Podcasts about Incidence

Does psychiatric medication withdrawal exist — or is it just a myth?For anyone who's lived through it, the question alone can feel insulting.Psychiatric drug withdrawal is real. While the experience varies widely, for many, it's not “brief and mild” as many guidelines state it is. It can be intense, destabilizing, and often misunderstood. One of the most painful challenges is trying to determine whether what you're experiencing is withdrawal or relapse.Unfortunately, current clinical guidelines don't help. They often frame withdrawal as short-lived and minor, dismissing anything more severe as a return of illness. A potentially dangerous oversimplification that can leave patients feeling gaslit or unsupported.In this interview, Dr. Mark Horowitz, a psychiatrist and researcher who's both studied and experienced withdrawal firsthand, unpacks a new JAMA study that exemplifies the problem: guidelines built on inadequate evidence.In this episode, you'll hear:Why current drug withdrawal guidelines fall shortOverview of the new JAMA paper Incidence and Nature of Antidepressant Discontinuation SymptomsThe critical distinction between withdrawal and relapseThe truth about psychiatric drug withdrawalHow to design better research that reflects real-world experiencesWhy this information is often not reaching cliniciansHow we can conduct research that can better inform patient supportDr. Horowitz's story is one of courage and insight. As a clinician, he had no idea how wrong the guidelines were, until he tried coming off medication himself. What he discovered was far more complex than anything he'd been taught.To those navigating psychiatric medication withdrawal — especially in the face of oversimplified headlines and a healthcare system not yet equipped to support you — our hearts go out to you. You deserve care that is informed, compassionate, and grounded in lived experience as well as science. We won't stop until you have this.Expert Featured:Dr. Mark HorowitzX: @markhoroWebsite: https://markhorowitz.org/Resources Mentioned:Incidence and Nature of Antidepressant Discontinuation Symptoms A Systematic Review and Meta-Analysishttps://jamanetwork.com/journals/jamapsychiatry/article-abstract/28362623 Long-Term Psychiatric Medication Studieshttps://www.biologicalpsychiatryjournal.com/article/S0006-3223(98)00126-7/abstracthttps://journals.lww.com/intclinpsychopharm/abstract/2002/09000/discontinuation_symptoms__comparison_of_brief.2.aspxhttps://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/interruption-of-selective-serotonin-reuptake-inhibitor-treatment/F0241958CB073C51F366E2AABE636B5DOutro Clinichttps://www.outro.com/The Maudsley Desprescribing Guidelines: Antidepressants, Benzodiazepines, Gabapentinoids and Z-drugs

Have “get the epidural” circled on your birth plan? Or maybe you're curious but not sure if it's for you? In this episode, we're pulling back the curtain on what epidurals really are, how they work, what they don't do—and why preparation still matters deeply, even if you're planning on pain meds.We'll explore:What epidurals actually do (and don't do)How they're administered, and what it feels likeCommon misconceptions that leave people unpreparedSide effects and interventions that often come with themWhat to do if an epidural fails or doesn't fully workWhy birth prep is still crucial with or without medsThe essential tools every birthing person needs—no matter the planIf you're planning an epidural, undecided, or just open to options, this episode will leave you feeling informed, empowered, and ready to advocate for the birth you deserve.Resources Mentioned:The Path to a Powerful Birth – Clara's childbirth course blending research, mindfulness, advocacy, and surrender.Research Citations:Anim-Somuah, M., Smyth, R. M. D., & Cyna, A. M. (2018). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, (5), CD000331. https://doi.org/10.1002/14651858.CD000331.pub4Sharma, S. K., & McGrady, E. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database of Systematic Reviews, (10), CD007238. https://doi.org/10.1002/14651858.CD007238.pub3Pan, P. H., Bogard, T. D., & Owen, M. D. (2004). Incidence and characteristics of failed conversion of labor epidural analgesia to cesarean delivery anesthesia: A retrospective analysis of 19,259 deliveries. Anesthesiology, 100(4), 908–914. https://doi.org/10.1097/00000542-200404000-00014Torvaldsen, S., Roberts, C. L., Simpson, J. M., Thompson, J. F., & Ellwood, D. A. (2006). Intrapartum epidural analgesia and breastfeeding: A prospective cohort study. International Breastfeeding Journal, 1, 24. https://doi.org/10.1186/1746-4358-1-24Beilin, Y., Bodian, C. A., Weiser, J., Hossain, S., Arnold, I., Feierman, D. E., & Martin, G. (2005). Effect of labor analgesia with and without fentanyl on infant breastfeeding: A prospective, randomized, double-blind study. Anesthesiology, 103(6), 1211–1217. https://doi.org/10.1097/00000542-200512000-00018Get 20% off your first monthly subscription with NEEDED Vitamins 

The incidence of early onset colorectal cancer (EOCRC) has been rising prompting the change in change in screening guidelines to 45 years of age for average risk patients. Join us for an in-depth discussion with guest speakers Dr. Andrea Cercek and Dr. Nancy You, where we provide a comprehensive look at the growing challenge of EOCRC. Hosts: - Dr. Janet Alvarez - General Surgery Resident at New York Medical College/Metropolitan Hospital Center - Dr. Wini Zambare – General Surgery Resident at Weill Cornell Medical Center/New York Presbyterian - Dr. Phil Bauer, Graduating Colorectal Surgical Oncology Fellow at Memorial Sloan Kettering Cancer Center  - Dr. J. Joshua Smith MD, PhD, Chair, Department of Colon and Rectal Surgery at MD Anderson Cancer Center - Dr. Andrea Cercek - Gastrointestinal Medical Oncologist at Memorial Sloan Kettering Cancer Center - Dr. Y. Nancy You, MD MHSc - Professor, Department of Colon and Rectal Surgery at MD Anderson Cancer Center Learning objectives:  - Describe trends in incidence of colorectal cancer, with emphasis on the rise of EOCRC. - Identify age groups and demographics most affected by EOCRC. - Summarize USPSTF recommendations for colorectal cancer screening. - Distinguish between screening methods (e.g., colonoscopy, FIT-DNA) and their sensitivity. - Understand treatment approaches for colon and rectal cancer (CRC) - Understand the role of mismatch repair (MMR) status in guiding treatment. - Outline the importance of genetic counseling and testing in young patients. - Discuss racial, ethnic, and socioeconomic disparities in CRC incidence and outcomes. - Describe the impact of cancer treatment on fertility and sexual health. -  Review fertility preservation options. - Identify the value of integrated care teams for young CRC patients. References: 1.         Siegel, R. L. et al. Colorectal Cancer Incidence Patterns in the United States, 1974–2013. JNCI J. Natl. Cancer Inst. 109, djw322 (2017). https://pubmed.ncbi.nlm.nih.gov/28376186/ 2.         Abboud, Y. et al. Rising Incidence and Mortality of Early-Onset Colorectal Cancer in Young Cohorts Associated with Delayed Diagnosis. Cancers 17, 1500 (2025). https://pubmed.ncbi.nlm.nih.gov/40361427/ 3.         Phang, R. et al. Is the Incidence of Early-Onset Adenocarcinomas in Aotearoa New Zealand Increasing? Asia Pac. J. Clin. Oncol.https://pubmed.ncbi.nlm.nih.gov/40384533/ 4.         Vitaloni, M. et al. Clinical challenges and patient experiences in early-onset colorectal cancer: insights from seven European countries. BMC Gastroenterol. 25, 378 (2025). https://pubmed.ncbi.nlm.nih.gov/40375142/ 5.         Siegel, R. L. et al. Global patterns and trends in colorectal cancer incidence in young adults. (2019) doi:10.1136/gutjnl-2019-319511. https://pubmed.ncbi.nlm.nih.gov/31488504/ 6.         Cercek, A. et al. A Comprehensive Comparison of Early-Onset and Average-Onset Colorectal Cancers. J. Natl. Cancer Inst. 113, 1683–1692 (2021). https://pubmed.ncbi.nlm.nih.gov/34405229/ 7.         Zheng, X. et al. Comprehensive Assessment of Diet Quality and Risk of Precursors of Early-Onset Colorectal Cancer. JNCI J. Natl. Cancer Inst. 113, 543–552 (2021). https://pubmed.ncbi.nlm.nih.gov/33136160/ 8.         Standl, E. & Schnell, O. Increased Risk of Cancer—An Integral Component of the Cardio–Renal–Metabolic Disease Cluster and Its Management. Cells 14, 564 (2025). https://pubmed.ncbi.nlm.nih.gov/40277890/ 9.         