Podcasts about echocardiogram

Welcome to the emDOCs.net podcast! Join us as we review our high-yield posts from our website emDOCs.net.Today on the emDOCs cast with Rachel Bridwell, MD, and Brit Long, MD (@long_brit), we cover left ventricular outflow tract obstruction, or LVOTO. To continue to make this a worthwhile podcast for you to listen to, we appreciate any feedback and comments you may have for us. Please let us know!Subscribe to the podcast on one of the many platforms below:Apple iTunesSpotifyGoogle Play

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on echocardiogram vector embeddings via R3D transformer for the advancement of automated echocardiography.

Someone who needs no introduction. FA WSL legend and England Lioness great Jade Moore joins us on a very special episode of the Pro Player Podcast. Jade talks everything from her glittering career all round the world, representing England at Major tournaments like the FIFA Womens World Cup and her important role as Cardiac Risk in the Young Ambassador.Jade is authentic as she is inspiring - enjoy this very special extended episode...Cardia Risk in the Younghttps://www.c-r-y.org.ukPreventing young sudden cardiac deaths through awareness, screening and research, and supporting affected familiesCardiac ScreeningCRY offers subsidized ECG and Echocardiogram screening to all young people between the ages of 14 & 35 in the UK. There is a simple way to diagnose most cardiac abnormalities. This is by having an ECG (electrocardiogram) test. Results should be read by a cardiologist. For extra clarity an Echocardiogram (ultrasound scan) can also be done.If there has been a young (under 35) sudden death in the family, the family is entitled to be screened on the NHS. All of CRY's public events are free to attend.

Northfield High School student Evan Loe provides information about the Play for Patrick heart screening, which is a free heart screen for young adults ages 14-24, April 20, 9am-5pm at Northfield Middle School. Register on Play For Patrick.  Heart screens include checking of; Height/Weight, Blood Pressure, EKG (electrical current of the heart), Echocardiogram (video of […]

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This week we discuss an important 'general cardiology' question - namely, do all exertional chest pain patients need an echocardiogram. In this debate from the World Congress of Pediatric Cardiology and Cardiac Surgery, we hear 2 noted authorities in non-invasive imaging. First up is Dr. Carolyn Altman of Texas Children's Hospital taking the stance that it is indicated in the majority and following Dr. Altman is Dr. Kenan Stern of Mount Sinai Kravis Children's Hospital defending the role of discretion in these decisions and how 'one size may not fit all'. Both authorities provide deep insights into general cardiology and the nuances of evaluating a common cardiology complaint seen in general practice.

Overview BNP Normal Value Range Pathophysiology Special considerations Lab value elevations Nursing Points General Normal value range 100 pg/mL Pathophysiology Increased pressure overload due to increased SVR or volume Ventricular stretching causes release of BNP into bloodstream BNP released to aid in stress due to overload by: Increases excretion of sodium in urine = natriuresis Sodium follows water Decreased intravascular volume Decreased workload on the heart = improved cardiac function Special considerations Lavender tube (EDTA) NT-proBNP may be requested instead Submit in serum separator tube (tiger top) Elevated lab values >100 pg/mL – heart failure likely The higher the value, the more likely the diagnosis of heart failure Assessment Assess patient for acute exacerbation of heart failure Lung sounds Oxygen status Need for supplemental oxygen Radiographic evaluation May need diagnostics for evaluation Echocardiogram can determine contractility function Therapeutic Management Treatment Treat heart failure Diurese Improve contractility Nursing Concepts Lab Values Perfusion

The normal heart is very robust. Some people are born with abnormalities of the heart structure. Others acquire damage to the heart valves which become too narrow or unable to close properly. The muscle and linings of the heart may be affected by infections, drugs or other inherited or acquired diseases. All of these can cause heart failure or death if not treated.This lecture will consider the prevention and treatment of structural heart disease.A lecture by Sir Chris Whitty recorded on 16 May 2023 at Barnard's Inn Hall, London.The transcript and downloadable versions of the lecture are available from the Gresham College website: https://www.gresham.ac.uk/watch-now/heart-diseasesGresham College has offered free public lectures for over 400 years, thanks to the generosity of our supporters. There are currently over 2,500 lectures free to access. We believe that everyone should have the opportunity to learn from some of the greatest minds. To support Gresham's mission, please consider making a donation: https://gresham.ac.uk/support/Website:  https://gresham.ac.ukTwitter:  https://twitter.com/greshamcollegeFacebook: https://facebook.com/greshamcollegeInstagram: https://instagram.com/greshamcollegeSupport the show

It's another session of CardioNerds Rounds! In these rounds, Dr. Karan Desai (Formerly FIT at University of Maryland Medical Center and currently faculty at Johns Hopkins School of Medicine) joins Dr. Dan Burkhoff (Director of Heart Failure, Hemodynamics and MCS Research at the Cardiovascular Research Foundation) to discuss mechanical circulatory support options through the lens of pressure-volume loops! Dr. Burkhoff is the author of Harvi, an interactive simulation-based application for teaching and researching many aspects of ventricular hemodynamics. Don't miss this wonderfully nerdy episode with a world-renowned expert in hemodynamics and MCS! Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Hemodynamics and Mechanical Circulatory Support Case Synopsis: Case SynopsisWe focused on one case during these rounds. A man in his mid-50s presented to his local community hospital with 3 days of chest pain, nausea, and vomiting. He appeared ill in the emergency room with HR in the 150s, BP 90/70s and ECG demonstrating inferior ST elevations. He was taken emergently to the catheterization lab and received overlapping stents to his right coronary artery. Over the next 24 hours, he developed a new harsh systolic murmur heard throughout his precordium and progressed to cardiogenic shock. Echocardiogram demonstrated a large basal inferoseptum ventricular septal rupture. From this point, we discussed the hemodynamics of VSR and MCS options. Case Takeaways Dr. Burkhoff took us through the hemodynamics of VSR with pressure-volume loops to better understand the pathology and impact of various MCS options. Of note, there are no MCS devices specifically approved to treat acute ventricular septal rupture. In regards to the acute hemodynamic effects of a VSR (an abrupt left to right shunt), there are several aspects to note. First, the effective LV afterload is reduced; however, there is less “forward flow” as well and as a consequence, decreased left-sided cardiac output (“Qs”) and blood pressure. At the same time, flow through the pulmonary artery increases (the “Qp”). Additionally, due to the abrupt shunt flow, there is increased RV “loading” with increasing central venous pressure and pulmonary artery pressure. The hemodynamic priorities in treating patients with cardiogenic shock and VSR are to normalize blood pressure, cardiac output, and oxygen delivery, while attempting to minimize shunt flow to allow healing. However, medications and MCS are unlikely to completely normalize hemodynamics. For instance, if the patient was placed on peripheral VA ECMO, while total CO and BP may increase, flow across the VSR could also increase at high ECMO flows (e.g., by introducing more LV afterload). In patients with persistent cardiogenic shock and VSR, short-term MCS to divert flow away from the shunt can be an effective strategy. LV-to-aorta or LA-to-arterial MCS may provide the best single-device hemodynamic profiles by decreasing shunt flow, reducing pulmonary capillary wedge pressure, and improving blood pressure. Surgical and percutaneous VSD repair are the definitive treatment options. If able to stabilize patients and pursue delayed repair,

