Hi everybody. I'm Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation. Today we're joined by Dr. David Ha, who's a pharmacist in infectious diseases and antimicrobial stewardship at Stanford HealthCare. He's going to talk to us about establishing an effective antimicrobial stewardship program. Good morning, David. Thank you so much for joining us today. Good morning, Donna. Thank you so much for the invite. And as you can see, David is following appropriate protocol and wearing his PPE to keep himself and everyone else safe by wearing a mask today. So thank you again, David, for joining us at this unprecedented time in this pandemic and taking the time to talk to us. Absolutely. So I wonder if you could tell us, start by just telling us a little bit about your background. Sure. So I'll start a little earlier. I'm not sure how many folks watching this will be familiar with the background and training of pharmacists specifically, but I completed my doctorate pharmacy at the University of California in San Diego and did two years of residency in general acute care and then infectious diseases at the UC San Diego Medical Center. And after that, I spent the better part of six to seven years down in Los Angeles. I was a faculty at the Keck Graduate Institute School of Pharmacy and also served as an infectious diseases pharmacist starting and running our antimicrobial stewardship program at the Pomona Valley Medical Center, which is a community regional medical center down in eastern Los Angeles County. And about a little over a year ago now, I've moved up to the Bay Area and joined the team up here at Stanford. Excellent. Well, you know, antimicrobial stewardship programs haven't been around for that long, you know, compared to a lot of other things in medicine. Can you tell us just a little bit about why these programs are important and, you know, what do they typically look like in an organization? Yeah, you know, that's a good question. And it's kind of an interesting question and an interesting comment about how they, it's right, you're right that they haven't been around for a long time formally. But I will say that really at a fundamental level, and I'm taking this from one of our medical directors here, that antimicrobial stewardship really is just good clinical medicine in infectious diseases. And infectious diseases is one of those interesting specialties that is generalized amongst general practitioners. And so, you know, I like to use the analogy of if you have cancer and you need chemotherapy, you're not going to do that without working with an oncologist and the oncologist really is going to be driving that. You know, if you need a heart transplant, you're going to be working with a cardiologist, a cardiothoracic surgeon, and, you know, a number of other specialists. But if a patient comes in with pneumonia or a urinary infection, you're not always going to be consulting with infectious diseases. And so the vast majority of infectious diseases that we encounter in the hospital setting or in the outpatient setting, which is an even larger arena in terms of antimicrobial stewardship, you know, you have disseminated that specialty out to out to generalists. And it's a complex specialty. And so what's also interesting about infectious diseases is the tools that we use to treat them become less effective over time the more we use them. And this is relatively unique to the field of infectious disease and the, you know, the antibiotic drug class in that bacteria. And to a certain extent as well, fungi and viruses that can cause infections can develop resistance over time. And that prevalence of resistance increases in the population. The more we use antibiotics, we obviously need to use antibiotics to treat people, to cure them of their infections. But in so doing, we are increasing that resistance and making it less likely the next time either that patient or another patient who has maybe, you know, caught the pathogen that they have, you know, gets a subsequent infection makes it less likely that the antibiotics we use the first time are going to be affected the second time. And I will say if you take a walk around any intensive care units or, you know, any setting like that in a hospital, you will find the consequences of that antibiotic resistance, unfortunately. And so it's a it's a dire problem that needs to be addressed. Thankfully, organizations like yours have recognized this issue and have have really supported this. And, you know, the federal government and other entities have supported antimicrobial stewardship more recently. And so there's been a more concerted effort institutionally to improve antimicrobial use. And that has been more recent. But the concept of antimicrobial stewardship, I would say is as old as antimicrobials themselves. And so tell us a little bit about when you implemented your program. How did you get started? And who did you have to involve in the process? Sure. So I will put the caveat that mine is an experience is one person's experience and everybody's experience is quite a bit different. But I'm actually going to call back from some prior experience in starting an antimicrobial stewardship at a at a large medical center. It takes a village. It's, you know, I struggle to think about how to answer this question, because I really don't recall how we started, we just sort of started reaching out into out into thin air and kind of made things happen. But but I will say traditionally speaking, antimicrobial stewardship programs are led by infectious diseases physicians and infectious diseases pharmacists. And I think that the synergy of those two professions is kind of the special sauce, if you will, of antimicrobial stewardship. And you kind of pair that diagnostic with therapeutic expertise that really, you know, sort of serves as, you know, an important foundation for antimicrobial stewardship. There's a number of other and I know we can talk about this in a second. But, you know, there's a number of other professions that are critically involved in antimicrobial stewardship as well. But it really starts there. And that's how I started my program previously down in LA. And myself and an infectious diseases physician, actually a set of infectious diseases physicians really took on the directives of the state of California. And then later, the directives of the Joint Commission and CMS to start an antimicrobial stewardship program at our hospital. And, you know, we, I think, I think really where where we started was getting an idea of where we were. We didn't know what to do if we, you know, didn't know where we were and where we were sitting and where we wanted to go. And where we were in relation to that. So we spent a lot of time in data collection, initially, looking at our antimicrobial use doing a number of use evaluations, syndromic use evaluations, like, you know, how are we, how are we doing in terms of our treatment of urinary infections? How are we doing in our treatment of pneumonia? What does our, what do our resistance patterns look like relative to the types of antimicrobials that we were you're using? Are we using drugs that are way too, you know, big and broad spectrum when we could be using much more narrow spectrum antibiotics to save some of those broad spectrum antibiotics for the times that we actually need them. And so from that, we were able to capture really what our focus areas were going to be and using national practice guidelines and and published literature to to identify what the most appropriate therapy would be. And we came to institutional practice guidelines. We were able to disseminate a lot of education about appropriate use of antibiotics, education about our resistance rates at our center, making people aware of various providers aware of things that they had not really heard of, even in, you know, many years of practicing at the institution. And, you know, the same way you practice medicine in, in medical school or in your, you know, in your residency training is, is almost certainly not the way you should be practicing now, considering that, considering the changing nature of infectious diseases. So, you know, and that's not to fault any individual.  