Podcasts about Continuum

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/WZY865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Scaling New Heights in Gastric/GEJ Cancer: Aligning the Evidence on Targeted and Immunotherapeutic Approaches Across the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and Hope For Stomach Cancer. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent medical education grants from AstraZeneca, BeOne Medicines, and Jazz Pharmaceuticals.Disclosure information is available at the beginning of the video presentation.

This podcast was created using NotebookLM.This podcast advocates for a life course perspective in dentistry, viewing oral health as a single continuous arc rather than a series of disconnected stages. 

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/WZY865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Scaling New Heights in Gastric/GEJ Cancer: Aligning the Evidence on Targeted and Immunotherapeutic Approaches Across the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and Hope For Stomach Cancer. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent medical education grants from AstraZeneca, BeOne Medicines, and Jazz Pharmaceuticals.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/WZY865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Scaling New Heights in Gastric/GEJ Cancer: Aligning the Evidence on Targeted and Immunotherapeutic Approaches Across the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and Hope For Stomach Cancer. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent medical education grants from AstraZeneca, BeOne Medicines, and Jazz Pharmaceuticals.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/WZY865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Scaling New Heights in Gastric/GEJ Cancer: Aligning the Evidence on Targeted and Immunotherapeutic Approaches Across the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and Hope For Stomach Cancer. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent medical education grants from AstraZeneca, BeOne Medicines, and Jazz Pharmaceuticals.Disclosure information is available at the beginning of the video presentation.

Faith deconstruction has become one of the defining conversations in modern Christianity—but what does it actually mean to deconstruct your faith? In this episode of The Biblical Mind Podcast, Dru Johnson sits down with pastor, YouTuber, and book reviewer Joel Wentz to explore why so many Christians are questioning their beliefs and how those questions can lead to deeper spiritual maturity rather than cynicism.Drawing from his own experience growing up in evangelical Christianity, Joel shares how wrestling with doctrines like hell, eschatology, and biblical interpretation led him through a season of deconstruction before discovering a richer understanding of historic Christian faith. Together, Dru and Joel discuss the difference between sincere faith exploration and tearing down beliefs for their own sake, the role of church culture and church hurt, why asking difficult questions is deeply biblical, and how the Nicene Creed and church history provide stability amid uncertainty.The conversation also explores theological humility, the importance of Christian tradition, the dangers of intellectual arrogance, and how pastors, churches, and Christian communities can create safe spaces for honest questions without abandoning biblical orthodoxy.Whether you're personally deconstructing your faith, walking alongside someone who is, or simply want to understand one of today's most important conversations in Christianity, this episode offers thoughtful, compassionate, and biblically grounded wisdom.Visit Joel's youtube channel (Click Here), or his Patreon (Click Here)Contact us at The Biblical Mind: Click HereWe are listener supported. Give to the cause here:https://thebiblicalmind.org/give/For more articles:https://thebiblicalmind.org/Social Links:Facebook: https://www.facebook.com/HebraicThoughtInstagram: https://www.instagram.com/hebraicthoughtThreads: https://www.threads.net/hebraicthoughtX: https://www.twitter.com/HebraicThoughtBluesky: https://bsky.app/profile/hebraicthought.orgChapters:00:00 Introduction to Deconstruction and Faith04:56 Different Understandings of Deconstruction06:03 Interrogating Inherited Beliefs Without Negativity08:16 Biblical Questions and Cultural Fears09:39 The Skeptical Mood of Scripture10:53 Questioning in the Bible: Examples from Scripture12:26 Personal Stories of Faith and Questioning16:30 Deconstruction of Eschatology and Hope19:11 The Compelling Vision of the Renewed Earth21:24 The Impact of Eschatology on Personal Hope23:42 Starting the YouTube Journey During COVID25:03 Sharing Faith and Books Online27:24 Encouraging Questions and Faith in Community28:51 Balancing Questions and Faithful Answers30:38 The Dangers of Going to Foundations Without Humility31:48 The Role of Sincerity and Humility in Deconstruction33:10 The Pool Analogy: Standing in the Water34:41 Rich Christian Thought on Deconstruction Questions36:24 Historical Answers to Faith Questions38:31 Healing Through Confession and Love40:30 Trust and Gentle Care in Discipleship42:00 The Continuum of Beliefs and Non-negotiables44:32 The Nicene Creed and Core Doctrines45:58 Evolving Views on Doctrine of Hell49:00 The Journey from Open Theism to Classical Theism52:31 The Impact of Doctrine on Prayer and Spiritual Life55:09 The Richness of Christian Thought and TraditionSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Intracerebral hemorrhage carries high morbidity and mortality, but growing evidence highlights meaningful opportunities for prevention, risk reduction, and long-term recovery. This episode covers key strategies, including blood pressure management, interpretation of neuroimaging markers, and individualized decisions around antithrombotic therapy. It also emphasizes the prolonged recovery timeline and the importance of a holistic, patient-centered approach to improving outcomes. In this episode, Casey S. Albin, MD, FAAN, speaks with Wendy C. Ziai, MD, and Vishank A. Shah, MD, coauthors of the article "Intracerebral Hemorrhage" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Ziai is a professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Shah is an assistant professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Intracerebral Hemorrhage Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Guest: @VishankShah3 Full episode transcript available here Dr Albin: A patient has suffered an intracerebral hemorrhage. They're taken to the neuro ICU, and they fortunately survive. But the journey does not end there. In fact, in some ways, the journey has just begun. Join us today as we unpack holistic care for ICH patients.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Albin: Hello to our audience. This is Dr. Casey Albin. Today, I'm interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I am so delighted that both of you are joining. To begin, let's just do a brief introduction of who you are and, and a little bit of how you got interested in the topic.  Dr Ziai: Hi, I'm Wendy Ziai. Thank you for having me on this podcast. I am a professor of neurology at Johns Hopkins. I am a neurointensivist, and I think I got primarily interested in this topic through clinical trials that I have been a part of since my fellowship days.  Dr Shah: Hi, everyone. I'm, uh, Vishank Shah. I am also, uh, very thankful for being invited to be a part of this podcast. I'm also a neurointensivist at Hopkins and the fellowship program director here for neurocritical care, and I'm interested in recovery after ICH, and that's why I'm a part of this work.  Dr Albin: Welcome to you both. It is such a treat for me to get to interview fellow neurointensivist, particularly those who have such a wealth of experience. So, I am delighted to dive into this. All right. So, to set the stage for our audience, intracerebral hemorrhage has long been approached with pessimism. But your article really highlights that there are meaningful advantages in prevention and risk stratification and long-term recovery for these patients. Though you both are neurointensivist, this article really emphasizes primary prevention and the holistic long-term care for the survivors. And so, to begin, Dr. Shah, can you just lay out a little bit for our listeners the scope of intracerebral hemorrhage and its community impact?  Dr Shah: Yeah. So, you know, ICH is the second most common type of stroke. There are more than three million new cases of ICH globally each year, and it accounts for thirty percent of all stroke types, but it is the one that has the highest mortality, with more than forty to fifty percent of the patients dying in the first thirty days, and then continued long-term impact on both functional as well as outcomes, as well as survivorship after the early period. And it also disproportionately impacts lower socioeconomic, and then minority races like Blacks, Asians, as well as Hispanic ethnicity. And so, there's a lot of work that needs to be done to reduce the burden of this disease.  Dr Albin: Absolutely. I mean, these can really be devastating for families, and I really am appreciative of your highlighting that there's a lot of disparities, and there's a lot of work to be done to really increase equity to these patients. I think a lot of this goes into really the AAN's focus on brain health and trying to improve some of what we're doing to maintain brain health. And I really wanted to kind of drill down on this because for ICH, there's a lot that can be done upfront as we think about how do we counsel patients who may walk into the office about strategies to prevent ever becoming an intracerebral hemorrhage patient. So, Dr. Shah, can you walk us through a little bit about what neurologists in the community need to be doing to make sure that no one ends up with us in the neurointensive care unit?  Dr Shah: Yeah, sure. So, I think, you know, one of the most important risk factors is, of course, hypertension and long-standing uncontrolled hypertension. And so really recognizing the need for early onset screening with regular blood pressure monitoring at a very early age, particularly in the races that I discussed earlier. And then I think another big part, obesity, metabolic syndrome, and type two diabetes. And I think there's a lot of interesting new work that with the GLP-1 agonist, you know, in a large multicenter cohort studies showing that patients receiving these had a significantly lower reduction risk of ICH. And so, this might be a really important part that, you know, clinicians need to start increasingly recognizing and using in their practice. And then, of course, other risk factors that are common include smoking, diet high in sodium, exposure to air pollution, both indoor as well as outdoor. And so, mitigating all of these risk factors can also reduce the burden of ICH.  Dr Albin: Absolutely. And I really want to highlight that hypertension plays such an important role and that we as neurointensivist, as community neurologists, really need to be creative about ways that we can help people meet those blood pressure target and meeting people in the community where they are, making sure that they're not suffering from side effects from their medication that would prevent them from sticking with it long term. Dr. Ziai, anything else to add about what we can do in the community?  Dr Ziai: So, we really want to emphasize, even in the acute phase, that patients moving forward need to have targeted interventions to reduce blood pressure, smoking, enhance their physical activity, have a diet that is high in fruits and vegetables and low in alcohol and salt, and then promoting weight loss, of course.  Dr Albin: And Dr. Ziai, I'm gonna ask you a little bit about one of the things that maybe not all of our listeners have heard about is this APOE2, APOE4 genetic risk for intracerebral hemorrhage. What's going on there and, and should clinicians be testing for that? Dr Ziai: That's a great question, and it is not one that we currently test people for at least acute ICH presentation. APOE2 and A4- E4 alleles, these give patients a two to three times higher risk of ICH by increasing cerebral amyloid deposition. And if you happen to have APOE2 carrier ship status, then along with other risk factors like white matter disease and vascular risk factors, these predict the onset of new microbleeds even during very short follow-up periods of about two years. And as we know, having cerebral microbleeds are associated with an increased risk of all strokes, ischemic and ICH, but they are one of many MRI markers of small vessel disease, which along with cortical superficial siderosis, does significantly increase future ICH risk. And so even in people who've never had an ICH, if they happen to have an MRI, it may be reasonable to look at the MRI and incorporate this burden of small vessel disease, and especially these hemorrhagic markers into, uh, decision-making about interventions.  Dr Albin: That's a really excellent point. And so, I think that your article did a really beautiful job of thinking holistically about the patient, incorporating clinical markers of their risk for having ICH, but also those radiographic markers. I'm just gonna ask you to summarize those again one more time because not everyone will be familiar with these. So, when you're looking at an MRI, what are the things that you're particularly clued in on that would increase the patient's risk of future ICH?  Dr Ziai: In the past, what we're looking for really is markers of cerebral amyloid angiopathy, which significantly increase a person's risk for lobar hemorrhage in particular. And so, we have a set of criteria called the Boston Criteria, and there's a new version of these, version 2.0. And these, um, incorporate a number of imaging markers that provide a very high sensitivity and specificity to diagnose CAA after an ICH. But even if someone's never had an ICH, and they evaluate that risk-benefit ratio for different cardiovascular prevention strategies. And so, the markers that we're specifically interested in are, of course, microbleeds. But not just having microbleeds, but are they lobar or are they deep? Lobar having a higher risk for lobar ICH. How many microbleeds are there? Is it greater than five, or is it just one or two? Also, cortical superficial siderosis is a marker, a hemorrhagic marker, that does portend a significant increased risk of recurrent ICH, along with having a lobar ICH. And now we have these new markers, which are the white matter hyperintensity multi spot pattern, which requires these hyperintensities on flare imaging in the subcortical area, having greater than at least ten of these multi spots, and also having enlarged perivascular spaces in the centrum semiovale, and having at least twenty of those. And finally, white matter hyperintensities, which can be measured with the physica score or just by visualizing them. We can look at white matter hyperintensities as well as being a measure of small vessel disease.  Dr Albin: Got it. And so just to summarize, we're looking for small vessel disease markers because that puts our patients at higher risk of ongoing future bleeds. And then we're also looking for markers of particularly small vessel disease that's caused by cerebral amyloid angiopathy, which again, because it's having that protein deposition, that puts the patient at risk of those leptomeningeal very small vessels, putting the patient at risk of lobar ICH. Just confirming I've summarized this all correctly.  Dr Ziai: Yes. That was perfect.  Dr Albin: Amazing. Dr. Shah, I'm gonna go back to you. Let's say we have a patient. Let's say this is a sixty-five-year-old man who comes in and they want follow-up and they're... And you're trying to think about they've had an ICH in the past, and they are also at risk for ischemic disease. Let's say they, they have hypertension, they've had a smoking history. They have some risk for ischemic events. And you're trying to think about how do you balance those. Let's say the patient needs to be on aspirin but does have some of those high-risk features on their MRI. Is there any guidance on how we think through preventing them from having a recurrent bleed if they're a high-risk patient, also preventing them from having an ischemic event, which they might be at high risk for as well?  Dr Shah: Yes. So, I think, you know, the first step is of course trying to understand what was the type of bleed. I think that has a very important role, like you mentioned. If it's a lobar hemorrhage versus a deep hemorrhage, the risk of recurrent ICH and ischemic events is very variable. So lobar hemorrhages, there's obviously a higher risk of recurrent hemorrhage events, whereas deep hemorrhage is actually at or behaves sort of like small vessel ischemic strokes and have a higher risk of recurrent arterial ischemic events. So that distinction in itself can help you gauge which patients would be safe and would benefit from these therapies. To begin, and of course, looking for some of these markers on MRI that were mentioned by Dr. Ziai for recurrence of hemorrhage risk. In terms of antiplatelet, the, there is a lot more data now to guide treatment, and we have the RESTART as well as the ESTART trial that showed that starting an, a single antiplatelet after intracerebral hemorrhage did not increase the risk of hemorrhage recurrence. They were very variable in the timing when aspirin was started, and so that remains still a question about what is the safest time point to start aspirin. For example, in the ESTART trial, they started them very early, within the first three days, whereas in  the RESTART it was all the way up to two months after the hemorrhage. And so... But in general, the risk of recurrent ICH was very low with a single antiplatelet agent. And so, if it's needed for ischemic prevention, it's relatively safe broadly across all types of hemorrhages.  Dr Ziai: Yeah. I would just mention that there was also a subgroup analysis of the RESTART trial using MRI. And so, this more than likely included patients with CAA, since 40% of the hemorrhages were lobar in that study, and therefore seeing that there was no increased risk of recurrent ICH in RESTART, it is thought that putting patients back on their antiplatelet therapy is safe.  Dr Albin: That's a really huge takeaway pearl for our listeners, that regardless of whether it's a lobar bleed or a deep bleed, if there is a strong indication, you know, this is not just, oh, because someone gave them aspirin 81, but truly that there is a reason that they need to be on a single antiplatelet agent, it probably benefits them to be on that agent, and there's good data that there's not a huge increase in risk. Summarizing all of that?  Dr Ziai: Great.  Dr Albin: Now, things are gonna get a little bit tricky here, because what if the patient, what if they need to be on dual antiplatelet therapy? Or what if they need to be on anticoagulation? Dr. Ziai, I'll, I'll throw that to you. How do you tackle that patient population?  Dr Ziai: Yeah, the safety of dual antiplatelet therapy hasn't really been studied in patients who've had a prior ICH. Although, in people who've had previous strokes, putting them on dual antiplatelets doesn't seem to increase the risk of ICH, but it does increase extracranial hemorrhage. And so there may be other reasons not to put patients on dual antiplatelet agents. Patients who have cancer and also cardiovascular or cerebrovascular disease, putting them on dual antiplatelet therapy does seem to increase the risk for intracranial hemorrhage. So, I think there is enough of a bias against DAPT therapy in patients who have had an ICH that we would not recommend DAPT for patients with a prior ICH.  Dr Albin: Absolutely. And, and then what about, let's say they have atrial fibrillation, and you know that they have a high CHA2DS2-VASc score, and they are at very high risk of ischemic events, but they've also had a prior intracerebral hemorrhage. Walk us through a little bit, how should we approach that patient? Dr. Ziai, I'm gonna start with you again.  Dr Ziai: Sure. So again, looking at the MRI, which all patients with ICH should have nowadays. If patients do have these hemorrhagic findings, a lobar ICH, evidence of CSS, cortical superficial siderosis, especially if it's disseminated, and also lobar microbleeds, especially if there are greater than five, if they're multiple, then anticoagulation should really be avoided in those patients.  Dr Albin: Absolutely. So, I'm really hearing that when we have a patient with ICH, it is just critically important that we understand is this a hypertensive bleed or is this a lobar bleed that is probably related to cerebral amyloid angiopathy? And getting to that distinction is going to play a major role in our deciding whether or not the patient can be on DAPT or can be on anticoagulation. And then what are some of the strategies for patients that you're referring them to if they really cannot tolerate being on anticoagulation, but they have atrial fibrillation, and they do need some sort of ischemic stroke prevention?  Dr Shah: There's still a lot of controversy, even in non-lobar hemorrhages, about resuming anticoagulation and when that would be safe. HAF trial, there was a reduction in ischemic stroke recurrence, uh, but a significantly higher increase in hemorrhage recurrences. I think that trial included both deep and lobar hemorrhages. So, we still need more data, and I think the ASPIRE trial and maybe a meta-analysis would answer that eventually. But in the meantime, if a, specifically for lobar hemorrhages, which are, uh, thought to be CAA related, if they, uh, and the patient has AFib, you know, where anticoagulation would be contraindicated, a watchman device or, you know, AFib ablation may be some of the other strategies that can be looked into for those patients specifically.  Dr Albin: Right. I think that's a really important point to emphasize, that we don't just don't give up and say, "Oh, you're not a candidate for anticoagulation," but we really reach out to our cardiovascular friends and say, "Hey, what other procedures can you offer that will minimize the risk of recurrence?" You know, we don't want them to have an ischemic event, but we also know long-term that there would be a real risk of anticoagulation. Just reminder to our listeners that there are new procedures, and our cardiology colleagues are always doing new trials and new devices, and so we should really leverage their expertise here. I am in the final minutes gonna just switch gears a little bit from talking about sort of the nitty-gritty of secondary ischemic prevention and secondary hemorrhagic stroke prevention and thinking about there has been this degree of pessimism around ICH patients, and that, you know, they have a much more severe outcome than our patients with ischemic strokes. I think that that is probably a myth that we need to do some debunking around, and I think maybe we need to reframe in terms of thinking about just the trajectory. So, Dr. Shah, walk us through a little bit about what we can expect about the recovery trajectory in ICH compared to those patients who have an ischemic stroke. Dr Shah: Yes. From some newer data and studies, it is becoming clear that recovery after ICH is much slower than we expect. In general, for ischemic stroke, recovery is measured within the first few weeks to up to 90 days. But in ICH, we now know that patients can keep recovering all the way up to six months and even beyond. In general, from just a, a study of heart recovery that occurs after ischemic stroke, there's a steep recovery in the first seven days, and then sort of after that, patients still continue to recover, but it, it starts plateauing where up to 90 days. Whereas with ICH, there is not much recovery in the first 7 to 30 days, but after that, there is a recovery that occurs significantly between day 30 and day 180, and then some patients continue to recover all the way up to one year. The more severe the hemorrhage, the slower the recovery, but there's still some evidence to suggest that even severe hemorrhage patients can recover all the way up to one year out and beyond. This is, of course, in terms of functional recovery.  Dr Albin: I think that's a really important point for our audience. Many of the listeners are residents, they're fellows, they're seeing these patients in the hospital, and they may not see a whole lot of improvement over even 30 days. But to keep in mind that just because the patient has not had a dramatic recovery within that first month that they may be in the ICU and then on the floor does not mean that that patient will never have recovery, and that we reset our expectations that recovery is possible, it's just gonna be slower. And I think that that's not only important for the healthcare team to take in mind, but also for patients and their families to know there is hope here. It's just gonna be slower. Dr. Ziai, looking ahead, what developments in this are you most excited about that you think will move the needle for care for the long-term outcomes and the prevention for these patients? What's ahead in, in ICH?  Dr Ziai: Yeah, I think the research that's going on is very exciting at the moment. We just saw the presentation at the World Stroke Organization conference in the fall of the TRIDENT trial, Triple therapy prevention of Recurrent intracerebral Disease events, meaning strokes. And these investigators found that a single pill, a fixed dose of three blood pressure-lowering agents actually was successful in significantly reducing the risk of recurrent stroke in patients who have had a history of ICH and have just normal or low-grade hypertension. So rather than having patients on multiple antihypertensive agents, it may be possible to have them on a single pill, and may dramatically reduce their stroke risk. So that's exciting. There is also a trial ongoing, ASPIRING, testing whether antiplatelet monotherapy after 24 hours only can reduce the risk of all serious vascular events in ICH survivors. So very early antiplatelets. The SATURN trial, we didn't talk about statins yet, but it is comparing continuation versus discontinuation of statin therapy in ICH patients. And then we have ongoing epidemiological studies that are really needed to understand this interaction between the cardiovascular prevention strategies, the antithrombotic use, the blood pressure targets, and these high-risk neuroimaging markers for ICH. And I think that's gonna be key, personalizing the interventions for these patients.  Dr Albin: So, I love that. And what I'm hearing is that it's really important to think about the personalized approach as well as how do we simplify things. We know that blood pressure control is critically important to the primary and secondary prevention of ICH, but we have to make it easy for patients to do so. Dr. Shah, I want to end with kind of understanding, you know, this was an unusual topic for neurointensivists to talk about. This was really about prevention. It was about long-term survivorship. It was about not what's happening in the neuro ICU. How did you guys get interested in sort of that aspect of care?  Dr Shah: Yeah, so that's a great question. Dr. Ziai has been my mentor since I was in fellowship, so now about eight years that I've been working with her, and this was a project that I started in fellowship with under her mentorship, looking at long-term recovery in ICH patients, and specifically severe patients. Happy that work has received a lot of recognition. It was published in JAMA Neurology. We looked at patients with severe intracerebral and intraventricular hemorrhage, those that survived with an mRS of four and five at day 30, and what happened to them over the course of the year. There was really not much data on recovery after ICH. And we were very surprised to see that up to 40% of patients that were an mRS of four and five, so really, really severely disabled at day 30, recovered to an mRS of zero to three by one year. About one-third of that group that recovered actually achieved functional independence with an mRS of zero to two, which was very surprising, really breaking the myths around the pessimism with ICH. We found that a lot of the baseline comorbidities like diabetes, white matter disease, as well as what happens to them during the acute hospitalization, were adding all of that information to the severity of the hemorrhage significantly improved our ability to predict long-term recovery after ICH. And so that's kind of how we got interested in this work, looking at how factors in the care that we provide in the ICU, as well as what the patients come in with, how all of that could be modified to promote recovery in these patients that are often been forgotten.  Dr Albin: I think that there's one takeaway to our listeners is that this is really a place where there's a lot of hope for recovery, and that the nihilism that has really surrounded ICH is a thing of the past, and we have to move forward with thinking about how do we proactively impact the recovery and counsel the patients and give them hope. Because just as your research shows, there really is the ability that they can attain that functional independence, which is absolutely astounding. It's really amazing. Again, today I've been interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. Please go and check out. They have a wonderful article with lots of tables and figures, so much data. And again, thank you to our listeners for joining us today. Thank you, Dr. Ziai and Dr. Shah.  Dr Ziai: Thanks very much.  Dr Shah: 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.