The importance of recognition and diagnosis of cardiac amyloidosis is at an all-time high due to its high prevalence and improved therapeutic strategies. Here we discuss what CardioNerds need to know about the manifestations, diagnosis, and management of transthyretin (ATTR) and light chain (AL) cardiac amyloidosis. Join Dr. Dan Ambinder (CardioNerds Cofounder), Dr. Dinu-Valentin Balanescu (Series Cochair, Chief Resident at Beaumont Health, and soon FIT at Mayo Clinic), and Dr. Dan Davies (Episode FIT Lead and FIT at Mayo Clinic) as they discuss cardiac amyloidosis with Dr. Omar Siddiqi, cardiologist at the Boston University Amyloidosis Center and program director for the general cardiovascular fellowship program at Boston University, a CardioNerds Healy Honor Roll Program. Episode notes were drafted by Dr. Dan Davies. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah. Access the CardioNerds Cardiac Amyloidosis Series for a deep dive into this important topic. This episode is supported by a grant from Pfizer Inc. This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.  Pearls • Notes • References • Production Team CardioNerds Cardio-Oncology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes Cardiac amyloidosis is no longer considered a rare disease, especially transthyretin amyloidosis in older male patients with HFpEF and aortic stenosis. Echocardiogram is the “gate keeper” of cardiac imaging and provides initial evidence of amyloid infiltration, while cardiac MRI can help refine the presence of an infiltrative cardiomyopathy versus other causes of increased wall thickness. The most clinically important types of amyloid heart disease are transthyretin (ATTR) and light chain (AL) amyloidosis. The workup to differentiate these disorders includes a gammopathy panel to screen for the presence of potentially amyloidogenic light chains (serum and urine electrophoresis WITH immunofixation and serum free light chains), and cardiac scintigraphy with Technetium-99m-labeled bone-seeking tracers (PYP, DPD, etc.) to identify cardiac aTTR infiltration if the gammopathy panel is unrevealing. There is still a role for endomyocardial biopsy in the diagnosis of cardiac amyloidosis! All patients in whom there is concern for cardiac amyloidosis and gammopathy panel indicates the presence of monoclonal light chains should have a biopsy to obtain a tissue diagnosis of likely AL amyloidosis. Alternatively, an endocardial biopsy may prove valuable in patients who have confusing phenotypic features between amyloid types, such as a patient with abnormal monoclonal protein and positive PYP imaging. Be suspicious of heart failure patients that do not tolerate typical medications that lower heart rate. In the restrictive cardiomyopathy of cardiac amyloidosis, patients are reliant on higher heart rates to compensate for the inability to augment stroke volume. Be suspicious of amyloidosis in patients with recurrent left atrial thrombi despite anticoagulation. Show notes CardioNerds Cardiac Amyloid, updated 1.20.21 1. What is cardiac amyloidosis and how common is it? Cardiac amyloidosis is adisorder caused by misfolding of proteins into insoluble forms which are deposited into extracellular spaces of the heart, commonly causing a stiff and thick heart with progressive diastolic dysfunction with restrictive hemodynamics and ensuing heart failure. The two most common types of amyloid protein that affect the heart are transthyretin (ATTR) and light chain (AL).

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Computerized Left Ventricular Hypertrophy Detection Guest: Bob Farrell, Ph.D.   Hosts: Anthony H. Kashou, M.D. (@anthonykashoumd) When the heart in the human body's source to pump blood has decreased, it is referred to as the left ventricle. Furthermore, the hypertrophy or the heart's wall eventually loses its firmness, which leads to a higher risk of hypertension or high blood pressure. Often, the heart tends to lose its ability to pump blood. In addition, some signs to stay aware of are feeling fatigued, dizziness, fainting, and frequent chest pain. Patients affected by Left Ventricular Hypertrophy are more at risk of becoming diagnosed if they experience decreased or increased heart rhythm signals or congestive heart failure. Therefore, when the doctor recommends testing, an Electrocardiogram is used to record signals to test the heart rhythm and abnormalities. In addition, an MRI or Echocardiogram is used to test Computerized Left Ventricular Hypertrophy as well. Joining us today to discuss Computerized Left Ventricular Hypertrophy Detection is Bob Farrell, M.D., professor of medicine at Queen's University in Kingston, Ontario, Canada. Furthermore, Dr. Farrell is currently a member of the board of directors of the International Society of Computerized Electrocardiology. Specific topics discussed: With other modalities available to clinicians (e.g., echo, cardiac MR), is ECG still relevant in the discussion of LVH? You have recently made some updates in the GE “12SL” program related to LVH. What drove the changes that you made? Customer feedback, opaqueness of the criteria, ACC/AHA recommendations to manufacturers So what were the changes you made? How did you pick which of the many criteria out there to use and how important was it to explicitly list the positive criteria in the interpretation? You mentioned earlier that ECG-LVH is an entity in its own right and is associated with poorer outcomes. Can you talk about ECG-LVH and risk prediction, and how the changes you've made in the GE 12SL program aid in the risk prediction? Connect with Mayo Clinic's Cardiovascular Continuing Medical Education online at https://cveducation.mayo.edu or on Twitter @MayoClinicCV and @MayoCVservices. Facebook: MayoCVservices LinkedIn: Mayo Clinic Cardiovascular Services NEW Cardiovascular Education App: The Mayo Clinic Cardiovascular CME App is an innovative educational platform that features cardiology-focused continuing medical education wherever and whenever you need it. Use this app to access other free content and browse upcoming courses. Download it for free in Apple or Google stores today! No CME credit offered for this episode. Podcast episode transcript found here.

