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This week John Wyatt Greenlee, Colin Colbourn, and Alan Malfavon flyover to talk about James Gunn's Superman, the need for heroes in everyday lives, and casting the rest of the DCU.About our guests:Alan Malfavon is Assistant Professor of History at California State University San Marcos.  His first book, Men of the Leeward Port: Veracruz's Afro-Descendants in the Making of Mexico, under contract with the University of Alabama Press, focuses on the understudied Afro-Mexican population of Veracruz and its hinterland of Sotavento (Leeward) and uses it to reframe the historical and historiographical transition between the colonial and national period. It argues how Afro-Mexicans facilitated, complicated, and participated in multiple socio-political processes that reshaped Veracruz and its borderlands. Colin Colbourn holds a Ph.D in U.S. History from the University of Southern Mississippi. His expertise includes mass communication and assisting in research efforts for unresolved casualties from past conflicts. Since 2007 he has published articles on Marine Corps history in Leatherneck: Magazine of the Marines, and was Associate Editor for the West Point History of Warfare. John Wyatt Greenlee is a medievalist and a cartographic historian, as well as a historian of roads and pathways and pilgrimage. But he is best well known for his work on the role of eels in pre-modern England from the tenth through the seventeenth centuries. He is heavily engaged in outreach and public engagement to make the eel history more widely known, and to raise awareness for the role of eels as an endangered species. His work with eels and eel history has been profiled in TIME, The Guardian, Atlas Obscura, Hakai Magazine, and The New Yorker  (click here for a full list of earned media) 

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.

Send us a textDr. Seth Parsons talks to us about the power of the teacher, the value of good curriculum, and motivation and engagement in learning. Seth is known for his work in the areas of elementary literacy instruction, student engagement and motivation, adaptive teaching, and metacognitive strategy development. His research has been published in many of the field's top journals, including the Journal of Literacy Research, Review of Educational Research, Educational Researcher, Reading Research Quarterly, Elementary School Journal, The Reading Teacher, and Literacy Research and Instruction. In addition to journal articles, he has co-authored and edited several practitioner-facing books, including Principles of Effective Literacy Instruction, Grades K–5, and Accelerating Learning Recovery for All Students (both co-authored with past Classroom Caffeine guest Margaret Vaughn) and Becoming a Metacognitive Teacher. He has served as President of Association of Literacy Educators and Researchers (ALER) and currently serves as Executive Editor of The Journal of Educational Research, and Co-Editor of the Literacy Research Association's Journal of Literacy Research, and Associate Editor of Reading and Writing Quarterly. Dr. Seth A. Parsons is a Professor of Literacy in the Sturtevant Center for Literacy at George Mason University. You can connect with Seth on Instagram @sethaparsons or by email at sparson5@gmu.edu. To cite this episode: Persohn, L. (Host). (2025, July 15). A conversation with Seth A. Parsons. (Season 5, No. 12) [Audio podcast episode]. In Classroom Caffeine Podcast series. https://www.classroomcaffeine.com/guests. DOI: 10.5240/E135-3828-6E19-4385-B8E5-YConnect with Classroom Caffeine at www.classroomcaffeine.com or on Instagram, Facebook, Twitter, and LinkedIn.

Microbiologist and Associate Professor at the University of Washington Dr. Olusegun Soge reviews four U.S. based surveillance programs: GISP, eGISP, SURGG, and CARGOS – the umbrella program rolled out in August 2024. Dr. Soge and National STD Curriculum Podcast Host Dr. Meena Ramchandani also discuss a vaccine and another STI pathogen developing resistance. View episode transcript and references at www.std.uw.edu.This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs. Editor and host Dr. Meena Ramchandani is an Assistant Professor of Medicine at the University of Washington (UW), Program Director of the UW Infectious Diseases Fellowship Program, and Associate Editor of the National STD Curriculum.   

Labour fought the 2024 general election on a manifesto which promised “a new way of doing government” – one built on the concept of mission-driven government. But how much has this government's decisions, trade-offs and policy priorities really been shaped by its five missions? And how far have they been able to make progress on their priorities in the first year? To mark the first year of Keir Starmer becoming prime minister, the Institute for Government and the Institute for Fiscal Studies hosted a joint event to explore what progress the government has made and whether Starmer's government is really doing things differently to its predecessors. Are the government's missions realistic or do they lack ambition? Have Rachel Reeves' tax and spending choices supported or hindered mission delivery? What did the spending review reveal about the government's priorities? How could government be better structured – and decisions made – in a way that is more mission-driven? And one year on since the general election, can the government really say it is governing in a “new way”? To explore these questions and more, the IfG and IFS brought together an expert panel featuring: Stephen Bush, Associate Editor and columnist at the Financial Times Helen Miller, Director of the Institute for Fiscal Studies Dr Gemma Tetlow, Chief Economist at the Institute for Government The event was chaired by Dr Hannah White, Director and CEO of the Institute for Government.

John Maytham is joined by Ferial Haffajee, award-winning journalist and Associate Editor at Daily Maverick, whose recent reporting calls into sharp focus Ramaphosa’s pattern of inaction. Despite explosive findings from both the Sandy Africa Report (after the July 2021 unrest) and the NACAC Report by Firoz Cachalia (now acting police minister), neither has been implemented or even publicly engaged with. Presenter John Maytham is an actor and author-turned-talk radio veteran and seasoned journalist. His show serves a round-up of local and international news coupled with the latest in business, sport, traffic and weather. The host’s eclectic interests mean the program often surprises the audience with intriguing book reviews and inspiring interviews profiling artists. A daily highlight is Rapid Fire, just after 5:30pm. CapeTalk fans call in, to stump the presenter with their general knowledge questions. Another firm favourite is the humorous Thursday crossing with award-winning journalist Rebecca Davis, called “Plan B”. Thank you for listening to a podcast from Afternoon Drive with John Maytham Listen live on Primedia+ weekdays from 15:00 and 18:00 (SA Time) to Afternoon Drive with John Maytham broadcast on CapeTalk https://buff.ly/NnFM3Nk For more from the show go to https://buff.ly/BSFy4Cn or find all the catch-up podcasts here https://buff.ly/n8nWt4x Subscribe to the CapeTalk Daily and Weekly Newsletters https://buff.ly/sbvVZD5Follow us on social media:CapeTalk on Facebook: https://www.facebook.com/CapeTalkCapeTalk on TikTok: https://www.tiktok.com/@capetalkCapeTalk on Instagram: https://www.instagram.com/CapeTalk on X: https://x.com/CapeTalkCapeTalk on YouTube: https://www.youtube.com/@CapeTalk567See omnystudio.com/listener for privacy information.

Martin Wolf is Associate Editor and Chief Economics Commentator at the Financial Times, London. In this week's conversation, Yascha Mounk and Martin Wolf discuss Donald Trump's “big, beautiful bill,” the impact it will have on Trump's supporters, and whether the United States is facing a looming economic crisis. Podcast production by Mickey Freeland and Leonora Barclay. Connect with us! Spotify | Apple | Google X: @Yascha_Mounk & @JoinPersuasion YouTube: Yascha Mounk, Persuasion LinkedIn: Persuasion Community Learn more about your ad choices. Visit megaphone.fm/adchoices

 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.

Drawing from intensive on-the-ground reporting in Israel, Gaza, and Lebanon, Douglas Murray places the latest violence in its proper historical context. He takes listeners on a harrowing journey through the aftermath of the October 7 massacre, piecing together the exclusive accounts from victims, survivors, and even the terrorists responsible for the atrocities. Douglas Murray is a bestselling author and journalist. His books include the Sunday Times number-one bestsellers The War on the West: How to Prevail in the Age of Unreason; The Strange Death of Europe: Immigration, Identity and Islam; and The Madness of Crowds: Gender, Race and Identity. He has been Associate Editor and regular writer at The Spectator since 2012, and contributes to other publications, including the Wall Street Journal, The Times, the Sunday Times, the Sun, the Mail on Sunday and the New York Post. A regular guest on broadcast news channels, he has also spoken at numerous universities, parliaments, and the White House. His new book is On Democracies and Death Cults.

Scot Bertram is joined by Matt Lamb, Associate Editor at The College Fix, to discuss a controversial statement from a dean at Grand Valley State University, who claimed the school “accepts virtually all students of color.” Civil rights experts are now calling for further investigation into whether the university's admissions practices could constitute racial discrimination. Lamb provides context, reactions, and what this could mean for the future of race-conscious policies in higher education.

As China’s manufacturing engine powers ahead, this segment looks at how Southeast Asia is grappling with a fresh wave of competition or what some have called the “Second China Shock.” We explore how cheap, tech-driven Chinese exports are reshaping industries from textiles to autos, why ASEAN’s own export markets are feeling the strain, and what options the region has to protect local jobs without jeopardising ties with Beijing. Ravi Velloor, Associate Editor and Senior Columnist with The Straits Times joins the Breakfast Show to share his perspectives.See omnystudio.com/listener for privacy information.

In this episode I'm thrilled to be joined by friend and colleague Sarah Kenny. We discuss her journey and career transition from a professional dancer to her current role in academia, as a professor at The University of Calgary in the combined Bachelor of Kinesiology / Bachelor of Arts (Dance) undergraduate degree program. We learn about Sarah's current research interests, and how these have shifted throughout the years as the field of dance science has evolved. Sarah also shares her insight and advice for dancers who might be interested in the more academic and research side of the dance world.About SarahSarah J. Kenny, PhD is an Associate Professor in the Faculties of Kinesiology and Arts at the University of Calgary in Canada where she leads a combined Bachelor of Kinesiology / Bachelor of Arts (Dance) undergraduate degree program. As a dance science researcher, Dr. Kenny investigates areas described as: ‘health for dance' and ‘dance for health'. Specifically, Dr. Kenny's research applies her experience as a contemporary dance artist to the science of injury epidemiology and focuses on reducing the burden of injuries across all dance populations. In addition, Dr. Kenny explores the psychosocial experience of community dance as a form of creative physical activity across the age spectrum. Currently, Dr. Kenny serves as President for Healthy Dancer Canada, the Dance Health Alliance of Canada and as an Associate Editor for the Journal of Dance Medicine and Science. She is also a registered provider of the Safe in Dance International certificates.Connect with Sarah:University of Calgary Dance/Kinesiology programEmail Sarah: kennys@ucalgary.caLearn more about Erika Mayall:Follow me on Instagram: @dancephysioerikaLearn more about me on my website: https://www.allegroperformance.comSign up for my newsletter: Click hereSend me an email: hello@allegroperformance.com

In Episode 118, Patrick welcomes back returning guest Prineha Narang, professor at UCLA and a leader at the intersection of quantum science and materials engineering.They explore the accelerating trajectory of Quantum Computing, including the rising private venture interest, and how hybrid approaches are advancing both materials science and energy efficiency. From distributed quantum sensor networks to diverse quantum architectures, the conversation highlights how interdisciplinary expertise is driving innovation across the field.Dr. Narang is a Professor in Physical Sciences and Electrical and Computer Engineering at UCLA with an interdisciplinary group spanning areas of physics, chemistry, and engineering. Prior to moving to UCLA, she was an Assistant Professor of Computational Materials Science at Harvard University. Before starting on the Harvard faculty in 2017, Dr. Narang was an Environmental Fellow at HUCE, and worked as a research scholar in condensed matter theory in the Department of Physics at MIT. She received an M.S. and Ph.D. in Applied Physics from Caltech. Her group works on theoretical and computational quantum materials, non-equilibrium dynamics, and quantum information science. Narang's work has been recognized by many awards and special designations, Narang's work has been recognized by many awards and special designations, including the 2023 Guggenheim Fellowship in Physics, Maria Goeppert Mayer Award from the American Physical Society, 2023 ONR Young Investigator Award, 2022 Outstanding Early Career Investigator Award from the Materials Research Society, Mildred Dresselhaus Prize, Bessel Research Award from the Alexander von Humboldt Foundation, a Max Planck Sabbatical Award from the Max Planck Society, and the IUPAP Young Scientist Prize in Computational Physics all in 2021, an NSF CAREER Award in 2020, being named a Moore Inventor Fellow by the Gordon and Betty Moore Foundation, CIFAR Azrieli Global Scholar by the Canadian Institute for Advanced Research, a Top Innovator by MIT Tech Review (MIT TR35), and a leading young scientist by the World Economic Forum in 2018.In 2017, Dr. Narang was named by Forbes Magazine on their “30under30” list for her work in atom-by-atom quantum engineering, that is, designing materials at the smallest scale, using single atoms, to enable the leap to quantum technologies. Dr. Narang has held leadership roles in a DOE EFRC ‘Photonics at Thermodynamic Limits', DOE NQI Quantum Science Center, and the NSF ERC ‘Center for Quantum Networks', among others. Her continued service to the science community includes chairing the Gordon Conference on Ultrafast and Cooperative Phenomena, Materials Research Society (MRS) Spring Meeting (2022) and the MRS-Kavli Foundation Future of Materials Workshop: Computational Materials Science (2021), organizing APS, Optica (OSA), and SPIE symposia, and a leadership role in APS' Division of Materials Physics. Narang is an Associate Editor at ACS Nano of the American Chemical Society, an Associate Editor at Applied Physics Letters of the American Institute of Physics, and the Editorial Advisory Boards of Nano Letters and Advanced Photonics. 

This week please join guest author Adam Griesemer and Associate Editor and Digital Strategies Editor Maryjane Farr as they discuss the Review Article "Cardiac Xenotransplantation: Current State and Future Directions." For the episode transcript, visit: https://www.ahajournals.org/do/10.1161/podcast.20250707.102697

In this 21WIRE LIVE midweek edition with hostPatrick Henningsentalking to guests, Associate Editor for Global Affairs at 21WIRE,Freddie Ponton, and author and international human rights lawyer, Arnaud Develay, to discuss a new front developing in the ongoing East vs West battle for Eurasia, as the US, UK and Israel begin operationalizing their new client state, Azerbaijan, in a dangerous game of geopolitical brinksmanship, recently triggered by a hostile move against Russian news agency staff working in the former Soviet Republic of Azerbaijan - amid a new flare-up in relations between Moscow and Baku. Are the West trying to shape Azerbaijan into another Ukraine? All this and more. Also, listen to the Sunday Wire every Sunday at 5pm UK Time/12pm EST: https://21stcenturywire.com/category/sunday-wire-radio-show/ *SUBSCRIBE/DONATE TO OUR MEDIA PLATFORM HERE: https://21w.co/support VISIT OUR AFFILIATE SPONSORS: Health Solutions - Shop at Clive de Carle: https://21w.co/shop-clive FOLLOW OUR TELEGRAM CHANNEL: https://t.me/My21wire OUR FEATURED MUSIC ARTISTS: Joseph Arthur: https://josepharthur.bandcamp.com/ Peyoti for President: https://peyoti.com/ Red Rumble: https://www.youtube.com/@RedRumbleBand Peter Conway: https://www.peterconway.net/ Countdown Music: Song: Cartoon, Jéja - On & On (feat. Daniel Levi) [NCS Release] - Music provided by NoCopyrightSounds Free Download/Stream: http://ncs.io/onandon Watch: http://youtu.be/K4DyBUG242c  

On this episode of the AMSSM Sports Medcast, host Dr. Devin McFadden, MD, is joined by Dr. Irfan Asif, MD, FAMSSM, and Dr. Jonathan Finnoff, DO, FAMSSM, to discuss the multi-faceted topic of Paralympic Sports Medicine. In this conversation, Dr. Asif and Dr. Finnoff discuss the following: How they first got involved in USOPC and Paralympic team sports The number of sports in Paralympic competition and the athlete classifications that aim to level the playing field for athletes of different abilities What it's like to take care of Paralympic athletes and their unique requirements The planning process for delivering medical services for Team USA during the Paralympic Games Current and future research efforts regarding Paralympic athletes Overcoming the perceived barriers to entry when providing care for Paralympic athletes and ways to get more involved Dr. Asif is the associate dean for primary care and rural health and professor and chair of the Department of Family and Community at the University of Alabama at Birmingham (UAB). He currently serves as the 2nd Vice President for AMSSM and is an Associate Editor for both the British Journal of Sports Medicine and Sports Health: A Multi-Disciplinary Approach. Dr. Finnoff is the Chief Medical Officer for the United States Olympic and Paralympic Committee, a Clinical Professor in the Department of Physical Medicine and Rehabilitation, University of Colorado, and a Professor in the Department of Physical Medicine and Rehabilitation at Mayo Clinic College of Medicine and Science. He currently serves as the 1st Vice President for AMSSM. Resources: 2025 USOPC Paralympic Sports Medicine Conference https://www.usopc.org/2025-paralympic-sports-medicine-conference PARA-Wise Registry Screening Survey: https://redcap.link/PARAWISE

This week on the podcast we examine the latest attacks on international student recruitment as Policy Exchange calls for new restrictions and a £1,000 levy on international fees.Are universities really "selling immigration not education," and what would raising English language requirements to advanced level mean for the sector?Plus we discuss what incoming student leaders are promising in their manifestos – from subsidised laundry to lecture materials uploaded in advance – and ask whether the new metascience unit can deliver on its promise of a more efficient and transparent research funding system.With Duncan Ivison, President and Vice Chancellor at the University of Manchester, Vicki Stott, Chief Executive at the Quality Assurance Agency for Higher Education, Debbie McVitty, Editor at Wonkhe and presented by Jim Dickinson, Associate Editor at Wonkhe.The attack lines on international students are built on shaky foundations – but won't go away that easilyShould students' unions reach for the stars?Metascience comes of age Hosted on Acast. See acast.com/privacy for more information.