Start Artist Song Time Album Year NEW ALBUMS 0:01:24 Kashgar Dam Mast Qalandar 5:26 Dam Mast Qalandar 2026 0:06:50 If These Trees Could Talk Sea of Glass 5:19 The Hidden Hand 2026 0:13:10 Phideaux Siren In The Storm 3:54 Automoto Animus 2026 0:17:04 Jane Getter Premonition Still Dreaming 4:46 Transmogrify 2026 0:21:50 Ed O’Brien Blue Morpho 6:00 Blue Morpho 2026 FEATURED ARTIST 0:28:32 Android Superstation Archetype 6:20 Continuum 2026 0:35:45 Android Superstation Human 5:50 Continuum 2026 0:42:00 Android Superstation Aurora 5:23 Continuum 2026 0:47:23 Android Superstation Allusions 3:30 Continuum 2026 0:52:10 Android Superstation Currency of Kings 6:41 Continuum 2026 1:00:03 Android Superstation Holograms 5:55 Continuum 2026 NEW ALBUMS (CONT.) 1:07:07 Hypnoma For Those It May Concern 6:59 High And Just Proceedings 2026 1:14:12 Lost In Psalms End of a Kalpa 5:37 End of a Kaipa 2026 1:19:48 Blackwater Holylight How Will You Feel 5:28 Not Here Not Gone 2026 1:25:17 LOR3L3I Black Widow 4:06 Peace By Proxy 2026 1:30:11 Lunar & The Deception No More Secrets 4:12 The Somnambulist 2026 1:34:27 inner:i Falling 5:06 Lavender 2026 1:39:33 Moonspell Cross Your Heart 4:45 Far From God 2026 1:45:03 Artificial Astronaut The Vow 4:05 When The Familiar Ends 2026 1:49:12 Diatom Until 3:29 Low Light 2026 1:52:41 Lynx Voyager 7:47 Trinity of Suns 2026 2:01:09 The Winter Tree The Ocean 3:14 Songs of the Sea 2026 2:04:23 Siiga It’s Only Love (feat. Riley) 4:26 Nostalgia Burns 2026 2:08:48 Dina Ögon Människobarn 3:32 Människobarn 2026 2:13:19 Mothertomb Beware 6:52 DYING TO LIVE 2026 Punch Brothers Found in a Frozen Fog 5:53 The Unsung Adventures of Punch Brothers 2026 Bloodflowers Magma Red 7:22 Devotion 2026 Ups and Downs Out Of Thin Air 4:25 Radio Is Dead EP 2026 FEW MORE NEW SINGLES Eric Gillette The Vessel – Torn and Tried 4:17 The Watcher 2026 Going Up North Love Is Lord Of All 2:29 Single 2026 REZN Cloudfall 3:58 Cycles In The Infinite Dream 2026 JUST RELEASED CLOSING SONG Emerald Dawn Paradise 8:49 The Land The Sea The Air Pt. II 2026

Links For The Occult Rejectshttps://linktr.ee/theoccultrejectsOccult Research Institutehttps://www.occultresearchinstitute.org/Substackhttps://substack.com/@theoccultrejects?r=7auau0&utm_campaign=profile&utm_medium=profile-pageCash Apphttps://cash.app/$theoccultrejectsVenmo@TheOccultRejectsBuy Me A Coffeebuymeacoffee.com/TheOccultRejectsPatreonhttps://www.patreon.com/TheOccultRejectsAssmann, Jan. Death and Salvation in Ancient Egypt. Translated by David Lorton. Cornell University Press, 2005.Ariès, Philippe. The Hour of Our Death. Translated by Helen Weaver. Knopf, 1981.Beard, Mary, John North, and Simon Price. Religions of Rome. 2 vols. Cambridge University Press, 1998.Blackmore, Susan. Dying to Live: Near-Death Experiences. Prometheus Books, 1993.Boyce, Mary. Zoroastrians: Their Religious Beliefs and Practices. Routledge, 1979.Bremmer, Jan N. The Rise and Fall of the Afterlife: The 1995 Read-Tuckwell Lectures at the University of Bristol. Routledge, 2002.Chalmers, David J. “Facing Up to the Problem of Consciousness.” Journal of Consciousness Studies 2, no. 3 (1995): 200–219.Fenwick, Peter, and Elizabeth Fenwick. The Art of Dying: A Journey to Elsewhere. Continuum, 2008.Graf, Fritz, and Sarah Iles Johnston. Ritual Texts for the Afterlife: Orpheus and the Bacchic Gold Tablets. 2nd ed. Routledge, 2013.Greyson, Bruce. After: A Doctor Explores What Near-Death Experiences Reveal about Life and Beyond. St. Martin's Essentials, 2021.Greyson, Bruce. “The Near-Death Experience Scale: Construction, Reliability, and Validity.” Journal of Nervous and Mental Disease 171, no. 6 (1983): 369–375.Griffiths, Roland R., William A. Richards, Una McCann, and Robert Jesse. “Psilocybin Can Occasion Mystical-Type Experiences Having Substantial and Sustained Personal Meaning and Spiritual Significance.” Psychopharmacology 187, no. 3 (2006): 268–283.Hornung, Erik. The Ancient Egyptian Books of the Afterlife. Translated by David Lorton. Cornell University Press, 1999.Johnston, Sarah Iles. Restless Dead: Encounters between the Living and the Dead in Ancient Greece. University of California Press, 1999.Kerr, Christopher W., et al. “End-of-Life Dreams and Visions: A Longitudinal Study of Hospice Patients' Experiences.” Journal of Palliative Medicine 17, no. 3 (2014): 296–303.Le Goff, Jacques. The Birth of Purgatory. Translated by Arthur Goldhammer. University of Chicago Press, 1984.Moody, Raymond A. Life After Life. Mockingbird Books, 1975.Nahm, Michael, Bruce Greyson, Emily Williams Kelly, and Erlendur Haraldsson. “Terminal Lucidity: A Review and a Case Collection.” Archives of Gerontology and Geriatrics 55, no. 1 (2012): 138–142.Nelson, Kevin R., Michelle Mattingly, Sherman A. Lee, and Frederick A. Schmitt. “Does the Arousal System Contribute to Near Death Experience?” Neurology 66, no. 7 (2006): 1003–1009.Obayashi, Hiroshi, ed. Death and Afterlife: Perspectives of World Religions. Greenwood Press, 1992.Osis, Karlis, and Erlendur Haraldsson. At the Hour of Death. Avon, 1977.Parnia, Sam, et al. “AWAreness during REsuscitation—II: A Multi-Center Study of Consciousness and Awareness in Cardiac Arrest.” Resuscitation 191 (2023).Plato. Phaedo. In Plato: Complete Works. Edited by John M. Cooper. Hackett, 1997.Segal, Alan F. Life After Death: A History of the Afterlife in Western Religion. Doubleday, 2004.Stevenson, Ian. Children Who Remember Previous Lives: A Question of Reincarnation. Rev. ed. McFarland, 2001.Taylor, John H., ed. Journey through the Afterlife: Ancient Egyptian Book of the Dead. Harvard University Press / British Museum Press, 2010.Tucker, Jim B. Life Before Life: A Scientific Investigation of Children's Memories of Previous Lives. St. Martin's Press, 2005.van Gennep, Arnold. The Rites of Passage. Translated by Monika B. Vizedom and Gabrielle L. Caffee. University of Chicago Press, 1960.van Lommel, Pim, Ruud van Wees, Vincent Meyers, and Ingrid Elfferich. “Near-Death Experience in Survivors of Cardiac Arrest: A Prospective Study in the Netherlands.” The Lancet 358, no. 9298 (2001): 2039–2045.Xu, Gang, et al. “Surge of Neurophysiological Coupling and Connectivity of Gamma Oscillations in the Dying Human Brain.” Proceedings of the National Academy of Sciences 120, no. 19 (2023).Also want to remind people about the website, if you're into reading we have tons of information by multiple contributors, and we got t-shirts up on the site if you're interested. Fun fact, the art is all based on the eyeball. 

Highlights from the PER® CME activity "Show Me the Data™: Redefining Treatment Paradigms in Triple-Negative Breast Cancer Across the Disease Continuum" — this podcast is not certified for credit. To participate in the full accredited activity and earn CME credit, use the link below.In this podcast, experts Hope S. Rugo, MD, FASCO; Neil M. Iyengar, MD; Heather McArthur, MD, MPH; and Jason Aboudi Mouabbi, MD; discuss the latest data to inform management of patients with early-stage triple negative breast cancer (TNBC).Earn CME credit by completing the full accredited activity (available through June 30, 2027): https://www.gotoper.com/courses/show-me-the-data-redefining-treatment-paradigms-in-triple-negative-breast-cancer-across-the-disease-continuum-h5knThis podcast, including the narration, was developed by PER® (Physicians' Education Resource®, LLC) editorial staff from the full online CME activity developed with these faculty. The narration was voiced by a PER staff member or by an AI tool. The podcast contains no product advertising. The full activity is supported by educational grants from AstraZeneca Pharmaceuticals; BioNTech; Daiichi Sankyo, Inc.; and Merck Sharp & Dohme LLC.This content is for educational purposes only and is not a substitute for the independent clinical judgment of a health care professional. Faculty may discuss investigational or off-label uses; consult prescribing information for any products discussed.

Stroke in children and younger adults differs significantly from adult stroke, with varied presentations and a broader range of underlying causes such as congenital heart disease and arteriopathies. This episode highlights key diagnostic considerations and evolving approaches to treatment in these younger populations. In this episode, Aaron L. Berkowitz, MD, PhD, FAAN, speaks with Thalia S. Field, MD, FRCPC, MHSc, coauthor of the article "Stroke in Children and Younger Adults" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Berkowitz is a Continuum® Audio interviewer and a professor of neurology in the Department of Neurology at the University of California, San Francisco, in San Francisco, California. Dr. Field is a professor at the University of British Columbia and the Sauder Family Heart and Stroke Professor of Stroke Research, and a stroke neurologist at the Vancouver Stroke Program, Vancouver Coastal Health in Vancouver, British Columbia, Canada. Additional Resources Read the article: Stroke in Children and Younger Adults 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: @AaronLBerkowitz Full episode transcript available here Dr Berkowitz: Most neurologists are used to evaluating and treating adults with stroke since it's one of the most common neurologic conditions. But stroke can also occur in children, in infants, and even in utero. Today, I have the privilege of interviewing Dr. Thalia Field to talk about pediatric stroke.  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. Thalia Field about her article on stroke in children and younger adults. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, Dr. Field, and could you please introduce yourself to our audience?  Dr Field: Well, thanks so much. It's a pleasure to, uh, be speaking to you. I'm a stroke neurologist, and I treat adults generally. My wonderful colleague, Thivya Selvanathan, who's a neonatal neurologist, co-wrote the chapter with me. We do, unfortunately, have to treat some children with stroke collaboratively and I do advise on those cases. My practice is about one-quarter clinical, so I treat patients with acute stroke, look after them on the wards, see patients in stroke prevention clinic, and the rest of my time is mainly research and some administrative work and teaching. I run the clinical trials program for the Vancouver Stroke Program, and I do research of my own, mainly focused on stroke in younger adults. We previously did a trial and registry on cerebral venous thrombosis, and more recently, I've been running a national study looking at brain health in adults and children with congenital heart disease.  Dr Berkowitz: Fantastic. Wow, that is a lot that you do, and we'll look forward to the results of some of those studies. So, when adults suffer a stroke, they typically present with sudden onset focal neurologic deficits, very common scenario we're consulted on.  And one thing you and your colleague talk about in the article is that strokes can present differently in infants and in young children. Can you talk a little bit about the differing clinical presentations of stroke in the youngest young as compared to our usual experience treating the older adults?  Dr Field: Sure. So, you know, speaking about this as someone who doesn't see the children directly but has had the opportunity to discuss these patients with my colleagues and, like we all do, learn about it during our training, I think one of the distinctions, especially with neonates, is that it's generally not a presentation with focal neurologic deficits. Often these babies will have seizures or encephalopathy as their main presentation, and sometimes we're only finding out after the fact if they're presenting with developmental delay or early preference for handedness and hypotonia, things like that. So, in very young children, that's a distinction. And in older children, there can be sudden onset deficits and, and unfortunately, sometimes these are mistaken for other conditions that are more common in children, like seizures. But sometimes you can have a more indolent course, say, with something like a focal cerebral arteriopathy or something like that. So, it depends on the scenario, but the big difference primarily is in neonates, as far as I understand.  Dr Berkowitz: Perfect. That's very helpful. So as an adult neurologist, when I think about causes of stroke or teach sort of the categories of causes of stroke to our residents and students, when we think about the evaluation of stroke, I divide them broadly into causes related to the heart, causes related to the blood vessels, and causes related to the blood with, in the adult world, the most common things, of course, being atrial fibrillation for the heart, atherosclerosis for the blood vessels, and then risk factors for atherosclerosis in the blood, diabetes, hyperlipidemia, very rarely picking up a hypercoagulable disorder in the blood column. And reading your article, it seems that, correct me if I'm wrong, stroke in young adults, stroke in the pediatric population can basically be organized into those same broad categories, heart, blood vessels, and blood, just that there's many more conditions on the differential diagnosis that you would consider in young adults to begin with and then children and then neonates as we get into the younger and younger population. So, I'd like to talk about each of these sort of buckets of etiology in turn and ask you about some of the causes we would consider in young adults and children in each of these, and then as they come up, probably ask you more questions about how frequently we find these sorts of things, how frequently they're the cause of stroke treatment, et cetera. So, let's start with the heart. As I said, in adults, we're mostly looking for rhythm disorders, right, atrial fibrillation. Sometimes we'll pick up a patent foramen ovale or PFO or other structural abnormalities, but mostly we're thinking about atrial fibrillation. But reading your paper, I was struck by the huge variety of conditions that you might be looking for in the heart in children or infants with stroke. So, can you tell us a little more about cardiac etiologies of stroke in the young?  Dr Field: Yeah. So, I'd say unlike in older adults, where it tends more often to be a rhythm disorder, in children and adults who are younger, it's primarily a structural cause, and congenital heart disease being the most common. And it changes a little bit from younger adults shifting downwards in age to younger children in terms of the fact that often if we're seeing an adult with stroke related to congenital heart disease, it can be a paradoxical embolism from a previously undiagnosed PFO. Not in all cases, but fortunately this is improving over time. You know, generally people with diagnoses of more severe congenital heart disease are followed up from childhood and people are aware of the diagnosis, and hopefully they're being managed and watched for things like premature arrhythmias or depressed heart function or other things that can develop and require their own distinct antithrombotic management, for example. In young children, however, more severe causes of congenital heart disease tend to more frequently be associated with stroke. And in many cases, those strokes can be early on in life or associated, say, with perioperative complications or other iatrogenic-related causes in, in that way. Again, congenital heart disease can be associated with stroke at, at any point in the life course. But as adult neurologists, most frequently we're seeing very simple lesions like PFO with large shunts, and in children, it tends to be the more complex causes of congenital heart disease.  Dr Berkowitz: Got it. So, let's move on to the blood vessels. Again, in adults, we're usually thinking about atherosclerotic disease, be that of the cervical arteries or of the intracranial arteries. But in your paper, a lot of discussion about the various vasculopathies, arteriopathies that can be cause of stroke in younger adults and in children. Could you talk a little bit more about some of the vasculopathies and vascular conditions that are causes of stroke in the younger population?  Dr Field: Sure. Before I do that, I will say that especially in older younger adults, particularly over the age of thirty-five, and you know, kind of makes me shudder that that's an older younger adult. But, um, in, in any case, certainly conventional vascular risk factors are more common in this population with stroke, especially in those who don't have PFO-associated stroke. Like conventional atherosclerosis, you know, certainly is a cause of stroke in younger adults. But that being said, certainly other vascular causes and vasculopathy in particular is a much more common cause of stroke in younger adults and, and children than it is in older adults. In particular, dissection is an extremely common cause of stroke in younger adults. Generally cervical artery dissection from non-inflammatory vasculopathy, usually on, sometimes on the FMD fibromuscular dysplasia spectrum and, and sometimes, you know, provoked by minor trauma or something post-infectious that may make the vessels a little bit more susceptible. And in younger children, this inflammatory focal cerebral arteriopathy is a distinct cause that is a common cause of stroke in, in young children. There are other causes that can affect the blood vessels, you know, rarer things like vasculitis and vasculopathies that can develop in the context, say, of sickle cell anemia. But in general, as a bucket, vessels are still very important, but the pathology tends to shift.  Dr Berkowitz: Got it. And you, um, alluded to a point that I wanted to ask you about. You mentioned the sort of, there's stroke in the young, and then where do you draw the line at young? Less than sixty, less than thirty-five, and then we've also talked about strokes as young as before the age of birth. Yeah, I'm remembering, is it the Helsinki study, one of the early large series of stroke in younger individuals? I think that, was it eighteen to forty-nine in that or fifty-nine? I don't remember the exact age, but being struck reading that paper as a resident and thinking about the workup for exotic causes we do, right, and when a young patient has a stroke. And correct me if I'm wrong, the most common etiologies of stroke in that series, and I'm curious the other large series yourself have been involved with, have still been vascular risk factors and arrhythmias and things that we, even common, quote unquote, common things in the young, such as dissection or hypercoagulable states. Uh, the things that we sort of tend to think about first are actually less common. But acknowledging that that paper has folks up to the late forties when the vascular risk factors may be, um, unfortunately kicking in earlier, uh, and earlier due to dietary and lifestyle factors. So is that true, or do you have sort of an age cutoff when it's, we say stroke in the young, people sort of think, "Oh, they'd work someone up differently if they're less than sixty, and they have no vascular risk factors or few vascular risk factors." When do we start getting into the kind of younger population where atherosclerosis and cardiac arrhythmias are not number one and two?  Dr Field: I'd say first of all, you and I must have trained around the same time because I was also in my training, really struck by the results of the Helsinki study going, "Wow, I, I really didn't know how much of a role these conventional vascular risk factors still play." And I think we're seeing that information reiterated, unfortunately, like even with higher prevalences and more attributable risk in some of the newer series. There are newer European series looking at stroke in younger adults, and more recently, there's been one that we mentioned in the article from the Florida Stroke Registry. And it's true that generally the burden is in the older younger adults. But what I would say overall in terms of kind of how things guide the workup, you need to look at the patient and consider things. I mean, obviously you don't want to miss things that can be treated differently and identified by tests easily. You know, things like ruling out syphilis or antiphospholipid antibody disease in, in younger patients. You really want to make sure that that's not something that, that you'd miss because, you know, obviously your treatment is going to change. However, certainly we start with the basics for stroke workup in any patient that's coming in. At my center, CT angiography. Some centers it may be MR angiography and echocardiography. We take a careful history. We look at the blood work. We look at the vascular risk factor burden. We find out if there's kind of any worrisome personal history, family history, look at their general health context. I think that really helps to guide how far we go in a particular workup, and it also helps to direct the other investigations and types of follow-up we need to do. For example, if a patient has a fairly suspicious story for dissection, let's say they're getting over a cold, and they went to the gym, and, you know, there was a sudden movement that they did that really produced headache and neck pain, and there's an obvious cervical artery dissection. I'm not going to go too far down testing them for rare infections and doing advanced cardiac imaging unless something shows up on their initial echo, for example. But I will make an effort to do more detailed vascular imaging of the rest of their body, find out careful family history. If there's additional manifestations of a non-inflammatory vasculopathy elsewhere, say consider sending them to medical genetics, or obviously, if this is, you know, a second event, your flags raise even more. So, it really depends on the patient. If I find out that there's, you know, a family history of premature cardiac disease and things like that, you know, obviously we're gonna be keeping a close eye on their cholesterol, making sure that we're not identifying, for example, familial hypercholesterolemia, which is, you know, something that comes up not infrequently where we'll see an LDL in an untreated patient of more than five. I apologize, you're gonna have to do the conversion to American units on that. But there are things we identify and, you know, again, you don't want to fall solely on heuristics and your preconceived notion of, of the patient. You do have to consider the results of the investigations that you do order. But I think you can certainly be mindful in terms of how you direct your workup and in turn, how you direct your follow-up.  Dr Berkowitz: That's great to hear your approach. Yeah, as you said, our approach always begins with the same, coming back to these three categories, right? Doing some type of structural imaging of the heart, rhythm monitoring for the heart, and then vascular imaging of the head and neck. And then I was going to ask you, and you sort of began to answer this question. Yeah. What's next and how far do you go? I think most people think the expanded stroke workup in the young is at a minimum, a TEE if there's been no signal thus far on the original workup. I just mentioned and you spoke about, and then probably hypercoagulable testing and only sending arterial side if there's no shunt and venous and arterial side if there's a shunt. Is that your second pass approach or did I miss anything, or are there other nuances there that are helpful to discuss?  Dr Field: No, I think that's generally in keeping with what I do. I think with TEE being very important. I mean, the first pass are arterial stuff. Really, it's antiphospholipid antibodies and, and making sure there's no cancer. Like you said, only if there's a shunt do I pursue other venous hypercoagulability testing. Again, you [chuckles] kind of reiterate, go through with the history, make sure there's kind of no red flags. And sometimes, obviously, you do your best reasonable job with the first pass workup, and you will find out when someone presents with a second event that it's something very unexpected. Maybe first manifestation, someone with no obvious history and very initially normal-looking imaging, say with, with CATASL or something like Fabry's disease or something where you would consider it if there was kind of a more classical picture. But it wouldn't be something you would do kind of on your first or even second pass workup in the absence of any sort of clinical suspicion, family history, or something along those lines.  Dr Berkowitz: I'm curious just as far as rough percentage. I feel like many of these patients we see it's a patient who's young and who's had a stroke, and the initial first pass has been unremarkable, and we do our TEE, and we do our hypercoagulable workup. Again, antiphospholipid antibodies only if it's-- there's no shunt. And if there's a shunt, adding on some of the venous hypercoagulability protein C, protein S, factor five, Leiden, et cetera. A lot of the times I feel like we don't find anything. What's your sort of general gestalt? Again, as a general neurologist who does a lot of inpatient neurology, I feel like when these cases come up, it's not that common that you say, "Oh, I actually diagnosed protein S deficiency." Or every once in a while, diagnose an antiphospholipid antibody, or you'll find a PFO on TEE. You didn't find on TT. I've maybe found one fibroelastoma in many years. How often do you find something? How often is it just as an adult a cryptogenic stroke in a young adult or child?  Dr Field: So much of what we see is PFO-related, dissection-related, conventional vascular risk factor-related. We do send referrals to medical genetics. Sometimes we'll do testing for rare things like Fabry's or consider other diagnoses. But I mean, those tend to be the exceptions. About one in four to one in five young adults with stroke end up with this cryptogenic label. I like to keep them on my radar for a few reasons. I think, one, it produces tremendous anxiety for them to not have a cause of stroke identified and just to kind of have a generic approach to secondary prevention. So, I think just to kind of keep an eye on them, manage their anxieties each year, make sure there's kind of no updates in, in terms of general secondary preventionAnd sometimes just things dawn on you later or there are new conditions, say things like, you know, DADA2, this, you know, adenosine deaminase deficiency. You know, there are new diagnoses that, that come on the radar. And sometimes treatments change. You know, for example, when I was starting my early career, the evidence hadn't yet been in place for PFO closure, and then all of a sudden, the paradigm completely changed. And you want to make sure that you can get in touch with those patients to reconsider your approach at the time. So I realize that not everybody has the luxury of extended follow-up with their patients, but I think often you can kind of encourage them or their healthcare team or just, you know, patient themselves to keep in touch periodically just to make sure that there haven't been any changes in treatment paradigms or just with your own awareness of particular, you know, diagnoses or, or just kind of readdressing the situation, uh, a year after and seeing if there's anything that may have occurred to you in the interim.  Dr Berkowitz: Perfect. Really illuminating to hear your approach to these challenging cases. And as you said here and then a couple of times, I think, in this interview is in many of these cases it's your first pass, maybe even your second pass, you haven't found anything. And the key is, unfortunately, as distressing as it may be for the patient as well as for us to not have an answer, to just keep following these patients. And sometimes you really can't sort it out until something else happens, either neurologically or systemically, where you say, "Oh, that's what this was." But there would've been no way to know it from the first presentation. So, we've talked a lot about the diagnosis of causes of stroke in younger adults and children. And in the last minute or two here, I just wanted to talk a little bit about treatment. You mentioned early on that you're involved in thrombectomy cases in children. What's the state of evidence or at least state of practice in terms of offering therapies like thrombolysis and thrombectomy in our patient population? I guess it would be under 18, right, who is not studied in the major trials. Do we have evidence and, or in the absence of evidence, what's sort of the, the expert guidance on treating young adults under 18 and children with some of these acute therapies?  Dr Field: So, trying to keep up with the literature on this. You know, certainly the evidence has been more established in a small trial and pediatric registries for use of tPA, tissue plasminogen activator, in children just because, you know, it's been around much longer. In terms of tenecteplase, which I, I really think signifies a, a practice shift in adult stroke because of its, you know, non-inferior efficacy and ease of use and potentially better rates of recanalization over time. In children, to my knowledge, that evidence base is, is limited to case series and anecdotal shifts in availability of drug and, and different practices. So, the evidence base is not particularly strong for tenecteplase in children who are identified within a reasonable amount of time who are still otherwise candidates for thrombolysis, you know, thrombolysis in children. Children who are a little bit older, I think, can't remember the exact age, but generally very young, like neonates, children who are under the age of two, I believe. I would want to double-check that thrombolysis is less commonly used and just because the safety has not really been that well-established. And for thrombectomy, it's now recommended to use thrombectomy in otherwise eligible children in the newest AHA guidelines. It gets a little bit more controversial in very young children. Under the age of six, there's less of an evidence base and, and often it will depend on people's level of comfort in terms of the size of the arteries. It's my understanding that once you get to about age six, the artery diameter is similar to that in fully grown people. But in younger children, I think just because of the catheters, there can be risk of, of injury. So, it's more of a case-by-case conversation with your interventionalist for younger children. And again, the evidence to intervene is not there for very, very young babies, for example.  Dr Berkowitz: That's very helpful to hear the current state of the evidence and the current state of practice, acknowledging, of course, there's not that much evidence, and these are relatively uncommon occurrences, fortunately, for children, but making it challenging for practitioners and practices may, um, vary based on different institutional protocols. So again, today I've been interviewing Dr. Thalia Field about her article on stroke in children and younger adults. This article appears in the June 2026 Continuum issue on cerebrovascular disease. 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.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

In this episode of Reading With Your Kids, Jed welcomes three fantastic guests who each showcase a different way stories can shape our lives. First, Bruce Littlefield joins from his farm in upstate New York to celebrate his picture book "Everything You Need to Know About Life You Can Learn from a Dog." Bruce shares how his usually optimistic outlook was shaken by a rough morning—bad news, a broken porch—and how his dog Felix, joyfully unfazed, inspired him to rethink who the real "lifestyle expert" in the house was. Drawing on years of watching dogs in New York City and at home, Bruce turns traits like self-acceptance, curiosity, forgiveness, and the ability to "shake things off" into gentle life lessons for kids and grown-ups. He and Jed swap heartfelt dog stories—border collies carving tracks in the yard, childhood pets like Snuggles and London teaching responsibility, calm, and empathy—and reflect on how dogs help children learn to care for others. Then Gregory Rizzi discusses his YA sci‑fi novel "Continuum." Set on a harsh distant planet, the book follows Jacob, a Praetorian Guard soldier, as he discovers the planet's hidden history, strange creatures, and deeper truths about creation, fathers, and sons. Gregory talks about how becoming a father and returning to his faith reshaped the story's themes of suffering, resilience, and what we pass on to our kids. Finally, Amy Doslich introduces her picture book "STEM Day" and her kid-powered podcast "Kids Ask Authors Answer." A former actuary turned author-illustrator, Amy celebrates lesser-known STEM careers and invites children to ask authors their own fun, surprising questions—plus she's organizing a big free kids' ebook day on August 5.

