percent, A very.

0:26:46.920 --> 0:26:49.440
<v Speaker 1>Small proportion of our T cells are being activated by

0:26:49.440 --> 0:26:53.440
<v Speaker 1>any given antigen or exposed to super anigens are activating

0:26:53.760 --> 0:26:56.320
<v Speaker 1>five to thirty percent of our T cells.

0:26:56.720 --> 0:27:03.520
<v Speaker 3>But now, okay, what what scarlet fever another super antigen?

0:27:04.280 --> 0:27:08.200
<v Speaker 3>What about what makes a super antigen a super anti

0:27:08.320 --> 0:27:10.679
<v Speaker 3>Like obviously we know the characteristics of it, right, but like,

0:27:11.800 --> 0:27:14.520
<v Speaker 3>what is there a range? Is there a spectrum of

0:27:15.000 --> 0:27:21.960
<v Speaker 3>antigenicity from not very I mean obviously, but to super antigen? Why? Why?

0:27:22.080 --> 0:27:23.000
<v Speaker 3>I guess it's just the.

0:27:23.000 --> 0:27:27.480
<v Speaker 1>Question that's the QUESTIONNAIREIC. It's a great question, well formulated,

0:27:28.600 --> 0:27:29.640
<v Speaker 1>Thank you so much.

0:27:31.359 --> 0:27:32.439
<v Speaker 3>Yeah.

0:27:32.560 --> 0:27:33.359
<v Speaker 1>I don't know though.

0:27:36.400 --> 0:27:38.720
<v Speaker 3>Fascinating, Okay, isn't it? Yeah?

0:27:38.760 --> 0:27:40.919
<v Speaker 1>So yeah, So I mean that that is toxic shock,

0:27:40.960 --> 0:27:44.800
<v Speaker 1>and that is you know, how it happens and what

0:27:45.119 --> 0:27:47.440
<v Speaker 1>like what is going on in our bodies in terms

0:27:47.440 --> 0:27:48.440
<v Speaker 1>of the path of physiology.

0:27:48.600 --> 0:27:52.640
<v Speaker 3>Okay, So question about the two different strip and staff

0:27:52.800 --> 0:27:56.120
<v Speaker 3>give it toxic shock. Is there a difference in case

0:27:56.119 --> 0:28:00.960
<v Speaker 3>fatality rate? Is there a difference in treatment and management?

0:28:01.359 --> 0:28:05.640
<v Speaker 3>And is there a difference in susceptibility again in the.

0:28:05.600 --> 0:28:11.080
<v Speaker 1>Future to it such fun question, barren case fatality definitely

0:28:11.560 --> 0:28:18.080
<v Speaker 1>let me scroll in minotes. Case fatality rates for streptococcle

0:28:18.200 --> 0:28:23.119
<v Speaker 1>toxic shock are very depressing, anywhere from like thirty to

0:28:23.200 --> 0:28:29.680
<v Speaker 1>sixty percent. Okay, so very very very deadly. And remember

0:28:29.800 --> 0:28:35.879
<v Speaker 1>that streptococcle toxic shock is very almost always associated with

0:28:35.920 --> 0:28:40.120
<v Speaker 1>some kind of invasive infection. So the treatment requires that

0:28:40.160 --> 0:28:43.280
<v Speaker 1>you identify what that infection is. You try and get

0:28:43.280 --> 0:28:45.600
<v Speaker 1>like source control if you can. So that means if

0:28:45.640 --> 0:28:47.600
<v Speaker 1>there's like a necrotizing fasci i itis, you have to

0:28:47.600 --> 0:28:51.360
<v Speaker 1>debreed all of that dead tissue that is completely overrun

0:28:51.400 --> 0:28:55.120
<v Speaker 1>with bacteria, and then you need to also treat the

0:28:55.160 --> 0:28:57.160
<v Speaker 1>toxic shock, which I'll talk about in just a second.

0:28:57.440 --> 0:29:03.280
<v Speaker 1>With staffholococcle toxic shock, the case fatality rates really can vary,

0:29:03.800 --> 0:29:07.480
<v Speaker 1>and most of what I saw estimated that the majority

0:29:07.680 --> 0:29:13.200
<v Speaker 1>of staphloccle toxic shock cases are actually not menstrual, and

0:29:13.240 --> 0:29:14.800
<v Speaker 1>we'll talk a little bit more about what that means,

0:29:15.480 --> 0:29:19.280
<v Speaker 1>but they're actually more likely to be something like a

0:29:19.320 --> 0:29:22.360
<v Speaker 1>wound related or a post operative infection. Something like sixty

0:29:22.400 --> 0:29:26.600
<v Speaker 1>percent of staffaccle toxic shock is from that rather than

0:29:26.600 --> 0:29:31.760
<v Speaker 1>from menstrual sources. The fatality rates, I've seen a real

0:29:31.880 --> 0:29:36.440
<v Speaker 1>range anywhere between like eight and twenty percent. But most

0:29:36.680 --> 0:29:41.360
<v Speaker 1>places also say that menstrual toxic shock is very rare

0:29:41.560 --> 0:29:44.280
<v Speaker 1>to cause fatalities. And I don't know if that's just

0:29:44.360 --> 0:29:47.360
<v Speaker 1>based on like current data or if that has been

0:29:47.360 --> 0:29:49.920
<v Speaker 1>true historically as well, but that is what all of

0:29:49.960 --> 0:29:51.480
<v Speaker 1>the literature that I read suggested.

0:29:51.880 --> 0:29:52.400
<v Speaker 3>Interesting.

0:29:52.840 --> 0:29:57.120
<v Speaker 1>Yes, okay, it's very interesting. And is that because of

0:29:57.240 --> 0:30:00.000
<v Speaker 1>you know, like demographics, because people who are getting made

0:30:00.200 --> 0:30:03.800
<v Speaker 1>wound infections or operative infections are maybe like older, or

0:30:03.800 --> 0:30:05.120
<v Speaker 1>have more comorbidities or.

0:30:05.120 --> 0:30:07.360
<v Speaker 3>Something comprise in some way.

0:30:07.080 --> 0:30:09.600
<v Speaker 1>Or is it because that they also have this infection

0:30:09.720 --> 0:30:12.480
<v Speaker 1>that you're dealing with, where most of the time with

0:30:12.640 --> 0:30:18.640
<v Speaker 1>menstrual associated toxic shock, there's no infection. So like ten

0:30:18.760 --> 0:30:22.920
<v Speaker 1>to forty percent of menstruating people just have staff areas

0:30:23.000 --> 0:30:26.280
<v Speaker 1>in their vagina at any given time, And the amount

0:30:26.440 --> 0:30:30.280
<v Speaker 1>and quantity of different bacteria really changes during your menstrual

0:30:30.320 --> 0:30:33.160
<v Speaker 1>cycle because of changes in the pH and things like

0:30:33.200 --> 0:30:35.520
<v Speaker 1>that with menstrual blood and all that kind of stuff.

0:30:36.680 --> 0:30:40.240
<v Speaker 1>And I said that it's only certain strains of these

0:30:40.280 --> 0:30:44.560
<v Speaker 1>bacteria that produce this toxin. It's estimated that like eighteen

0:30:44.600 --> 0:30:47.160
<v Speaker 1>to twenty five percent of strains of staff orius across

0:30:47.160 --> 0:30:51.240
<v Speaker 1>the board have the gene that encodes for this toxin.

0:30:52.120 --> 0:30:56.520
<v Speaker 1>But even then, not all of those bacteria, even if

0:30:56.520 --> 0:30:58.440
<v Speaker 1>they have that gene, are going to make the toxin

0:30:58.480 --> 0:31:02.040
<v Speaker 1>because the environment also has to be right to induce

0:31:02.120 --> 0:31:04.480
<v Speaker 1>them to actually make that toxin.

0:31:05.080 --> 0:31:08.720
<v Speaker 3>Right, Interesting, Okay, so they have It's not like these

0:31:08.720 --> 0:31:11.600
<v Speaker 3>are just going around producing this toxin all of the time. No,

0:31:11.880 --> 0:31:14.360
<v Speaker 3>it's not dependent upon and do we know what those

0:31:14.440 --> 0:31:15.720
<v Speaker 3>environmental conditions are?

0:31:15.840 --> 0:31:21.000
<v Speaker 1>We do erin so glad you asked, so one of

0:31:21.000 --> 0:31:23.200
<v Speaker 1>the things that we know is that it has to

0:31:23.240 --> 0:31:27.600
<v Speaker 1>be an environment that is aerobic. They need oxygen. Staff

0:31:27.600 --> 0:31:30.920
<v Speaker 1>Ores can grow with or without oxygen, but in order

0:31:30.960 --> 0:31:35.040
<v Speaker 1>to produce this toxin in strains that can produce this toxin,

0:31:35.280 --> 0:31:37.000
<v Speaker 1>they need the presence of oxygen.

0:31:37.320 --> 0:31:37.680
<v Speaker 3>Okay.

0:31:37.760 --> 0:31:40.760
<v Speaker 1>They also need like a warm but not too warm

0:31:40.800 --> 0:31:43.240
<v Speaker 1>of temperature. They need like a certain pH range, not

0:31:43.280 --> 0:31:48.000
<v Speaker 1>too high, not too low, things like that. And so

0:31:48.800 --> 0:31:53.800
<v Speaker 1>conditions have to be right for this bacteria to grow

0:31:54.120 --> 0:31:58.440
<v Speaker 1>to a degree and then to have the toxin, like

0:31:58.520 --> 0:32:01.720
<v Speaker 1>the gene to make this toxin in, and then to

0:32:01.880 --> 0:32:06.360
<v Speaker 1>actually be induced to produce this toxin before somebody can

0:32:06.400 --> 0:32:09.520
<v Speaker 1>even be exposed to potentially get toxic shock. And then

0:32:09.600 --> 0:32:14.840
<v Speaker 1>you asked, Aaron, what about recurrent infections? This is such

0:32:14.840 --> 0:32:18.040
<v Speaker 1>a good question because we're talking about an anigen and

0:32:18.080 --> 0:32:22.560
<v Speaker 1>we usually make antibodies against antigens, right, uh huh. Something

0:32:22.640 --> 0:32:28.080
<v Speaker 1>like eighty percent of people have antibodies against these types

0:32:28.080 --> 0:32:31.080
<v Speaker 1>of superanigens, especially when we're looking at the common one

0:32:31.160 --> 0:32:36.360
<v Speaker 1>TSST one. Most people, like if you just surveyed, a

0:32:36.440 --> 0:32:39.320
<v Speaker 1>random group of people have antibodies against this, meaning that

0:32:39.320 --> 0:32:41.640
<v Speaker 1>we're probably exposed to it at low levels and we're

0:32:41.640 --> 0:32:42.960
<v Speaker 1>making antibodies against it.

0:32:44.000 --> 0:32:44.640
<v Speaker 3>Okay.

0:32:45.000 --> 0:32:47.560
<v Speaker 1>When we're thinking about who is it that ends up

0:32:47.560 --> 0:32:50.400
<v Speaker 1>getting toxic shock, it is not a simple question.

0:32:50.720 --> 0:32:50.960
<v Speaker 2>No.

0:32:51.360 --> 0:32:53.800
<v Speaker 1>It is not like, oh, if you have a tampon

0:32:53.840 --> 0:32:59.040
<v Speaker 1>in for too long. No, it is not anything near straightforward,

0:33:00.120 --> 0:33:02.680
<v Speaker 1>because there has to be the correct environment. One to

0:33:02.760 --> 0:33:05.720
<v Speaker 1>five percent of people are thought to be colonized in

0:33:05.760 --> 0:33:09.840
<v Speaker 1>the vagina with strains that can potentially produce this toxin.

0:33:10.000 --> 0:33:10.280
<v Speaker 3>Hmm.

0:33:11.040 --> 0:33:13.440
<v Speaker 1>Okay, so one to five percent of people we're talking

0:33:13.440 --> 0:33:16.760
<v Speaker 1>about menstrul Focus on that for a second. Then you

0:33:16.880 --> 0:33:20.560
<v Speaker 1>have to have an environment that is conducive, so you

0:33:20.640 --> 0:33:25.680
<v Speaker 1>need to have enough oxygen. Now, menstrual blood blood contains oxygen,

0:33:26.480 --> 0:33:29.600
<v Speaker 1>so that can increase the oxygenation level of the environment

0:33:29.680 --> 0:33:34.560
<v Speaker 1>and potentially help to shift those bacteria into producing the toxin.

0:33:35.000 --> 0:33:35.280
<v Speaker 3>Yep.

0:33:36.160 --> 0:33:40.200
<v Speaker 1>Tampons, as you'll talk about aaron, are strongly associated with

0:33:40.360 --> 0:33:44.440
<v Speaker 1>especially the emergence of toxic shock as a syndrome. And

0:33:44.480 --> 0:33:47.040
<v Speaker 1>the thought on part of the reason why is that

0:33:47.920 --> 0:33:52.640
<v Speaker 1>because these are absorbent materials, they contain oxygen.

0:33:54.040 --> 0:33:56.760
<v Speaker 3>I mean, there's talk a little bit about it, but

0:33:56.920 --> 0:34:00.080
<v Speaker 3>like it's just like this is the part where I

0:34:00.080 --> 0:34:04.640
<v Speaker 3>I still have found so much disagreement, not not even disagreement,

0:34:04.680 --> 0:34:09.360
<v Speaker 3>but lack of clarity on and these are the characteristics.

0:34:09.440 --> 0:34:11.680
<v Speaker 3>This is how step you know, step one, step two,

0:34:11.680 --> 0:34:15.960
<v Speaker 3>step three? Is it that? Is it the tampons? Is

0:34:16.000 --> 0:34:18.839
<v Speaker 3>it the blood? Is it like? Is it a micro abrasions?

0:34:19.080 --> 0:34:21.399
<v Speaker 3>Is it leaving tampons in too long? Is it taking

0:34:21.400 --> 0:34:23.719
<v Speaker 3>them out? It's like all these different questions.