CME credits: 1.00 Valid until: 29-07-2023 Claim your CME credit at https://reachmd.com/programs/cme/the-echocardiogram-is-of-central-importance-to-ctd-pah-diagnosis-and-referral/14404/ tbd

Last week on Instagram I asked if anyone wanted to hear about my experience of two ECGs and a tilt table test as part of my ongoing chest pain investigations, and the majority of those who voted said yes! So, I wanted to record this whilst the experience was fresh in my mind. If you're not sure why I had these tests, you can listen to episode ep.204/ the thing that's been happening with my heart and why it's important to talk about it in the endo community. So, as I said in my last episode about this, I am not a cardiologist, and I am not a health coach specialising in heart disease or any heart related conditions. As an endometriosis health coach however, I do see a lot of postural tachycardia syndrome and mast cell activation syndrome, both of which can cause symptoms like chest pain, dizziness, shortness of breath, palpitations, etc. and so many of my clients do have to go through these processes and tests to get the right diagnoses. Read more Let's get social! Come say hello on Instagram or sign up to my newsletter. I'm excited to announce that I've joined a new podcast network called Connectd Podcasts. Connectd Podcasts is a new mission-driven network focused on helping podcasts like this grow and thrive! I'm thrilled to be a part of a network bringing positive content to the world through diverse voices and perspectives. Be sure to check out some of the other great shows including The Period Party by Nicole Jardim and Beyond Trauma by Lara Land! My cookbook This EndoLife, It Starts with Breakfast is out now! Get 28 anti-inflammatory, hormone friendly recipes for living and thriving with endometriosis. Order your copy here. If you feel like you need more support with managing endometriosis, you can join Your EndoLife Coaching Programme. A 1-to-1 three month health and life coaching programme to help you thrive with endometriosis. To find out more about the programme and to discuss whether it could be right for you, email me at hello@thisendolife.com or visit my website. This episode is produced by Ora Podcasts. Ora provides audio editing, management and other services to make podcasting simple and sustainable for their clients. Health coaches, nutritionists, mediums, personal trainers, tarot readers, teachers, or just those striving for a better world, Ora can help you start and maintain your podcast. Get in touch today. This episode is sponsored by BeYou. Soothe period cramps the natural way with these 100% natural and discreet menthol and eucalyptus oil stick on patches and CBD range. Click here to find out more and to shop: https://beyouonline.co.uk This episode is sponsored by Semaine. Try their supplement for period pain and daily supplement for hormonal balance and PMS prevention with code ENDOLIFE to get 20% off your first order. Show Notes https://www.nhs.uk/conditions/postural-tachycardia-syndrome/ https://www.nhs.uk/conditions/echocardiogram/ https://www.nhs.uk/conditions/electrocardiogram/ https://www.bhf.org.uk/informationsupport/tests/tilt-test https://www.potsuk.org/about-pots/diagnosis/ https://www.theendobellycoach.com/podcast/endo-and-chest-pain https://www.theendobellycoach.com/podcast/endometriosis-and-ehlers-danlos-syndrome?rq=postural

Join us as we take a deep dive into fetal echocardiogram's with Dr. Elijah Bolin, Pediatric Cardiologist at Arkansas Children's Hospital. A fetal echocardiogram is a highly specialized type of prenatal ultrasound. This type of imaging study is performed to evaluate the structure of the heart of the unborn child. We discuss how a fetal echo is performed, what conditions it can diagnose in your baby, what patients it is essential for, and hear Dr. Bolin talk about real scenarios where fetal echo's catch cardiovascular conditions before birth..

The fetal echocardiogram is a targeted ultrasound that is used to examine the fetal heart in more detail than a standard anatomy ultrasound.  This test is typically performed after the 18th week of gestation by a highly trained sonographer and is do in addition to a routine anatomy ultrasound. This test can be utilized to determine the structure and the function of the fetal heart and gives a better imaging of any inconclusive or insufficient readings on a standard test. This episode explores the benefits of fetal echos and who needs them and why.   We'd love to hear your feedback.    Our practice website can be found at: Maternal Resources: https://www.maternalresources.org/ Remember to subscribe wherever you get your podcasts.  Please consider leaving us a review on iTunes Our Social Channels are as follows Twitter: https://twitter.com/integrativeob YouTube: https://www.youtube.com/maternalresources IG: https://www.instagram.com/integrativeobgyn/ Facebook: https://www.facebook.com/IntegrativeOB  