In this episode, host Dr. Skip Gill welcomes Dr. Matthew Smith to discuss his Clinical Science in Manual Therapy Grant-funded study, “Mapping the Continuum: Enhancing Orthopedic Manual Physical Therapy Education Through Instruction and Training.”Dr. Smith shares how his own OMPT training shaped his interest in clinical reasoning, mentorship, and the way manual therapy is taught across different stages of professional development. He explains why his study looks at the continuum from entry-level DPT education through residency and fellowship, and how instruction changes depending on both the learner and the mentor.The conversation also explores the value of qualitative research, the complexity of analyzing interview data, early observations from the study, and the importance of near-peer instruction in helping students understand what advanced OMPT training can offer.For educators, mentors, fellows, residents, and clinicians interested in the future of orthopedic manual physical therapy, this episode offers a thoughtful look at how OMPT principles can be taught more clearly, consistently, and meaningfully across the profession.Key TakeawaysOMPT is more than technique execution. Dr. Smith emphasizes that his own training helped place clinical reasoning at the center of practice.The education continuum matters. DPT, residency, and fellowship training should not be conflated. Each level has different expectations, depth, and nuance.Qualitative research captures what surveys often miss. Dr. Smith's interest is in the “why” and “how” behind clinician behavior, mentorship, and decision-making.Fellowship programs may vary in method but align in goals. Early observations suggest different programs use different teaching routes while aiming toward similar outcomes.Near-peer instruction may be powerful. Exposure to residents and fellows can help DPT students better understand advanced training pathways.Mentorship drives academic and research growth. Dr. Smith reinforces that being a strong clinician does not automatically make someone a strong educator or researcher.

Rapid advances in acute ischemic stroke care have expanded treatment windows and improved patient outcomes through thrombolysis, mechanical thrombectomy, and optimized antithrombotic strategies. This episode highlights evolving approaches to patient selection, the growing role of tenecteplase, and the importance of team-based systems of care in delivering timely, effective treatment. In this episode, Casey S. Albin, MD, FAAN, speaks with Christopher R. Leon Guerrero, MD, author of the article "Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Leon Guerrero is an associate professor of neurology and the adult neurology residency program director at Atrium Health Carolinas Medical Center in Charlotte, North Carolina, where he also serves as outpatient stroke director. Additional Resources Read the article: Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Full episode transcript available here Dr Albin: In stroke care, every minute kills nearly two million neurons. But today, we're going to unpack all the details about the latest treatments that can give those neurons back.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Albin: Hello and welcome. This is Dr. Casey Albin. Today, I'm interviewing Dr. Christopher Leon-Guerrero about his article on Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I always like to start by just having you introduce yourself so our listeners know a little bit about you.  Dr Leon-Guerrero: Thanks for the introduction, Dr. Albin. Really glad to be here today. My name is Chris Leon-Guerrero. I'm a vascular neurologist at Atrium Health in Charlotte, North Carolina, at Carolinas Medical Center. I'm an associate professor in the Department of Neurology. I serve as our Neurology Residency Program Director, and I also wear the hat of an outpatient stroke director in our clinics.  Dr Albin: So, you are wearing a lot of hats and balancing a lot of things, and it's a really exciting time to be talking about this. For our listeners, we are recording this right after the launch of the American Heart Association, American Stroke Association just released their new guidelines on acute ischemic care. So, no better time to kind of dive into some of this. And really, when I think about acute ischemic stroke care, it's dramatically transformed in the last two to three decades. I mean, from lengthening time windows for IV thrombolysis to expanded thrombectomy eligibility, this is really, I think, some of the most exciting stuff in neurology. And your article did a fantastic job of distilling those rapid advancements and clarifying some of the evidence behind some of these new evolving treatment selections and imaging modalities, and it's exciting. So, let's just start with thrombolysis. Where are we now with IV thrombolytics and the time windows there?  Dr Leon-Guerrero: So, a lot has changed in the last decade, since that initial trial with NINDS, nearly thirty years ago. We're still giving intravenous thrombolysis in the traditional time window up to 4.5 hours, and really emphasizing we should be selecting patients for treatment early and quickly as possible. In most of those cases, a non-con head CT is sufficient to rule out bleeding and initiate treatment as quickly as possible. Where things have gotten really exciting is using advanced neuroimaging to help select patients beyond that traditional 4.5 hour window, and we're able to treat patients even up to twenty-four hours from symptom onset.  Dr Albin: Which is really exciting. It has really totally shifted the paradigm here. You know, I think most listeners are going to be pretty familiar with three to four and a half hours. Like, that's sort of our standard. What can you tell us about some of the advanced imaging we're using for that later selection period?  Dr Leon-Guerrero: It's around the principle of you want to be able to, uh, rescue significant salvageable tissue without a lot of core. So, this large profusion deficit and small core is really how you're trying to select out these patients. And two types of modalities are used. One is going to be MRI, and a lot of those imaging protocols, you know, are outlined in the WAKE UP trial and basically are looking for patients with DWI hyperintense lesions and FLAIR negative lesions to suggest that patients in an early time window that's treatable for thrombolysis. And then in the other category, we'll be using profusion imaging, whether that's CT profusion or MR profusion, to look for patients with large salvageable tissue.  Dr Albin: Yeah. And I think that this has been one of the things that, to me, has been really impactful is I think when WAKE UP came out, it was exciting. It was fun to sort of think about, "Hey, we're going to be able to use MRI." But MRI can be very challenging to get acutely, especially in community centers where they don't have the capabilities to get someone from the emergency department into an MRI rapidly enough to make thrombolysis decisions. So, to see some of that expand to CT profusion has been really exciting. How are you going about sort of counseling patients or thinking about their risk when you're using some of those, like, advanced imaging techniques?  Dr Leon-Guerrero: Yeah. I think it's similar to the conversations we've had with patients even within the traditional 4.5 hour window. The risk for intravenous thrombolysis is hemorrhage, and counseling patients on the, you know, the risk and benefits of hemorrhage and the potential clinical benefit of receiving thrombolytics is important. And then providing patients with that information to make an informed decision, so that they can make the best decision for their own care.  Dr Albin: Totally. And it's, again, time sensitive, but trying to give families enough information and enough time to sort of process those, especially when it's a little bit beyond the standard that we're so used to consenting for. The other big area that's really changed is that tenecteplase has become the star of the show. It's really gained momentum, so what should clinicians understand about this?  Dr Leon-Guerrero: Yeah. There's been an explosion of data over the last decade on tenecteplase supporting its use for clinical practice. You know, there was recent updates even from the neurology journal with a large meta-analysis with all of the data showing good clinical outcomes and perhaps even lower risk of bleeding. And so, I think you're seeing a lot of centers across the country switching from alteplase to tenecteplase. There's some practical advantages. So tenecteplase is a one-time bolus dose. And then biologically, it seems to have better fibrin specificity, longer half-life, which may ultimately make it a more attractive drug and may make it even more effective. But I think the practical aspects of tenecteplase are not to be understated. I think there's a lot of advantages for speed and efficiency and for centers to make that switch.  Dr Albin: Yeah. I remember when our health system made the pivot from alteplase to tenecteplase. Like any changes, that obviously created some adjustments with the new workflow. But, the fact that this could be given just as a one-time dose and not with the "we got to calculate the bolus, and now we got to get the infusion on board," like really simplified workflow. So, I think that's been pragmatically one of the nicest things we've done in stroke care. Really exciting.  Dr Leon-Guerrero: Yeah. And, you know, it's a doable thing. I think you have to be, very deliberate about it at whatever center you're at to make sure that all stakeholders are aware of that change. I think that's helpful to get everybody involved and have a lot of planning to avoid wrong dosing errors or inadvertently dosing as alteplase versus tenecteplase. But it's certainly doable, and I think in the long term, centers that have switched have been pretty satisfied with tenecteplase.  Dr Albin: And you know, initially when this came out, there really was sort of a debate about, is it gonna be 0.25? Was it gonna be 0.4? Where have we landed with that debate?  Dr Leon-Guerrero: So, I think we found the correct dose is 0.25 milligrams per kilogram is the recommended dose with a max out of 25 milligrams. There's some within the American Heart Association guidelines that were just published. They mentioned even tier dosing based on 10 kilograms, so intervals. So, that may be an easier way for centers to do it. But that cap out dose of 25 milligrams at 0.25 milligrams per kilogram, I think, is the sweet spot.  Dr Albin: Yeah. That's great, and I think that that has helped, you know, say, "This is what we're doing. There's not a debate that's happening anymore." And that really just got codified in the new ASA guidelines, so really exciting there. So, there is a lot of guidance for these patients, but I think one of the things that your article really tackled is the fact that there are some special populations, where we really still don't have a lot of guidance. And so, I think just to kind of distill those for the listeners, thinking about our pregnant patients, thinking about children, how are we approaching thrombolysis decisions in these special populations?  Dr Leon-Guerrero: These are always tough cases. For example, for pregnant women, they've often been excluded in the thrombolytic trials. But there's still evidence. You know, there's some inference based on the evidence we do have, and there's a lot of registry and case reports suggesting potential safe treatment for pregnant women. And I think when you're approaching those cases, again, it's gonna be patient-centered and really should be multidisciplinary. These are the types of cases you really need to lean on your maternal fetal medicine colleagues, your high-risk OBGYNs, your obstetricians to help with that decision-making. And I think, a multidisciplinary approach is the way to go for these cases. It's the same thing with the pediatric population. We had some data. There was one trial, randomized control trial, called TIPS trial that looked at using intravenous alteplase for acute ischemic stroke in patients under the age of 18. It had difficulty with enrollment. But I think most experts would argue that patients with pediatric stroke should be considered for intravenous thrombolysis if appropriate. Again, same thing. You want to make it a multidisciplinary approach, really getting your pediatric neurologists, your pediatricians involved early to make the best decision for the patient.  Dr Albin: Yeah. That's just really an important takeaway, just thinking about this as a multidisciplinary decision, because there are going to be other stakeholders to the patient's care who may have some different information than what we as neurologists are bringing to the approach. And obviously, our perspective really matters. But trying to work in everyone's unique vantage point of the patient really helps to make the most effective decision. When we talk about acute ischemic stroke care, I really don't think that you could do justice to the topic without pivoting to mechanical thrombectomy, which, you know, as we think about how the medical field as a whole, not just neurology, how the medical field has evolved. I mean, there's probably no bigger impact than mechanical thrombectomy has made in terms of reducing not just morbidity, but mortality from stroke. I mean both. So, thrombectomy has been around for a while, but just walk our listeners through what's the core that we for sure know that these are the patients that this works for?  Dr Leon-Guerrero: The types of patients we should be selecting for intervention are patients with large vessel occlusions. And those initial trials that were published in 2015 really demonstrated that this is a quite an effective treatment for patients with large vessel occlusion ischemic strokes in the anterior circulation. When that smattering of publications occurred in 2015, the general consensus, we should be treating all patients up to six hours from symptom onset if they do have a large vessel occlusion. And then, Dr. Albin, as you know, the, the windows continue to expand. So, we were using advanced neuroimaging with MR selection and perfusion selection based on DAWN and DEFUSE 3 trial protocols to select patients all the way out to the 24 window, and it's even expanded beyond that over the last few years.  Dr Albin: I think that when we think about trials that really, totally, changed the game, when we think about DAWN and DEFUSE 3, and we switched from that time-based window to more of that, like we talked about for thrombolysis, that tissue-based clock and, like, looking at what is salvageable and where can we make an impact on salvageable tissue, truly moved the needle in terms of just bringing this therapy for people who, you know, it's hard to get in within six hours. When we moved the needle to 24, it made a huge difference. But people were still coming in with a lot of ischemic damage already done, and they would have traditionally been excluded from being enrolled in thrombectomy trials. But that's changing too. So where are we there?  Dr Leon-Guerrero: Yeah. I think there were lessons learned from DEFUSE and DAWN that we were probably over-selecting. Perhaps too stringent. You know, we had number needed to treat in the range of two to three for good outcome based on those trials. And so, I think those were lessons learned to move forward, and we, and, and people started looking at large core infarctions. And in the last few years, we've seen a multitude of randomized control trials examining large core infarctions. These are patients with ASPECT scores all the way down to zeros. A lot of the trials relied on three to six as their score, but there was at least one large core study that looked at ASPECT scores down to zero to two, and all of these studies showing benefit.  Dr Albin: Yeah. And we've really moved into if there's some tissue to spare there, probably getting clot out really makes a big difference in impact. You know, it was really surprising to me as a neurointensivist looking at these trials, that the trials had such low rates of hemorrhage, and pretty low rates of dramatic cerebral edema after thrombectomy. I don't know that we've seen all of that in sort of real world applications, but again, we are still seeing some of these patients come in, that really would've been devastated having some amount of functional recovery regained, which is incredible. In terms of another patient population that I think gives a lot of people pause or stickiness, is those basilar artery occlusions, right? Another large vessel, but one that we've had a little bit harder of a time enrolling in trials and having well-selected trials. Where are we now on whether or not basilar artery occlusion should go to mechanical thrombectomy?  Dr Leon-Guerrero: So, a lot of excitement in this area, too. There's at least two studies that were published in the last five years that were showing benefit in doing thrombectomy for patients with basilar artery occlusion up to 24 hours, and these were patients with moderate to severe deficits with NIH Stroke Scale scores greater than 10. And then making sure that they don't have large core, so using a newer scoring algorithm on the CAT scan called PC ASPECT, so basically a posterior circulation ASPECT score, to kind of make sure that patients don't have large core infarctions that are being considered for thrombectomy. All of those things collectively in those two recent studies, the ATTENTION trial and the BAOCHI trial, I think is what ended up making those studies positive, is that we were selecting the right types of patients, uh, without large core, early core, and patients with moderate to severe deficits that made the difference from previous trials.  Dr Albin: Yeah. I think that that's so important. Those trials to me, and like how long it took to get those enrolled, really emphasized to me that there really was a selection bias. Like, we believed this worked, which made it hard to then do a trial. But I'm so glad to hear that we have the data now to support moving forward in a more rigorous way.  Dr Leon-Guerrero: You're absolutely right. I think that was some of the challenges with the initial trials. In fact, the authors had commented on that. There's a lot of difficulties with lack of clinical equipoise, or experts wanting to take these patients anyways out of clinical trial and treat them, and so that's always been an issue. And then, you know, we all remember basilar artery occlusion cases. They can be severe, devastating cases in our career, but the reality is they're not that common. So, if you look at large vessel occlusions, they only account for about 10%, and if you look at all stroke patients presenting to most centers, they represent about 1% of cases. So really hard clinical trials to do just because there's thankfully not a lot of patients walking around with basilar artery occlusions, but certainly makes for challenges when you're trying to conduct randomized controlled trials on this subset of patients.  Dr Albin: Absolutely. But we did it, and I think that, like, really if, if the listeners take nothing else, it's that the field of vascular neurology is really moving forward with evidence-based, doing very rigorously controlled clinical trials, which is, I think, is what makes this field so exciting. Finally, closing out, cause we could talk all day, but we don't have all day. You know, it seems to me that more and more we are just using dual antiplatelet therapy all the time. And maybe that is, uh, a little bit of a hyperbole, cause I don't think it's all the time, but let's walk through— when is there good evidence for dual antiplatelet therapy?  Dr Leon-Guerrero: Yeah. So, there's strong evidence for early initiation of dual antiplatelet therapy or DAPT in patients with minor stroke or high-risk TIAs, and it's been studied using both clopidogrel as an add-on to aspirin and ticagrelor. Both seem like they're viable options in patients. I think one of the key things is the duration of therapy. So, in these cases with minor stroke and high-risk TIAs, we really should be confining the treatment of early DAPT for 21 days. The risk profile changes, so the risk of recurrent stroke starts to decline with time, and that risk of hemorrhage complications increases with time. And so that sweet spot of 21 days, or even some centers will do 30 days for just practical purposes, you know, really is what we should be doing in most of those cases. Other instances where DAPT can be considered, is in patients with intracranial atherosclerosis that's symptomatic, extrapolating from the SAMMPRIS trial that in the, in the medical management arm alone, used dual antiplatelet therapy with aspirin and clopidogrel for up to 90 days. So, you'll see that as well in clinical practice. Some people will opt for a 90-day duration for those patients with symptomatic intracranial atherosclerosis and stroke.  Dr Albin: Just so I emphasize, this is not set it and forget it. You can stay on DAPT forever. It is you're going to have a definitive time course, 21 days, 90 days. We have directed instructions where we're doing more benefit than harm because of that risk of hemorrhage.  Dr Leon-Guerrero: That's correct. In most cases, we really should be confining the duration of DAPT either to 21 days or 90 days. This is a challenging clinical practice. Centers really have been making an emphasis on stroke follow-up, so making sure these patients get appropriate and timely stroke follow-up to address these issues and to make sure that DAPT is discontinued if appropriate.  Dr Albin: Yeah. I love that, and I want to pull on that a little bit because you as someone who is helping direct a stroke center– A lot of this really does rely on systems of care. When we think about early lysis decisions or mechanical thrombectomy, it's how do we get the patient to one of those capable centers as quickly as possible? And then on the back end, when you're discharging a patient, how do you make sure that they are getting follow-up, making sure that they're getting their Holter monitor if they need it? You know, all the stuff that goes into kind of figuring out, why did the stroke happen? What are some of the things that you, in your role, are really excited about, that will move the needle over the next five or 10 years?  Dr Leon-Guerrero: Yeah. I think a lot of centers are doing it just like we're doing it. It really has to be a team-based approach, and you really want to reach the patient where they are in terms of the continuum of care. And so making sure if it's the in the field that you've reached out to your EMS and first responders to make sure they understand triage protocols to get patients where they need to be, to get the acute treatments that they need for the type of stroke that they're presenting with, to the actual centers that you work at, making sure your whole team, nurses, emergency physicians, APPs that are involved in care are all aware of the stroke protocols and how we're selecting these patients, making sure that your imaging protocols are up to date, and so that it's seamless when patients come in, that we're not adding on perfusion if we should have gotten that up front– We already know, have made decisions before that patient gets there. And then thinking about the patient after that hospital stay, I think, is critical. We really want to reduce their risk of recurrence, making sure that we're leveraging transitions of care, getting those patients seen in our stroke clinics for follow-up, and then make sure we're passing that baton to the long term. All of their long-term comorbidities that may be increasing their risk of stroke are managed and reduced as best as possible.  Dr Albin: From the Continuum journal to the continuum of stroke care.  Dr Leon-Guerrero: That's right.  Dr Albin: I mean, we have it all. I think that that really is so important. I'll just close with what's one thing that is your favorite part about being a vascular neurologist?  Dr Leon-Guerrero: I think it's what attracted to me to this field. As a medical student at that time, all we had was intravenous thrombolysis, and there was so much promise. There was so much promise that there was going to be widespread advancements in acute stroke, and here we are. There's been a tremendous amount of advancements and improvements for patients. I'm really excited to see what unfolds in the next few years, and I'm really excited that we've been able to increase the number of patients we're able to treat with acute ischemic stroke. I hope that we continue to expand the time window, the inclusion criteria, all of those things that we can treat more stroke patients effectively.  Dr Albin: It is really a very exciting time to be a vascular neurologist. Again, today, I've been interviewing Dr. Christopher Leon-Guerrero about his article on Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues, and thank you again, Dr. Leon Guerrero and our listeners for joining today.  Dr Leon-Guerrero: Thanks for having me.  Dr Monteith: This is Dr. Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Text the Show⭐️ Affiliate item of the week: The Lexham English Septuagint (LES) is a new translation of the Septuagint, the Greek version of the Old Testament writings used during New Testament times and in the early church. Retaining the familiar forms of personal names and places, the LES gives readers the ability to read it alongside their favored English Bible. Translated directly from Swete's edition of the Septuagint, the LES maintains the meaning of the original text, making the Septuagint accessible to readers today. https://amzn.to/44wwLLUNo guest tonight so we will be going on a few journey's with you all back in time and looking ahead to a future that is taking shape right in front of us today. Join us live in the chats, phone line will be open for you to call in 248-238-8155.The Secret History of Lyme Disease and Biological Weapons article."Are modern alien-hybrid stories like Raechel's Eyes simply the latest version of an ancient narrative that once appeared as Watchers, Nephilim, fae, changelings, demigods, and hidden bloodlines? Have the entities changed—or just the names we've given them?"What if the world ended... and nobody noticed? What if history changed, but only some people remembered the way it used to be? SUPPORTBuy Me A Coffee http://buymeacoffee.com/DangerousinfopodcastSubscribeStar http://bit.ly/42Y0qM8Super Chat Tip https://bit.ly/42W7iZHBuzzsprout https://bit.ly/3m50hFTPaypal http://bit.ly/3Gv3ZjpPatreon http://bit.ly/3G3 SMART is the acronym that was created by technocrats that have setup the "internet of things" that will eventually enslave humanity to their needs. Support the showLeave Voicemail: https://www.speakpipe.com/DangerousInfoWebsite https://www.dangerousinfopodcast.com/Discord chatroom: https://discord.gg/8feGHQQmwgEmail the show dangerousinfopodcast@protonmail.comJoin mailing list http://bit.ly/3Kku5YtWatch LiveYouTube https://www.youtube.com/@DANGEROUSINFOPODCASTRumble https://bit.ly/4q1Mg7Z Twitch https://www.twitch.tv/dangerousinfopodcastPilled.net https://pilled.net/profile/144176  Facebook: https://www.facebook.com/DangerousInfoPodcast/SocialsInstagram https://www.instagram.com/dangerousinfo/TwitterX https://twitter.com/jaymz_jesseYouTube https://bit.ly/436VExnFacebook https://bit.ly/4gZbjVa

https://www.amazon.co.uk/Villain-Venice-Steampunk-Adventure-Expanded/dp/B0GYVW1ZM3?source=ps-sl-shoppingads-lpcontext&ref_=fplfs&psc=1&smid=A3P5ROKL5A1OLE This title was released in June 2026. It will be exclusively available to buy from the Big Finish website until 31 July 2026, and on general sale after this date. The Doctor takes the TARDIS into the future where many great scientific leaps are taking place. But every new advance has its risks - and some of these risks are deadlier than others. 15.3 Green and Pleasant Planet by Tim Foley The Doctor and Sarah find themselves exploring an alien world alongside a British space expedition. It's never been visited before... so what's a model village doing on the surface of the planet? Finding the answer may prove deadly. 15.4 The Continuum by John Dorney The Doctor and Sarah land on the space-station Daedalus on the day it makes history. The first journey through hyperspace has just been completed. But it hasn't gone as smoothly as posterity suggests. Something terrible is happening - and the clock is ticking down. 15.5 The Audience by Lizzie Hopley A cultural festival on Gakoria should be light relief for the TARDIS crew. But when one of the cast of a play dies, Sarah has to join the troupe. And the Audience on this world are very demanding. Because on this planet... the play's the thing. **Please note: the collector's edition CD box set is strictly limited to 1,500 copies**

In today's podcast we have a conversation with Mitchell Hora of Continuum Ag about the recent release of the updated CI scoring model and methodology from USDA. We review what this means for farmers who can deliver their crop directly to a biofuel plant or an elevator that then delivers the crop. This guidance was sorely needed, but we still have to wait for IRS to provide even more guidance. See omnystudio.com/listener for privacy information.

Greg Peterson, a.k.a. Machinery Pete, talks about trends he's seeing in the used equipment market plus shares recent auction highlights, including his Pick of the Week. Mitchell Hora of Continuum.Ag joins us to discuss USDA's carbon intensity calculator for 45Z. And Jennifer Strailey of The Packer discusses USMCA evaluation from the U.S. produce perspective.See omnystudio.com/listener for privacy information.