0:34:23.640 --> 0:34:26.040
<v Speaker 1>And Aaron, it's all of these different things. And that's

0:34:26.080 --> 0:34:28.960
<v Speaker 1>the point. It's not one thing. Is it is not

0:34:29.160 --> 0:34:32.000
<v Speaker 1>one thing? It is an individual risk factor. Are you

0:34:32.040 --> 0:34:34.799
<v Speaker 1>colonized with this? It's an individual risk factor. Do you

0:34:34.880 --> 0:34:37.960
<v Speaker 1>already have enough neutralizing antibodies or not? Do you have

0:34:38.040 --> 0:34:40.319
<v Speaker 1>some kind of immuno compromise where you're not producing as

0:34:40.360 --> 0:34:43.200
<v Speaker 1>many antibodies for some reason or another. Have you been

0:34:43.200 --> 0:34:45.840
<v Speaker 1>exposed to this at lower levels and developed antibodies or not?

0:34:47.600 --> 0:34:50.440
<v Speaker 1>What is the oxygenation level in your vagina and in

0:34:50.480 --> 0:34:53.960
<v Speaker 1>your menstrual blood? What kinds of like how heavy is

0:34:54.000 --> 0:34:57.279
<v Speaker 1>your flow? Are there microabrasions that make it easier for

0:34:57.400 --> 0:35:00.600
<v Speaker 1>either bacteria or the toxin to get into like pass

0:35:00.680 --> 0:35:04.359
<v Speaker 1>through that mecause membrane get into your bloodstream? How much

0:35:04.400 --> 0:35:08.799
<v Speaker 1>oxygen is being contained in the tampon versus in the

0:35:08.840 --> 0:35:10.920
<v Speaker 1>menstrual cup, because, by the way, there have been at

0:35:11.000 --> 0:35:14.480
<v Speaker 1>least two cases reported from menstrual cup use. So I

0:35:14.520 --> 0:35:18.120
<v Speaker 1>feel like, especially when we're thinking about menstrual toxic shock,

0:35:18.920 --> 0:35:21.359
<v Speaker 1>what I took away from all of this, and we'll

0:35:21.360 --> 0:35:23.400
<v Speaker 1>talk more about it in the like looking at the

0:35:23.520 --> 0:35:26.640
<v Speaker 1>numbers of all of this and how rare this disease is,

0:35:26.640 --> 0:35:30.680
<v Speaker 1>is that we need a lot more research when it

0:35:30.719 --> 0:35:34.040
<v Speaker 1>comes to reproductive health and like the best menstrual products

0:35:34.040 --> 0:35:37.760
<v Speaker 1>and all of this stuff, but we cannot weaponize tampon

0:35:37.880 --> 0:35:42.600
<v Speaker 1>saying that like tampons are the problem here. Well, yeah,

0:35:42.719 --> 0:35:47.719
<v Speaker 1>it's complicated. It's complicated. It's complicated, but it is not

0:35:48.000 --> 0:35:50.680
<v Speaker 1>like the tampons are not introducing any bacteria that we

0:35:50.760 --> 0:35:52.799
<v Speaker 1>know of. These are bacteria that are already present in

0:35:52.840 --> 0:35:58.319
<v Speaker 1>the environment, and we have a lot of data that

0:35:59.120 --> 0:36:01.239
<v Speaker 1>we do not have nearly as much data as I

0:36:01.280 --> 0:36:03.680
<v Speaker 1>feel like we should. But I think it is in

0:36:03.719 --> 0:36:08.040
<v Speaker 1>part because of how rare this disease is and how

0:36:08.160 --> 0:36:12.040
<v Speaker 1>many complicated factors there are that go into this right

0:36:12.120 --> 0:36:14.279
<v Speaker 1>like it is, it is just not as straightforward, and

0:36:14.320 --> 0:36:16.759
<v Speaker 1>so I feel like the takeaway that I got is

0:36:16.800 --> 0:36:20.359
<v Speaker 1>not like this is evil, this is good, but like, no,

0:36:20.840 --> 0:36:23.200
<v Speaker 1>we need more information on this. And we also can't

0:36:23.200 --> 0:36:25.960
<v Speaker 1>because one of the papers I read suggested as a

0:36:25.960 --> 0:36:29.960
<v Speaker 1>way to prevent it to not use feminine hygiene products erin,

0:36:31.120 --> 0:36:31.640
<v Speaker 1>and I was.

0:36:31.640 --> 0:36:40.160
<v Speaker 3>Like, horry, what I mean? That is not a very

0:36:40.600 --> 0:36:44.240
<v Speaker 3>well thought out solution. No, to put it mildly.

0:36:44.080 --> 0:36:49.880
<v Speaker 1>To put it mildly, okay, But yes, I feel like

0:36:49.920 --> 0:36:51.560
<v Speaker 1>I got a little bit off track and probably out

0:36:51.560 --> 0:36:52.480
<v Speaker 1>of order there.

0:36:52.560 --> 0:36:56.160
<v Speaker 3>No, no, okay. So but to maybe get us back

0:36:56.200 --> 0:36:59.080
<v Speaker 3>on track, treatment, treatment, what do we do?

0:36:59.320 --> 0:37:01.880
<v Speaker 1>Yeah, so I'm source control. That's going to be important.

0:37:01.920 --> 0:37:03.799
<v Speaker 1>So that means taking care of any infection that we

0:37:03.880 --> 0:37:06.440
<v Speaker 1>know of, if it is a mentual toxic shock and

0:37:06.480 --> 0:37:08.600
<v Speaker 1>there is a mental device in place, like a cup

0:37:08.680 --> 0:37:12.960
<v Speaker 1>or a tampon or whatever, removing that. And then the

0:37:13.000 --> 0:37:16.640
<v Speaker 1>most important thing is using antibiotics that are going to

0:37:16.800 --> 0:37:21.000
<v Speaker 1>have ability to prevent more toxin production. And so that

0:37:21.120 --> 0:37:25.480
<v Speaker 1>usually means clindamycin because that helps block protein synthesis and

0:37:25.520 --> 0:37:27.960
<v Speaker 1>so it helps block production of the toxin. But then

0:37:28.000 --> 0:37:30.960
<v Speaker 1>it's also a lot of like supportive care. Right, it's

0:37:31.000 --> 0:37:34.960
<v Speaker 1>fluid resuscitation, it's blood pressure support. It's broad spectrum antibiotics

0:37:34.960 --> 0:37:36.719
<v Speaker 1>because a lot of times you can't you don't know

0:37:36.760 --> 0:37:38.399
<v Speaker 1>what it is yet. All of this takes a long

0:37:38.400 --> 0:37:39.239
<v Speaker 1>time to figure.

0:37:38.960 --> 0:37:40.440
<v Speaker 3>Out act fast. Yeah.

0:37:40.440 --> 0:37:44.560
<v Speaker 1>Interestingly, there's some evidence for the use of ivig okay,

0:37:44.880 --> 0:37:49.520
<v Speaker 1>which is like IV combined immunoglobulin from like a bunch

0:37:49.520 --> 0:37:52.720
<v Speaker 1>of different sources. It's basically pooled antibodies and giving people

0:37:52.719 --> 0:37:55.279
<v Speaker 1>really high doses of a ton of random antibodies. The

0:37:55.320 --> 0:37:57.640
<v Speaker 1>thought is that that will help like bind to this

0:37:57.719 --> 0:38:01.640
<v Speaker 1>toxin and inactivate it. There's not super strong data for it,

0:38:01.680 --> 0:38:03.799
<v Speaker 1>but it's in part because of the difficulties of doing

0:38:03.800 --> 0:38:06.320
<v Speaker 1>these kinds of clinical trials on very small sample sizes.

0:38:06.360 --> 0:38:09.200
<v Speaker 1>But there's some data that it might be helpful, especially

0:38:09.320 --> 0:38:12.239
<v Speaker 1>for streptococcle more than staff of a cockle, just because

0:38:12.239 --> 0:38:15.040
<v Speaker 1>that's the data that we have, Okay, Yeah, and that's

0:38:15.080 --> 0:38:18.240
<v Speaker 1>mostly it aarin okay.

0:38:18.880 --> 0:38:20.160
<v Speaker 3>Yeah.

0:38:20.200 --> 0:38:22.000
<v Speaker 1>And you asked if you can get it again, you can,

0:38:22.440 --> 0:38:24.560
<v Speaker 1>which makes it even that much more interesting because you

0:38:24.600 --> 0:38:27.680
<v Speaker 1>can you can get it again even under different conditions.

0:38:29.080 --> 0:38:32.319
<v Speaker 1>People who have had menstrual toxic shock, especially in the

0:38:32.360 --> 0:38:35.240
<v Speaker 1>context of tampon use, there has been reports that people

0:38:35.280 --> 0:38:40.680
<v Speaker 1>have had recurrences without tampon use, which again points to

0:38:40.719 --> 0:38:43.160
<v Speaker 1>the fact that it's not just the tampons, not that

0:38:43.200 --> 0:38:48.200
<v Speaker 1>it's much more complicated thing than that, right, But yes.

0:38:48.280 --> 0:38:51.719
<v Speaker 3>Yeah, I think I have more questions, but I'm gonna

0:38:51.760 --> 0:38:53.600
<v Speaker 3>they're just gonna have to come to me, Like I

0:38:53.719 --> 0:38:55.319
<v Speaker 3>just there's so much that I know.

0:38:55.600 --> 0:38:58.840
<v Speaker 1>Yeah, well, I have questions too, Erin because like obviously

0:38:59.000 --> 0:39:00.600
<v Speaker 1>a lot of the papers that I write, I couldn't

0:39:00.640 --> 0:39:03.160
<v Speaker 1>not say, like, well, we first found out about this.

0:39:03.440 --> 0:39:05.839
<v Speaker 3>I mean, I'm so literally just going to be talking

0:39:05.880 --> 0:39:06.640
<v Speaker 3>about tampons.

0:39:06.640 --> 0:39:09.520
<v Speaker 1>So I cannot wait to talk about tampons.

0:39:09.840 --> 0:39:30.560
<v Speaker 3>I can't wait to tell you. Let's take a quick break, Aaron,

0:39:30.640 --> 0:39:34.960
<v Speaker 3>do you remember when you first learned about toxic shock syndrome?

0:39:35.320 --> 0:39:40.480
<v Speaker 1>Ooh, good question. No. No, I just feel like in

0:39:40.560 --> 0:39:42.800
<v Speaker 1>my memory and this is not I'm sure not correct,

0:39:42.800 --> 0:39:46.480
<v Speaker 1>but I just feel like I have always known about.

0:39:46.719 --> 0:39:48.200
<v Speaker 3>You were born with the knowledge.

0:39:48.320 --> 0:39:52.000
<v Speaker 1>No, no, no, it was like tampon's toxic shock, Like

0:39:52.040 --> 0:39:55.760
<v Speaker 1>that was a connection that existed in my memory from

0:39:55.960 --> 0:39:57.840
<v Speaker 1>the first time that I can remember using a tampon.

0:39:57.880 --> 0:39:59.440
<v Speaker 1>And I don't know if I actually learned it that

0:39:59.480 --> 0:40:02.040
<v Speaker 1>first time or if it was like later knowledge.

0:40:02.280 --> 0:40:05.040
<v Speaker 3>I mean that's similar to me. Like I don't know

0:40:05.160 --> 0:40:09.279
<v Speaker 3>if it was in like health class or something like that,

0:40:09.360 --> 0:40:09.840
<v Speaker 3>but I'm.

0:40:09.800 --> 0:40:12.919
<v Speaker 1>Sure it wasn't in health class for me probably, Yeah,

0:40:13.560 --> 0:40:15.520
<v Speaker 1>just speaking personally, Yeah.

0:40:15.160 --> 0:40:18.479
<v Speaker 3>I mean I get Yeah, I don't know, but I do.

0:40:19.000 --> 0:40:23.319
<v Speaker 3>I do have this this memory of being in my

0:40:23.440 --> 0:40:26.440
<v Speaker 3>house in northern Kentucky, like getting my first period and

0:40:26.520 --> 0:40:29.720
<v Speaker 3>reading that little instruction pamphlet that came in the box

0:40:29.760 --> 0:40:32.759
<v Speaker 3>and tampons, and like in one little corner was this

0:40:32.880 --> 0:40:36.800
<v Speaker 3>dire warning about this deadly disease called toxic shock syndrome

0:40:36.840 --> 0:40:40.880
<v Speaker 3>that you could get from using tampons. Yeah, And I

0:40:40.880 --> 0:40:45.000
<v Speaker 3>feel like that made such an indelible mark on me.

0:40:45.200 --> 0:40:48.680
<v Speaker 3>For years after, I was like worried but also a

0:40:48.680 --> 0:40:51.960
<v Speaker 3>little confused, like what was it using it again? Like

0:40:51.960 --> 0:40:54.200
<v Speaker 3>all these questions, Am I going to get it because

0:40:54.200 --> 0:40:56.040
<v Speaker 3>I used a tampon for too long or because I

0:40:56.040 --> 0:40:58.680
<v Speaker 3>took it out too soon? Like what is going wrong

0:40:58.760 --> 0:40:59.919
<v Speaker 3>giving me toxic shock?

0:41:00.120 --> 0:41:00.440
<v Speaker 1>Yes?

0:41:00.680 --> 0:41:03.120
<v Speaker 3>Should I be using tampons at all? Is that gonna

0:41:03.120 --> 0:41:03.480
<v Speaker 3>help me?

0:41:03.640 --> 0:41:03.719
<v Speaker 1>Like?

0:41:03.920 --> 0:41:09.200
<v Speaker 3>Right, clearly, I think that the takeaway that I had

0:41:09.760 --> 0:41:12.320
<v Speaker 3>was if I got toxic shock, it was my fault

0:41:12.360 --> 0:41:15.640
<v Speaker 3>because I didn't know the answers, and I wasn't sure

0:41:16.080 --> 0:41:17.800
<v Speaker 3>where to get them or who to ask.

0:41:18.000 --> 0:41:21.120
<v Speaker 1>Oh my gosh, Erin, that's so heartbreaking to imagine little

0:41:21.160 --> 0:41:23.399
<v Speaker 1>like baby Erin being like, well, if I die, it's

0:41:23.400 --> 0:41:23.719
<v Speaker 1>on me.

0:41:24.040 --> 0:41:26.520
<v Speaker 3>I mean, it was just like you're if you use

0:41:26.640 --> 0:41:30.279
<v Speaker 3>because it's like use the right amount, use the right absorbency.

