Podcasts about Aan

Aan de slag!Lieve vrouw, steek symbolisch een kaars aan en bedenk: Ik laat het licht schijnen!Deze overdenking is geschreven door schrijfster Joanne van de Vendel

Aan de slag!Neem jouw geefgedrag eens onder de loep. Bid erover. Vraagt God iets van jou?

Aan de slag!Ga in de Bijbel op zoek naar waarheid en zet deze tegenover jouw onzekerheden.Bijvoorbeeld: Leugen: Ik kan het niet. Waarheid: Ik kan alles aan door Hem die mij kracht geeft. (Filippenzen 4:13, NBV21)Leugen: ... Waarheid: ...Deze overdenking is geschreven door schrijfster Marianne de Bart- van der Lee

Je favoriete vlekverwijderaars vieren vakantie, maar omdat sommige vlekken hardnekkig zijn, herhalen we deze zomer een aantal van onze eerdere afleveringen. LET OP: in deze aflevering gebruiken we nog de door sommigen als validistisch ervaren term 'blinde vlek'. Ook zit er helaas (nog) geen transcript bij.Als journalist ⁠Karin Sitalsing⁠ haar visitekaartje met ‘Noorderling' erop laat zien, gaan mensen er meestal vanuit dat ze uit Amsterdam-Noord komt. Maar Karin woont en werkt in Groningen en begrijpt weinig van de enorme focus die (ook bij journalisten) vaak op de Randstad/Amsterdam lijkt te liggen. Aan ons vertelt de Brabantse waarom ze ooit in Noord-Nederland ging werken, welke clichés over de provincie echt niet meer herhaald hoeven te worden en waarom journalisten uit ‘de regio' eens moeten ophouden met hun Calimero-complex. Met zijn drieën kiezen we twee gelukkigen die effen t-shirt ontvangen voor hun scherpe oog voor diversiteit, reiken we een fles wasmiddel uit aan een medium dat nog wat vlekken heeft weg te wassen en luisteren we hoe Atta de Tolk ons gesprek weer prachtig samenvatte. Heb jij zelf voorbeelden van missers of opstekers in de media, volg ons dan op www.instagram.com/bontewaspodcast en geef ze daar aan ons door. Word vriend van onze podcast door eenmalig of vaker te doneren via www.vriendvandeshow.nl/bontewaspodcast.

Aan het zwembad liggen betaalt de rekeningen niet, dus zelfs op vakantie kruipt Soundos even achter de microfoon. Edson zou ook wel een frisse duik kunnen gebruiken, nadat hij online werd afgebrand voor zijn hot takes. Quinty doet er nog een schepje bovenop met een gênante weddenschap die Edson slecht gaat zetten. Al gaat ze zelf ook gevuurd worden met haar hot take: social media is niet voor hetero mannen.

Aan de slag! Laat dit lied nog eens tot je doordringen: Maak heel mijn leven tot een lied ook als de dag verstiltMaak wie ik ben getuige vanuw wezen en uw wil In wie ik ben, in wat ik doein al mijn gaan en staanklinkt zo de lof aan U, mijn God en wordt uw wil gedaan Vul mij daarom met diepe dank tot heel mijn leven zingvan U en van uw liefde voorwie klein is en gering Nooit zal mijn leven, dag en nacht dan zonder zegen zijn Bij elke voetstap die ik zet bent U zelf het refrein. (Maak heel mijn leven tot een lied - Sytze de Vries, naar een lied van Horatius Bonar, Fill thou my life).Deze overdenking is geschreven door oud-schrijfster Anne-Saar Kunz

Parkinson disease is a neurodegenerative movement disorder that is increasing in prevalence as the population ages. The symptoms and rate of progression are clinically heterogenous, and medical management is focused on the individual needs of the patient. In this episode, Kait Nevel MD, speaks with Ashley Rawls, MD, MS, author of the article “Parkinson Disease” in the Continuum® August 2025 Movement Disorders issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Rawls is an assistant professor at the University of Florida Health, Department of Neurology at the Norman Fixel Institute for Neurological Diseases in Gainesville, Florida Additional Resources Read the article:  Parkinson Disease Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @DrRawlsMoveMD Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Nevel: Hello, this is Dr Kait Nevel. Today I'm interviewing Dr Ashley Rawls about her article on Parkinson disease, which appears in the August 2025 Continuum issue on movement disorders. Ashley, welcome to the podcast, and please introduce yourself to the audience. Dr Rawls: Thank you, Kait. Hello everyone, my name is Dr Ashley Rawls. I am a movement disorder specialist at the University of Florida Fixel Institute for Neurologic Diseases in Gainesville, Florida. It's a pleasure to be here. Dr Nevel: Awesome. To start us off talking about your article, can you share what you think is the most important takeaway for the practicing neurologist? Dr Rawls: Yes. I would say that my most important takeaway for this article is that Parkinson disease remains a clinical diagnosis. I think the field has really been advancing and trying to find a biomarker to help with diagnosis through ancillary testing. For example, with the dopamine transporter, the DAT scan, an alpha-synuclein skin biopsy, an alpha-synuclein amplification assay that can happen in blood and CSF. However, I think it's so critical to make sure that you have a very strong history and a very thorough physical exam and use those biomarkers or other testing to help with, kind of, bolstering your thoughts on what's going on with the patient. Dr Nevel: Great. And I can't wait to talk a little bit more about the ancillary testing and how you use that. Before we get to that, can you review with us some of the components of the clinical diagnosis of Parkinson disease? Dr Rawls: Yes. So, when I think about a person that comes in that might have a neurodegenerative disease, I think about two different features, mainly: both motor and Manon motor. So, for my motor features, I'm thinking about resting tremor, bradykinesia---which is fullness of movement with decrement over time---rigidity, and then a specific gait disturbance, a Parkinsonian gait, involving stooped posture, decreased arm swing. They can also have reemergent tremor while walking if they do have tremor as part of their disease process, and also in-block turning as they are walking down the hallway. So, those are my motor features that I look for. So now, when we're talking about a specific diagnosis of Parkinson disease, the one motor feature that you need to have is bradykinesia. The reason why I make sure to speak about bradykinesia, which is slowness of movement with decrement over time, is because people can still have Parkinson disease without having tremor, a resting tremor. So even though that's one of the core cardinal features that most of us will be able to notice very readily, you don't have to necessarily have a resting tremor to be diagnosed with Parkinson' disease. When I talk about nonmotor features, those are going to be the three, particularly the prodromal features that can occur even ten years before people have motor features, can be very prominent early on in the disease process. For example, hyposmia or anosmia for decrease or lack of sense of smell. Another one that we really look for is going to be RBD, or rapid eye movement behavior disorder; or REM behavior disorder, the person acting out their dreams, calling out, flailing their limbs, hitting their bed partner. And then the other one is going to be severe constipation. So those three prodromal nonmotor symptoms of hyposmia/anosmia, RBD or REM behavior disorder, and severe constipation can also make me concerned as a red flag that there is a sort of neurodegenerative issue like a Parkinson disease that may be going on with the patient. Dr Nevel: Great, thank you so much for that overview. While we're talking about the diagnosis, do you mind kind of going back to what you mentioned in the beginning and talking about the ancillary tests that sometimes are used to kind of help, again, bolster that diagnosis of Parkinson disease? You know, like the DAT or the alpha-synuclein skin biopsy. When should we be using those? Should we be getting these on everyone? And what scenarios should we really consider doing one of those tests? Dr Rawls: The scenario in which I would order one of the ancillary testing, particularly like a DAT scan or a skin biopsy, looking for alpha-synuclein is going to be when there are potential red flags or a little bit of confusion in regard to the history and physical that I need to have a little bit more clarification on. For example, if I have a patient that has a history of using dopamine blocking agents, for example, for severe depression; or they have a history of cancer diagnosis and they've been on a dopamine agent like metoclopramide; those I want to be mindful because if they're coming in to see me and they're having the symptoms of Parkinsonism---which is going to be resting tremor, bradykinesia rigidity, or gait disturbance---I need to try to figure out is it potentially due to a medication effect, particularly if they're still on the dopamine blockade medication, or is it something where they're actually having a neurodegenerative illness underneath it, like a Parkinson disease? The other situation that would make me order a DAT skin or a skin biopsy is going to be someone who is coming in that maybe has elements of essential tremor, they have more of a postural or an intention tremor that's very flapping and larger amplitude, and maybe have some mild symptoms and Parkinsonism that might be difficult to distinguish between other musculoskeletal things like arthritis, other imbalance issues from, you know, hip problems or knee problems and what have you. Then I might say, okay, let's see if there is some sort of neurodegeneration underneath this; that may be- that there could be, you know, potentially two elements like a central tremor and Parkinson disease going on. Or is this someone who actually really has Parkinson disease, but there's other factors that are kind of playing into that. Dr Nevel: Great, thank you for that. Gosh, things have really changed over the past fifteen years or so where we have this ancillary testing that we're able to use more, because what you read in the textbook isn't always what you see in clinic. And as you described, there are patients who… it's not as clear cut, and these tests can be helpful. Could you tell us more about the levodopa challenge test? How is this useful in clinical practice? And what are some key points that we should know about when utilizing this strategy for patients who we think have Parkinson disease? Dr Rawls: So, before we had all this ancillary testing with the DAT scan, the skin biopsy, the alpha-synuclein amplification assay, many times if you had a suspicion that a person that had Parkinson disease, but you weren't entirely sure, you would say, hey, listen, let us give you back the dopamine that your body may be missing and see if you have an improvement, in particular in your motor symptom. So, when I talk with my patients, I say, listen, I might have a strong suspicion that you have Parkinson disease. Doing a levodopa trial can not only be diagnostic, but also can be therapeutic as well. So, with this levodopa trial, what I end up doing is saying, okay, we're going to start the medication at a low dose because we are looking to see if you have improvement in three of the main cardinal motor symptoms. Obviously, tremor is much easier for us to see if it gets better. It's very obvious on exam, and the patients are more readily able to see it. Whereas stiffness and slowness is much harder to quantify and try to figure out. Am I stiff and slow because of potential muscle tightness from Parkinson disease, or is it something that's more of a musculoskeletal issue? So, I will tell persons, okay, we're looking for improvement in these three cardinal motor symptoms, and things that we're looking for is getting into and out of a car, into and out of a chair, turning over in bed, seeing how do we navigate ourselves in our daily lives? I give people the example of going through the grocery store, going through a busy airport. Are we able to move better and respond better to different changes in our environment which can give us a better clue of if our stiffness and slowness in particular are being improved with the medication? The other part of this is talking about potential side effects of the carbidopa- of the levodopa in particular. One big thing that I think limits people initially is going to be the nausea, vomiting, potential GI upset when starting this medication initially. So, oftentimes I will find people coming in, oh, you know, my outside doctor started me immediately on one tab of carbidopa/levodopa three times per day. I got nauseous, I threw up, and I never took the medication again. So often times I will start low and go slow because once someone throws up my medication, they are not going to want to take it again---with good reason. So, often times I will ask the patient, hey listen, are you very sensitive to medications? If you are very sensitive, we might start one tablet per day for a week, one tablet twice a day, and then go up until we get to two tablets three times a day if we're talking about carbidopa/levodopa. If someone is not as sensitive then I might go up a little bit quicker. What do we mean when we talk about 600 milligrams per day? So usually, the amount that I use is carbidopa/levodopa, 25/100; so, 100 milligrams being the levodopa portion. Many people just start off at 1 tab 3 times a day, which gives you 300 milligrams of levodopa, and they say, oh, it didn't work, I must not have Parkinson or something else. Well, it just may have been that we did not give an adequate trial and adequate dose to the person. Now if they're not able to tolerate the medication because of the side effects, that's something different. But if they don't have side effects and don't notice a difference, there is room to increase the carbidopa/levodopa or the levodopa replacement that you are using so that you can give it, you know, a very good try to see, is it actually improving resting tremor, bradykinesia and rigidity? Dr Nevel: Yeah, great. Thanks for that. When you diagnose a patient with Parkinson disease, how do you counsel that patient? How do you break that difficult news? And how do you counsel them on what to expect in the future and goals of treatment? I know that's a lot in that question, but it also is a lot that you do in one visit, oftentimes, or at least introduce these kind of concepts to patients in a single visit. Dr Rawls: One thing that I think is helpful for me is trying to understand where the patients and their families are when they come in. Because some of the patients come in and have no prior inkling that they may have a neurodegenerative illness like Parkinson disease. Some of my patients come in and say, I'm here for a second opinion for Parkinson disease. So, then I have an idea of where we are in regard to potential understanding of how to start the conversation going forward. If it is someone who is coming in and has not heard about Parkinson disease, or their family has not been made aware that that's the one reason why they're coming to see a movement disorder specialist, then I will start at the beginning After we finish our history, do a very thorough physical exam, I will talk about things that I heard in the history and that I see on the physical exam that make me concerned for a disease like Parkinson disease. I make sure to tell them where I'm getting my criteria from and not just start off, I think you have Parkinson, here's your medication. I think that's very jarring when you're talking with patients and their families, particularly if they had no idea that this could be a potential diagnosis on the table. Like I said, I will start off with recounting, this is what I've heard in your history that makes me concerned. This is what I've seen on your physical exam that makes me concerned. And I think you have Parkinson disease and here is why. And I'll tell them about the tenants like we discussed about Parkinson disease, both the motor and nonmotor symptoms that we see. So that's kind of the first part is, I make sure to lay it out and then open the room up for some questions and clarification. The other portion of this is that, when I'm talking about counseling the patient, I say, we do not expect Parkinson disease to decrease your lifespan. However, over time, our persons, because it is a neurodegenerative illnesses will accumulate deficits over time. So, more stiffness, more slowness, more walking problems. They may, if they have tremor, the tremor may become worse. If they don't have tremor, they might develop tremor in the future. If we're talking about the nonmotor symptoms that we talk about, the main ones are going to be issues with urinary problems, issues with bowels, and then the other thing is going to be neuropsychiatric issues like anxiety and depression. And those things become more prominent, usually, the nonmotor symptoms later on in the disease process, and then also cognitive impairment as well. I really want to make sure that they have the information that I'm seeing, and if there's anything that they want to correct on their end, as in they're saying, oh wait, well, actually I noticed something else, then that's usually when that comes out around kind of the wrapping-up portion of the visit. So, I think that's really important to, one, be very clear in what I am seeing and if there's red flags, and then tell them, okay this is not going to shorten your lifespan. However, over time, we do have other issues and problems that will arise and we can support you as best as we can through that. The one thing I also been very open with people about is- because our patients will say, is there anything I can do? What can be done? Is there any medication to slow down or stop things? And I let people know that unfortunately, right now there's not an intervention that slows down, stops, or reverses disease progression, with the exception of exercise. Consistent exercise has been found to help to slow down disease progression, okay? And also, it can help to release the dopamine already being made innately in the brain. And also, it can help with our cardiovascular health in the big thing: being balanced. Core strength, quadricep strength. So that's also something that people can work on that they should. And I let people know that exercise is as important as the medications themselves. Dr Nevel: Absolutely. And it's incredible how much they incorporate exercise into their daily lives and get active, people who weren't active before their diagnosis, and how much that can help. One question that I think patients sometimes ask is, when they understand how carbidopa/levodopa works and what the expectations are for that medication, that it's not a disease-modifying medication, but that it can help with their symptoms. And then they kind of hear, well as time goes on, they need higher doses or, you know, it doesn't control their motor symptoms as well. They'll say, okay well, is it better to wait then? Should I wait to start carbidopa/levodopa? Like in my mind, I'm only maybe going to get X amount of time from carbidopa/levodopa. So, I'd rather wait to start it than start it now. What do you say to them and how do you counsel them through that? Dr Rawls: So that is a common question that I do get with my patients. So, I tell people, I'm here for you. And it really depends on how you feel at this time. Because you have to weigh the risks and benefits of the medication itself. If someone who's very, very mild decides to take the medication, they feel nauseous, they're just going to say, hey, listen, it's not for me right now. I don't feel like I need it, and then stop, which is with definitely within their right. But what I always counsel patients as well is to say, the dopamine-producing neurons in the substantia nigra are starting to die over time. That is why we are getting the signs and symptoms of Parkinson disease. At some point, your brain is not going to produce enough dopamine that is needed for you to move when you want to move and not move when you don't want to move. Okay? Giving you at least the motor symptoms of Parkinson disease. With this, it's not that the medication stops working, it's just that you need more dopamine to help replace the dopamine that's being lost. However, the dopamine that you are taking or levodopa that you're taking orally is not going to be released as consistently as it is in your brain on demand and shut off when you don't need it. Hence the reason we get more motor fluctuations. Also, potential side effects in the medication like orthostatic hypertension, hallucinations, impulse control disorders. Because you're having to take more escalating doses, those side effects can become more prominent and also lead us to have to balance between the side effects and the medication itself. So, it's not that the medication does not work, your body needs more of it. Some people will say, oh, well, I want to wait, and I say, that's completely fine. However, my cutoff is basically saying, if you are finding that you, as the person who's afflicted is not able to get up in the morning like you want to, you're avoiding going to walk your dog or working in your garden, you know, because you feel stiff and feel slow; you're avoiding, you know, going out to the community, having lunch with your friends or your family because you're embarrassed by your tremor; this is something that is keeping you from living your life. And that's the time that we need to strongly consider starting the medications. So, a person afflicted will accumulate deficits. However, it's how much the deficits are going to affect you. So, if it's really affecting your life, we have tools and ways to help mitigate that. Dr Nevel: Yeah, absolutely. Are there any aspects of Parkinson disease management that you feel are maybe underrecognized or perhaps underutilized? In other words, you know, are there things that we the listeners should be maybe more aware of or think about offering or recommending to our patients that you think maybe aren't as much as they could be? Dr Rawls: I will say the nonmotor symptoms---in particular the neuropsychiatric symptoms with the anxiety and depression, usually later on disease process but also can be earlier as well---I think that is going to be something that is recognized but maybe undertreated in a lot of our patient population. I think part of that is also the fluctuations in dopamine that are occurring naturally in the person, but also, our patients, oftentimes with their medication regimen, really have to be on the ball taking the medication. If they're even 15 minutes late, 10 minutes late, 5 minutes late, we're now off, and now we're waiting for it to kick in. And so that can cause a lot of anxiousness even throughout the day. And then knowing that slowly over time that they're going to accumulate these motor and nonmotor deficits can definitely be problematic as well. There is obvious reason for this underlying potential anxiety and depression. And while we do talk about that and bring that up, sometimes patients will say, oh well, I don't think it's a problem right now. I don't have to mess with this. But usually at some point it does become an issue that usually the family members will bring up and saying, hey, you know, my loved one is very anxious. Or I've noticed that they're just really disengaged from what's going on in their lives and they are not talking as much, they're not going out as much. Again, that could be a combination of depression/anxiety, but it also can be a physical- a combination of, I'm not physically able to do these things, or, they're much more difficult for me to initiate doing these activities. I always want to be mindful. If my patients come in and they already have a diagnosis of depression or anxiety and they're already being treated by a mental health counselor, provider, or a psychiatrist, then I will work with providers so that we can try to optimize their medication regimen. The other thing is, well, if this is the first time that they're really being seen by someone and talking about their anxiety and depression, then oftentimes I will have them go back to their primary care and see if maybe an SSRI or SNRI will be helpful to try to help with the neuropsychiatric symptoms they may be experiencing. So that's one big one. Another one that I think that might be a little bit underappreciated is going to be drooling. Sometimes I'll come in and see my patients and notice some drooling that's happening with the mouth being open, not being able to initiate the swallowing reflex consistently throughout the day. Or they may be patting their face a lot with a napkin or a towel and then bringing that up and bringing it to light. Oh yeah. I have a lot of drooling while I'm awake. It's on my shirt. It's embarrassing. I feel like it's a little bit too much for me or my family. We have to put a bib on because I'm just drooling all throughout the day. That can really be uncomfortable and cause skin breakdown. It can also be socially embarrassing. So, there are some tools that I talk to people about with drooling. One thing I start with is going to be using sugar-free gum or candy while the person is awake to help initiate the swallow reflex, and sometimes that's all that's needed. There are other agents that can be used---like glycopyrrolate, sublingual atropine drops, and scopolamine patches---that can help with decreasing saliva production. But there can be side effects of making the entire body feel dry, and then also potential cardiac arrhythmias. If those are not helpful or they're contraindicated with the patient, another thing is going to be botulinum toxin injections. So those can be done on the parotid and salivary glands to decrease the amount of saliva that's being produced. So oftentimes people will come to me, because I'm also a botulinum toxin injector. I've been sent by some of my colleagues to inject our persons that have significant sialorrhea. Dr Nevel: Wonderful. Well, thank you so much for chatting with me today about your article. Again, today I've been interviewing Dr Ashley Rawls about her article on Parkinson disease, which appears in the August 2025 Continuum issue on movement disorders. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining today. And thank you, Ashley, for sharing all your knowledge with us today. Dr Rawls: Thank you, Kate, I appreciate your time. And have a great day, everyone. Dr Monteith: This is Dr Teshmae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Aan tafel zitten Marc Veeningen, Aimée Kiene en Spraakmaker Tim Knol. De voedseldroppings in Gaza maakt het voor journalisten mogelijk om actuele beelden van de oorlog te maken vanuit vliegtuigen. Een 'monotoon grijs', zoals Volkskrant-journalist Jenne Jan Hotland het omschrijft. De enorme verwoesting wordt daardoor duidelijk, evenals hoe gevaarlijk dit soort ondernemingen zijn. Aimée Kiene, hoofdredacteur van Volkskrant Magazine, vond het verhaal "indrukwekkend" en "belangrijk", omdat dit voor het eerst is dat Westerse journalisten weer bij het gebied in de buurt komen. "Het is belangrijk om daar met eigen ogen te kunnen kijken." Marc Veeningen, hoofdredacteur nieuws bij Talpa, ziet dit als een "snipper" van wat er aan informatie komen gaat. "Het echte verhaal zal op de grond gehaald moeten worden en daar is nog altijd geen toegang toe. Het is in elk geval iets."