Normal pressure hydrocephalus (NPH) is a clinical syndrome characterized by the triad of gait apraxia, cognitive impairment, and bladder dysfunction in the radiographic context of ventriculomegaly and normal intracranial pressure. Accurate diagnosis requires consideration of clinical and imaging signs, complemented by tests to exclude common mimics. In this episode, Lyell Jones, MD, FAAN speaks with Abhay R. Moghekar, MBBS, author of the article “Clinical Features and Diagnosis of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Moghekar is an associate professor of neurology at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Clinical Features and Diagnosis 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 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 Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today I'm interviewing Dr Abhay Moghekar, who recently authored an article on the clinical features and diagnosis of normal pressure hydrocephalus for our first-ever issue of Continuum dedicated to disorders of CSF dynamics. Dr Moghekar is an associate professor of neurology and the research director of the Cerebrospinal Fluid Center at Johns Hopkins University in Baltimore, Maryland. Dr Moghekar, welcome, and thank you for joining us today. Why don't you introduce yourself to our listeners? Dr Moghekar: Thank you, Dr Jones. I'm Abhay Moghekar. I'm a neurologist at Hopkins, and I specialize in seeing patients with CSF disorders, of which normal pressure hydrocephalus happens to be the most common. Dr Jones: And let's get right to it. I think most of our listeners who are neurologists in practice have encountered normal pressure hydrocephalus, or NPH; and it's a challenging disorder for all the reasons that you outline in your really outstanding article. If you were going to think of one single most important message to our listeners about recognizing patients with NPH, what would that be? Dr Moghekar: I think I would say there are two important messages. One is that the triad is not sufficient to make the diagnosis, and the triad is not necessary to make the diagnosis. You know these three elements of the triad: cognitive problems, gait problems, bladder control problems are so common in the elderly that if you pick 10 people out in the community that have this triad, it's unlikely that even one of them has true NPH. On the other hand, you don't need all three elements of the triad to make the diagnosis because the order of symptoms matters. Often patients develop gait dysfunction first, then cognitive dysfunction, and then urinary incontinence. If you wait for all three elements of the triad to be present, it may be too late to offer them any clear benefit. And hence, you know, it's neither sufficient nor necessary to make the diagnosis. Dr Jones: That's a really great point. I think most of our listeners are familiar with the fact that, you know, we're taught these classic triads or pentads or whatever, and they're rarely all present. In a way, it's maybe a useful prompt, but it could be distracting or misleading, even in a way, in terms of recognizing the patient. So what clues do you use, Dr Moghekar, to really think that a patient may have NPH? Dr Moghekar: So, there are two important aspects about gait dysfunction. Say somebody comes in with all three elements of the triad. You want to know two things. Which came first? If gate impairment precedes cognitive impairment, it's still very likely that NPH is in the differential. And of the two, which are more- relatively more affected? So, if somebody has very severe dementia and they have a little bit of gait problems, NPH is not as likely. So, is gait affected earlier than cognitive dysfunction, and is it affected to a more severe degree than cognitive dysfunction? And those two things clue me in to the possibility of NPH. You still obviously need to get imaging to make sure that they have large ventricles. One of the problems with imaging is large ventricles are present in so many different patients. Normal aging causes large ventricles. Obviously, many neurodegenerative disorders because of cerebral atrophy will cause large ventricles. And there's an often-used metric called as the events index, which is the ratio of the bitemporal horns- of the frontal horns of the lateral ventricles compared to the maximum diameter of the skull at that level. And if that ratio is more than 0.3, it's often used as a de facto measure of ventriculomegaly. What we've increasingly realized is that this ratio changes with age. And there's an excellent study that used the ADNI database that looked at how this ratio changes by age and sex. So, in fact, we now know that an 85-year-old woman who has an events index of 0.37 which would be considered ventriculomegaly is actually normal for age and sex. So, we need to start adopting these more modern age- and sex-appropriate age cutoffs of ventriculomegaly so as not to overcall everybody with big ventricles as having possible NPH. Dr Jones: That's very helpful. And I do want to come back to this challenge that we've seen in our field of overdiagnosis and underdiagnosis. But I think most of us are familiar with the concept of how hydrocephalus could cause neurologic deficits. But what's the latest on the mechanism of NPH? Why do some patients get this and others don't? Dr Moghekar: Very good question. I don't think we know for sure. And it for a long time we thought it was a plumbing issue. Right? And that's why shunts work. People thought it was impaired CSF absorption, but multiple studies have shown that not to be true. It's likely a combination of impaired cerebral blood flow, biomechanical factors like compliance, and even congenital factors that play a role in the pathogenesis of NPH. And yes, while putting in shunts likely drains CSF, putting in a shunt also definitely changes the compliance of the brain and affects blood flow to the subcortical regions of the brain. So, there are likely multiple mechanisms by which shunts benefit, and hence it's very likely that there's no single explanation for the pathogenesis of NPH. Dr Jones: We explored this in a recent Continuum issue on dementia. Many patients who have cognitive impairment have co-pathologies, multiple different causes. I was interested to read in your article about the genetic risk profile for NPH. It's not something I'd ever really considered in a disorder that is predominantly seen in older patients. Tell us a little more about those genetic risks. Dr Moghekar: Yeah, everyone is aware of the role genetics plays in congenital hydrocephalus, but until recently we were not aware that certain genetic factors may also be relevant to adult-onset normal pressure hydrocephalus. We've suspected this for a long time because nearly half of our patients who come to us to see us in clinic with NPH have head circumferences that are more than 90th percentile for height. And you know, that clearly indicates that this started shortly at the time after birth or soon afterwards. So, we've suspected for a long time that genetic factors play a role, but for a long time there were not enough large studies or well-conducted studies. But recently studies out of Japan and the US have shown mutations in genes like CF43 and CWH43 are disproportionately increased in patients with NPH. So, we are discovering increasingly that there are genetic factors that underlie even adult onset in patients. There are many more waiting to be discovered. Dr Jones: Really fascinating. And obviously getting more insight into the risk and mechanisms would be helpful in identifying these patients potentially earlier. And another thing that I learned in your article that I thought was really interesting, and maybe you can tell us more about it, is the association between normal pressure hydrocephalus and the observation of cervical spinal stenosis, many of whom require decompression. What's behind that association, do you think? Dr Moghekar: That's a very interesting study that was actually done at your institution, at Mayo Clinic, that showed this association. You know, as we all get older, you know, the incidence of cervical stenosis due to osteoarthritis goes up, but the incidence of significant, clinically significant cervical stenosis in the NPH population was much higher than what we would have expected. Whether this is merely an association in a vulnerable population or is it actually causal is not known and will need further study. Dr Jones: It's interesting to speculate, does that stenosis affect the flow of CSF and somehow predispose to a- again, maybe a partial degree for some patients? Dr Moghekar: Yeah, which goes back to the possible hydrodynamic theory of normal pressure hydrocephalus; you know, if it's obstructing normal CSF flow, you know, are the hydrodynamics affected in the brain that in turn could lead to the development of hydrocephalus. Dr Jones: One of the things I really enjoyed about your article, Abhay, was the very strong clinical focus, right? We can't just take an isolated biomarker or radiographic feature and rely on that, right? We really do need to have clinical suspicion, clinical judgment. And I think most of our listeners who've been in practice are familiar with the use and the importance of the large-volume lumbar puncture to determine who may have, and by exclusion not have, NPH, and then who might respond to CSF diversion. And I think those of us who have been in this situation are also familiar with the scenario where you think someone may have NPH and you do a large-volume lumbar puncture and they feel better, but you can't objectively see a difference. How do you make that test useful and objective in your practice? What do you do? Dr Moghekar: Yeah, it's a huge challenge in getting this objective assessment done carefully because you have to remember, you know, subconsciously you're telling the patients, I think you have NPH. I'm going to do this spinal tap, and if you walk better afterwards, you're going to get a shunt and you're going to be cured. And you can imagine the huge placebo response that can elicit in our subjects. So, we always like to see, definitely, did the patient subjectively feel better? Because yes, that's an important metric to consider because we want them to feel better. But we also wanted to be grounded in objective truths. And for that, we need to do different tests of speed, balance and endurance. Not everyone has the resources to do this, but I think it's important to test different domains. Just like for cognition, you know, we just don't test memory, right? We test executive function, language, visuospatial function. Similarly, walking is not just walking, right? It's gait speed, it's balance, and it's endurance. So, you need to ideally test at least most of these different domains for gait and you need to have some kind of clear criteria as to how are you going to define improvement. You know, is a 5% improvement, is a 10% improvement in gait, enough? Is 20%? Where is that cutoff? And as a field, we've not done a great job of coming up with standardized criteria for this. And it varies currently, the practice varies quite significantly from center to center at the current time. Dr Jones: So, one of the nice things you had in your article was helpful tips to be objective if you're in a lower-resource setting. For you, this isn't a common scenario that someone encounters in their practice as opposed to a center that maybe does a large volume of these. What are some relatively straightforward objective measures that a neurologist or someone else might use to determine if someone is improving after a large-volume LP? Dr Moghekar: Yeah, excellent question, Dr Jones, and very practically relevant too. So, you need to at least assess two of the domains that are most affected. One is speed and one is balance. You know, these patients fall ultimately, right, if you don't treat them correctly. In terms of speed, there are two very simple tests that anybody can do within a couple of minutes. One is the timed “up-and-go” test. It's a test that's even recommended by the CDC. It correlates very well with faults and disability and it can be done in any clinic. You just need about ten feet of space and a chair and a stopwatch, and it takes about a minute or slightly more to do that test. And there are objective age-associated norms for the timed up-and-go test, so it's easy to know if your patient is normal or not. The same thing goes for the 10-meter walk test. You do need a slightly longer walkway, but it's a fairly easy and well-standardized test. So, you can do one of those two; you don't need to do both of them. And for balance, you can do the 30-second “sit-to-stand”; and it's literally, again, 30 seconds. You need a chair, and you need somebody to watch the patient and see how many times they can sit up and stand up from a seated position. Then again, good normative data for that. If you want to be a little more sophisticated, you can do the 4-stage balance test. So, I think these are tests that don't add too much time to your daily assessment and can be done with even trained medical assistants in any clinic. And you don't need a trained physical therapist to do these assessments. Dr Jones: Very practical. And again, something that is pretty easily deployed, something we do before and then after the LP. I did see you mentioned in your article the dual timed up-and-go test where it's a simultaneous gait and executive function test. And I've got to be honest with you, Dr Moghekar, I was a little worried if I would pass that test, but that may be beyond the scope of our time today. Actually, how do you do that? How do you do the simultaneous cognitive assessment? Dr Moghekar: So, we asked them to count back from 100, subtracting 3. And we do it particularly in patients who are mildly impaired right? So, if they're already walking really good, but then you give them a cognitive stressor, you know, that will slow them down. So, we reserve it for patients who are high-performing. Dr Jones: That's fantastic. I'm probably aging myself a little here. I have noticed in my career, a little bit of a pendulum swing in terms of the recognition or acceptance of the prevalence of normal pressure hydrocephalus. I recall when I was a resident, many, many people that we saw in clinic had normal pressure hydrocephalus. Then it seemed for a while that it really faded into the background and was much less discussed and much less recognized and diagnosed, and less treated. And now that pendulum seems to have swung back the other way. What's behind that from your perspective? Dr Moghekar: It's an interesting backstory to all of this. When the first article about NPH was published in the Newman Journal of Medicine, it was actually a combined article with both neurologists and neurosurgeons on it. They did describe it as a treatable dementia. And what that did is it opened up the floodgates so that everybody with any kind of dementia started getting shunts left, right, and center. And back then, shunts were not programmable. There were no antibiotic impregnated catheters. So, the incidence of subdural hematomas and shunt-related infections was very high. In fact, one of our esteemed neurologists back then, Houston Merritt, wrote a scathing editorial that Victor and Adam should lose their professorships for writing such an article because the outcomes of these patients were so bad. So, for a very long period of time, neurologists stopped seeing these patients and stopped believing in NPH as a separate entity. And it became the domain of neurosurgeons for over two or three decades, until more recently when randomized trials started being done early on out of Europe. And now there's a big NIH study going on in the US, and these studies showed, in fact, that NPH exists as a true, distinct entity. And finally, neurologists have started getting more interested in the science and understanding the pathophysiology and taking care of these patients compared to the past. Dr Jones: That's really helpful context. And I guess that maybe isn't rare when you have a disorder that doesn't have a simple, straightforward biomarker and is complex in terms of the tests you need to do to support the diagnosis, and the treatment itself is somewhat invasive. So, when you talk to your patients, Dr Moghekar, and you've established the diagnosis and have recommended them for CSF diversion, what do you tell them? And the reason I ask is that you mentioned before we started recording, you had a patient who had a shunt placed and responded well, but continued to respond over time. Tell us a little bit more about what our patients can expect if they do have CSF diversion? Dr Moghekar: When we do the spinal tap and they meet our criteria for improvement and they go on to have a shunt, we tell them that we expect gait improvement definitely, but cognitive improvement may not happen in everyone depending on what time, you know, they showed up for their assessment and intervention. But we definitely expect gait improvement. And we tell them that the minimum gait improvement we can expect is the same degree of improvement they had after their large-volume lumbar puncture, but it can be even more. And as the brain remodels, as the hydrodynamics adapt to these shunts… so, we have patients who continue to improve one year, two years, and even three years into the course of the intervention. So, we're, you know, hopeful. At the same time, we want to be realistic. This is the same population that's at risk for developing neurodegenerative disorders related to aging. So not a small fraction of our patients will also have Alzheimer's disease, for example, or go on to develop Lewy body dementia. And it's the role of the neurologist to pick up on these comorbid conditions. And that's why it's important for us to keep following these patients and not leave them just to the neurosurgeon to follow up. Dr Jones: And what a great note to end on, Dr Moghekar. And again, I want to thank you for joining us, and thank you for such a wonderful discussion and such a fantastic article on the clinical diagnosis of normal pressure hydrocephalus. I learned a lot reading the article, and I learned a lot more today just in the conversation with you. So, thank you for being with us. Dr Moghekar: Happy to do that, Dr Jones. It was a pleasure. Dr Jones: Again, we've been speaking with Dr Abhay Moghekar, author of a wonderful article on the clinical features and diagnosis of NPH in Continuum's first-ever issue dedicated to disorders of CSF dynamics. Please check it out. 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.

David Strom, Associate Editor with HotAir.com joins to talk about the big beautiful.

On this episode, Mark Simon speaks to Marcela García, associate editor and columnist for the op-ed page at The Boston Globe. Marcela often writes about Latinx communities in Boston including in a newsletter she launched, ¡Mira!, that is written in English and Spanish. She also writes some of the Globe's unsigned editorials.For that, she and two of her colleagues were finalists for this year's Pulitzer Prize in editorial writing. As the Pulitzer board noted "For their politically courageous and deeply reported editorials on how Boston can humanely and effectively close underutilized schools in ways that improve student learning."We talked to Marcela about the series, the work that goes into reporting and writing, and her advice for students with aspirations of writing op-eds and editorials. If you like the former podcast, Longform, I think you'll enjoy this episode.Link to the Pulitzer series: https://www.pulitzer.org/finalists/22653Marcela's salutes: New Bedford Light and Texas TribuneThank you for listening. You can e-mail me at journalismsalute@gmail.comVisit our website: thejournalismsalute.org Mark's website (MarkSimonmedia.com)Tweet us at @journalismpod and Bluesky at @marksimon.bsky.socialSubscribe to our newsletter– journalismsalute.substack.com

Kevin Maguire, Associate Editor at the Daily Mirror and Patrick Maguire, Chief political commentator, The Times, and co-Author of ‘Get In' - The Inside Story of Labour Under Starmer

On this episode of the AMSSM Sports Medcast, host Dr. Devin McFadden, MD, is joined by Dr. Irfan Asif, MD, FAMSSM, and Dr. Jonathan Finnoff, DO, FAMSSM, to discuss the multi-faceted topic of Paralympic Sports Medicine. In this conversation, Dr. Asif and Dr. Finnoff discuss the following: How they first got involved in USOPC and Paralympic team sports The number of sports in Paralympic competition and the athlete classifications that aim to level the playing field for athletes of different abilities What it's like to take care of Paralympic athletes and their unique requirements The planning process for delivering medical services for Team USA during the Paralympic Games Current and future research efforts regarding Paralympic athletes Overcoming the perceived barriers to entry when providing care for Paralympic athletes and ways to get more involved Dr. Asif is the associate dean for primary care and rural health and professor and chair of the Department of Family and Community at the University of Alabama at Birmingham (UAB). He currently serves as the 2nd Vice President for AMSSM and is an Associate Editor for both the British Journal of Sports Medicine and Sports Health: A Multi-Disciplinary Approach. Dr. Finnoff is the Chief Medical Officer for the United States Olympic and Paralympic Committee, a Clinical Professor in the Department of Physical Medicine and Rehabilitation, University of Colorado, and a Professor in the Department of Physical Medicine and Rehabilitation at Mayo Clinic College of Medicine and Science. He currently serves as the 1st Vice President for AMSSM. Resources: 2025 USOPC Paralympic Sports Medicine Conference https://www.usopc.org/2025-paralympic-sports-medicine-conference PARA-Wise Registry Screening Survey: https://redcap.link/PARAWISE

This week on the podcast we examine the government's new industrial strategy and what it really means for higher education – from regional clusters and research funding to skills bootcamps and spin-out support.Will the plans finally integrate universities into the UK's economic future, or is this another case of policy promises outpacing delivery?Plus we discuss the franchising scandal and the damning case for urgent reform, and ask whether new research on social mobility challenges the sector's claims about access, aspiration, and advancement.With Katie Normington, Vice Chancellor at De Montfort University, Johnny Rich, Chief Executive at the Engineering Professors' Council and Push, James Coe, Associate Editor at Wonkhe and presented by Mark Leach, Editor-in-Chief at Wonkhe.Higher education and the industrial strategy priority areasThe cashpoint campus comeback franchising, fraud, and the failure to learn from the FE experienceOn the move: how young people's mobility responds to and reinforces geographical inequalitiesInequalities in Access to Professional Occupations Hosted on Acast. See acast.com/privacy for more information.