And so it makes sense that institutions spend some resources to have some individuals collate this information and provide best practices, you know, or help to provide best practices to, to frontline clinicians. So that's really how we started and, you know, started talking to a number of people. We got our microbiology laboratory involved very, very quickly. They were a key, key collaborator. You know, we started getting hospital administration involved. We, you know, we really wanted to, in terms of driving institutional practice, I'm sure a lot of folks in various areas of patient care quality will understand that it's, it's the profession of herding cats, essentially. And your ability to herd cats is directly proportional to your effectiveness, I think, in a lot of these initiatives. And, you know, so we started from the ground up and we also started from the top down at the same time. And so we, you know, we engage frontline clinicians in terms of educations and one-on-one conversations on the floors about their patient that they're taking care of today right now. And we also engaged hospital leadership as well. And we found a natural collaboration with infection prevention and control. They look at a lot of things, I mean, mainly things like clostridia odys difficile infections that are associated with a number of infection prevention issues, but also with antimicrobial stewardship and appropriate antimicrobial use. And so that being already an established, you know, an established priority of the hospital with, to be quite honest, dollars attached to it when it comes to, you know, when it comes to CMS and other agencies and regulatory issues attached, that helped to get hospital administration to, to prioritize it as well. And I think, you know, as we continue to move on, success kind of spurred more success. And so it was a, it was a nucleating effect, I guess, that we got a lot of folks involved over, over that period of time. You know, I love how you said hurting cats. That's a great term, I think. So, you know, it's way too accurate. That's right, it is, it is, you know, especially in some kind, in any kind of, you know, system improvement program. So tell us what specific barriers or maybe resistance did you, did you receive when you were trying to get this initiated? Yeah. You know, I think that there's always, you know, anyone who's an antimicrobial stewardship, anyone who's in a lot of areas of quality and quality improvement will, will kind of speak to, you know, will kind of speak to the folks that are resistant to change as, as a barrier. And, you know, there was, I will say that at my former institution, we had an excellent set of leadership. And so we didn't, thankfully, did not run into very many barriers from a leadership level. But I think from a frontline frontline clinician level, I will say for the vast majority of the time, folks were very collaborative and willing to, you know, willing to, you know, have conversations and actively try to improve their practice. But I think for some, because this idea that you have an external entity trying to come in and influence your practice, there can be some resistance there that you have, you know, you have a lot of, you've obviously spent a lot of time cultivating your practice, you put a lot of thought into it. And to be quite honest, I mean, sometimes we just don't know what we don't know. And so, you know, if you don't realize that what you're doing might be inappropriate or you're not seeing downstream consequences of the things that happened as a result of what you did because that patient is now, you know, suffering the consequences outside of, you know, outside of your immediate field of view, you know, that can be a little difficult for some people. And so I will say that while we did, while that certainly was not, you know, the majority by any means, we definitely had some clinicians that were more difficult to work with. But we were able to move the dial with a lot of those folks over time. And so overall, I think it was pretty successful. And I will say, I mean, as you can see here, the other elephant in the room more recently has been COVID-19. And, you know, COVID, you know, you can kind of extend some of the lessons that we've learned here. I mean, it's definitely a lot more dramatic than anything that we've experienced in the recent past. But, you know, you can extend it to other things like, you know, to H1N1 and other potential things, you know, anything that lies in the future, we just don't really know.   And now we're, you know, sort of in the process of delivering vaccine and, you know, and other things, stepping up to do these things while also maintaining the quality of work that you were doing before. And so that is, you know, I will say that's an additional challenge. But to, you know, to kind of circle back a little bit more fundamentally, because I forgot to mention this earlier, I still think that one of the major limitations of stewardship in general, because I did some work with the county public health department down in Southern California when I was there and worked with a lot of other stewardship programs to help them, you know, to help them improve some of the things that they were doing. And, you know, I will say that the number one complaint that we've heard from folks is that they just don't have sufficient time to do what they need to do. And, you know, I know that's an easy thing for everyone to say. You know, I wish I had more time. I wish we had more staff. But I will say that, you know, there have been, you know, there have been a number of studies now that have, you know, have tried to look at what the optimal, you know, optimal number of, you know, you know, full-time equivalent staff, whether it's pharmacists or ID physicians, microbiologists, you know, infection prevention, as whomever, depending on the structure of the institution that you need to successfully engage in antimicrobial stewardship. Oh, information technology as well is very important, you know, to have dedicated support. You know, to be quite honest, most hospitals have taken on antimicrobial stewardship on top of other things that folks were doing. And so I think a lot of institutions have dedicated stewardship personnel now, which is great. But I think we are, you know, we're far from goal in terms of, you know, the numbers of those individuals that are needed.  And you know, I think that, you know, regulatory agencies should as well look at what type, and I know they are to a degree, but I guess I would continue to advocate that they look at, you know, what type of, you know, human resource support is being given to antimicrobial stewardship programs and the diversity of that support. That's an excellent point. So what have your outcomes been and how did you sustain the program? Yeah. So, you know, I think that outcomes is an interesting thing in antimicrobial stewardship. I think that for, I always relate things, you know, to some other outcomes that we look at in infection prevention like, like C. difficile or, you know, catheter associated urinary infections where we're trying to get down to as close to zero as possible. With antibiotics, it's quite a bit different and, you know, zero antibiotic use would obviously be not what we want. I think the tendency in the absence of formal stewardship programs of clinicians is to over prescribe because they, you know, it's about the taking care of the individual now versus the, you know, larger population and that's it. It's a challenging thing to think about for really anybody. And so the, you know, the typical outcome, initial outcome at least of a stewardship program is to reduce antimicrobial use. But I think that, and that's certainly what, you know, what we've seen. But, you know, I think the challenge is really trying to get to a level of optimal antimicrobial use. And that is a much, much harder thing to measure because there are so many factors that go into the choice of an antimicrobial, even simple things like allergies or, you know, other types of potential side effects that a drug may have that to a particular patient that may make another drug more optimal, even if it is maybe less optimal from a, you know, broader narrow spectrum perspective. And without reviewing every single patient in the hospital in detail, it is hard to get to what that appropriate number is. But, you know, suffice it to say, I think that, you know, we're getting more and more sophisticated metrics over time. The CDC has made a lot of movements to capture antimicrobial use between hospitals and also try to get some semblance of a benchmark for various hospitals. And then, of course, the goal is not zero, but perhaps the goal is to look similar to other institutions that look similar to you. All the caveats, you know, notwithstanding, of course. And so, you know, I think that, you know, you ask about sustainability, and that's a really important question. You know, I think that what's challenging about stewardship is that it's always changing, right? Or the appropriate, you know, the appropriate use of antibiotics or the definition of appropriate use is always changing. And it will be different next year than it is this year.  