Zwaar verslaafd aan de heroïne vat Barry het plan om zijn drugsdealer te vermoorden en zijn voorraad te stelen. Het slachtoffer overleeft de aanval en vlucht weg. Barry ook, maar een paar maanden later wordt hij toch aangehouden. Aan de rechters vraagt Barry om een plek op de longstay afdeling van de tbs. Hij ziet geen andere plek voor zichzelf en is vastberaden binnen de muren te sterven. Ben je benieuwd naar dit verhaal, luister deze aflevering van VEROORDEELD nu op Podimo. Podimo is een app waarin je exclusieve podcasts en luisterboeken kunt luisteren. Via podimo.nl/veroordeeld kan je Podimo 30 dagen gratis uitproberen. Dat zijn acht afleveringen van VEROORDEELD en vele andere mooie podcasts en luisterboeken. Probeer Podimo nu via podimo.nl/veroordeeldSee omnystudio.com/listener for privacy information.

Aan de slag!Bid elke keer als je aanklagende gedachten hebt of God je wil vullen met positieve gedachten en vrij wil maken van oordeel. Breng het direct bij God. Zo geef je de aanklager geen kans!Deze overdenking is geschreven door schrijfster Suzanne Verschoor. 

In the August episode of the President's Spotlight, Dr. Jason Crowell and Dr. Natalia Rost discuss the mid-year assessment of AAN's five-year strategic plan.  Show reference:  https://www.aan.com/about-the-aan/presidents-spotlight   

Aan de slag!Vraag aan God of Hij je wil laten zien of er dingen zijn in je leven die erin zijn geslopen waarvan Hij liever wil dat je ze laat.Dank God voor het feit dat we dankzij Jezus' sterven een nieuw leven kunnen ontvangen.Deze overdenking is geschreven door schrijfster Marije Dekker-Brandwijk.

Op sommige momenten kan het leven donker en zwaar aanvoelen. De duisternis in je eigen leven of in de wereld kan je soms het zicht op het licht, op God ontnemen. En wat hebben de beloften in de Bijbel dan voor betekenis? Aan de hand van Psalm 23 ontdekken we dat geloven vraagt dat we als het ware anders leren kijken. Daar waar wij teleurgesteld zijn, ons focussen op wat ons ontbreekt, de duisternis zien, daar is God aanwezig als de Herder die ons leidt en voor ons uitgaat. Hij geeft genoeg voor dit moment, en veranderd een droge woestijn in een plek van overvloed.

In the third episode of this series, Dr. Andy Southerland discusses the latest Capitol Hill Report, which outlines the 2026 Medicare fee schedule proposal.  Stay updated with what's happening on the hill by visiting aan.com/chr.  Learn how you can get involved with AAN advocacy. 

Het is maandag. De dag dat je weet dat je weer vol aan de bak moet. Het lanterfanten is voorbij, tijd om de handen uit de mouwen te steken. Dat doen wij bij Gamekings ook. En wel door een nieuwe editie van Brievenmaandag voor je produceren. Aan de desk bevinden zich Boris, Daan en Jelle. Klaar om alle prangende vragen te beantwoorden. En vragen waren er. Volop. Zo wilde iemand weten welke PC hij nodig heeft voor Battlefield 6. Hij heeft een budget van 2000 euro. Een andere vraag draait om de keuzes die je maakt in RPG's als The Witcher en Elder Scrolls. Hoe spelen wij die? Als ons zelf of als een betere of juist slechtere versie van onszelf? En wat was onze digitale vuistvlam in onze jeugdige jaren? Wil je weten wat een vuistvlam is en of we die hadden, check dan de Brievenmaandag van maandag 4 augustus 2025.Op zoek naar een PC om Battlefield 6 op te laten draaienEen briefschrijver wijst ons op de game The Alters. Voor hem een potentiële GOTY voor 2025. Wat vinden wij van deze game? Hebben we er van gehoord? En hoe kijken we aan tegen de veranderingen die de indie developers doorvoeren binnen de gamesindustrie? De drie heren gaan er in deze video een passend antwoord op geven.Wie deed vroeger wat met onze joystick?Iemand wil weten wat onze ervaringen zijn met de Nintendo Classic games? Draaien die lekker op de Switch 2 en zijn ze de moeite waard? Switch 2-bezitter Boris kan daar zeker advies over geven. En dan die vuistvlam? Wat is dat? En wie was ooit onze vuistvlam toen we nog jonge honden waren. Of hadden we die niet en raakten we niet opgewonden van pixel art? Je gaat het zien en horen in deze Brievenmaandag.

Aan de slag!Heb je wel eens om je heen iets gezien wat klein leek, maar uiteindelijk een grote impact had voor Gods Koninkrijk?Vraag of God jou wil gebruiken in het kleine, wat misschien wel uit mag groeien tot iets groots.Deze overdenking is geschreven door schrijfster Marije Dekker-Brandwijk.

Send us a textRomeine 2:5b-8 ....daardie dag wanneer God, die regverdige regter, almal sal oordeel volgens wat hulle gedoen het. Aan dié wat met volharding aanhou om goed te doen, en op hierdie manier streef na die toekomstige heerlikheid, eer en onsterflikheid wat Hy vir hulle weggebêre het, sal Hy die ewige lewe gee. Maar dié wat hardkoppig weier om die waarheid te gehoorsaam en toegee aan die ongeregtigheid, sal Hy in sy woede straf. (NLV) As ons mooi daaraan dink, besef ons dat liefdevolle gesinne die grondslag van menswees in die gemeenskap vorm. Sonder gesinne sal die samelewing ineenstort ... en dit verklaar heel moontlik die gemors waarin die wêreld vandag is.Natuurlik is nie elke kind geseën om groot te word in ‘n huisgesin waar hy omring word deur 'n liefdevolle, alhoewel onvolmaakte, moeder en vader nie. Gelukkig het ek in so ‘n huis grootgeword en is die opvoeding wat ek gehad het, iets wat ek vir ewig sal koester.Maar weet jy, daardie opvoeding het 'n bietjie ‘liefde met gevoel' oftewel tough love behels! Dit het dissipline behels. Dit het selfs van tyd tot tyd die kweperlat behels – nie dat dit iets is wat ek vandag sal voorstaan nie. Tog was my ouers vasbeslote om my te leer dat dade gevolge het.Ons liefdevolle God wil ook vir ons dissiplineer en gehoorsaamheid leer; want indien ons dit nie leer nie, sal dit ewige gevolge hê:Romeine 2: 5b-8 ....daardie dag wanneer God, die regverdige regter, almal sal oordeel volgens wat hulle gedoen het. Aan dié wat met volharding aanhou om goed te doen, en op hierdie manier streef na die toekomstige heerlikheid, eer en onsterflikheid wat Hy vir hulle weggebêre het, sal Hy die ewige lewe gee. Maar dié wat hardkoppig weier om die waarheid te gehoorsaam en toegee aan die ongeregtigheid, sal Hy in sy woede straf. (NLV)Sjoe, is dit werklik in die Bybel? Ja, dit is! Wat het geword van ‘n God van barmhartigheid en genade? Wel, Hy is steeds die God van barmhartigheid en genade, maar ons aanvaar of verwerp daardie barmhartigheid en genade, deur hoe ons leef. Aan diegene wat in gehoorsaamheid reageer, sal Hy die ewige lewe gee. Vir diegene wat in ongehoorsaamheid reageer, sal Hy met toorn en woede straf.Ja, my vriend, dade het inderdaad gevolge.Dis God se Woord. Vars ... vir jou ... vandag. Support the showEnjoying The Content?For the price of a cup of coffee each month, you can enable Christianityworks to reach 10,000+ people with a message about the love of Jesus!DONATE R50 MONTHLY

Vraag jij je af of supplementen écht nodig zijn, of dat je vooral een hoop geld uitgeeft aan dure pillen zonder resultaat?In deze aflevering neem ik je mee in de wereld van supplementen en vertel ik je eerlijk waar je wél en niet wat aan hebt. Want steeds meer mensen zoeken naar de beste supplementen, hebben kasten vol staan met potjes, maar vergeten hierdoor de belangrijkste basis voor hun gezondheid.Luister en ontdek:Waarom supplementen vaak gebruikt worden als symptoombestrijding (en wat het alternatief is)Welke voedingsstoffen vrijwel iedereen tekort komt én hoe je dat doormiddel van gezonde voeding kunt oplossen Hoe de supplementenindustrie inspeelt op ons verlangen naar gezondheid, en wanneer dat niet zuiver is Mijn visie op voeding als basis: welke rol speelt dierlijke voeding, wanneer is suppleren wél een goed idee én welke supplementen gebruik ik zelf en raad ik aan?Wil je weten waar je lichaam behoefte aan heeft en hoe je loskomt van die kast vol potjes? Druk op ‘play' en laat je verrassen door een andere kijk op supplementen!