0:41:30.600 --> 0:41:32.480
<v Speaker 1>How the heck are you supposed to know, especially when

0:41:32.520 --> 0:41:34.960
<v Speaker 1>you're actually eighteen years old, when you're sixteen years old,

0:41:34.960 --> 0:41:37.239
<v Speaker 1>if you have irregular periods, like, there are so many

0:41:37.239 --> 0:41:39.560
<v Speaker 1>different things where it's like but I felt like, okay, well,

0:41:39.560 --> 0:41:40.640
<v Speaker 1>this is just like part of.

0:41:40.560 --> 0:41:42.200
<v Speaker 3>What it means to be a woman, right, Like I

0:41:42.200 --> 0:41:46.960
<v Speaker 3>have my period, now I have to deal with toxic shock. Oh.

0:41:47.120 --> 0:41:50.680
<v Speaker 3>I mean, it wasn't like something in life. This is right,

0:41:51.200 --> 0:41:52.920
<v Speaker 3>But I just sort of felt like, okay, like this

0:41:53.000 --> 0:41:55.640
<v Speaker 3>is this is the knowledge, this is part of it, Okay.

0:41:56.080 --> 0:41:59.880
<v Speaker 3>And I feel like after reading for this episode, it

0:42:00.160 --> 0:42:03.760
<v Speaker 3>seems to me that the history of toxic shock syndrome

0:42:03.840 --> 0:42:08.239
<v Speaker 3>reveals how the silence and the shame surrounding menstruation and

0:42:08.280 --> 0:42:12.440
<v Speaker 3>menstrual products. It presented a challenge both in identifying the

0:42:12.440 --> 0:42:15.719
<v Speaker 3>source of this deadly infection, as well as raising awareness

0:42:16.200 --> 0:42:20.800
<v Speaker 3>at a time when words like tampon, menstruation, and period

0:42:20.960 --> 0:42:22.760
<v Speaker 3>were still taboo words.

0:42:22.960 --> 0:42:24.319
<v Speaker 1>I cannot.

0:42:25.719 --> 0:42:29.640
<v Speaker 3>And I think it also demonstrates how the blame has

0:42:29.680 --> 0:42:34.560
<v Speaker 3>been shifted away from tampon manufacturers who did not properly evaluate.

0:42:34.760 --> 0:42:36.560
<v Speaker 3>This is very true to menstruating people.

0:42:36.600 --> 0:42:38.640
<v Speaker 1>Yeah, I can't wait. I can't wait to hear about

0:42:38.680 --> 0:42:42.360
<v Speaker 1>this because I learned so much inefertently about how little

0:42:42.760 --> 0:42:45.279
<v Speaker 1>testing or standardization existed. But prior to this.

0:42:45.360 --> 0:42:49.040
<v Speaker 3>Oh yeah, oh my god, I mean did any Yeah? Yeah,

0:42:49.800 --> 0:42:52.000
<v Speaker 3>and so I really only knew the bare bones of

0:42:52.040 --> 0:42:54.799
<v Speaker 3>this history before researching for this episode, and there is

0:42:55.080 --> 0:42:57.800
<v Speaker 3>so much more to it. Like, like you said, I'm

0:42:58.080 --> 0:43:01.760
<v Speaker 3>I'm I'm excited. Let's start at the beginning. Okay, okay, okay, okay.

0:43:02.880 --> 0:43:07.560
<v Speaker 3>September twenty fifth, nineteen seventy seven. Okay, Denver, Colorado, Oh

0:43:08.000 --> 0:43:11.560
<v Speaker 3>I know. A girl fifteen years old was rushed to

0:43:11.600 --> 0:43:15.200
<v Speaker 3>the children's hospital quote delirious and in shock after a

0:43:15.239 --> 0:43:19.440
<v Speaker 3>two day history of worsening pharyngitis and vaginitis associated with

0:43:19.520 --> 0:43:23.680
<v Speaker 3>vomiting and watery diarrhea. On admission, her temperature was forty

0:43:23.680 --> 0:43:26.359
<v Speaker 3>point nine degrees celsius, which is one of five point

0:43:26.400 --> 0:43:30.600
<v Speaker 3>six degrees fahrenheit, and her blood pressure was sixty six

0:43:30.760 --> 0:43:35.360
<v Speaker 3>over zero And what yeah that's what it said. I

0:43:35.400 --> 0:43:36.320
<v Speaker 3>read it like eight times.

0:43:36.600 --> 0:43:38.720
<v Speaker 1>Oh my god. Yeah.

0:43:38.840 --> 0:43:42.320
<v Speaker 3>She was described as having red, bloodshot eyes, a hugely

0:43:42.360 --> 0:43:46.080
<v Speaker 3>swollen face and limbs, a red scaly rash covering her

0:43:46.280 --> 0:43:50.960
<v Speaker 3>entire body, tender abdomen, pure you lin, I can't, I

0:43:51.000 --> 0:43:52.239
<v Speaker 3>cannot say that word erin.

0:43:52.560 --> 0:43:53.520
<v Speaker 1>It's a tough word.

0:43:53.600 --> 0:43:57.320
<v Speaker 3>Okay, we know what I'm saying. Vaginal discharge and severe

0:43:57.480 --> 0:44:03.799
<v Speaker 3>prolonged shock. She was described as quote unquote confused and aggressive. Like, no,

0:44:03.880 --> 0:44:04.880
<v Speaker 3>wonder right.

0:44:05.120 --> 0:44:07.480
<v Speaker 1>I'm sorry that you're going to put the word aggressive

0:44:07.520 --> 0:44:07.839
<v Speaker 1>in there.

0:44:08.040 --> 0:44:11.239
<v Speaker 3>I know, I know, confused and aggressive, right, but like

0:44:11.920 --> 0:44:14.680
<v Speaker 3>just putting yourself on her shoes. Imagine how terrifying can.

0:44:14.560 --> 0:44:16.600
<v Speaker 1>You not just describe her as dying?

0:44:16.680 --> 0:44:16.879
<v Speaker 2>Right?

0:44:18.560 --> 0:44:21.640
<v Speaker 3>She's acting a little aggressive? Oh, that is all aggressive.

0:44:22.800 --> 0:44:26.600
<v Speaker 3>Her doctor's pumped her full of ivy fluids, antibiotics, steroids,

0:44:26.640 --> 0:44:31.160
<v Speaker 3>heprin digitalis, and put her on a ventilator. Unfortunately, after

0:44:31.239 --> 0:44:34.200
<v Speaker 3>eight days of intensive care, she made a complete recovery,

0:44:34.640 --> 0:44:37.760
<v Speaker 3>except for some necrosis in a few of her toes,

0:44:37.760 --> 0:44:40.680
<v Speaker 3>which ultimately had to be amputated, and the fact that

0:44:40.719 --> 0:44:45.319
<v Speaker 3>her entire skin had started to slush off, but she

0:44:45.440 --> 0:44:47.960
<v Speaker 3>was stable and after seventeen days in the hospital she

0:44:48.040 --> 0:44:48.799
<v Speaker 3>was discharged.

0:44:49.040 --> 0:44:51.400
<v Speaker 1>My goodness. Yeah.

0:44:52.160 --> 0:44:56.520
<v Speaker 3>Her doctors were stumped. They had run tests for Rocky

0:44:56.520 --> 0:45:01.080
<v Speaker 3>Mountain spotted fever, leptosporosis, scarlet fever, and other viral rash

0:45:01.120 --> 0:45:05.000
<v Speaker 3>causing diseases, but nothing had lit up. There was something

0:45:05.080 --> 0:45:09.200
<v Speaker 3>familiar about this case, though, because over the previous couple

0:45:09.200 --> 0:45:11.759
<v Speaker 3>of years there had been a few more just like

0:45:11.800 --> 0:45:15.839
<v Speaker 3>it in children aged eight to seventeen seven total from

0:45:15.920 --> 0:45:19.680
<v Speaker 3>nineteen seventy five to nineteen seventy seven, including one death

0:45:20.120 --> 0:45:23.480
<v Speaker 3>in Colorado or in Colorado in the hot Yeah, that

0:45:23.520 --> 0:45:25.120
<v Speaker 3>had been like I think, I don't know if it

0:45:25.160 --> 0:45:27.560
<v Speaker 3>was like the hospital system or that hospital or like

0:45:27.680 --> 0:45:31.239
<v Speaker 3>within the state. Yeah, yeah, Okay. The doctors that had

0:45:31.280 --> 0:45:34.640
<v Speaker 3>been working on these cases couldn't find anything that linked them.

0:45:34.719 --> 0:45:38.799
<v Speaker 3>There was no food, no drug overdose, no exposure to

0:45:38.840 --> 0:45:42.120
<v Speaker 3>an animal or a chemical. But the clinical picture was

0:45:42.200 --> 0:45:45.720
<v Speaker 3>similar and resembled some of the syndromes caused by staff

0:45:45.719 --> 0:45:50.320
<v Speaker 3>oreas infections like scalded skin syndrome and some staff food

0:45:50.320 --> 0:45:55.280
<v Speaker 3>poisoning cases. Swab cultures confirmed that a toxin producing staff

0:45:55.320 --> 0:45:58.279
<v Speaker 3>orius may be the culprit, and so, in combination with

0:45:58.360 --> 0:46:01.280
<v Speaker 3>shock being a unifying future of the syndrome, the Denver

0:46:01.320 --> 0:46:04.360
<v Speaker 3>doctors named the new condition toxic shock syndrome in a

0:46:04.480 --> 0:46:08.799
<v Speaker 3>nineteen seventy eight paper. Okay, yeah, was it actually new?

0:46:09.560 --> 0:46:13.000
<v Speaker 3>Was this brand new? I mean probably not. There were

0:46:13.040 --> 0:46:15.080
<v Speaker 3>a few other cases that people found in the medical

0:46:15.120 --> 0:46:18.120
<v Speaker 3>literature from as far back as the early nineteen hundreds,

0:46:18.160 --> 0:46:22.640
<v Speaker 3>and there was some other like ancient plague that someone proposed.

0:46:22.680 --> 0:46:26.839
<v Speaker 3>It doesn't really seem to track in my eyes, but

0:46:26.960 --> 0:46:30.200
<v Speaker 3>one research one researcher suggested that it might be like

0:46:30.280 --> 0:46:33.320
<v Speaker 3>a new toxin producing strain, sort of like how we

0:46:33.360 --> 0:46:36.319
<v Speaker 3>talked about with scarlet fever against piogenies went from being

0:46:36.360 --> 0:46:39.880
<v Speaker 3>like super super deadly to them not like just massive.

0:46:39.520 --> 0:46:43.320
<v Speaker 1>Shifts in shifts in what strains strains? Yeah, yeah, yeah.

0:46:43.400 --> 0:46:45.359
<v Speaker 3>And so regardless of whether this was do or not,

0:46:45.760 --> 0:46:48.520
<v Speaker 3>the nineteen seventy eight paper, which is by Todd at

0:46:48.600 --> 0:46:50.960
<v Speaker 3>all if you want to read it, was a critical

0:46:51.120 --> 0:46:54.839
<v Speaker 3>milestone for toxic shock syndrome. Besides giving it a name,

0:46:55.040 --> 0:46:58.080
<v Speaker 3>they also set out this clear clinical picture and described

0:46:58.120 --> 0:47:01.720
<v Speaker 3>a general patient population, and so other physicians who happened

0:47:01.719 --> 0:47:04.920
<v Speaker 3>to read this article began to connect the dots in

0:47:04.960 --> 0:47:09.839
<v Speaker 3>their own patients, starting with physicians in Wisconsin and then Minnesota,

0:47:10.080 --> 0:47:13.480
<v Speaker 3>and then gaining enough momentum that the CDC got involved

0:47:13.960 --> 0:47:18.239
<v Speaker 3>with what was rapidly becoming a public health crisis. The

0:47:18.320 --> 0:47:23.080
<v Speaker 3>first Morbidity Immortality Weekly report on that featured toxic shock

0:47:23.120 --> 0:47:28.200
<v Speaker 3>syndrome was published in May nineteen eighty. With these additional

0:47:28.239 --> 0:47:31.960
<v Speaker 3>reported cases from these other states, researchers zeroed in on

0:47:32.040 --> 0:47:35.480
<v Speaker 3>a toxin producing strain of staphoius. Right, like, that seemed

0:47:35.520 --> 0:47:39.080
<v Speaker 3>to be behind it all, behind these cases, right, but

0:47:39.160 --> 0:47:44.200
<v Speaker 3>the root of transmission was still unclear. The CDC initiated

0:47:44.200 --> 0:47:46.520
<v Speaker 3>a study to find out how people were getting sick

0:47:46.520 --> 0:47:49.799
<v Speaker 3>with this condition, and they identified about fifty women who

0:47:49.840 --> 0:47:52.960
<v Speaker 3>had toxic shock syndrome and fifty women who did not

0:47:53.680 --> 0:47:57.320
<v Speaker 3>matched by sex, geographic area, age, and were often friends

0:47:57.320 --> 0:47:59.279
<v Speaker 3>of the cases. So they were like, okay, what is

0:47:59.280 --> 0:48:02.080
<v Speaker 3>different about that these two individuals. Let's match them these

0:48:02.160 --> 0:48:03.200
<v Speaker 3>pairs love it?

0:48:03.239 --> 0:48:03.880
<v Speaker 1>Case control.

0:48:03.920 --> 0:48:07.719
<v Speaker 3>There we go, and then using phone surveys importantly conducted

0:48:07.760 --> 0:48:12.359
<v Speaker 3>by a woman EIS Officer Catherine Shans, because I think

0:48:12.360 --> 0:48:14.319
<v Speaker 3>that was a really crucial part of getting people to

0:48:14.360 --> 0:48:16.200
<v Speaker 3>actually these women to feel like they could open up,

0:48:16.160 --> 0:48:19.960
<v Speaker 3>which actually taught their experience. Yeah, they asked a million,

0:48:20.560 --> 0:48:24.680
<v Speaker 3>carefully awarded questions about their lives, including menstruation and use

0:48:24.719 --> 0:48:28.680
<v Speaker 3>of menstrual products, and a tentative pattern began to emerge.