And that's a tough one. And it means that you need continued involvement from your antimicrobial stewards, like myself and others, to kind of keep this moving, because it is a naturally moving target. But the other thing is you don't want, in my opinion, you don't want your antimicrobial stewards to be doing the same thing today that they were doing five years ago. And I'm a huge, huge fan of decentralizing antimicrobial stewardship and that there is no way that I or even 10 of me could look at all the patients in my hospital in a day and provide recommendations on appropriate antimicrobial therapy. It's just not, it's just not realistic. It's not sustainable. And it's not reasonable because you, with appropriate education, with appropriate partnerships, you can empower frontline clinicians to make those, you know, to help to make those assessments, make those decisions, educating physicians, educating pharmacists, educating microbiologists, educating nurses. I think nurses are a huge, untapped force in antimicrobial stewardship. And we, we haven't even hit the tip of the ice, we haven't even found the iceberg yet in terms of, you know, in terms of engaging nurses. And, and I think, you know, there's, there's a lot to be said about, you know, the, the efforts of, you know, what is that 1% of 100 people's efforts versus 100% of one person's efforts. And in trying to, in trying to disseminate that knowledge and disseminate the activity of antimicrobial stewardship, because again, it's really, it's really just good clinical medicine. And so, you know, we're really trying to help to support people to practice good clinical medicine. And so I think if you can, you can push the culture of your institution to be sort of a continued learning, you know, a learning model. And that naturally we will change the way that I prescribe today will not be the way that I prescribed in two years. I know that and I'm expecting that. That is certainly not the narrative that has existed in the past. It's really been more so that this is how I treated a urinary infection back in 1976. And so that's how I'm going to treat it today. And so I think, I think those types of efforts are really important. It's hard to be specific in that regard. But I think that, but that is probably one of the most valuable things that that an antimicrobial stewardship program can do. The last thing I'll say on that is just to quote a qualitative researcher in antimicrobial stewardship. And this may be a quote from somebody else, but, but culture eats strategy for breakfast, lunch, and dinner. And so you can have all the strategy you want. But if you don't have the culture change in your institution, you're going to be, you're going to be walking uphill for a very long time. That's such a great point about culture. And, you know, it's funny, I always used to say culture eats strategy for lunch, but I really like the breakfast, lunch, and dinner. That's great. You've given me two things to say. So, so David, you know, before we go, any other final advice or recommendations for organizations who are trying to get their programs off the ground? You know, I would say that just to just keep at it and make partners. You know, the, the, the interesting thing about stewardship is it's, it's very rewarding and it can be very taxing at the same time. And I'm sure this will, you know, this will resonate with a lot of folks who are in any sort of quality improvement initiative that, you know, if you spend all day hurting cats, I mean, it's hard to, it's, it's really hard. It can be tough sometimes, and it can be disheartening sometimes, you know, if you're, you know, if your efforts aren't making their way up the chain or you're not seeing the outcomes that, you know, you would like to see. But, you know, I would say that one thing that certainly has kept me going is the people within stewardship. And so, you know, if you can make, if you can help to kind of push people towards being your allies, and it's not necessarily always about just thinking that you know it all and pushing that, pushing your own agenda, that you're coming in and, you know, you for some reason have all the knowledge that nobody else has. I think that, that's certainly a big fellacy. But, you know, talking to people and, you know, getting to understand what issues they're dealing with, with antibiotics and trying to think about ways that folks can be involved in big or small ways is, you know, is really helpful. And it kind of, it really humanizes that antimicrobial stewardship approach and does start to change your culture or improve your culture. And, you know, every institution can stand to improve its culture in lots of ways, particularly with regard to embracing change and embracing fluidity in terms of what they do.  And a lot of times that means getting on, you know, getting on everyone else's team, you know, trying to help with other initiatives that maybe relate to some of the things that you're doing, you know, some of the things that come to mind certainly would be, like I mentioned, infection prevention efforts. Anything that's going on in the microbiology laboratory is going to be very, very important.  I keep saying this over and over again, but I think nurses really are extremely important. They are the, you know, they are truly the last line of defense when it comes to administering antibiotics, and they're the first line of defense when it comes to recognizing any adverse drug reactions and any maybe suboptimal outcomes. Perhaps the antibiotic we're using is not working to treat the infection. The nurse is going to be the first one to know about that, not the physician, not the pharmacist. So, you know, can we, you know, can we provide our nurses with more training and things, you know, specific things to be, you know, to be looking out for? Can we make nurses more critical assessors of antimicrobial therapy to capture more of the relevant information upfront, like drug allergies? I can't tell you how many times I've looked at a chart and it just says allergy to penicillin unknown or the patient vomited or something like that. And, you know, and that leads somebody to prescribe something different down the line, kind of, you know, bringing that full circle and having people recognize, you know, the, you know, maybe unexpected consequences of some of the things that might happen as a result of, you know, some of the things that they cannot even realize that they have done initially. And so, yeah, I think making, making a lot of friends, making a lot of allies, getting a lot of folks on your team as much as possible, and really trying to invest your pro, you know, their initiatives into your outcomes and your initiatives into theirs, I think really helps to, again, you know, improve that culture and really drive, drive lasting change. Wow. Well, David, this has been so incredibly helpful. We really, really appreciate your time and we will let you get back to fighting the pandemic there on the front lines and thank you again so much for joining us. Thank you so much, Donna. Have a great day. You too.