With Antonia Sambola and Javier Limeres Freire, University Hospital Vall d'Hebron, Barcelona - Spain. Link to European Heart Journal paper Link to European Heart Journal editorial  

Which way is right? Learn how to stop comparing and settle on a path that's best for you (right now). #ThePitch #INICIVOX #VirtualMentorship

Pregnancy and the postpartum period are critical windows of increased stroke risk, driven by physiologic changes such as hypercoagulability and blood pressure fluctuations. This episode highlights key warning signs, including headache and hypertension, along with practical guidance on evaluation, management, and risk reduction to improve outcomes for pregnant and postpartum patients. In this episode, Kait Nevel, MD, speaks with Michelle H. Leppert, MD, author of the article "Pregnancy and Stroke Risk" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Leppert is an associate professor of neurology at Tufts Medical Center in Boston, Massachusetts. Additional Resources Read the article: Pregnancy and Stroke Risk Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @humich Full episode transcript available here Dr Nevel: The time during and around pregnancy is often thought of as a very joyful time, full of hope. But for some, medical complications such as stroke can lead to devastating disability and sometimes even death. Today, we're going to learn about pregnancy and postpartum stroke, including stroke risk evaluation and best practices in management and risk reduction to help our pregnant and peripartum patients reduce stroke risk and achieve best possible outcomes.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Nevel: Hello, this is Dr. Kait Nevel. Today, I'm interviewing Dr. Michelle Leppert about her article on pregnancy and stroke risk. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Michelle, welcome to the podcast, and please introduce yourself to the audience.  Dr Leppert: My name is Michelle Leppert. I'm a stroke neurologist, and I currently work at the Tufts Medical Center in Boston, Massachusetts.  Dr Nevel: Thank you so much for being here, Michelle, and I'm looking forward to talking to you about your article. I always love starting with the question, what's the most important takeaway from your article for the practicing neurologist?  Dr Leppert: I think in this article, I'm trying to highlight that during pregnancy and especially postpartum, there's a heightened risk of stroke for women, and that's important for clinical neurologists to understand that this is a particularly vulnerable time for the population that we take care of. I think that one of the few of the things that could be informing this heightened stroke risk are the physiological changes that women undergo during pregnancy. So, that includes coagability, where there's an increased likelihood of clotting, and also the cardiovascular adaptations, including increased cardiac output and having an increased cardiac volume. And all of these mechanisms all contribute to the increased risk of strokes around pregnancy and postpartum.  Dr Nevel: Great. Thanks for that. What are some of the unique aspects of stroke types in etiology in pregnancy that we should be aware of?  Dr Leppert: When we think of strokes overall, generally the majority of our strokes are ischemic. So, for the overall population, about eighty-seven percent of strokes are ischemic, while the remainder are hemorrhagic. However, interestingly, during pregnancy, what we're seeing is about half of our strokes become hemorrhagic strokes, and now only a half of our strokes are ischemic, and this is in contrast to what we see in the overall population. One of the reasons is because pregnancy is associated with preeclampsia, and preeclampsia increases the risk of hemorrhagic stroke during pregnancy.  Dr Nevel: Can you tell us just more about headache in general in pregnancy and association of headache with secondary causes of headache and how that relates to stroke risk in this patient population? It seems like in this patient population that when somebody has a headache, we need to be very careful in our headache questions and evaluation.  Dr Leppert: Yeah. And I think the most concerning symptom that we're finding in this population is headaches, and the reason is because headaches is one of the clinical signs of having preeclampsia, which dramatically increases your risk of having a stroke, and especially a hemorrhagic stroke. So just to back up, we can talk about blood pressure for a little bit and some of the pathophysiologic changes during pregnancy. What most people may not know is that there's a dramatic vascular expansion that occurs during pregnancy. And somewhere during the second trimester, your blood pressure is actually the lowest. So, it can drop below pre-pregnancy levels and make your blood pressure appear low for the baseline. However, during the third trimester, as the baby is growing, there is increased vascular volume. The blood pressure starts to increase. We're seeing some of the highest prevalence of blood pressures, which is a sign for preeclampsia, and headaches develop during that third trimester, and particularly during the time around delivery and postpartum. And one of the most concerning signs, the most common sign of preeclampsia is having a headache. So, I think that with any patient that's presenting with a headache, especially during the third trimester or after delivery, that we really need to pay attention and take their blood pressure. That's one of the easiest clinical indicators that something could be going very wrong. Some of the other red flags clinically that we look for in headaches is that acute onset of a severe headache. That headache quality is different from what they usually have. Any woman with focal neurological symptoms associated with their headache, kind of excessive nausea and vomiting that's not characteristic for them. Not getting any relief with medications, and then lastly, checking that blood pressure is very important.  Dr Nevel: And what are the thoughts on blood pressure management in this patient population? I know that there is a little bit of difference in guidance in some of the obstetric societies on how we should manage blood pressure in this patient population. And then, is there anything beyond blood pressure management that we should be thinking about doing for this patient population to reduce their stroke risk?  Dr Leppert: I think that's a good question, and I hadn't really understood that this could be an area of controversy, cause my practice is mostly in stroke, and for most of adult population, the guidelines for blood pressure is very clear. We treat everybody over 130/80. If you're elderly, then your blood pressure limit might be a little higher. However, there's disagreement in the OBGYN guidelines from the American guidelines to the European guidelines. So, what the current American guidelines suggests is that if you have a history of chronic hypertension, then we would want your blood pressure treated during pregnancy below 140/90. However, if you don't have a history of chronic hypertension, then we allow the blood pressure to be higher and then it's an acute intervention if it's anything over 160. One of the issues with this strategy that is concerning is we had just mentioned that the pathophysiology of a pregnancy where you have the lowest blood pressure in that second trimester, and so your blood pressure may be abnormally good. [laughs] And it appears that it's better than your baseline. And so, by the OBGYN definition, any gestational blood hypertension is considered at 20 weeks and later. Sometimes these blood pressures are masked in some women who are pregnant. I think regardless of the controversy and what the practice should be, the focus is that most of the strokes are happening actually peripartum and postpartum, right? So, the woman's no longer pregnant. It is these time periods of the highest risk that we wanna make sure that the blood pressure is controlled. So, after the woman delivers the baby, we're no longer, you know, hampered by the whatever is chronic or gestational. We should be treating that blood pressure to 140/90. I think that not focusing on the controversy until the science catches up is probably what we should do. But like, really, the message here is that we should be checking women around the time of delivery and also postpartum, that we can't forget about their blood pressures postpartum, cause it actually doesn't peak until day five after they deliver the baby.  Dr Nevel: Does knowing that, that blood pressure peaks around day five, do you think that that should impact how we counsel patients in checking their blood pressure at home? Cause most women at day five are home. They're not still in the hospital.  Dr Leppert: Yeah, I think that's a really good point. One of the best interventions has been having a blood pressure at home for pregnant women. So even during their pregnancy and then postpartum, allow them to check their blood pressures, cause there's... Most of the cases, to be honest, that I've seen of preeclampsia and intracranial hemorrhage has happened postpartum. And I think what's unfortunate is that the woman is at home, they're distracted cause they have a newborn baby. They have a headache. They're just taking some Tylenol. And then if you have that blood pressure cuff readily accessible, that's a, a really easy way for them to check and notice that, hey, the blood pressure's too high, they have to go into the hospital.  Dr Nevel: Yeah, absolutely, and it's not just like a headache because you're sleep deprived and have a newborn. It's a headache that you need to pay attention to. Okay, maybe we could talk a little bit now about evaluation when we are suspicious of potential stroke. What do we need to know about imaging modalities and safety considerations of imaging in this patient population?  Dr Leppert: Yeah, that's a great question. I think when I was training, it was fairly controversial to give a pregnant woman MR contrast with gadolinium during their pregnancy. And as I was researching for this article, actually there's not definitive evidence that that is harmful for the fetus. However, in general, for the acute evaluation of patients during pregnancy, we're recommending using the CAT scan and then a CT angiogram. And then if the acute evaluation is not necessary, then an MRI. And if we need vessel imaging, you can employ an MRA time-of-flight study. That doesn't require the gadolinium contrast. However, one thing that I learned from this article that I thought was really interesting was the use of abdominal shielding. So, you're scanning someone's brain. I always thought, "Hey, doesn't it make sense to put a lead shield over the abdomen?" It turns out the lead shield actually interferes with the automatic calibration of the CT machine, so studies have found that actually increases the dose of radiation that the fetus is exposed to. So, it's much better when we're doing acute evaluations to not shield the abdomen, and really the only thing that can help reduce the radiation dose is the duration of the study. So, what we would recommend is if you want a rapid CT angiogram, rapid CT head, go ahead and obtain it. But if you don't need extra sequences, like a delayed phase of the CT angiogram, then to avoid that and reduce the exposure. Dr Nevel: I'm so glad that you talked about that because I was shocked when I read that in your article that we shouldn't be using abdominal shielding in pregnant women. I had no clue. I thought that that was, like, something that we absolutely should do. So, I found that really interesting. Thank you for that. So, any special considerations for acute stroke intervention or management in pregnancy in the postpartum phase, especially things like thrombolysis and thrombectomy?  Dr Leppert: Yeah. So, I think that as our evidence is getting better for thrombectomy, I would be more judicious about using IV thrombolysis, especially around the time of delivery, cause there is some evidence that it can be associated with postpartum hemorrhage. Patient selection, I think, is key here. So, women who have disability associated with their stroke, and then women who aren't candidates for thrombectomies are still candidates for IV thrombolysis. But understanding that this is a little bit of an unchartered territory for us, and only using IV thrombolytics when we think that there is a big benefit to be had.  Dr Nevel: Can you talk a little bit more about RCVS and PRESS in pregnancy and some of the overlap that we see in this patient population and its relationship to preeclampsia? It seems like there's a lot of interconnections there, and I thought that that was pretty interesting in your article.  Dr Leppert: Right now, the thinking is that RCVS and PRESS are on the same spectrum of pathology, and we think that it has something to do with the autoregulation of vascular resistance in the posterior circulation of the brain. We're not sure what triggers this, but there is something about pregnancy that classically we'll see this postpartum RCVS phenomenon. It likely has to do also with blood pressure that we're seeing. So really classically we think of this, like, thunderclap headache. You see vasospasms on imaging that is transient, that are kind of the classical signs of RCVS. But I think that we're still not completely sure what triggers it, but it's a very well-described clinical phenomenon.  Dr Nevel: Great. Thank you. Could you share a little bit about migraines in pregnancy and stroke risk? [laughs] I also thought that this also a segment of your article that caught my attention because migraines are so common. What's the association of migraine, pregnancy, and stroke risk?  Dr Leppert: Yeah. So that's a very complicated association. So, we know that migraines are associated independently with strokes, and especially people with migraines with aura. However, migraines are also highly associated with PFOs, right? And during pregnancy, what we see is that there is a hypercoagulability state, and so we see lots more DVTs, we see more PEs associated with women during pregnancy. So potentially, because migraineurs also are more likely to have PFOs, they could be presenting with more cardioembolic, kind of paradoxical emboli from these thrombus. But I'm not quite sure that we know why migraines in and of itself, especially with migraines with aura, lead to strokes. And especially during pregnancy, I'm not sure because we have very little understanding about pathophysiology of pregnancy while having migraines with aura also leads to more strokes, or that risk is really just associated with PFOs. So, I think that we need to think about that a lot more. The recommendation is a baby aspirin if you have some of these risk factors for preeclampsia, any vascular risk factors, and including migraines with aura during pregnancy. And we think that baby aspirin is relatively safe, especially starting around the 12 to 16-week period.  Dr Nevel: So just to clarify, in a woman who's pregnant, who's 12 weeks or beyond in their pregnancy and who has migraine with aura, is that a patient that we should consider aspirin for them to reduce their stroke risk?  Dr Leppert: I think you can. I am not sure that there is a specific recommendation. I think that, like, a conversation with your OBGYN is, you know, a good idea. But we do recommend that baby aspirin for women, um, above 35 years old because it's considered advanced maternal age. And then we recommend baby aspirin with women with a history of hypertension, multiple gestations, diabetes, renal disease, autoimmune disease. So, I definitely think that is something to consider.  Dr Nevel: Yeah. Interesting. Okay, great. Thank you for that. When someone has a stroke and they're pregnant again, what are some strategies for secondary stroke prevention? And you mentioned some of the primary risk reduction, but are there any others that you haven't mentioned yet other than aspirin and blood pressure control for primary prevention? Dr Leppert: Yeah, absolutely. So, I think that it's important to plan ahead. So, for women who are thinking about getting pregnant after they've had a stroke, one of the tenets of stroke neurology is trying to figure out why the first stroke happened. So, I feel like before getting pregnant, it's great to have a very thorough stroke workup so that you understand what the risk factors were and that those risk factors are controlled. One of the interventions, one of the only interventions that's, has evidence in young people with strokes is PFO closure. So, if you do have a stroke from a PFO, we recommend you get that closed prior to your pregnancy because then hopefully even given the hypercoagulability of pregnancy, there's some protection against another embolic stroke.  Dr Nevel: Another really interesting part of your article that I did not know before I read it was about the risk of cardiovascular disease long term in women who have had stroke during pregnancy. Could you talk a little bit more about that?  Dr Leppert: What we understand is that gestational diabetes and gestational hypertension sets you up for having diabetes and hypertension later on in life, and it's really developing the actual diabetes to the hypertension that increases your risk of strokes. So, what's really an important takeaway for providers is that after women develop gestational diabetes or they have gestational hypertension or they develop preeclampsia, it's very important for their primary or their neurologist to be very vigilant of these risk factors developing so that they can be modified before the women are at higher risk for strokes. And the reason why we think this happens is because pregnancy is like a stress test for your body. And so, the fact that you've developed the gestational diabetes or the gestational hypertension kind of already suggests that you're more likely and more vulnerable to developing these traditional risk factors later on.  Dr Nevel: That makes sense. Thank you for that. What do you think is a common misconception about stroke in pregnancy?  Dr Leppert: When I was earlier in my training, it kind of felt like having a stroke during pregnancy was being struck by lightning. It was really random. There was nothing you could do. It just happened to people. And I think as I learned more in my career, and especially researching for this article, I'm kind of shocked and disturbed by how much of the strokes in pregnancy we can actually prevent. Through management and monitoring of blood pressure for women. And so, I do think that it does our patients a disservice if we think that these are rogue events. But really, it might be a sign of the failure of our health system where we're not taking care of women around their delivery and postpartum and being more vigilant about their blood pressure and more vigilant about the clinical signs that they're developing.  Dr Nevel: Yeah, I really got that from your article, how important it is to monitor for blood pressure and other risk factors, and that that continues after the baby's born. Thank you so much for that, and thank you for talking with me today about your article about stroke and pregnancy. Again, today I've been interviewing Dr. Michelle Leppert about her article on pregnancy and stroke risk. This article appears in the June 2026 Continuum issue on cerebral vascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. And thank you so much 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.

In this episode Dr. Anthony Fitzpatrick talks about a unique apprenticeship program designed to enhance skills of teachers and facilitate movement on the salary schedule all without intrusive amounts of time after regular school hours. Who benefits? Everyone!Links:LinkedIn:  Anthony Fitzpatrick, Ed.D. | LinkedInFacebook:  (1) anthony fitzpatrick - Search Results | FacebookInstagram: antfitz55Website: Anthony Fitzpatrick | Enhance Education Today – Get InspiredTik Tok: https://www.tiktok.com/@antfitzyAnthony's most recent book:The Evolving Science of Reading: Building a Continuum from Foundations to Fluent Thinking This podcast sponsored by:The Bell Ringer, a weekly newsletter providing news, tools, and resources on the science of learning, written by education reporter Holly Korbey. Subscribe here. 

Adelio Fusé"Souvenirs in continuum"Poesie 2003 - 2023Prefazione di Andrea RompianesiPostfazione di René CoronaBook Editorewww.bookeditore.itI souvenirs del titolo erano inizialmente previsti al singolare, con allusione ironica – vale la pena notare che a souvenir fonicamente ben si accompagna sourire – all'oggetto-ricordo che si porta in regalo da un viaggio e, di riflesso, a questa autoantologia, surrogato di un percorso idealmente destinato alle poche lettrici e ai pochi lettori su cui la poesia può fare affidamento. Quanto all'autore, l'occasione gli consente di dichiarare il proprio les jeux sont faits, almeno in riferimento a ciò che fin qui si è lasciato alle spalle ma con la prospettiva di aprire nuovi ‘giochi'.Lo slittamento dal singolare al plurale sposta l'accento sulle singole tappe (i souvenirs) che hanno preceduto la sintesi (l'antologia-souvenir), rendendola possibile. Tappe ‘mobili', in movimento costante, come quelle di un viaggio, appunto, costituite da sette libri (Il boomerang non torna, Orizzonti della clessidra distesa, Canti dello specchio bifronte, L'obliqua scacchiera, La veglia del sonnambulo, Tempo ventriloquo, Mosaico del viandante). Tappe, inoltre, in comunicazione tra loro, che via via, procedendo, si passano il testimone sino a formare due cicli – “Quadrilogia degli oggetti anomali”, “Trilogia dell'erranza” – sconfinanti l'uno nell'altro. Il continuum è la forma di confluenza che ne deriva.Nel loro succedersi le poesie del settetto costituiscono un teatro-mosaico di situazioni variabili e in progressione, dove l'esterno (l'alterità, i luoghi come fucine di storie) conta innegabilmente più dell'interno (il famigerato io o il ‘chiuso' di un rifugio). Di spostamento in spostamento ci si trova soprattutto en plein air – aree urbane e periferiche, monti e pianure, spiagge vuote e isole –, dentro un'esperienza in divenire che dal presente guarda al futuro riattualizzando il passato e che interseca verosimile e inverosimile, realtà e sogno. L'io è centrifugo, un personaggio tra i personaggi. Anzi, vero attore protagonista è il tu, imprescindibile figura di dialogo.Si è cominciato con un boomerang che non torna e prolunga il lancio, e si è giunti al mosaico di un viandante a cui mancherà sempre un tassello per potersi completare. L'erranza-continuum era già nell'avvio. Adelio Fusé (1958) è autore di saggi su Sade, Kafka, Sartre, Handke, Eno (Materiali Sonori-Auditorium, 1999) e dei romanzi North Rocks (Campanotto, 2001), L'astrazione non è la mia passione principale (Manni, 2018), Le direzioni dell'attesa (Manni, 2020), Di chi sono queste insonnie (Manni, 2025, candidato al premio “Procida-Isola di Arturo-Elsa Morante”). I suoi libri di poesia, tutti pubblicati da Book Editore, hanno ottenuto riconoscimenti a diversi premi (“Lorenzo Montano”, “Camaiore-Francesco Belluomini”, “Bologna in Lettere”). Collabora con artisti, fotografi, musicisti e scrive per varie riviste.www.adeliofuse.itDiventa un supporter di questo podcast: https://www.spreaker.com/podcast/il-posto-delle-parole--1487855/support.IL POSTO DELLE PAROLEascoltare fa pensarehttps://ilpostodelleparole.it/

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat explore procedural sedation in the pediatric ICU. They cover sedation levels, pre-screening, risk stratification using ASA classifications, and medication selection tailored to each patient's hemodynamic and respiratory status. Through real-world case discussions involving respiratory failure, septic shock, and acute neurological decline, they highlight the importance of end-tidal CO2 monitoring and early adverse event recognition. Key takeaways include avoiding the term "conscious sedation," preparing rescue plans, and prioritizing patient safety through careful assessment and monitoring.Show Highlights:Definitions and levels of sedation (minimal, moderate, deep sedation, and general anesthesia)Importance of terminology in procedural sedationMonitoring sedation levels using scales like the Richmond Agitation-Sedation Scale (RASS)Pre-screening and risk stratification considerations for pediatric patientsASA physical status classification system for assessing patient riskUnique challenges of procedural sedation in critically ill childrenAdverse events associated with pediatric procedural sedation, particularly respiratory complicationsManagement strategies for specific cases requiring sedation (e.g., respiratory failure, septic shock)Importance of end-tidal CO2 monitoring during sedationKey takeaways for safe sedation practices in the pediatric ICU settingReferences: Nir Atlas; Rahul C. Damania; Pradip P. Kamat In Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 135, 1624-1628Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia by Committee on Quality Management and Departmental Administration. Last Amended: October 23, 2024.Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019 Jun;143(6):e20191000. doi: 10.1542/peds.2019-1000. PMID: 31138666.xKrauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006 Mar 4;367(9512):766-80. doi: 10.1016/S0140-6736(06)68230-5. PMID: 16517277.Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth. 2024 Mar;132(3):491-506. doi: 10.1016/j.bja.2023.11.050. Epub 2024 Jan 6. PMID: 38185564.Smith, Heidi A. B. MD, MSCI (Chair)1,2; Besunder, James B. DO, FCCM3,4; Betters, Kristina A. MD1; Johnson, Peter N. PharmD, BCPS, BCPPS, FCCM, FPPA, FASHP5,6; Srinivasan, Vijay MBBS, MD, FCCM7,8; Stormorken, Anne MD9,10; Farrington, Elizabeth PharmD, FCCM11; Golianu, Brenda MD12,13; Godshall, Aaron J. MD14; Acinelli, Larkin CPNP-AC, ACHPN15; Almgren, Christina CPNP16; Bailey, Christine H. MD17; Boyd, Jenny M. MD18,19; Cisco, Michael J. MD20; Damian, Mihaela MD, MPH21,22; deAlmeida, Mary L. MD23,24; Fehr, James MD13,25; Fenton, Kimberly E. MD, FCCM14; Gilliland, Frances DNP, CPNP-AC/PC26,27; Grant, Mary Jo C. CPNP-AC, PhD, FAAN28; Howell, Joy MD29; Ruggles, Cassandra A. PharmD, BCCCP, BCPPS30; Simone, Shari DNP31,32; Su, Felice MD21,22; Sullivan, Janice E. MD33,34; Tegtmeyer, Ken MD, FAAP, FCCM35,36; Traube, Chani MD, FCCM29; Williams, Stacey CPNP-AC37; Berkenbosch, John W. MD, FAAP, FCCM (Chair)33,34. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric Critical Care Medicine 23(2):p e74-e110, February 2022. | DOI: 10.1097/PCC.0000000000002873Benzoni T, Agarwal A, Cascella M. Procedural Sedation. [Updated 2025 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551685/Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. J Intensive Care. 2016 Oct 26;4:65. doi: 10.1186/s40560-016-0189-5. PMID: 27800163; PMCID: PMC5080705.Tel-Dan SF, Shavit D, Nates R, Samuel N, Shavit I. Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia. Pediatr Emerg Care. 2021 Dec 1;37(12):e1209-e1212. doi: 10.1097/PEC.0000000000001975. PMID: 31929389.Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med. 2022 Dec;80(6):485-496. doi: 10.1016/j.annemergmed.2022.05.002. Epub 2022 Jun 23. PMID: 35752522.Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006 Sep;118(3):1087-96. doi: 10.1542/peds.2006-0313. PMID: 16951002.

rWotD Episode 3333: Expressive therapies continuum Welcome to random Wiki of the Day, your journey through Wikipedia's vast and varied content, one random article at a time.The random article for Friday, 19 June 2026, is Expressive therapies continuum.The Expressive Therapies Continuum (ETC) is a model of creative functioning used in the field of art therapy that is applicable to creative processes both within and outside of an expressive therapeutic setting. The concept was initially proposed and published in 1978 by art therapists Sandra Kagin and Vija Lusebrink, who based the continuum on existing models of human development and information processing.This schematic model serves to describe and assess an individual's level of creative functioning based on aspects such as the artist's purpose for creating a piece, choice of medium, interaction with the chosen medium, and imagery within the piece. Conversely, it also serves to meet the needs of the client by assisting the art therapist in choosing a developmentally or situationally appropriate activity or art medium. By analyzing an individual's art making process and the resulting artwork using the ETC, art therapists can assess strengths, weaknesses, and disconnect in various levels of a client's cognitive functioning - suggesting or substantiating diagnosis of, or recovery from, a mental health condition.This recording reflects the Wikipedia text as of 01:07 UTC on Friday, 19 June 2026.For the full current version of the article, see Expressive therapies continuum on Wikipedia.This podcast uses content from Wikipedia under the Creative Commons Attribution-ShareAlike License.Visit our archives at wikioftheday.com and subscribe to stay updated on new episodes.Follow us on Bluesky at @wikioftheday.com.Also check out Curmudgeon's Corner, a current events podcast.Until next time, I'm generative Kajal.