Aan de slag!In het Jodendom kennen we een gestructureerde manier van rouwen. Iets wat wij erg nodig hebben met de hoeveelheid trauma's die op ons afkomen. Slechts zes dagen na Tisha Be'av vieren we Tu Be'av, het feest van de liefde.Dit is het Jodendom: zorg dat de weegschaal van het leven altijd in balans is! Hoe is jouw balans? Ben je uit balans? Als je in een periode van rouw zit: hoe geef je uiting aan die rouw?Deze overdenking is geschreven door oud-schrijfster Sarah Rokach.

Aan de slag!Hoe ervaar jij de uitdaging van geloven? Luister met dit nieuwe inzicht nog eens naar ‘Oceans'.Leestip: Goed, beter, stress! (Gootjes, M.) over prestatiegerichtheid.Deze overdenking is geschreven door schrijfster Marijke Gootjes-Verhoeve.

Aan tafel zitten Jan-Kees Emmer, Kefah Allush en Spraakmakers Paul van Ass. Eveline van Rijswijk van het Taalteam sluit het Mediaforum af. Journalist Derk Sauer is dinsdag op 72-jarige leeftijd overleden aan de gevolgen van een zeilongeluk. Jan Kees Emmer (voormalig adjunct-hoofdredacteur Telegraaf) zat pasgeleden nog met Sauer in een talkshow. 'Een fascinerende vent', omschrijft Emmer hem. Sauer was oprichter van 'The Moscow Times' en haalde de krant, na de Russische in val in Oekraïne, naar Nederland. 'Hij heeft ervoor gezorgd dat DPG de gastheer is van de Russische journalisten', aldus Emmer. 'Laten we hopen dat DPG dat niet alleen voor Derk heeft gedaan, maar er ook echt achter blijft staan om deze een veilige haven te bieden.' Programmamaker Kefah Allush had ook bewondering voor Sauer. 'Je merkte aan alles zijn liefde voor Rusland en de Russen. Maar aan de andere kant kon hij ook kritisch zijn.'

18 september 1961, even na middernacht. Een Douglas DC-6 vliegtuig nadert de luchthaven van Ndola in Noord-Rhodesië. Aan boord zit Dag Hammarskjöld, de 56-jarige Secretaris-Generaal van de Verenigde Naties, op weg naar cruciale vredesonderhandelingen in de Congo. Het vliegtuig zou nooit veilig landen. In de donkere bossen nabij Ndola crashte het toestel, waarbij alle inzittenden omkwamen.

Aan de slag!Luister vandaag naar het lied ‘Jezus, alles geef ik U'.Deze overdenking is geschreven door schrijfster Naomi Muda.

Aan het eind van de week stapelen de luisteraarsvragen zich op voor Evert Santegoeds. In de podcast Strikt Privé daarom een XXL-editie van de rubriek Eventjes aan Evert vragen. Bewaart de hoofdredacteur van Privé wel eens juice voor de nieuwsluwe komkommerperiode? Wat zit er achter de liefdesbreuk van goochelaar Steven Kàzan en echtgenote Jamie? En van welke presentator kan Evert geen genoeg krijgen?See omnystudio.com/listener for privacy information.

18 september 1961, even na middernacht. Een Douglas DC-6 vliegtuig nadert de luchthaven van Ndola in Noord-Rhodesië. Aan boord zit Dag Hammarskjöld, de 56-jarige Secretaris-Generaal van de Verenigde Naties, op weg naar cruciale vredesonderhandelingen in de Congo. Het vliegtuig zou nooit veilig landen. In de donkere bossen nabij Ndola crashte het toestel, waarbij alle inzittenden omkwamen. Officiële rapporten zeggen dat het een pilootfout was. Maar al snel ontstonden er geruchten: was dit werkelijk een ongeluk, of werd de machtigste man van de VN vermoord? Zestig jaar later worstelen onderzoekers nog steeds met deze vraag. Want wie profiteerde van Hammarskjölds dood? En waarom blijven cruciale documenten tot op de dag van vandaag geheim? Presentator Paul Sanders onderzoekt deze beruchte cold case. Hij spreekt met Fank Gerits, historicus van internationale relaties aan de Universiteit Utrecht, over de secretaris-Generaal die onder hele mysterieuze omstandigheden stierf.Factor Kuifje is een Paco Podcast productieRedactie en montage: Cornelis van der PlasPresentatie en montage: Paul SandersEindredactie: Annick van der Leeuw-Nijland Luister elke vrijdag een nieuwe aflevering van Factor Kuifje in je podcast-app of in de BNR-app. Download 'm hier voor Android, en hier voor Iphone.See omnystudio.com/listener for privacy information.

Aan de slag! Darius loofde God door Daniëls bijzondere redding. Waar deze koning getuige van was, maakte dat hij onwaarschijnlijk geloof liet zien. Hoe bijzonder zou het zijn als wij eenzelfde rol in iemands leven zouden kunnen spelen, ‘simpelweg' door de manier waarop wij geloven en getuigen? Concreet betekent dat: hoe kunnen wij leven als Daniël en zo tot getuigenis zijn voor anderen? Zonder krampachtigheid, maar mét een flinke dosis bewustzijn? Neem het vandaag mee in je gebed en laat de Heilige Geest je leiden. Stel je open voor iedere grote of ‘kleine' manier die in je opkomt en neem zijn input serieus. Deze overdenking is geschreven door oud-schrijfster Mandy Wittekoek.

Aan tafel zitten Carmen Fernald, Niki van der Naald en Spraakmaker Nicolaas Veul. De eerste peilingen over de aanstaande verkiezingen zijn uitgekomen. VVD lijkt verder weg te zakken waar het CDA naar een derde plek lijkt te klimmen, met de PVV en GL-PvdA nog altijd als koplopers. Maar hoeveel waarde moet er gehecht worden aan zulke vroege peilingen? "Het is allemaal heel relatief en extreem vroeg, dat moeten we benadrukken", aldus Niki van der Naald, adjunct-hoofdredacteur van De Gelderlander. "Je kunt wel zeggen dat er een Bontenbal-effect is. Dat proef je en zie je in de samenleving." Programmaker Nicolaas Veul hoopt dat er een regering komt die kan samenwerken. "Ik hoop dat de redelijkheid wint en het is prima als Bontenbal het gezicht daarvan is." Carmen Fernald, hoofdredacteur van de NTR, hekelt hoe partijen op voorhaan elkaar al uitsluiten. "Daar gaan de kiezers toch over?"

Jens en Matthijs uit Oostzaan hadden een paar weken geleden een vondst gedaan in hun speeltuin. Daar wilden ze graag mee in de krant. Dat lukte bij De Orkaan niet, maar ze kwamen toch langs om hun gevonden klavertjes te laten zien. Aan het bezoek was nogal wat vooraf gegaan. Jens (8) en zijn broertje Matthijs (6) hadden een brief gestuurd. Daarop reageerde De Orkaan en op die reactie kregen we een brief terug. En zo belandden de twee boers in onze podcaststudio. Daar vertelden ze niet alleen over hun vondst, maar ook over wat ze later willen worden. Het gesprek kun je in deze podcast beluisteren.

Luister deze podcast met nieuwsgierigheid, openheid en met de intentie om iets nieuws te leren. Niet om jezelf te veroordelen of mij ;) , maar om inzichten op te doen.Want stel je dit eens voor…Als medicatie écht de oplossing was, waarom moet je dan telkens weer een nieuw recept halen?Laat me duidelijk zijn:Ik ben niet tegen medicatie.Wat ik wél ben, is een therapeut met bijna 10 jaar ervaring die ziet hoe we massaal voorbijgaan aan de kern. Aan het lichaam. Aan de oorzaak.Ik leg het je uit in deze aflavering!Schrijf je in voor de nieuwsbrief:https://echtinbalans.nl/de-echtinbalans-mail/#ECHTINBALANS herstel traject:www.echtinbalans.nl/programmaWhatsapp community:https://chat.whatsapp.com/LWWrgLL24kv7fKztt2vXkM?mode=r_c

In deze aflevering van Vitamine A spreken we met Esther Kox, cognitief psycholoog en expert op het gebied van vertrouwen tussen mens en kunstmatige intelligentie. Esther promoveerde aan de Universiteit Twente en doet onderzoek naar hoe mensen omgaan met technologie die steeds slimmer en zelfstandiger lijkt te worden.Het gesprek richt zich op een centrale vraag: wat betekent het eigenlijk om AI te vertrouwen? Esther legt uit waarom we geneigd zijn om technologie menselijke eigenschappen toe te kennen en hoe dat ons oordeel beïnvloedt. Ook introduceert ze het begrip ‘gekalibreerd vertrouwen': een evenwichtige balans tussen wat AI werkelijk kan en wat wij denken dat het kan.Aan de hand van herkenbare voorbeelden laat Esther zien hoe snel we ons laten overtuigen, maar ook hoe belangrijk het is om als professional kritisch en bewust te blijven. Zeker voor accountants, die van oudsher het vertrouwen vertegenwoordigen in cijfers en controle, is dat essentieel. In een wereld waar AI steeds vaker data genereert en beslissingen beïnvloedt, gaat het erom technologie verstandig te gebruiken.Deze aflevering is een eerste verkenning van deze thematiek. De vragen die het oproept komen verder aan bod op 19 november tijdens de Accountantsdag 2025 in het AFAS Theater in Leusden. Esther is daar ook spreker in het middagprogramma.Links:Meer informatie over haar onderzoek is te vinden via de Universiteit Twente, waar zij promoveerde op het proefschrift Maintaining Human‑AI Trust: Understanding Breakdowns and Repair (lees meer).Informatie over haar sessie op de Accountantsdag 2025 is beschikbaar op de website van de NBA (nba.nl/Accountantsdag).

Aan de slag!Maakt het voor God uit dat je twijfelt? Daar lijkt het niet op. De opdracht die Hij geeft in Matteüs 28 is voor iedere discipel. Oók voor hen die twijfelden. Deel je twijfels gerust met God, aanbid Hem ondanks alles en ga met Hem verder op weg. Op een dag zullen alle twijfels verdwenen zijn.Deze overdenking is geschreven door schrijfster Marianne de Bart-van der Lee.

Over social media, algoritmes, marketingverantwoordelijkheid en vrouwelijke rolmodellenDe gemiddelde tienermeisje spendeert 5,4 uur per dag op social media. Meer dan de helft krijgt daar te maken met seksisme, haat of commentaar op haar uiterlijk. Een op de drie voelt zich daarna rot. Toch blijven we als samenleving - en als merken - deze platforms voeden en normaliseren. Hoe kunnen we dat keren?5,4 uur per dag online… en dan?Tienermeisjes brengen gemiddeld 5,4 uur per dag door op social media. 60% krijgt daar te maken met haat, seksisme of uiterlijk commentaar. En 30% voelt zich daarna rot. “We zien dat meisjes elkaar naar beneden praten. Op uiterlijk, gedrag, kleding. En dat gebeurt vaak op platforms waar ouders geen zicht op hebben, zoals Snapchat,” vertelt Anne-Marie.De invloed van algoritmesSocial media zijn gebouwd op algoritmes die niet alleen aandacht, maar ook gedrag sturen. Eén klik op een filmpje over automutilatie of lichaamsissues, en een kind belandt in een ‘rabbit hole' van vergelijkbare content. “Weet je, ik zie algoritmes als iets neutraals. Maar als je het voedt met extreme content, dan versterkt het dat. En het is een systeem dat niet vraagt: ‘Is dit goed voor jou?' Het vraagt: ‘Wil je dit nog een keer zien?'” zegt Maartje. De effecten daarvan zijn op jonge leeftijd vaak nog intenser, zeker wanneer ouders geen zicht hebben op de platformen waarop dit gebeurt.Offline als nieuw luxeproductToch is er hoop. We zien een groeiende behoefte aan offline samenzijn. Aan échte verbinding. Aan communities. “Steeds meer mensen verlangen naar plekken waar je zonder telefoon kunt zijn, waar je echt contact maakt,” vertelt Maartje. “Het is niet voor niets dat mensen honderden euro's per maand betalen voor clubs of retraites waar je verplicht offline moet. Dat zegt iets. Offline is het nieuwe exclusief.”Wat merken kunnen doenBeide vrouwen zijn het eens: merken hebben hier een rol in te pakken. Niet alleen door campagnes die awareness creëren, maar juist door mensen fysiek samen te brengen. Door digitale én fysieke werelden op een slimme manier te verbinden. Anne-Marie: “Kijk naar campagnes als die van SportCity over mentale gezondheid. Of Doritos x Minecraft, waarin jongeren letterlijk van de bank kwamen.”En ook binnen communities kan het anders. “In de Female Leaders Club bouwen we heel bewust aan een veilige, fysieke omgeving. Niet iedereen mag zomaar binnen, en we bewaken dat actief,” zegt Maartje. “Want juist in die veilige setting ontstaan gesprekken die je online nooit voert, omdat je je in een fijne community wél kwetsbaar op durft te stellen.”Van rolmodel naar normEen belangrijke rode draad in dit gesprek is het belang van rolmodellen. Niet als symbool, maar als gedrag. “Monkey see, monkey do,” zegt Anne-Marie. “Onze dochters kijken naar wat we doen, niet wat we zeggen.” En dat geldt niet alleen voor ouders, maar ook voor leiders in media, marketing en merken.Conclusie: we hebben iets te doenDe wereld is online. Maar het leven gebeurt offline. Als we willen dat onze dochters stevig staan in een wereld die hen voortdurend vertelt wat ze moeten zijn, dan moeten wij die andere wereld bouwen. In ons werk, in onze gezinnen, en in de communities die we vormgeven.Over Maartje Blijleven Maartje Blijleven is #1 bestsellerauteur, keynote spreker en senior community strateeg met meer dan 24 jaar ervaring bij o.a. Endemol, KLM en Facebook. Ze is oprichter van de Female Leaders Club: dé plek voor vrouwen die niet alleen dromen van impact, maar het ook waarmaken. Over Anne-Marie Twigge Anne-Marie Twigge is Insights Director bij creatief bureau Fitzroy | Part of Unitec Playgrounds in Amsterdam. Ze brengt een brede expertise in gedragspsychologie, merkstrategie en culturele trends mee. Wil je meer weten? Stuur een mail naar: anne-marie@fitzroy.nl