Why would doctors choose to spend time volunteering in another country and creating a nonprofit organization to save children's lives overseas?Dr. Tom Forsberg and Dr. Chad Hoyt are co-founders of Healing Hearts Vietnam. Dr. Forsberg is an emergency physician with Centra Health in Central Virginia.  He currently serves in four emergency departments throughout the region. Dr. Chad Hoyt specializes in advanced cardiovascular imaging and has been in partnership with Centra Health for the past sixteen years. He currently serves as the executive medical director of Centra's Heart & Vascular Center, a busy four-hospital system with seven office locations and forty clinical providers. For nearly a decade, Dr. Forsberg and Dr. Hoyt have shared their expertise with Vietnam. During their trips, they became aware of the great need for cardiac surgeries in children. Upon returning from Vietnam, Dr. Forsberg led the charge to form Healing Hearts Vietnam which was established in 2015. Today, Healing Heart Vietnam provides financial assistance to allow children with congenital heart disease to access life-saving surgeries.In this episode of "Heart to Heart with Anna," Dr. Tom Forsberg and Dr. Chad Hoyt share with Anna how they came to form a nonprofit organization to save the lives of children and adults in Vietnam with broken hearts. They share how certain devices have helped them identify who they can serve and how they can best help the people of Vietnam. They also share how people in the community can donate to their organization in a variety of ways.Links mentioned in the episode:Healing Hearts Vietnam websiteHealing Hearts Vietnam Facebook pageVietnamese Boat People episode with Amy M. LeVietnamese Boat People podcastPlease visit our Social Media and Podcast pages:Apple PodcastsFacebookInstagramMeWeTwitterYouTubeWebsiteAnna's Buzzsprout Affiliate Link (we both benefit if you sign up with Buzzsprout with my link - yay!) Support the show (https://www.patreon.com/HearttoHeart)

In conclusion to healthy heart month we wanted to do a small rerun and reminder on what to do to prevent heart problems in future. We hope that the past few episodes we were able to really dig in on what you as person have to do keep you heart healthy and happy. Doing regular exercise and healthy eating will always be the key notes to take from these episodes and hopefully you apply them regularly to your life!

This week we delve into the world of heart transplantation and echocardiography to review a recent work on non-invasive assessment of the pediatric heart transplant patient. Can stress echo and real time myocardial contrast echo identify coronary vasculopathy in this patient group? How do the results compare to coronary angiography? How difficult is this form of imaging and can it be done by pediatric echo techs and staff physicians? Professor Jonathan N. Johnson of the Mayo Clinic shares his insights this week. DOI: 10.1016/j.echo.2020.12.009

This week we delve into the world of noninvasive imaging and review a very novel approach from the team at Stanford University about tele-visits and the use of remote parentally acquired, focused echocardiograms for monitoring of Marfan's patients. Can any parent be trained to perform a focused echocardiogram in their homes? What is the cost associated with this approach? Can this technique be applied to other cardiovascular problems? We speak with Associate Professor of Pediatrics, Seda Selamet Tierney about her recent work on this interesting topic. doi: 10.1016/j.jpeds.2021.01.004

For a while, Cassie's experienced heart palpitations. It's a scary feeling, but she brushed it off. Eventually, things got worse, and Cassie knew it was time to see a doctor. At her last appointment, the doctors ran a few tests. And now, Cassie knows what's wrong. See acast.com/privacy for privacy and opt-out information.

This week we delve into the world of fetal cardiology to review a recent work on accuracy of fetal echo in the diagnosis of congenital heart disease. We speak with Dr. Namrita Mozumdar of Pediatric Cardiology Of Long Island about her work. What factors are associated with diagnostic discrepancies? DOI: 10.1016/j.echo.2020.06.017 Also joining us is Professor Kenan Stern of Mount Sinai Children's Heart Center to share with us information about the upcoming Mount Sinai Hot Topics In Fetal Cardiology Conference on May 1. Information can be found at: https://mssm.cloud-cme.com/course/courseoverview?P=3000&EID=4460

In this episode, Paul Grayburn, MD, FACC, and Rebecca Hahn, MD, FACC, discuss the five key elements of a comprehensive mitral regurgitation echocardiogram: etiology/morphology, severity, left ventricular size and function, left atrial size and pulmonary artery pressure estimate, and anatomic suitability for intervention.

IT'S BABY QUEST! The show where Mike and Leah talk about the trials and even more trials of having a baby. This week we talk about the results of Squid's fetal echocardiogram (heart thing) and how that might play out in the months ahead. We also hear about a couple celeb losses from this week including Meghan Markle, the Duchess of Sussex.Here is a link to her piece in the NYT. (You'll need a free account to read it.)Send us your questions, comments, or just say hi on Instagram @BabyQuestPod or Twitter @BabyQuestCast! And we even have an email address now: babyquestpod@gmail.com! WOW!