In this 21WIRE LIVE midweek edition with host Patrick Henningsen talking to Associate Editor for Global Affairs at 21WIRE,Freddie Ponton, to discuss Trump's alleged "ceasefire" deal between Iran and Israel, which is increasingly looking like another classic fake negotiation by Trump and Israel who are more likely reloading and preparing for a long regime change war in Iran, on the road to confronting China in Asia. We also look at the IAEA's betrayal of Iran and the UN, and how Palantir was used to generate fake intel that Iran was building a nuclear bomb. All this and more.   Also, listen to the Sunday Wire every Sunday at 5pm UK Time/12pm EST: https://21stcenturywire.com/category/sunday-wire-radio-show/ *SUBSCRIBE/DONATE TO OUR MEDIA PLATFORM HERE: https://21w.co/support VISIT OUR AFFILIATE SPONSORS: Health Solutions - Shop at Clive de Carle: https://21w.co/shop-clive FOLLOW OUR TELEGRAM CHANNEL: https://t.me/My21wire OUR FEATURED MUSIC ARTISTS: Joseph Arthur: https://josepharthur.bandcamp.com/ Peyoti for President: https://peyoti.com/ Red Rumble: https://www.youtube.com/@RedRumbleBand Peter Conway: https://www.peterconway.net/ Countdown Music: Song: Cartoon, Jéja - On & On (feat. Daniel Levi) [NCS Release] - Music provided by NoCopyrightSounds Free Download/Stream: http://ncs.io/onandon Watch: http://youtu.be/K4DyBUG242c  

Idiopathic intracranial hypertension (IIH), a condition of increased intracranial pressure (ICP), causes debilitating headaches and, in some, visual loss. The visual defects are often in the periphery and not appreciated by the patient until advanced; therefore, monitoring visual function with serial examinations and visual fields is essential. In this episode, Kait Nevel, MD speaks with John J. Chen, MD, PhD, and Susan P. Mollan, MBChB, PhD, FRCOphth, authors of the article “Treatment and Monitoring of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Chen is a professor of ophthalmology and neurology at the Mayo Clinic in Rochester, Minnesota. Dr. Mollan is an honorary professor of metabolism and systems science in the department of neuro-ophthalmology at University Hospitals Birmingham in Birmingham, United Kingdom. Additional Resources Read the article: Treatment and Monitoring of Idiopathic Intracranial Hypertension 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 Guests: @chenmayo, @DrMollan 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 Kate Nevel. Today, I'm interviewing Drs John Chen and Susan Mollan about their article on treatment and monitoring of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics. Drs Chen and Mollan, welcome to the podcast. And please, could you introduce yourselves to the audience? Dr Chen: Hello, everyone. I'm John Chen, one of the neuro-ophthalmologists at the Mayo Clinic. Thanks for having us here. Dr Mollan: Yeah, it's great to be with you here. I'm Susan Mollan. I'm a consultant neuro-ophthalmologist in Birmingham, England. Dr Nevel: Wonderful. So great to have you both here today, and our listeners. To start us off, talking about your article, can you share with us what you think is the most important takeaway from your article for the practicing neurologist out there? Dr Chen: Yeah, so our article talked about the treatment and monitoring of IIH. And I think one takeaway point is, IIH is becoming much more prevalent now that there's this worldwide obesity epidemic with obesity having- essentially being the largest risk factor for IIH other than female. It's really important to monitor vision because vision loss is often peripheral vision loss at first, which the patient may be completely unaware of. And so, it's important to pair up with an ophthalmologist so you can monitor the papilledema of the visual fields and make sure they don't get permanent vision loss. And in the article, we also talk about- there's been changes in the treatment of severe IIH, where traditionally, we used VP shunts; but there's been a trend toward using more venous sinus stenting in addition to the traditional surgeries. Dr Nevel: Great, thank you. I think probably most of our listeners or a lot of neurologists out there have a pretty good understanding of kind of the basics of the IIH. But can you kind of just go over a few key characteristics of IIH, and maybe some things that are less commonly known or things that are maybe just been kind of better understood over the past decade, perhaps? Dr Mollan: Yes, certainly. I think, as Dr Chen said, it's because this condition is becoming more prevalent, people recognize it. I think it's- we like to go back to the diagnostic criteria so that we're making a very accurate diagnosis. So, the patients may come in to the emergency room with, say, papilledema that's been identified elsewhere or crashing headaches. And it's important to go through that sort of diagnostic pathway, taking a blood pressure, taking a full blood count to make sure the patient is anemic, and then moving forward with that confirmation of papilledema into urgent neuroimaging, whether it's CT or MRI, but including venography to exclude a venous sinus thrombosis. And then if you have no structural lesion that's causing the raised ICP, it's moving forward with your lumbar puncture and carefully checking those pressures. But the patients may not only have crashing headache, they often have pulsatile tinnitus and neck pain. I think some of the features that we're now recognizing is the systemic metabolic effects that are unique to IIH. And so, there's an increased risk of cardiometabolic disease that's over and above what is conferred by obesity. Also, our patients have a sort of maternal health burden where they get impaired fertility, gestational diabetes and preeclampsia. And there's also an associated mental health burden, amongst other things. So we're really starting to understand the spectrum of the disease a bit more. Dr Nevel: Yeah, thank you for that. And that really struck me in your article, how important it is to be aware of those things so that we're making sure that we're managing our whole patient and connecting them with the appropriate providers for some of those other issues that may be associated. For the practicing neurologist out there without all the neuro-ophthalmology equipment, if you will, what should our bedside exam focus on to help us get maybe an early but accurate picture of the patient's visual function when we suspect IIH to be at play, perhaps before they can get in with the neuro-ophthalmologist? Dr Chen: Yeah, I think at the bedside you can still check visual acuity and confrontational visual fields, you know, with finger counting. Of course, you have to know that those are, kind of, crude kind of ways of screening. With papilledema, oftentimes the visual acuity is intact. And the confrontational visual fields aren't as sensitive as automated perimetry. Another important thing will be to do your direct ophthalmoscope and look at the amount of papilledema. If it's grade one or two papilledema on the more mild side, it's actually not vision threatening. It's the higher degrees of papilledema that can cause rapid vision loss. And so, if you look in and you see grade one papilledema, obviously you need to do the full workup, the MRI, MRV, lumbar puncture. But in terms of rapidly getting to an ophthalmologist to screen for vision loss, it's not going to be as important because you're not going to have vision loss at that low grade. If you look in and you see this rip-roaring papilledema, grade five papilledema, that patient is going to be at very severe risk of vision loss. So, I think that exam, looking at the optic nerve can be very helpful. And of course, talking to the patient about symptoms; is there decreased vision Is there double vision from a sixth nerve palsy? Are there transient visual obscurations which would indicate at least a higher degree of papilledema? That'd be helpful as well. Dr Nevel: Great, thank you. And when the patient does get in with a neuro-ophthalmologist, you talk in your article and, of course, in clinical practice, how OCT testing is important to monitor in this condition. Can you provide for the listeners the definition of OCT and how it plays a role in monitoring patients with IIH? Dr Mollan: Sure. So, OCT is short for optical coherence tomography imaging, and really the eye has been at the forefront of OCT alone. Our sort of cardiology colleagues are catching up on the imaging of blood vessels. But what it allows us to do is give us really good cross-sectional, anatomical-level changes that we can see both in the retina and also at the optic nerve head. And it gives us some really good measurements. It's not so good at sort of saying, is this definitely papilledema or not? That sort of lower end of disc elevation. But it is very good at ruling out what we call the pseudopapilledema. So, things like drusens or these other little masses we find underneath the optic nerve head. But in terms of monitoring, because we can longitudinally take these images and the reproducibility is pretty good at the optic nerve head, it allows us to see whether there's direct changes: either the papilledema getting worse or the papilledema getting better at the optic nerve head. It also gives us some indication of what's going on in the ganglion cell layer complex. And that can be helpful when we're thinking about sort of looking at structure versus function. So, ophthalmologists in general, we love OCT; and we spend much more time nowadays looking at the OCT than we really do the back of the eye. And it's just become critical for patients with papilledema to be able to be very accurate from visit to visit to see what's changing. Dr Nevel: How do you determine how frequently somebody needs to see the neuro-ophthalmologist with IIH and how often they need that OCT evaluation? Dr Chen: Once the diagnosis of IIH is made, how often they need to be seen and how frequent they need to be seen depends on the degree of papilledema. And again, OCT is really nice. You can quantify it and then different providers can actually use the same OCT numbers, which is super helpful. But again, if it's grade three papilledema or higher, or article thickness of 200 or higher, I tend to follow them a little bit more closely, trying to treat them more aggressively. Try to get the papilledema down into a safer zone. If it's grade one or two papilledema, we see them less frequently. So, my first visit might be three months out. They come with grade five papilledema, I'm seeing them within a few days to make sure that's papilledema's come down quickly because we're trying to decide, are they going to need surgery or not? Dr Nevel: Yeah, great. And that's a nice segue into talking a little bit about how we treat patients with IIH after the diagnosis is confirmed. And I'd like to just point out you have a very lovely figure in your article---Figure 5-6,---that I'd like to direct our listeners to read your article and check out that figure, which is kind of an algorithm on how we think about the various treatment options for patients who have IIH, which seems to rely a lot on the degree of presence of papilledema and the presence of vision disturbance. Could you maybe walk us through a little bit about how you think about the different treatment options for patients with IIH and when more urgent surgical intervention might be indicated? Dr Mollan: Yeah, sure. We always find it quite hard in any medical specialty to write these kind of flow diagrams because it's really an individual we're looking at. But these are kind of what we'd say is “broad brushstrokes” into those patients that we worry about, sort of, red disease in those patients, more amber disease. Now obviously, even those patients that may not have severe papilledema, they may have crashing headaches. So, they may be an urgent referral themselves because of that. And so, it's nice to try and work out which end of the spectrum you're working with. If we think of the papilledema, Dr Chen's already laid out the sort of lower end of the prison's scale---our grades one, our grades two---that we're less anxious about. And those patients, we would definitely be having discussions about medical management, which includes acetazolamide therapy; but also thinking about weight management. And it may well be that we talk a little bit further about weight management, but I think it's helpful to sort of coach those conversations after you've made a definite diagnosis. And then laying out the risk that's caused, potentially, the IIH in an individual. And then having a sort of open conversation with them about what changes they can have in their lifestyle alongside thinking about medical therapy. There's some patients with very low levels of papilledema that we decide not to put on medicines initially. As patients progress up that papilledema grade, we're definitely thinking about medical therapy. And our first line from the IIH treatment trial would be using acetazolamide, but we need to be thinking about using appropriate dosing. So, a lot of the patients that I see can be sent to me with very low doses that may be inappropriate for that person. In the IIHTT they used up to four grams daily in a divided dose. And you do need to counsel your patients when you're putting them on acetazolamide because of the side effects. You've got quite a nice table in this article about the side effects. I think if you get the patient on board, that they understand that they will experience side effects, that is helpful because they will expect it, and then possibly tolerate it a bit better. Moving through to that area where we're more anxious, that visual-threatening papilledema. As Dr Chen said, it's sort of like you look in and it's sort of “blood and thunder” in there. And you need to be getting on and encouraging the ophthalmologist to get a formal assessment of the visual field. It's very difficult to determine exactly the level at which- and we talk about the mean deviation in a lot of our research studies. But in general, it's a combination of things: the patient's journey to get to you, their symptoms, what's going on with the visual field, but what's also happening at the OCT. So, we look in and we see that fluid is seeping towards the fovea. We get very anxious, and those patients may not even have enough time for a rapid escalation of acetazolamide. It may well be at the first presentation, which we would term, like, fulminant; that we'd be thinking about surgical intervention. And I think before I stop, the other thing to say is, the surgical landscape is really changing. So, we're having some good studies coming out in terms of stenting. And so, there is a sort of bracket where it may well be that we are thinking about neuroradiological intervention in an earlier case. They may not quite be at that visual-threatening stage, but they may be resistant to medical treatments. Dr Nevel: Thank you for that. What do you think is a potential pitfall or a mistake to avoid, if you will, in the management of patients with IIH? Dr Chen: I think it's- in terms of pitfalls, I think the potential pitfalls I've seen are essentially patients where we don't necessarily create a good patient physician relationship. Where they don't have buy-ins on the treatment, they don't have buy-ins to come back, and they're lost to follow-up. And these patients can be dangerous, because they could have vision threatening papilledema and if not getting the appropriate treatment---and if they're not monitoring the vision---this can lead to poor outcomes. So, I've definitely seen that happen. As Dr Mollan said, you really have to tell them about the side effects from the medications. If you just take acetazolamide, letting them know the paresthesias and the changes in taste and some of these other side effects, they're going to immediately stop the medication. Again, and these medications do work, proven in the IIH treatment trial. So again, I think that patient-physician relationship is very important to make sure they have appropriate follow up. Dr Nevel: The topic of weight loss in this patient population can be tricky, and I know I talked with Susie in a prior interview about how to approach this topic with our patients in a sensitive and compassionate manner. Once this topic is broached, I find many patients are looking for advice on strategies for weight loss, or potentially medications or other interventions. How do you prioritize or think about the different weight loss strategies or treatments with your patients, and how do you think about the way that you recommend these different treatments or not? Dr Mollan: Yeah. I think that's a really great question because we sort of stray here into a specialty that we have not been trained in. One thing I definitely ask my patients: if they've been on a weight loss journey before, and what's worked for them and what's not worked for them. And within our different healthcare systems, we have access to different tiers of weight management approaches. But for the person sitting in front of me, that possibly there may be a long journey to access more professional care, it's about understanding. iIs there things that are free, such as, we have some apps in the National Health Service which are weight management applications where they can actually just start putting in their calories, their daily calorie intake. And those apps can be quite helpful and guiding in terms of targeting areas, but also informing the patient of what types of foods to avoid in their diet and what types of foods to include in their diet. And with some of the programs that are completely complementary, they also sometimes add on things about exercise. But I think it is a really difficult thing to manage as, say, an ophthalmologist or a neurologist, mainly because it's not our area of expertise. And I think we've all got to find, in our local hospitals and healthcare systems, those pathways where the patients may be able to access nutritional support, and sort of behavioral lifestyle therapy support, all the way through to the new medications for weight loss; and also for some people, bariatric surgery pathways. It's a tricky topic. Dr Nevel: So how should we counsel our patients about what to expect in the future in terms of visual outcomes? Dr Chen: I think a lot of that depends on the degree of papilledema when they present. If a patient comes in with grade five papilledema, that fulminant IIH that Dr Mollan had mentioned, these patients can have very severe vision loss. And even if we treat them very aggressively with high-dose medications and urgent surgical interventions, sometimes they can have permanent vision loss. And so, we counsel them that, you know, there's a strong chance that they're going to have a good amount of vision loss. But some patients, we're very surprised and we get a lot of vision back. So, we kind of set expectations, but we're cautiously optimistic that we can get vision back. If a patient presents with more mild papilledema like grade one or two papilledema, they're most likely not going to have any permanent vision loss as long as we're treating them, we're monitoring their vision, they're coming to their follow-ups. They tend to do very well from a vision perspective. Dr Nevel: That's great, thank you. And you know, ties into what you said earlier about really making sure that, you know, we create good- as with any patient, but good physician-patient relationships so that they, you know, trust us and they come to follow up so we can really monitor their vision appropriately. What do you think is going on in research in this area that's exciting? What do you think one of the next breakthroughs or thing that we need to understand the most about treatment and monitoring of IIH? Dr Chen: I think surgically, venous sinus stenting is going to probably take over the bulk of surgeries. We still need that randomized clinical trial, but we have some amazing outcomes with venous sinus stenting. And there's many efforts on randomized clinical trials for venous sinus stenting. So we'll have those results soon. From a medical standpoint, Dr Mollan can actually say, actually, more about this. Dr Mollan: I completely agree. The GLP-1 receptor agonists, the twofold prong approach: one is the weight loss where these patients, you know, have significant weight loss to put their disease into remission; and the other side of it is whether certain GLP-1s have the ability to reduce intracranial pressure. So, a phase 2 study that we undertook here in Birmingham did show that we were able to reduce intracranial pressure, but we don't think it's a class effect. So, I think the sort of big breakthrough will be looking at novel therapies like xenotide and other drugs that, say, work on the proximal kidney tubule. Are they able to reduce intracranial pressure directly? And I think we are on the cusp of a real breakthrough for this disease. Dr Nevel: Great. Thank you so much for chatting with me today. And I really learned a lot, appreciated the opportunity. I hope our listeners learned something today, too. So again, today I've been interviewing Drs John Chen and Susan Mollan about their article on treatment and monitoring of idiopathic intracranial hypertension, which 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.