With the increase in the public's attention to all aspects of brain health, neurologists need to understand their role in raising awareness, advocating for preventive strategies, and promoting brain health for all. To achieve brain health equity, neurologists must integrate culturally sensitive care approaches, develop adapted assessment tools, improve professional and public educational materials, and continually innovate interventions to meet the diverse needs of our communities. In this BONUS episode, Casey Albin, MD, speaks with Daniel José Correa, MD, MSc, FAAN and Rana R. Said, MD, FAAN, coauthors of the article “Bridging the Gap Between Brain Health Guidelines and Real-world Implementation” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Correa is the associate dean for community engagement and outreach and an associate professor of neurology at the Albert Einstein College of Medicine Division of Clinical Neurophysiology in the Saul Korey Department of Neurology at the Montefiore Medical Center, New York, New York. Dr. Said is a professor of pediatrics and neurology, the director of education, and an associate clinical chief in the division of pediatric neurology at the University of Texas Southwest Medical Center in Dallas, Texas. Additional Resources Read the article: Bridging the Gap Between Brain Health Guidelines and Real-world Implementation Subscribe to Continuum®: shop.lww.com/Continuum Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Guests: @NeuroDrCorrea, @RanaSaidMD Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. This exclusive Continuum Audio interview is available only to you, our subscribers. We hope you enjoy it. Thank you for listening. Dr Albin: Hi all, this is Dr Casey Albin. Today I'm interviewing Dr Daniel Correa and Dr Rana Said about their article on bridging the gap between brain health guidelines and real-world implementation, which they wrote with Dr Justin Jordan. This article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Thank you both so much for joining us. I'd love to just start by having you guys introduce yourselves to our listeners. Rana, do you mind going first? Dr Said: Yeah, sure. Thanks, Casey. So, my name is Rana Said. I'm a professor of pediatrics and neurology at the University of Texas Southwestern Medical Center in Dallas. Most of my practice is pediatric epilepsy. I'm also the associate clinical chief and the director of education for our division. And in my newer role, I am the vice chair of the Brain Health Committee for the American Academy of Neurology. Dr Albin: Absolutely. So just the right person to talk about this. And Daniel, some of our listeners may know you already from the Brain and Life podcast, but please introduce yourself again. Dr Correa: Thank you so much, Casey for including us and then highlighting this article. So yes, as you said, I'm the editor and the cohost for the Brain and Life podcast. I do also work with Rana and all the great members of the Brain Health Initiative and committee within the AAN, but in my day-to-day at my institution, I'm an associate professor of neurology at the Albert Einstein College of Medicine in the Montefiore Health System. I do a mix of general neurology and epilepsy and with a portion of my time, I also work as an associate Dean at the Albert Einstein College of Medicine, supporting students and trainees with community engagement and outreach activities. Dr Albin: Excellent. Thank you guys both so much for taking the time to be here. You know, brain health has really become this core mission of the AAN. Many listeners probably know that it's actually even part of the AAN's mission statement, which is to enhance member career fulfillment and promote brain health for all. And I think a lot of us have this kind of, like, vague idea about what brain health is, but I'd love to just start by having a shared mental model. So, Rana, can you tell us what do you mean when you talk about brain health? Dr Said: Yeah, thanks for asking that question. And, you know, even as a group, we really took quite a while to solidify, like, what does that even mean? Really, the concept is that we're shifting from a disease-focused model, which we see whatever disorder comes in our doors, to a preventative approach, recognizing that there's a tremendous interconnectedness between our physical health, our mental health, cognitive and social health, you know, maintaining our optimal brain function. And another very important part of this is that it's across the entire lifespan. So hopefully that sort of solidifies how we are thinking about brain health. Dr Albin: Right. Daniel, anything else to add to that? Dr Correa: One thing I've really liked about this, you know, the evolution of the 2023 definition from the AAN is its highlight on it being a continuous state. We're not only just talking about prevention of injury and a neurologic condition, but then really optimizing our own health and our ability to engage in our communities afterwards, and that there's always an opportunity for improvement of our brain health. Dr Albin: I love that. And I really felt like in this article, you walked us through some tangible pillars that support the development and maintenance of this lifelong process of maintaining and developing brain health. And so, Daniel, I was wondering, you know, we could take probably the entire time just to talk about the five pillars that support brain health. But can you give us a pretty brief overview of what those are that you outlined in this article? Dr Correa: I mean, this was one of the biggest challenges and really bundling all the possibilities and the evidence that's out there and just getting a sense of practical movement forward. So, there are many organizations and groups out there that have formed pillars, whether we're calling them seven or eight, you know, the exact number can vary, but just to have something to stand on and move forward. We've bundled one of them as physical and sleep health. So really encouraging towards levels of activity and not taking it as, oh, that there's a set- you know, there are recommendations out there for amount of activity, but really looking at, can we challenge people to just start growing and moving forward at their current ability? Can we challenge people to look at their sleep health, see if there's an aspect to improve, and then reassess with time? We particularly highlight the importance of mental health, whether it's before a neurologic condition or a brain injury occurs or addressing the mental health comorbidities that may come along with neurologic conditions. Then there's of course the thing that everyone thinks about, I think, with brain health in terms of is cognitive health. And you know, I think that's the first place that really enters either our own minds or as we are observers of our elder individuals in our family. And more and more there has been the highlight on the need for social interconnectedness, community purpose. And this is what we include as a pillar of social health. And then across all types of neurologic potential injuries is really focusing on the area of brain injury. And so, I think the area that we've often been focused as neurologists, but also thinking of both the prevention along with the management of the condition or the injury after it occurs. Dr Albin: Rana, anything else to add to that? That's a fantastic overview. Dr Said: Daniel, thank you for- I mean, you just set it up so beautifully. I think the other thing that maybe would be important for people to understand is that as we're talking through a lot of these, these are individual. These sound like very individual-basis factors. But as part of the full conversation, we also have to understand that there are some factors that are not based on the individual, and then that leads to some of the other initiatives that we'll be talking about at the community and policy levels. So, for example, if an individual is living in an area with high air pollution. Yes, we want them to be healthy and exercise and sleep, but how do we modify those factors? What about lead leaching from our aging pipes or even infectious diseases? So, I think that outside of our pillars, this is sort of the next step is to understand what is also at large in our communities. Dr Albin: That's a really awesome point. I love that the article really does shine through and that there are these individual factors, and then there there's social factors, there's policy factors. I want to start just with that individual because I think so many of our patients probably know, like, stress management, exercise, sleep, all of that stuff is really important. But when I was reading your article, what was not so obvious to me was, what's the role that we as neurologists should play in advocating? And really more importantly, like, how should we do that? And again, it struck me that there are these kind of two issues at play. And one is that what Daniel was saying that, you know, a lot of our patients are coming because they have a problem, right? We are used to operating in this disease-based care, and there's just limited time, competing clinical demands. If they're not coming to talk about prevention, how do we bring that in? And so Rana, maybe I'll start with you just for that question, you know, for the patients who are seeing us with a disease complaint or they're coming for the management of a problem, how are you organizing this at the bedside to kind of factor in a little bit about that preventative brain health? Dr Said: You know, I think the most important thing at the bedside is, one, really identifying the modifiable risk factors. These have been well studied, we understand them. Hypertension, diabetes, smoking, weight management. And we know that these definitely are correlative. So is it our role just to talk about stroke, or should we talk about, how are you managing your blood pressure? Health education, if there was one major cornerstone, is elevating health literacy for everyone and understanding that patients value clear and concise information about brain health, about modifiable risk factors. And the corollary to that, of course, are what are the resources and services? I completely understand---I'm a practicing clinician---the constraints that we have at the bedside, be it in the hospital or in our clinics. And so being the source of information, how are we referring our families and individuals to social workers, community health worker support, and really partnering with them, food banks, injury prevention programs, patient advocacy organizations? I think those are really ways that we can meet the impacts that we're looking at the bedside that can feel very tangible and practical. Dr Albin: That's really excellent advice. And so, I'd like to ask a follow-up question. With your knowledge of this, trying to get more multidisciplinary buy-in from your clinic so that you really have the support to get these services that are so critically important. And how do you do that? Dr Said: Yeah, I think it's, one, being a champion. So, what does a champion mean? It means that somebody has to decide this is really important. And I think we all realize that we're not the only ones in the room who care about this. We're all in this, and we all care about it. But how do we champion it and carry it through? And so that's the first. Second you find your partnerships: your social workers, your case managers, your other colleagues. And then what is the first-level entry thing that you can do? So for example, I'm a pediatric epileptologist. One of the things we know is that in pediatric epilepsy, depression and anxiety are very strong comorbidities. So, before we get to the point where a child is in distress, every single one of our epilepsy patients who walks in the door over the age of twelve has an age-appropriate screener that is given to them in both English and Spanish. And we assess it and we determine stratifying risk. And then we have our social workers on the back end and we decide, is this a child who needs resources? Is this a child who needs to be walked to the emergency room, escorted? And anything in between. And I think that that was a just a very tangible example of, every single person can do this and ask about it. And through the development of dot phrases and clear protocols, it works really well. Dr Albin: I love that, the way that you're just being mindful. At every step of the way, we can help people towards this lifelong brain health. And Daniel, you work with an adult population. So I wonder, what are your tips for bringing this to a different patient population? Dr Correa: Well, I think---adult or child---one thing that we often are aware of with so many of the other things that we're doing in bedside or clinic room counseling, but we don't necessarily think of in this context of brain health, is, remember all the people in the room. So, at the bedside, whether it's in the ICU, discharge counseling, the initial admission, the whole family is often involved and really concerned about the active issue. But you can look for opportunities- we often try to counsel and support families about the importance of their own sleep and rest and highlighting it not just as being there for their family member, but highlighting it to them as a measure of their own improvement of their brain health. So, looking at ways where, one, I try to find, is there something I can do to support and educate the whole family about their brain health? And then- and with an epilepsy, or in many other situations, I try to look for one comorbidity that might be a pillar of brain health to address that maybe I wasn't already thinking. And then I consider, is there an additional thing that they wouldn't naturally connect to their epilepsy or their headaches that I can bring in for them to work on? You know, we can't often give people twelve different things to work on, and they'd just feel like, okay like, you have no realistic understanding of my life. But if we can just highlight on one, and remind them that there can be many more ways to improve their health and to follow up either with us as their neurologist or their future primary care doctors to address those additional needs. Again, I would really highlight the importance of a multidisciplinary approach and looking for opportunities. We've too often, I feel, relied on primary care as being the first line for addressing unmet social health needs. We know that so many people, once they have a neurologic condition or the potential, even, of a neurologic condition, they're concerned about dementia or something, they may view us, as their neurologist, as their most important provider. And if they don't have the resource of time and money to show up at other doctors, we may be the first one they're coming to. And so, tapping into your institution's resources and finding out, are there things that are available to the primary care services that for some reason we're not able to get on the inpatient side or the outpatient side? Referring to social workers and care workers and showing that our patients have an independent need, that they're not somehow getting captured by the primary care doctors. Dr Albin: I really love that. I think that we- just being more invested and just being ready to step into that role is really important. I was noticing in this article, you really call that being a brain health ambassador, being really mindful, and I will direct all of our listeners to Figure 3, which really captures what practitioners can do both at the bedside, within their local community, and even at the professional society level, to really advocate for policies that promote brain wellness. Rana, at the very beginning of this conversation, you noted, you know, this is not just an individual problem. This really is something that is a component of our policy and the structure of our local communities. I really loved in the article, there's a humility that this cannot be just a person-by-person bedside approach, that this is a little bit determined by the social determinants of health. And so, Rana, can you walk us through a little bit of what are the social determinants of health, and why are these so crucially important when we think about brain health for all? Dr Said: Yeah, social determinants of health are a really key factor that it looks at, what are the health factors that are environmental; for example, that are not directly like what your blood pressure is, what, you know, what your BMI is, that definitely impact our health outcomes. So, these include environmental things like where people are born, where they live, where they learn, work, play, worship, and age. It encompasses factors like your socioeconomic status, your education, the neighborhoods where you are living, definitely healthcare access. And then all of this is in a social and community context. We know that the impact of social determinants of health on brain health are profound for the entire lifespan and that- so, for example, if someone is from a disadvantaged background or that leads to chronic stress, they can have limited access to healthcare. They can have greater risk of exposure to, let's say, environmental toxins, and all of that will shape how their brain health is. Violence, for example. And so, as we think about how we're going to target and enhance brain health, we really have to understand that these are vulnerable populations, special high-risk populations, that often have a disproportionate burden of neurologic disorders. And by identifying them and then developing targeted interventions, it promotes health equity. And it really has to be done in looking at culturally- ethnocultural-sensitive healthcare education resources, thinking about culturally sensitive or adaptive assessment tools that work for different populations so that these guidelines that we have, that we've already identified as being so valuable, can be equitably applied, which is one crucial component of reducing brain health risk factors. And lastly, at the neighborhood level, this is where we really rely on our partnerships with community partners who really understand their constituents and they understand how to have the special conversations, how to enhance brain health through resource utilization. And so, this is another plug for policy and resources. Dr Albin: I love that. And thinking about the neighborhood and the policy levels and all the things that we have to do. Daniel, I'd like to ask you, is there anything else you would add? Dr Correa: Yeah, you know, so I really wanted to come back to this thing is that often and unfortunately, in the beginning understanding of social determinants of health, they're thought of as a positive or a negative factor, and often really negative. These are just facts. They're aspects about our community, our society, and some of them may be at the individual level. They're not at fault of any individual or community, or even our society. They're just the realities. And when someone has a factor that may predict a health disparity or an unmet social need---I wanted to come back to that concept and that term---one or two positive factors that are social determinants of health for that individual are unmet social needs. It's a point of promise. It's a potential to be addressed. And seeking ways to connect them with community services, social work, caregivers, these are ways where- that we can remove a barrier to, so that the possibility of the recommendations that we're used to doing, giving recommendations about medications and management, can be fully appreciated for that person. And the other aspect is, like brain health, this is a continuous state. The social determinants of health may be different for the child, the parent, and the elderly family member in the household, and there might be some that are shared across them. And when one of those individuals has a new medical illness or a new condition, a stroke, and now has a mobility limitation, that may change a social determinant of health for that person or for anyone else in the family, the other people now becoming caregivers. We're used to this. And for someone after a stroke or traumatic brain injury, now they have mobility changes. And so, we work on addressing those. But thinking on how those things now become a barrier for engaging with community and accessing things, something as simple as their pharmacy. Dr Albin: I hear a lot of “this is a fluid situation,” but there's hope here because these are places that we can intervene and that we can really champion brain health throughout this fluid situation. Which kind of brings me to what we're going to close out with, which is, I'm going to have you do a little thought exercise, which is that you find a magic lamp and a genie comes out. And we'll call this the brain health genie. The genie says that they are going to grant you one wish for the betterment of brain health. Daniel, I'll start with you. What is the one thing that you think could really move the needle on promoting and maintaining brain health? Dr Correa: I will jump on nutrition and food access. If we could somehow get rid of food insecurity and have access to whole and fresh foods for everyone, and people could go back to looking at opportunities from their ancestral and cultural experiences to cook and make whole-food recipes from their own cultures. Using something like the Mediterranean diet and the mind diet as a framework, but not looking at those as cultural barriers that we somehow all have to eat a certain way. So, I think that would really be the place I would go to first that would improve all of our brain health. Dr Albin: I love that. So, wholesome eating. Rana, how about you? One magic wish. Dr Said: I think traumatic brain injury prevention. I think it's so- it feels so within our reach, and it just always is so heart-hurting when you think that wearing helmets, using seatbelts, practicing safety in sports, gun safety---because we know unfortunately that in pediatric patients, firearm injury is the leading cause of traumatic brain injury. In our older patients, fall reduction. If we could figure out how to really disseminate the need for preventative measures, get everyone really on board, I think this is- the genie wouldn't have to work too hard to make that one come true. Dr Albin: I love that. As a neurointensivist, I definitely feel that TBI prevention. We could talk about this all day long. I really wish we had a longer bit of time, but I really would direct all of our listeners to this fantastic article where you give really practical advice. And so again, today I've been interviewing Drs Daniel Correa and Rana Said about their article on bridging the gap between brain health guidelines and real-world implementation, written with Dr Justin Jordan. This article appears in the most recent issue of Continuum on the disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues. And thank you so much for our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. We hope you've enjoyed this subscriber-exclusive interview. Thank you for listening.