Okay, so now I need to make sure that I can find the comments. Yes. So we're just warming up right now. This is really pre-show banter, welcome, have a sip of your coffee. Yeah, well, Adam, maybe a lot of our listeners are not actually having coffee at this time. It might be like 10 o'clock or midnight for them. They might be having a nice, I don't know, what are you, cold water? Tea? Tea maybe? Tea. Nice calming tea. A nice chamomile. Is this? Anyway. A oatmeal? Chamomile. Oh, chamomile. That makes a lot more sense, Adam. Great job. Anyway, if you're watching this on either Facebook or YouTube, please make a comment. Let us know that you're seeing us. Let us know where you're from, and I am going to roll this little introduction. Send us proof of life. Proof of life. Exactly. Let's... All right, we are back. I'm still figuring things out. Truly is live here, Spotlight Live. Welcome. I am Adam Navas. I'm joined with Liz Wade. Liz, how are you today? I'm good. I have the camera set up up here, but to see your comments, I have to look down here. It looks like I'm paying attention to something else, but I actually am paying attention to your comments. Oh, we already have one. Abdera Mane says it's 3.31 p.m. from Algeria. Hello to Algeria. That's great. Yeah. We are so excited to hear where you are from. What do you like to have? Do you...  I know in a lot of different cultures, people eat late at night. I know when I visited Argentina, they have dinner quite late. I don't sleep as well when I eat or drink right before bed, but of course, in the morning, I love coffee. Yeah. I do have my listeners have mocked me about the size of this cup before. It looks a lot bigger. Right now, it looks the size of your head. It looks like it's two feet. Yeah. See? It's this big. No. See? It's this big. Yes, it is. But this is just... Yeah. It is two layers, so there's some air in there to keep it cold, but this is my coffee. I like an iced coffee. Yeah. 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And if you want to be part of that action, hit the Join button below. And that will give you some more information about that. Well, I think this is a great opportunity. You've joined us here on our Spotlight Live to hear us native English speakers having a conversation. And if you really want to take your English learning to the next level, it's just an opportunity for you to say, hey, I want to take this seriously. I want more and help support us. And we're really excited about where that's going to go. But we have a lot of people saying hello. Yeah. Oh, my goodness. Suleiman from Burkina Faso on Facebook, hello. Abdullah Hassan, watching from Sudan, hello. Seida from Turkey, another country I've been to. Vesalza says hi. That is a person who's usually, I see a lot of comments from that person on YouTube. So hello to you. Hi from Saudi Arabia and Abdullah Said. Hi from Vietnam, Longhawk. And from Yakutia. I've never heard about that. We do also love to answer questions from you on this live show. So if you have a question for either me or Adam or about a recent program, we would love to answer your question. So write it down here. It's also a good way for you to practice English writing in a comment. And so, yeah, do that. So we do have one question, Adam. It says, please, this is from H. Hamdi. Please talk about speaking and how to improve it. Yeah. Well, I think one of the, so I have two answers to that. The first is you just have to do it. You have to just not be afraid and just try it. Put yourself in situations where you are forced to speak English. The other is we would love if you record a short video and post it. I don't think that you can post a video in comments, can you? I don't think so. You'd have to either send it or link to it. If you have a YouTube channel, even if it's your personal one, we'd love to watch that, share that video, and even get a few people who are trying the same sentence or paragraph. And we'd be happy to talk about how your English pronunciation is, what you could do to improve in a certain word. If you have a certain word, even now, if you just asked, how do you pronounce if you have a certain word, we're happy to help you pronounce that word here. Yeah, we did that last time, didn't we? Speaking is a really challenging way. We've often talked about accents as well. People want to not only know what the word is, not only know how to pronounce it, but to pronounce it and sound like a native English speaker. We're toying with creating a course all about accents and how to... Because, of course, even native English speakers have different accents depending on where you live. Well, but it's more about, for example, the sound TH is not in every language. And this is for English speakers who learn a different language as well, where there are not sounds that we make.  Right. So that is, yeah. That's what we would really love to be able to share with you. Yeah. Oh, go ahead, Adam. Did you second part of your answer, or did I miss it? No, that was the first part of his try. The second part is, yeah, find little ways using technology, even if you can't be with a native English speaker, make a video. Even in audio recording, we could listen to and talk about. Yeah, it's true. Well, and you can record yourself and listen to yourself as well. We do have a program that I recommend to people who may not feel confident speaking English or who really do want to practice their speaking. It's called Crazy English, and it is on our website. And it actually talks about a person's method for learning English. And it is a little funny, but a lot of people say that it works, and it can give you confidence. But it is about making mistakes and learning from those mistakes. The other thing I wanted to say is that we also recommend that if you want to improve your speaking, you can listen to one of our classic spotlight programs with the script with you and read along as we read, trying to copy the accent of the person who is reading the program. And if you get really good at that, you can advance to our advanced program where it will start to sound more like a native speaker. So it will have phrases that are together and words that kind of flow into each other. So there is a way for you to start sort of at a beginning level and then go up to another advanced level. So I think that's a lot of good tips. Hey, Liz, we got a question. That is very legitimate. Nasser asks, are you guys going to complete the series of 10 Ways to Fight Hate? Because there's only four here on YouTube. Yes. Well, OK, so we have been running that series. We don't want to just run just that series. We do have the fifth program coming up. And probably over the next year, we will be adding them, I mean, not a year from now, through 2021. But yes, we will be continuing that series. I think we started running it maybe in January. So really, that is something to look forward to. There's still a lot more. There's teaching tolerance. There's Dig Deeper, Create an Alternative. See, it's there. They are coming. We haven't forgotten. I'm really glad that you have enjoyed that series and are looking forward to more. Yeah. There's another one. Hi, Adam and Liz. How to recognize difference between can't and can't in pronunciation. Ooh. That is a really difficult one. I think that mostly it is the context, right? But even now, sometimes I will ask a native English speaker, did you say can't or can? Yeah. Yeah, that's such a small difference. Words that are, why am I blanking? Conjunctions? No, contractions. Contractions, yeah. Contractions, which is, if you don't know what a contraction is, it's two words that get pushed together and become one word. And they are some of the hardest English words to figure out. Right. Because can't, can't, I'm. Can't and wouldn't. There's like something could be made of would and be wouldn't. Or it could be you don't want to do something, so you wouldn't do it. Well, and one of the things is in spotlight, we don't, well, we don't teach English. We are a practice program. But we do not use contractions in our program because they are difficult. I wonder if people even knew that. Yeah, it's a good point. We have one contraction in our whole program. It's in every program. So maybe people know what it is. If you know what one contraction word we use in our program, every program, right? Every single program. Yep. That's probably a pretty big hint. What? Do you know what it is? Hold on. I'm guessing it's from the introduction. Well, I wasn't going to have you answer it, Adam. I don't know what it is. I'm just saying. Oh, OK. Yeah, I would be curious. If you can recognize, not you, Adam, but our listeners. Yeah, put it in the comments. Yeah, put it in the comments. What's the one contraction we use in every program? Yeah, that would be interesting. I'm sure it's, they've snuck through somehow, but I don't know why they would. Well, I love this comment from Anatole, too, on YouTube. We were talking about improving your speaking. And Anatole says that, yes, I try copying your pronunciation. And then, maybe I don't understand, but I'm copying. And I love that. I think it's great. One of