Primary stroke prevention is a critical opportunity for neurologists, with most stroke risk driven by modifiable factors such as hypertension and lifestyle behaviors. This episode highlights practical tools and strategies, including Life's Essential 8 and contemporary risk calculators, while also exploring evolving approaches to shared decision making and secondary prevention. In this episode, Katie Grouse, MD, FAAN, speaks with Mitchell S. Elkind, MD, MS, FAAN, author of the article "Stroke Prevention" in the Continuum® June 2026 Cerebrovascular Disease 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. Elkind is the Chief Science Officer for Brain Health and Stroke at the American Heart Association in Dallas, Texas, and a professor of neurology and epidemiology at Columbia University in New York, New York. Additional Resources Read the article: Stroke Prevention 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 Guest: @MitchElkind Full episode transcript available here Dr Grouse: Neurologists have generally been more involved in secondary stroke prevention, but primary stroke prevention is increasingly recognized as an important topic of discussion for neurologists. Today, I have the opportunity to interview Dr. Mitchell Elkind, who wrote the article on stroke prevention in the newest Continuum issue on cerebrovascular disease.  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. Mitchell Elkind about his article on stroke prevention. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, and please introduce yourself to the audience.  Dr Elkind: Thank you so much, Katie. So, my name is Mitch Elkind, and I'm the Chief Science Officer for Brain Health and Stroke at the American Heart Association and a stroke neurologist by background.  Dr Grouse: Well, I just want to start by saying that I really enjoyed reading this article. I think this is just a really wonderful article I recommend strongly. Such a high yield, an important topic for a lot of us who see patients who are interested in learning about their stroke risks or need help with, uh, stroke prevention after having a stroke. So, I wanted to start. What's changed in the last couple of years? You know, what are some big highlights that you really want to stress that are different from maybe the last time we reviewed this topic?  Dr Elkind: Sure. Well, there's been a lot of development in the field of secondary stroke prevention, for one thing. But even beyond that, I think we increasingly appreciate how important it is to control what we call the social drivers of health on the earlier side, primordial or primary prevention. And that has been a big advance, I'd say. And I would also say, I think it's really important for neurologists to understand some of those questions about primordial and primary prevention. You know, we tend to get involved with patients after they've had a stroke or maybe a TIA, some kind of event. But sometimes we find people who are following for, you know, non-stroke related conditions who have risk factors also. And we can really play an important role in identifying those risk factors and helping to prevent a first stroke or vascular event as well. So, I think it's real important for us to be doctors even before we're neurologists. So, you know, Katie, about ninety percent of stroke risk is modifiable, so we can do a great job as neurologists in preventing stroke. And one of the most important things that we can do is to identify and treat high blood pressure. And recently, actually, the American Heart Association, American College of Cardiology guidelines on the management of hypertension have said that treatment of high blood pressure not only prevents stroke, but it can also help to prevent cognitive decline and dementia. And this is the first time that we've had a class of recommendation one and level of evidence A, the highest level of recommendation we give for the use of blood pressure treatment to prevent dementia. And that's largely based on the results of some large trials that have come out recently showing that you can prevent dementia with blood pressure control. So that's a really exciting link, I think, between cardiovascular risk factor control and subsequent brain health. It just illustrates the role that neurologists can play in, so many conditions outside of stroke as well.  Dr Grouse: That's a really great point, and I want to get a little more into the idea of primordial stroke prevention. Can you tell us a little bit more about what that might be?  Dr Elkind: So primordial prevention refers to addressing how we can prevent risk factors from occurring in the first place, and how can we improve the environments in which people live. You know, we know that only about twenty percent of health outcomes is dependent on what happens between the patient and their doctor in the office. About eighty percent of it is due to what happens in the environments in which we live, work, pray, and play. And so that's what we mean when we refer to the social drivers of health. What is the neighborhood like where somebody lives? Do they have access to healthy food? Do they have places where they can go to exercise? Is there air pollution in the area that may affect their health? You know, one really interesting fact that's become apparent in the last few years is that air pollution is a major risk factor for stroke. Something like a sixth of all strokes can be attributed to the quality of air. And so, what are the things we can do at the broader public policy, community level to reduce the risk of risk factors like high blood pressure and diabetes even before somebody has an event that brings them to the attention of the doctor? So that's what we're thinking about with regard to primordial prevention. It's the earliest stage in prevention.  Dr Grouse: And that's really fascinating. You know, I think an area that we haven't, as neurologists, really put a lot of our time thinking about, but clearly a very important thing. I really appreciated reading your article about how you incorporated the fact that, you know, a lot of these risk factors overlap very, very closely with all the risk factors for various types of cardiovascular events. And I would imagine that the work you've done as the Chief Clinical Science Officer for the American Heart Association has informed a lot of the way you've thought about-Trying to bring all these risks together and think a little bit more holistically about the whole thing. Could you tell us a little bit more about that and the work that you've done on the American Heart Association's Life's Essential 8 score?  Dr Elkind: Sure. I can't take credit for it. It's really work that was done by others at the Heart Association, particularly a cardiologist and epidemiologist named Don Lloyd-Jones. But many other volunteers participated. Life's Essential 8 is our approach to primary stroke prevention and cardiovascular prevention more broadly. We say Life's Essential 8 because it includes four health behaviors and four health factors that people can observe to reduce their risk of cardiovascular disease. The four factors are kind of things like know your numbers, your blood pressure, your blood sugar, your body mass index, right, which is a combination of weight and height, and your cholesterol level. So, know those numbers and keep them within the recommended ranges, and talk to your doctor if they're not. And then four lifestyle behaviors. So, one of them is to eat a healthy diet, and typically that means the Mediterranean diet. It means getting regular exercise, and we recommend 150 minutes a week of moderate to vigorous physical activity. Of course, it means abstinence from smoking or other tobacco products. And the last one, the eighth one, which I was so excited about when we added this, is sleep, recommending at least seven hours of sleep a night. So, I was really excited about this because we used to talk about Life's Simple 7, and then the last iteration of our recommendations included this recommendation for adequate sleep because of the mounting evidence of the importance of sleep to cardiovascular health. But sleep is really a brain function, right? And so, it was really the first, in a way, specific brain function that was added to our recommendations. So that's Life's Essential 8. People can read about it online at heart.org and recommend it to your patients as a simple way for people to understand the best approach to reducing their risk of cardiovascular disease, including stroke.  Dr Grouse: I checked it out myself after reading the article. It's very accessible to patients. It's a great education tool. And they can, you know, see their own score and use that in their own way to, to think about what their risks are and how they can help mitigate and then rescore themselves down the line. There's also, though, on the kind of more the clinician side, the PREVENT calculator as well. Could you tell us a little bit more about how we could use that in approaching this patient population?  Dr Elkind: Yeah. So, I think of Life's Essential 8 as being a patient-focused tool that people can use. PREVENT is really more for clinicians. Anybody can look it up online and enter your data into it. There's a risk calculator online. But the basic idea behind PREVENT and other similar risk calculators is that it's a way to estimate somebody's risk of having a cardiovascular event like stroke or a heart attack or even heart failure by entering information about your health. And we used to think, we used to use something called the ASCVD, atherosclerotic cardiovascular disease risk calculator, or the Framingham score. Framingham Heart Score, for example, was another one. PREVENT is the latest version, and it has several advantages over those earlier types of risk predictors. For one thing, it predicts risk at younger ages as well. It goes down to age 30. It predicts risk over a longer duration of time, so over 30, 10 or 30 years. It eliminates the use of race as an item to put into the calculator and substitutes for that socioeconomic status, so it's not a race base, but a measure of social disadvantage. And it also includes kidney elements, kidney measures. It includes renal function, for example, that weren't included in prior measures, and it can also be used to predict heart failure, which was not part of the original calculators. Another major advantage of the PREVENT study is that it was based on real-world data from about three million patients, many, many more than the 50,000 or so that the earlier risk calculators were based on. So, it has a much more robust data set and therefore allows a bit more precision in the ability to predict future risk of events. And typically, primary care doctors would enter their patient's data, calculate a risk, and then based on the results of the risk calculator, they can make recommendations about what type of medications a person should take or what other strategies they could use to reduce their risk. And so that's the role that PREVENT plays, is really being focused more for the clinician than the patient.  Dr Grouse: Really great tool for us to be aware of. You earlier alluded to the fact that neurologists are in the situation where we sometimes are helping patients with this primary prevention. But you also make a case for why it's in the patient's best interest for us to be involved in, in these conversations when we can, when we have the opportunity. Can you tell us more about that?  Dr Elkind: Shared decision-making is really important because we know that people aren't going to lead the healthiest possible lives if they're not invested in their care. And so, a doctor telling somebody what to do if the patient doesn't want to do it is gonna have limited benefit.So we emphasize the importance of shared decision-making as much as possible. And I think that where this comes up a lot is actually in the situation of, for example, atrial fibrillation, where patients will often be put on a blood thinner. And many people are fearful of blood thinners. They worry about the risk of bleeding. Maybe they know a relative who's had a bleeding complication from a blood thinner, and so they may be disinclined to try it. And so, it's really important to have these discussions about the risks and the benefits of medication and engage the patient in thinking about this. And there are even tools and visual aids that people can look to to help explain some of these complicated concepts to patients. So, these are the kinds of things that reflect implementation science as a way to improve adherence. We know what works in a clinical trial setting often, but the challenge is translating that into the real world and getting our patients to use the medications that we believe scientifically have been shown to be of benefit. I've actually been surprised sometimes at conversations I've had with people, in some cases, healthcare professionals who resist going on blood thinners because of their fear of the complications. And I feel like the evidence is there. Why don't they believe me? And that's why it's really important to have the conversation. Even our peers and colleagues can sometimes question the evidence, and it's important for us to be aware of that.  Dr Grouse: Absolutely. I think that sounds very reasonable to me, and hopefully these tools will help us with making some of these decisions with our patients. Now, turning our attention a little bit to secondary prevention. So, you know, someone's already had a stroke or a TIA, sort of thinking about what we can do to optimize their risk factors for further strokes. You know, I think there has been some changes that have happened, I think, in the last few years that might be affecting some of the decisions we're making and some of the advice we're giving our patients. I wanted to talk a little bit about GLP-1 receptor agonist medications. Is the data there to support use of this either in secondary prevention or even in primary prevention in the case of stroke?  Dr Elkind: There is evidence that supports the use of GLP-1s for stroke prevention. We need more data, though. We need trials that focus only on patients with stroke, for example, there have been studies in patients with cardiovascular disease broadly that include stroke patients. But if you look at the subcategory just of stroke patients alone, the data in that subgroup alone don't always show a benefit. And so, we need more data that's focused on stroke patients alone. So, I think the data are continuing to emerge, but we need more still.  Dr Grouse: Is there any development in the thought about whether we should be putting patients on antiplatelet therapies for incidental, incidentally identified strokes? For instance, if you got an MRI for migraine or for other reasons and you found one, no history of any stroke-like symptoms. Should we be putting these patients on aspirin or any other types of therapies?  Dr Elkind: That's a really great question. And again, it's an area where there's some controversy and really, there's really no definitive data that would support using antiplatelet therapy in people with incidentally discovered infarcts or what we call, you know, whispering strokes or silent strokes. Many stroke neurologists will use antiplatelet agents. This is one of those areas where it's so important to identify the risk factors. As we were saying before, patients who have other neurological disorders like migraine or epilepsy may turn out to have cardiovascular risk factors like diabetes and high blood pressure. That's why it's so important for neurologists to be able to treat those patients or refer them to specialists who can. Patients who have incidentally discovered lesions similarly are a group where we should be looking for risk factors. So, I don't think of it only in terms of do we put them on an antiplatelet or not, but really more holistically, can we identify their other risk factors and address those? Should the patient's information be entered into a risk calculator like PREVENT, for example, so that we can come up with a more global or holistic measure of their cardiovascular risk and address that as appropriate? Because if they are at risk for stroke, they're also at risk for cardiac events, including heart attack, heart failure, sudden cardiac arrest, and so forth. So, I think of it as a, as a great kind of teachable moment or an opportunity to catch somebody and bring them into the healthcare system more broadly and address those other potential risk factors.  Dr Grouse: Speaking of, of risk factors that we often like to think about and work up when possible, in cases where it seems certainly possible the patient had an embolic stroke, but perhaps we've done a few weeks or four weeks of cardiac monitoring, have not found any evidence of atrial fibrillation. What's new and what's the current recommendations for doing further monitoring when there's high suspicion for cardioembolic stroke?  Dr Elkind: This is a really active area of investigation, and guidelines suggest that we should do some cardiac monitoring for atrial fibrillation after an unexplained stroke, but it's not clear how much we should do. Studies generally show that the longer you follow somebody on a cardiac monitor after stroke, the more likely you are to detect atrial fibrillation. It could be as high as thirty percent after a few years. And that's great. And if you detect atrial fibrillation, people usually end up being recommended for a blood thinner. But how extensively we should monitor remains unknown. And I think a lot of the investigation recently has been around the question of, are there other ways to get that information rather than waiting six months or a year for the person to develop atrial fibrillation?It's a little bit funny logically to think a person has a stroke today, a year later you discover atrial fibrillation on the monitor, and you say, "Oh, now I know what caused your stroke a year ago." Right? The temporality, the causality perhaps is off in that case. And so, wouldn't it be better if we could tell what somebody's risk of having another cardioembolic stroke is, or the likelihood that they have atrial fibrillation is at the time that you first see them for the stroke, you know, in the hospital, for example. And so, there's some really new technologies that have evolved like AI or artificial intelligence interpretation of EKGs that can give a really good indication of which people are gonna go on to develop atrial fibrillation. And so, I think we need some more trials in that area to demonstrate that we can detect the risk of AFib and treat that even before it appears on one of those delayed monitors. That's an area that I think is very exciting right now. There's also a further question with regard to how to treat these patients, which is that sometimes atrial fibrillation is a consequence of the stroke itself. So, we can think about what people call known AF, meaning atrial fibrillation that's known about before the stroke even occurs, versus AF that's detected after a stroke, or AF-DAS, people will say. Those may have very different implications for the risk of recurrence and what the person's cardiovascular status is. So, I think what we've learned over the last few years is that atrial fibrillation, it used to be like the slam dunk for a stroke neurologist. It was the easy thing. You know, you had a stroke, you have AFib, you should be on a blood thinner. Now we know that there's lots of different kinds of AFib. There's AFib before stroke, there's AFib after stroke, there's burden of atrial fibrillation. So, some people may have 30 seconds of AFib, some people may have several hours, some people may be in it continuously. It comes and goes, and that can make it challenging to manage. So, we have a lot more work to do to understand this problem better.  Dr Grouse: That also gets me into some other interesting areas that I think there's still some question, you know, how aggressive should you be? How often is it a case of is this correlated or is this causative? For instance, when a patent foramen ovale is, is discovered in patients with cryptogenic stroke. Are there any tools or new developments to help us understand whether these PFOs should be closed in these cases?  Dr Elkind: PFO and stroke is a great story that's been going on for decades. And again, we've made tremendous progress in the last several years. So, it's true that about 20% or so of people have a PFO, and because of that, it can be really hard to say with any certainty whether an individual patient sitting in front of you, that the PFO was the cause of their stroke. Rarely we can have a really high degree of certainty. You know, if somebody has, uh, a DVT, for example, and shortly after that maybe they have pulmonary embolism and then a stroke, and we can say, "Oh, clearly this was a paradoxical embolism," went to the lungs and then some crossed over and went to the brain. That happens really infrequently. Most of the time you're faced with a patient who has a PFO and a stroke, and they may have some other risk factors. There are some tools that we can use to help figure out the likelihood that a PFO is related to a stroke. One of those is called the ROPE score or the risk of paradoxical embolism score that was developed by David Thaler and, uh, David Kent from Tufts and a group of other investigators as well. That score allows one to say what the likelihood is that the PFO was causative of the stroke, and it's based on a person's risk factors such that the younger you are, the more likely it is the PFO caused the stroke. And the absence of risk factors make it more likely that the PFO caused the stroke. So, the higher your ROPE score indicating the fewer other reasons you have a stroke, the more likely the PFO is to be causative. So that can be helpful in identifying patients who may have had a stroke due to their PFO. There are other features that are identified in something called the PASCAL score, which is a way of assessing the degree of shunting and whether or not there's an atrial septal aneurysm that can be used as additional factors that lead to the likelihood that a PFO was causative rather than just incidental. So, by putting this kind of information together, we can kind of do precision neurology or precision prevention by identifying which patients with a PFO are really the ones we need to worry about and do procedures like closure.  Dr Grouse: I look forward to hearing more and learning more as more advances are made in these areas. Dr Elkind: Thank you.   Dr Grouse: And thank you so much for joining us today to talk about your article.   Dr Elkind: Oh, I appreciate it. Thank you for giving me the opportunity. I really enjoyed it.  Dr Grouse: Again, today I've been interviewing Dr. Mitchell Elkind about his article on stroke prevention. This article appears in the June 2026 Continuum issue on cerebrovascular disease. 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.

Text the Show⭐️ Affiliate item of the week: Duracell Tri-Power Rechareable Emergency Lantern 3000 Lumens with QI Charging:  https://amzn.to/4xpENnfNo guest tonight so we will be going on a few journey's with you all back in time and looking ahead to a future that is taking shape right in front of us today. Join us live in the chats, phone line will be open for you to call in 248-238-8155.The story of the "Angel's Glow" is one of the most fascinating legends to come out of the Battle of Shiloh during the American Civil War.The Berserkers (Old Norse: berserkir) were legendary Norse warriors who were said to enter a battle frenzy so intense that they seemed almost superhuman. Their reputation was so powerful that the English word "berserk" comes directly from them.What if the world ended... and nobody noticed? What if history changed, but only some people remembered the way it used to be? SUPPORTBuy Me A Coffee http://buymeacoffee.com/DangerousinfopodcastSubscribeStar http://bit.ly/42Y0qM8Super Chat Tip https://bit.ly/42W7iZHBuzzsprout https://bit.ly/3m50hFTPaypal http://bit.ly/3Gv3ZjpPatreon http://bit.ly/3G3SMART is the acronym that was created by technocrats that have setup the "internet of things" that will eventually enslave humanity to their needs. Support the showLeave Voicemail: https://www.speakpipe.com/DangerousInfoWebsite https://www.dangerousinfopodcast.com/Discord chatroom: https://discord.gg/8feGHQQmwgEmail the show dangerousinfopodcast@protonmail.comJoin mailing list http://bit.ly/3Kku5YtWatch LiveYouTube https://www.youtube.com/@DANGEROUSINFOPODCASTRumble https://bit.ly/4q1Mg7Z Twitch https://www.twitch.tv/dangerousinfopodcastPilled.net https://pilled.net/profile/144176  Facebook: https://www.facebook.com/DangerousInfoPodcast/SocialsInstagram https://www.instagram.com/dangerousinfo/TwitterX https://twitter.com/jaymz_jesseYouTube https://bit.ly/436VExnFacebook https://bit.ly/4gZbjVa

What if your vertigo anxiety isn't “just anxiety” — but your brain and body reacting to feeling deeply unsafe and unsteady?In this episode of Migraine Heroes Podcast, host Diane Ducarme explores the complex relationship between vertigo, dizziness, and anxiety. When the world feels like it's spinning, your nervous system naturally shifts into survival mode. But too often, people are told to simply “calm down” without addressing what may actually be happening inside the brain and body.Blending neuroscience with a compassionate, holistic perspective, this episode helps you understand why the cycle of vertigo and anxiety can become so difficult to break — and what true regulation may really require.You'll discover:

Ashley Roberts chats with Brad Duncan, account director at Continuum, about zone-based pricing, the importance of co-mail consolidation, and more.

What should you really expect from a financial advisor? Is your advisor acting as a fiduciary, managing risk, helping with taxes, retirement income, estate planning, and behavioral coaching, or just selling products and chasing performance? Richard Rosso & Jonathan McCarty break down the real role of a financial advisor, what services matter most, how advisors are compensated, and the warning signs investors often miss. We also discuss fiduciary standards, portfolio management, communication expectations, financial planning, and why transparency matters more than promises.. Here's a topical rundown of today's show: 0:00 - INTRO 0:33 - Jerome Powell, Kevin Warsh, & CPI Review 3:43 - Employment Numbers & Data Centers 5:28 - What Does Your Advisor Do? 9:34 - What Should You Expect? 13:07 - What Are You Getting vs Giving Up? 16:56 - Looking at Taxes on a Continuum 19:26 -Investment Management is Important 24:37 - Financial Advisors with Open Minds 27:41 - Fixed-cost vs Fee-based Financial Planning 26:15 - How to Deal with Emotional & Cognitive Biases 27:11 - Fiduciaries Focus on Things You Miss 28:30 - Proper Asset Location 30:03 - Fee Transparency - How advisors get paid 31:35 - Red Flag Warnings When Choosing an Advisor 33:11 - What Annuities Do (and Don't Do) 34:44 - Big Firms vs Small Firms - KYC 35:38 - Fee-only vs Fee-based Advisors 36:49 - What Comprehensive Wealth Management Should Look Like Hosted by RIA Advisors Director of Financial Planning, Richard Rosso, CFP, w Senior Investment Advisor, Jonathan McCarty, CFP Produced by Brent Clanton, Executive Producer ------- Articles Mentioned in Today's Show: "The Perfect Planning Experiemce" https://realinvestmentadvice.com/ria-e-guide-library/ ------- Do you enjoy our content? Rate us on Google: https://bit.ly/4b9JtEo ------- Watch Today's Full Video on our YouTube Channel: https://youtube.com/live/HXafEWQMFuI?feature=share ------- Watch today's "Before the Bell" feature, "Momentum Mania Meets Market Rotation," here: https://youtu.be/bNIRIssbDP8 ------- Watch our previous show, "Inflation Surge Hits Markets?" https://youtube.com/live/UOSeQNOhcwI ------- * REGISTER for our next Candid Coffee, THIS Saturday, May 16: "Financial Organization Made Simple:" https://streamyard.com/watch/SA6aj2aMdMhf -------- Download Lance's Latest e-book, "Laws of Money & Wealth:"https://realinvestmentadvice.com/ria-e-guide-library/ -------- SUBSCRIBE to The Real Investment Show here: http://www.youtube.com/c/TheRealInvestmentShow -------- Visit our Site: https://www.realinvestmentadvice.com Contact Us: 1-855-RIA-PLAN -------- Subscribe to SimpleVisor: https://www.simplevisor.com/register-new -------- Connect with us on social: https://twitter.com/RealInvAdvice https://twitter.com/LanceRoberts https://www.facebook.com/RealInvestmentAdvice/ https://www.linkedin.com/in/realinvestmentadvice/ #FinancialAdvisor #RetirementPlanning #Investing #WealthManagement #Fiduciary

We talk about the election results, a couple events we went to, a protest that kate went to, and safe injection facilities. Decriminalize drugs!!!! Huge spoilers for I Love Boosters, the new Boots Riley movie!The music in this episode is from the I Love Boosters (Original Motion Picture Score)Supervised consumption explained: types of sites and servicesSupervised injection facilities in Canada: past, present, and future The Law (and Politics) of Safe Injection Facilities in the United StatesSupervised Injection Facilities and International LawNew Strategies Are Needed to Stop Overdose Fatalities: The Case for Supervised Injection FacilitiesCircumstances of First Injection Among Illicit Drug Users Accessing a Medically Supervised Safer Injection FacilityChanges in injecting practices associated with the use of a medically supervised safer injection facilitySituating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual FrameworkThe public health impacts of supervised injection sites in Canada: Moving beyond social acceptability and impacts on crimeFabulosa BooksWhat Is Reverse Tolerance and Why Does It Matter in Recovery?Bay Area Artists Connect Hosted on Acast. See acast.com/privacy for more information.

Click here for more on this topic and other free resources - https://www.drjimrichards.com So many people spend years struggling with failure, shame, and regret. They make a mistake, fall into a destructive pattern, and eventually begin to believe they have disqualified themselves from God's purpose. In this message, I want to help you see why that isn't true. Over the years, I've worked with people battling addictions, broken relationships, moral failures, and life-controlling problems. One thing I've learned is that real recovery is about much more than changing behavior. It happens when we understand how God's grace works in our lives. In this episode of Rescue & Recovery, I share what I call The Grace Continuum. Unfortunately, grace is one of the most misunderstood concepts in Christianity today. Many people confuse grace with mercy, forgiveness, or permission to continue in destructive patterns. But biblical grace is far more powerful. Grace is God's power working in your heart, enabling you to become everything He created you to be. I'll share why true grace never leads to lawlessness, why God's mercy always points us toward restoration, and how understanding the finished work of Jesus can free you from condemnation and empower you to move forward. No matter what has happened in your past, there is hope for your future. If you've ever wondered whether God can still use you after you've failed, this message is for you.