Deze zomer is het 25 jaar geleden dat het Europees Kampioenschap van 2000 in Nederland en België werd gehouden. In deze serie van de Staantribune podcast blikken we terug op elfde editie van het door de UEFA georganiseerde eindtoernooi.  Aan de hand van diverse gasten en verschillende invalshoeken voelt iedereen zich weer voor even terug in die zomer van 2000. In deze aflevering bespreken we met Joris van de Wier de landen Joegoslavië, Slovenië, Denemarken, Noorwegen, Zweden en Tsjechië. Van stylist Zlatko Zahovič tot topscorer Savo Milošević en van Vladimír Šmicer tot de saaie Noren.Deze podcastserie werd mede mogelijk gemaakt door Kick and Rush. Kick and Rush is een webshop waar iedere voetballiefhebber komt voor zijn of haar unieke en klassieke voetbalshirts en -attributen.Vragen, tips of suggesties over onze podcast zijn altijd welkom: ⁠⁠⁠⁠⁠⁠⁠⁠podcast@staantribune.nl⁠⁠⁠⁠⁠⁠⁠⁠.Word abonnee van hét magazine over voetbalcultuur: ⁠⁠⁠⁠⁠⁠https://staantribune.nl/word-abonnee

Dit is het nieuwe seizoen van Wilde Eeuwen, het begin. Zes afleveringen over het begin van geschiedenis. Over rotstekenaars en neanderthalers, over landbouwuitvinders en sjamanen, over dichters en oeroude verhalen. Over hoe beschaving ontstond, en mensen de wereld naar hun hand gingen zetten.Aan de hand van zes personages vertelt Hendrik Spiering dat onze verre voorouders echt geen hulpeloze stumpers waren en dat vrijwel alles wat ons tot mensen maakt al verschrikkelijk lang bestaat. Wilde Eeuwen, het begin. Vanaf 1 augustus iedere vrijdag een nieuwe aflevering. Tekst en presentatie: Hendrik SpieringRedactie en regie: Mirjam van ZuidamMuziek, montage en mixage: Rufus van BaardwijkBeeld: Jeen BertingVormgeving: Yannick MortierHeeft u vragen, suggesties of ideeën over onze journalistiek? Mail dan naar onze ombudsman via ombudsman@nrc.nl.Zie het privacybeleid op https://art19.com/privacy en de privacyverklaring van Californië op https://art19.com/privacy#do-not-sell-my-info.

In this episode of the Brain & Life Podcast, hosts Dr. Daniel Correa and Dr. Katy Peters answer listener question to celebrate World Brain Day! They discuss healthy habits, finding support in small towns, and coping with big changes after a diagnosis. Do you have a question or topic you'd like to hear featured? Send us an email!   Additional Resources Try These Habits for a Healthy Brain on World Brain Day—and Every Day Natural Disasters Can Be More Dangerous for People with Neurological Conditions—Here's How You Can Prepare A Call to Action to Provide Poststroke Care for Impoverished and Rural Patients Functional Connectivity in Adult Brain Tumor Patients: A Systematic Review   Other Brain & Life Podcast Episodes on Similar Topics Answering Your Rare Disease Day Questions! Holiday Episode with our Listeners Answering Your Spinal Cord Injury Questions with Dr. Shelly Hsieh We want to hear from you! Have a question or want to hear a topic featured on the Brain & Life Podcast? Record a voicemail at 612-928-6206 Email us at BLpodcast@brainandlife.org   Social Media Hosts: Dr. Daniel Correa @neurodrcorrea; Dr. Katy Peters @KatyPetersMDPhD

Childhood-onset hydrocephalus encompasses a wide range of disorders with varying clinical implications. There are numerous causes of symptomatic hydrocephalus in neonates, infants, and children, and each predicts the typical clinical course across the lifespan. Etiology and age of onset impact the lifelong management of individuals living with childhood-onset hydrocephalus. In this episode, Casey Albin, MD, speaks with Shenandoah Robinson, MD, FAANS, FAAP, FACS, author of the article “Childhood-onset Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Robinson is a professor of neurosurgery, neurology, and pediatrics at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Childhood-onset Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Albin: Hi, this is Dr Casey Albin. Today I'm interviewing Dr Shenandoah Robinson about her article on childhood onset hydrocephalus, which appears in the June 2025 Continuum issue on disorders of CSF dynamics. Dr Robinson, thank you so much for being here. Welcome to the podcast. I'd love to start by just having you briefly introduce yourself to our audience. Dr Robinson: I'm a pediatric neurosurgeon at Johns Hopkins, and I'm very fortunate to care for kids and children from the neonatal intensive care unit all the way up through young adulthood. And I have a strong interest in developing better treatments for hydrocephalus. Dr Albin: Absolutely. And this was a great article because I really do think that understanding how children with hydrocephalus are treated really does inform how we can care for them throughout the continuum of their lifespan. You know, I was shocked in reading your article about the scope of the problem for childhood onset hydrocephalus. Can you walk our listeners through what are the most common reasons why CSF diversion is needed in the pediatric population? Dr Robinson: For the United States, and Canada too, the most common reasons are spina bifida---so, a baby that's born with a myelomeningocele and then develops associated hydrocephalus---and then about equally as common is posthemorrhagic hydrocephalus of prematurity, congenital causes such as from aquaductal stenosis, and other genetic causes are less common. And then we also have kids that develop hydrocephalus after trauma or meningitis or tumors or other sort of acquired problems during childhood. Dr Albin: So, it's a really diverse and sort of heterogeneous causes that across sort of the, you know, the neonatal period all the way to, you know, young adulthood. And I'm sure that those etiologies really shift based on sort of the subgroup population that you're talking about. Dr Robinson: Yes, they definitely shift over time. Fortunately for our kids that are born with problems that raise concerns, such as myelomeningocele or if they're born preterm, they sort of declare themselves by the time they're a year old. So, if you're an adult provider, they should have defined themselves and it's unlikely that they will suddenly develop hydrocephalus as a teenager or older adult. Dr Albin: Totally makes sense. I think many of the listeners to this podcast are adult neurologists who are probably very familiar with external ventriculostomies for temporary CSF diversion, and with the more permanent ventricular peritoneal shines or ventricular atrial or plural shines that are needed when there's the need for permanent diversion. But you described in your article two procedures that provide temporary CSF diversion that I think many of our listeners are probably not as familiar with, which is the ventricular access devices and ventriculosubgaleal shunts. Can you briefly describe what those procedures provide? Who are the candidates for them? And then what complications neurologists may need to think about if they're consulted for comanagement in one of these complex patients? Dr Robinson: Well, the good thing is that if as an adult neurologist you encounter someone with, you know, residual tubing from one of these procedures, you are unlikely to need to do anything about it. So, we put in ventricular access device or ventriculosubgaleal shunts, usually in newborns or infants. And sometimes when they no longer need the device, we just leave it in because that saves them an extra surgery. So, if you encounter one later on, it's most likely you won't need to do anything. Often if the baby goes on to show that they need a permanent shunt, we go ahead and put in that permanent shunt. We may or may not go back and take out the reservoir or the subgaleal shunt. The reservoir and subgaleal shunts are often put in the frontal location. Sometimes we'll put the permanent shunt in the occipital location and just leave the residual tubing there. So, you're very unlikely to need to intervene with a reservoir or subgaleal shunt if you encounter an older child or adult with that left in. We use these in the small babies because the external ventricular drains that we're very familiar with have a very high complication rate in this population. In the adult ICU, you often see these, and maybe there's, you know, a few percent risk of infection. It actually heads into 20 to 25% in our preterm infants and other newborns that require one of these devices for drainage. So, we try not to use external ventricular drains like we use in older patients. We use the internalized device: either the ventricular reservoir with a little area for us to tap every day, every other day; or the ventriculosubgaleal shunt, which diverts the spinal fluid to a pocket in the scalp. So, we use these in preterm infants that are too tiny for a permanent shunt. And for some of our babies that are born, for example, with an omphalocele, that we can't use their peritoneal cavity and so we need some temporizing device to manage their CSF. Dr Albin: Totally makes sense. And so just to clarify, I mean, this is a tube that's placed into the ventricles of the brain and then it's tunneled into the subgaleal space and the collection, the CSF, just builds up there, like? Dr Robinson: Yeah. Dr Albin: And over time either, you know, the baby will learn how to account for that extra CSF, and then I guess it's just reabsorbed? Dr Robinson: Yeah. When it's present, though, it looks like maybe, I don't know if you're familiar with like a tissue expander. There is this bubble of fluid under the scalp, but it's prominent, it can be several centimeters in diameter. Dr Albin: Wow, that's just absolutely fascinating. And I don't think I've ever had the opportunity to see this in clinical practice. I've really learned quite a bit about this. I assume that these children are going to go on to get some sort of permanent diversion. And then, you know, over time, those permanent shunts do create a lot of problems. And so, I was hoping you could kind of walk us through, you know, what are some of the things that you're seeing that you're concerned about? And then if you've just inherited a patient who had a shunt placed at, say, a different institution, how do you go about figuring out what kind of shunt it is and if they're still dependent on it? Dr Robinson: There's a few things that, fortunately, technology is helping with. So, it is much easier now for patients to get their images uploaded to image-sharing software, and then we can download their images into our institutional software, which is very helpful. Another option is that we are strongly encouraging our families to use a app such as HydroAssist that's available from the Hydrocephalus Association. So that's an app that goes on your phone, and you can upload the images from an MRI or a CT scan or x-rays from a shunt series. And then that you can take if you're traveling and you have to go to emergency department or you're establishing care with a new provider, you can have your information right there and not be under stress to remember it. It also has areas so you can record the type of valve. And all of our valves have pluses and minuses, they all tend to malfunction a little bit. And they can be particularly helpful with different types of hydrocephalus. I really doubt that we're going to narrow down from the fifteen or so valves we have access to now. And so, recording your valve type, the manufacturer as well as the setting, is very helpful when you're transferring care or if you're traveling and then have to, unfortunately, stop in the emergency department. Dr Albin: Yeah, I thought that was a really great pearl that, like, families now are empowered to sort of take control of understanding sort of the devices that they have, the settings that they're using. And what an incredible thing for providers who are going to care for these patients who, you know, unfortunately do end up in centers that are not their primary center. The other challenge that I find… I practice as a neurointensivist, and sometimes patients come in and they have a history of being shunt dependent and they present with a neurologic change. And I think that we as neurologists can be a little quick to blame the shunt and want the shunt to be tapped. And I was really struck in reading this article about the complexity of shunt taps. And I was hoping, you know, can you kind of walk us through what's involved and maybe why we should have a little bit of a higher threshold before just saying, ah, just have the neurosurgeons tap the shunt. Like, it's not that straightforward. Dr Robinson: And it may depend on the population you're caring for. So, when I was at a different institution, we actually published that there's about a 5% complication rate from shunt taps. And that may be- that was in pediatric patients. And again, that may be population dependent, but you can introduce infection to a perfectly clean shunt by doing a shunt tap. You can also cause an acute shunt malfunction. So that's why we tend to prefer that only neurosurgeons are doing shunt taps for evaluation of a shunt malfunction. There are times that, for example, our patients who are getting intrathecal chemotherapy or something have a CSF access device like an Ommaya reservoir, and other providers may tap that reservoir to instill medicine. But that's different than an evaluation, like, you're talking about somebody with a neurological change. And so, it is possible that if somebody has small ventricles or something, if you tap that shunt, you can take a marginally functioning shunt and turn it into an acute proximal malfunction, which is an emergency. Dr Albin: Absolutely. I think that's a fantastic pearl for us to take away from this. It's just that heightened level. And kind of on the flip side of that, you know, and I really- I do feel for us when we're trying to kind of, you know, make a case that it's, it's not the shunt. Many of our shunted patients also have a lot of neurologic complexity, which I think you really talked upon in this article. I mean, these are patients who have developmental cognitive delays and that they have epilepsy and that they're at risk for, you know, complications from prematurity, since that's a very common reason that patients are getting shunts. But from your experience as a neurosurgeon, what are some of the features that make you particularly concerned about shnut malfunction? And how do you sort of evaluate these patients when they come in with that altered mental status? Dr Robinson: It is challenging, especially for our patients that have, you know, some intellectual delay or other difficulties that make it hard for them to give an accurate history. Problem is, if they're sick and lethargic, they may not remember the symptoms that they had when they were sick. But sometimes there's hopefully there's a family member present that does remember and can say, oh, no, this is what they look like when they have a viral illness. And this is different from when they have the shot malfunction, which was projectile emesis, not associated with a fever. It's rare to have a fever with a shunt malfunction, although shunt infection often presents with malfunction. So, it's not completely exclusionary. We often look at the imaging, but it's taking the whole picture together. Some of the common other diagnoses we see are severe constipation that can decrease the drainage from the shunt and even cause papilledema in some people. So, we look at that as well on the shunt series. It's very important to have the shunt series if you're concerned about shunt malfunction or- the shunt tubing is good. It tends to last maybe 20to 25 years before it starts to degrade. And so, you may have had a functioning shunt for decades and it worked well and you're very dependent on it, and then it breaks and you become ill. But on the flip side, we have patients that have had a broken shunt for years, they just didn't know about it. And we don't want to jump in and operate on them and then cause complexities. And so, it is a challenge to sort out. The simplest thing is obviously if they come in and their ventricles are significantly larger, and that goes along with a several-hour or a couple-day deterioration, that's a little more clear-cut. Dr Albin: Absolutely. And you talked about this shunt series. What other imaging- and, sort of maybe walk us through, what's involved in a shunt series, what are you looking at? And then what other imaging is sort of your preferred method for evaluating these patients? Dr Robinson: In adult patients, the shunt series is the x-ray from the entire shunt. And so, if they have an atrial shunt, that would be skull x-ray plus a chest x-ray; or the shunt ends in the perineal cavity, it goes to the perineum. And we're looking for continuity. We're looking for the- sometimes as people grow and age, the ventricular catheter can pull out of the ventricle. So, we're looking to make sure that the ventricular catheter is in an optimal position relative to the skull. We can also look at the valve setting to see the type of valve. So, that can also be helpful as well. And then in terms of additional imaging, a CT scan or an MRI is helpful. If you don't know what type of valve they have, they should not, ideally, go in the MRI scanner. We like to know what their setting is before they go in the MRI because we're going to have to reset the valve after they come out of the MRI if it's a programmable valve. Dr Albin: This is fantastic. I've heard several pearls. So, one is that with the shunt series, which, am I correct in understanding those are just plain X-rays? Dr Robinson: Yes. Dr Albin: Right. Then we can look for constipation, and that might be actually something really serious in a pediatric patient that could clue us in that they could actually be developing hydrocephalus or increased ICP just because of the abdominal pressure. And then that we need to be mindful of what are the stunt settings before we expose anyone to the MRI machine. Is that two good takeaways from all of this? Dr Robinson: Yes. And it's very rare that there'll be an MRI tech that will allow a patient with a valve in the MRI without knowing what it is. So, they have their job security that way. But yeah, if you're not sure, just go ahead and get the CT. Obviously, in our younger kids, we're trying to avoid CT scans. But if you're weighing off trying to decide if somebody has a shunt malfunction versus, you know, waiting 12 or 24 hours for an MRI, go ahead and get the CT. Dr Albin: Absolutely. I love it. Those are things I'm going to take with me for this. I have one more question about these shunts. So, every now and then, and I think you started to touch on this, we will get a shunt series and we'll see that the catheter is fractured. Do the patients develop little- like, a tract that continues to allow diversion even though the catheter is fractured? Dr Robinson: Yes. So, they can develop scar tissue around, and some people have more scar tissue than others. You'll even see that sometimes, say, the catheter has fractured and we'll take out that old fractured tubing and put in new tubing on the other side. But if you go and palpate their neck or chest, you'll still feel that tract is there because it calcifies along the tract. Some patients drain through that calcified tract for weeks or months without symptoms, and then it can occlude off. So, we don't consider it a reliable pathway. It's also not a reliable pathway if you're positioned prone in the OR. So some of our orthopedic colleagues, for example, if they go to do a spine fusion, we like to confirm that the shunt is working before you undergo that long anesthesia, but also that you're going to be positioned prone and you could potentially- you know, the pressure could occlude that track that normally is open. Dr Albin: This is fantastic. I feel like I've gotten everything I've ever wanted to know about shunts and all of their complications in this, which is, you know, this is really difficult. And I think that because we are not trained to put these in, sometimes we see them and we just say, oh, it's fractured that must be a malfunction. But it's good to know that sometimes those patients can drain through, you know, a sort of scarred-down tract, but that it may not be nearly as reliable as when they have the tubing in place. Another really good thing that I'm going to put in my back pocket for the next time I see a patient with a potential shunt malfunction. Dr Robinson: And we do have some patients that the tubing is fractured years ago and they don't need it repaired, and that totally can be challenging when they then transfer to your practice for follow-up care. We tend to follow those patients very closely, both our clinic visits as well as having them seen by ophthalmology. So, there are teenagers and young adults out there that have… their own system has recovered and they are no longer shunt-dependent; and they may have a broken shunt and not actually be using that track, but they usually have had fairly intensive follow up to prove that they're not shunt-dependent. And we still have a healthy respect there that, you know, if they start to get a headache, we're going to take that quite seriously as opposed to, you know, some of our shunt patients, about 10 to 20%, have chronic headaches that are not shunt-related. So, not everybody who has a headache and has a shunt has a shunt malfunction. It's tough. Dr Albin: This is really tough. That actually brings me to sort of the last clinical scenario that I was hoping we could get your perspective on. And I think this would be of great interest to neurologists, especially in the context that these children may develop headaches that have nothing to do with the shunt. I'd like to sort of give you this hypothetical case that I'm a neurologist seeing a patient in clinic and it's a teenager, maybe a young adult, and they had a shunt placed early in childhood. They've done really well. And they've come to me for management of a new headache. And, you know, as part of this workup, their primary care provider had ordered an MRI. And, you know, I look at the MRI, and I don't think that the ventricles look really enlarged. They don't look overdrained. Is having an MRI that looks pretty okay, is that enough to exonerate the shunt in this situation? Dr Robinson: In most cases it is. The one time that we don't see a substantial change in the ventricles is if we have a pseudocyst in the abdomen. The ventricles cannot enlarge initially, and then later on they might enlarge. So, we see that sometimes that somebody will come in and their ventricles will be stable in size, but we're still a little bit suspicious. They've got this persistent headache. They may have, you know, some emesis or loss of appetite, loss of activity, and a slower presentation than you would get with an acute proximal malfunction. We can check an abdominal ultrasound for them. And sometimes, even though the ventricles haven't changed in size, they still have a malfunction because they have that distal pseudocyst. One of the questions that we ask our patients when we're establishing care, in addition to what valve type they have and what sort of their shunt history or other interventions such as endoscopic third ventriculostomy, is to ask if their ventricles enlarge when they have a shunt malfunction. There is a small fraction where they do not. They kind of have a stiff brain, if you will. And so, it's good to know that. That's one of the key factors is asking somebody, do the ventricles enlarge when they have a malfunction? If they have enlarged in the past, they're likely to enlarge again if they have a malfunction. But again, it's not 100%. So, in peds, 20% of the time the ventricles don't enlarge. So, in adults, I'm not that- you know, I don't know what percentage it is, but it's something to consider that you can have a stable ventricular size and still have a shunt malfunction. So, if your clinical judgment, you're just kind of, like, still uneasy, you know, respect that and maybe do a little more workup. That's why we so much want patients to establish care with somebody, whether it's a neurologist or a neurosurgeon or other provider in some areas that have fewer neurospecialists, but to establish care so that you all know what a change is for that patient. That's really important. Dr Albin: That's fantastic. So, to summarize that, it's really important to understand the patient's baseline and how they presented with prior shunt complications, if they've had some. That if they're coming in with a new headache that we don't have a baseline, so, we should just have a heightened level of awareness that, like, the shunt has a start and it has an end. And even if the start of the shunt in the brain looks okay, there still could be the potential for complications in the abdomen. And maybe the third thing I heard from that is that we should look for GI symptoms and sort of be aware of when there could be a complication in the abdomen as well. Does that all sound about right? Dr Robinson: And especially for our kids with spina bifida and for posthemorrhagic hydrocephalus are now adults, because the preterm infants are prone to necrotizing enterocolitis. And they may not have had surgery for it, but they still may have adhesions and other things that predispose them to develop pseudocysts over time. And then our individuals with spina bifida often have various abdominal surgeries and other procedures to help them manage their bowel and bladder function. And so that can also create adhesions that then predisposes to pseudocysts. So, we do have a healthy respect for that. In addition, it used to be---because we have gotten a little better with shunts over time---it used to be, like, when I was in training that you heard, you know, if you haven't had a shunt malfunction for 10 or 15 years, you must- you may no longer be dependent. And that's not really true. There are some people who outgrow their need for shunt dependence, but not everyone does outgrow it. And so, you can be 15, 20 years without a shunt revision and still be shunt-dependent. Dr Albin: Those are fantastic pearls. I think most of them, walking away with this, like, a very healthy respect for the fact that these are complex patients, which the shunt is one component of sort of the things that can go wrong and that we have to have a really healthy respect and really detailed investigation and sort of take the big picture. I really like that. Dr Robinson: Yeah, I know. I think it's- there's a very strong push amongst pediatric neurosurgery and a lot of the related, our colleagues in other areas, to develop multidisciplinary transition clinics and lifespan programs for these patients to help keep everything else optimized so that they're not coming in, for example, with seizures. But then you have to figure out if this is a seizure or a shunt; you know, if we can keep them on track, if we can keep them healthy in all their other dimensions, it makes it safer for them in terms of their shunt malfunction. Dr Albin: Absolutely. I love that, and just the multidisciplinary preventative aspect of trying to keep these patients well. So important. Dr Robinson, I really would like to thank you for your time. We're getting towards the end of our time together. Are there any other points about the article that you just are anxious that leave the readers with, or should I just direct them back to the fantastic review that you've put together on this topic? Dr Robinson: No, I think that we covered a lot of the high points. I think one of the really exciting things for hydrocephalus is that there's a lot of investigations into other options besides shunts for certain populations. We are seeing less hydrocephalus now with the fetal repair of the myelomeningocele, which is great. And we're trying to make inroads into posthemorrhagic hydrocephalus as well. So, there are a lot of great things on the horizon and, you know, hopefully someday we won't have the need to have these discussions so much for shunts. Dr Albin: I love it. I think that's really important. And all of those points were touched on the article. And so, I really invite our listeners to go and check out the article, where you can see sort of, like, how this is evolving in real time. Thank you, Dr Robinson. Please go and check out the childhood-onset hydrocephalus article, which appears in the most recent issue of Continuum on the disorders of CSF dynamics. And be sure to check out Continuum Audio episodes from this and other issues. Thank you again to our listeners for joining us today. And thank you, Dr Robinson. Dr Robinson: Thanks for having me. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Deze zomer is het 25 jaar geleden dat het Europees Kampioenschap van 2000 in Nederland en België werd gehouden. In deze serie van de Staantribune podcast blikken we terug op elfde editie van het door de UEFA georganiseerde eindtoernooi.  Aan de hand van diverse gasten en verschillende invalshoeken voelt iedereen zich weer voor even terug in die zomer van 2000. In deze aflevering bespreken we met journalist Eric de Jager Groep A van het toernooi. In deze groep des doods zaten Engeland, Roemenië, Portugal en Duitsland met elkaar opgescheept. Eric vertelt over Gheorge Hagi, falende Duitsers, het frisse Portugal en een Engeland dat weer eens onderpresteert.Deze podcastserie werd mede mogelijk gemaakt door Kick and Rush. Kick and Rush is een webshop waar iedere voetballiefhebber komt voor zijn of haar unieke en klassieke voetbalshirts en -attributen.Vragen, tips of suggesties over onze podcast zijn altijd welkom: ⁠⁠⁠⁠⁠⁠⁠podcast@staantribune.nl⁠⁠⁠⁠⁠⁠⁠.Word abonnee van hét magazine over voetbalcultuur: ⁠⁠⁠⁠⁠https://staantribune.nl/word-abonnee