0:48:29.400 --> 0:48:33.720
<v Speaker 3>The people developing toxic shock syndrome were young, otherwise healthy

0:48:33.719 --> 0:48:37.360
<v Speaker 3>women who were menstruating at the time that symptoms developed,

0:48:37.440 --> 0:48:42.720
<v Speaker 3>and who used tampons. And I say tentative to describe

0:48:42.760 --> 0:48:45.719
<v Speaker 3>the pattern because it wasn't really a smoking gun. There

0:48:45.719 --> 0:48:48.640
<v Speaker 3>were plenty of tampon users who did not have toxic shock.

0:48:49.520 --> 0:48:52.200
<v Speaker 3>But the devil, of course, would be in the details,

0:48:54.080 --> 0:49:00.719
<v Speaker 3>because tampons are not all created equal. Go to your

0:49:00.719 --> 0:49:04.840
<v Speaker 3>local grocery store and check out the menstrual products aisle.

0:49:05.320 --> 0:49:08.959
<v Speaker 3>You haven't lately, she got shelves. I mean I haven't

0:49:08.960 --> 0:49:11.560
<v Speaker 3>looked lately because I haven't had a period in years

0:49:11.560 --> 0:49:14.560
<v Speaker 3>now because the miracle of birth control pill for me.

0:49:15.719 --> 0:49:19.480
<v Speaker 3>But it's shelves upon shelves of different brands, different absorbencies,

0:49:19.480 --> 0:49:23.759
<v Speaker 3>different materials. I mean, the branding, the variety really is

0:49:24.040 --> 0:49:29.320
<v Speaker 3>something else. The sense I cannot, I mean I cannot. Yeah,

0:49:29.360 --> 0:49:32.720
<v Speaker 3>And the landscape in the late nineteen seventies when toxic

0:49:32.719 --> 0:49:37.279
<v Speaker 3>shock began popping up was roughly similar to this. So

0:49:37.480 --> 0:49:40.960
<v Speaker 3>why then, like what was happening in the late nineteen

0:49:41.000 --> 0:49:45.120
<v Speaker 3>seventies that led to suddenly the syndrome being recognized on

0:49:45.280 --> 0:49:49.239
<v Speaker 3>a nation on a national scale. Tell me, okay, here's

0:49:49.239 --> 0:49:52.880
<v Speaker 3>where we have to get into some tampon nuance. Yes,

0:49:53.560 --> 0:49:56.560
<v Speaker 3>in the decades since the first commercially available tampon in

0:49:56.640 --> 0:50:01.520
<v Speaker 3>nineteen thirty six, just tampacs tampon technol had undergone some

0:50:01.560 --> 0:50:06.360
<v Speaker 3>pretty big changes, very gradually at first, since the demand

0:50:06.360 --> 0:50:09.880
<v Speaker 3>for tampons remained pretty low until the nineteen sixties. Interesting,

0:50:09.920 --> 0:50:12.600
<v Speaker 3>I mean, well, you couldn't advertise easily, so word of

0:50:12.640 --> 0:50:14.719
<v Speaker 3>mouth was the main way that people learned about them.

0:50:14.920 --> 0:50:17.480
<v Speaker 3>And then there was a great deal of handwringing over

0:50:17.520 --> 0:50:20.000
<v Speaker 3>how tampons were a threat to young women's purity and

0:50:20.080 --> 0:50:22.879
<v Speaker 3>like it's going to ruin them right. But eventually though,

0:50:22.920 --> 0:50:25.960
<v Speaker 3>the benefits that tampons provided, like being able to swim

0:50:26.080 --> 0:50:29.320
<v Speaker 3>or dance or go on, you know, being work long shifts,

0:50:29.600 --> 0:50:32.839
<v Speaker 3>all of these things won out over these anxieties and

0:50:32.960 --> 0:50:36.080
<v Speaker 3>by the nineteen sixties, tampons were seen as a symbol

0:50:36.120 --> 0:50:40.560
<v Speaker 3>of bodily freedom of women's liberation, and as the consumer

0:50:40.640 --> 0:50:44.160
<v Speaker 3>base for tampons grew, so did the companies making them,

0:50:44.680 --> 0:50:48.520
<v Speaker 3>and slightly different versions of tampons appeared on the shelves,

0:50:48.520 --> 0:50:51.120
<v Speaker 3>like each of them trying to edge out the competition, right,

0:50:51.200 --> 0:50:53.480
<v Speaker 3>like they each have. Oh, this one's slightly different. This

0:50:53.520 --> 0:50:55.480
<v Speaker 3>one has a better name, this one is better catchphrase,

0:50:55.520 --> 0:50:57.680
<v Speaker 3>this one is more observant, this one is whatever. All

0:50:57.680 --> 0:51:02.239
<v Speaker 3>these different things the applicator. The first tampons made were

0:51:02.280 --> 0:51:05.920
<v Speaker 3>one hundred percent cotton, but these newer tampons began to

0:51:05.960 --> 0:51:11.279
<v Speaker 3>incorporate other fibers to increase absorbency, including synthetic fibers and

0:51:11.320 --> 0:51:15.120
<v Speaker 3>materials developed in the mid twentieth century, things like polyester

0:51:15.800 --> 0:51:20.120
<v Speaker 3>viscos rayon, which is derived from wood cellulose and processed

0:51:20.200 --> 0:51:25.120
<v Speaker 3>with other chemicals, polyacrylate, which you can also find as

0:51:25.160 --> 0:51:27.240
<v Speaker 3>an absorbent and disposable baby diapers.

0:51:27.400 --> 0:51:28.799
<v Speaker 1>Okay, that makes sense.

0:51:28.600 --> 0:51:32.680
<v Speaker 3>Carboxy methyl cellulose, which comes from plant cellulose and shifts

0:51:32.719 --> 0:51:37.040
<v Speaker 3>from powder to gel when introduced to liquids, and even

0:51:37.120 --> 0:51:41.160
<v Speaker 3>today it's next to impossible to find tampons made of

0:51:41.239 --> 0:51:44.520
<v Speaker 3>one hundred percent cotton alone, like, very very very few

0:51:44.960 --> 0:51:49.320
<v Speaker 3>do use those or usee just cotton Procter and gambles.

0:51:49.360 --> 0:51:53.000
<v Speaker 3>Rely tampon which took I know you right, no cane.

0:51:53.160 --> 0:51:54.520
<v Speaker 1>I hated to hear all about Rely.

0:51:55.120 --> 0:51:57.920
<v Speaker 3>This is the tampon that took center stage in the

0:51:57.960 --> 0:52:02.480
<v Speaker 3>toxic shock syndrome crisis of the nineteen eighties. Rely was

0:52:02.520 --> 0:52:08.600
<v Speaker 3>composed of quote, a polyester sheath, compressed polyurethane foam cubes,

0:52:09.000 --> 0:52:12.719
<v Speaker 3>and carboxy methyl cellulose end quote. And I just want

0:52:12.760 --> 0:52:16.480
<v Speaker 3>to like make a point here to say that just

0:52:16.520 --> 0:52:22.200
<v Speaker 3>because chemical names of things are long and like sound complicated,

0:52:22.280 --> 0:52:26.200
<v Speaker 3>does not mean that they are inherently bad. Right. But

0:52:27.560 --> 0:52:29.640
<v Speaker 3>the issue, and then I'll get into this a little

0:52:29.680 --> 0:52:32.359
<v Speaker 3>bit more, is just like the testing of this, right, right,

0:52:32.640 --> 0:52:34.879
<v Speaker 3>because I feel very much like, oh, well, those don't

0:52:34.920 --> 0:52:37.760
<v Speaker 3>sound like natural words, and it's like that doesn't it.

0:52:38.040 --> 0:52:40.200
<v Speaker 1>Yeah? And it's also like, just because something is so

0:52:40.320 --> 0:52:43.560
<v Speaker 1>called natural or is cotton rather than rayon does also

0:52:43.600 --> 0:52:46.120
<v Speaker 1>does not mean that it is safer for you, right,

0:52:46.440 --> 0:52:49.279
<v Speaker 1>So something being a synthetic fiber does not make it

0:52:49.360 --> 0:52:53.439
<v Speaker 1>inherently less or inherently more dangerous.

0:52:52.960 --> 0:52:56.279
<v Speaker 3>Across the board. I mean, maybe research will show that

0:52:56.360 --> 0:52:59.000
<v Speaker 3>it does. Maybe research will show that it does not.

0:52:59.160 --> 0:53:02.439
<v Speaker 3>But yeah, yeah, we just the sweeping generalizations I think,

0:53:02.480 --> 0:53:04.440
<v Speaker 3>and just like the idea that like, oh that has

0:53:04.480 --> 0:53:10.040
<v Speaker 3>a lot of big words. Yeah, yes, yeah that being said,

0:53:10.840 --> 0:53:12.160
<v Speaker 3>yeah really was going.

0:53:12.480 --> 0:53:12.640
<v Speaker 1>Yeah.

0:53:12.680 --> 0:53:16.200
<v Speaker 3>A big part of this so rely was considered and

0:53:16.320 --> 0:53:20.399
<v Speaker 3>advertised as a super absorbent tampon with lightweight materials able

0:53:20.440 --> 0:53:24.760
<v Speaker 3>to hold fifty to fifteen hundred times their weight in water.

0:53:25.120 --> 0:53:28.399
<v Speaker 1>Wow. Yeah sounds like it'll dry you out real good.

0:53:28.840 --> 0:53:30.840
<v Speaker 3>Well yeah it did, I know.

0:53:31.000 --> 0:53:33.200
<v Speaker 1>Yeah, that's a problem. That's probably is supposed to be

0:53:34.080 --> 0:53:36.880
<v Speaker 1>moist anyways, keep going.

0:53:36.760 --> 0:53:41.319
<v Speaker 3>Anyways, So with all of these new tampons coming onto

0:53:41.320 --> 0:53:44.839
<v Speaker 3>the market, coming onto the grocery store shelves in the

0:53:45.120 --> 0:53:49.759
<v Speaker 3>late nineteen seventies, what was that approval process like, tell

0:53:49.800 --> 0:53:53.680
<v Speaker 3>me to be honest, close to non existence, Yes I knew,

0:53:54.280 --> 0:53:59.279
<v Speaker 3>I mean yeah, until nineteen seventy six, tampons and sanitary

0:53:59.320 --> 0:54:04.839
<v Speaker 3>pads were cloudsified as cosmetics. Wow, which and so they

0:54:04.840 --> 0:54:08.439
<v Speaker 3>were technically under the jurisdiction of the FDA, But there

0:54:08.480 --> 0:54:12.239
<v Speaker 3>really wasn't any formalized review process for devices like those

0:54:12.239 --> 0:54:15.200
<v Speaker 3>that were worn or implanted in the body or used

0:54:15.239 --> 0:54:21.440
<v Speaker 3>to diagnose diseases. Wow, no official approval for these was necessary? Yeah,

0:54:21.520 --> 0:54:23.319
<v Speaker 3>I mean in this this is a case I think

0:54:23.320 --> 0:54:26.520
<v Speaker 3>of like technology moving faster than our ability to understand

0:54:26.560 --> 0:54:28.239
<v Speaker 3>the implications of it. Yeah.

0:54:28.360 --> 0:54:28.760
<v Speaker 1>Yeah.

0:54:28.800 --> 0:54:31.520
<v Speaker 3>And over the nineteen seventies it became apparent that, like,

0:54:31.920 --> 0:54:34.239
<v Speaker 3>we need to do a better job. This was a

0:54:34.280 --> 0:54:36.760
<v Speaker 3>mistake to not have any sort official approval.

0:54:37.040 --> 0:54:37.839
<v Speaker 1>Uh huh.

0:54:37.880 --> 0:54:44.480
<v Speaker 3>Serious issues with pacemakers, IUDs like the Dalcon shield, lens implants,

0:54:44.560 --> 0:54:48.200
<v Speaker 3>and other medical devices had left people with severe injuries

0:54:48.520 --> 0:54:53.040
<v Speaker 3>and pursuing lawsuits. So in nineteen seventy six, the Medical

0:54:53.080 --> 0:54:57.240
<v Speaker 3>Device Amendments was added to the Federal Drug the Federal Food,

0:54:57.320 --> 0:55:00.560
<v Speaker 3>Drug and Cosmetic Act. And it's worth getting a bit

0:55:00.600 --> 0:55:03.120
<v Speaker 3>into the nitty gritty here because of the bearing that

0:55:03.160 --> 0:55:06.360
<v Speaker 3>this would have on the emerging issue of toxic shock syndrome.

0:55:06.920 --> 0:55:10.279
<v Speaker 3>So under this amendment, devices were put into one of

0:55:10.360 --> 0:55:13.680
<v Speaker 3>three categories based on their perceived risk. Class one was

0:55:13.800 --> 0:55:18.279
<v Speaker 3>almost no risk, like bedpans, nitrial examination gloves, that sort

0:55:18.320 --> 0:55:21.800
<v Speaker 3>of thing. Class two devices carried a bit more potential

0:55:21.840 --> 0:55:25.520
<v Speaker 3>for risk, so like tampons and hearing aids, and required

0:55:25.520 --> 0:55:29.799
<v Speaker 3>more testing, labeling, and monitoring. And then there was Class three.

0:55:30.000 --> 0:55:33.319
<v Speaker 3>This was the riskiest bunch, like artificial hearts or other

0:55:33.400 --> 0:55:39.239
<v Speaker 3>experimental devices. But when this amendment was introduced, what do

0:55:39.280 --> 0:55:43.920
<v Speaker 3>you do about the existing devices like tampons? Right, most

0:55:44.000 --> 0:55:47.200
<v Speaker 3>of these pre amendment devices were just grandfathered into the

0:55:47.280 --> 0:55:52.000
<v Speaker 3>system and no disruption to sales or production happened. Any

0:55:52.080 --> 0:55:54.960
<v Speaker 3>new tampons I'm talking about tampons specifically here could be

0:55:55.080 --> 0:55:59.160
<v Speaker 3>ushered through this approval process pretty quickly. If the company

0:55:59.160 --> 0:56:02.400
<v Speaker 3>could demonstrate that they were quote unquote substantially equivalent to

0:56:02.520 --> 0:56:06.239
<v Speaker 3>free Amendment devices, that's a problem. It is a problem.