Social determinants of health, including housing, food access, insurance status, and structural inequities, significantly influence stroke prevention, recovery, and long term outcomes. These factors affect biological risk, treatment adherence, and disparities in care, even when traditional clinical measures are addressed. This episode highlights practical strategies for integrating screening, leveraging multidisciplinary teams, and identifying opportunities for advocacy to improve patient outcomes. In this episode, Teshamae Monteith, MD, FAAN, speaks with Nneka L. Ifejika, MD, MPH, author of the article "Social Determinants of Health and Their Impacts on Stroke Prevention and Outcomes" in the Continuum® June 2026 Cerebrovascular Disease 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. Ifejika is an adjunct professor of physical medicine and rehabilitation at UT Southwestern Medical Center in Dallas, Texas, and the chief scientific officer of the Division of Academics at Ochsner Health System in New Orleans, Louisiana. Additional Resources Read the article: Social Determinants of Health and Their Impacts on Stroke Prevention and Outcomes 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 Full episode transcript available here Dr Monteith: Two patients have the same stroke, but when they return, they have very different outcomes. We can look into some of their comorbidities, but something we don't spend enough time talking about is the social determinants of health. Stay tuned to this discussion. I promise you, you'll become a better neurologist. 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: This is Dr. Teshamae Monteith. Today I'm interviewing Dr. Nneka Ifejika about her article on social determinants of health and their impacts on stroke prevention and outcomes. This article appears in the June 2026 Continuum issue on cerebrovascular disease. How are you? Welcome to our podcast. Dr Ifejika: Thanks for having me. I'm doing great. Dr Monteith: Great. So, can you introduce yourself to our audience? Dr Ifejika: Sure. I'm Dr. Nneka Ifejika. I am the Chief Scientific Officer of Ochsner Health System in New Orleans, Louisiana. But I'm also a cerebrovascular rehabilitation doctor. I've been practicing for about nineteen years, and am happy and honored to be a contributor to this Continuum Neurology article. It's a really important topic. Dr Monteith: Great. So, what got you into this field, first of all? Dr Ifejika: Well, I was deciding between PM&R and neurology, and I was putting in both match lists. And I thought about it and I leaned toward PM&R, but stroke still had a grasp on my heart and my mind. And so, after I finished my residency, I joined the UT Houston stroke team, and I did a, thankfully did a two-year fellowship and became cross-trained in stroke as well as physical medicine rehab. So, I am a jack of both trades. Dr Monteith: So, you got your way in a way. Dr Ifejika: I did. Dr Monteith: You know, we have a lot of learners that are listening, so it's always, uh, nice for them to be inspired, I think, by people's career paths. So why don't we talk about the objectives of your article? Dr Ifejika: Sure. So, one of the most important things that we wanted to do was make sure that medical students, residents, faculty, and fellows understood the impact of social determinants of health on stroke recovery and stroke rehabilitation. It's not as simple as you have hypertension, hyperlipidemia, we're going to manage your stroke risk factors. Oh, you had an ischemic stroke. You presented in time for the window. We're going to give you endovascular therapy and then modified Rankin scale at hospital discharge in ninety days. No, no, no. The stroke survivor and their caregivers and their family have a lot more to deal with outside of what we look at during the acute stroke hospitalization and post-acute rehabilitation. Things like, can they afford the medication that we're prescribing? Antiplatelet agents or anticoagulation can be extremely expensive. Do they have housing insecurity? Is there food insecurity? What's going on behind the scenes that we are not addressing that can directly impact the admission rate and the readmission rate after we take care of a stroke survivor? Dr Monteith: I love the article because you took a real deep dive into social determinants of health, what they are, why they matter, and what we can do about them. And so why don't we talk a little bit about the NINDS framework for social determinants of health? I think many of us might not be familiar with the framework per se. Dr Ifejika: So, the framework consists of multiple domains specifically that relate to social determinants of health that were published in Neurology a couple of years ago. So, I do hope that people who are hearing this recording actually read them. There are interpersonal domains, there are classic medical domains, there are indeterminate domains, and there are six total domains. And health domains are the last domain. So, things like when it comes to housing insecurity, food insecurity, that's a domain of social determinants of health. When it comes to chronic racism, when it comes to biases that patients experience, those actually impact outcomes. So, there are six separate indices that we're going to get into in detail and how we address them as clinicians, whether it be at the medical student level, resident level, faculty level, to integrate the social determinants of health in our care plans, because we could be doing a much better job. And I think it'll be really important from the interpersonal perspective when we really relate to our patients and their families that we ask these questions. For example, if we're prescribing someone to have treatment for their diabetes mellitus and ha- and, and be taking insulin, if they have housing insecurity and they're in a homeless shelter, they have to leave the homeless shelter during the day. So, what happens to the insulin that we prescribe? These are variables that we are not considering on a regular basis, but they directly relate to compliance. Dr Monteith: Great. So that was one thing I wanted to bring up. We're very good at measuring blood pressure and trying to determine, uh, the association between stroke outcomes and things that we can measure, glucose, lipids, blood pressure. What is the evidence for social determinants of health and stroke outcome? Dr Ifejika: The evidence is growing, and there have been many publications that have come out that are, are going to be highlighted in this article related to structural determinants of health inequities, like structural racism, as well as disparities related to ethnicity and race. There's geographical disparities. For example, a lot of patients are, are primarily concerned about rural versus urban, whether you have access to different post-acute rehabilitation, whether you have access to secondary stroke prevention because you simply don't have the transportation from a, a rural area to get to a drugstore to get things available to you. Social status. There are actually publication related to socioeconomic status and the concerns when it comes to air pollution. So particulate matter 2.5, we know that that has a direct impact on stroke outcomes and health overall, but we don't really think about it as a structural determinant of health inequity. There's several multiple layers of research that have gone on specifically that have been cited in the literature that relate directly to social determinants of health and how we can address them moving forward. Dr Monteith: And what I found interesting in your article in that you gave at least a few examples where social factors like income, education were controlled for, and maybe in large part it is, but even when you control for some of these very obvious social risk factors, you still have inequities. Dr Ifejika: Absolutely. And I think it was really important to show that we had strong peer review evidence behind this, as it wasn't just something that we were creating or hypothesizing about. There have been studies that have been done over this over decades of time, showing the impacts of social determinants of health on outcomes. But the question and concern that we have is we know this growing body of literature continues to expand. What are we doing about it when it comes to education of the future generations of providers who will be caring for this population? Dr Monteith: Before we get into how, you know, what we're going to do about that, let's just kind of put that link, cause the evidence is there. How does it drive biology? Dr Ifejika: It's a great question. So, for example, particulate matter 2.5 in air pollution has been shown to have an existing impact on hypertension, raising your blood pressure. So that's a direct effect of a social determinant of health related to socioeconomic status because people who live in areas with higher air pollution are... They're not green spaces. They live near highways. Those are areas that unfortunately are also impacted by food deserts. Food deserts, if you're not able to get fresh fruits, vegetables, whole foods, increases your risk of developing diabetes, hyperlipidemia, also increases your sodium intake, again, increasing hypertension. These things are all connected to biological determinants. It's just that we're not asking about them necessarily within the social history when we're taking people into the hospital, but they have direct effects. Dr Monteith: Great. Neurologists tend to be busy and, you know, we're... have all of these things that we're being asked to do and chart and click and all of that stuff. And so how can we more readily integrate screening for social determinants of health and that conversation into the work we do? We recognize it's important. We recognize it's an important risk factor. There's a lot of these determinants. So, what is a good way to do so? And I, I know that in the paper you've, you've given different roles to different team players, so I want you to talk about that too, but just kind of even a regular routine office visit. Walk us through a way we can more easily integrate that kind of conversation. Dr Ifejika: It's an excellent question, and what I've recommended that we do in a standard office visit is utilize the time before the visit to send out screeners. So, for example, usually with an electronic medical record, you can send documents before the visit even starts, where people can check off whether they have any concerns regarding housing, food insecurity. They can check out their location of where they live, whether they live near a highway or not near a highway. It's specifically related to socioeconomic status. We can ask about insurance status, whether they have insurance, insured versus uninsured, but then also types of insurance, whether they have Medicaid insurance versus Medicare insurance. Then even drilling even further, type of Medicare insurance, Medicare Advantage versus traditional Medicare, cause all of those things actually play a role in this. Dr Ifejika: And evaluate these things and don't take time during your office visit. Send these screeners out beforehand. Have them be assimilated by your medical staff. Make sure you're utilizing every resource that you have at your disposal to help streamline things, so by the time the person comes in for the visit, you've primed the pump. You have this information already in your hands at your fingertips cause it was sent out in advance, and you have your medical staff already have an understanding of. If they didn't fill it out electronically, give it to them in the lobby. Make sure they have a handwritten copy in the lobby so that when they come into the office visit, you have the information at your fingertips. Dr Monteith: Are there any particular resources that you recommend for those types of screeners? Dr Ifejika: What I've used in the past, if you have patient-reported outcomes, so the PROMIS instruments, that's a good start. It doesn't get into the details of housing insecurity, food insecurity, but it's a good start to help prime questions and to start the conversation during your office visit. In my clinics, I do a PROMIS 27 on every patient, as well as a PHQ-9 for depression on everyone. And then I collect data longitudinally, and I can always drill down on factors that I noticed that could become a problem moving forward. Dr Monteith: Yeah. And then also in your article, you spoke a bit about this impact from the acute presentation in the hospital to rehab. Dr Ifejika: Yeah. Dr Monteith: So why don't you talk about these different entry points where we can really engage our patients and try and help reduce their burden? Dr Ifejika: Sure. So, healthcare can be quite fragmented, and the stroke patient, stroke survivor, and their family member have no grasp of that. They've had a stroke, and they may be going from the ER to the ICU to the stroke unit to the floor to the rehab unit, and we see it as multiple levels of care, multiple types of providers. They see it as one hospital. And the concern that we have is, at those branch points, things get dropped, and we have the opportunity to pick things up at those branch points. So, during the acute care hospitalization-Primarily, that's the establishment of what has happened, how we're gonna treat it, what are the variables that we can control for right now to address those determinants of health moving forward, and to specifically looking at whether they were taking medications before, whether they could afford medications before, what that looks like at hospital discharge. Is there any duplication of medications? If a person is taking Coreg and you prescribe metoprolol, but they still have the Coreg at home, should we have really prescribed the metoprolol? We're just spending money that they may have concerns when it comes to access to care and the cost of these prescriptions. So, it's the responsibility of the acute care physician to kind of look at that. Those are subtle things that we think are subtle, but they add up quickly for the family when it comes to having one group of medications that's the same class and having to buy another type. When it comes to post-acute rehabilitation, it's really an important time to screen for whether the caregiver can handle what's occurring. So specifically, if the caregiver is already burning out and the average length of stay for a stroke patient is five days and they've come to rehab for two weeks, what's gonna happen in the next two years or the next four years? So, during the post-acute rehabilitation phase, it's time to kind of look at that and drill down on those kind of questions. Also, the levels of care, Dr Ifejika: it's really important to look at other levels of rehabilitation, so skilled nursing facilities, making sure people have access to that if they need to, if the caregiver is burned out and they don't have the ability to go straight home. Because acute inpatient rehab, the goal of it afterwards, is to go straight home. It's not to go to another facility. So, you need to have that screener in place when it comes to whether the family can take care of this person, and whether the family can do it in an effective way to prevent them being readmitted. Dr Monteith: Great. I also like that you spoke about kind of the team approach and different roles, both for screening and for intervention, both being very important, especially the intervention. And so why don't you give us a few examples how the team could break up the responsibility and how also for the intervention component that can be done. Dr Ifejika: Sure. So, I broke up the team into several levels. So, the team medically is the medical student, resident, and faculty physician. However, the team also includes the support staff, so your case manager, your social worker, the therapist, physical therapy, occupational therapy, speech therapy, the pastoral services, all these members of the team. You know, sometimes as physicians, we don't read those notes. There's a lot of information in the notes from social work, care coordination, and the therapist. They get down to subtleties cause they're asking questions, for example, "What kind of equipment do you have at home? How many stairs do you have at home? What level of house do you have, one story, two story? If you live in an apartment, do you have an elevator access?" That's important for someone with hemiparesis. When it comes to medications, when it comes to insurance status, when it comes to your ability to have the mechanisms to pay for care as an outpatient, social workers are required to ask these questions cause they have to figure out resources for the patient and their family to help facilitate improved outcomes. So, they have to ask questions regarding these tasks. The concerns are, do we read what they're saying? So, it's really important to interact with them, and if it's not something that you're looking at in the chart, cause we're all so tied to our computers, find where they are in the hospital. Walk by their office and have a chat. Run your list with them, especially for people who you're concerned have vulnerabilities, and make sure that you're setting an example for your medical students with your faculty doing so. If you're looking at it from the medical student, resident, faculty perspective, medical students, listen. This is your opportunity to really contribute to the team as well as learn about social determinants of health and research in their fields. You are the boots on the ground for the medical team. You are the ones who should be priming the pump and asking these questions of the family members. We're sending you into the rooms to do a history and physical. Social determinants of health should be a part of your history and physical, and you should be taking what we're saying in this article and asking these questions and tying it into your resident. Now, the resident is the work person of the hospital. We all know this. Things run through the resident. Things run through the fellow. It's really important that they have this information in a manner that is negotiable. The list keeps getting longer, and a resident doesn't need to be overburdened. It needs to be synthesized in a manner that can help facilitate the resident being able to act as well as communicate any concerns to the faculty. And at the faculty level, we are the voices that can affect change. So, if there's any concerns when it comes to advocacy, research, making sure that people are accessing care in a way that makes sense, particularly when it comes to the ability for us to galvanize change on a national level, that's kind of our job. Dr Monteith: Great, and so let's talk about intervention. What are things that, let's say, the neurologist can do to deal with some of these social factors? Dr Ifejika: From the neurology perspective, I think it's really important to identify missed opportunities and making sure that we address them. For example, the conversations around the ability to have access to care related to insurance versus no insurance. There are many, many ways that neurologists are able to advocate for a person being able to get to Medicare insurance, particularly in the outpatient setting. When we see patients in clinic, it takes two years, them, to qualify for Medicare, two years at a minimum. But there's a gap there that can be filled by us making sure that we document what's happened, contact their providers, facilitate communication with their employers, if they're employees, they can get some short-term disability benefits to help bridge that gap prior to receiving Medicare insurance. It behooves us to do this because if we do not, they fall into the gap and they get readmitted and they're back on service anyway. So, what's important is the outpatient that we really kind of focus on things that we can impact and things like insurance and getting people transitioned from having employer-based insurance versus getting to Medicare is a really important way that we can effect change in a, in a way that's viable and, and replicable. So, in the outpatient setting, neurologists have a wonderful opportunity to effect change in social determinants of health. When it comes to employed persons, who had a stroke transitioning to Medicare, it takes two years to do so. So, in the outpatient clinic, if you have an employed person, make sure that you fill out their short-term disability benefits forms, their long-term disability benefits form. Bridge the gap. Get that information to their employer so they can maintain constant coverage. Because if they do not, if they have to choose between refilling medications and putting food on the table, they're going to choose putting food on the table, and that's going to directly impact their outcomes if they're not taking the medication that we recommend. Dr Monteith: I think that's a great point. I mean, there's a lot that we can do, and in some ways, it may not take that much to document and to be able to ask the questions and to include some of that information into the assessment and plan is really a, a great idea. Dr Ifejika: And you know, if we don't bring these things up and have these conversations, it doesn't get addressed. And that's why I'm very, very thankful that I had the opportunity to do so, cause this is a part of what I do all day. I think that if I wasn't integrating these kind of conversations into my practice, I wouldn't have the ability to share these tips and these abilities to move things forward in a manner that will be constructive for our field overall and for our patients. Dr Monteith: And towards the end of the article, you brought up something I think we don't see in many articles, and that's the role of advocacy and getting involved in health policy. So, can you talk a little bit about that? Dr Ifejika: You know, it's really important to facilitate change when you see that there are things that need to be changed. And the best way to do that is through advocacy at the local or state or federal level. A lot of these variables that we're dealing with can be addressed through legal changes. I'll give you an example. End-stage renal disease, if you have immediate hemodialysis and you have that requirement upon hospital discharge, you qualify for Medicare immediately. Immediately. Before you even leave the hospital. Why wouldn't something be similar for a stroke? Well, the reason why is because there was a level of advocacy that came around end-stage renal disease and a member of Congress's wife had hemodialysis requirements. And so, a law was passed to make sure Medicare covered it immediately after hospital discharge. So, it requires advocacy in some significant ways to get things done, but we have the bandwidth to do this. We take care of a population that has some of the highest rates of preventable disability. That's not going away. We need to make sure that we're effecting change for this group to make sure that they have the best possible outcomes they can experience. Dr Monteith: So, any final messages for our listeners? Dr Ifejika: I look forward to hearing everyone's feedback about our issue. I am thankful for the opportunity to talk about, address, and write about this important topic, and look forward to everyone's feedback. Dr Monteith: Well, thank you so much for being on our podcast. It was a really wonderful summary and we had a very thorough conversation, but you didn't give away too much, so I think they're going to have to read the article. Dr Ifejika: You're going to have to read the article. And we want medical students, residents, fellows, faculty, all of our ancillary staff within the hospitals, please read this article. We really appreciate it. Dr Monteith: Again today, I've been interviewing Dr. Nneka Ifejika about her article on social determinants of health and their impacts on stroke prevention and outcomes. This article appears in the June 2026 Continuum issue on cerebrovascular disease. 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.

Does it ever look "awfully peopley out there"? Community is one of the great gifts of being human, but it comes with its share of hurt and problems...Belonging is a transformation agent crucial for cultivating emotional resilience. In this On the Trail episode, we discuss Building Bounce Chapter Seven: Connecting with People, where we talk about relationships in the Bible, vulnerabilty and authenticity and a continuum of trust, relational skills tools, and more.Thank you for joining us – father-daughter duo Marcus Warner and Stephanie Warner – on the trail to a deeper walk with God!  

The return of "What About?" Wednesdays! Text us your questions for apologist and pastor Robby Lashua!Although thoroughly secular in nature, the National Center for Science Education benignly labels it as the "Creation/Evolution Continuum".  Running from the extreme of Flat Earth creationism on the Biblical side to the extreme of atheistic evolution on the secular side, it is, however, anything but benign.  There are so many different views!  So many different perspectives!All the parties are looking at the same physical, natural evidence and the same passages of scripture.  Yet, along this continuum there has historically been so much heat and disagreement!It's almost like God never intended for us to fully understand...Wait.  Could that be it?And, if we were never intended to understand the particulars of creation, what did He intend for us to draw from the passages of scripture that encompass the topic?Robby Lashua is the lead pastor at Palmcroft Church in Phoenix, Arizona.  Having also served with Stand to Reason, he's a leading apologist who brings the defense of scripture and Biblical truth to bear powerfully within his teaching.In short, he's the perfect individual to help us answer these questions! "Kingdom Culture Conversations" is a podcast created by Northwest Christian School in Phoenix, Arizona.For more information on Northwest Christian School, visit:  https://www.ncsaz.org/To reach out to Geoff Brown, please email gbrown@ncsaz.org or you can reach him by cell phone:  (623)225-5573.

Microsoft Build 2026 announced an end-to-end agentic AI stack. COMPUTEX Taipei confirmed heterogeneous AI infrastructure across ARM, Marvell, Intel, Qualcomm, and NVIDIA. Alphabet raised $80 billion. Cisco Live repositioned the network as the AI platform. Patrick Moorhead and Daniel Newman break it all down alongside earnings from Broadcom, HPE, Palo Alto Networks, and CrowdStrike, plus the token cost conversation, the edge AI push, and what Palantir and Oracle are saying about proprietary data as the real AI moat. The handpicked topics for this week are: Microsoft Build 2026 Announced an End-to-End Agentic AI Stack: Microsoft shipped MAI-Thinking-1, its first homegrown thinking model, alongside Scout, Microsoft IQ, Project Solara, and a Majorana 2 quantum update targeting a 2029 commercial timeline with claims of a 1,000x reliability gain. Pat describes MAI-Thinking-1 as likely better than Sonnet 4.6 in blind testing and delivering close to GPT 5.5 quality at a far lower cost. Scout is Microsoft's first autopilot agent, anchoring the M365 Agent Suite with Office Pilot Agent Mode and Agent 365. Microsoft IQ serves as the context layer, integrating M365, business data, boundary IQ, and web IQ with GitHub Copilot, Foundry, and Copilot Studio. Project Solara is a new Android-based platform built for agent-first devices across transportation, retail, and hospital settings. Microsoft also added 83 Unix commands to the Windows stack. Dan frames Microsoft's real play as distribution, not frontier model development, noting that the open model ecosystem being pulled into the platform will matter more to CFOs managing token costs at scale. (The Decode) The AI Stack Goes Multi-Silicon — COMPUTEX Taipei 2026 Confirms Heterogeneous AI Infrastructure: ARM's AGI CPU is in production with Google moving its TPU head node to ARM, and adding Oracle and ByteDance as new customers. ARM also introduced a new switch, the TT100, and put the 51T CPO switch on stage. Marvell received a trillion-dollar company endorsement from Jensen Huang, adding $90 billion in market cap on the comment alone. Intel announced disaggregated inference details and Xeon 6+ Clearwater Forest, its first 18A data center processor. Vista Equity and Cambium Capital announced a NeoCloud called Vector Core Compute, with Xeon 6 handling orchestration, Salmonova RUs handling decode, and Blackwell GPUs handling pre-fill. Qualcomm's Cristiano Amon announced the Dragonfly data center brand with Snapdragon C details coming at their June investor day. The WSTS raised the 2026 semiconductor TAM forecast by 90% to $1.51 trillion, with Pat noting the market could hit a trillion dollars if memory is excluded entirely. (The Decode) NVIDIA RTX Spark and the Edge AI Push: NVIDIA coordinated with ARM and Microsoft around the RTX Spark at COMPUTEX, with the shared message being that the future of Windows is here. Signal65's Ryan Shrout asked Jensen directly why NVIDIA wants to be in the PC business, given low margins and diminishing returns. Dan frames the answer in the context of devices increasingly becoming mobile data centers, capable of running models at much greater efficiency than cloud delivery. The edge AI conversation is also directly tied to token cost economics: as intelligence delivery moves closer to the device, the cost per token drops significantly. The jury is still out on whether NVIDIA will meaningfully disrupt the PC market, but its influence over OEMs like Lenovo and Dell that depend on it for data center gives it real leverage over SKUs. (The Decode) Token Economics and Frontier Model Cost Pressure: Dan and Pat discuss a substantive shift in how enterprises are thinking about AI consumption costs. Dan argues that "token maxing," the practice of defaulting to the most powerful frontier model for every task, has now effectively peaked, as bills have come due at scale. Companies paying for tokens in volume are starting to question whether they can afford the prices that frontier models actually cost to deliver. Pat pushes back, saying the dynamic is still present, but both analysts agree that the market is moving toward a model where token selection is matched to the job, with Microsoft's MOE approach and thinking models positioned to help CFOs manage that economics story. (The Decode) Continuum Goes Public at Highest Valuation for an AI Platform: Dan notes that Continuum, the Honeywell-spawned quantum company, went public this week at what he calls the highest valuation for an AI platform to date. He flags that IonQ will likely contest that characterization. The broader context is Microsoft entering the quantum conversation with Majorana 2 at Build, a name that has largely been absent from the quantum race, while IBM has received most of the attention. (The Decode) AI CapEx Has Outgrown Cash Flow — Alphabet's $80 Billion Equity Raise: On June 1, Alphabet announced an $80 billion equity capital raise, upsized to $85 billion, structured as $40 billion ATM, $30 billion underwritten, and a $10 billion private placement with Berkshire Hathaway anchoring. Pat frames the questions over CapEx returns as entirely dependent on whether you are an AI boomer or a doomer: if the payback comes, the raise is the right move. If it does not, the math doesn't close. Dan argues the investment is existential, drawing parallels to how infrastructure-first companies have always spent ahead of monetization, and notes that Google's equity is being used as a capital engine that may be more efficient than the debt markets right now. Both analysts flag the downstream implications for Broadcom, MediaTek, and Marvell given the TPU connection. (The Decode) The Network Becomes the AI Platform: Cisco Live 2026: Cisco launched Silicon One P200, the Secure AI Factory with NVIDIA and Spectrum X, AgenticOps, MCP-native automation, Cisco IQ, LiveProtect, and folded Astrix Security and Galileo into Splunk under one control plane. Pat identifies Cisco Cloud Control as the biggest announcement of the entire show, pulling together Catalyst, Meraki, Nexus, Firewall, and WebEx under agentic ops that run natively through MCP, with code running directly on smart switches that have x86 processors. Pat also credits Cisco for establishing Silicon One as a credible chip alternative for hyperscalers capable of taking on Tomahawk and Jericho. Dan frames the long-term opportunity as campus and branch enablement when industrial AI and robotics deployments accelerate, arguing that the numerator of AI's economic impact has barely started, as edge deployment spending has not yet begun. (The Decode) The Flip: Did Microsoft Build 2026 Effectively End the OpenAI Partnership? Pat argues the divorce decree has been filed. MAI-Thinking-1 was built with zero distillation from third-party models offering clean enterprise data lineage, with Maia 200 in production plus Anthropic chip supply, which signals vendor hedging. OpenAI is going all-in on AWS, which means you cannot be married to two people, and the full Build stack covering model, OS containment via MXC, agents via Scout and Agent 365, and context via Microsoft IQ removes every architectural dependency on OpenAI. Dan counters that Microsoft is hedging rather than leaving and predicts the partnership will run through the decade. Enterprise Copilot customers are explicitly showing in data that they demand GPT 5.5, internal benchmarks have not been independently validated, and Microsoft stands to make meaningful money from the OpenAI IPO. (The Flip) Broadcom Q2 FY26 Earnings: Broadcom posted revenue of $22.19 billion, a narrow miss depending on which consensus data set is used, with EPS of $2.44 beating estimates and AI semis at $10.8 billion. Hock Tan declined to raise the $100 billion full-year AI chip target, and the stock dropped 13% in premarket trading. Q3 guide came in at $29.4 billion. Pat calls the miss a timing issue driven by Google's multi-sourcing across Marvell, MediaTek, and Broadcom rather than a fundamental problem. Dan flags that Hock Tan opened the earnings call by accidentally reading from the 2025 print, calling it "not the best moment." Sell-side re-ratings held in the 500s across Jefferies, Mizuho, and Deutsche Bank despite the drop, with Futurum Equities having it at 600. (Bulls and Bears) Hewlett Packard Enterprise Q2 FY26 Earnings: HPE delivered revenue of $10.68 billion, up 40% year over year, and EPS of $0.79, up 100%. Juniper integration and AI servers both outperformed, and all FY26 guides were raised. The stock jumped 19% after hours before settling into a roughly 15% gain, with HPE up 68% over the last month. Pat frames HPE as a value play rather than a volume play, methodically targeting enterprise and sovereign cloud deals where it can maintain profitability, rather than competing for massive NeoCloud volume. Antonio Neri was clear on the call that the profitability pull-forward is a one-shot deal. Pat and Dan will both be at HPE Discover the week after next to interview Neri and the C-suite. (Bulls and Bears) Palo Alto Networks Q3 FY26 Earnings: Palo Alto posted revenue of $3.0 billion, up 31% year over year, beating the $2.94 billion estimate, with non-GAAP EPS of $0.85, beating the $0.79 to $0.81 range. NGS ARR reached $8.1 billion, up 60% year over year, including $1.6 billion from CyberArk and Chronosphere. RPO hit $18.4 billion, up 36%. Both FY26 revenue and EPS guides were raised. Adjusted FCF margin came in at 38.5% TTM, up 430 basis points. The stock jumped 11% immediately after hours, then drifted lower. Pat points to 2,200 platformized customers and 120% net retention as the most important metrics. Dan notes the SaaSpocalypse thesis continues to be wrong. (Bulls and Bears) CrowdStrike Q1 FY27 Earnings and the Proprietary Data Moat Argument: CrowdStrike posted revenue of $1.39 billion with EPS of $1.10 and ARR of $5.51 billion. Net new ARR of $255.8 million set a Q1 record, up 32% year over year. FY27 net new ARR guide was raised by $52 million to a $1.29 billion midpoint, and FY27 revenue was raised to $5.915 to $5.959 billion. A 4-for-1 stock split was announced effective July 2nd. The stock dropped 11% despite the beat after a 64% year-to-date run into earnings. Dan uses the results to make a broader argument against the software disruption thesis, referencing Palantir CEO Alex Karp daring customers to build without him using Anthropic or OpenAI, and Larry Ellison's argument that the real AI value unlock sits in proprietary enterprise data that is not accessible to frontier models. Enterprises with governed, secure, proprietary data will continue to need platforms like CrowdStrike regardless of what frontier models can do. (Bulls and Bears) Six Five Summit is coming. Salesforce CEO Mark Benioff will kick off the event. Register and stay current at sixfivemedia.com/summit. Watch the full video at sixfivemedia.com, and be sure to subscribe to our YouTube channel so you never miss an episode.   The Decode Microsoft Declares Independence — Build 2026 Ships an End-to-End Agentic AI Stack (MAI-Thinking-1 + Scout + Microsoft IQ + Project Solara + Majorana 2) https://www.theverge.com/tech/941738/microsoft-build-2026-biggest-announcements The AI Stack Goes Multi-Silicon — Computex 2026 Confirms a Heterogeneous AI Infrastructure (ARM + Marvell + Intel ASIC + Qualcomm + RTX Spark); WSTS Raises 2026 Semi TAM Forecast 90% to $1.51T https://www.tomshardware.com/tag/computex AI Capex Has Outgrown Cash Flow — Alphabet's $80B Equity Raise Is the Largest in U.S. Corporate History; Berkshire Anchors $10B https://abc.xyz/investor/news/news-details/2026/Alphabet-Announces-Proposed-80-Billion-Equity-Capital-Raise-to-Expand-AI-Infrastructure-and-Compute-2026-b0myAMewCa/default.aspx The Network Becomes the AI Platform — Cisco Live 2026 Launches Silicon One P200, Secure AI Factory (with NVIDIA), AgenticOps, Astrix Security + Galileo https://www.cisco.com/site/us/en/about/whats-new/index.html The Flip Did Microsoft Build 2026 Effectively End the OpenAI Partnership? MAI-Thinking-1 Beats Sonnet 4.6 in Blind Testing, Microsoft Claims GPT-5.5 Parity at 10x Cost Efficiency — Will MS Quietly Wind Down OpenAI Exclusivity by FY28, or Is OpenAI Still the Frontier Anchor Microsoft Needs?   FOR:  MAI-Thinking-1 beating Sonnet 4.6 in blind preference + GPT-5.5 parity at 10x cost efficiency is a frontier-model independence proof point https://www.latent.space/p/ainews-microsoft-build-mai-thinking Build 2026: Accumulating Evidence of Microsoft's AI Independence — EDN (June 4) — https://www.edn.com/build-2026-accumulating-evidence-of-microsofts-ai-independence/ Maia 200 in production + Anthropic-Maia chip talks signal Microsoft is hedging its inference vendor stack https://blogs.microsoft.com/blog/2026/01/26/maia-200-the-ai-accelerator-built-for-inference/ Microsoft canceled Anthropic's internal software licenses + pivoted to chip-supply pursuit — customer-not-competitor positioning https://www.cnbc.com/2026/05/21/anthropic-microsoft-maia-200-ai-chip.html   AGAINST:  Enterprise Copilot customers explicitly demand GPT-5.5 — internal benchmarks don't replace the brand https://learn.microsoft.com/en-us/microsoft-365/copilot/release-notes?tabs=all MAI-Thinking-1 benchmarks haven't been third-party verified — Microsoft is the only source https://www.latent.space/p/ainews-microsoft-build-mai-thinking The MS-OpenAI partnership is contractual through 2030+ — unwinding it is impractical and expensive https://blogs.microsoft.com/blog/2026/04/27/the-next-phase-of-the-microsoft-openai-partnership/ Microsoft's actual strategic risk is OpenAI leaving, not MS leaving — Anthropic + OpenAI IPOs make OpenAI exit risk the real concern https://www.anthropic.com/news/confidential-draft-s1-sec Bulls & Bears Broadcom (AVGO) Q2 FY26 ACTUALS — Rev $22.19B (Narrow Miss) + EPS $2.44 (Beat); AI Semis $10.8B; Hock Tan Refuses to Raise the $100B Full-Year AI Chip Target — Stock −13% Premarket; Q3 Guide $29.4B https://www.cnbc.com/2026/06/03/broadcom-avgo-earnings-report-q2-2026.html Hewlett Packard Enterprise (HPE) Q2 FY26 ACTUALS — Blowout: Rev $10.68B (+40%), EPS $0.79 (+100%); Juniper Integration + AI Servers Both Outperform; FY26 Guides All Raised; Stock +19% AH https://www.businesswire.com/news/home/20260601866494/en/HPE-Reports-Fiscal-2026-Second-Quarter-Results Palo Alto Networks (PANW) Q3 FY26 ACTUALS — Beat-and-Raise: Rev $3.0B (+31% YoY, Beat $2.94B), Non-GAAP EPS $0.85 (Beat $0.79-0.81); NGS ARR $8.1B (+60% YoY, $1.6B from CyberArk + Chronosphere); RPO $18.4B (+36%); FY26 Revenue + EPS Guides BOTH RAISED; Adj FCF Margin 38.5% TTM (+430 bps); Stock +11% Immediate AH, Then Drifted Lower https://www.paloaltonetworks.com/company/press/2026/palo-alto-networks-reports-fiscal-third-quarter-2026-financial-results CrowdStrike narrowly beats estimates on AI tailwinds, but stock falls 9% — CNBC (June 3) — https://www.cnbc.com/2026/06/03/crowdstrike-crwd-q1-2027-earnings.html  