In the second episode of this series, Dr. Andy Southerland discusses the latest Capitol Hill Report, breaking down what a reconciliation bill is and why it matters.  Stay updated with what's happening on the hill by visiting aan.com/chr.  Learn how you can get involved with AAN advocacy. 

Deze zomer is het 25 jaar geleden dat het Europees Kampioenschap van 2000 in Nederland en België werd gehouden. In deze serie van de Staantribune podcast blikken we terug op elfde editie van het door de UEFA georganiseerde eindtoernooi.  Aan de hand van diverse gasten en verschillende invalshoeken voelt iedereen zich weer voor even terug in die zomer van 2000. In deze aflevering bespreken we met journalist Rypke Bakker leuke feitjes over Oranje rondom dit toernooi en waar ging het nou echt mis bij de strafschoppen? Rypke geeft de luisteraar een heldere analyse.Deze podcastserie werd mede mogelijk gemaakt door Kick and Rush. Kick and Rush is een webshop waar iedere voetballiefhebber komt voor zijn of haar unieke en klassieke voetbalshirts en -attributen.Vragen, tips of suggesties over onze podcast zijn altijd welkom: ⁠⁠⁠⁠⁠⁠podcast@staantribune.nl⁠⁠⁠⁠⁠⁠.Word abonnee van hét magazine over voetbalcultuur: ⁠⁠⁠⁠https://staantribune.nl/word-abonnee

datum: woensdag 2 juli 2025 gasten: Vanessa Morgan, Jordi Ostir en Maarten Melon We gaan het hebben met de horror vriendjes over een horror franchise. Deze keer bespreken we de vijf Phantasm films en andere films van de regisseur Don Coscarelli.  Aan het eind van de aflevering beslissen we om samen naar I Know What You Did Last Summer (2025) te gaan. En daar kun jij bij zijn! Op donderdag 24 juli 2025 om 19:00 uur spreken we af in UGC Antwerpen om de film te zien en aansluitend (om 21:45) doen we een live podcastje in The Joker. Kom mee griezelen met de horror vriendjes!   Artwork: Les Van Eck

Aan de hand van de nieuwste wetenschappelijke inzichten en negen concrete tools leert Petr Ludwig je in deze wereldwijde bestseller hoe je afrekent met uitstelgedrag en je werk beter kunt organiseren Uitgegeven door Kosmos Uitgevers Spreker: Jurjen van Loon

Stefan, Laurens en Lars gaan verder! ​​De Tour is inmiddels halverwege, maar vandaag begint het échte werk. Etappe 12 voert de renners naar de iconische Hautacam en dat betekent één ding: spektakel, vuurwerk en misschien wel krakende klassementsmannen. De juiste renners zullen boven komen drijven.De heren blikken terug op de naweeën van etappe 11, denken dat Mathieu nu wel klaar zal zijn, en vragen zich af: hoe komt Pogi uit de val? Aan tafel worden namen genoemd: Alaphilippe, Arensman, Tadej? De heren maken zich op voor dag 13 van deze Villa Tour!En hoe zit het nou met die Live Slow Ride Fast logo's op de weg?Je hoort het allemaal in de Live Slow Ride Fast podcast.

In this two-part episode of the Brain & Life Podcast, co-host Dr. Katy Peters is joined by Elizabeth Ansell, founder and director of #NotJustFatigue. #NotJustFatigue is a nonprofit organization shining a light on myalgic encephalomyelitis/chronic fatigue syndrome, also known as ME/CFS, and educates patients, clinicians, and health organizations about the condition. Elizabeth shares how raising awareness, and furthering research really improves the everyday lives of people living with ME/CFS. Dr. Peters is then joined by Dr. W. Ian Lipkin, who is known internationally for his research and is the John Snow Professor of Epidemiology, Professor of Neurology, and Professor of Pathology and Cell Biology at Columbia University Irving Medical Center, Mailman School of Public Health. Dr. Lipkin discusses what's next in ME/CFS research and what the future could hold.   Additional Resources #NotJustFatigue How to Fight Fatigue Understanding the Impact of Invisible Illnesses on Daily Life How Families Are Leading the Charge in Rare Disease Advocacy   Other Brain & Life Podcast Episodes on Similar Topics Rare Thoughts on a Rarer Neurologic Condition Shedding Light and Love on a Rare Genetic Condition with Deborah Vauclare Neurofibromatosis Advocacy and Community Building with the Gilbert Family Foundation We want to hear from you! Have a question or want to hear a topic featured on the Brain & Life Podcast? Record a voicemail at 612-928-6206 Email us at BLpodcast@brainandlife.org   Social Media: Elizabeth Ansell @notjustfatigue; Dr. W. Ian Lipkin @columbiapublichealth Guests: Hosts: Dr. Daniel Correa @neurodrcorrea; Dr. Katy Peters @KatyPetersMDPhD

In this episode, editor-in-chief Joseph E. Safdieh, MD, FAAN, highlights articles about upadacitinib, a new treatment for giant-cell arteritis; growing evidence linking oral health to a higher risk of neurologic conditions; and why a trial of a new meningitis B vaccine drew a mixed response.