my favorite stories, and I think this is a great tip, too, for learning English, is of someone who told this story on YouTube, or not YouTube, Facebook. Someone who wrote to us on Facebook and said that they would listen to spotlight programs every morning as they made breakfast. So they would just have it on in the background. And they would not understand a lot of it. And then one morning, I forget if this was a man or a woman, this person was listening to a very sad program about a person who lost their family and then found their family again. And they were listening. And they just suddenly noticed that they were crying because they realized they were understanding the program as it was going on. So maybe they did not understand programs before. But with all of that practice, just in the background, they began to recognize more words until they just kind of understood, I am understanding this program now. So I think that's a great tip. And you know what, Anatole? Keep going because that work will pay off, that copying and that reading and that consistency that will help you. Yeah. It is, you know, I've been thinking a lot about this. And I haven't talked to you about this, Liz. I watched a video the other day where someone was talking about social media. They were talking about should you make a nice big video, use cinematic, use editing, music, sound effects, high production values, or should you pull out your phone, throw it up on TikTok, just like what do people want? People obviously want the easy short things. But you and I are working to try to help people practice English. That is a hard thing to do. Oh, yeah. I'm sure there are people on TikTok helping people learn English, maybe a word of the day. But we really are committed to a long-term journey of learning English. So when you say, keep doing it, learning a language is not something you can do with just a swipe, or whichever way you're going to swipe on your phone. Yeah, it is consistency. Yes. And so we're committed to that. And I think you should be too, because there are certain things in this world you can't learn quickly. It just takes time. And I do want to bring up again for anyone who missed it at the end, at the beginning, that we do have memberships now on our channel, where you can get access to more resources for practicing your English. So you can get exclusive video content, which we have a lot of exciting things coming out just for members, additional content, shorter spotlight programs, vocabulary videos, all of those things. So check that out for members. Mistakes that we make. Yeah. We never make mistakes. Things that we, behind the scenes stuff, you get to see what really happens when we try to record these things. Yeah, you can get PDFs of scripts. You can get access to our just members-only Facebook group. So really, I hope that you click that join button below if you want some more resources. And yeah, learn some more about it. You know, I'm going to give people a little watch this. Like this is the kind of behind the scenes stuff. You can see, oh, look, huh? You get to see that kind of high quality. That kind of realness. Realness. There's no studio here. Adam, I want to point out that we have a member here right now. And you can see there's a little badge behind Quok's name. I think that's how you say it. I'm very sorry. But Quok says, your English accent is very clear to listen to and understand. So great job. And thank you for being a member. It's so amazing. Yeah. Well, we have worked hard over many years to make sure that when we talk in the spotlight method, there is a little space between our words. Because obviously, in English, you run your words together when you normally speak. But we work really hard in our programs to make sure each word is clear, each word is understandable. And it's good to know that works. It's good to know that you're understanding us. Yeah. And I want to apologize. Because many of our listeners or viewers might recognize that I'm in a different space today. It was just so sunny and beautiful outside that I decided to go on to the porch. But unfortunately, my neighbor is building something. So he is using a saw. It's not as loud for us as maybe it is for you. Maybe you heard that. We can just hear it a little bit. But you know what? I think that's a, that is an experience that many people have, maybe a neighbor making noise. That happens here, too. Sometimes we are the neighbors making noise. So, yeah. Let me see. We have an upcoming program we wanted to talk about. Let's make sure we talk about that. We do. Well, don't we want to talk about it? Which program? Which program? I thought we were going to talk about the COVID program. Oh, that's this week. Oh, that's already out. Yeah, that's this week. I hope that you have had a chance to listen to our program this week about life and loneliness during COVID-19. And there's also a conversation, a real conversation, between Adam and I where we talk about this program. But I really think this is such a universal feeling and experience that I think we'll be talking about this for a long time. Not maybe like at Spotlight, but people in general will be talking about COVID for a very long time. And we did, we asked people to tell their stories. And you can read through some of them on the COVID programs, on the life and loneliness during COVID-19 programs. And it was really heart-breaking to read some of them about one person who had planned to visit their friend in Canada, but the friend died of COVID-19 this year and they were not able to visit their friend. Some of them were just acknowledging, yes, COVID-19 has changed all of our lives or it's going up in my country or it's coming down in my country. And yeah, until we can vaccinate everyone and until everyone has access to those vaccines, it's going to be a while. Yeah, yeah, it is. And I think the loneliness is one of the worst things. If bad things happen and you're with it and you go through those suffering with other people, it's still bad. But even good things, when good things happen, if you're all alone, they don't feel good. And so, I mean, you might be watching this video and you might have tuned in because you want to improve your English or you want to practice English, but I want to say we see you. You are not alone and the little community we have here that you can be a part of, that I'm happy to be a part of and I know Liz is as well. I'm more than happy. Yes. I'm overjoyed to be a part of this spotlight community. We say it all the time, there's no better community than people who listen to spotlight. There really isn't.  And we feel privileged to be able to participate in this with you. So thank you. So I just didn't want to end on a downer note of talking about a tough program, a tough topic, but a good one. But I want to ask one more time, if anyone has any more questions, throw them in the chat right now. We'll try and answer them. And yeah, thanks everyone for joining us. It's so cool to see people from all around the world joining in here. Like, how amazing is that? Yeah. I think it's amazing. I think it's, yeah. So if you have not, if this is maybe you're new to Spotlight, I think you should just check us out. We know we're streaming to Facebook and to YouTube right now. So subscribe and like, and all the things you're supposed to do to help us out. But also, please, just like this video. Check out the Join button. You can subscribe. That would be super great. And then hit the little bell so that you always see when we have a new video out. You won't miss any live chats then, or any of our conversation or advanced or classic videos. Yeah. So yeah, do all that. And we will continue to make programs that look for that 10 ways series. We have great playlists that we're constantly adding to. So maybe you found a topic or a subject that you are interested in. So make sure to dive into the playlist section on our channel. Liz does an amazing job managing that and curating that. So there's going to be some programs that maybe if you're new, you should go back and check out. Hey, and I want to give one challenge as we close here. And if that is everyone watching this right now, could recommend Spotlight either on Facebook or YouTube or post about it on YouTube or Twitter or Instagram. That would be awesome. Or walk to your neighbor's house and knock on the door and tell them about Spotlight. Yeah. My challenge to you is to share the Spotlight website or YouTube channel or Facebook page with someone that you know today who is practicing English. And who knows, maybe you and that person can start using Spotlight to practice your English together. And that is one way that you can form a community and that you can practice your English. So that's my challenge to you. Share Spotlight with somebody today right now as this live show ends. And we want to say thank you so much for watching. Thank you especially to our members, those of you who have really committed to studying and practicing English and using our resources. We really appreciate you. We appreciate you as a whole community, all of you watching right now. Thank you so much. Thank you.