0:56:06.719 --> 0:56:10.960
<v Speaker 3>And one of these substantially equivalent tampons was Procter and

0:56:11.000 --> 0:56:16.920
<v Speaker 3>Gamble's Rely tampon. Okay, Rely it even absorbs the worry. Yeah, yeah,

0:56:17.000 --> 0:56:20.600
<v Speaker 3>ya ya. This was the tagline on the sample box

0:56:20.719 --> 0:56:24.960
<v Speaker 3>containing four Rely tampons that was shipped out in mass

0:56:25.080 --> 0:56:28.799
<v Speaker 3>across the US to millions of homes from the mid

0:56:28.880 --> 0:56:31.360
<v Speaker 3>nineteen seventies to nineteen eighty. It's just as like you

0:56:31.400 --> 0:56:32.840
<v Speaker 3>get free tampons in the Mad tampon.

0:56:32.880 --> 0:56:33.399
<v Speaker 1>Try it out.

0:56:33.680 --> 0:56:38.040
<v Speaker 3>Maybe you like this super absorbent. The materials that were

0:56:38.280 --> 0:56:42.040
<v Speaker 3>used in Reli tampons had been used in other tampons

0:56:42.360 --> 0:56:47.000
<v Speaker 3>on the market, just not the precise configuration, right, But

0:56:47.160 --> 0:56:49.000
<v Speaker 3>how could anyone know that?

0:56:49.600 --> 0:56:50.120
<v Speaker 1>It cannot?

0:56:50.640 --> 0:56:55.560
<v Speaker 3>Manufacturers are not required to disclose the exact composition of

0:56:55.600 --> 0:56:59.840
<v Speaker 3>tampons like materials, fragrances, et cetera, because it qualifies as

0:56:59.840 --> 0:57:00.720
<v Speaker 3>a trade secret.

0:57:01.080 --> 0:57:04.040
<v Speaker 1>Yeah, yeah, the trade secret, trade secrets.

0:57:04.200 --> 0:57:07.239
<v Speaker 3>I mean, I have a lot of thoughts on that.

0:57:07.280 --> 0:57:13.040
<v Speaker 3>In some recent news about certain quote unquote unextinct animals anyway.

0:57:12.840 --> 0:57:17.680
<v Speaker 1>Oh my gosh, we should do an episode dire Wolves.

0:57:17.720 --> 0:57:21.440
<v Speaker 3>I mean, I can't say it without using quotes. But

0:57:21.480 --> 0:57:28.080
<v Speaker 3>because anyway, overall back to toxic shock. As far as I

0:57:28.120 --> 0:57:31.320
<v Speaker 3>could tell, until the late nineteen seventies, though tampons had

0:57:31.320 --> 0:57:34.560
<v Speaker 3>not been associated with any significant health issues or outbreaks

0:57:34.600 --> 0:57:37.400
<v Speaker 3>since they had hit the shelves decades before. Like there,

0:57:37.440 --> 0:57:39.880
<v Speaker 3>it really doesn't seem to be like something. It was

0:57:39.920 --> 0:57:45.960
<v Speaker 3>like more maybe very sporadic types of you know, individual issues,

0:57:46.360 --> 0:57:52.480
<v Speaker 3>not outbreaks. So the spate of toxic shock syndrome cases

0:57:53.680 --> 0:57:57.680
<v Speaker 3>with the beginning in the late nineteen seventies would reconfigure

0:57:57.880 --> 0:58:02.840
<v Speaker 3>the perception of these devices as inert and completely benign.

0:58:03.160 --> 0:58:06.600
<v Speaker 3>What had changed. That was the question that the CDC

0:58:06.720 --> 0:58:10.640
<v Speaker 3>sought to answer. The June twenty seventh, nineteen eighty MMWR

0:58:10.760 --> 0:58:14.360
<v Speaker 3>described the link between toxic shock and tampons. Of the

0:58:14.360 --> 0:58:18.280
<v Speaker 3>one hundred and five cases since September nineteen seventy eight,

0:58:18.920 --> 0:58:22.440
<v Speaker 3>ninety six percent occurred in women aged twelve to fifty

0:58:22.440 --> 0:58:26.240
<v Speaker 3>two during their mental periods, Okay, ninety six percent, and

0:58:26.280 --> 0:58:28.440
<v Speaker 3>the case fatality rate was fifteen percent.

0:58:28.680 --> 0:58:31.040
<v Speaker 1>Wow. See that's so high, so high, That's.

0:58:30.880 --> 0:58:32.480
<v Speaker 3>What I was asking, And you were like, oh, that's

0:58:32.480 --> 0:58:35.120
<v Speaker 3>pretty low, Like fifteen percent is very high.

0:58:35.200 --> 0:58:37.920
<v Speaker 1>Yeah, And that's why I said, I don't know all

0:58:37.960 --> 0:58:40.240
<v Speaker 1>the numbers I saw, I think were from current data,

0:58:40.560 --> 0:58:44.400
<v Speaker 1>right right, So yeah, brands of salt exactly.

0:58:44.520 --> 0:58:48.240
<v Speaker 3>Yeah. In one case control study where they matched someone

0:58:48.320 --> 0:58:51.080
<v Speaker 3>who had toxic shock with another person who didn't like

0:58:51.120 --> 0:58:53.840
<v Speaker 3>similar age, so it's your economic statist, geographicalcation, et cetera,

0:58:54.160 --> 0:58:58.160
<v Speaker 3>they found that one hundred percent of the cases used tampons,

0:58:58.520 --> 0:59:04.680
<v Speaker 3>compared to eighty six percent of the controls. Vaginal cultures

0:59:04.720 --> 0:59:08.600
<v Speaker 3>of those with toxic shock before starting antibiotics showed ninety

0:59:08.600 --> 0:59:11.960
<v Speaker 3>four percent positivity rate for staff aureus okay, and no

0:59:12.040 --> 0:59:16.680
<v Speaker 3>similar cultures had been done for controls because yeah, yeah, retrospective,

0:59:16.760 --> 0:59:19.560
<v Speaker 3>yeah right, But in general, the prevalence of the bacterium

0:59:19.600 --> 0:59:22.560
<v Speaker 3>in the vagina and cervix ranges from two to fifteen percent,

0:59:22.640 --> 0:59:24.440
<v Speaker 3>is what I saw in this book.

0:59:24.600 --> 0:59:26.600
<v Speaker 1>Yeah, well, because it depends too on It can be

0:59:26.680 --> 0:59:28.720
<v Speaker 1>up to forty percent when it's just staff orious. But

0:59:28.760 --> 0:59:30.800
<v Speaker 1>not all of them are going to produce it. Hoxsent's right,

0:59:30.840 --> 0:59:31.720
<v Speaker 1>ver very yis.

0:59:32.920 --> 0:59:35.480
<v Speaker 3>Follow up studies sought to get a handle on which

0:59:35.560 --> 0:59:39.040
<v Speaker 3>tampons and why, and what they found is that across

0:59:39.080 --> 0:59:42.800
<v Speaker 3>the board, tampons with higher absorbancies were associated with toxic

0:59:42.800 --> 0:59:46.760
<v Speaker 3>shock syndrome. Several brands were implicated, but the clear winner,

0:59:47.480 --> 0:59:50.520
<v Speaker 3>if you could call it that, I guess, was rely,

0:59:50.880 --> 0:59:54.920
<v Speaker 3>with seventy one percent of those who had contracted toxic

0:59:54.960 --> 0:59:56.160
<v Speaker 3>shock using the brand.

0:59:56.520 --> 0:59:58.240
<v Speaker 1>Wow, I didn't realize it was that high.

0:59:58.360 --> 1:00:02.800
<v Speaker 3>Seventy one Well, yeah, and it's hard to say how

1:00:02.880 --> 1:00:06.480
<v Speaker 3>much of it was realized popularity, because it had become

1:00:06.840 --> 1:00:09.880
<v Speaker 3>very popular over a very short time, especially with all

1:00:09.880 --> 1:00:11.960
<v Speaker 3>those mail out you know, sample looxes.

1:00:12.240 --> 1:00:14.479
<v Speaker 1>Like what percentage of those eighty six percent of people

1:00:14.480 --> 1:00:18.240
<v Speaker 1>who didn't get toxic shock also were using relyed tampons.

1:00:17.760 --> 1:00:21.240
<v Speaker 3>Twenty six percent of those control group the brands. Yeah, yeah,

1:00:21.920 --> 1:00:25.680
<v Speaker 3>but it wasn't just down to relized popularity. The risks

1:00:25.680 --> 1:00:28.480
<v Speaker 3>seemed to be higher for that specific tampon compared to

1:00:28.640 --> 1:00:32.440
<v Speaker 3>other tampon brands, and researchers suspected that it had something

1:00:32.480 --> 1:00:35.600
<v Speaker 3>to do with the composition of the tampon itself. So,

1:00:35.720 --> 1:00:38.520
<v Speaker 3>like I mentioned, all of the individual components of the

1:00:38.520 --> 1:00:41.960
<v Speaker 3>relied tampon had been used in other tampons previously, but

1:00:42.120 --> 1:00:45.080
<v Speaker 3>not in combination, right, And there seemed to be something

1:00:45.160 --> 1:00:49.400
<v Speaker 3>specific about the blend of polyester and carboxy methyl cellulose

1:00:49.400 --> 1:00:53.160
<v Speaker 3>that encouraged bacterial growth. As you can imagine, this was

1:00:53.280 --> 1:00:55.960
<v Speaker 3>not welcome news to Practor and Gamble, who were busy

1:00:56.000 --> 1:01:00.000
<v Speaker 3>conducting their own studies that naturally were intended to cast

1:01:00.160 --> 1:01:03.800
<v Speaker 3>doubt on what the CDC had found. They even tried

1:01:03.800 --> 1:01:06.480
<v Speaker 3>to strong arm the CDC into giving them the names

1:01:06.480 --> 1:01:08.920
<v Speaker 3>and contact information of the women who had been included

1:01:08.960 --> 1:01:12.240
<v Speaker 3>in the first study. Excuse me, yeah, because they were like,

1:01:12.760 --> 1:01:15.880
<v Speaker 3>the CDC is inflating cases of toxic shock, Like, we

1:01:15.920 --> 1:01:18.520
<v Speaker 3>don't think that these women actually had toxic shocks, So

1:01:18.520 --> 1:01:20.600
<v Speaker 3>we're going to have to go to their doctors and

1:01:20.720 --> 1:01:22.000
<v Speaker 3>look in their medical records.

1:01:22.120 --> 1:01:23.960
<v Speaker 1>Absolutely not Yeah.

1:01:24.000 --> 1:01:29.640
<v Speaker 3>The CDC was like, I'm sorry, no, no, no, So

1:01:29.880 --> 1:01:33.400
<v Speaker 3>instead the Proctor and Gamble tracked down women who had

1:01:33.400 --> 1:01:36.520
<v Speaker 3>called the company and complained that the tampons had made

1:01:36.520 --> 1:01:39.200
<v Speaker 3>them sick, which, like there were a lot of compliants

1:01:39.240 --> 1:01:44.600
<v Speaker 3>about Rely specifically, their intention with tracking these women down

1:01:44.800 --> 1:01:47.960
<v Speaker 3>was to try to undermine the CDC study, saying that

1:01:48.000 --> 1:01:50.880
<v Speaker 3>the cases of toxic shock they included weren't really toxic shock,

1:01:50.960 --> 1:01:54.880
<v Speaker 3>and so Rely has you know, nothing going on. This

1:01:55.320 --> 1:01:59.360
<v Speaker 3>didn't work, and in response then they were like, well,

1:01:59.360 --> 1:02:01.000
<v Speaker 3>we'll try something out else. They were like, let's do

1:02:01.080 --> 1:02:05.160
<v Speaker 3>this this contradictory pr approach where they touted Rely as

1:02:05.200 --> 1:02:08.560
<v Speaker 3>you know, these outstanding tampons, super unique and they give

1:02:08.560 --> 1:02:11.600
<v Speaker 3>you what no other tampon does. Also at the same

1:02:11.600 --> 1:02:14.360
<v Speaker 3>time by being like, but like, Rely is just another tampon,

1:02:14.400 --> 1:02:16.720
<v Speaker 3>it's not any different than these other tampons, are not

1:02:16.720 --> 1:02:19.160
<v Speaker 3>any more dangerous than the other tampons out there. So

1:02:19.200 --> 1:02:20.840
<v Speaker 3>it's like they're saying, really.

1:02:21.000 --> 1:02:23.360
<v Speaker 1>The best were so different. We're just like everyone.

1:02:23.080 --> 1:02:27.760
<v Speaker 3>We're just like everyone else, exactly exactly. But at a

1:02:27.800 --> 1:02:30.439
<v Speaker 3>certain point they realized that there was nothing that could

1:02:30.480 --> 1:02:35.160
<v Speaker 3>be done, and the CDC data was pretty damning, and

1:02:35.240 --> 1:02:38.760
<v Speaker 3>so in September nineteen eighty they realized the inevitable and

1:02:38.800 --> 1:02:41.120
<v Speaker 3>they tried to get ahead of like the bad PR storm,

1:02:41.120 --> 1:02:44.240
<v Speaker 3>and so they voluntarily pulled Rely from the shelves and

1:02:44.320 --> 1:02:45.240
<v Speaker 3>issued a recall.

1:02:47.040 --> 1:02:50.120
<v Speaker 1>I don't think I realized that it was a voluntary

1:02:50.200 --> 1:02:52.680
<v Speaker 1>so they didn't actually get banned.

1:02:53.520 --> 1:02:55.920
<v Speaker 3>No, it was a voluntary recall. And this included like

1:02:55.960 --> 1:02:58.920
<v Speaker 3>print and television campaigns, and there's I think that, like

1:03:00.200 --> 1:03:03.160
<v Speaker 3>there's more to that story in terms of like I

1:03:03.160 --> 1:03:04.880
<v Speaker 3>think that they saw the writing on the wall.

1:03:04.840 --> 1:03:07.120
<v Speaker 1>Well totally, but I just like thought that they also

1:03:07.240 --> 1:03:08.560
<v Speaker 1>actually got banned.