ASML kreeg het hard te verduren op de dag van de kwartaalcijfers. Het bedrijf was niet 100 procent zeker dat het volgend jaar zou groeien, maar de gepresenteerde cijfers waren prima. Toch begrijpt Stan Westerterp (Bond Capital Partners) de reactie van beleggers wel. "Als je geen groei laat zien, dan heb je in de techsector niks te zoeken. Aan de andere kant, misschien legt de nieuwe ceo de lat nu bewust laag, zodat de resultaten laten meevallen", iets wat Stan niet bevalt. Koen Bender (Mercurius Vermogensbeheer) sluit niet uit dat de nieuwe topman bewust met een schone lei wil beginnen. "Maar je gaat mij niet vertellen, met de vraag die er is in de wereld, dat ASML volgens jaar niet gewoon weer groei laat zien." Stan is het daar ook helemaal mee eens. Het sentiment, afgezien van ASML, is helemaal niet slecht. De S&P500, en niet alleen de techsector, laten records zien. Het heeft er alle schijn van dat beleggers het handelstumult met een korrel zout nemen. Dat wordt ook gereflecteerd in bedrijfscijfers, zeker die van Amerikaanse banken, die er nog steeds uitstekend uitzien. Verder in de podcast aandacht voor de bitcoin, en dan met name de blockchain, de definitieve cijfers van TSMC en de Amerikaanse grootbanken. Daarnaast bespreken we de luisteraarsvragen (FlowTraders en Kinepolis) en geven de experts hun tips. Stan tipt drie techbedrijven die niet tot de Magnificent Seven behoren, Koen tipt een bedrijf met de ISIN-code US3377381088. Geniet van de podcast! Let op: alleen het eerste deel is vrij te beluisteren. Wil je de hele podcast (luisteraarsvragen en tips) horen, wordt dan Premium lid van BeursTalk. Dat kost slechts 9,95 per maand, 99 euro voor een heel jaar. Abonneren kan hier!See omnystudio.com/listener for privacy information.

Aan het ontbijtbuffet openen de oogjes zich langzaam onder begeleiding van een paar extra sterke espresso’s. De Casino Night van gisteravond lijkt nog maar een paar uur geleden. “Where are we today? Another Saint, I guess?” Gister was het Saint Thomas, morgen Saint Kitts. “Then today must be Sint Maarten. Wait, what? Are we in France? Or Holland? Or both?” Jawel, het cruiseleven zit vol ingewikkelde vragen. Elke dag een nieuwe droombestemming vereist snel schakelen. Onze drijvende stad meert aan en spuwt ons uit, samen met duizenden anderen. Iedereen waaiert uit. Het eiland heeft tot 16:00 vanmiddag even een tijdelijke bevolkingsgroei van 10 procent, zet alle zeilen bij totdat vanavond de rust wederkeert. En dan, aan het avondbuffet, varend naar het volgende paradijs, buigen alle cruisepassagiers zich over dezelfde vraag? Wat maakte dit eiland uniek? We zijn nooit volledig, wel origineel. Geen experts, maar wel liefhebbers. Hebben we tóch iets verkeerd gezegd of zijn we iets cruciaals vergeten? Volg ons en laat het weten.

Normal pressure hydrocephalus (NPH) is a pathologic condition whereby excess CSF is retained in and around the brain despite normal intracranial pressure. MRI-safe programmable shunt valves allow for fluid drainage adjustment based on patients' symptoms and radiographic images. Approximately 75% of patients with NPH improve after shunt surgery regardless of shunt type or location. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Kaisorn L. Chaichana, MD, author of the article “Management of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Berkowitz is a Continuum® Audio interviewer and a professor of neurology at the University of California San Francisco in the Department of Neurology in San Francisco, California. Dr. Chaichana is a professor of neurology in the department of neurological surgery at the Mayo Clinic in Jacksonville, Florida. Additional Resources Read the article: Management of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @kchaichanamd Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Kaisorn Chaichana about his article on management of normal pressure hydrocephalus, which he wrote with Dr Jeremy Cutsforth-Gregory. The article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr Chaichana: Yeah, thank you for having me. I'm Kaisorn Chaichana. I'm a neurosurgeon at Mayo Clinic in Jacksonville, Florida. Part of my practice is doing hydrocephalus care, which includes shunts for patients with normal pressure hydrocephalus. Dr Berkowitz: Fantastic. Well, before we get into shunt considerations and NPH specifically, which I know is the focus of your article, I thought it would be a great opportunity for a neurologist to pick a neurosurgeon's brain a bit about shunts. So, to start, can you lay out for us the different types of shunts and shunt procedures, the advantages, disadvantages of each type of shunt, how you think about which shunt procedure should be used for which patient, that type of thing? Dr Chaichana: Yeah. So, there are different types of shunts, and the most common one that is used is called a ventricular peritoneal shunt. So, it has a ventricular catheter, it has a catheter that tunnels underneath the skin and it goes into the peritoneum where the fluid goes from the ventricular system into the peritoneum. Typically, the shunts are in the ventricle because that is the largest fluid-filled space in the brain. Other terminal areas include the atrium, which is really the jugular vein, and those are called ventricular atrial shunts. You can also have ventricular pleural shunts, which end in the pleural space and drain flui into the pleural space. Those are pretty much the most common ventricular shunts. There's also a lumboperitoneal shunt that drains from the lumbar spine, similar to a lumbar drain into the peritoneum. For the lumbar shunts, we don't typically have a lumbar pleural or lumbar atrial shunt just because of the pressure dynamics, because the lumbar spine is below the lung and as well as the atrium. And so, the drainage pattern is very different than ventricular peritoneal which is top to bottom. The most common shunt, why we use the ventricular peritoneal shunt the most, is because it has the most control. So, the peritoneum is set at a standard pressure in the intraabdominal pressure, whereas the ventricular atrial shunt depends on your venous return or venous pressure and your ventricular pleural shunt varies with inspiration and expiration. So, the easiest way for us to control the fluid, the ventricular system is through the ventricular peritoneal shunt. And that's why that's our most common shunt that we use. Dr Berkowitz: Fantastic. So, as you mention in the article, neurologists may be reluctant to offer a shunt to patients with NPH because many patients may not improve, or they improve only transiently; and out of fear of shunt complications. So, of course, as neurologists, we often only hear about a patient's shunt when there is a problem. So, we have this sort of biased view of seeing a lot of shunt malfunction and shunt infection. Of course, we might not see the patient if their shunt is working just fine. How common are these complications in practice, and how do you as a neurosurgeon weigh the risks against the often uncertain or transient benefits of a shunt in a patient with NPH who may be older and multiple medical comorbidities? How do you think about that and talk about it with patients? Dr Chaichana: When you hear about shunt complications, most of the shunt complications you hear about are typically in patients with congenital hydrocephalus. Those patients often require several shunt revisions just from either growing or the shunt stays in for a long time or the ventricular caliber is a lot less than some with normal pressure hydrocephalus. So, we don't really see a lot of complications with normal pressure hydrocephalus. So that shunt placement in these patients is typically pretty safe. The procedure's a relatively short procedure, around 30 minutes to 45 minutes to place a shunt, and we can control the pressure within the shunt setting so that we don't overdrain---which means too much fluid drains from the ventricular system---which can cause things like a subdural, which is probably the most common complication associated with normal pressure hydrocephalus. So, to obviate those risks, what we do is typically insert the shunt and then keep the shunt setting at a high setting. The higher the setting, the less it drains, and then we bring it slowly down based on the patient's symptoms to try to minimize the risk of this over drainage in the subdural hematoma while at the same time benefiting the patient. So, there's a concern for shunt in patients with normal pressure hydrocephalus. The concern or the complication risks are very low. The problem with normal pressure hydrocephalus, though, is that over time these patients benefit less and less from drainage or their disease process takes over. So, I do recommend placing this shunt as soon as possible just so that we can maximize their quality of life for that period of time. Dr Berkowitz: So, if I'm understanding you, then the risk of complication is more sort of due to the mechanical factors in patients with congenital hydrocephalus or sort of outgrowing the shunt, their pressure dynamics may be changing over time. And in your experience, an older patient with NPH, although they may have more medical comorbidities, the procedure itself is relatively quick and low-risk. And the actual complications due to mechanical factors, my understanding, are just much less common because the patient is obviously fully grown and they're getting one sort of procedure at one point in time and tend to need less revision, have less complication. Is that right? Dr Chaichana: Yeah, that's correct. The complication risk for normal hydrocephalus is a lot less than other types of hydrocephalus. Dr Berkowitz: That's helpful to know. While we're talking about some of these complications, let's say we're following a patient in neurology with NPH who has a shunt. What are some of the symptoms and signs of shunt malfunction or shunt infection? And what are the best studies to order to evaluate for these if we're concerned about them? Dr Chaichana: Yeah. So basically, for shunt malfunction, it's basically broken down into two categories. It's either overdrainage or underdrainage. So, underdrainage is where the shunt doesn't function enough. And so basically, they return to their state before the shunt was placed. So that could be worsening gait function, memory function, urinary incontinence are the typical symptoms we look for in patients with normal pressure hydrocephalus and underdrainage, or the shunt is not working. For patients that are having overdrainage, which is draining too much, the classic sign is typically headaches when they stand up. And the reason behind that is when there's overdrainage, there's less cerebrospinal fluid in their ventricular system, which means less intracranial pressure. So that when they stand up, the pressure differential between their head and the ground is more than when they're lying down. And because of that pressure differential, they usually have worsening headaches when standing up or sitting up. The other thing are severe headaches, which would be a sign of a subdural hematoma or focality in their neurological symptoms that could point to a subdural hematoma, such as weakness, numbness, speaking problems, depending on the hemisphere. How we work this up is, regardless if you're concerned about overdrainage or underdrainage, we usually start with a CAT scan or an MRI scan. Typically, we prefer a CAT scan because it's quicker, but the CAT scan will show us if the ventricular caliber is the same and/or the placement of the proximal catheter. So, what we look for when we see that CAT scan or that MRI to see the location of the proximal catheter to make sure it hasn't changed from any previous settings. And then we see the caliber of the ventricles. If the caliber of the ventricles is smaller, that could be a sign of overdrainage. If the caliber of the ventricles are larger, it could be a sign of underdrainage. The other thing we look for are subdural fluid collections or hydromas or subdural hematomas, which would be another sign of lower endocranial pressure, which would be a sign of overdrainage. So those are the biggest signs we look for, for underdrainage and overdrainage. Other things we can look for if we're concerned of the shunt is fractured, we do a shunt X-ray and what a shunt x-ray is is x-rays of the skull, the neck and the abdomen to see the catheter to make sure it's not kinked or fractured. If you're really concerned, you can't tell from the x-ray, another scan to order is a CT of the chest and abdomen and pelvis to look at the location of the catheter to make sure there's no brakes in the catheter, there's no fluid collections on the distal portion of the catheter, which would be a sign of shunt malfunction as well. Other tests that you can do to really exclude shunt malfunction is a shunt patency test, and what that is a nuclear medicine test where radionucleotide is injected into the valve and then the radionucleotide is traced over time or imaged through time to make sure that it's draining appropriately from the valve into the distal catheter into the peritoneum or the distal site. If there's a shunt malfunction that's not drainage, that radioisotope would remain stagnant either in the valve or in the catheter. There's overdrainage, we can't really tell, but there will be a quick drainage of the radioisotope. For shunt infection, we start with an imaging just to make sure there's not a shunt malfunction, and that usually requires cerebrospinal fluid to test. The cerebrospinal fluid can come from the valve itself, or it can come from other areas like the lumbar spine. If the lumbar spine is showing signs of shunt infection, then that usually means the shunt is infected. If the valve is aspirated with- at the bedside with a butterfly needle into the valve and that shows signs of shunt infection, that also could be a sign of infection. Dr Berkowitz: That's very helpful. You mentioned CT and shunt series. One question that often comes up when obtaining neuroimaging in patients with a shunt, who have NPH or otherwise, is whether we need to call you when we're doing an MRI to reprogram the shunt before or after. Is there a way we can know as a neurologists at the bedside or as patients carry a card, like with some devices where we know whether we have to call and bother our neurosurgery colleagues to get this MRI? Or if the radiology techs ask us, is this safe? And is the patient's shunt going to get turned off? How do we go about determining this? Dr Chaichana: Yeah, so unfortunately, a lot of patients don't carry a card. We typically offer a card when we do the shunt, but that card, there's two problems with it. One is it tells the model, but the second thing is it has to be updated any time the shunt is changed to a different setting. Oftentimes patients don't know that shunt setting, and often times they don't know that company brand that they use. There are different types of shunts with different types of settings. If there's ever concern as to what type of shunt they have, an x-ray is usually the best bet to see with a shunt series, or a skull x-ray. A lateral skull x-ray usually looks at the valve, and the valve has certain radio-dense markers that indicate what type of shunt it is. And that way you can call neurosurgery and we can always tell you what the shunt setting is before the MRI is done. Problem with an MRI scan if you do it without a shunt x-ray before is that you don't know the setting before unless the patient really knows or it's in the patient chart, and the MRI can need to change the setting. It doesn't usually turn it off, but it would change the setting, which would change the fluid dynamics within their ventricular system, which could lead to overdrainage or underdrainage. So, any time a patient needs MRI imaging, whether it's even the brain MRI, a spine MRI, or even abdominal MRI, really a shunt x-ray should be done just to see the shunt setting so that it could be returned to that setting after the MRI is done. Dr Berkowitz: So, the only way to know sort of what type of shunt it would be short of the patient knowing or the patient getting care at the same hospital where the shunt was placed and looking it up in the operative reports would be a skull film. That would then tell us what type of shunt is there and then the marking of the setting. And then we would be able to call our colleagues in neurosurgery and say, this patient is getting an MRI this is the setting, this is the type of shunt. And do we need to call you afterwards to come by and reprogram it? Is that right? Dr Chaichana: That's correct, yeah. Dr Berkowitz: Is there anything we would be able to see on there, or it's best we just- best we just call you and clarify? Dr Chaichana: The easiest thing to do is, when you get the skull x-ray, you can Google different types of shunts or search for different shunts, and they'll have markers that show the type of shunt it is as well as the setting that it's at. And just match it up with the picture. Dr Berkowitz: And as long as it's not a programmable shunt, there's no concern about doing the MRI. Is that right? Dr Chaichana: Correct. So, if it's a programmable shunt, even if it's MRI-compatible, we still like to get the setting before and make sure the setting after the MRI is the same. Nonprogrammable shunts can't be changed with MRI scans, and those don't need neurosurgery after the MRI scan, but it should be confirmed before the scan is done. Dr Berkowitz: Very helpful. Okay, so let's turn to NPH specifically. As you know, there's a lot of debate in the literature, some arguing, even, NPH might not even exist, some saying it's underdiagnosed. I think. I don't know if it was last year at our American Academy of Neurology conference or certainly in recent years, there was a pro and con debate of “we are underdiagnosing NPH” versus “we are overdiagnosing NPH.” What's your perspective as a neurosurgeon? What's the perspective in neurosurgery? Is this something we're underdiagnosing, and the times you shunt these patients you see miraculous results? Is this something that we're overdiagnosing, you get a lot of patients sent to that you think maybe won't benefit from a shunt? Or is it just really hard to say and some patients have shunt-responsive noncommunicating hydrocephalus of unclear etiology and either concurrent Parkinson's disease, Alzheimer's, cervical lumbar stenosis, neuropathy, vestibular problems, and all these other issues that play into multifactorial gait to sort of display a certain amount of the percentage of problem in a given patient or take overtime? What's your perspective if you're open to sharing it, or what's the perspective of neurosurgery? Is this debated as it is in neurology or this is just a standard thing you see and patients respond to shunt to some degree in some proportion of the time? And what are the sort of predictors you see in your experience? Dr Chaichana: Yeah, so, for me, I'd say it's too complicated for a neurosurgeon to evaluate. We rely on neurology to tell us whether or not they need a shunt. But I think the problem is, obviously, a part of the workout for at least the ones that I like to do, is that I want them to have a high-volume lumbar puncture with pre- and postgait analysis to see if there's really an objective measure of them improving. If they have an objective measure of improvement---and what's even better is that they have a subjective measure of improvement on top of the objective measure of improvement---then they benefit from a shunt. The problem is, some patients do benefit even though they don't have objective performance increases after a high-volume shunt. And those are the ones that make me the most worrisome to do the shunt, just because I don't like to do a procedure where there's no benefit for the patient. I do see, according to the literature as well, that there's around a 30 to 40%, even 50%, increase in gait function, even in patients that don't have large improvements following the high-volume lumbar puncture. And those are the most challenging patients for us as neurosurgeons because we'll put the shunt in, they say we're no better in terms of their gait, no better in terms of their urinary incontinence. We try to lower their shunt down to a certain setting and we're kind of stuck after that point. The good thing about NPH, though, is that, from the neurosurgery side, the shunt, like I said, is a pretty benign, low-risk procedure. So, we're not putting the patient through a very severe procedure to see if there's any benefit. So, in cases where we try to improve their quality of life in patients that don't have a benefit from high-volume lumbar puncture, we give them the odds of whether or not it's improving and say it might not improve. But because the procedure's minimally invasive, I think it's a good way to see if we can benefit their quality of life. Dr Berkowitz: Yeah, it's a very helpful perspective. Yeah, those are the most challenging cases on our side as well, right. If the patient- we think they may have NPH, or their gait and/or urinary and/or cognitive problems are- at least have a component of NPH that could be reversible, we certainly want to do the large volume lumbar puncture and/or consider a lumbar drain trial, all discussed in other articles and interviews for this issue of Continuum, But the really tough ones, as you said, there is this literature on patients who don't respond to the large-volume lumbar puncture for some reason but still may be shunt responsive. And despite all the imaging predictors and all the other ways we try to think about this, it's hard to know who's going to benefit. I think that's really a helpful perspective from your end that, as you say in the very beginning of your article, right, maybe there's a little bit too much fear of shunting on the neurology side because when we hear about shunts, it's often in the setting of complication. And so, we're not sort of getting the full spectrum of all the patients you shunt and you see who are doing just fine. They might not improve---the question is related to NPH---but at least they're not harmed by the shunt, and we're maybe overbiased and/or seeing a overly representative sample of negative shunt outcomes when they're actually not that common in practice. Is that a fair summary of your perspective? Dr Chaichana: Yeah, that's correct. So, I mean, complications can occur---and anytime you do a surgery, there are risks of complications---but I think they're relatively low for the benefit that we can help their quality of life. And the procedure's pretty short. So, the risk, it mostly outweighs the benefits in cases with normal pressure hydrocephalus. Dr Berkowitz: Very helpful perspective. So, well, thanks so much again. Today I've been interviewing Dr Kaisorn Chaichana about his article on management of normal pressure hydrocephalus, which he wrote with Dr Jeremy Cutsforth-Gregory. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