Microbiologist and Associate Professor at the University of Washington Dr. Olusegun Soge reviews six different ways that the microbiology of Neisseria gonorrhoeae contributes to its antimicrobrial resistance. Dr. Soge and National STD Curriculum Podcast Host Dr. Meena Ramchandani then explore how current overuse and misuse of antibiotics in the STI field might be part of the problem. View episode transcript at www.std.uw.edu.This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs. Editor and host Dr. Meena Ramchandani is an Assistant Professor of Medicine at the University of Washington (UW), Program Director of the UW Infectious Diseases Fellowship Program, and Associate Editor of the National STD Curriculum.  

The residential property market is about to be split into very clear segments thanks to a wave of generous home loan incentives. For investors, there is a clear opportunity here: Competition will be slim and values will improve in the market categories just above the incentive thresholds. In fact, the government has usefully provided a guide to how and where the opportunities will arise. Cameron Kusher of Kusher Consulting joins Associate Editor, Wealth James Kirby. In today's episode, we cover: * The new opportunity for investors in a distorted market * Queensland takes the prize for loan incentives with a 2% deposit scheme* The bad news for those waiting for the apartment gap to narrow * Capital Gains and Land tax tipped as new tax targets See omnystudio.com/listener for privacy information.

The Author Events Series presents Jonathan Capehart  | Yet Here I Am: Lessons from a Black Man's Search for Home Tickets to the Montgomery Auditorium are now sold out, but you can still get tickets for the simulcast live screening in Room 108.  REGISTER In Conversation with David Brooks Pulitzer Prize-winning writer, editor, and TV host Jonathan Capehart on growing up, coming out, finding his voice, battles lost and won, and the path to a meaningful life Before meeting with success as a journalist, Jonathan Capehart struggled with his identity. Capehart grew up without his father and, as a child, lived with his mother in New Jersey and spent his summers living with relatives in North Carolina. Whether in the North or the South, Capehart had to contend with being told he was too smart or not smart enough, too black or not black enough. His was a struggle to identify and become. Yet Here I Am takes us along Capehart's journey, from his years at Carleton College, where he learns to embrace his identity as a gay, black man surrounded by a likeminded community; to his decision to come out to his family, risking rejection; and finally, his move to New York City and where he landed his first break in television news. Capehart, gaining confidence, eventually found his singular voice – as a writer, editor, and broadcaster – and used it to propel himself and the causes of others. Indeed, it was his voice that helped him find his place in the world, contemplating the complexities of race, place, reporting, and home. Honest and endearing, Yet Here I Am is an inspirational memoir of identity, opportunity, and purpose.  Pulitzer Prize-winning journalist Jonathan Capehart is anchor of The Saturday Show and The Sunday Show on MSNBC. In the spring, he will become a co-host of the morning edition of The Weekend on MSNBC. Capehart is Associate Editor at the Washington Post, where he is also an opinion writer. He is also an analyst on The PBS News Hour. Capehart was deputy editorial page editor of the New York Daily News (2002-2004) and served on its editorial board (1993-2000). His editorial campaign in 1999 to save the Apollo Theater earned the board the Pulitzer Prize for Editorial Writing. David Brooks is a columnist for The New York Times and a contributor to The Atlantic. He is a commentator on ''The PBS Newshour." His latest book is ''How To Know A Person: The Art of Seeing Others Deeply and Being Deeply Seen.'' His previous three books were ''The Second Mountain,'' ''The Road to Character,'' and ''The Social Animal: The Hidden Sources of Love, Character, and Achievement,'' all #1 New York Times bestsellers.  The 2024/25 Author Events Series is presented by Comcast. Because you love Author Events, please make a donation when you register for this event to ensure that this series continues to inspire Philadelphians. Books will be available for purchase at the library on event night! All tickets are non-refundable. (recorded 5/22/2025)

Central Asia's vast yet mostly untapped mineral wealth is garnering global attention at a moment of rising competition for critical minerals. The European Union and the United States are increasingly focusing on the raw materials of a region that has often been overlooked. Ellie Saklatvala, Senior Editor of Argus Non-Ferrous Markets, recently discussed the current state of mineral production in Central Asia with Cristina Belda, Argus' Associate Editor, and reporter Maeve Flaherty. They examined what the region needs to realise its full potential in the coming years and explored how these developments could alter the landscape of critical minerals. Covered this episode: • The mineral resources of Central Asian countries • Tajikistan's role as a supplier of antimony • Kazakhstan and the shifting trade flows of chrome metal • Challenges related to infrastructure, logistics, and geological data • The geopolitical dynamics of the region Speakers: • Ellie Saklatvala, Editorial Lead for non-ferrous metals at Argus • Cristina Belda, Associate Editor for metals at Argus • Maeve Flaherty, Reporter for metals at Argus

Welcome to Episode 103 of The Modelgeeks Podcast!   In this episode we are privileged to have Mr. Rob Riviezzo, host of the “Modeling Insanity” podcast” and the “Quarter Scale Madness” podcast, sitting in the studio with us. Rob shares his insight into the hobby, and his own modeling influences with us. Rob is also the U.S. Associate Editor of Military Modelcraft International magazine (http://www.militarymodelcraft.co.uk/), and I'm sure a huge influence in his own right on many armor modellers out there. In response to an email from listener Luis Toledo, of Lancaster CA, we get into a great discussion on entering contests and should that be a barometer of one's modeling skills? Each host weighs in on that topic. In our Main Topic we each discuss who or what has influenced our modeling through the years. Some famous, and infamous folks make the list!  We would like to thank all you listeners out there for the continued support you have given the show. Share your work with us and the rest of the scale modeling community through our web page, or through our Facebook community page. We love seeing other people's work. Who knows who you may inspire someone through your latest masterpiece! Modelgeeks web page: Model Geeks PodcastFacebook community: The ModelGeeks Model Shack …and of course you can email us at: contact@modelgeekspodcast.com Mentioned in the Episode:PAXCON 2025 Hobbyshop Shoutout! MTS Aviation Models Nimpex World of Models We also want to thank each of our sponsors for their support. We are very lucky to have their support. When you have the time, pay a visit to their web sites, and have a look at their fine products. Sponsors:Furball Aero-DesignTamiya USADetail & ScaleSprueBrothersLionHeart HobbyBases By BillHypersonic ModelsMatters Of Scale  If you're a wicked ModelGeek go check out the following links! IPMS USA Events PageAMPSButch O'Hare Modeling ClubThe Interesting Modeling Company We are very fortunate to be able to join the scale modeling podcast community and are in the company of several other really GREAT podcasts. Hopefully, someday we'll earn our wings and be able to keep up with those guys!  Please check them all out at Scale Model Podcasts. Blogs:The Kit BoxSprue Pie with FretsModel Airplane MakerSupport the showModel Geeks Podcast

In this 21WIRE LIVE midweek edition with host Patrick Henningsen talking to guests, Associate Editor for Global Affairs at 21WIRE, Freddie Ponton, and author and international human rights lawyer, Arnaud Develay, to discuss the conspicuous White House fall-out and subsequent public disappearance of Trump's Director of National Intelligence (DNI), Tulsi Gabbard, as the world inches close to nuclear war following Israel's unprovoked war of aggression against Iran - and with Trump hinting the US will join in the illegal war this week. Gabbard had previously stated in March that Iran was NOT pursing a nuclear weapon - an assessment which Trump categorically dismissed this week. Considering we are now on the brink of WWIII, can she retain her integrity without resigning from her post? All this and more. Also, listen to the Sunday Wire every Sunday at 5pm UK Time/12pm EST: https://21stcenturywire.com/category/sunday-wire-radio-show/ *SUBSCRIBE/DONATE TO OUR MEDIA PLATFORM HERE: https://21w.co/support VISIT OUR AFFILIATE SPONSORS: Health Solutions - Shop at Clive de Carle: https://21w.co/shop-clive OUR FEATURED MUSIC ARTISTS: Joseph Arthur: https://josepharthur.bandcamp.com/ Peyoti for President: https://peyoti.com/ Red Rumble: https://www.youtube.com/@RedRumbleBand Peter Conway: https://www.peterconway.net/ Countdown Music: Song: Cartoon, Jéja - On & On (feat. Daniel Levi) [NCS Release] - Music provided by NoCopyrightSounds Free Download/Stream: http://ncs.io/onandon Watch: http://youtu.be/K4DyBUG242c  