athlete heart covid https://www.the-scientist.com/news-opinion/college-athletes-experienced-heart-damage-after-covid-19-study-67929 titiles like- “Images of the players’ hearts showed signs of inflammation consistent with myocarditis, a rare but potentially fatal condition.” “two dozen of Ohio State University players using cardiac magnetic resonance (CMR), they found evidence of myocarditis in 15 percent, while a further 30 percent had cellular damage or swelling “ The Ny york times said- https://www.nytimes.com/2020/09/16/well/move/is-coronavirus-affecting-the-hearts-of-college-athletes.html Is Coronavirus Affecting the Hearts of College Athletes? “In a new study of 26 college athletes who tested positive for coronavirus, four later showed signs of inflammation in their heart muscles.” and my favorite-- CNN says https://www.cnn.com/2020/09/14/health/covid-heart-inflammation-athletes-study/index.html Covid-19 study suggests to screen recovering athletes for heart inflammation before they return to play “As athletes recover from Covid-19, taking images of their hearts to screen for inflammation may help doctors determine when it could be safe to get back in the game, new research suggests.” Now lets look at this paper and see if this paper says what you think it says or at least does it say what the Big Ten thinks it says!! In the press release for the big ten return to football they say “The Big Ten Council of Presidents and Chancellors (COP/C) adopted significant medical protocols including daily antigen testing, enhanced cardiac screening and an enhanced data-driven approach when making decisions about practice/competition. “ they go on to say “All COVID-19 positive student-athletes will have to undergo comprehensive cardiac testing to include labs and biomarkers, ECG, Echocardiogram and a Cardiac MRI.” The thing I find funny is they say things like ‘data-driven approach but then say things like ‘a positive athlete can not return for a minimum of 21 days’ and athletes must get a cardiac MRI along with a bunch of other non evidence based and non data driven recommendations. BUT this podcast is about the cardiac MRI in athletes so let's look at that paper and why it is dead fricken wrong!! This is a perfect example of why school presidents should play doctor and realistically speaking, I as a doctor don’t want to be a school president. https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645?guestAccessKey=ad3c4563-167f-452a-917f-7bfe15663b06&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=091120 The paper that has created this cardiac MRI craze is titled - Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection it was in jama cardiology on sept 11 and they researchers at ohio state did CMR imaging in 26 competitive college athletes who previously had been diagnosed with COVID19. and they found “Four athletes (15%; all male individuals) had CMR findings consistent with myocarditis and Pericardial effusion was present in 2 athletes with CMR evidence of myocarditis.” the authors conclusions, “Cardiac magnetic resonance imaging has the potential to identify a high-risk cohort for adverse outcomes and may, importantly, risk stratify athletes for safe participation because CMR mapping techniques have a high negative predictive value to rule out myocarditis.4” they go on to say “cardiac magnetic resonance imaging evidence of myocardial inflammation has been associated with poor outcomes, including myocardial dysfunction and mortality.6 “ this sounds terrible!!! I will give you a second to grab a drink and sit down because I think in the next several minutes you will be both relieved and frustrated about what this article really says. music this was first released by anish koka on twitter but she was spot on and this sort of information needs widespread dissemination. As I said there were 26 athletes but out of those 12 had mild symptoms DURING the infection and 14 were asymptomatic during the infection. None of these pts had chest pain or required hospitalization not even a slightly elevated troponin from demand ischemia during their infection was reported and per the paper, “There were no diagnostic ST/T wave changes on electrocardiogram, and ventricular volumes and function were within the normal range” now the current return to play protocol is all expert opinion but in the article is cited as 2-week not activity and if asymptomatic then no diagnostic cardiac testing but if symptomatic then an electrocardiogram and transthoracic echocardiogram. The authors want you to look at this and say hey we might need to add CMRI lots look at their logic “Cardiac magnetic resonance imaging has the potential to identify a high-risk cohort for adverse outcomes and may, importantly, risk stratify athletes for safe participation because CMR mapping techniques have a high negative predictive value to rule out myocarditis.4” https://www.sciencedirect.com/science/article/pii/S0735109718388430?via%3Dihub and they site Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations which the opening line says “This Journal of American College Cardiology Scientific Expert Panel provides consensus recommendations for an update of the cardiovascular magnetic resonance (CMR) diagnostic criteria for myocardial inflammation in patients with suspected acute or active myocardial inflammation” This is the first fault--remember these were healthy athlets THAT DID NOT HAVE SUSPECTED ACUTE OR ACTIVE MYOCARDIAL INFLMMATION!! you cant say well this test does really good at detecting a specific illness in this population so it must do a could job at detecting it in every population. That it like say well antibiotics work well to make people feel better when they have bacterial infections so they must work to make patients with cancer feel better. NO NO NO next they said, “Cardiac magnetic resonance imaging evidence of myocardial inflammation has been associated with poor outcomes, including myocardial dysfunction and mortality.6 “ and this comes from a paper titled “Prognostic value of cardiac magnetic resonance tissue characterization in risk stratifying patients with suspected myocarditis.” WITH SUSPECTED MYOCARDITIS!! this study was 670 patients who had CLINICALLY SUSPECTED myocarditis who then got a CMRI. just to get in to that study you had to have one of the following 1) acute chest pain syndromes with symptom onset

It’s the most common heart valve condition in the U.S., affecting around 8 million people: mitral valve prolapse. It’s also known as click-murmur syndrome or floppy valve syndrome. What are the symptoms? How serious is it? And how is it diagnosed? In this episode, Dr. Jonathan Fialkow explores this condition with cardiologist Socrates Kakoulides, M.D., medical director of the ambulatory diagnostic center at Miami Cardiac & Vascular Institute, part of Baptist Health South Florida.