Musicians recount the strange and unexpected story behind the making of your favorite albums. John Mayer is tall, handsome, and white. What else is there to say? Adam, Tom, Rob, and a special guest get together to discuss blues guitar prowess, spouting off in the press, and the mom demographic.Join the comment thread NOW available on our free Patreon to continue the conversation about this episode and get early access to the weekly show 100% ad free, plus 60+ bonus shows like Song Battle and Guilty Pleasureshttps://www.patreon.com/1001AlbumComplaintsJoin our Mailing List here: https://linktr.ee/1001albumcomplaintsEmail us your complaints (or questions / comments) at 1001AlbumComplaints@gmail.comListen to our episode companion playlist (compilation of the songs we referenced on this episode) here:https://open.spotify.com/playlist/4MmEAGB2bLtPrypSLpw7lx?si=fc15c660ab43402fListen to Continuum here:https://open.spotify.com/album/1Xsprdt1q9rOzTic7b9zYM?si=vlqLXUWLQFSBa3QCqsv_HgAnd our international playlists continue to grow:Thai, German, Sweden 1, 2, & 3, Italian, Australian, Belgium 1 & 2Intro music: When the Walls Fell by The Beverly CrushersOutro music: After the Afterlife by MEGAFollow our Spotify Playlist of music produced directly by us. Listen and complain at homeFollow us on instagram @thechopunlimited AND @1001AlbumComplaintsWe have 1001 Merch! Support us by buying some.US Merch StoreNext week's album: Neil Young - HarvestSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Why do anomalous experiences so often arrive in the wake of trauma? And what happens when the people who understand that connection decide to use it as a weapon? This episode of Inquiry follows trauma as the hidden throughline connecting UFOs, consciousness, psychological operations, and the engineering of belief at scale. Kelly Chase starts with how human perception actually works, drawing on Donald Hoffman's "The Case Against Reality," James Madden's umwelt and über-umwelt from "Unidentified Flying Hyperobject," and Jeffrey Kripal's Filter Thesis, then grounds it all in the predictive processing model of the brain and Karl Friston's free energy principle. The picture that emerges is unsettling: trauma doesn't only wound a person, it makes them porous, loosening the filters that hold consensus reality in place. From there the conversation turns toward how that vulnerability has been exploited. It traces belief manipulation from the 1980 "From PSYOP to MindWar" paper by Michael Aquino and Paul Vallely, through MKULTRA and Operation Mockingbird, to the declassified reality of Operation Northwoods and the manufacturing of consent. It brings in Jacques Vallée's control system hypothesis and Colm Kelleher's concept of bidirectional mimicry to ask whether human institutions and the phenomenon itself may be using the same lever: disruption, destabilization, and the reshaping of belief in the rupture's aftermath. Then it turns the dread on its head. Research on openness to experience and Post-Traumatic Growth suggests the architects of mass stress made a critical miscalculation. Trauma creates openings, and openings go both ways. You can crack the shell of consensus reality to make people malleable, but you cannot control what hatches. Topics explored: Trauma and anomalous experience | experiencer patterns | the Filter Thesis | Donald Hoffman | perception as interface | umwelt and über-umwelt | James Madden | Jeffrey Kripal | predictive processing | Karl Friston | free energy principle | belief malleability | shattered assumptions | meaning violation | belief engineering | MindWar | Michael Aquino | Paul Vallely | psychological operations | MKULTRA | Operation Mockingbird | cognitive sovereignty | bidirectional mimicry | Colm Kelleher | black triangle craft | Jacques Vallée | control system hypothesis | Operation Northwoods | manufactured consent | openness to experience | Post-Traumatic Growth | consciousness-level immune response | non-human intelligence | contact experiences Inquiry with Kelly Chase is brought to you by SpectreVision Radio.Produced in partnership with Voltage.fm.  Referenced In This Episode The Case Against Reality: Why Evolution Hid the Truth from Our Eyes — Donald Hoffman (2019) Unidentified Flying Hyperobject: UFOs, Philosophy, and the End of the World — James Madden (2023) How to Think Impossibly: About Souls, UFOs, Time, Belief, and Everything Else — Jeffrey J. Kripal (2024) The Flip: Epiphanies of Mind and the Future of Knowledge — Jeffrey J. Kripal (2019) "The Free-Energy Principle: A Unified Brain Theory?" — Karl Friston (2010) "Trauma or Drama: A Predictive Processing Perspective on the Continuum of Stress" — Valery Krupnik (2020) "Predictive Processing and the Varieties of Psychological Trauma" — Sam Wilkinson, Guy Dodgson & Kevin Meares (2017) "Assumptive Worlds and the Stress of Traumatic Events" — Ronnie Janoff-Bulman (1989) Shattered Assumptions: Towards a New Psychology of Trauma — Ronnie Janoff-Bulman (1992) "PTSD as Meaning Violation: Testing a Cognitive Worldview Perspective" — Crystal L. Park, Mary Alice Mills & Donald Edmondson (2012) "Making Sense of the Meaning Literature: An Integrative Review of Meaning Making and Its Effects on Adjustment to Stressful Life Events" — Crystal L. Park (2010) From PSYOP to MindWar: The Psychology of Victory — Paul E. Vallely & Michael Aquino (1980) MindWar: The New Battle for the Mind — Michael Aquino (2016) Project MKULTRA, the CIA's Program of Research in Behavioral Modification — U.S. Senate Select Committee on Intelligence (1977) MKULTRA Collection — CIA Reading Room Intelligence Activities and the Rights of Americans, Book II (Church Committee Report) — U.S. Senate (1976) Justification for US Military Intervention in Cuba (Operation Northwoods) — Joint Chiefs of Staff (1962) "The Anxious State: Stress, Polarization, and Elections in America" — The Conversation (2025) "Politics Is Taking a Toll on People's Well-Being" — Psychology Today (2025) "Stressful Life Events and Openness to Experience: Relevance to Depression" — Chiappelli et al. (2021) "The Social Psychology of Responses to Trauma: Social Identity Pathways Associated with Divergent Traumatic Responses" — Orla Muldoon et al. (2019) "Posttraumatic Growth: Conceptual Foundations and Empirical Evidence" — Richard Tedeschi & Lawrence Calhoun (2004) "The Post-Traumatic Growth Approach to Psychological Trauma" — Richard Tedeschi (2023) "Confidence in U.S. Institutions Down; Average at New Low" — Gallup (2022) 2025 Edelman Trust Barometer — Edelman (2025) Support The Show Patreon: inquirywithkellychase.com Substack: inquirywithkellychase.substack.com Connect with Kelly Website: kellychase.media X: @kellychasemedia Instagram: @kellychasemedia TIMESTAMPS 04:12 Trauma and The Anomalous 07:01 Perception Is an Interface 11:05 Umwelt and Uber Umwelt 14:05 Kripal and Filter Thesis 18:27 Predictive Brain and Trauma 23:11 Belief Becomes Malleable 28:08 MindWar Doctrine 32:36 MKUltra and Mockingbird 36:58 Mimicry and Control System 42:17 False Flags and Consent 46:09 Algorithms as Trauma Engine 49:23 Openness and Growth 55:59 Consciousness Immune Response 57:18 Closing and Next Steps Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Cheryl Bushnell, MD, MHS, who served as the guest editor of the June 2026 Cerebrovascular Disease issue. They provide a preview of the issue, which publishes on June 3, 2026. 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. Bushnell is a Professor of Neurology and Director of the Center for Transformative Stroke Care at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Additional Resources Read the issue: continuum.aan.com Subscribe to Continuum®: shop.lww.com/Continuum Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @CBushnellMD  Full episode transcript available here Dr Jones: One of the core tenets of our field is that we learn neurology one stroke at a time. But what do we have to learn about preventing them altogether? The science of stroke prevention, acute treatment, and recovery are evolving rapidly, and it's hard to keep up. Today, we're speaking with Dr. Cheryl Bushnell, guest editor of our latest Continuum issue on Cerebrovascular Disease, to discuss these topics and much more.  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 subscribing to the journal, listening to verbatim recordings of the articles, 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. Cheryl Bushnell, who is Continuum's guest editor for our latest issue on Cerebrovascular Disease. Dr. Bushnell is a professor of neurology and the director of the Center for Transformative Stroke Care at the Wake Forest University School of Medicine in Winston-Salem, North Carolina, where she specializes in the care of stroke patients and their social and functional determinants of recovery and health, and is an internationally recognized expert on those topics. Dr. Bushnell, welcome. Thank you for joining us today. Why don't you introduce yourself to our listeners?  Dr Bushnell: Absolutely. Thank you for the invitation. It's really an honor to be here. So, as you mentioned, I am the director of the Center for Transformative Stroke Care at Wake Forest. It's a really fun transition for me to be involved with different care models for stroke, and I think a lot of the Continuum topics are directly relevant to some of the things that I'm doing now as an administrator and sort of a facilitator of new research. So, thanks again for having me.  Dr Jones: Yeah, and, and you have a wonderful perspective, and we're gonna pull that out today in our interview questions, and I'm looking forward to sharing that with our listeners. But before we get to the questions, we're gonna start off today's podcast with another Continuum Audio trivia question for our listeners. Anticoagulation has played a critical role in secondary ischemic stroke prevention for a long time now. While direct oral anticoagulants have taken on a greater role in the treatment of prevention of stroke, there are still some use cases for vitamin K antagonists like warfarin. The trivia question for our listeners is this: How was warfarin discovered, and how did it get its name? Stick around and we'll share the answer to that question toward the end of our interview today. So, Dr. Bushnell, let's get right to it. You alluded to your various roles, and your leadership in the field has been exemplary. The interventions for acute ischemic stroke have really exploded over the last decade or so, and they get a lot of attention and discussion, but prevention and recovery are just as important in the care of these patients. Tell us a little more about how you approached this issue, about the article topics you chose, etc.  Dr Bushnell: Well, once I was chosen to lead the guest editorship, I wanted to come up with a group of topics that were maybe a little bit different from previous issues. So, I kind of looked at the previous issues and saw, as you said, an emphasis on acute stroke, and that's really important because it has been evolving. But my thought was, how about what happens to patients after they get the intervention and they're discharged home? And because a lot of trainees may not get to see these patients ever again, or it's months before they might see them, or if they're readmitted, which is what we don't want to see, but that certainly is a lot of the exposure is in the inpatient setting. So, I thought I would kind of transport the education into the outpatient and transitional setting, as well as prevention, not only secondary, but primary prevention, with an emphasis on brain health. Some of the populations that may not get as much attention. So, sex differences, stroke in women, pregnancy, the transitions of care, and also the emphasis on holistic view of patients and their challenges, which includes the non-medical factors that drive health, otherwise known as social determinants of health.  Dr Jones: I appreciate that perspective, and obviously th-this is an area of your deep expertise, and it's great to have an issue that really digs into some of those topics a little more deeply. As an educator, I'm really glad you mentioned that about the trainee's perspective. You know, especially junior neurology trainees that are in the hospital all the time. They're seeing patients in the middle of a cerebrovascular catastrophe. But there's a long tail of recovery, right? And they'll get to see that in continuity clinic, but it's a good message to share from an evidence and, um, experiential perspective in the issue. So, appreciate that perspective. You've just read all these articles and edited them. Was there anything that you ran across that was a surprise to you?  Dr Bushnell: Well, I personally chose a lot of the authors based on my knowledge of their work. So, I wouldn't say that it was completely surprising, but I do think that I was just genuinely impressed with the quality of the writing and the synthesis of information. I just was incredibly proud of the work that these co-authors have put together. I'd say that that was-- it wasn't surprising so much as just a sense of pride that I had with the product that's coming out. But of course, there have been some new trials that had to be incorporated at the last minute, some of which were presented at the International Stroke Conference just a few weeks ago.  Dr Jones: Yeah. We try to be as up-to-date as we can, and I will completely agree with you. We have some really good writers in our field, and it's really just a pleasure when you read an article that's by an expert, and it's a joy to read. I can tell you it's one of the best parts of this job, and you get to learn a lot. I think one of the more challenging scenarios that I hear about from colleagues in recent years has been optimal management of patients with asymptomatic extracranial atherosclerosis. The pivotal trials that inform how we manage those patients were from a long time ago, decades ago, predating a lot of the more intensive medical management tools that we have today. In that scenario, Dr. Bushnell, what's the latest on that, and what should our listeners know?  Dr Bushnell: Well, obviously, the CREST 2 trial has been long awaited. It's been going on for over ten years, I believe. Of course, it's, uh, two different trials all in one, the carotid stenting and angioplasty versus intensive medical management. And of course, each of the carotid vascularization arms of the trial also had intensive medical management. And then the other trial is the carotid endarterectomy as the form of revascularization. And it interestingly did not show any benefit of carotid endarterectomy compared to intensive medical management. But of course, the somewhat surprising result was that carotid angioplasty and stenting truly was superior, although it was a small number of events in the trial overall. But that stenting plus intensive medical management was somewhat better than intensive medical management alone. And I think stenting has come a long way in terms of safety, and so I think that's been part of the evolution of the field. I do wanna say that I'm a huge fan of the intensive medical management, and I think that what the protocol does in terms of blood pressure management, cholesterol management is very much above and beyond what's done in private practice even. And the health coaching for all the other things related to diabetes and weight loss and smoking cessation and physical activity, that is what we need to be doing to actually decrease the risk of stroke, and I think that it's very effective. I can't say enough about the design of the study for that reason, that everyone gets the intensive medical management, and then you just layer on the type of revascularization on top of it. So, I wouldn't have been surprised if this was a completely negative trial overall. They just happened to have some better outcomes in the stenting arm.  Dr Jones: I recall a few years ago when the series of endovascular therapy trials for acute stroke came out, and I think there was a, a period of time where the field had to adapt to that. I wonder what you think about with the CREST 2 findings on stenting. I mean, is that gonna be a big change? Because obviously atherosclerosis is highly prevalent. Is that gonna be a big change? Is the field ready for that? How much adjustment do we have in store?  Dr Bushnell: I'm not sure it's gonna be a really big change. If you read the editorial that accompanied the trial in the New England Journal, just a few patients in either direction would have changed the outcome. I kind of look at it as an absolute difference that's relatively small. So, I'm not sure that it will have a huge impact on the field. I do think that the specialists who insert the stents may have some differences of opinion of who should be stented and who shouldn't. Because I think, you know, all of the specialists who do procedures were involved with the trial. But I would say there's a larger percentage of vascular surgeons who were involved, and so I'd say they may have a change of their practice. And neurologists may not even get involved at all.  Dr Jones: Right.  Dr Bushnell: That was one of the challenges for getting patients in the trial is that, you know, not all of us see the asymptomatic carotid stenosis, that they tend to get referred to vascular surgery. So, I think maybe in a corner of the practices of vascular surgeons is where you might see the differences.  Dr Jones: Your point about the way the trial was designed or the trials were designed, that intensive medical management is really important, and we have huge gaps in that. In our specialty, it's, you know, we have probably an opportunity in primary care even to address that. And that leads me to my next question. You know, given your perspective and your expertise, what do you think is the biggest practice gap in the care of patients with stroke or with cerebrovascular disease of any kind?  Dr Bushnell: I think by far the biggest gap is transitions of care and access to follow-up in a specialty clinic after discharge and continuous secondary prevention. We only call it secondary prevention because it happened to come after a stroke, but I really feel like we should just focus on prevention and call it that. There are a lot of people who are trying to kind of, get us away from primary versus secondary prevention. And, and Mitch Elkind is phenomenal and had a beautiful chapter weaving in prevention and brain health. So, I highly recommend that people, if they don't read any other chapters of the Continuum to read his, because I think that it's getting to your point about where the gaps are, and I think prevention is the biggest one. I think we could do so much more in models of care to ensure that there is a pathway once patients are discharged. We have no quality metrics. We have no measurement of how well people are doing after they're discharged. We have all of these fancy things and sophisticated acute treatments, but all of those are for naught if somebody goes home and they fall and they have a severe head injury or hip fracture because they weren't properly supervised or they didn't have the help that they needed at home. So, you got me on my soapbox here for a second, but that is definitely what I see as the gap.  Dr Jones: That's an important soapbox, an important gap, and obviously, if it was a simple problem, we could solve it. But it's obviously something that education is a valuable tool for that, and that's part of why we are including so much content in this issue of Continuum. So, if we put that aside as a gap that we would love to close, when you look into the near future or distant future, Dr. Bushnell, and what's the next big thing on the horizon? New interventions, new prevention tools, or something else entirely? What do you think?  Dr Bushnell: There are two things that I would mention. One is sort of the new category of anticoagulants, antithrombotics, the factor XIa inhibitors. We had an amazing presentation of the oceanic stroke trial at the International Stroke Conference, and this is probably going to be a game changer for the arsenal of antithrombotic therapies that we can offer to patients that do not have a reason for anticoagulation. So, they, they don't have atrial fibrillation, for example, or something else that requires anticoagulation. And so, the factor XI, asundexian, is the drug that they used in that trial. The safety profile is pretty amazing. There was very little bleeding complications and a great benefit in those patients with some degree of atherosclerosis, but, you know, of course, not enough to require carotid revascularization, but then also, um, small vessel disease and cryptogenic stroke. I think those are the three categories of patients, and that's a lot of the strokes that we see all benefited from this new drug. So, I think that's gonna be exciting. There, of course, it has to go through the FDA approval process, and so it might take a little bit of time before that's on the market, and we don't know how much it's gonna cost, but I think it is a, a major breakthrough. And of course, there are other similar medications in that category that are coming. And then I think the other thing is the emphasis on brain health and lifestyle factors and the things that we can do to prevent stroke and dementia because they are the same, essentially. Those are really important. And when we have someone in the hospital with a stroke or a TIA in particular, it's a great teaching opportunity for those patients to say, "Hey, here's what you can do to protect your brain." These are things that we always tell people to prevent a stroke, but just think about it as protecting your brain and keeping your brain as healthy as possible.  Dr Jones: That's a great message, and one that you get to share with patients directly. You're joining us today for this interview. You're on stroke service, so you're actively involved in caring for patients with stroke. What in your practice is the most rewarding aspect of caring for these patients? What is it that you find most rewarding?  Dr Bushnell: I've been involved in a clinical trial that has focused on managing blood pressure and also coaching and other aspects of stroke recovery. I think that has probably been the most rewarding aspect of my career. Until I was involved with this trial, I didn't necessarily do intensive blood pressure monitoring, but I'm seeing the benefits of having data from home, what those blood pressures are over a span of time. I see the immediate or intermediate effects of the blood pressure medication changes that I've made, and I see how the patients respond. So, I have to say that this is not part of usual practice, but I think it should be. And I think it's been incredible from the perspective of a neurologist who is really intensively trying to make the patients' lives better. And it's not just what I do, it's what the health coaches do as part of this intervention. And again, very similar to intensive medical management. So, I, I feel like I've been living it in a slightly different setting than in the CREST 2 trials. But there are other trials that have used the intensive medical management as approach as well. But I would say that's the most rewarding. I've seen people who've lost weight, who are physically fit, who are able to get off of blood pressure medications practically by the end of six months, and that's amazing. And then they continue doing it because they see the benefits.  Dr Jones: You've had a front row seat to a lot of that. That's really got to feel rewarding.  Dr Bushnell: It is, absolutely.  Dr Jones: You know, when you put it that way, it makes me want to go home and check my blood pressure, which I haven't done in a while. But I think that's a message to all of our listeners that we do have plenty of opportunity for risk factor optimization and following the evidence that has been generated and is being generated. Huge opportunity, not only at the population level, but I think the, um, individual patient level too. Okay, so now we're back to our Continuum Audio trivia question, and I'll repeat it for our listeners. How was warfarin discovered, and how did it get its name? Dr. Bushnell and I were talking about this earlier, so I'll just go ahead and share the answer. So, in the early 20th century in the U.S. Midwest, there were epidemics of a hemorrhagic disease in cattle, of all places, and this was eventually traced to moldy cattle feed that was made from sweet clover. And in 1940, researchers at the University of Wisconsin discovered that the anticoagulant in the sweet clover was a compound that was later synthesized for therapeutic use in 1954 as warfarin. And the name came from, uh, the support for the research. The research support came from the Wisconsin Alumni Research Foundation, or WARF, and the end of the word came from the underlying compound, which was coumarin. So that was a little bit of trivia that I had never heard. It's not in the issue, everyone, so you're getting something extra here on the podcast. But been using the drug forever. It still has its uses, even though it's become less advantageous than some of the newer agents. But-- And of course, Dr. Bushnell already knew that when I brought it up, but I just thought that was an interesting bit of history. Well, Dr. Bushnell, thank you for joining us. Thank you for such a great conversation about the latest in cerebrovascular disease. I learned a lot today. I learned a lot in reading these wonderful articles. I hope our listeners learned a lot today as well. I'm really grateful for your hard work on the issue, which I think will come in handy for junior readers and subscribers, as well as our more experienced neurologists as well. Sometimes it's hard to keep up with a rapidly changing subspecialty of our field. So, thank you for joining us today.  Dr Bushnell: Thank you for having me. It's been my pleasure.  Dr Jones: Again, today we've been speaking with Dr. Cheryl Bushnell, guest editor of Continuum's most recent issue on cerebrovascular disease. 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. Thank you for listening to Continuum Audio.