Idiopathic intracranial hypertension (IIH) is characterized by symptoms and signs of unexplained elevated intracranial pressure (ICP) in an alert and awake patient. The condition has potentially devastating effects on vision, headache burden, increased cardiovascular disease risk, sleep disturbance, and depression.  In this episode, Teshamae Monteith, MD, FAAN speaks with Aileen A. Antonio, MD, FAAN, author of the article “Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Antonio is an associate program director of the Hauenstein Neurosciences Residency Program at Trinity Health Grand Rapids and an assistant clinical professor at the Michigan State University College of Osteopathic Medicine in Lansang, Michigan. Additional Resources Read the article: Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension 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: @headacheMD Guest: @aiee_antonio 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 Monteith: Hi, this is Dr Teshamae Monteith. Today I'm interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics.  Hi, how are you? Dr Antonio: Hi, good afternoon. Dr Monteith: Thank you for being on the podcast. Dr Antonio: Thank you for inviting me, and it's such an honor to write for the Continuum. Dr Monteith: So why don't you start off with introducing yourself? Dr Antonio: So as mentioned, I'm Aileen Antonio. I am a neuro-ophthalmologist, dually trained in both ophthalmology and neurology. I'm practicing in Grand Rapids, Michigan Trinity Health, and I'm also the associate program director for our neurology residency program. Dr Monteith: So, it sounds like the residents get a lot of neuro-ophthalmology by chance in your curriculum. Dr Antonio: For sure. They do get fed that a lot. Dr Monteith: So why don't you tell me what the objective of your article was? Dr Antonio: Yes. So idiopathic intracranial hypertension, or IIH, is a condition where there's increased intracranial pressure, but without an obvious cause. And with this article, we want our readers---and our listeners right now---to recognize that the typical symptoms and learning about the IIH diagnostic criteria are key to avoiding errors, overdiagnosis, or sometimes even misdiagnosis or underdiagnosis. Thus, we help make the most of our healthcare resources. Early diagnosis and management are crucial to prevent disability from intractable headaches or even vision loss, and it's also important to know when to refer the patients to the appropriate specialists early on. Dr Monteith: So, it sounds like your central points are really getting that diagnosis early and managing the patients and knowing how to triage patients to reduce morbidity and complications. Is that correct? Dr Antonio: That is correct and very succinct, yes. Dr Monteith: And so, are there any more recent advances in the diagnosis of IIH? Dr Antonio: Yes. And one of the tools that we've been using is what we call the optical coherence tomography. A lot of people, neurologists, physicians, PCP, ER doctors; how many among those physicians are well-versed in doing an eye exam, looking at the optic disc? And this is a great tool because it is noninvasive, it is high resolution imaging technique that allows us to look at the optic nerve without even dilating the eye. And we can measure that retinal nerve fiber layer, or RNFL; and that helps us quantify the swelling that is visible or inherent in that optic nerve. And we can even follow that and monitor that over time. So, this gives us another way of looking at their vision and getting that insight as to how healthy is their vision still, along with the other formal visual tests that we do, including perimetry or visual field testing. And then all of these help in catching potentially early changes, early worsening, that may happen; and then we can intervene more easily. Dr Monteith: Great. So, it sounds like there's a lot of benefits to this newer technology for our patients. Dr Antonio: That is correct. Dr Monteith: So, I read in the article about the increased incidence of IIH, and I have to say that I completely agree with you because I'm seeing so much of it in my clinic, even as a headache specialist. And I had a talk with a colleague who said that the incidence of SIH and IIH are similar. And I was like, there's no way. Because I see, I can see several people with IIH just in one day. That's not uncommon. So, tell me what your thoughts are on the incidence, the rising incidence of IIH; and we understand that it's the condition associated with obesity, but it sounds like you have some other underlying drivers of this problem. Dr Antonio: Yes, that is correct. So, as you mentioned, IIH tends to affect women of childbearing age with obesity. And it's interesting because as you've seen that trend, we see more of these IIH cases recently, which seem to correlate with that rising rate of obesity. And the other thing, too, is that this trend can readily add to the burden of managing IIH, because not only are we dealing with the headaches or the potential loss of vision, but also it adds to the burden of healthcare costs because of the other potential comorbidities that may come with it, like cardiovascular risk factors, PCOS, and sleep apnea. Dr Monteith: So why don't we just talk about the diagnosis of IIH? Dr Antonio: IIH, idiopathic intracranial hypertension, is also called pseudotumor cerebri.  It's essentially a condition where a person experiences increased intracranial pressure, but without any obvious cause. And the tricky part is that the patients, they're usually fully awake and alert. So, there's no obvious tumor, brain tumor or injury that causes the increased ICP. It's really, really important to rule out other conditions that might cause these similar symptoms; again, like brain tumors or even the cerebral venous sinus thrombosis. Many patients will have headaches or visual disturbances like transient visual obscurations---we call them TVOs---or double vision or diplopia. The diplopia is usually related to a sixth nerve palsy or an abducens palsy. Some may also experience some back pain or what we call pulsatile tinnitus, which is that pulse synchronous ringing in their ears. The biggest sign that we see in the clinic would be that papilledema; and papilledema is a term that we only use, specifically use, for those optic nerve edema changes that is only associated with increased intracranial pressure. So, performing of endoscopy and good eye exam is crucial in these patients. We usually use the modified Dandy criteria to diagnose IIH. And again, I cannot emphasize too much that it's really important to rule out other secondary causes to that increased intracranial pressure. So, after that thorough neurologic and eye evaluation with neuroimaging, we do a lumbar puncture to measure the opening pressure and to analyze the cerebrospinal fluid. Dr Monteith: One thing I learned from your article, really just kind of seeing all of the symptoms that you mentioned, the radicular pain, but also- and I think I've seen some papers on this, the cognitive dysfunction associated with IIH. So, it's a broader symptom complex I think than people realize. Dr Antonio: That is correct. Dr Monteith: So, you mentioned TVOs. Tell me, you know, if I was a patient, how would you try and elicit that from me? Dr Antonio: So, I would usually just ask the patient, while you're sitting down just watching TV---some of my patients are even driving as this happens---they would suddenly have these episodes of blacking out of vision, graying out of vision, vision loss, or blurred vision that would just happen, from seconds to less than a minute, usually. And they can happen in one eye or the other eye or both eyes, and even multiple times a day. I had a patient, it was happening 50 times a day for her. It's important to note that there is no pain associated with it most of the time. The other thing too is that it's different from the aura that patients with migraines would have, because those auras are usually scintillating and would have what we call the positive phenomena: the flashing lights, the iridescence, and even the fortification that they see in their vision. So definitely TVOs are not the migraine auras. Sometimes the TVOs can also be triggered by sudden changes in head positions or even a change in posture, like standing up quickly. The difference, though, between that and, like, the graying out of vision or the tunneling vision associated with orthostatic hypotension, is that the orthostatic hypotension would also have that feeling of lightheadedness and dizziness that would come with it. Dr Monteith: Great. So, if someone feels lightheaded, less likely to be a TVO if they're bending down and they have that grain of vision. Dr Antonio: That is correct. Dr Monteith: Definitely see patients like that in clinic. And if they have fluoride IIH, I'm like, I'll call it a TVO; if they don't, I'm like, it's probably more likely to be dizziness-related. And then we also have patient migraines that have blurriness that's nonspecific, not necessarily associated with aura. But I think in those patients, it's usually not seconds long, it's usually probably longer episodes of blurriness. Would you agree there, or…? Dr Antonio: I would agree there, and usually the visual aura would precede the headache that is very characteristic of their migraine, very stereotypical for their migraines. And then it would dissipate slowly over time as well. With TVOs, they're brisk and would not last, usually, more than a minute. Dr Monteith: So, why don't we talk about routine imaging? Obviously, ordering an MRI, and I read also getting an MRV is important. Dr Antonio: It is very important because, one: I would say IIH is also a diagnosis of exclusion. We need to make sure that the increased ICP is not because of a brain tumor or not because of cerebral venous sinus thrombosis. So, it's important to get the MRI of the brain as well as the MRV of the head. Dr Monteith: Do you do that for all patients' MRV, and how often do you add on an orbital study? Dr Antonio: I usually do not add on an orbital study because it's not really going to change my management at that point. I really get that MRI of the brain. Now the MRV, for most of my patients, I would order it already just because the population that I see, I don't want to lose them. And sometimes it's that follow-up, and that is the difficult part; and it's an easy add on to the study that I'm going to order. Again, it depends with the patient population that you have as well, and of course the other symptoms that may come with it. Dr Monteith: So, why don't we talk a little bit about CSF reading and how these set values, because we get people that have readings of 250 millimeters of water quite frequently and very nonspecific, questionable IIH. And so, talk to me about the set value. Dr Antonio: Right. So, the modified Dandy criteria has shown that, again, we consider intracranial pressure to be elevated for adults if it's above 250 millimeters water; and then for kids if it's above 280 millimeters of water. Knowing that these are taken in the left lateral decubitus position, and assuming also that the patients were awake and not sedated during the measurement of the CSF pressure. The important thing to know about that is, sometimes when we get LPs under fluoroscopy or under sedation, then these can cause false elevation because of the hypercapnia that elevated carbon dioxide, and then the hypoventilation that happens when a patient is under sedation. Dr Monteith: You know, sometimes you see people with opening pressures a little bit higher than 25 and they're asymptomatic. Well, the problem with these opening pressure values is that they can vary somewhat even across the day. People around 25, you can be normal, have no symptoms, and have opening pressure around 25- or 250; and so, I'm just asking about your approach to the CSF values. Dr Antonio: So again, at the end of the day, what's important is putting everything together. It's the gestalt of how we look at the patient. I actually had an attending tell me that there is no patient that read the medical textbook. So, the, the important thing, again, is putting everything together. And what I've also seen is that some patients would tell me, oh, I had an opening pressure of 50. Does that mean I'm in a dire situation? And they're so worried and they just attach to numbers. And for me, what's important would be, what are your symptoms? Is your headache, right, really bad, intractable? Number two: are you losing vision, or are you at that cusp where your optic nerve swelling or papilledema is so severe that it may soon lead to vision loss? So, putting all of these together and then getting the neuroimaging, getting the LP. I tell my residents it's like icing on the cake. We know already what we're dealing with, but then when we get that confirmation of that number… and sometimes it's borderline, but this is the art of neurology. This is the art of medicine and putting everything together and making sure that we care and manage it accordingly. Dr Monteith: Let's talk a little bit about IIH without papilledema. Dr Antonio: So, let's backtrack. So, when a patient will fit most of the modified Dandy criteria for IIH, but they don't have the papilledema or they don't have abducens palsy, the diagnosis then becomes tricky. And in these kinds of cases, Dr Friedman and her colleagues, when they did research on this, suggested that we might consider the diagnosis of IIH. And she calls this idiopathic intracranial hypertension without papilledema, IIHWOP. They say that if they meet the other criteria for modified Dandy but show at least three typical findings on MRI---so that flattening of the posterior globe, the tortuosity of the optic nerves, the empty sella or the partially empty sella, and even the narrowing of the transverse venous sinuses---so if you have three of these, then potentially you can call these cases as idiopathic intracranial hypertension without papilledema. Dr Monteith: Plus, the opening pressure elevation. I think that's key, right? Getting that as well. Dr Antonio: Yes. Sometimes IIHWOP may still be a gray area. It's a debate even among neuro-ophthalmologists, and I bet even among the headache specialists. Dr Monteith: Well, I know that I've had some of these conversations, and it's clear that people think this is very much overdiagnosed. So, that's why I wanted to plug in the LP with that as well. Dr Antonio: Right. And again, we have not seen yet whether is, this a spectrum, right? Of that same disease just manifesting differently, or are they just sharing a same pathway and then diverging? But what I want to emphasize also is that the treatment trials that we've had for IIH do not include IIHWOP patients. Dr Monteith: That is an important one. So why don't you wrap this up and tell our listeners what you want them to know? Now's the time. Dr Antonio: So, the- again, with IIH, with idiopathic intracranial hypertension, what is important is that we diagnose these patients early. And I think that some of the issues that come into play in dealing with these patients with IIH is that, one: we may have anchoring bias. Just because we see a female with obesity, of reproductive age, with intractable headaches, it does not always mean that what we're dealing with is IIH. The other thing, too, is that your tools are already available to you in your clinic in diagnosing IIH, short of the opening pressure when you get the lumbar puncture. And I need to emphasize the importance of doing your own fundoscopy and looking for that papilledema in these patients who present to you with intractable headaches or abducens palsy. What I want people to remember is that idiopathic intracranial hypertension is not optic nerve sheath distension. So, these are the stuff that you see on neuroimaging incidentally, not because you sent them, because they have papilledema, or because they have new headaches and other symptoms like that. And the important thing is doing your exam and looking at your patients. Dr Monteith: Today, I've been interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which 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. Thank you again. Dr Antonio: Thank you. 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 this episode, I sit down with Dr. David Klurfeld—longtime USDA scientist and one of the few insiders to publicly challenge the WHO's classification of red meat as a carcinogen. We go deep into the flawed evidence behind the infamous 2015 IARC report, why nutritional epidemiology often fails to prove causality, and how a small group of researchers helped shape global policy with low-quality science. If you've ever felt confused about meat, saturated fat, or dietary guidelines, this conversation will help you think critically about what “counts” as evidence—and who gets to decide. We cover:Dr. Klurfeld's personal journey and lessons from a career in public healthWhy the 2015 IARC red meat classification was based on weak and inconsistent evidenceHow observational studies and “allegiance bias” mislead nutrition scienceThe politics of dietary guidelines and the role of the USDA and WHOWhat the media got wrong—and why red meat remains a nutrient-dense foodWhether you're a clinician, dietitian, or simply trying to make better nutrition decisions, this episode is a powerful reminder that bias, groupthink and weak data can distort science and mislead the public. We need to be discerning about the nutrition and health advice we follow. Who is Dr. David Klurfeld?Dr. David Klurfeld is a nutritional scientist and former National Program Leader for Human Nutrition at the USDA's Agricultural Research Service. He also served as Professor and Chair of Nutrition and Food Science at Wayne State University and Associate Editor of The American Journal of Clinical Nutrition. He has authored more than 200 scientific publications and was one of 22 experts invited to the 2015 IARC working group on red meat and cancer. He is a longtime advocate for scientific integrity in public health policy.This episode is brought to you by: LMNT- Free Sample Pack with any purchase, visit https://DrinkLMNT.com/DRLYONTimeline - Get 20% off your order of Mitopure - https://timeline.com/LYONMUDWTR - Use code DRLYON to get up to 43% off your starter kit - https://mudwtr.com/DRLYONNeeded - Use code DRLYON for 20% off your first order - https://thisisneeded.com Find Dr. David Klurfeld at: Indiana University Bloomington - https://publichealth.indiana.edu/about/directory/David-Klurfeld-dmklurfe.html Google Scholar - https://scholar.google.ca/citations?user=Ym5Og20AAAAJ&hl=en LinkedIn - https://www.linkedin.com/in/david-klurfeld-812845209/ Find me at:Instagram:@drgabriellelyon TikTok: @drgabriellelyonFacebook: facebook.com/doctorgabriellelyonYouTube:

Curtis Mitch, M.A., is the principal annotator and Associate Editor of the Ignatius Study Bible series. Mitch joined the Augustine Institute in 2022 as a Bible Projects Managing Editor and concurrent Associate Professor of Sacred Scripture. Curtis joins Keith to discuss his personal faith journey and his work with the Ignatius Study Bible, which he worked on for twenty-one years! https://ignatius.com/ignatius-catholi... This episode is sponsored by Brandon Grysko and Fausone & Grysko PLC/. Law firm. https://www.thefgfirm.law/attorneys/b... If you would like to sponsor an episode, please email keith@down2earthministry.org To support the channel and Keith's ministry: Become a supporter and part of Keith's locals community https://keithnester.locals.com We also have Patreon:   / keithnester   For more info about Keith visit: http://down2earthministry.org/ Social media links: https://x.com/KeithNester1    / keithnestercatholic     / keithnestercatholic    

Steven Ellis, Associate Editor and Prospect Analyst at DailyFaceoff joins the show to talk players in the 2025 NHL Draft Class.  From Matthew Schaefer to Justin Carbonneau, Steven covers a ton of ground on a wealth of prospects entering the 2025 NHL Draft.      Give us a follow and a like and please give us a 5-Star review on Apple Podcasts and Spotify You can submit questions to our mailbag anytime via our Discord Channel or Twitter. || FHFH Twitter || FHFH Discord || FHFH Patreon || FHFH YouTube ||  

Editor's Summary by Linda Brubaker, MD, Preeti Malani, MD, MSJ, Deputy Editors, and Christopher W. Seymour, MD, MSc, Associate Editor of JAMA, the Journal of the American Medical Association, for articles published from June 7-13, 2025.

In the final installment of the MacVoices Live! WWDC 2025 coverage, the panel explores Apple's latest innovations across Maps, Apple Music, live translation, and Vision Pro. Discussions include the practical benefits of pinned playlists and AutoMix, personalized navigation in Maps, and the long-awaited shared spatial experiences in Vision Pro. Chuck Joiner, Brittany Smith,Marty Jencius, Ben Roethig, Eric Bolden, and Brian Flanigan-Arthurs also touch on translation through AirPods, Continuity upgrades, and new input options for Vision Pro like styluses and VR controllers.  MacVoices is supported by Macstock Conference and Expo in Crystal Lake IL on July 11 - 13. Use the code “macvoices50” to save $50 on conference registration. Show Notes: Chapters: 00:09 Introduction to WWDC 2025 Highlights00:30 Features of the New Maps03:57 Guest Insights and Farewells05:15 Live Translation Possibilities07:49 Apple Music Innovations16:22 Continuity and Device Integration18:11 Vision Pro Updates and Features28:37 Wrapping Up the Discussion35:32 Macstock Conference Announcement Guests: Eric Bolden is into macOS, plants, sci-fi, food, and is a rural internet supporter. You can connect with him on Twitter, by email at embolden@mac.com, on Mastodon at @eabolden@techhub.social, on his blog, Trending At Work, and as co-host on The Vision ProFiles podcast. Brian Flanigan-Arthurs is an educator with a passion for providing results-driven, innovative learning strategies for all students, but particularly those who are at-risk. He is also a tech enthusiast who has a particular affinity for Apple since he first used the Apple IIGS as a student. You can contact Brian on twitter as @brian8944. He also recently opened a Mastodon account at @brian8944@mastodon.cloud. Dr. Marty Jencius has been an Associate Professor of Counseling at Kent State University since 2000. He has over 120 publications in books, chapters, journal articles, and others, along with 200 podcasts related to counseling, counselor education, and faculty life. His technology interest led him to develop the counseling profession ‘firsts,' including listservs, a web-based peer-reviewed journal, The Journal of Technology in Counseling, teaching and conferencing in virtual worlds as the founder of Counselor Education in Second Life, and podcast founder/producer of CounselorAudioSource.net and ThePodTalk.net. Currently, he produces a podcast about counseling and life questions, the Circular Firing Squad, and digital video interviews with legacies capturing the history of the counseling field. This is also co-host of The Vision ProFiles podcast. Generally, Marty is chasing the newest tech trends, which explains his interest in A.I. for teaching, research, and productivity. Marty is an active presenter and past president of the NorthEast Ohio Apple Corp (NEOAC). Ben Roethig has been in the Apple Ecosystem since the System 7 Days. He is the a former Associate Editor with Geek Beat, Co-Founder of The Tech Hangout and Deconstruct and currently shares his thoughts on RoethigTech. Contact him on  Twitter and Mastodon. Brittany Smith is a trained cognitive neuroscientist who provides ADD/ADHD, technology, and productivity coaching through her business, Devise and Conquer, along with companion video courses for folks with ADHD. She's also the cofounder of The ADHD Guild, a community for nerdy folks with ADHD. She, herself, is a self-designated “well-rounded geek”. She can be found on Twitter as @addliberator, on Mastodon as @addliberator@pdx.social, and on YouTube with tech tips.   Support:      Become a MacVoices Patron on Patreon     http://patreon.com/macvoices      Enjoy this episode? Make a one-time donation with PayPal Connect:      Web:     http://macvoices.com      Twitter:     http://www.twitter.com/chuckjoiner     http://www.twitter.com/macvoices      Mastodon:     https://mastodon.cloud/@chuckjoiner      Facebook:     http://www.facebook.com/chuck.joiner      MacVoices Page on Facebook:     http://www.facebook.com/macvoices/      MacVoices Group on Facebook:     http://www.facebook.com/groups/macvoice      LinkedIn:     https://www.linkedin.com/in/chuckjoiner/      Instagram:     https://www.instagram.com/chuckjoiner/ Subscribe:      Audio in iTunes     Video in iTunes      Subscribe manually via iTunes or any podcatcher:      Audio: http://www.macvoices.com/rss/macvoicesrss      Video: http://www.macvoices.com/rss/macvoicesvideorss

In the final installment of the MacVoices Live! WWDC 2025 coverage, the panel explores Apple's latest innovations across Maps, Apple Music, live translation, and Vision Pro. Discussions include the practical benefits of pinned playlists and AutoMix, personalized navigation in Maps, and the long-awaited shared spatial experiences in Vision Pro. Chuck Joiner, Brittany Smith,Marty Jencius, Ben Roethig, Eric Bolden, and Brian Flanigan-Arthurs also touch on translation through AirPods, Continuity upgrades, and new input options for Vision Pro like styluses and VR controllers.  http://traffic.libsyn.com/maclevelten/MV25166.mp3 MacVoices is supported by Macstock Conference and Expo in Crystal Lake IL on July 11 - 13. Use the code “macvoices50” to save $50 on conference registration. Show Notes: Chapters: 00:09 Introduction to WWDC 2025 Highlights 00:30 Features of the New Maps 03:57 Guest Insights and Farewells 05:15 Live Translation Possibilities 07:49 Apple Music Innovations 16:22 Continuity and Device Integration 18:11 Vision Pro Updates and Features 28:37 Wrapping Up the Discussion 35:32 Macstock Conference Announcement Guests: Eric Bolden is into macOS, plants, sci-fi, food, and is a rural internet supporter. You can connect with him on Twitter, by email at embolden@mac.com, on Mastodon at @eabolden@techhub.social, on his blog, Trending At Work, and as co-host on The Vision ProFiles podcast. Brian Flanigan-Arthurs is an educator with a passion for providing results-driven, innovative learning strategies for all students, but particularly those who are at-risk. He is also a tech enthusiast who has a particular affinity for Apple since he first used the Apple IIGS as a student. You can contact Brian on twitter as @brian8944. He also recently opened a Mastodon account at @brian8944@mastodon.cloud. Dr. Marty Jencius has been an Associate Professor of Counseling at Kent State University since 2000. He has over 120 publications in books, chapters, journal articles, and others, along with 200 podcasts related to counseling, counselor education, and faculty life. His technology interest led him to develop the counseling profession ‘firsts,' including listservs, a web-based peer-reviewed journal, The Journal of Technology in Counseling, teaching and conferencing in virtual worlds as the founder of Counselor Education in Second Life, and podcast founder/producer of CounselorAudioSource.net and ThePodTalk.net. Currently, he produces a podcast about counseling and life questions, the Circular Firing Squad, and digital video interviews with legacies capturing the history of the counseling field. This is also co-host of The Vision ProFiles podcast. Generally, Marty is chasing the newest tech trends, which explains his interest in A.I. for teaching, research, and productivity. Marty is an active presenter and past president of the NorthEast Ohio Apple Corp (NEOAC). Ben Roethig has been in the Apple Ecosystem since the System 7 Days. He is the a former Associate Editor with Geek Beat, Co-Founder of The Tech Hangout and Deconstruct and currently shares his thoughts on RoethigTech. Contact him on  Twitter and Mastodon. Brittany Smith is a trained cognitive neuroscientist who provides ADD/ADHD, technology, and productivity coaching through her business, Devise and Conquer, along with companion video courses for folks with ADHD. She's also the cofounder of The ADHD Guild, a community for nerdy folks with ADHD. She, herself, is a self-designated “well-rounded geek”. She can be found on Twitter as @addliberator, on Mastodon as @addliberator@pdx.social, and on YouTube with tech tips.   Support:      Become a MacVoices Patron on Patreon      http://patreon.com/macvoices      Enjoy this episode? Make a one-time donation with PayPal Connect:      Web:      http://macvoices.com      Twitter:      http://www.twitter.com/chuckjoiner      http://www.twitter.com/macvoices      Mastodon:      https://mastodon.cloud/@chuckjoiner      Facebook:      http://www.facebook.com/chuck.joiner      MacVoices Page on Facebook:      http://www.facebook.com/macvoices/      MacVoices Group on Facebook:      http://www.facebook.com/groups/macvoice      LinkedIn:      https://www.linkedin.com/in/chuckjoiner/      Instagram:      https://www.instagram.com/chuckjoiner/ Subscribe:      Audio in iTunes      Video in iTunes      Subscribe manually via iTunes or any podcatcher:      Audio: http://www.macvoices.com/rss/macvoicesrss      Video: http://www.macvoices.com/rss/macvoicesvideorss