Welcome back to my channel guys. It's your girl Coco styles and on this channel. We talk about beauty fashion and lifestyle and Styling guys. So in today's video, I'm gonna give you guys two little things that will show you guys one thing that I purchased and Something else that I got tailored And I think I'm gonna start off with the jacket so the jacket that I am wearing right now is by Blank Blank NYC I think and I had it for a couple of years But I've never really was a hundred percent happy on how it fit my arms You guys know I am six feet tall and the jacket was kind of hitting right at my watch and I didn't really like it It didn't have enough extra fabric to pull down to extend it fully to like pass my watch So what I did was I had my tailor Go ahead and crop it for me So she cropped the sleeves to like a three-quarter sleeve So I didn't have to roll it up Um, what do you guys think about that? So that's a quick tip that I will always tell women who are tall Um, I want to say five nine and up if you struggle or actually anyone who has long arms guys And what you can do is if it's not enough material for them to take out and extend it Get it cropped guys make it into something that you love, right? So that's what I did with this What do you guys think? I'm not going to put this in the title of the video, but I just think it's something extra But the video is actually going to be about a pair of boots that I purchased from Alexandria Berman, okay Can you guys see this box? Probably not because of the light And I'm going to see how close I can no that's not going to work. The box is a very light I want to say tan But it has like a hint of blush in it And these are the evelyn booty 85 Um It says that they're waterproof I will tell you guys this let me just show you and I got a size 42 um, and this is a 42 in italian numbers and Let me see neem and marcus has them for Maybe 200 dollars cheaper and I said 200 then the actual website Zappos I saw that they had them in the green color And they weren't sell so If this is your type of boot, I will link it below and you guys can check them out So it comes with A really nice dust bag It's actually really nice. Um, I don't know a lot of these companies. I think they should start giving two bags So it's a really nice bag Better than expected Um for your travel Here's my receipt Packaging is really good Has the name on it light paper tissue and here are The boots guys now these boots are not for everyone And the reason why I wanted them I wanted something similar was because I wanted a pair of moto boots, but I wanted them to still be girly to me So that's why I got something with a heel and I'm gonna come close to the camera so you guys can see So here's the boot. This is their signature little bow here um The strings are leather and My only concern Well, the only thing that I don't really like Is a lot of these brands are making boots and stuff and they have a zipper with strings If you have strings, you don't need a zipper. Okay And it actually takes away from the boot to me being Expensive looking. However, I still really love the boot um difficulty putting them on because the strings were tied so tight here And I don't know if you guys can see that little tip Right there. It doesn't come off So it limits you from it stops you from pulling the string through the last The top hoop um if you want it to so If you have a high end step Unstring them as much as you can to get your foot in And go from there. So again, this is the size 42 They smell amazing. Um, I haven't had a boot that smells like real leather in so long because I think a lot of brands are Cheating us on the material The jennifer lee boots are actually really really nice guys. I said that before Um, but this is for my big foot gals and I think I'm going to start showing you guys any shoes that I purchased Because we do struggle with shoes. So this is a 42 and I got a 42 because The front looked a little narrow But once my foot is in there, it's fine. Um, but again, I did have some issues With loosening up the strings and stuff Here's their signature. The strings are actually leather also And I love and let's see the bottom Let me see if I can give you a good Good grip on the bottom The name is here and the size and the heel. I think it's a pretty good Block heel. So this is something that you could wear All the time. So my plan because I have a nice little Moto jacket, I think it'll go good with my moto jacket or pretty much anything guys. Um So yeah, I'm not going to try them on because I don't have one of these socks right now But I wanted to give you guys a good view of them. I mean, I could I guess Um, a good view of them. Um, I do really love the bottom a lot of boots are made with slick bottoms So this is I don't know. They seem like they waterproof but I wouldn't wear these in the rain guys. I wouldn't do it. Um, they're a really nice boot So and I think honestly the reason why they had them strung up so tight because it gives it like like a sleek sleek sleekness look a sleek look and I don't know. I love them And I actually think the older they get they may look even better. Um, because I think the just the strings being leather I think that's a really really good touch. So Let me know what you guys think about the boots and let me know what you guys think about the jacket And I'm trying to see what else let me actually open it up Really quick. It's so much You know, I've given to these brands that put um All the tissue paper in So the ins it's a really it's a really good made boot so Again, you cannot take the string out from here So if you wanted to adjust to move the tongue around You kind of really can't because the string is here. It doesn't come out um, but the tongue you can move the tongue around so The tongue is pretty much attached to this so you can shift that if it gets like, you know, a little stuck there And let's see As far as the inside It's not much actually some padding Between the sole of the foot and the heel. So there's some padding in there. You guys can't really see it um And what else? That's about it guys If you are into stuff like this, I would definitely say give it a go. Try it out Um, it looks like it's coming up shiny on camera, but they're not shiny um, they're like a nice nappa level and I love them. I don't know. Can you guys see the sleekness here? Uh, so you probably can't stuff your jeans in here. I will say that Um, maybe skinny jeans or maybe something a little higher skirt You can probably wear it with skirts um I probably would wear this with like a shirt dress.  What did I say everland? Because the name is looking a little weird Oh, yeah, just everland 85 leather waterproof leather booties So it actually says waterproof guys So let me know what you guys think about this this little bow at first I didn't know if I was feeling it, but I realized I'm like, oh, this is their signature So I like it. I like it. It's very understated. They're not a cheap shoe so Yeah You guys know, I'm all about quality and not necessarily names being written all over it So I'm good with this This is something that I would consider a basic in my wardrobe because it's a black booty And I can wear it dressed up and I can wear it dressed down So that is what we do on this channel. We try to Maximize what we purchase right in smart and shop. So Okay guys, that's the end of this video So if you say to the end of this video, please comment cocoa We see you and don't forget to hit that like comment and Subscribe to this channel guys And don't forget to follow me on instagram because I do post tips every single day Maybe three or four times a day um That's instagram at cocoa styles and y dot com For a cocoa sauce and why and then my website is cocoa sauce and why for your styling services and cocoa styles nyc Dot com for the style blog guys. So I will catch you guys in the next one. Bye