Hi everyone Sorry long time no record. I'm back with a reading of a recent article I did for BISH (my website aimed at a younger / general audience) about Foreplay. As I have done in the past, I'm reading it and then interjecting myself with further thoughts and ideas - this time explaining the Body Without Organs (BwO). Here's the article at BISH What Is Foreplay https://www.bishuk.com/sex/what-is-foreplay/ please share it around for to help alert the algorithm to its existence. If you look in the episode art you'll see a little drawing that might help you to understand the becoming, here it is from the BISH article too. https://i0.wp.com/www.bishuk.com/wp-content/uploads/2026/05/what-is-foreplay-bish-a-becoming.png?w=600&ssl=1 Through paying attention to the difference a thing makes (and the difference that difference makes) is how we unfold, or 'become', through time. Leading us towards the interesting, valuable, important and remarkable (this is from the Todd May article below). Here were those references I mentioned Deleuze, G. and Guattari, F., 2004. A Thousand Plateaus: Capitalism and Schizophrenia. (tr, Massumi, B.) London. Continuum. Fox, N.J. and Alldred, P., 2013. The Sexuality-Assemblage: Desire, Affect, Anti-Humanism. Sociological Review. 61. 769–789. 10.1111/1467-954X.12075. Komisaruk, B. R., & Whipple, B. (2011). Non-genital orgasms. Sexual and Relationship Therapy, 26(4), 356–372. https://doi.org/10.1080/14681994.2011.649252 May, T., 2003. When is a Deleuzian becoming? Continental Philosophy Review 36, 139–153. https://doi.org/10.1023/A:1026036516963

Urdu Friday Sermon delivered by Khalifa-tul-Masih on May 29th, 2026 (audio)

In this episode, the crew makes like a remora and dives into… a new topic! Cloacal diving has been making its way around the internet and these manta rays and remoras don't even know how famous they are. Join us as we discuss the dynamics of a host and its symbionts with Emily Yeager, who published this enrapturing paper on fish swimming up into manta rays and much much more!Links to the papers referenced in this episode can be found on our Substack. The cloacal diving study we discussed in this episode was a collaborative effort between the University of Miami Shark Research and Conservation Program, the Marine Megafauna Foundation, and the Manta Trust. Be sure to check out these organizations and programs if you want to support them or learn more!This podcast is brought to you by the yellow perch, a freshwater fish native to North America. Known for its characteristic yellow and black vertical bars, the freshwater perch inhabits lakes, ponds and streams. Unlike birds, yellow perch are incapable of perching anywhere. During the breeding season, females lay their eggs and males follow them to fertilize them as a group, in what can only be considered a sperm race. Sounds freaky as hell! Cheers to you, yellow perch!Thanks for listening to Gettin' Fishy With It! You can find our website at www.gettinfishywithit.com/. You can find us on BlueSky at @gettinfishypod.bsky.social, and on Instagram ⁠⁠@gettingfishypod⁠⁠. You can also find us on ⁠⁠Facebook⁠⁠ and ⁠⁠LinkedIn⁠⁠. If you want to drop us an email, you can send your complaints (or questions!) to gettingfishypod@gmail.com.Our theme music is “Best Time” by ⁠⁠FASSOUNDS⁠⁠. Our audio in this episode is edited and produced by Christine Archer. Check her out on all the socials @nerdrvt!We very much appreciate you taking the time to listen to our seventy-eighth episode! Please help out the podcast by subscribing on your podcast platform of choice. If you could leave us a review, that would be super helpful!If you would like to support the show, you can sign up as a paid member on our⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ Substack⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠, or you can ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠buy us a coffee⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠!Thanks and we'll “sea” you again in two weeks!Additional audio credits this episode:"Adventures in Adventureland" Kevin MacLeod (incompetech.com)Licensed under Creative Commons: By Attribution 4.0 Licensehttp://creativecommons.org/licenses/by/4.0/

Balancing disease control with pregnancy and neonatal considerations in people with neuroinflammatory disease throughout the family planning, pregnancy, and postpartum periods is crucial. Modern treatment paradigms enable women to safely become pregnant and breastfeed alongside effective disease management. Shared decision making is an important part of this process. In this episode, Kait Nevel, MD, speaks with Ruth Dobson, MD and Kerstin Hellwig, MD, authors of the article "Family Planning in Neuroinflammatory Disease" in the Continuum® April 2026 Multiple Sclerosis and Related Disorders issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Dobson is a professor in the Centre for Preventive Neurology at the Wolfson Institute of Population Health, Queen Mary University of London, and a consultant neurologist in the Department of Neurology at the Royal London Hospital, Barts Health NHS Trust, in London, United Kingdom. Dr. Hellwig is a professor in the Department of Neurology at Katholisches Klinikum, Ruhr‑Universität Bochum, in Bochum, Germany. Additional Resources Read the article: Family Planning in Neuroinflammatory Disease Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @drruthdobson Full episode transcript available here

In this episode of Paradigm Shifting Books, hosts Stephen and Britain Covey take a deeper dive into one of the foundational ideas behind The 7 Habits of Highly Effective People: the maturity continuum. Building on their recent conversation with Dan Coyle about flourishing and human connection, they explore the progression from dependence to independence to interdependence, and why so much of modern self-improvement culture stops short of the ultimate goal. Drawing directly from the teachings of Stephen R. Covey, they unpack why independence is often celebrated as the highest form of growth, even though life itself is inherently interconnected.Stephen and Britain reflect on how these ideas apply to leadership, relationships, teamwork, and personal fulfillment. They discuss the dangers of victim thinking, the rise of hyper-individualism, and the growing appeal of “monk mode” culture in a world that increasingly rewards isolation and self-focus. Through personal stories, sports analogies, and timeless insights from The 7 Habits, they make the case that true flourishing happens not in separation from others, but through meaningful collaboration, trust, and shared growth. This episode is a powerful reminder that independence is not the final destination of maturity, but the foundation that allows us to fully thrive together.What We Discuss[00:00] Introduction[01:43] The maturity continuum explained[02:13] Dependence: the starting point[02:58] Independence: personal responsibility and discipline[03:55] Interdependence: the highest level of the continuum[05:25] Reading from The 7 Habits of Highly Effective People: the limits of independence[10:16] Self-reflection: where are you on the maturity continuum?[11:13] The role of “monk mode” and private victories[13:08] Modern life: isolation vs. interdependence[14:53] Conclusion Notable Quotes[03:41] "Independence is the paradigm of I can do it, right? I am responsible, I am self-reliant, I can choose." – Britain Covey[10:03] "Strength is found in differences more than it is in similarities in a relationship." – Britain Covey[13:02] "Growth doesn't stop at independence. That's really just the foundation." – Stephen Covey[10:56] "Interdependence is a choice only independent people can make." – Stephen R. CoveyResourcesParadigm Shifting BooksPodcastInstagram YouTube BookThe 7 Habits of Highly Effective People by Stephen R. CoveyBritain CoveyLinkedIn InstagramStephen H. CoveyLinkedInMentioned EpisodeWhy We Need Other People to Become Our Best Selves (Part 1) with Daniel Coyle

Palliative care in multiple sclerosis spans the disease course, from early screening and support after diagnosis to symptom management and quality‑of‑life optimization in midstage disease, and end‑of‑life care in advanced MS. This episode outlines a staged approach to palliative care, highlights the roles of neurology and primary care teams, and discusses tools such as patient‑reported outcomes and symptom scales to support ongoing assessment of patients and care partners. In this episode, Katie Grouse, MD, FAAN, speaks with Penelope Smyth, MD, FRCPC and Janis M. Miyasaki, MD, MEd, FRCPC, coauthors of the article "Palliative Care in Multiple Sclerosis" in the Continuum® April 2026 Multiple Sclerosis and Related Disorders 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. Smyth is the director of the Division of Neurology in the Department of Medicine at the University of Alberta in Edmonton, Alberta, Canada. Dr. Miyasaki is a professor in the Division of Neurology in the Department of Medicine at the University of Alberta and the zone clinical department head for Clinical Neurosciences at Alberta Health Services in Edmonton, Alberta, Canada. Additional Resources Read the article: Palliative Care in Multiple Sclerosis 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 Grouse: With the new treatments for MS, people might be saying palliative care is not relevant at all. It's about giving up hope and hopelessness. But this article covers why palliative care is important for your patients and families throughout their illness trajectory. 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 Drs Penelope Smyth and Janis Miyasaki about their article on palliative care in multiple sclerosis, which appears in the April 2026 Continuum issue on multiple sclerosis. Welcome to the podcast, and please introduce yourselves to our audience.  Dr Smyth: Thank you, Katie. I'm Penny Smyth. I am a neurologist at the University of Alberta, a professor in neurology, and a clinical multiple sclerosis specialist.  Dr Miyasaki: Hi, Katie. Thanks for having us. I'm Janis Miyasaki. I am a movement disorder neurologist primarily who also provides neuropalliative care at the University of Alberta in Edmonton, Canada.  Dr Grouse: It's so great having you today to talk with us about your article. I thought this article was really a wonderful take on the topic. I learned a lot, and I'm really hoping all of our listeners will take advantage of this article and take advantage of all the learning they can get from reading about this topic. So, I wanted to start with a more general question, which is, what is the key message from this article that you're hoping your readers will take away?  Dr Smyth: In terms of key takeaways, I think it's our hope that neurologists will come away from reading this article with, really, an expanded understanding of what palliative care is and how that might be applicable to them in their care for their patients with MS along a continuum of treating people with MS, that there can be components of palliative care and strategies that can be integrated early after diagnosis in, really, anywhere along the continuum of caring for people with MS. We've called that kind of mid-stage. And then there are particular needs for people with MS and their care partners in late-stage or severe MS and end of life that might require different palliative care strategies. I think we kind of have maybe a bit of a bias sometimes in thinking of palliative care as more directed towards those that are near end-of-life. But in fact, it's a much expanded concept.  Dr Miyasaki: And I'll just add that we also discuss a palliative approach, that palliative care skills and philosophies can be used by generalists---in this case, neurologists who are providing care to people with MS---and that adopting certain skills and communication techniques can help us better address our patients' and their families' symptoms. And also to keep in mind that for most people with neurologic illness, the unit of care is not only the patient, but it's the patient and the family, however that family looks.  Dr Grouse: Now, Penny, I'm curious, how are early-stage and mid-stage multiple sclerosis palliative care strategies different from, say, a typical evaluation and counseling that a neurologist would give, say, an MS specialist or even a general neurologist?  Dr Smyth: Thank you, Katie. That's a great question, and something that actually I learned in writing this piece with Janice and from her as a neuropalliative care expert. I think in terms of early strategies around palliative care that can be helpful to the general neurologist in their office, palliative care is about holistic support for patients and their care providers spiritually, emotionally, physically. There are components of palliative care and symptom management and making sure that the patient is at the center of the care, as well as support for their care partners with their holistic approach of relief of suffering as well as offering hope. When I started this piece, I was thinking that many of us neurologists, I think, often informally utilize many of these components already when we're dealing with patients early on after diagnosis in terms of communication, counseling, and education; going through their fear of an uncertain future; spiritual well-being; and then connecting them with supports for adaptive coping strategies. And then as well in mid-stage, which is really around what we can do in symptom management and improving quality of life, with screening tools and patient-reported outcome measures. However, I have to say that there are many unmet needs for people with MS and their care partners that they identify that are clearly not being met by us neurologists in this day and age. So even though we may be incorporating some of these strategies, I don't think we're meeting the mark all the time and hitting the target, especially in our busy office practices, in various ways. Dr Grouse: Given that, at a high level, what are some important early-stage MS palliative care concepts that we should be keeping in mind when we are counseling patients in these stages of the disease? Dr Miyasaki: An important concept to keep in mind for neurologists dealing with early-stage MS patients is that for us, we feel successful that we have made a diagnosis. And yet for the patient, it is taking away that hope. Maybe it's not MS. Maybe I just have a numb hand and it's gonna go away. And for us to appreciate that while we make this diagnosis multiple times a week---or, for MS specialists multiple times a day---for this person, it is the first time, the first experience, and it shakes their entire foundation of who they are as a person, how they will perform all the tasks and roles that they have in society, in their professional lives, in their family structures, and in their close, intimate relationships. As physicians, we may be overwhelmed by acknowledging that. I feel that it's important for us to understand the needs that our patients have and to allow them to have their feelings. You know, feelings can feel messy and time-consuming, and yet when we fully see our patients, I feel that this is the best of medicine. And it certainly is, in terms of palliative care, the principle that we seek. We accept all of the patient, the joy and the sorrow, the anger and the frustration. We accept it all, and we try to determine what will serve this person who is suffering in front of us now.  Dr Smyth: There's another piece to this, which came up as Janice and I were writing together. We were talking about offering a prognosis to a patient as to how they would do, and this was something that I thought deeply about, because I said, we always communicate how uncertain the prognosis is and how we can't predict the future. And then she said to me, well, what about offering a roadmap to a person with MS soon after diagnosis as to how you're gonna determine how they do over the next couple of years? Which are really important years in terms of determining how patients are doing on their disease-modifying therapies, whether they're having progression or not, and things. It's a pivotal time. So, if you can offer a roadmap to a person with MS and say, look, this is when we will be following you up. This is how we will be following you with MRI and biomarkers if you have that available, and this is how we will determine how responsive you are and then how we move forward from there. Dr Grouse: Really important concepts. And the roadmap certainly makes a lot of sense to me and something that, apart from just being useful to the patient for so many reasons to help set expectations, you know, is useful for us to better partner with the patient so they understand this is sort of how we do things and everyone's sort of expectations are met. So, I think those sound like really great goals and things to keep in mind. Now, we talked about early-stage MS palliative care concepts. How does that change as you get into the mid-stage of the disease?  Dr Smyth: Yeah. So, this is reflecting the fact that the course of MS is so different and the experience of MS is so different person to person. And so, what do we do as neurologists when we follow these people long-term over years and decades of living with their MS as their needs evolve, as their symptoms evolve, and as their disability evolves? Well, really, this is about the time of getting into, what are the symptoms that they're struggling with, what are the causes of their suffering at various points? And then how do we identify that, maybe with use of patient-reported outcome measures, screening scales, things like that. And then how do we direct symptomatic management to the specific symptoms that are causing distress to the patient? As well as trying to improve their quality of life in various ways, treating their comorbidities, making sure to check on exercise, healthy living, and that kind of thing.  Dr Grouse: Now getting into, I think, topics that we're more used to thinking about when we think about palliative care: a lot of us, I think, are really unsure of the right time to discuss advanced care directives in the course of multiple sclerosis, and I think that's not helped by the fact that many of us are just, in general, not terribly comfortable talking about those types of things in general. What is your advice to questions like this?  Dr Smyth: And this is something that, again, Janice and I had to come together on, because there is no universal accepted time for when is the right time in multiple sclerosis to discuss advanced care directives and goals of care. And in fact, when they have looked at it in the literature, different things have come out. It has come out that neurologists can be uncomfortable discussing this. There's unique challenges to people with MS in that they have a diagnosis at a young age with an uncertain trajectory of how their course of disease is going to go. And many of these things lead care providers to be somewhat hesitant as to when is the right time, as well as, there were identified barriers within patients themselves as to when the right time might be to discuss. In that, you know, some of the coping strategies might be, as identified by some of the qualitative studies that have been done on this, around the fact that they would prefer to focus on the present rather than the future. In some studies expressed an ambivalence as to when they thought the right time might be, as well as some negative experiences that they might have had from providers trying to discuss these things in their previous experience. So, I went back to looking at the European guidelines for palliative care in MS, who suggested when a person might have severe MS---which they define as walking with bilateral aids for at least twenty meters or an EDSS of six or higher---or trigger-based, when there has been a change in the patient's status, when there's been a decline in some way or progression. Now, this is a little different, actually, than what we offer other people with neurologic diseases, and I don't know if that's the right answer. And this is where I'm going to turn it over to Janice, because I think we could learn something, as neurologists who treat people with MS, from our palliative care specialists.  Dr Miyasaki: I think of advanced care planning in a very different way. I think what a lot of the patients were expressing in the studies was that being asked about advanced care planning signaled to them in some way that they have reached this point in their illness where things aren't going so great and I anticipate that you may run into complications. Whereas in our movement disorder clinic, one of our fellows did a study looking at capacity for decision-making. And even in people who scored normally on the Montreal Cognitive Assessment, they had impairments in some of the domains of decision-making. And so, our philosophy in movement disorders at least---and some of our patients are quite young who have multiple system atrophy, they could be in their forties---we take the philosophy that everyone over the age of decision-making capacity, which is generally eighteen, should have some goals of care established. And how I introduce it in my clinic is, you know, for the young resident, you want the full-meal deal, because the likelihood of the resident surviving the ICU admission is very high. And then when we look at me, who… I am older, the likelihood of surviving an ICU admission is considerably lower. And so, the appropriate goals of care might be that I am willing to go to the ICU, and if things go well, then they can continue. But if things are not going well, they can have a discussion with my personal directive or power of attorney to talk about what the goals of care should be. And then the other aspect is sometimes having the conversation with family is really important because most of our families in hospital express an uncertainty. Am I doing the right thing? And they want to do the right thing for their loved ones. And most people actually say, if you ask them, I don't want to burden my family with making decisions that are going to tear at their hearts. So, then we can't actually make good informed decisions for our loved ones unless we have clear conversations. I think it does speak to our superstitious beliefs that if we talk about death, it's going to happen. But I hope the listeners will take my word for it, it really doesn't. And someone had a really good saying about the advanced directive. They're kind of like evening clothes. You should take them out every once in a while and make sure they still fit. And so, when you normalize it in this way, it helps people to just say, oh, yeah, it's once a year. Dr. Miyasaki is gonna ask me about how do I feel about those goals of care. And then it doesn't have this portent of, oh, I'm not doing well. Instead, it's just, this is what we should all be doing for our sake and for our family's sake.  Dr Smyth: Now, one thing that I have to add on to this is that it is important to try to establish advanced care directives before patients experience cognitive decline, because then that can make it a much more challenging conversation and brings nuances of challenge into the interactions, which, you know, are hard.  Dr Grouse: And Penny, I'm glad you brought that up, because I was really struck by that point too when reading this article, how easy it is to miss the subtle signs that cognitive changes are happening. I think it's just- it's a good kind of segue into that topic in general, but it is such an important link to, you know, making sure that you get those advanced directives at a time when the patient's really able to express and understand what they're talking to you about. Now, on the topic of the cognitive screenings, what's a good way to do this type of screening, and why is this type of screening so particularly important in the case of multiple sclerosis?  Dr Smyth: Yeah. Thank you, Katie. I think that it's important for our listeners to think about and recognize when we see our patients with MS because it is one of the invisible symptoms that people with MS can live with and may not be apparent on regular conversation in the office. So, it's important to deliberately ask about subjective challenges in cognition. Ask the partner about how they're doing in terms of their cognition in various ways. As well as asking them and exploring then, how are they doing in their professional roles if they're working or in their surroundings? How are they coping on a daily basis on a cognitive level in addition to a physical level? We know that cognitive issues are actually the biggest contributor for not working and are a huge driver of disability in MS in terms of functioning, even more than physical decline in many ways. So, it is important for us neurologists to keep top of mind and to think about and deliberately attend to. There are screening tests that we can do in the office. The easiest for us, which measures the verbal processing speed, is the SDMT test, which is a ninety-second test matching symbols and numbers. It's easy to do. You can train a MOA to do it before you see the patient and things like that, and it just gives you an idea as to where the patient is at. And usually they're having difficulties if they're greater than two standard deviations below the norm for their age, or if there's a significant drop of four or eight points, and that might signal to you that there might be more going on. You can explore it, and then if you do have this available, the ability to refer for neuropsychological testing if there's questions. But often we can't get it with the MoCA score, unfortunately.  Dr Grouse: Talking about all these concepts, I think they all sound great. I think a lot of us hearing this will naturally say, "Yes, these are absolutely things we should be incorporating in the care of these patients." What I wondered about was, certainly we're all very busy, it is really hard to find time for a lot of these things. We don't always have access to specialists who can help us with some of these conversations. How can we find time, and how can we work this into the care of our patients effectively and still make time for all the other things we have to talk about, and make sure that we're seeing all of our other patients and staying on time and all of those things?  Dr Miyasaki: Yes. I think that's the challenges of dealing with people who actually, over time, their care needs increase, is huge in neurology. I can't think of a single subspecialty where care actually gets easier. It's constantly getting harder. You know, having come from private practice, I completely understand my colleagues' challenges in the community. Some of the ways that other groups have managed this when they don't have government or university support in their center is actually to look at not-for-profits. There are a lot of not-for-profits that can help in terms of wayfinding for social services, explaining to the patients and the family what is available to them. And in fact, some of them can also provide some cognitive supports, as well as point them in the way of day programs. And many of them have very established caregiver support groups, as well as patient support groups for various stages of their illness. So, I think it requires for the individual or small or even a large group practice to be inventive, to look in your community and see what resources are available and free for your patients in order to establish that loose team without boundaries to help your patients. Of course, for those in academic centers, I know that times are tight for all of us, and if you haven't established a team, it is a challenge; and then learning how to write a business plan or a briefing note for your institution and to learn how to speak the love language of administrators, is really key to putting forward the needs of our patients. Which, compared to heart attack patients or hips and knees, they are very rare, and yet our patients can result in significant cost to the healthcare system. So, we do have an opportunity to make the case that putting a little bit of investment in the ambulatory setting can result in significant cost savings to the system when it comes to acute care hospitalization.  Dr Smyth: So, I was thinking, Janis, as you were talking about that, when you were talking about not-for-profit groups, it's really the MS societies in various countries that are very active in this and have a lot of resources available, especially for care partners.  Dr Grouse: Those are really great tips. Thank you for bringing those up as potential other resources we can take advantage of. I wanted to ask specifically about physician-assisted death and assisted suicide, which certainly does come up, especially in later-stage parts of the disease. How can palliative care specialists be helpful when patients do express interest in these types of interventions?  Dr Miyasaki: As you know, Katie, in Canada, we've had a legislative right to access to what we call medical assistance in dying. When the legislation passed, one of my other colleagues and I felt that these were the only conversations we were having with our patients. In all this experience, I have sort of developed in my mind a framework of people who are what we call MAID-curious. They want to know what their rights are and how it would look, when they feel the time is close, for them to exercise that right. And then there are those who are fearful of future suffering. And some of them may have a very unrealistic view of what the future will look like. And this may be in particular for multiple sclerosis because many of the public's view is based on what treatment was like thirty years ago. It may not be informed by more recent treatment where patients actually do quite well, and the majority never get to progressive MS. And so, to explore and be open to that request is the first thing that is important. And then if the person has unresolved symptoms that, traditionally, we can't care for, the palliative care specialist can be very helpful because they just have inventive ways of looking at things. They look at it outside the box, and they have a different toolkit available to them. I would not want all neurologists to just send all these patients requesting physician-assisted death to their palliative care colleagues. But I think for those who are having unaddressed symptoms, it can be very helpful. Certainly, if there is an acute event in the hospital, then this is a time of crisis. And often hospitals will have an in-hospital palliative care team who can come and speak to the patient about what is going on and address some of their needs. And I would also like to emphasize the importance of spiritual care, because for many of our patients, they are not just having the physical suffering, they are also having the spiritual suffering of hopelessness or of feeling that they are a burden or that they just are not seen because a lot of the symptoms in MS are invisible. To have that understanding by a spiritual care counselor is really helpful for the people to feel understood and to reduce some of that suffering.  Dr Grouse: That's a really great point, I think, to end on, and I think it really ties in a lot of the themes that we've been talking about today. Thank you so much for coming to talk with us today. It's been such a pleasure having you both here. Dr Smyth: Thank you. Dr Miyasaki: Thank you, Katie. Dr Grouse: Again, today I've been interviewing Drs Penelope Smyth and Janis Miyasaki about their article on palliative care in multiple sclerosis, which appears in the April 2026 Continuum issue on multiple sclerosis. 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.

What should you really expect from a financial advisor? Is your advisor acting as a fiduciary, managing risk, helping with taxes, retirement income, estate planning, and behavioral coaching, or just selling products and chasing performance? Richard Rosso & Jonathan McCarty break down the real role of a financial advisor, what services matter most, how advisors are compensated, and the warning signs investors often miss. We also discuss fiduciary standards, portfolio management, communication expectations, financial planning, and why transparency matters more than promises.. Here's a topical rundown of today's show: 0:00 - INTRO 0:18 - Jerome Powell, Kevin Warsh (Janet Yellen) & CPI Review 4:18 - Employment Numbers & Data Centers, & Robots Chasing Hogs 6:26 - What Does Your Advisor Do? 10:16 - What Should You Expect? 14:24 - What Are You Getting vs Giving Up? 16:02 - Looking at Taxes on a Continuum 19:35 -Investment Management is Important 20:44 - AI, Robots, and Animatronic Beavers 25:40 - Financial Advisors with Open Minds 27:41 - Fixed-cost vs Fee-based Financial Planning 30:10 - How to Deal with Emotional & Cognitive Biases 34:22 - Math & Movie Voice-overs 36:02 - Fiduciaries Focus on Things You Miss 37:45 - Proper Asset Location 38:14 - Fee Transparency - How advisors get paid 41:20 - Red Flag Warnings When Choosing an Advisor 42:59 - What Annuities Do (and Don't Do) 45:25 - Fee-only vs Fee-based Advisors44;31 - Big Firms vs Small Firms - KYC 47:02 - What Comprehensive Wealth Management Should Look Like 47:54 - Candid Coffee - Financial Organization Made Simple Hosted by RIA Advisors Director of Financial Planning, Richard Rosso, CFP, w Senior Investment Advisor, Jonathan McCarty, CFP Produced by Brent Clanton, Executive Producer ------- Articles Mentioned in Today's Show: "The Perfect Planning Experiemce" https://realinvestmentadvice.com/ria-e-guide-library/ ------- Do you enjoy our content? Rate us on Google: https://bit.ly/4b9JtEo ------- Watch Today's Full Video on our YouTube Channel: https://youtube.com/live/HXafEWQMFuI?feature=share ------- Watch today's "Before the Bell" feature, "Momentum Mania Meets Market Rotation," here: https://youtu.be/bNIRIssbDP8 ------- Watch our previous show, "Inflation Surge Hits Markets?" https://youtube.com/live/UOSeQNOhcwI ------- * REGISTER for our next Candid Coffee, THIS Saturday, May 16: "Financial Organization Made Simple:" https://streamyard.com/watch/SA6aj2aMdMhf -------- Download Lance's Latest e-book, "Laws of Money & Wealth:"https://realinvestmentadvice.com/ria-e-guide-library/ -------- SUBSCRIBE to The Real Investment Show here: http://www.youtube.com/c/TheRealInvestmentShow -------- Visit our Site: https://www.realinvestmentadvice.com Contact Us: 1-855-RIA-PLAN -------- Subscribe to SimpleVisor: https://www.simplevisor.com/register-new -------- Connect with us on social: https://twitter.com/RealInvAdvice https://twitter.com/LanceRoberts https://www.facebook.com/RealInvestmentAdvice/ https://www.linkedin.com/in/realinvestmentadvice/ #FinancialAdvisor #RetirementPlanning #Investing #WealthManagement #Fiduciary