In part two of the WWDC 2025 keynote discussion, the MacVoices Live! panel dives deeper into hands-on impressions of Apple's latest OS betas and features. Highlights include the enthusiasm around call screening and hold assist, improvements to multitasking and UI unification, and Apple Watch additions like Workout Buddy and wrist flick gestures. Chuck Joiner, David Ginsburg, Brittany Smith, Marty Jencius, Ben Roethig, Jeff Gamet, Eric Bolden, and Brian Flanigan-Arthurs also examine a new focus on gaming, privacy-focused on-device AI, and new Shortcuts automations on the Mac. (Part 2)  Today's MacVoices is supported by CleanMyMac by MacPaw, your ultimate solution for Mac control and care. Try CleanMyMac for 7 days free, then use the code “MacVoices20” for 20% off at CLNMY.com/MacVoices. Show Notes: Chapters: 00:09 Introduction to WWDC Keynote Insights 13:07 Call Screening and Hold Assist Innovations 27:00 Game Center's Comeback and Features 33:41 Automations and Shortcuts on Mac Guests: Eric Bolden is into macOS, plants, sci-fi, food, and is a rural internet supporter. You can connect with him on Twitter, by email at embolden@mac.com, on Mastodon at @eabolden@techhub.social, on his blog, Trending At Work, and as co-host on The Vision ProFiles podcast. Brian Flanigan-Arthurs is an educator with a passion for providing results-driven, innovative learning strategies for all students, but particularly those who are at-risk. He is also a tech enthusiast who has a particular affinity for Apple since he first used the Apple IIGS as a student. You can contact Brian on twitter as @brian8944. He also recently opened a Mastodon account at @brian8944@mastodon.cloud. Jeff Gamet is a technology blogger, podcaster, author, and public speaker. Previously, he was The Mac Observer's Managing Editor, and the TextExpander Evangelist for Smile. He has presented at Macworld Expo, RSA Conference, several WordCamp events, along with many other conferences. You can find him on several podcasts such as The Mac Show, The Big Show, MacVoices, Mac OS Ken, This Week in iOS, and more. Jeff is easy to find on social media as @jgamet on Twitter and Instagram, jeffgamet on LinkedIn., @jgamet@mastodon.social on Mastodon, and on his YouTube Channel at YouTube.com/jgamet. David Ginsburg is the host of the weekly podcast In Touch With iOS where he discusses all things iOS, iPhone, iPad, Apple TV, Apple Watch, and related technologies. He is an IT professional supporting Mac, iOS and Windows users. Visit his YouTube channel at https://youtube.com/daveg65 and find and follow him on Twitter @daveg65 and on Mastodon at @daveg65@mastodon.cloud. Dr. Marty Jencius has been an Associate Professor of Counseling at Kent State University since 2000. He has over 120 publications in books, chapters, journal articles, and others, along with 200 podcasts related to counseling, counselor education, and faculty life. His technology interest led him to develop the counseling profession ‘firsts,' including listservs, a web-based peer-reviewed journal, The Journal of Technology in Counseling, teaching and conferencing in virtual worlds as the founder of Counselor Education in Second Life, and podcast founder/producer of CounselorAudioSource.net and ThePodTalk.net. Currently, he produces a podcast about counseling and life questions, the Circular Firing Squad, and digital video interviews with legacies capturing the history of the counseling field. This is also co-host of The Vision ProFiles podcast. Generally, Marty is chasing the newest tech trends, which explains his interest in A.I. for teaching, research, and productivity. Marty is an active presenter and past president of the NorthEast Ohio Apple Corp (NEOAC). Ben Roethig has been in the Apple Ecosystem since the System 7 Days. He is the a former Associate Editor with Geek Beat, Co-Founder of The Tech Hangout and Deconstruct and currently shares his thoughts on RoethigTech. Contact him on  Twitter and Mastodon. Brittany Smith is a trained cognitive neuroscientist who provides ADD/ADHD, technology, and productivity coaching through her business, Devise and Conquer, along with companion video courses for folks with ADHD. She's also the cofounder of The ADHD Guild, a community for nerdy folks with ADHD. She, herself, is a self-designated “well-rounded geek”. She can be found on Twitter as @addliberator, on Mastodon as @addliberator@pdx.social, and on YouTube with tech tips. Support: Become a MacVoices Patron on Patreon      http://patreon.com/macvoices      Enjoy this episode? Make a one-time donation with PayPal Connect: Web:      http://macvoices.com Twitter: http://www.twitter.com/chuckjoiner      http://www.twitter.com/macvoices Mastodon:      https://mastodon.cloud/@chuckjoiner Facebook:      http://www.facebook.com/chuck.joiner MacVoices Page on Facebook:      http://www.facebook.com/macvoices/ MacVoices Group on Facebook:      http://www.facebook.com/groups/macvoice LinkedIn:      https://www.linkedin.com/in/chuckjoiner/ Instagram:      https://www.instagram.com/chuckjoiner/ Subscribe:      Audio in iTunes      Video in iTunes      Subscribe manually via iTunes or any podcatcher: Audio: http://www.macvoices.com/rss/macvoicesrss      Video: http://www.macvoices.com/rss/macvoicesvideorss

K. Giriprakash is a seasoned business journalist based in Bengaluru, with over three decades of experience covering key sectors of the Indian economy. Currently serving as the Business Editor at The Federal, he previously held prominent roles at The Hindu BusinessLine—including Chief of Bureau and Associate Editor—and contributed to Business Standard, Reuters, and The Pioneer.He is the author of The Vijay Mallya Story, published by Penguin Random House in 2014—a meticulously reported biography that charts Mallya's rise across liquor, aviation, and sports, and his subsequent fall from grace.In addition to his editorial work and authorship, Giriprakash shares his expertise as a faculty member teaching business journalism at the Indian Institute of Journalism & New Media (IIJNM) in Bengaluru.He holds an active presence on social media (e.g., X/platform-wide bylines) and maintains a robust portfolio with more than 300 articles spanning alcohol, IT, aviation, and economic policy.

In part two of the WWDC 2025 keynote discussion, the MacVoices Live! panel dives deeper into hands-on impressions of Apple's latest OS betas and features. Highlights include the enthusiasm around call screening and hold assist, improvements to multitasking and UI unification, and Apple Watch additions like Workout Buddy and wrist flick gestures. Chuck Joiner,  David Ginsburg, Brittany Smith, Marty Jencius, Ben Roethig, Jeff Gamet, Eric Bolden, and Brian Flanigan-Arthurs also examine a new focus on gaming, privacy-focused on-device AI, and new Shortcuts automations on the Mac. (Part 2)  http://traffic.libsyn.com/maclevelten/MV25165.mp3 Today's MacVoices is supported by CleanMyMac by MacPaw, your ultimate solution for Mac control and care. Try CleanMyMac for 7 days free, then use the code “MacVoices20” for 20% off at CLNMY.com/MacVoices. Show Notes: Chapters: 00:09 Introduction to WWDC Keynote Insights 13:07 Call Screening and Hold Assist Innovations 27:00 Game Center's Comeback and Features 33:41 Automations and Shortcuts on Mac Guests: Eric Bolden is into macOS, plants, sci-fi, food, and is a rural internet supporter. You can connect with him on Twitter, by email at embolden@mac.com, on Mastodon at @eabolden@techhub.social, on his blog, Trending At Work, and as co-host on The Vision ProFiles podcast. Brian Flanigan-Arthurs is an educator with a passion for providing results-driven, innovative learning strategies for all students, but particularly those who are at-risk. He is also a tech enthusiast who has a particular affinity for Apple since he first used the Apple IIGS as a student. You can contact Brian on twitter as @brian8944. He also recently opened a Mastodon account at @brian8944@mastodon.cloud. Jeff Gamet is a technology blogger, podcaster, author, and public speaker. Previously, he was The Mac Observer's Managing Editor, and the TextExpander Evangelist for Smile. He has presented at Macworld Expo, RSA Conference, several WordCamp events, along with many other conferences. You can find him on several podcasts such as The Mac Show, The Big Show, MacVoices, Mac OS Ken, This Week in iOS, and more. Jeff is easy to find on social media as @jgamet on Twitter and Instagram, jeffgamet on LinkedIn., @jgamet@mastodon.social on Mastodon, and on his YouTube Channel at YouTube.com/jgamet. David Ginsburg is the host of the weekly podcast In Touch With iOS where he discusses all things iOS, iPhone, iPad, Apple TV, Apple Watch, and related technologies. He is an IT professional supporting Mac, iOS and Windows users. Visit his YouTube channel at https://youtube.com/daveg65 and find and follow him on Twitter @daveg65 and on Mastodon at @daveg65@mastodon.cloud. Dr. Marty Jencius has been an Associate Professor of Counseling at Kent State University since 2000. He has over 120 publications in books, chapters, journal articles, and others, along with 200 podcasts related to counseling, counselor education, and faculty life. His technology interest led him to develop the counseling profession ‘firsts,' including listservs, a web-based peer-reviewed journal, The Journal of Technology in Counseling, teaching and conferencing in virtual worlds as the founder of Counselor Education in Second Life, and podcast founder/producer of CounselorAudioSource.net and ThePodTalk.net. Currently, he produces a podcast about counseling and life questions, the Circular Firing Squad, and digital video interviews with legacies capturing the history of the counseling field. This is also co-host of The Vision ProFiles podcast. Generally, Marty is chasing the newest tech trends, which explains his interest in A.I. for teaching, research, and productivity. Marty is an active presenter and past president of the NorthEast Ohio Apple Corp (NEOAC). Ben Roethig has been in the Apple Ecosystem since the System 7 Days. He is the a former Associate Editor with Geek Beat, Co-Founder of The Tech Hangout and Deconstruct and currently shares his thoughts on RoethigTech. Contact him on  Twitter and Mastodon. Brittany Smith is a trained cognitive neuroscientist who provides ADD/ADHD, technology, and productivity coaching through her business, Devise and Conquer, along with companion video courses for folks with ADHD. She's also the cofounder of The ADHD Guild, a community for nerdy folks with ADHD. She, herself, is a self-designated “well-rounded geek”. She can be found on Twitter as @addliberator, on Mastodon as @addliberator@pdx.social, and on YouTube with tech tips. Support:      Become a MacVoices Patron on Patreon      http://patreon.com/macvoices      Enjoy this episode? Make a one-time donation with PayPal Connect:      Web:      http://macvoices.com      Twitter:      http://www.twitter.com/chuckjoiner      http://www.twitter.com/macvoices      Mastodon:      https://mastodon.cloud/@chuckjoiner      Facebook:      http://www.facebook.com/chuck.joiner      MacVoices Page on Facebook:      http://www.facebook.com/macvoices/      MacVoices Group on Facebook:      http://www.facebook.com/groups/macvoice      LinkedIn:      https://www.linkedin.com/in/chuckjoiner/      Instagram:      https://www.instagram.com/chuckjoiner/ Subscribe:      Audio in iTunes      Video in iTunes      Subscribe manually via iTunes or any podcatcher:      Audio: http://www.macvoices.com/rss/macvoicesrss      Video: http://www.macvoices.com/rss/macvoicesvideorss