Episode 23: Blood Clots: DVTThe sun rises over the San Joaquin Valley, California, today is August 14, 2020. Pain relief is a task that always keeps doctors very busy, especially if pain relief can be accomplished by a medication that is easily-administered, given at a convenient frequency, with no adverse effects, and with no addiction potential (specially to fight the so-called “opioid epidemic”). And if that medication contributes to healing the pain-causing condition, then that’s a perfect medication for pain relief. As a result of that endless search for a perfect pain reliever, the University of Southern California Health Sciences presented a new study on July 13, 2020, revealing that kappa opioids, a significantly less addictive opioid, may both preserve cartilage in joints and also ease pain in osteoarthritis (1). Sorry UCLA, we have to accentuate the positive regardless of the source. Go Bruins!  On August 11, 2020, we woke up to the news that Russia’s government registered the first COVID 19 vaccine in the world. President Vladimir Putin stated that his own daughter was inoculated with the vaccine and “she is feeling well and has high number of antibodies”. While some celebrated the Russian “big step for humanity”, some experts expressed concerns about safety, including the World Health Organization, warning Russia to adhere to standard protocols for testing a vaccine (2). Coronavirus has brought more than a disease to the world, it has brought extensive material for political debate and controversy. There is a joke that circulated in social media that may be relevant in this case: A patient asks her doctor, “When will this coronavirus be over?”, and the doctor answers, “I don’t know, I’m not that involved in politics”. We hope humanity steps up and joins forces to overcome this devastating disease.____________________________Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. ____________________________“[As doctors, let’s], never forget that we have the opportunity to do more good in one day than most people have in a month."― Dr. Suneel DhandDear residents, how many opportunities did you have to do good today? It’s a great privilege to be instruments to relief pain, find a solution, and bring peace and happiness to your fellow men. It’s really a privilege. We have today an experienced doctor with whom I’ve had multiple conversations, and I’m very happy for having him in our residency program. Welcome, Dr Gonzalez.Question Number 1: Who are you? My name is Alejandro Gonzalez Perez, I am a second-year resident in the Rio Bravo Family Medicine Residency Program here in Clinica Sierra Vista, Bakersfield, California. I was born in Cuba where I finished medical school and completed a medical residency in Family medicine, and then a residency in Radiology. I am a father of three children, two boys and one girl. I enjoy spending time with my family and friends. My favorite music: Latin music. Favorite sport: I like to go to the gym but I enjoy seeing martial art combats. Favorite movies: action, fiction, and martial arts.Comment: I recently watched The Karate Kid in Netflix, it’s a good show, and they’ll have a sequel in Netflix this month with the same actors of the original movie. Question number 2: What did you learn this week?Currently I’m on the Cardiology rotation. My number one goal in this rotation is optimize treatment for patients in the inpatient and outpatient settings. For example, I am learning how to better handle medication for Heart failure, CAD, HTN, and arrhythmias. And, almost all the patients have combined diagnosis, so you need to select the appropriate medication for HF with CAD, or HF combined with CAD and HTN, or HF with Afib, etc. In addition, my knowledge about diagnostic tests has improved, ECG, Echocardiogram, Cardiac Cath, troponin management. Also, I have learned how to improve the interactions between different services in the hospital. I hadn’t had a previous rotation with Internal Medicine, but in this rotation, I’m spending time with some IM residents, and it’s been positive for me.Venous thromboembolism (VTE)VTE refers to a blood clot that starts in a vein. It is the third leading vascular diagnosis after heart attack and stroke, affecting between 300,000 to 600,000 Americans each year. The mos common presentations are: Deep vein thrombosis (DVT) of the lower extremity and pulmonary embolism (PE). PathophysiologyThe Virchow's triad proposes that VTE is a result of three conditions: Alterations in blood flow (i.e., stasis), Vascular endothelial injury, and Alterations in the constituents of the blood.The causes of venous thrombosis can be divided into two groups: hereditary and acquired.Hereditary causes: Factor V Leiden mutation, Prothrombin gene mutation, Protein S deficiency, Protein C deficiency, Antithrombin deficiency.Acquired risk factors: Prior thrombotic event, recent major surgery, presence of a central venous catheter, trauma, immobilization, malignancy, pregnancy, the use of oral contraceptives or heparin, myeloproliferative disorders, antiphospholipid syndrome (APS), and a number of other major medical illnesses. Of note, a special risk factor is the s-called “Sitting Disease” which, broadly speaking, is defined as a condition of increased sedentary behavior associated with adverse health effects.Provoked vs Unprovoked DVTThe term unprovoked deep vein thrombosis (DVT) implies that there is not an evident cause for DVT. In contrast, a provoked DVT is usually caused by a known event.Proximal vs Distal DVTProximal DVT is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, it is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins)Symptomatic vs Asymptomatic DVTSymptomatic DVT refers to the presence of symptoms that usually leads to the radiologic confirmation of DVT, whereas asymptomatic DVT refers to the incidental finding of DVT on imaging in a patient without symptoms (eg, computed tomography).Symptoms of DVTThrobbing or cramping pain in 1 leg (rarely both legs), usually in the calf or thigh.Swelling in 1 leg (rarely both legs)Warm skin around the painful area.Red or darkened skin around the painful area.Swollen veins that are hard or sore when you touch them. Diagnosis of DVTDuplex ultrasonography: It can detect blockages or blood clots in the deep veins.  It is the standard imaging test to diagnose DVT. Comment: Yeah! for POCUS in clinic?D-dimer: It rules out DVT if it is negative.Contrast venography: Dye is injected into a large vein in the foot or ankle deep veins in the leg and hip.  It is the most accurate test for diagnosing blood clots but it is an invasive procedure, for that reason, this test has been largely replaced by duplex ultrasonography, and it is used only in certain patients.Magnetic resonance imaging (MRI) and computed tomography (CT) scan. These tests can provide images of veins and clots, but they are not generally used to diagnose DVT.Treatment of DVTAnticoagulants: Anticoagulation (commonly referred to as “blood thinners”) is the mainstay of therapy for patients with deep vein thrombosis (DVT). Anticoagulation is indicated for all patients with proximal DVT and select cases of distal DVT. To decide on anticoagulation, we must weigh the benefits versus the risk of bleeding. The primary objective of anticoagulation is the prevention of further thrombosis and of early and late complications. Major early complications of DVT include clot extension, pulmonary embolism (PE), major bleeding (from anticoagulation), and death. Late complications include recurrent clot, post-thrombotic (post phlebitic) syndrome, and chronic thromboembolic pulmonary hypertension. The most frequently used injectable anticoagulants are: unfractionated heparin (IV), Low molecular weight heparin (LMWH) (SQ), and Fondaparinux (SQ). Anticoagulants that are taken orally (swallowed) include Warfarin and NOACs: Dabigatran, Rivaroxaban, Apixaban, and Edoxaban. All of the anticoagulants can cause bleeding, so people taking them have to be monitored to prevent unusual bleeding. Monitoring can be with INR (Warfarin) or clinically (NOAC). Thrombolytics: Thrombolytics (commonly referred to as “clot busters”) work by dissolving the clot. They have a higher risk of causing bleeding compared to the anticoagulants, so they are reserved for severe cases. Inferior vena cava filter: When anticoagulants cannot be used or don’t work well enough, a filter can be inserted inside the inferior vena cava (a large vein that brings blood back to the heart) to capture or trap an embolus (a clot that is moving through the vein) before it reaches the lungs. Thrombectomy/Embolectomy: In rare cases, a surgical procedure to remove the clot may be necessary.  Thrombectomy involves removal of the clot in a patient with DVT.   Embolectomy involves removal of the blockage in the lungs caused by the clot in a patient with PE.  Question number 3: Why is that knowledge important for you and your patients?In primary practice, we encounter patients with symptoms that may be suspicious for DVT. We must be able to diagnose and treat these patients in a timely manner to prevent further complications. DVT is just below MI and stroke in frequency.Question number 4: How did you get that knowledge?I got interested in this topic because of many previous patients I had with this condition. I investigated multiple sources, including, of course, Up to Date, Medscape, but this knowledge has been accumulated over the years of study.Question number 5: Where did that knowledge come from?Up to Date, Medscape, Family Practice Notebook, and Epocrates.____________________________Speaking Medical: Phlegmasia cerulean dolensby Dr. Valerie CivelliPhlegmasia cerulea dolens means “painful blue inflammation”. It is an uncommon but severe form of DVT which results from extensive blockage by a thrombus of the major and the collateral veins of an extremity. This phenomenon was discovered by Jonathan Towne a vascular surgeon in Milwaukee, USA. Phlegmasia cerulea dolens (PCD) is a precursor of frank venous gangrene. It is characterized by severe swelling, cyanosis and blue discoloration. The next time you look down at a leg that appears like it’s from the blue man group in Las Vegas or appears smurf-like, think of Phlegmasia cerulea dolens.  ____________________________Espanish Por Favor: Coáguloby Dr Valerie CivelliCoágulo may be a word difficult to pronounce, but it is very important in the context of DVT, MI, or stroke. You may guess what coágulo means by remembering the word anticoagulant. Yes, coágulo means blood clot. “Señor Pérez, usted tiene un coágulo en las piernas” means “Mr Perez, you have a blood clot in your legs”. Coágulo may be used by a patient who also has blood clots in her menstrual period during an episode of menorrhagia or during other excessive bleeding. Now you know the Spanish word of the week: Coágulo.____________________________For your Sanity by Drs. Steven Saito, Gina Cha, and Alyssa Der MugrdechianWhat’s black, long and hangs from an a*hole? A stethoscope.--Patient: Doctor, my son ate a firefly!--Doctor: Why did he do that?--Patient: He wanted a light snack. --Patient: Doctor, doctor, I’ve had a terrible stomachache after eating tamales.--Doctor: Were they fresh?--Patient: I don’t know, how can you tell?--Doctor:  How did they look when you removed the corn husk?--Patient: Were you supposed to remove the corn husk?Now we conclude our episode number 23 “Blood Clots: DVT”. Dr Gonzalez explained the basics of Deep Venous Thrombosis (DVT) and reminded us that DVT can be easily diagnosed by ultrasound, and that timely treatment prevents acute and chronic complications. Phlegmasia cerulean dolens is just another way to say “painful blue inflammation”, a severe type of DVT that occurs when the MAJOR and COLATERAL veins in a limb are occluded; then, were given the advice by Dr Civelli to recall the word anticoagulant to remember the Spanish word coágulo (blood clot). And we cannot finish this episode without mentioning the name of the first registered COVID-19 vaccine. It’s called Sputnik V. We tried several times to record that name in the intro, but we could not stop laughing. We honestly hope the Sputnik V is a great success regardless of its amusing name.This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Alejandro Gonzalez, Steven Saito, Valerie Civelli, Gina Cha, and Ariana Lundquist. Audio edition: Suraj Amrutia. See you soon!_____________________References:University of Southern California - Health Sciences. (2020, July 13). Significantly less addictive opioid may slow progression of osteoarthritis while easing pain. ScienceDaily. Retrieved August 12, 2020 from www.sciencedaily.com/releases/2020/07/200713120014.htm“Russia registers COVID-19 vaccine, Putin says daughter already inoculated” by Yaron Steinbuch. August 11, 2020, New York Post.Sterns, Richard H, “Causes of hypotonic hyponatremia in adults”, Up to Date, retrieved on Aug 13, 2020. https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults?search=potomania&source=search_result&selectedTitle=2~2&usage_type=default&display_rank=2