Welcome to module 42 of point set topology part 1. So today we will take up study of properties of topological properties. So recall that we are defined a topological property by which something is true for one space then it must be true for all spaces which are homomorphic. Such a property is called topological property or topological invariant. Then we made a definition this also we I am recalling that a property is called small property if whenever a topology on a given set X has it then all topologies top prime smaller than that should also have the property. Similarly a largeness property is one whenever tau has it and tau prime is a larger topology then tau prime should also have it. Most of the topologies that we have that properties that we have studied in this chapter they belong to the first category namely those which are smallness properties except perhaps the first and second countability they are not exactly of this nature I have already told you. The next chapter will consider those which are likely to be called as largeness properties some of them just like host or some of like first and second countability there will be some which are not exactly largeness properties in our definition. At present what all things they have studied like path connectivity connectivity and all these things right. So what we would like to do is look at a topological property for a space we did be automatically true for a subspace will it be true for a quotient space if it is true for several of them then will it be true for the product space so these are the questions which keep bothering us so we would like to do that in a systematic way as much as possible to begin with in one single place later on we can't do all like that as soon as a new topology comes we can keep asking this question for that topology according to the time availability or our mood and then there are many other kinds of questions also I can ask whether it will be persistent on a taking close subspaces or open subspaces instead of arbitrary subspaces so there are modifications of such questions also so this is what I mean by studying the properties of the topological property. So let us tentatively make a few definitions if we need more and more definitions or modify these definitions we can keep doing that first property is that hereditaryness so P is called a property P is called hereditary if whenever X possesses it all subspace it should possess the same property it will be cohereditary whenever X possesses it all quotients of X should possess it similarly a product invariant there are three different versions here one is finite product invariant another is countable product invariant the third one is product invariant without any quantifier qualifier okay so that is most general what is the meaning of product invariant whenever a family depending upon finite or countable family of X size are given such that if each X i has a property then the product should have and conversely the product has it each factor should also have it okay sometimes people do not bother about this one whenever X size is product has it is called product invariant so the other one they may call it as factor invariant once again there are variants of these concepts that is what I want to tell you so depending upon the author and concepts and you know what exactly you want to study and so on okay there are variants like I already told you hereditary instead of general things you can just take open subspaces you may call it open hereditary or it may be true for only close subspaces then you may call it a close hereditary and so on so they are weaker than actual being hereditary so we may call together they may call it as weekly hereditary but then just really hereditary there will be still ambiguity in this definition similarly for co-hereditary under any quotient map if the property persists then you may call it a co-hereditary but suppose it is only true for open quotients then you may call it weekly hereditary or some other people may call only closer quotients then they may call it weekly hereditary and so on okay so there are various versions of this so here is a table okay which will give you fairly good idea of whatever you are going to do right now and a little more in the in this chapter true maybe in the next section and so on so here I have listed seven of the properties that we have studied so far compactness lindelofness first and second countable separable connected path connected then these are the three properties of the property that we like to study hereditaryness over-hereditaryness and productivity between productivity there are three types i have to define had productivity countable productivity and arbitrary productivity so this being a little more complicated we will do it next time so today let us see whether we will cover this much okay so what i will do first i will take hereditaryness for all these things one after another then you go to co-hereditaryness one after another okay so let us look at compact spaces you already know that closed interval is compact but the open interval is subspace it is not compact so compactness is not hereditary on the other hand you have also proved that every closure subspace of a compact space is compact we have already proved such a thing right so that means it is weakly hereditary exactly same thing goes for lindelofness also every closed subspace of a lindelof space is lindelof right have you seen that lindelofness is not hereditary at all do you remember when we have done that can you see it easily with some example what is to be done take any lindelof space so that there is a subspace which is not lindelof what is lindelofness every open cover should have a countable sub cover space which is not lindelof we have seen that you can take for example an uncountable set and a discrete topology on that that is the easiest example of non-lindelof space okay now instead of taking subspaces you make this one in a larger space by putting one extra point namely a syrpinsky's point okay as soon as you put a syrpinsky's point what is the meaning of that that extra point the only open set containing that point is a whole space therefore when you take a covering every covering of this space must have the whole space as one of the members therefore that singleton subspace they said that will be a cover you take the text member x that's a cover so it's automatically lindelof so this is the space looks like as if we are cheating but that's a you know legal example of a lindelof space such a subspace is not lindelof you can cook up more pleasant examples or or more unpleasant examples also if you like okay so let us keep going first countable and second countable okay this is easy to check that both first and second countability are both hereditary let me do it for second countable first countable you can do exactly same way take a countable base for a topology okay now take a subspace what are the open subspace subspace take any open subset in the original thing intersect with a subspace suppose y is the subspace of x now b is a countable base for y take any member of b intersect with y now collect them that will become a countable base for y that's all okay so so up till here we have come that countability and second countability are hereditary separability connectivity path connectivity they are not hereditary connectivity and path connectivity you know already okay you take an interval remove a point it's gone the connectivity is gone right so subspaces are hardly need to be connected for a connected space and path connected space but for a separability how do you do that why separability is not hereditary remember separability is what there is a countable dense countable dense set when you go to subspace this is dense set may go away that may not mean the subspace right but that doesn't mean that there is no other countable subset so how do you how do you come how do you give an example of a space such that subspace is not separable so perhaps you may try to do similar to slindle ofness start with a non-separable thing and then hook up something bigger which is separable you know that may work no so there are ideas you have to you have to sometimes think about these things right so I have given you an example here remember we had this semi open interval topology in which the basic open subset where a comma b a closer b open so this was left semi interval so rl on the on the space of on the set of real numbers okay consider semi open interval let us see okay this is separable you can check that namely again set of rational numbers will give you a dense set okay though this is this is a this topology is larger than the visual topology so this is a dense subset so this is separable once you have dense set in x so a is a dense set a cross a will be dense inside x cross x so x cross x is separable okay but now I look for a nice subspace here namely the anti diagonal the line given by x plus y equal to 0 okay in the usual topology this is homeomorphic to r but in the in this in this separable in this semi interval topology in the product what happens this becomes a discrete space every point is open now why because given any point x comma minus x you can take x plus x to x plus epsilon and minus x to minus x plus epsilon take the product so this is half half closed rectangle sitting on the point x one of the corners will be on x comma minus x okay so this rectangle half closed rectangle will open its intersection with the the line should be open but intersection if the line is just single point so all the single points are