1:03:09.560 --> 1:03:14.560
<v Speaker 3>No, okay, cool? Well, and then yeah, because this there

1:03:14.640 --> 1:03:19.000
<v Speaker 3>were implications to this, right, because on the one hand,

1:03:19.000 --> 1:03:22.120
<v Speaker 3>this is great, this is what needed to happen. There

1:03:22.200 --> 1:03:26.280
<v Speaker 3>was a clear association with RELY specifically and toxic shock syndrome,

1:03:26.760 --> 1:03:29.600
<v Speaker 3>so this meant that this potentially dangerous product was no

1:03:29.680 --> 1:03:33.200
<v Speaker 3>longer going to be available for purchase. But on the

1:03:33.240 --> 1:03:38.640
<v Speaker 3>other hand, this focus on RELY tampons only provided a

1:03:38.640 --> 1:03:41.800
<v Speaker 3>false sense of security once they were removed from the shelves,

1:03:42.320 --> 1:03:45.560
<v Speaker 3>and it obscured the nuance in the relationship between tampons

1:03:45.600 --> 1:03:50.880
<v Speaker 3>and toxic shock syndrome. Yes, it's hard to overstate the

1:03:50.960 --> 1:03:55.280
<v Speaker 3>media frenzy surrounding toxic shock syndrome. In nineteen eighty it

1:03:55.400 --> 1:03:59.520
<v Speaker 3>was the third leading news story in the nation, behind

1:03:59.640 --> 1:04:03.560
<v Speaker 3>only the Iranian hostage situation and the presidential election.

1:04:03.920 --> 1:04:06.320
<v Speaker 1>Wow, toxic shock, toxic shock.

1:04:06.480 --> 1:04:09.760
<v Speaker 3>It was everywhere. Yeah, and this was overall, like we

1:04:09.800 --> 1:04:11.640
<v Speaker 3>talked about a good a good thing in terms of

1:04:11.720 --> 1:04:15.800
<v Speaker 3>raising awareness. The CDC estimated that tampon use dropped from

1:04:15.840 --> 1:04:18.360
<v Speaker 3>seventy percent to fifty five percent by the end of

1:04:18.440 --> 1:04:21.200
<v Speaker 3>nineteen eighty because of toxic shock syndrome.

1:04:21.280 --> 1:04:21.920
<v Speaker 1>Wow.

1:04:22.480 --> 1:04:27.600
<v Speaker 3>But because the research was so new, misinformation was everywhere,

1:04:28.360 --> 1:04:32.280
<v Speaker 3>with journalists and news anchors reporting all kinds of unsubstantiated

1:04:32.320 --> 1:04:36.160
<v Speaker 3>hypotheses about the nature of this infection, things like, rely,

1:04:36.320 --> 1:04:39.440
<v Speaker 3>tampons cause toxic shock syndrome. Period, that's it.

1:04:39.520 --> 1:04:39.600
<v Speaker 1>Ye.

1:04:40.040 --> 1:04:43.920
<v Speaker 3>Toxic shock syndrome is a variant of scarlet fever. Tampons

1:04:43.960 --> 1:04:47.280
<v Speaker 3>cause abrasions or ulcerations that serve as a root of

1:04:47.400 --> 1:04:50.120
<v Speaker 3>entry for the bacterium. Tampons act as a plug that

1:04:50.160 --> 1:04:53.720
<v Speaker 3>allows for bacterial growth, leaving tampons in too long causes

1:04:53.760 --> 1:04:57.680
<v Speaker 3>toxic shock, Removing tampons too soon causes toxic shock. I mean,

1:04:57.760 --> 1:05:02.160
<v Speaker 3>like just so many there was no clear, coherent message, right,

1:05:02.480 --> 1:05:04.720
<v Speaker 3>And part of it is like we discussed that because

1:05:04.760 --> 1:05:08.800
<v Speaker 3>it is a very nuanced thing. But I think another

1:05:08.840 --> 1:05:11.760
<v Speaker 3>part is because there was such fear and anxiety about

1:05:11.800 --> 1:05:14.600
<v Speaker 3>like we need to solve this, and so we need

1:05:14.640 --> 1:05:16.520
<v Speaker 3>to report this as like we need to have a

1:05:16.560 --> 1:05:19.560
<v Speaker 3>clear message to get out to the public. Rely, tampons

1:05:19.600 --> 1:05:20.800
<v Speaker 3>cause toxic shock.

1:05:20.720 --> 1:05:22.800
<v Speaker 1>So that's that's the message. Thing, that's the.

1:05:22.720 --> 1:05:27.440
<v Speaker 3>Message, or tampon's cause toxic shock or taking them out

1:05:27.440 --> 1:05:29.280
<v Speaker 3>too soon, you know, like all of these different things.

1:05:30.040 --> 1:05:33.200
<v Speaker 3>And then you have some older male news acres that

1:05:33.280 --> 1:05:36.320
<v Speaker 3>refuse to say the words tampon or menstrual cycle on

1:05:36.360 --> 1:05:39.880
<v Speaker 3>the air. So what did they say? They just didn't

1:05:40.240 --> 1:05:43.600
<v Speaker 3>report on it, or they made somebody else do it, right, Yeah,

1:05:43.840 --> 1:05:47.040
<v Speaker 3>but the rest of them ran with the story. The

1:05:47.080 --> 1:05:52.160
<v Speaker 3>mixed messaging and extensive airtime given to guesswork both contributed

1:05:52.200 --> 1:05:56.600
<v Speaker 3>to the fears that surrounding toxic shock syndrome. I'm surprised

1:05:56.640 --> 1:06:00.480
<v Speaker 3>I haven't stumbled more over toxic shock syndrome to stay

1:06:00.520 --> 1:06:03.360
<v Speaker 3>over and over again, TSS I might maybe I'll switch

1:06:03.440 --> 1:06:08.480
<v Speaker 3>to that. Yeah, But by also so, you're contributing to

1:06:08.480 --> 1:06:12.600
<v Speaker 3>the fears and then also shifting blame to the consumer. Right,

1:06:12.800 --> 1:06:13.360
<v Speaker 3>That's the thing.

1:06:13.560 --> 1:06:15.360
<v Speaker 1>That's the thing I think erin and I think that

1:06:15.360 --> 1:06:17.960
<v Speaker 1>that still happens today, even in the talk of like, well,

1:06:18.000 --> 1:06:19.920
<v Speaker 1>did are you using the right absorbances? Are you using

1:06:20.400 --> 1:06:21.120
<v Speaker 1>it into long?

1:06:21.200 --> 1:06:21.360
<v Speaker 2>Yes?

1:06:21.440 --> 1:06:24.520
<v Speaker 1>Blah blah blah, And I'm like, did you not buy

1:06:24.520 --> 1:06:25.640
<v Speaker 1>the organic ones?

1:06:26.160 --> 1:06:26.320
<v Speaker 2>Right?

1:06:26.800 --> 1:06:27.840
<v Speaker 1>I'm sorry what?

1:06:28.280 --> 1:06:28.520
<v Speaker 2>Yeah?

1:06:28.760 --> 1:06:32.680
<v Speaker 3>Yeah, Because that's the thing is that the removal of

1:06:33.080 --> 1:06:36.960
<v Speaker 3>RELY tampons didn't mean the removal of the threat of

1:06:37.000 --> 1:06:38.280
<v Speaker 3>toxic shock syndrome.

1:06:38.560 --> 1:06:39.000
<v Speaker 1>Yeah.

1:06:39.040 --> 1:06:42.440
<v Speaker 3>And in fact, one report found that between January and

1:06:42.520 --> 1:06:45.480
<v Speaker 3>September of nineteen eighty, which is when Rely was still

1:06:45.520 --> 1:06:49.840
<v Speaker 3>on the market, fifty cases of TSS were reported in Minnesota,

1:06:50.280 --> 1:06:53.640
<v Speaker 3>forty five percent associated with Rely. So it's fifty cases

1:06:53.720 --> 1:06:56.560
<v Speaker 3>between that those months, and in a similar period of

1:06:56.600 --> 1:07:00.800
<v Speaker 3>time after Rely had been pulled, there were fifty nine cases. Yeah,

1:07:00.840 --> 1:07:04.960
<v Speaker 3>mostly associated with other super absorbent tampon brands. But now

1:07:05.000 --> 1:07:09.000
<v Speaker 3>that there was no single brand to blame, right, no scapegoat,

1:07:09.240 --> 1:07:13.520
<v Speaker 3>no scapegoat, the responsibility to prevent the condition fell entirely

1:07:13.560 --> 1:07:16.600
<v Speaker 3>to the consumer, with the logic following that if someone

1:07:16.600 --> 1:07:19.920
<v Speaker 3>developed TSS, it was because they weren't using tampons properly.

1:07:20.360 --> 1:07:21.880
<v Speaker 1>You didn't read the instruction, you.

1:07:21.840 --> 1:07:25.400
<v Speaker 3>Didn't read the instructions. And on top of finally standardizing

1:07:25.440 --> 1:07:28.640
<v Speaker 3>what Junior, Regular, super and super plus actually meant, which

1:07:28.680 --> 1:07:31.200
<v Speaker 3>happened in nineteen eighty nine, Aaron, I.

1:07:31.160 --> 1:07:34.800
<v Speaker 1>Want to do a whole episode on the Tampon Task Force. Oh, yes,

1:07:34.840 --> 1:07:39.080
<v Speaker 1>the Tampon Task Force, Yes, and the Syngina. I learned

1:07:39.080 --> 1:07:39.640
<v Speaker 1>so much.

1:07:39.760 --> 1:07:44.120
<v Speaker 3>I know, I know there is I just it seems

1:07:44.120 --> 1:07:47.760
<v Speaker 3>like there was it took so long to get anything

1:07:47.800 --> 1:07:48.840
<v Speaker 3>so long.

1:07:49.600 --> 1:07:53.560
<v Speaker 1>Yeah, it took so long. It's unfathomable how it died

1:07:53.600 --> 1:07:55.560
<v Speaker 1>so long. And how then even after all that work,

1:07:55.600 --> 1:07:57.640
<v Speaker 1>people are still like, yeah, I'm just going to use

1:07:57.640 --> 1:07:58.440
<v Speaker 1>saline still.

1:07:58.920 --> 1:08:03.200
<v Speaker 3>Yes, I know, I know, I know all of that. Yeah,

1:08:03.200 --> 1:08:06.000
<v Speaker 3>there's there's so much there. I recommend the book at

1:08:06.040 --> 1:08:10.080
<v Speaker 3>the end of this, but yeah, but so Yeah, they

1:08:10.280 --> 1:08:15.280
<v Speaker 3>standardized absorbencies and then the FDA had also issued guidelines

1:08:15.320 --> 1:08:17.600
<v Speaker 3>for warnings to be included on the tampon box or

1:08:17.640 --> 1:08:20.879
<v Speaker 3>in an insert inside the box, but the initial warnings

1:08:20.920 --> 1:08:25.719
<v Speaker 3>were very vague. Attention. Tampons are associated with toxic shock syndrome.

1:08:26.000 --> 1:08:29.120
<v Speaker 3>TSS is a rare but serious disease that may cause death.

1:08:29.439 --> 1:08:36.320
<v Speaker 3>Read and save the enclosed information. Wow, no detail on symptoms. No, So,

1:08:36.400 --> 1:08:39.439
<v Speaker 3>like you're just like, there's this deadly disease, right, we don't.

1:08:39.240 --> 1:08:41.120
<v Speaker 1>Know what it looks like. Is it from the tampon

1:08:41.280 --> 1:08:42.920
<v Speaker 1>or is what are I looking for? How do you

1:08:43.160 --> 1:08:44.120
<v Speaker 1>know if I have it?

1:08:44.640 --> 1:08:48.120
<v Speaker 3>Yeah, no information on how tampons were associated, even though

1:08:48.160 --> 1:08:51.439
<v Speaker 3>at that point it had been uncovered through research that

1:08:51.520 --> 1:08:54.639
<v Speaker 3>it was likely that super absorbent tampons created, like you said,

1:08:54.640 --> 1:08:58.120
<v Speaker 3>this more aerobic environment for staph rias to multiply, and

1:08:58.240 --> 1:09:02.640
<v Speaker 3>frequent changing created even more more aerobic conditions. Oh. Interesting,

1:09:02.800 --> 1:09:05.080
<v Speaker 3>that's what some of the research said. But like you said,

1:09:05.880 --> 1:09:08.960
<v Speaker 3>its nuance, there's more, yeah, more factors at play.

1:09:09.320 --> 1:09:09.519
<v Speaker 2>Yeah.

1:09:10.040 --> 1:09:13.400
<v Speaker 3>But even that messaging wasn't simple enough to be reported

1:09:13.439 --> 1:09:16.600
<v Speaker 3>by major media outlets, and so the issue continued to

1:09:16.640 --> 1:09:20.880
<v Speaker 3>be one of individual responsibility rather than consumer protection. Women

1:09:20.920 --> 1:09:23.160
<v Speaker 3>were told to monitor their own bodies for signs of

1:09:23.160 --> 1:09:27.200
<v Speaker 3>this deadly disease, rather than manufacturers being forced to reevaluate

1:09:27.240 --> 1:09:30.479
<v Speaker 3>their product and improve it to protect the health of

1:09:30.520 --> 1:09:35.880
<v Speaker 3>their consumers if there was an association between whatever component,

1:09:35.960 --> 1:09:40.639
<v Speaker 3>whatever material, and an increase in aerobic environment or whatever

1:09:40.680 --> 1:09:45.759
<v Speaker 3>it was. And yet, as Sera Vostrel, who's the author

1:09:45.840 --> 1:09:49.000
<v Speaker 3>of Toxic Shock of Social History points out just the

1:09:49.040 --> 1:09:51.439
<v Speaker 3>book that I read for this, things could have been

1:09:51.600 --> 1:09:55.720
<v Speaker 3>much worse. If the Toxic shock public health crisis had

1:09:55.760 --> 1:09:58.719
<v Speaker 3>happened a year later, which would have been the first

1:09:58.760 --> 1:10:02.320
<v Speaker 3>of the Reagan presidency, there wouldn't have been nearly as

1:10:02.400 --> 1:10:06.080
<v Speaker 3>many women in the administration to advocate for women's health,

1:10:06.600 --> 1:10:10.040
<v Speaker 3>women like doctor Catherine Shans, the eis officer at the

1:10:10.040 --> 1:10:14.519
<v Speaker 3>CDC during the time who led the TSS task force. Wow,

1:10:14.920 --> 1:10:17.519
<v Speaker 3>that could have led to decreased awareness, a slower change

1:10:17.520 --> 1:10:21.080
<v Speaker 3>to manufacturing guidelines, and even less attention to the lack

1:10:21.200 --> 1:10:26.240
<v Speaker 3>of transparency about tampon production. Since the height of the

1:10:26.280 --> 1:10:29.320
<v Speaker 3>toxic shock syndrome crisis in the late nineteen seventies and

1:10:29.360 --> 1:10:33.360
<v Speaker 3>early nineteen eighties, incidence has declined, thanks in large part

1:10:33.400 --> 1:10:36.560
<v Speaker 3>two from what I can tell, rely being pulled materials

1:10:36.600 --> 1:10:41.320
<v Speaker 3>like polycrylate, polyestrophoam, and carboxy methyl cellulose being discontinued in

1:10:41.400 --> 1:10:47.960
<v Speaker 3>tampon's absorbency being standardized and amazing advocacy and awareness work.