This week we speak with the incredible Heart Doctor, Dr. Carley Saelinger about the physiological functions of the heart and all the intricacies of this organ. We learn about the symptoms, causes and medications for different diseases and more specifically about Pulmonary Hypertension, the one that stole our heart, Freddie. 

The stethoscope has been around since 1816 and its basic design hasn't changed substantially in decades. But this tried and true tool has been launched into the world of machine learning and artificial intelligence in recent years largely thanks to the work of Jason Bellet and his co-founders at Eko. Today, over 50,000 clinicians in thousands of health systems across the globe are using Eko’s digital stethoscopes and echocardiograms to diagnose and monitor heart problems, and there's more change to come, as he explains to host Shiv Gaglani in this episode of Raise the Line.

The Cleveland Clinic Director of Cardiac MRI, Dr. Deborah Kwon, discusses the principles and clinical applications of cardiac MRI, taking us from the protons to the bedside with a series of illustrative cases. CardioNerds hosts Amit Goyal, Daniel Ambinder, and Carine Hamo are joined by Dr. Nicole Pristera (Cleveland Clinic cardiology fellow). Flutter moment by student doctor Arooma Shahid. On the CardioNerds Myocarditis page you will find podcast episodes, infographic, youtube videos, references, tweetorials and guest experts & contributors, flutter stars and so much more. Take me to the Myocarditis Series PageTake me to the Episode Topics PageCheck out Amit Goyal’s Myocarditis Tweetorial Links in this episode: Mental Filter: Matters of the Heart: Part 1Mental Filter: Matters of the Heart: Part 2Cardiac Imaging Agorà Dr. Debbie Kwon attended medical school at the University of Michigan and internal medicine residency at the University of Pennsylvania. She completed her general cardiology and cardiovascular imaging fellowships at the Cleveland Clinic. She is the Director of Cardiac MRI At the Cleveland Clinic and serves as the Core Lab MRI director for the Pulmonary Vascular Disease Phenomics (PVDOMICS) multicenter National institution of Health (NIH) Study. Dr. Nicole Pristera is a cardiology fellow at the Cleveland Clinic.  She earned her medical degree at Case Western Reserve University and completed her internal medicine residency training at Duke University. Her clinical interests include interventional cardiology and cardiac critical care. Outside of the hospital, she enjoys traveling, hiking, and learning foreign languages. Episode Outline What should we know about the common sequences for cardiac MRI?We all learn about the risks of NSF.  How much of these risks are a reality and when should we truly avoid gadolinium exposure?What are some challenges to MRI: Time of scanningPatient tolerability: breath holding, claustrophobia, lying flatNo patient monitorFerromagnetic devices (especially CIEDs) Artifacts (lead) CostWhat types of information about the heart can we obtain with a CMR?Anatomic: 0.5 x 0.5 x 0.5mm spatial resolutionChamber dimensions, volumes, mass, anomalies (LV aneurysm, hypertrophy)Aortic DissectionCardiac Tumors and Thrombi Congenital defects FunctionalCine images: EF, systolic wall thickening, wall motionMyocardial tagging → strain (infarct/scar)Measurement of blood flow velocity across the cardiac valves and the great vessels: regurg, stenosis, shunts, angioTissue characterization: gadolinium enhancementPerfusion (stress, rest)ViabilityScar (LGE)EdemaIron The role for Cardiac MRI in particular cases discussed with Dr. Kwon CAD: A 45 year old G1P1 woman with prior preeclampsia and anterior STEMI s/p LAD PCI 3 years ago is being seen for chest pain. TTE shows LVEF 45% with mid-apical anterior hypokinesis and apical aneurysm. How does CMR help delineate ischemic heart disease (perfusion, viability, chambers)  Pericarditis: her stress MRI shows an anteroapical perfusion defect and apical aneurysm with mural thrombus, with corresponding LGE. On further review, her chest pain is sharp, pleuritic, and worsens with recumbency. EKG on follow-up shows diffuse ST elevations and PR depressions except for in aVR which shows ST depression and PR elevation. ESR and CRP are moderately elevated.  ARVC: A 35 year old female athlete who is admitted after VF arrest that occurred during a tennis match. Thankfully she received immediate bystander CPR with early defibrillation and prompt ROSC. She has had prior syncope during training and an uncle died suddenly at age 40. Resting EKG shows an incomplete right bundle, right precordial TWIs, and epsilon waves in V1-V3.  On tele she’s had multiple runs of NSVT of LBBB morphology. Echocardiogram shows RV dilation. A heart failure consult is considering EMBx but requests a CMR beforehand.