open that means it is discrete a discrete set with a uncountable set a discrete topology and uncountable set right so that cannot be separable okay this example is quite peculiar I will I will use it again okay in the next chapter so as I have pointed out connectivity and path connectivity they are not hereditary that is seen easily okay now let us go to cohereditaryness compactness and lindelofness we have seen that the quotients are also compact and lindelof okay if you won't remember it you can just argue so take an open covering for the quotient inverse image will be an open covering for the for the original space take a finite covering and come back okay so that's it so three and four are what first countability and second countability right so these are weakly cohereditary in the sense that if it is an open coefficient it's open coefficient then x is second countable implies y is second countable once again it's very easy what you have to start with a countable base for b take f of b or b range over this curly b because f is open yeah b is open here first of all that is the crux of this now we can verify that this is a base for the topology on y so same thing works for the local base at a point also all right so open quotients are preserving the first countability and second countability so this is weakly cohereditary all right in general what happens once again we have to cook up examples here okay to examples if you do it for second countable for the whole space or even for a point the proofs will be more or less same okay so I will prove it for now this time first countability okay a space which is first countable but the quotient is not first countable quotient means what now general quotient not open quotient open quotient will be first countable okay all that I do is take infinitely many copies of r disjoint copies is it first countable any first countable space if you take any number of them and take disjoint union it will be still first countable the disjoint union does not disturb local properties all right so it is first countable now what I do I construct a quotient of this by identifying all the zeros in each copy to a single point so you can name them as r cross 0 r cross 1 r cross 2 r cross 3 and so on if you want okay these are the copies of r right now 0 cross n all of them will be identified to one single point we denote it as 0 no other identification this is all okay so equivalence classes what whenever it is 0 cross something it is equivalent to 0 cross that all other points are singleton classes so that is the quotient set give the quotient topology what is the quotient topology something is open in the quotient space if and only if its interest its inverse image is open in the disjoint union of all these copies of r okay so that is my example here x equal to disjoint union of x n countably many copies of r and why to be the quotient space obtained by identifying all the zeros to a single point the next is second countable but why is not first countable even at that point 0 which is the class of all the zeros okay the first countability fails okay so if it is not first countability cannot second countable so it this gives you example for both of them okay how to see that it is not first countable that is also easy suppose we have a countable base b n of our neighbourhoods of 0 okay local base space for this quotient space y okay let us tentatively denote this quotient space quotient map from x to y by q all right given any b n like b 1 you pick up then I can choose an interval in the x 1 x 1 copy of r around 0 so that it is so small that this b 1 intersection q of x 1 the image of that line okay that is not contained inside this q of i 1 do the same thing for all n b 1 b 2 b n and so on you look at the corresponding b n and then go to the corresponding copy of of r there you choose a neighborhood very small so that that neighborhood contain this that is all okay so once you have got for each each n this interval i n you take u to be this disjoint union of all the i n's in the disjoint union okay when you take q of those things that will be an open subset because the inverse image will be precisely disjoint union of these i n's okay so u equal to union of all these q i n's all right that is an open subset containing the point the 0 this 0 bracket you know the class of zeros but because of the choice is choice none of the b n's will be contained inside you okay if it is a base then some b n must be contained inside every open subset there must be a point in the there must be a member in the base which goes inside that so this is not a base in fact what we have proved here is no neighborhood system okay can be countable or take a countable set of neighborhood it cannot be a base that is what we have proved i started countable i never used that countable set of neighborhoods of zero okay then i showed that it is not a base all right once again five six seven what are they separability and path connect connectivity connectivity and path connectivity right so separability is easily seen to be now co-hereditary you see it was not hereditary but it is co-hereditary why take a countable set which is dense go to the quotient take the image that will be also countable set claim is that is dense very easy because all that you have to do is take an open set in the quotient space you have to show that it intersects this image right go to the inverse image that is an open subset in x so that will intersect the original dense set that point will be in the intersection of these two in the in the image that's all okay six and seven path connectivity connectivity we have seen that image just the image of a continuous function itself is has this property connected image will be connected path connected immediately path connected so it's much more stronger than being co-hereditary so the two columns we have seen accept a few things like or two examples like this we had all these things we had seen so it is like a you know this is like a summary of whatever we have done so far accept this example and this this example okay so so now we come to the the third column here product what we have seen is product of finitely many compact sets is compact have you seen that yes but lindelow space one doesn't know finitely but productivity as such okay means that it should be arbitrary product also so here I am saying yes but we don't have proof for arbitrary products not even countable products finite products you know similarly for lindelow we don't know okay the countability first countability again finitely many copies it is even you should take countabilities okay but arbitrary product we don't know okay similarly second countability the separability is more mysterious what we have done is for path connectivity we have seen this one remember connective path connectivity is easy connectivity also you have seen only for finite thing we have seen right so partly many of these things we have seen but we don't know all the full answers none of them properly right so we shall take up this one next time all right so let us stop here


I'm Uma Janeparati. I'm the founder and the managing director of Symetric. Symetric provides integrated IT solution for the clinical research industry and we have been in the business for the past seven years. And the kind of projects, pharmaceutical industry being a very, very traditional and conservative industry, they were always working on the paper businesses. Now, IT solutions have been bringing a shift from the traditional methods of using technology to the latest technologies and we work on the Microsoft suite and we have been progressing continuously or steadily in the past few years and there is a good change what we see in the industry, the way they are adopting technology. EQUALS program has been, it is really phenomenal to be selected to be a part of the EQUALS program and it was a fresh breath of air and we are launched on an international platform which wouldn't have happened otherwise. And there is a lot of learning here, the way we were trained or mentored on how to plan financially, how to present our businesses, how to scale up and how to ensure the leadership qualities and how to impart technology to other businesses. And also the platform gave an opportunity to meet with other businesses or entrepreneurs across the world and it's so great to connect with all the women who are raring to go and find their feet and find their wings to fly across the globe. Being in ITU telecom world has given us a global platform to reach out to all the other women, entrepreneurs and the SMEs and the kind of work they are doing in healthcare and life sciences and how we can collaborate with the other women and other businesses to go global.