Recently, sophisticated myelographic techniques to precisely subtype and localize CSF leaks have been developed and refined. These techniques improve the detection of various types of CSF leaks thereby enabling targeted therapies. In this episode, Katie Grouse, MD, FAAN, speaks with Ajay A. Madhavan, MD, author of the article “Radiographic Evaluation of Spontaneous Intracranial Hypotension” 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. Madhavan is assistant professor of radiology at the Mayo Clinic in Rochester, Minnesota. Additional Resources Read the article: Radiographic Evaluation of Spontaneous Intracranial Hypotension 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 Ajay Madhavan about his article on Radiographic Evaluation of Spontaneous Intracranial Hypotension, which he wrote with Dr Levi Chazen. 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 Madhavan:  Hi, thanks a lot, Katie. Yeah, so I'm Ajay Madhaven. I'm a neuroradiologist at the Mayo Clinic in Rochester, Minnesota. I did all my training here, so, I've been here for a long time. And I have a lot of interest in spinal CSF leaks, and I do a lot of that work. And so I'm really excited to be talking about this article with you. Dr Grouse:  I'm really excited too. And in fact, it's such a pleasure to have you here talking today on this topic. I know a lot's changed in this field, and I'm sure many of our listeners are really interested in learning about the developments and imaging techniques to improve detection and treatment of CSF leaks, especially since maybe we've learned about this in training. I want to start by asking you what you think is the most important takeaway from your article. Dr Madhavan:  Yeah, that's a great question. I think---and you kind of already alluded to it---I think the main thing is, I hope people recognize that this field has really changed a lot in the last five to ten years, through a lot of multi-institutional collaboration and also collaboration between different specialties. We've learned a lot about different types of spinal CSF leaks, how we can recognize the disease, particularly the types of myelography that we need to be using to accurately localize and treat these leaks. Those are the things that have really evolved in the last five to ten years, and they've really helped us improve these patients' lives. Dr Grouse:  Can you remind us of the different common types of spinal leaks that can cause spontaneous intracranial hypotension? Dr Madhavan:  Yeah, so there are a number of different spinal CSF leaks, types, and I would say the three most common ones that really most people should try to be aware of and cognizant of are: first, ventral dural tears. So those are, like, just physical holes in the dura. And they're usually caused by little bone spurs that come from the vertebral columns. So, they're often patients who have some degenerative changes in their spine. And those are really very common. Another type of spinal CSF leak that we commonly see is a lateral dural tear. So that's like the same thing in a slightly different location. So instead of being in the front, it's off to the side of the dura laterally. And so, it's also just a hole in the dura. And then the third and most recently discovered type of spinal CSF leak is a CSF-venous fistula. So those are direct connections between the subarachnoid space and little paraspinal vein. And it took us a long time to even realize that this was a real pathology. But now that it's been recognized, we've found that this is actually quite common. So those three types of leaks are probably the three most common that we see. And there's certainly others out there, but I would say over 90% of them fall into one of those three categories. Dr Grouse:  That's a great review, thank you. Just as another quick review, as we talk more about this topic, can you remind us of some of the most common or typical brain imaging findings that you'll see in cases of spontaneous intracranial hypotension? Dr Madhavan:  Yeah, absolutely. So, when you do a brain MRI in a patient who has spontaneous intracranial hypotension, you will usually, though not always, see typical brain MRI abnormalities. And I kind of think of those as falling into three different categories. So, the first one I think of is dural enhancement or thickening. So that's enlargement or engorgement of the dura, the pachymeninges, and enhancement on postgadolinium imaging. So, that's kind of the first category. The second is that, when you lose spinal fluid volume, other things often expand to take up the space. So, for example, you can get distension or enlargement of the dural venous sinuses, and sometimes you can also get subdural food collections or hematomas. They can arise spontaneously. And I kind of think of those as, you know, you, you've lost the cerebrospinal fluid volume and something else is kind of filling up the space. And then the third category is called brain sagging. And that's a constellation of findings where the posterior fossa structures and the pituitary gland in the cell have become abnormal because you've lost the fluid that normally cushions those structures and causes them to float up. For example, the brain stem will sag down, the distance between the mammillary body and the ponds may become reduced. The suprasellar cistern space may be reduced such that the optic chiasm becomes very close to the pituitary gland, and the prepontine cistern may also become reduced in size. And there are various measurements that can be used to determine whether something is subtly abnormal. But just generally speaking, those are really the three categories of brain MRI abnormalities you'll see. Dr Grouse:  That was a great review. And of course, I think in many times when we are thinking about or suspecting this diagnosis, we may be lucky to find those imaging findings to reinforce a diagnosis. Because as it turns out, after reading your article, I was really surprised to find out that in as many as 19% of cases we actually see normal brain imaging, which really was a surprise to me, I have to say. And I think that this really encompasses why spontaneous intercranial hypotension is such a difficult diagnosis to make. I think a lot of us struggle with how far to take the workup when, you know, spontaneous intercranial hypotension is clinically suspected, but multiple imaging studies are normal. Do you have any guidance on how to approach these more difficult cases? Dr Madhavan:  So, that's a really good question. And you know, it's- as you can imagine, that's a topic that comes up in most meetings where people discuss this, and it's been a continued challenge. And so, like you said, about 19 or 20% of patients who have this disease can have a, a normal brain MRI. And we've tried to do some work to figure out why that is and how we can identify patients who still have the disease. And I can just provide, I guess, some tips that have helped me in my clinical practice. One thing is, if I ever see a patient with a normal brain MRI where this disease is clinically suspected---for example, maybe they have orthostatic headaches or other very typical symptoms and we don't know why, but their brain MRI is normal---the first thing I do is I try to look back at their old imaging. So many times, these patients who present to us at Mayo, who, when we do their MRI scan here, their brain MRI looks normal… if you really look back at imaging that they've had done elsewhere---maybe even two to three years prior---at the time their symptoms started, they actually had some abnormalities. So, I might see that a patient, two years ago, had dural enhancement that spontaneously resolved; but now they still have symptoms of SIH and they may still have a CSF leak that we can find and treat, but their brain MRI has, for whatever reason, normalized. So, I always start by looking back at old imaging, and I found that to be very helpful. The other thing is, if you see a patient with a normal brain MRI, it's also important to look at their spine MRI because that can provide clues that might suggest that they could still have a spinal CSF leak. And the two things I look for on the spine MRI: one, if there's any extradural CSF. So, spinal fluid outside of where it's supposed to be within the confines of the subarachnoid space. And you know, really, if you see extradural CSF, you know they probably have a spinal fluid leak somewhere. Even if their brain MRI is normal, that just gives you the information that there is a dural tear probably somewhere. And so, in those patients we'll definitely still proceed to myelography or other testing, even if they have a normal brain MRI. And then the last thing I look for is whether or not they have prominent meningeal diverticula. Patients with CSF venous fistulas almost always have one or more prominent diverticula on their spine along the nerve root sleeves. And that's probably because most of these fistulas come from nerve root sleeve diverticula. We don't completely understand the pathogenesis of CSF venous fistulas, but they're clearly associated with meningeal diverticula. So, if I see a patient who has a normal brain MRI, but I see on their spine MRI that they have many meningeal diverticula that are relatively prominent, that makes me more inclined to be a little bit more aggressive in doing myelography to find a CSF leak. And then I look at other demographic features, too. So, for example, elevated BMI and older age are associated with CSF venous fistulas. So, that can help you determine whether or not it's warranted to go on to more advanced imaging, too. So those are all just a variety of different things that we've used to help us. Dr Grouse:  Thank you for sharing that. I wanted to go on to say that, you know, reading your article, of course, as you mentioned, you alluded to the fact there's lots of new imaging modalities out there. It was very illuminating and just an excellent resource for the options that exist and when they're useful. You did a great job summarizing it. And I encourage our readers to check out your article, to refresh themselves, update themselves on what's happened in this space. And of course, we can't summarize them all today, but I was wondering if you could possibly walk us through a hypothetical case of a patient who comes in with a history very suspicious for SIH? How would you approach this patient? Say you have gotten imaging that suggested that there is a spinal fluid leak and now you have to figure out where it is. Dr Madhavan:  Yeah. So, you know, I think the most typical scenario it'll be a patient who has been seen by one of my excellent neurology colleagues and they've done a brain MRI and they've made the diagnosis through a combination of clinical information and brain MRI finding. And then the next thing we'll do always is, we'll obtain a spine MRI. So, I think of the purpose of the spine MRI as to determine what type of spinal fluid leak they have. On the spine MRI, if you see extradural CSF, those patients essentially always will have a dural tear. And it may be a ventral dural tear or a lateral dural tear. But if you see extradural CSF, that is pretty much what they have. And conversely, if you don't see extradural CSF---if you just see, for example, many meningeal diverticula, but you don't see anything else particularly abnormal---most of those patients have a CSF venous fistula, just common things being common. So I use the spine MRI to determine what type of leak they have. And then the next thing I think about is, okay, I'm going to do a myelogram on this patient. How do I want to position them? Because it turns out that positioning is probably the most important factor for finding these spinal fluid leaks. You have to have the patient positioned correctly to find the leak that you're trying to localize. And so, if I suspect they have a ventral dural tear, I will always position those patients prone for their myelogram. And I might do one of many different types of myelograms. And, you know, the article talks about things like digital subtraction myelography and dynamic CT myelography. And you can find any of these leaks with any of those techniques, but you just have to have the patient positioned correctly. So, if I think I have a ventral dural tear, I'll put them prone for the myelogram. If I think they have a lateral dural tear, I'll put them in the cubitus position for the myelogram. And also, if they- if I think they have a CSF-venous fistula, I'll also put them in the decubitus position. Obviously if you're putting them in the decubitus position, you have to decide whether it's going to be left or right side down. So that may require a two-day exam. Sometimes you don't have to; in many cases, we're able to just do everything in one day. But those are all the different factors I think about when I'm trying to determine how I'm going to work those patients up further. So, I really use the spine MRI chiefly to think about what type of leak they're going to have and how I'm going to plan the myelogram. Dr Grouse:  That's really great. And it's, I think, really nice to emphasize how much the positioning matters in all this, which I think is not something we've been classically taught as far as the diagnosis of spinal leaks. Another thing I'm really interested in your opinion on is, you talked a lot about how to optimize and what can make you successful at diagnosis. I'm curious what you think one of the easiest mistakes to make or, you know, that we should hopefully avoid when treating patients with this disease. Dr Madhavan:  Yeah. And I think, you know, one other thing that's been discussed a lot in this topic… you know, we've talked about the patients with a normal brain MRI. Another barrier or challenge particularly with CSF-venous fistulas is, sometimes they can be very subtle on imaging. So, it's not always you see it very definitive CSF-venous fistula where you can say, like, there's no question, that's a fistula. There are many times where we do a good-quality myelogram and we see something that looks, like, possible for a CSF venous fistula, or probable. If I had to put a number on it, maybe there's a 50 to 70% chance of real. So, in those cases, we end up wondering, like, should we treat this suspected leak? And I think one common mistake  or one thing that needs to be looked at further is, how do we handle these patients where we don't know whether the fistula is real or not? That's usually something where I will have a discussion with the patient, and I'm usually just very upfront with him about my interpretation of the imaging. I'll just tell them, we did a good-quality myelogram. You did a great job. We got good images. I don't see anything definitive, but I see this thing that I think has maybe a 60% chance of being real. And then I'll confer with one of my neurology colleagues and we'll decide whether it's worth treating that or not. And we'll just be very upfront with a patient about whether- about the likelihood of its success and what their long-term prognosis is. And oftentimes we let them make the decision. But I think that remains to be one of the big challenges is, how do we treat these patients who have suspected leaks that are not definitive on imaging. Dr Grouse:  That sounds absolutely like an important area where there can be problems, so I appreciate that insight. I'm interested what you think in your article would come as the biggest surprise to our listeners who may not have kept up as much with all of the changes that have happened in recent years? Dr Madhavan:  One of the things that was certainly, at least, a surprise to me as I was going through my training and learning about this topic is how diverse myelography has really become. You know, when I was a radiology resident, I learned about myelography as this thing that we've been doing for 30 to 40 years. And historically we've used myelograms just to look for degenerative changes: disc bulges, you know, disc herniations and things like that. Now that MRI is more prevalent, we don't use it as much, but it has turned out that it has a very big role in patients with spinal fluid leaks. Furthermore, something that I've learned is just how diverse these different types of myelograms have become. It used to kind of be just that a myelogram is a myelogram is a myelogram, but now we have different types of positioning, different types of equipment that we use. We vary the timing between contrast injection and imaging to optimize success for finding spinal fluid leaks. So, I think many times I talk to people who may not be as familiar with this field and they're surprised at just how diverse that has become and how sophisticated some of the various myelographic techniques have become and how much that really makes a difference in being able to accurately diagnose these patients. Dr Grouse:  Well, I can say it was a surprise to me. Even as someone who does treat quite a few patients with this condition, I was surprised to see the breadth of different options that have become available. And then kind of a follow-up to that, what do you think the current area of controversy is in this area of diagnosis and treatment? Dr Madhavan:  The biggest ones are ones you've sort of already alluded to. So, one big one is, how far do we go in patients who have a normal brain MRI who still have a clinical suspicion of the disease? And sometimes it's really hard, because sometimes you will find patients who clinically have a very strong case for having spontaneous intracranial hypotension. You look at them, they have very acute-onset orthostatic headaches. There's no better explanation for their symptoms that we know of. And it's hard to know what to do with those patients, because some of them want to continue to undergo diagnostic workup, but you can only do so many myelograms and you can only do so much with this diagnostic workup that requires some radiation dose before it becomes very challenging. That's a major point of just, I guess, ongoing research as to what can we do better for that subset of patients. Fortunately, it's not all of them, it's a subset of them, but I think we could help those patients better in the future as we learn more about the disease. So that's one. And the other one is treating these equivocal findings, like I discussed.  And where should our threshold be to treat a patient, and what type of treatment should we do in patients where we don't know whether a leak is real? Should we just do a very noninvasive- relatively noninvasive blood patch? Do we do an embolization where we're leaving a foreign body there? Is it worth sending those patients to surgery? Those are all unanswered questions and things that continue to spark ongoing debate. Dr Grouse:  Do you think that there's going to be any new big breakthroughs, or even, do you know of any big developments on the horizon that we should be keeping our eyes out for? Dr Madhavan:  You know, I think for me the biggest thing is, imaging is dramatically improving. We talked a little bit about photon counting detector CT in our article, and that's one of the newest and best techniques for imaging these patients because it has very, very high resolution, it has a lower radiation dose, it has allowed us to find leaks that we were not able to find before. And there are other high-resolution modalities that are emerging and becoming more accessible to things like cone beam CT which we do in addition to digital subtraction myelography. And on top of that, we've started to use AI-based tools to make images look a lot better. So, there are various AI algorithms that have come out that allow us to remove artifacts from imaging. They help us image patients with a bigger body habitus better without running into a lot of imaging artifacts. They help us reduce noise in imaging. They can just give us better-quality images and aid us in the diagnosis. For me as a radiologist, those are some of the most exciting things. We're finding less invasive ways with less radiation to better diagnose these patients with just better-quality imaging. Dr Grouse:  Well, that is definitely something to be excited about. So, I just want to thank you so much for talking with us today. It's been such an interesting, informative discussion and a real privilege to talk with you about this important topic. Dr Madhavan:  Yeah, thanks so much. I really appreciate the time to talk with you, and I look forward to seeing the article out there and hopefully getting some interesting questions. Dr Grouse:  Again, today I've been interviewing Dr Ajay Madhavan about his article on Radiographic Evaluation of Spontaneous Intracranial Hypotension, which he wrote with Dr Levi Chasen. 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.

The MacVoices Live! panel took on the task of analyzing Apple's WWDC 2025 keynote, focusing on meaningful updates across iPadOS, Vision Pro, macOS, and iOS. Discussions included the new Liquid Glass interface, cross-platform consistency, and practical enhancements driven by Apple Intelligence. Panelists Chuck Joiner, David Ginsbug, Brittany Smith, Marty Jencius, Ben Roethig, Jeff Gamet, Eric Bolden, and Brian Flanigan-Arthurs debated the usefulness of iPad improvements, praised the Preview app's arrival on more devices, and examined accessibility implications. Before all that, the group paid tribute to Bill Atkinson, recognizing his pivotal role in Apple's legacy.  Today's MacVoices is supported by CleanMyMac by MacPaw, your ultimate solution for Mac control and care. Try CleanMyMac for 7 days free, then use the code “MacVoices20” for 20% off at CLNMY.com/MacVoices. Show Notes: Chapters: 00:08 Introduction to WWDC 2025 Keynote04:03 Remembering Bill Atkinson06:55 Keynote Highlights Begin09:55 iPad and Vision Pro Features13:07 Unified Interface Across Devices16:00 Apple Intelligence Discussion18:15 Preview App Recognition21:15 General Impressions of the Keynote25:30 Liquid Glass Interface Explained30:26 Accessibility Concerns with Liquid Glass Links: MacVoices #1019: MacVoices at Macworld – Bill Atkinson Shows Off His New PhotoCard iPhone App, and Comments on the iPadhttps://macvoices.com/macvoices-1019-macvoices-at-macworld-bill-atkinson-shows-off-his-new-photocard-iphone-app-and-comments-on-the-ipad/ MacVoices #1019: MacVoices at Macworld – Bill Atkinson Shows Off His New PhotoCard iPhone App, and Comments on the iPadhttps://www.youtube.com/watch?v=0_DjDdfqtUE Guests: Eric Bolden is into macOS, plants, sci-fi, food, and is a rural internet supporter. You can connect with him on Twitter, by email at embolden@mac.com, on Mastodon at @eabolden@techhub.social, on his blog, Trending At Work, and as co-host on The Vision ProFiles podcast. Brian Flanigan-Arthurs is an educator with a passion for providing results-driven, innovative learning strategies for all students, but particularly those who are at-risk. He is also a tech enthusiast who has a particular affinity for Apple since he first used the Apple IIGS as a student. You can contact Brian on twitter as @brian8944. He also recently opened a Mastodon account at @brian8944@mastodon.cloud. Jeff Gamet is a technology blogger, podcaster, author, and public speaker. Previously, he was The Mac Observer's Managing Editor, and the TextExpander Evangelist for Smile. He has presented at Macworld Expo, RSA Conference, several WordCamp events, along with many other conferences. You can find him on several podcasts such as The Mac Show, The Big Show, MacVoices, Mac OS Ken, This Week in iOS, and more. Jeff is easy to find on social media as @jgamet on Twitter and Instagram, jeffgamet on LinkedIn., @jgamet@mastodon.social on Mastodon, and on his YouTube Channel at YouTube.com/jgamet. David Ginsburg is the host of the weekly podcast In Touch With iOS where he discusses all things iOS, iPhone, iPad, Apple TV, Apple Watch, and related technologies. He is an IT professional supporting Mac, iOS and Windows users. Visit his YouTube channel at https://youtube.com/daveg65 and find and follow him on Twitter @daveg65 and on Mastodon at @daveg65@mastodon.cloud. Dr. Marty Jencius has been an Associate Professor of Counseling at Kent State University since 2000. He has over 120 publications in books, chapters, journal articles, and others, along with 200 podcasts related to counseling, counselor education, and faculty life. His technology interest led him to develop the counseling profession ‘firsts,' including listservs, a web-based peer-reviewed journal, The Journal of Technology in Counseling, teaching and conferencing in virtual worlds as the founder of Counselor Education in Second Life, and podcast founder/producer of CounselorAudioSource.net and ThePodTalk.net. Currently, he produces a podcast about counseling and life questions, the Circular Firing Squad, and digital video interviews with legacies capturing the history of the counseling field. This is also co-host of The Vision ProFiles podcast. Generally, Marty is chasing the newest tech trends, which explains his interest in A.I. for teaching, research, and productivity. Marty is an active presenter and past president of the NorthEast Ohio Apple Corp (NEOAC). Ben Roethig has been in the Apple Ecosystem since the System 7 Days. He is the a former Associate Editor with Geek Beat, Co-Founder of The Tech Hangout and Deconstruct and currently shares his thoughts on RoethigTech. Contact him on  Twitter and Mastodon. Brittany Smith is a trained cognitive neuroscientist who provides ADD/ADHD, technology, and productivity coaching through her business, Devise and Conquer, along with companion video courses for folks with ADHD. She's also the cofounder of The ADHD Guild, a community for nerdy folks with ADHD. She, herself, is a self-designated “well-rounded geek”. She can be found on Twitter as @addliberator, on Mastodon as @addliberator@pdx.social, and on YouTube with tech tips.   Support:      Become a MacVoices Patron on Patreon     http://patreon.com/macvoices      Enjoy this episode? Make a one-time donation with PayPal Connect:      Web:     http://macvoices.com      Twitter:     http://www.twitter.com/chuckjoiner     http://www.twitter.com/macvoices      Mastodon:     https://mastodon.cloud/@chuckjoiner      Facebook:     http://www.facebook.com/chuck.joiner      MacVoices Page on Facebook:     http://www.facebook.com/macvoices/      MacVoices Group on Facebook:     http://www.facebook.com/groups/macvoice      LinkedIn:     https://www.linkedin.com/in/chuckjoiner/      Instagram:     https://www.instagram.com/chuckjoiner/ Subscribe:      Audio in iTunes     Video in iTunes      Subscribe manually via iTunes or any podcatcher:      Audio: http://www.macvoices.com/rss/macvoicesrss      Video: http://www.macvoices.com/rss/macvoicesvideorss