1:10:48.920 --> 1:10:54.040
<v Speaker 3>Updated labeling requirements as of twenty seventeen have boxes prominently

1:10:54.080 --> 1:11:00.439
<v Speaker 3>display quote attention. Tampons are associated with toxic shock syndromes.

1:11:00.760 --> 1:11:04.040
<v Speaker 3>TSS is a rare but serious disease that may cause death.

1:11:04.400 --> 1:11:08.479
<v Speaker 3>Read and save the enclosed information. That enclosed information must

1:11:08.479 --> 1:11:14.200
<v Speaker 3>include symptoms and estimates of incidents, advises to use minimum absorbencies,

1:11:14.280 --> 1:11:17.280
<v Speaker 3>and declares that risk can be avoided altogether by not

1:11:17.400 --> 1:11:21.840
<v Speaker 3>using tampons and alternating tampons with pads, which is not true.

1:11:21.920 --> 1:11:23.400
<v Speaker 1>Risk can be avoided altogether.

1:11:23.680 --> 1:11:27.679
<v Speaker 3>Apparently that is what That is what I've read. Yeah, great, Yeah,

1:11:27.720 --> 1:11:30.280
<v Speaker 3>that's why I read that the enclosed information has to say. Okay,

1:11:30.960 --> 1:11:33.760
<v Speaker 3>despite the fact that it's been over forty five years

1:11:33.800 --> 1:11:37.320
<v Speaker 3>since this story broke, there is still confusion I feel

1:11:37.400 --> 1:11:42.439
<v Speaker 3>about tampons and toxic shock, about toxic shock overall, at

1:11:42.479 --> 1:11:46.320
<v Speaker 3>both the scientific and consumer levels. You know, how the

1:11:46.320 --> 1:11:51.320
<v Speaker 3>two related, How to reduce risk and what safer alternatives exist?

1:11:51.479 --> 1:11:54.720
<v Speaker 3>Can we make them? Do they exist? Given that more

1:11:54.760 --> 1:11:57.480
<v Speaker 3>than ten percent of women in the US are menstruating

1:11:57.560 --> 1:12:00.920
<v Speaker 3>at any given time, Oh, I love that statistic. Yeah,

1:12:00.960 --> 1:12:03.640
<v Speaker 3>this is not Okay, yeah, that we don't know the

1:12:03.640 --> 1:12:07.800
<v Speaker 3>answers to these Yeah. Research into women's reproductive health is

1:12:07.840 --> 1:12:13.160
<v Speaker 3>continually underfunded and deprioritized, and the shame that surrounded that

1:12:13.200 --> 1:12:17.200
<v Speaker 3>surrounds menstruation keeps many women from talking about these issues

1:12:17.320 --> 1:12:21.360
<v Speaker 3>or feeling like they are justified in demanding that things change.

1:12:22.479 --> 1:12:25.320
<v Speaker 3>So erin tell me are things changing? Do we know

1:12:25.479 --> 1:12:26.080
<v Speaker 3>more stuff?

1:12:26.120 --> 1:12:26.360
<v Speaker 2>Now?

1:12:27.520 --> 1:12:31.799
<v Speaker 1>I'm not going to be able to answer that question, really,

1:12:33.800 --> 1:12:36.880
<v Speaker 1>but I can tell you about what we do know.

1:12:37.680 --> 1:12:38.280
<v Speaker 3>I love it.

1:12:38.439 --> 1:13:09.960
<v Speaker 1>Okay, right after this break, So let's just talk numbers

1:13:10.000 --> 1:13:14.320
<v Speaker 1>for a quick second. Okay, this is so. Toxic shock syndrome,

1:13:14.360 --> 1:13:19.120
<v Speaker 1>staphloccle and non staphlococcle is a reportable disease in the US,

1:13:19.120 --> 1:13:24.000
<v Speaker 1>and that's how they're classified staphococal non staphloccleaxick shock. Since

1:13:24.080 --> 1:13:28.040
<v Speaker 1>nineteen eighty three, staphylococcle toxic shock has been notifiable, and

1:13:28.080 --> 1:13:30.960
<v Speaker 1>since nineteen ninety five, streptoccle toxic shock or non stapho

1:13:31.000 --> 1:13:35.760
<v Speaker 1>cockle has been notifiable. Global numbers pretty much impossible for

1:13:35.840 --> 1:13:42.960
<v Speaker 1>me to find. I don't have them, but this is

1:13:43.200 --> 1:13:48.800
<v Speaker 1>Both of these diseases are quite rare, and the numbers

1:13:48.920 --> 1:13:52.960
<v Speaker 1>in terms of the prevalence or the incidents each year

1:13:54.920 --> 1:13:58.599
<v Speaker 1>really really really varied depending on what paper that I read.

1:14:00.520 --> 1:14:03.280
<v Speaker 1>Most of them seem to come to the conclusion of

1:14:03.320 --> 1:14:09.320
<v Speaker 1>around one ish case per one hundred thousand people per year. Okay,

1:14:09.360 --> 1:14:12.680
<v Speaker 1>but when I say they vary, I mean like, there

1:14:12.800 --> 1:14:16.559
<v Speaker 1>was a paper from twenty eighteen that used UK biobank data,

1:14:17.280 --> 1:14:20.520
<v Speaker 1>and in Europe and the UK, these are not notifiable diseases,

1:14:21.400 --> 1:14:23.320
<v Speaker 1>so the data is even more sparse. But looking at

1:14:23.320 --> 1:14:26.800
<v Speaker 1>like biobank data, they estimated an incidence of point zero

1:14:27.120 --> 1:14:30.160
<v Speaker 1>seven cases of toxic shock per one hundred thousand, which

1:14:30.200 --> 1:14:31.639
<v Speaker 1>is really really really low.

1:14:32.000 --> 1:14:33.520
<v Speaker 3>Huh.

1:14:34.040 --> 1:14:36.960
<v Speaker 1>Most of the US data estimates between point five and

1:14:37.040 --> 1:14:39.280
<v Speaker 1>one per one hundred thousand, though I've seen some that

1:14:39.360 --> 1:14:42.639
<v Speaker 1>say up to two per one hundred thousand cases per year.

1:14:44.240 --> 1:14:46.320
<v Speaker 1>When it comes to strip tocccle, because most of that

1:14:46.400 --> 1:14:49.960
<v Speaker 1>is for staffococcle toxic shock, it's even more all over

1:14:50.000 --> 1:14:52.320
<v Speaker 1>the place in terms of like what the numbers are

1:14:52.360 --> 1:14:56.760
<v Speaker 1>the estimates are. But it is estimated that some somewhere

1:14:56.800 --> 1:14:59.080
<v Speaker 1>in the range of like ten to twenty percent of

1:14:59.120 --> 1:15:02.439
<v Speaker 1>people who have have an invasive group a strep infection

1:15:03.040 --> 1:15:06.559
<v Speaker 1>will go on to develop toxic shock, and so estimates

1:15:06.560 --> 1:15:10.240
<v Speaker 1>also range between like one and five per one hundred thousand. Okay,

1:15:10.840 --> 1:15:13.000
<v Speaker 1>but you'll be happy to know that because I was

1:15:13.080 --> 1:15:15.439
<v Speaker 1>unsatisfied with all of the numbers that I was finding,

1:15:15.600 --> 1:15:20.320
<v Speaker 1>and because we're not not quite erin yes, we're Aaron mathing, okay,

1:15:20.439 --> 1:15:24.800
<v Speaker 1>aerin ish math. I went, this is a notifiable disease

1:15:24.800 --> 1:15:27.040
<v Speaker 1>in the US. So if you didn't know this, you

1:15:27.040 --> 1:15:29.240
<v Speaker 1>can go directly to the CDC where they have a

1:15:29.360 --> 1:15:33.240
<v Speaker 1>National Notifiable Disease Survey, and they have an interactive tool

1:15:33.320 --> 1:15:36.679
<v Speaker 1>that can tell you that from I know me too.

1:15:37.040 --> 1:15:40.080
<v Speaker 1>From twenty sixteen to twenty twenty two, that's the most

1:15:40.120 --> 1:15:44.200
<v Speaker 1>recent timeframe that they had, there were two thousand, one

1:15:44.320 --> 1:15:48.479
<v Speaker 1>hundred and forty four cases of streptococcle toxic shock and

1:15:48.880 --> 1:15:53.200
<v Speaker 1>two hundred and seventeen cases of non streptococle or staffocockle

1:15:53.280 --> 1:15:54.919
<v Speaker 1>toxic shock that we're reported.

1:15:55.160 --> 1:16:00.360
<v Speaker 3>Interesting the difference between magnitude between the two, right, I.

1:16:00.360 --> 1:16:03.800
<v Speaker 1>Mean, streptoccal infections are like quite still rampant, and so

1:16:04.080 --> 1:16:06.439
<v Speaker 1>ten to twenty percent of them are developing toxic shock.

1:16:07.040 --> 1:16:09.000
<v Speaker 1>So if we look then if we air in math

1:16:09.080 --> 1:16:12.519
<v Speaker 1>that a little bit, there's a range in years, but

1:16:12.840 --> 1:16:14.839
<v Speaker 1>one hundred and forty five to four hundred and sixteen

1:16:14.880 --> 1:16:18.160
<v Speaker 1>cases per year was the range for streptococle toxic shock

1:16:18.280 --> 1:16:21.439
<v Speaker 1>in those different years, and then between fifteen and forty

1:16:21.439 --> 1:16:25.400
<v Speaker 1>four cases per year of staphflccle toxic shock in the

1:16:25.439 --> 1:16:28.320
<v Speaker 1>whole entire us. That's what gets reported. And this is

1:16:28.360 --> 1:16:32.120
<v Speaker 1>a reportable disease. So these numbers should be accurate in

1:16:32.200 --> 1:16:36.719
<v Speaker 1>terms of what is identified. And so this is where

1:16:36.720 --> 1:16:41.920
<v Speaker 1>we then have to remember that the like the case

1:16:41.960 --> 1:16:48.000
<v Speaker 1>definitions that we use to identify these cases are imperfect, right,

1:16:48.720 --> 1:16:52.920
<v Speaker 1>and so these are probably underestimates even though they are

1:16:53.160 --> 1:16:59.080
<v Speaker 1>accurate reported numbers, right, because these CDC criteria, and they

1:16:59.160 --> 1:17:01.000
<v Speaker 1>do say this on this CDC website, they're like, you

1:17:01.000 --> 1:17:03.400
<v Speaker 1>shouldn't use this as a clinical diagnosis, Like this isn't

1:17:03.400 --> 1:17:05.240
<v Speaker 1>what you should be using at the bedside to decide

1:17:05.320 --> 1:17:07.360
<v Speaker 1>am I calling this TSS or not? Because this is

1:17:07.360 --> 1:17:10.080
<v Speaker 1>what we're using from a research perspective, and that's a

1:17:10.080 --> 1:17:11.080
<v Speaker 1>little different.

1:17:10.840 --> 1:17:13.799
<v Speaker 3>Right, Interesting should they be different?

1:17:14.120 --> 1:17:16.840
<v Speaker 1>I mean they have to be in part because of

1:17:16.880 --> 1:17:20.800
<v Speaker 1>this the fact that like the probable case definition, like

1:17:21.640 --> 1:17:25.320
<v Speaker 1>you can't you can't do a full case definition without

1:17:25.400 --> 1:17:28.160
<v Speaker 1>the one to two weeks later having this sluffing rash.

1:17:28.640 --> 1:17:31.840
<v Speaker 1>You're not going to have that in the setting, right, right, right?

1:17:33.400 --> 1:17:35.920
<v Speaker 1>So yeah, so there is a little bit of variability there,

1:17:36.880 --> 1:17:40.080
<v Speaker 1>and so these criteria will will likely inevitably result in

1:17:40.120 --> 1:17:43.680
<v Speaker 1>some degree of underreporting. Because of that, a lot of

1:17:43.680 --> 1:17:46.120
<v Speaker 1>people are likely lost to follow up, and so you

1:17:46.200 --> 1:17:48.080
<v Speaker 1>might not get the records on did they end up

1:17:48.080 --> 1:17:50.439
<v Speaker 1>developing a rash? Can we confirm that that's what that was?

1:17:50.560 --> 1:17:50.760
<v Speaker 2>Or not?

1:17:51.240 --> 1:17:53.400
<v Speaker 1>Right, Like, don't get me started on our lack of

1:17:53.439 --> 1:17:55.720
<v Speaker 1>centralized medical records. So how can you go back and

1:17:55.720 --> 1:18:02.479
<v Speaker 1>find that information? It's hard, Yes, So the good news

1:18:02.560 --> 1:18:07.280
<v Speaker 1>is overall it is very very rare. Both stapflococcle, especially

1:18:07.320 --> 1:18:10.719
<v Speaker 1>staphfloccle toxic shock, as well as strupture cockle toxic shock

1:18:10.800 --> 1:18:16.120
<v Speaker 1>are both rare diseases, likely underreported, but still very rare.