With Sanjay Prasad & Daniel J. Hammersley, Royal Brompton Hospital. Link to paper Link to editorial

One high school-aged athlete suffers a Sudden Cardiac Arrest every three days in the U.S. The leading cause of death in young athletes on the playing field is an undetected heart condition. The best way to detect these heart conditions is through a heart screening using an ECG (Electrocardiogram) and in some cases an Echocardiogram (ultrasound) of the heart. However, virtually no young athletes are screened for heart abnormalities during their normal sports physical or well child checks. Mill Creek mom Darla Varrenti learned all of this in the worst possible way – when her seemingly perfectly healthy teenaged son Nick died unexpectedly after playing football. Despite her grief, she and her sister Suzanne started the Nick of Time Foundation, which has brought heart screenings to schools all over our area and the country, potentially saving countless lives. Josh Kerns visits with Darla, Suzanne and Kim Harmon, MD (UW Medicine) to discuss their vital work, what every parent and primary care physician should know, and how we can work together to prevent needless childhood deaths.

In this episode I cover pulmonary hypertension.If you want to follow along with written notes on pneumothorax go to zerotofinals.com/pulmonaryhypertension/ or find the respiratory section in the Zero to Finals medicine book.This episode covers the causes, presentation, investigation and management of pulmonary hypertension.The audio in the episode was expertly edited by Harry Watchman.

This week we review a recent report from the team at the Kravis Children's Hospital at Mount Sinai - Icahn School of Medicine at Mount Sinai on the use of pentobarbital for oral sedation for transthoracic echocardiography. Associate Professor of Pediatrics Rajesh Shenoy shares with us insights into sedation for this indication, the general approach of the echo lab at Sinai and how decisions are made regarding sedation for this reason. doi: 10.1111/echo.14301

This week we review a recent report from the team at the Kravis Children's Hospital at Mount Sinai - Icahn School of Medicine at Mount Sinai on the use of pentobarbital for oral sedation for transthoracic echocardiography. Associate Professor of Pediatrics Rajesh Shenoy shares with us insights into sedation for this indication, the general approach of the echo lab at Sinai and how decisions are made regarding sedation for this reason. doi: 10.1111/echo.14301

Podcast summary of articles from the February 2018 edition of Journal of Emergency Medicine from the American Academy of Emergency Medicine.  Topics include chest pain stress tests, clinical scoring systems for chest pain, sterno-clavicular joint infections with board review on AV node reentry tachycardia and the mumps.  Guest speaker is Dr. Aurelia Cheng from the Metrohealth Emergency Medicine Residency.

Enrich your knowledge of cardiac ultrasound with the help from experienced sonographer, Sharon Kay. Sharon covers a focused cardiac ultrasound of the heart, and gives examples of emergency cardiac conditions that can be detected with this versatile modality. This talk was recorded at Bedside Critical Care Conference 4. For the full post and other BCC4 posts, head over to www.intensivecarenetwork.com

Alex Rosenberg is an intensivist with more of an obsession with all things cardiac, but his experience in a large neuro ICU made him well placed to discuss the interaction between cerebral perfusion pressure, vasopressors and cardiac output. This is an important neuro topic that is relevant to anyone who looks after patients with injured brains. This is sadly the last talk from BCC3, but don't get too depressed - you can always join us this year in Cairns, or wait for those talks to come out on ICN, and there's always the torrent of superb free media that is flowing out from the smacc conference.

TEE (trans-esophageal echocardiogram) what we prefer to in the hospital as TEE is a process whereby we make a patient swallow a probe and the probe takes breathtaking pictures of the heart from the esophagus, from the food pipe the esophagus sits right behind the heart and the probe is very to the cardiac structures so we see surprising detail and TEE is invaluable when it comes to diagnosing certain conditions.

TEE (trans-esophageal echocardiogram) is very valuable when it comes to looking for clots in the heart, looking at the valves of the heart to make sure that they are not infected and don't have a condition called endocarditis. Looking for leaking heart valves or heart valves that don't open properly and that are stopped up. / Diet is extremely important, and includes weight loss, restriction of animal fats, consumption of sufficient amounts of fiber and restriction of amounts of refined carbohydrates.