The MacVoices Live! panel took on the task of analyzing Apple's WWDC 2025 keynote, focusing on meaningful updates across iPadOS, Vision Pro, macOS, and iOS. Discussions included the new Liquid Glass interface, cross-platform consistency, and practical enhancements driven by Apple Intelligence. Panelists Chuck Joiner, David Ginsbug, Brittany Smith, Marty Jencius, Ben Roethig, Jeff Gamet, Eric Bolden, and Brian Flanigan-Arthurs debated the usefulness of iPad improvements, praised the Preview app's arrival on more devices, and examined accessibility implications. Before all that, the group paid tribute to Bill Atkinson, recognizing his pivotal role in Apple's legacy.  Today's MacVoices is supported by CleanMyMac by MacPaw, your ultimate solution for Mac control and care. Try CleanMyMac for 7 days free, then use the code “MacVoices20” for 20% off at CLNMY.com/MacVoices. Show Notes: Chapters: 00:08 Introduction to WWDC 2025 Keynote 04:03 Remembering Bill Atkinson 06:55 Keynote Highlights Begin 09:55 iPad and Vision Pro Features 13:07 Unified Interface Across Devices 16:00 Apple Intelligence Discussion 18:15 Preview App Recognition 21:15 General Impressions of the Keynote 25:30 Liquid Glass Interface Explained 30:26 Accessibility Concerns with Liquid Glass Links: MacVoices #1019: MacVoices at Macworld – Bill Atkinson Shows Off His New PhotoCard iPhone App, and Comments on the iPad https://macvoices.com/macvoices-1019-macvoices-at-macworld-bill-atkinson-shows-off-his-new-photocard-iphone-app-and-comments-on-the-ipad/ MacVoices #1019: MacVoices at Macworld – Bill Atkinson Shows Off His New PhotoCard iPhone App, and Comments on the iPad https://www.youtube.com/watch?v=0_DjDdfqtUE Guests: Eric Bolden is into macOS, plants, sci-fi, food, and is a rural internet supporter. You can connect with him on Twitter, by email at embolden@mac.com, on Mastodon at @eabolden@techhub.social, on his blog, Trending At Work, and as co-host on The Vision ProFiles podcast. Brian Flanigan-Arthurs is an educator with a passion for providing results-driven, innovative learning strategies for all students, but particularly those who are at-risk. He is also a tech enthusiast who has a particular affinity for Apple since he first used the Apple IIGS as a student. You can contact Brian on twitter as @brian8944. He also recently opened a Mastodon account at @brian8944@mastodon.cloud. Jeff Gamet is a technology blogger, podcaster, author, and public speaker. Previously, he was The Mac Observer's Managing Editor, and the TextExpander Evangelist for Smile. He has presented at Macworld Expo, RSA Conference, several WordCamp events, along with many other conferences. You can find him on several podcasts such as The Mac Show, The Big Show, MacVoices, Mac OS Ken, This Week in iOS, and more. Jeff is easy to find on social media as @jgamet on Twitter and Instagram, jeffgamet on LinkedIn., @jgamet@mastodon.social on Mastodon, and on his YouTube Channel at YouTube.com/jgamet. David Ginsburg is the host of the weekly podcast In Touch With iOS where he discusses all things iOS, iPhone, iPad, Apple TV, Apple Watch, and related technologies. He is an IT professional supporting Mac, iOS and Windows users. Visit his YouTube channel at https://youtube.com/daveg65 and find and follow him on Twitter @daveg65 and on Mastodon at @daveg65@mastodon.cloud. Dr. Marty Jencius has been an Associate Professor of Counseling at Kent State University since 2000. He has over 120 publications in books, chapters, journal articles, and others, along with 200 podcasts related to counseling, counselor education, and faculty life. His technology interest led him to develop the counseling profession ‘firsts,' including listservs, a web-based peer-reviewed journal, The Journal of Technology in Counseling, teaching and conferencing in virtual worlds as the founder of Counselor Education in Second Life, and podcast founder/producer of CounselorAudioSource.net and ThePodTalk.net. Currently, he produces a podcast about counseling and life questions, the Circular Firing Squad, and digital video interviews with legacies capturing the history of the counseling field. This is also co-host of The Vision ProFiles podcast. Generally, Marty is chasing the newest tech trends, which explains his interest in A.I. for teaching, research, and productivity. Marty is an active presenter and past president of the NorthEast Ohio Apple Corp (NEOAC). Ben Roethig has been in the Apple Ecosystem since the System 7 Days. He is the a former Associate Editor with Geek Beat, Co-Founder of The Tech Hangout and Deconstruct and currently shares his thoughts on RoethigTech. Contact him on  Twitter and Mastodon. Brittany Smith is a trained cognitive neuroscientist who provides ADD/ADHD, technology, and productivity coaching through her business, Devise and Conquer, along with companion video courses for folks with ADHD. She's also the cofounder of The ADHD Guild, a community for nerdy folks with ADHD. She, herself, is a self-designated “well-rounded geek”. She can be found on Twitter as @addliberator, on Mastodon as @addliberator@pdx.social, and on YouTube with tech tips.   Support:      Become a MacVoices Patron on Patreon      http://patreon.com/macvoices      Enjoy this episode? Make a one-time donation with PayPal Connect:      Web:      http://macvoices.com      Twitter:      http://www.twitter.com/chuckjoiner      http://www.twitter.com/macvoices      Mastodon:      https://mastodon.cloud/@chuckjoiner      Facebook:      http://www.facebook.com/chuck.joiner      MacVoices Page on Facebook:      http://www.facebook.com/macvoices/      MacVoices Group on Facebook:      http://www.facebook.com/groups/macvoice      LinkedIn:      https://www.linkedin.com/in/chuckjoiner/      Instagram:      https://www.instagram.com/chuckjoiner/ Subscribe:      Audio in iTunes      Video in iTunes      Subscribe manually via iTunes or any podcatcher:      Audio: http://www.macvoices.com/rss/macvoicesrss      Video: http://www.macvoices.com/rss/macvoicesvideorss

Simon and Rachel speak to the journalist and author Ben Macintyre. Ben is the bestselling author of books including "A Spy Among Friends", "Agent Sonya", "Agent Zigzag", "Colditz", "Operation Mincemeat", "SAS: Rogue Heroes" and "The Spy and the Traitor". He is a columnist and Associate Editor at The Times, and has worked as the newspaper's correspondent in New York, Paris and Washington. Several of his books have been made into films and television series, including "Operation Mincemeat", "A Spy Among Friends" and "SAS: Rogue Heroes". We spoke to Ben about his work as a journalist for The Times, his long journey to becoming a successful non-fiction author, and his latest book, "The Siege", about the Iranian embassy hostage crisis - and subsequent special-forces raid - in London in 1980. We've made another update for those ⁠⁠⁠⁠⁠⁠⁠⁠⁠who support the podcast on the crowdfunding site Patreon⁠⁠⁠⁠⁠⁠⁠⁠⁠. We've added 40 pages of new material to the package of successful article pitches that goes to anyone who supports the show with $5 per month or more, including new pitches to the New York Times, the Washington Post and the BBC. The whole compendium now runs to a whopping 160 pages. For Patreons who contribute $10/month we're now also releasing bonus mini-episodes. Thanks to our sponsor, Scrivener, the first ten new signs-ups at $10/month will receive a lifelong license to Scrivener worth £55/$59.99 (eight are left). This specialist word-processing software helps you organise long writing projects such as novels, academic papers and even scripts. Other Patreon rewards include signed copies of the podcast book and the opportunity to take part in a monthly call with Simon and Rachel.A new edition of “Always Take Notes: Advice From Some Of The World's Greatest Writers” - a book drawing on our podcast interviews - is available now. The updated version now includes insights from over 100 past guests on the podcast, with new contributions from Harlan Coben, Victoria Hislop, Lee Child, Megan Nolan, Jhumpa Lahiri, Philippa Gregory, Jo Nesbø, Paul Theroux, Hisham Matar and Bettany Hughes. You can order it via ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Amazon⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ or ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Waterstones⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠.You can find us online at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠alwaystakenotes.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠, on Twitter @takenotesalways and on Instagram @alwaystakenotes. Always Take Notes is presented by Simon Akam and Rachel Lloyd, and produced by Artemis Irvine. Our music is by Jessica Dannheisser and our logo was designed by James Edgar.

Join Elevated GP: www.theelevatedgp.com Follow @dental_digest_podcast Instagram Follow @dr.melissa_seibert on Instagram Dr. Markus B. Blatz is Professor of Restorative Dentistry, Chairman of the Department of Preventive and Restorative Sciences and Assistant Dean for Digital Innovation and Professional Development at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, where he also founded the Penn Dental Medicine CAD/CAM Ceramic Center, an interdisciplinary venture to study emerging technologies and new ceramic materials while providing state-of-the-art esthetic clinical care. Dr. Blatz graduated from Albert-Ludwigs University in Freiburg, Germany, and was awarded additional Doctorate Degrees, a Postgraduate Certificate in Prosthodontics, and a Professorship from the same University. Dr. Blatz is co-founder and past President of the International Academy for Adhesive Dentistry (IAAD) and a founding member of the European Academy of Digital Dentistry (EADD). He is a board-certified Diplomat in the German Society for Prosthodontics and Biomaterials (DGPro) and a member of multiple other professional organizations, including the American Academy of Esthetic Dentistry, the European Academy of Esthetic Dentistry, the International College of Prosthodontists, the American College of Prosthodontists (honorary member), Academy of Osseointegration, and O.K.U. Honor Dental Society. He is the Editor-in-Chief of Compendium of Continuing Education in Dentistry, Associate Editor of the Journal of Esthetic and Restorative Dentistry and of Quintessence International, Section Editor for the International Journal of Prosthodontics, and serves on the editorial boards of numerous other recognized scientific dental journals. He is coauthor of the international bestseller “evolution – contemporary protocols for anterior single-tooth implants”, which has been translated on over 8 languages. Prior to joining Penn Dental Medicine as Chairperson of the Department of Preventive and Restorative Sciences in September 2006, Dr. Blatz was at Louisiana State University (LSU) Health Sciences Center School of Dentistry in New Orleans, where he served as Chairman of the Department of Comprehensive Dentistry and Biomaterials and Assistant Dean for Clinical Research. During his tenure at LSU, Dr. Blatz also directed the Masters of Science in Oral Biology Program and was a senior faculty member in the Department of Prosthodontics. From 1994 to 1998 he was an Assistant Professor and from 1998 to 1999 a senior faculty member in the Department of Prosthodontics at Albert Ludwigs University Freiburg School of Dentistry in Freiburg, Germany. A widely published and internationally respected lecturer, Dr. Blatz's main focus within clinical practice and research is esthetic dentistry with an emphasis on implantology and dental materials, particularly ceramics and adhesion. Dr. Blatz is the recipient of multiple teaching and research awards and has published and lectured extensively on dental esthetics, restorative materials, and implant dentistry. He was recently named one of the “World's Top 100 Doctors in Dentistry”.

The first of many rescission packages has found its way to Congress. The debate starts at its efficacy first, and to the chance of it being passed, second. Also in this episode: David Strom, Associate Editor of HotAir, joins to discuss the mental health ratings of conservatives versus liberals and much more. White House Sends Congress $9.4 Billion Rescissions Package https://dailycaller.com/2025/06/03/white-house-sends-congress-rescissions-package-trump-npr-pbs/ Trump's Justice Department examining pardons issued by Biden https://www.reuters.com/world/us/trumps-justice-department-examining-pardons-issued-by-biden-2025-06-02/ Murder Rates Plummet Under President Trump https://www.dailysignal.com/2025/06/03/murder-rates-plummet-under-president-trump/ Learn more about your ad choices. Visit podcastchoices.com/adchoices

It’s time for a rebroadcast of a wonderful interview with my old friend, Dr. Casey Means, where she talked about the launch of her book, Good Energy. It has been a year since we talked on the eve of her book launch, which was just about to go number one and become a New York Times bestseller, and in other news, Dr. Casey has just been appointed to become the Surgeon General of the United States of America. Amazing news, a bit controversial these days since everything in politics is controversial, but long time listeners know that I steer completely clear of politics on this show, however I did want to give a plug for Dr. Casey and encourage you to listen to this interview if you didn't hear it the first time around, as she now rises to the highest position in America for doctors. In this episode, you will learn all about Dr. Casey Means’ book Good Energy: The Surprising Connection Between Metabolism and Limitless Health, which she wrote with her brother, Calley Means, and hear her talk about the broken medical industrial complex—a subject that is of deep significance for her since (as she talked about in her first appearance on the show) she used to be a dutiful doctor, a highly trained throat surgeon who was just trying to do her best, until she realized how dysfunctional the whole system was. She had a realization: no one was really getting better. They were, however, coming in for more surgery, and this sparked her decision to pursue a career in the alternative health world instead, an issue that only became more important and personal to her after she experienced the deep pain and frustration of watching her mother die of a preventable disease. This is a great episode to listen to if you want to learn about all the nuances of our profit-driven medical system, the science and details of how mitochondrial function essentially represents the essence of our health, why mitochondrial dysfunction represents the whole cause of all disease, the scary statistic about Americans and metabolic syndrome risk factors that shocked me, and more! Casey Means, MD, Surgeon General of the United States of America, is a Stanford-trained physician, the Chief Medical Officer and Co-founder of metabolic health company Levels, and Associate Editor of the International Journal of Disease Reversal and Prevention. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech-enabled tools that can inform smart, personalized, and sustainable dietary and lifestyle choices. Check out her website and visit CaseyMeans.com/goodenergy to read her best-selling book, Good Energy. TIMESTAMPS: Sixty-eight percent of Americans are classified as metabolically unhealthy. [03:08] It's a totally unstainable path that we are on as a country. [09:04] After becoming a head and neck surgeon, Dr. Means realized that she was not improving people's health. She wanted to focus on prevention. [12:00] Cancer is a metabolic dysfunction. We are focusing on the wrong problem. [14:41] The health care industry is fast growing and it makes more money when you are sick than when you are well. [20:02] Everything in moderation is a very bad way to look at diet. [29:48] There is such a thing as bad food. [35:19] You need to understand your own body and read the signals your body sends to you. [36:23] We have normalized not feeling well, that we don't notice it. [41:55] When we eat processed foods, they are not benign. It's more than just calories. [46:53] The ingredients in the processed foods trigger your desire to overeat. The bigger the glucose spike, the bigger the crash [53:54] High fructose corn syrup is in so many foods and is very problematic. [58:39] There are five foods that you want to include to support your mitochondrial function. [01:01:36] In a few months, if you follow those suggestions, your markers on your blood tests will show a huge difference if you were pre-diabetic. [01:09:24] Why isn't the medical system focused more on prevention? [01:15:03] LINKS: Brad Kearns.com BradNutrition.com B.rad Whey Protein Superfuel - The Best Protein on The Planet! Brad’s Shopping Page BornToWalkBook.com B.rad Podcast – All Episodes Peluva Five-Toe Minimalist Shoes Good Energy Outlive Body by Science Podcast with Dr. Casey Means Casey Means Instagram Casey Means.com/GoodEnergy. Dr. Casey's Kitchen We appreciate all feedback, and questions for Q&A shows, emailed to podcast@bradventures.com. If you have a moment, please share an episode you like with a quick text message, or leave a review on your podcast app. Thank you! Check out each of these companies because they are absolutely awesome or they wouldn’t occupy this revered space. Seriously, I won’t promote anything that I don't absolutely love and use in daily life: B.rad Nutrition: Premium quality, all-natural supplements for peak performance, recovery, and longevity; including the world's highest quality whey protein! Peluva: Comfortable, functional, stylish five-toe minimalist shoe to reawaken optimal foot function. Use code BRADPODCAST for 15% off! Ketone-IQ Save 30% off your first subscription order & receive a free six-pack of Ketone-IQ! Get Stride: Advanced DNA, methylation profile, microbiome & blood at-home testing. Hit your stride the right way, with cutting-edge technology and customized programming. Save 10% with the code BRAD. 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From September 26, 2023: On August 21, the Human Rights Watch released a report detailing systematic abuses of Ethiopian migrants and asylum seekers at the Saudi Arabia-Yemen border. Researchers interviewed dozens of Ethiopian migrants and asylum seekers and found that Saudi border guards had used explosive weapons on them and shot migrants at close range.Lawfare's Associate Editor of Communications Anna Hickey sat down with Joey Shea, a researcher in the Middle East and North Africa Division of Human Rights Watch who investigates human rights abuses in Saudi Arabia and the United Arab Emirates. They discussed the Human Rights Watch recent report, how the international community has responded so far, and the human rights record of Prince Mohammed bin Salman since he ascended the throne in 2015. To receive ad-free podcasts, become a Lawfare Material Supporter at www.patreon.com/lawfare. You can also support Lawfare by making a one-time donation at https://givebutter.com/lawfare-institute.Support this show http://supporter.acast.com/lawfare. Hosted on Acast. See acast.com/privacy for more information.