 Normal pressure hydrocephalus (NPH) is a clinical syndrome of gait abnormality, cognitive impairment, and urinary incontinence. Evaluation of CSF dynamics, patterns of fludeoxyglucose (FDG) uptake, and patterns of brain stiffness may aid in the evaluation of challenging cases that lack typical clinical and structural radiographic features. In this episode, Katie Grouse, MD, FAAN, speaks with Aaron Switzer, MD, MSc, author of the article “Radiographic Evaluation of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California San Francisco in San Francisco, California. Dr. Switzer is a clinical assistant professor of neurology in the department of clinical neurosciences at the University of Calgary in Calgary, Alberta, Canada. Additional Resources Read the article: Radiographic Evaluation of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Grouse: This is Dr Katie Grouse. Today I'm interviewing Dr Aaron Switzer about his article on radiographic evaluation of normal pressure hydrocephalus, which he wrote with Dr Patrice Cogswell. This article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr. Switzer: Thanks so much for having me, Katie. I'm a neurologist that's working up in Calgary, Alberta, Canada, and I have a special interest in normal pressure hydrocephalus. So, I'm very happy to be here today to talk about the radiographic evaluation of NPH. Dr Grouse: I'm so excited to have you here today. It was really wonderful to read your article. I learned a lot on a topic that is not something that I frequently evaluate in my clinic. So, it's really just a pleasure to have you here to talk about this topic. So, I'd love to start by asking, what is the key message that you hope for neurologists who read your article to take away from it? Dr. Switzer: The diagnosis of NPH can be very difficult, just given the clinical heterogeneity in terms of how people present and what their images look like. And so, I'd like readers to know that detailed review of the patient's imaging can be very helpful to identify those that will clinically improve with shunt surgery. Dr Grouse: There's another really great article in this edition of Continuum that does a really great job delving into the clinical history and exam findings of NPH. So, I don't want to get into that topic necessarily today. However, I'd love to hear how you approach a case of a hypothetical patient, say, where you're suspicious of NPH based on the history and exam. I'd love to talk over how you approach the imaging findings when you obtain an MRI of the brain, as well as any follow-up imaging or testing that you generally recommend. Dr. Switzer: So, I break my approach down into three parts. First, I want to try to identify ventriculomegaly and any signs that would support that, and specifically those that are found in NPH. Secondly, I want to look for any alternative pathology or evidence of alternative pathology to explain the patient's symptoms. And then also evaluate any contraindications for shunt surgery. For the first one, usually I start with measuring Evans index to make sure that it's elevated, but then I want to measure one of the other four measurements that are described in the article, such as posterior colossal angle zed-Evans index---or z-Evans index for the American listeners---to see if there's any other features that can support normal pressure hydrocephalus. It's very important to identify whether there are features of disproportionately enlarged subarachnoid space hydrocephalus, or DESH, which can help identify patients who may respond to shunt surgery. And then if it's really a cloudy clinical picture, it's complicated, it's difficult to know, I would usually go through the full evaluation of the iNPH radscale to calculate a score in order to determine the likelihood that this patient has NPH. So, the second part of my evaluation is to rule out evidence of any alternative pathology to suggest another cause for the patient's symptoms, such as neurodegeneration or cerebrovascular disease. And then the third part of my evaluation is to look for any potential contraindications for shunt surgery, the main one being cerebral microbleed count, as a very high count has been associated with the hemorrhagic complications following shunt surgery. Dr Grouse: You mentioned about your use of the various scales to calculate for NPH, and your article does a great job laying them out and where they can be helpful. Are there any of these scales that can be reasonably relied on to predict the presence of NPH and responsiveness to shunt placement? Dr. Switzer: I think the first thing to acknowledge is that predicting shunt response is still a big problem that is not fully solved in NPH. So, there is not one single imaging feature, or even combination of imaging features, that can reliably predict shunt response. But in my view and in my practice, it's identifying DESH, I think, is really important---so, the disproportionately enlarged subarachnoid space hydrocephalus---as well as measuring the posterior colossal angle. I find those two features to be the most specific. Dr Grouse: Now you mentioned the concept of the NPH subtypes, and while this may be something that many of our listeners are familiar with, I suspect that, like myself when I was reading this article, there are many who maybe have not been keeping up to date on these various subtypes. Could you briefly tell us more about these NPH subtypes? Dr. Switzer: Sure. The Japanese guidelines for NPH have subdivided NPH into three different main categories. So that would be idiopathic, delayed onset congenital, and secondary normal pressure hydrocephalus. And so, I think the first to talk about would be the secondary NPH. We're probably all more familiar with that. That's any sort of pathology that could lead to disruption in CSF dynamics. These are things like, you know, a slow-growing tumor that is obstructing CSF flow or a widespread meningeal process that's reducing absorption of CSF, for instance. So, identifying these can be important because it may offer an alternative treatment for what you're seeing in the patient. The second important one is delayed onset congenital. And when you see an image of one of these subtypes, it's going to be pretty different than the NPH because the ventricles are going to be much larger, the sulcal enfacement is going to be more diffuse. Clinically, you may see that the patients have a higher head circumference. So, the second subtype to know about would be the delayed onset congenital normal pressure hydrocephalus. And when you see an image of one of these subtypes, it's going to be a little different than the imaging of NPH because the ventricles are going to be much larger, the sulcal enfacement is going to be more diffuse. And there are two specific subtypes that I'd like you to know about. The first would be long-standing overt ventriculomegaly of adulthood, or LOVA. And the second would be panventriculomegaly with a wide foramen of magendie and large discernomagna, which is quite a mouthful, so we just call it PAVUM. The importance of identifying these subtypes is that they may be amenable to different types of treatment. For instance, LOVA can be associated with aqueductal stenosis. So, these patients can get better when you treat them with an endoscopic third ventriculostomy, and then you don't need to move ahead with a shunt surgery. And then finally with idiopathic, that's mainly what we're talking about in this article with all of the imaging features. I think the important part about this is that you can have the features of DESH, or you can not have the features of DESH. The way to really define that would be how the patient would respond to a large-volume tap or a lumbar drain in order to define whether they have this idiopathic NPH. Dr Grouse: That's really helpful. And for those of our listeners who are so inclined, there is a wonderful diagram that lays out all these subtypes that you can take a look at. I encourage you to familiarize yourself with these different subtypes. Now it was really interesting to read in your article about some of the older techniques that we used quite some time ago for diagnosing normal pressure hydrocephalus that thankfully we're no longer using, including isotope encephalography and radionuclide cisternography. It certainly made me grateful for how we've come in our diagnostic tools for NPH. What do you think the biggest breakthrough in diagnostic tools that are now clinically available are? Dr. Switzer: You know, definitely the advent of structural imaging was very important for the evaluation of NPH, and specifically the identification of disproportionately enlarged subarachnoid space hydrocephalus, or DESH, in the late nineties has been very helpful for increasing the specificity of diagnosis in NPH. But some of the newer technologies that have become available would be phase-contrast MRI to measure the CSF flow rate through the aqueduct has been very helpful, as well as high spatial resolution T2 imaging to actually image the ventricular system and look for any evidence of expansion of the ventricles or obstruction of CSF flow. Dr Grouse: Regarding the scales that you had referenced earlier, do you think that we can look forward to more of these scales being automatically calculated and reported by various software techniques and radiographic interpretation techniques that are available or going to be available? Dr. Switzer: Definitely yes. And some of these techniques are already in development and used in research settings, and most of them are directed towards automatically detecting the features of DESH. So, that's the high convexity tight sulci, the focally enlarged sulci, and the enlarged Sylvian fissures. And separating the CSF from the brain tissue can help you determine where CSF flow is abnormal throughout the brain and give you a more accurate picture of CSF dynamics. And this, of course, is all automated. So, I do think that's something to keep an eye out for in the future. Dr Grouse: I wanted to ask a little more about the CSF flow dynamics, which I think may be new to a lot of our listeners, or certainly something that we've only more recently become familiar with. Can you tell us more about these advances and how we can apply this information to our evaluations for NPH? Dr. Switzer: So currently, only the two-dimensional phase contrast MRI technique is available on a clinical basis in most centers. This will measure the actual flow rate through the cerebral aqueduct. And so, in NPH, this can be elevated. So that can be a good supporting marker for NPH. In the future, we can look forward to other techniques that will actually look at three-dimensional or volume changes over time and this could give us a more accurate picture of aberrations and CSF dynamics. Dr Grouse: Well, definitely something to look forward to. And on the topic of other sort of more cutting-edge or, I think, less commonly-used technologies, you also mentioned some other imaging modalities, including diffusion imaging, intrathecal gadolinium imaging, nuclear medicine studies, MR elastography, for example. Are any of these modalities particularly promising for NPH evaluations, in your opinion? Do you think any of these will become more popularly used? Dr. Switzer: Yes, I think that diffusion tract imaging and MR elastography are probably the ones to keep your eye out for. They're a little more widely applicable because you just need an MR scanner to acquire the images. It's not invasive like the other techniques mentioned. So, I think it's going to be a lot easier to implement into clinical practice on a wide scale. So, those would be the ones that I would look out for in the future. Dr Grouse: Well, that's really exciting to hear about some of these techniques that are coming that may help us even more with our evaluation. Now on that note, I want to talk a little bit more about how we approach the evaluation and, in your opinion, some of the biggest pitfalls in the evaluation of NPH that you've found in your career. Dr. Switzer: I think there are three of note that I'd like to mention. The first would be overinterpreting the Evans index. So, just because an image shows that there's an elevated Evans index does not necessarily mean that NPH is present. So that's where looking for other corroborating evidence and looking for the clinical features is really important in the evaluation. Second would be misidentifying the focally enlarged sulci as atrophy because when you're looking at a brain with these blebs of CSF space in different parts of the brain, you may want to associate that to neurodegeneration, but that's not necessarily the case. And there are ways to distinguish between the two, and I think that's another common pitfall. And then third would be in regards to the CSF flow rate through the aqueduct. And so, an elevated CSF flow is suggestive of NPH, but the absence of that does not necessarily rule NPH out. So that's another one to be mindful of. Dr Grouse: That's really helpful. And then on the flip side, any tips or tricks or clinical pearls you can share with us that you found to be really helpful for the evaluation of NPH? Dr. Switzer: One thing that I found really helpful is to look for previous imaging, to look if there were features of NPH at that time, and if so, have they evolved over time; because we know that in idiopathic normal pressure hydrocephalus, especially in the dash phenotype, the ventricles can become larger and the effacement of the sulci at the convexity can become more striking over time. And this could be a helpful tool to identify how long that's been there and if it fits with the clinical history. So that's something that I find very helpful. Dr Grouse: Absolutely. When I read that point in your article, I thought that was really helpful and, in fact, I'm guessing something that a lot of us probably aren't doing. And yet many of our patients for one reason or other, probably have had imaging five, ten years prior to their time of evaluation that could be really helpful to look back at to see that evolution. Dr. Switzer: Yes, absolutely. Dr Grouse: It's been such a pleasure to read your article and talk with you about this today. Certainly a very important and helpful topic for, I'm sure, many of our listeners. Dr. Switzer: Thank you so much for having me. Dr Grouse: Again, today I've been interviewing Dr Aaron Switzer about his article on radiographic evaluation of normal pressure hydrocephalus, which he wrote with Dr Patrice Cogswell. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

In the July episode of the President's Spotlight, Dr. Jason Crowell and Dr. Natalia Rost discuss the role science plays in what the AAN does.  Show reference:  https://www.aan.com/about-the-aan/presidents-spotlight