1:18:17.320 --> 1:18:19.679
<v Speaker 1>And we talked already about the kind of mortality rates

1:18:19.680 --> 1:18:22.479
<v Speaker 1>and things like that. Those haven't changed from the data

1:18:22.840 --> 1:18:27.640
<v Speaker 1>that I found in recent years, at least when it

1:18:27.720 --> 1:18:31.000
<v Speaker 1>comes to the questions that you asked Aaron about, like

1:18:32.120 --> 1:18:33.240
<v Speaker 1>where are we going from here?

1:18:33.360 --> 1:18:36.799
<v Speaker 3>What else have we learned, what's what's good? What change?

1:18:36.960 --> 1:18:38.160
<v Speaker 3>What change has happened.

1:18:38.560 --> 1:18:41.360
<v Speaker 1>I don't know, Aaron, if we've come up with any

1:18:41.439 --> 1:18:44.719
<v Speaker 1>changes since the Tampon task Force of the nineteen eighties.

1:18:45.200 --> 1:18:46.160
<v Speaker 1>Isn't that depressing?

1:18:46.960 --> 1:18:48.120
<v Speaker 3>It is? It is?

1:18:51.080 --> 1:18:55.800
<v Speaker 1>It's so depressing, and I I, yeah, So I don't

1:18:55.840 --> 1:18:59.479
<v Speaker 1>have any I don't have any new news in terms

1:18:59.520 --> 1:19:04.320
<v Speaker 1>of what do we know about tampons and these relationships

1:19:04.400 --> 1:19:08.000
<v Speaker 1>besides what we've talked about already. H all of the

1:19:08.800 --> 1:19:14.200
<v Speaker 1>like across the board, the recommendations from CDC, from FDA,

1:19:14.280 --> 1:19:17.360
<v Speaker 1>like based on all the epidemiological evidence that we have,

1:19:17.439 --> 1:19:20.559
<v Speaker 1>and it's all epidemiological. And then there's some you know,

1:19:21.000 --> 1:19:24.200
<v Speaker 1>studies that have looked at like the composition of this

1:19:24.240 --> 1:19:27.240
<v Speaker 1>tampon versus that tampon. Is there a difference in lab

1:19:27.400 --> 1:19:30.040
<v Speaker 1>settings of how much bacteria that you can grow and

1:19:30.080 --> 1:19:32.840
<v Speaker 1>that kind of a thing. Yeah, and that's you're really perfect, right?

1:19:32.880 --> 1:19:35.719
<v Speaker 3>Does that translate to human exactly?

1:19:36.200 --> 1:19:38.760
<v Speaker 1>H And like who's funding those studies? I don't know.

1:19:40.560 --> 1:19:43.080
<v Speaker 1>Most of what I saw did not suggest huge differences

1:19:43.120 --> 1:19:45.920
<v Speaker 1>between the tampons that exist today, the tampons that are

1:19:45.960 --> 1:19:49.400
<v Speaker 1>on the market today, regardless of their composition in just

1:19:49.520 --> 1:19:53.040
<v Speaker 1>in a laboratory setting, how much bacteria are they growing, right,

1:19:53.240 --> 1:19:56.360
<v Speaker 1>which again points to that it's not it's not just

1:19:56.400 --> 1:19:59.760
<v Speaker 1>the tampons themselves, it's this interaction between the tampons and

1:19:59.800 --> 1:20:04.599
<v Speaker 1>the environment. The recommendations across the board are to use,

1:20:04.720 --> 1:20:08.920
<v Speaker 1>like you said, the lowest absorbency that you can, which

1:20:08.920 --> 1:20:10.440
<v Speaker 1>at least now they're standardized.

1:20:10.800 --> 1:20:13.360
<v Speaker 3>I mean, I guess yeah to some degree. Still, how

1:20:13.400 --> 1:20:14.200
<v Speaker 3>the heck do you like?

1:20:14.360 --> 1:20:17.400
<v Speaker 1>Yeah? Yeah, yeah, Well, also because I always think I

1:20:17.479 --> 1:20:19.200
<v Speaker 1>used to think about this a lot when I used

1:20:19.240 --> 1:20:24.280
<v Speaker 1>to use tampons, Like, what is six grams of menstrual blood?

1:20:25.000 --> 1:20:29.439
<v Speaker 3>I don't know, no idea, no glue, It's just a

1:20:29.479 --> 1:20:30.920
<v Speaker 3>little blue liquid.

1:20:30.560 --> 1:20:34.080
<v Speaker 1>Like, oh, yes, that's what it is, what it looks like.

1:20:35.120 --> 1:20:37.400
<v Speaker 1>So yeah, but that that is the recommendation to change

1:20:37.400 --> 1:20:40.040
<v Speaker 1>them at least every six to eight hours and not

1:20:40.120 --> 1:20:42.760
<v Speaker 1>go longer than that. I didn't know that you weren't

1:20:42.760 --> 1:20:45.360
<v Speaker 1>supposed to use them overnight growing up all the time

1:20:45.720 --> 1:20:46.200
<v Speaker 1>all the time.

1:20:46.280 --> 1:20:48.160
<v Speaker 3>Did Yeah?

1:20:48.360 --> 1:20:51.000
<v Speaker 1>But I mean again, because this is so rare, Like

1:20:51.240 --> 1:20:54.080
<v Speaker 1>I I really like Aaron, the way that you went

1:20:54.120 --> 1:20:57.760
<v Speaker 1>through all of the history of this and kind of

1:20:57.800 --> 1:21:01.360
<v Speaker 1>emphasize the fact that, like we need to hold accountable

1:21:01.439 --> 1:21:07.400
<v Speaker 1>the correct groups, right and it is not an individual's

1:21:07.520 --> 1:21:11.439
<v Speaker 1>job to make sure that they don't get it.

1:21:11.439 --> 1:21:14.439
<v Speaker 3>It's like, at the very least, I think that what

1:21:14.520 --> 1:21:16.599
<v Speaker 3>it shows is just and I know that there are

1:21:16.600 --> 1:21:18.679
<v Speaker 3>people working on this. And I'm not saying that there's

1:21:18.680 --> 1:21:20.599
<v Speaker 3>no one working on this, that there's no effort being,

1:21:20.760 --> 1:21:23.760
<v Speaker 3>you know, no interest, no effort, no awareness, but like

1:21:24.880 --> 1:21:27.439
<v Speaker 3>the fact that we don't have some of tools maybe

1:21:27.560 --> 1:21:30.479
<v Speaker 3>to be like who is likely who has antibodies at

1:21:30.560 --> 1:21:33.240
<v Speaker 3>high enough levels? What are the screening protocols? Like how

1:21:33.280 --> 1:21:36.000
<v Speaker 3>can we better get them to do better? Yes? How

1:21:36.000 --> 1:21:37.240
<v Speaker 3>can we do better? Yes?

1:21:37.840 --> 1:21:40.400
<v Speaker 1>Yeah, I And I do think that that's an interesting arena,

1:21:40.600 --> 1:21:43.160
<v Speaker 1>is like, and it's hard because of how rare it is, right,

1:21:43.200 --> 1:21:45.360
<v Speaker 1>So like, where's the funding for it? Because people don't

1:21:45.400 --> 1:21:49.080
<v Speaker 1>care as much? Where is the like high kind of

1:21:49.080 --> 1:21:51.880
<v Speaker 1>clinical suspicion to think, is there a test that do

1:21:51.920 --> 1:21:53.760
<v Speaker 1>I have a test that I can run? How do

1:21:53.800 --> 1:21:55.519
<v Speaker 1>I run that test on? What population? Should I be

1:21:55.600 --> 1:21:57.320
<v Speaker 1>running that test? When should I be thinking about it?

1:21:57.320 --> 1:21:58.840
<v Speaker 1>When should I not? And those kinds of things. So

1:21:58.840 --> 1:22:00.800
<v Speaker 1>it's all like they're it needs to be a lot

1:22:00.880 --> 1:22:05.640
<v Speaker 1>more done. I didn't find any updates on it, and

1:22:05.680 --> 1:22:07.519
<v Speaker 1>maybe I missed it. So if you know of things,

1:22:08.000 --> 1:22:08.559
<v Speaker 1>let us know.

1:22:08.680 --> 1:22:09.200
<v Speaker 3>Reach out.

1:22:09.320 --> 1:22:14.200
<v Speaker 1>Yeah, but if you want to know more, who sources

1:22:14.720 --> 1:22:16.599
<v Speaker 1>papers and sources for you, Yeah, we do.

1:22:17.200 --> 1:22:20.840
<v Speaker 3>I have some papers, but I would say again, I'm

1:22:20.840 --> 1:22:24.160
<v Speaker 3>just going to shout out that book Toxic Shocks Toxic Shock,

1:22:24.200 --> 1:22:27.200
<v Speaker 3>a Social History by Shara Vostrel.

1:22:27.600 --> 1:22:31.439
<v Speaker 1>Love it great. I had so many papers for this, Aaron.

1:22:32.000 --> 1:22:34.400
<v Speaker 1>Let me tell you some of my favorite ones. Okay,

1:22:35.560 --> 1:22:38.719
<v Speaker 1>from the Lancet twenty nineteen or sorry, the Lancet Infectious

1:22:38.720 --> 1:22:41.040
<v Speaker 1>Disease Is twenty nineteen by Burger at All. There was

1:22:41.160 --> 1:22:44.160
<v Speaker 1>Menstrual Toxic Shock Syndrome Case Report and Systematic Review of

1:22:44.160 --> 1:22:46.800
<v Speaker 1>the literature. Such an interesting case report in there, too,

1:22:47.640 --> 1:22:49.320
<v Speaker 1>really highlights how much we don't know and how we

1:22:49.400 --> 1:22:55.320
<v Speaker 1>likely underdiagnose it. There was a really very sick book

1:22:55.439 --> 1:22:58.200
<v Speaker 1>that I read just one chapter of called the Palgrave

1:22:58.240 --> 1:23:02.000
<v Speaker 1>Handbook of Critical Menstruation Studies, and the chapter was called

1:23:02.080 --> 1:23:04.519
<v Speaker 1>Toxic Shock Syndrome and Tampons. The Birth of a Movement

1:23:04.600 --> 1:23:08.920
<v Speaker 1>and a Research Agenda. So that was an interesting I

1:23:08.960 --> 1:23:10.720
<v Speaker 1>really liked it. But I also want to shout I

1:23:10.760 --> 1:23:13.400
<v Speaker 1>had a bunch more, like you know, research papers and things,

1:23:13.400 --> 1:23:15.120
<v Speaker 1>but I also wanted to give a shout out to

1:23:15.400 --> 1:23:21.200
<v Speaker 1>a Washington Post article from twenty sixteen by someone's last

1:23:21.240 --> 1:23:23.400
<v Speaker 1>name was Cowart because I didn't write their first name.

1:23:23.600 --> 1:23:25.880
<v Speaker 1>That was called women are still getting toxic shock syndrome

1:23:25.920 --> 1:23:28.800
<v Speaker 1>and no one quite knows why. It just as a

1:23:28.840 --> 1:23:31.760
<v Speaker 1>really it's kind of like this podcast, but in written form,

1:23:31.800 --> 1:23:34.200
<v Speaker 1>it was a really great overview. They went into the history,

1:23:34.200 --> 1:23:36.720
<v Speaker 1>They went into like way more detail on the biology

1:23:36.760 --> 1:23:40.160
<v Speaker 1>than I see in a lot of you know, non

1:23:40.160 --> 1:23:43.280
<v Speaker 1>your media. Yeah, so it was a really great, like

1:23:43.520 --> 1:23:46.280
<v Speaker 1>very overview of it. So I wanted to give that

1:23:46.320 --> 1:23:48.280
<v Speaker 1>one a shout out. But we have so many more

1:23:48.360 --> 1:23:51.479
<v Speaker 1>sources on our website. This podcast would kill you dot Com,

1:23:51.520 --> 1:23:53.320
<v Speaker 1>all of them from this episode in every one of

1:23:53.320 --> 1:23:54.360
<v Speaker 1>our episodes.

1:23:55.320 --> 1:23:58.599
<v Speaker 3>Thank you so much again to Autumn for sharing your

1:23:58.600 --> 1:24:01.920
<v Speaker 3>story with us. We we appreciate it just we mean

1:24:02.120 --> 1:24:02.960
<v Speaker 3>more than we can say.

1:24:03.080 --> 1:24:05.000
<v Speaker 1>It really does mean so much to us, So thank you.

1:24:05.360 --> 1:24:05.559
<v Speaker 3>Yeah.

1:24:06.000 --> 1:24:08.439
<v Speaker 1>Thank you also to Bloodmobile, who provides the music for

1:24:08.520 --> 1:24:10.800
<v Speaker 1>this episode and every single one of our episodes.

1:24:11.360 --> 1:24:15.080
<v Speaker 3>Thank you to Tom and Leanna and Pete and Brent

1:24:15.240 --> 1:24:17.960
<v Speaker 3>and everyone else who at exactly right, who does so

1:24:18.080 --> 1:24:20.040
<v Speaker 3>much to help us with this podcast.

1:24:20.240 --> 1:24:23.559
<v Speaker 1>We really love it. It's fun. Thank you to you for

1:24:23.680 --> 1:24:29.040
<v Speaker 1>listening and watching. Yeah, I'm embarrassed by that face. We

1:24:29.080 --> 1:24:29.640
<v Speaker 1>really like it.

1:24:30.040 --> 1:24:31.200
<v Speaker 3>I liked it. I like it.

1:24:31.360 --> 1:24:34.040
<v Speaker 1>Thank you so much for being with us through this.

1:24:34.080 --> 1:24:35.200
<v Speaker 1>I hope you liked this episode.

1:24:35.360 --> 1:24:38.240
<v Speaker 3>Yeah yeah, let us know, let us know what else

1:24:38.280 --> 1:24:41.120
<v Speaker 3>you want to hear, And as always, a special thank

1:24:41.160 --> 1:24:45.040
<v Speaker 3>you to our patrons. We appreciate your support so very much.

1:24:45.240 --> 1:24:47.320
<v Speaker 1>Yes, thank you well.

1:24:47.840 --> 1:24:50.240
<v Speaker 3>Until next time, wash your hands.

1:24:50.000 --> 1:24:51.000
<v Speaker 1>You feel the animals.

1:25:00.760 --> 1:25:12.280
<v Speaker 2>Bum bum bum bum