Muller, C., Ihionkhan, E., Stoffel, E. M. & Kupfer, S. S. Disparities in Early-Onset Colorectal Cancer. Cells 10, 1018 (2021). https://pubmed.ncbi.nlm.nih.gov/33925893/ 10.       US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 325, 1965–1977 (2021). https://pubmed.ncbi.nlm.nih.gov/34003218/ 11.       Fwelo, P. et al. Differential Colorectal Cancer Mortality Across Racial and Ethnic Groups: Impact of Socioeconomic Status, Clinicopathology, and Treatment-Related Factors. Cancer Med. 14, e70612 (2025). https://pubmed.ncbi.nlm.nih.gov/40040375/ 12.       Lansdorp-Vogelaar, I. et al. Contribution of Screening and Survival Differences to Racial Disparities in Colorectal Cancer Rates. Cancer Epidemiol. Biomarkers Prev. 21, 728–736 (2012). https://pubmed.ncbi.nlm.nih.gov/22514249/ 13.       Ko, T. M. et al. Low neighborhood socioeconomic status is associated with poor outcomes in young adults with colorectal cancer. Surgery 176, 626–632 (2024). https://pubmed.ncbi.nlm.nih.gov/38972769/ 14.       Siegel, R. L., Wagle, N. S., Cercek, A., Smith, R. A. & Jemal, A. Colorectal cancer statistics, 2023. CA. Cancer J. Clin. 73, 233–254 (2023). https://pubmed.ncbi.nlm.nih.gov/36856579/ 15.       Jain, S., Maque, J., Galoosian, A., Osuna-Garcia, A. & May, F. P. Optimal Strategies for Colorectal Cancer Screening. Curr. Treat. Options Oncol. 23, 474–493 (2022). https://pubmed.ncbi.nlm.nih.gov/35316477/ 16.       Zauber, A. G. The Impact of Screening on Colorectal Cancer Mortality and Incidence: Has It Really Made a Difference? Dig. Dis. Sci. 60, 681–691 (2015). https://pubmed.ncbi.nlm.nih.gov/25740556/ 17.       Edwards, B. K. et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 116, 544–573 (2010). https://pubmed.ncbi.nlm.nih.gov/19998273/ 18.       Cercek, A. et al. Nonoperative Management of Mismatch Repair–Deficient Tumors. New England Journal of Medicine 392, 2297–2308 (2025). https://pubmed.ncbi.nlm.nih.gov/40293177/ 19.       Monge, C., Waldrup, B., Carranza, F. G. & Velazquez-Villarreal, E. Molecular Heterogeneity in Early-Onset Colorectal Cancer: Pathway-Specific Insights in High-Risk Populations. Cancers 17, 1325 (2025). https://pubmed.ncbi.nlm.nih.gov/40282501/ 20.       Monge, C., Waldrup, B., Carranza, F. G. & Velazquez-Villarreal, E. Ethnicity-Specific Molecular Alterations in MAPK and JAK/STAT Pathways in Early-Onset Colorectal Cancer. Cancers 17, 1093 (2025). https://pubmed.ncbi.nlm.nih.gov/40227607/ 21.       Benson, A. B. et al. Colon Cancer, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J. Natl. Compr. Cancer Netw. JNCCN 19, 329–359 (2021). https://pubmed.ncbi.nlm.nih.gov/33724754/ 22.       Christenson, E. S. et al. Nivolumab and Relatlimab for the treatment of patients with unresectable or metastatic mismatch repair proficient colorectal cancer. https://pubmed.ncbi.nlm.nih.gov/40388545/ 23.       Dasari, A. et al. Fruquintinib versus placebo in patients with refractory metastatic colorectal cancer (FRESCO-2): an international, multicentre, randomised, double-blind, phase 3 study. The Lancet 402, 41–53 (2023). https://pubmed.ncbi.nlm.nih.gov/37331369/ 24.       Strickler, J. H. et al. Tucatinib plus trastuzumab for chemotherapy-refractory, HER2-positive, RAS wild-type unresectable or metastatic colorectal cancer (MOUNTAINEER): a multicentre, open-label, phase 2 study. Lancet Oncol. 24, 496–508 (2023). https://pubmed.ncbi.nlm.nih.gov/37142372/ 25.       Sauer, R. et al. Preoperative versus Postoperative Chemoradiotherapy for Rectal Cancer. N. Engl. J. Med. 351, 1731–1740 (2004). https://pubmed.ncbi.nlm.nih.gov/15496622/ 26.       Cercek, A. et al. Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer. JAMA Oncol. 4, e180071 (2018). https://pubmed.ncbi.nlm.nih.gov/29566109/ 27.       Garcia-Aguilar, J. et al. Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy. J. Clin. Oncol. 40, 2546–2556 (2022). https://pubmed.ncbi.nlm.nih.gov/35483010/ 28.       Schrag, D. et al. Preoperative Treatment of Locally Advanced Rectal Cancer. N. Engl. J. Med. 389, 322–334 (2023). https://pubmed.ncbi.nlm.nih.gov/37272534/ 29.       Kunkler, I. H., Williams, L. J., Jack, W. J. L., Cameron, D. A. & Dixon, J. M. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. N. Engl. J. Med. 388, 585–594 (2023). https://pubmed.ncbi.nlm.nih.gov/36791159/ 30.       Jacobsen, R. L., Macpherson, C. F., Pflugeisen, B. M. & Johnson, R. H. Care Experience, by Site of Care, for Adolescents and Young Adults With Cancer. JCO Oncol. Pract. (2021) doi:10.1200/OP.20.00840. https://pubmed.ncbi.nlm.nih.gov/33566700/ 31.       Ruddy, K. J. et al. Prospective Study of Fertility Concerns and Preservation Strategies in Young Women With Breast Cancer. J. Clin. Oncol. (2014) doi:10.1200/JCO.2013.52.8877. https://pubmed.ncbi.nlm.nih.gov/24567428/ 32.       Su, H. I. et al. Fertility Preservation in People With Cancer: ASCO Guideline Update. J. Clin. Oncol. 43, 1488–1515 (2025). https://pubmed.ncbi.nlm.nih.gov/40106739/ 33.       Smith, K. L., Gracia, C., Sokalska, A. & Moore, H. Advances in Fertility Preservation for Young Women With Cancer. Am. Soc. Clin. Oncol. Educ. Book 27–37 (2018) doi:10.1200/EDBK_208301. https://pubmed.ncbi.nlm.nih.gov/30231357/ 34.       Blumenfeld, Z. How to Preserve Fertility in Young Women Exposed to Chemotherapy? The Role of GnRH Agonist Cotreatment in Addition to Cryopreservation of Embrya, Oocytes, or Ovaries. The Oncologist 12, 1044–1054 (2007). 35.       Bhagavath, B. The current and future state of surgery in reproductive endocrinology. Curr. Opin. Obstet. Gynecol. 34, 164 (2022). 36.       Ribeiro, R. et al. Uterine transposition: technique and a case report. Fertil. Steril. 108, 320-324.e1 (2017). 37.       Yazdani, A., Sweterlitsch, K. M., Kim, H., Flyckt, R. L. & Christianson, M. S. Surgical Innovations to Protect Fertility from Oncologic Pelvic Radiation Therapy: Ovarian Transposition and Uterine Fixation. J. Clin. Med. 13, 5577 (2024). 38.       Holowatyj, A. N., Eng, C. & Lewis, M. A. Incorporating Reproductive Health in the Clinical Management of Early-Onset Colorectal Cancer. JCO Oncol. Pract. 18, 169–172 (2022). ***Behind the Knife Colorectal Surgery Oral Board Audio Review: https://app.behindtheknife.org/course-details/colorectal-surgery-oral-board-audio-review Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

In this JACC Deep Dive, Harlan M. Krumholz, MD, SM, FACC, discusses a new study in the July 8 issue of JACC, authored by Saket Girotra MD, SM, et al. In the study, which links national registry and Medicare data, the authors found striking hospital-level variation in cardiac arrest rates and outcomes—and identified better nurse staffing as a key factor in both preventing arrests and improving survival. Behind the scenes, the manuscript underwent multiple rounds of revision, with close collaboration between editors and authors to strengthen the analysis, add new visualizations, and clarify key takeaways. The study underscores the need to invest in systems and staffing that detect clinical deterioration before it becomes irreversible.

Episode 198: Fatigue.  Future doctors Redden and Ibrahim discuss with Dr. Arreaza the different causes of fatigue, including physical and mental illnesses. Dr. Arreaza describes the steps to evaluate fatigue. Some common misconceptions are explained, such as vitamin D deficiency and “chronic Lyme disease”. Written by Michael Ibrahim, MSIV, and Jordan Redden, MSIV, Ross University School of Medicine. Edits and comments by Hector Arreaza, MDYou are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Dr. Arreaza: Today is a great day to talk about fatigue. It is one of the most common and most complex complaints we see in primary care. It involves physical, mental, and emotional health. So today, we're walking through a case, breaking down causes, red flags, and how to work it up without ordering the entire lab catalog.Michael:Case: This is a 34-year-old female who comes in saying, "I've been feeling drained for the past 3 months." She says she's been sleeping 8 hours a night but still wakes up tired. No recent illnesses, no weight loss, fever, or night sweats. She denies depression or anxiety but does report a lot of work stress and taking care of her two little ones at home. She drinks 2 cups of coffee a day, doesn't drink alcohol, and doesn't use drugs. No medications, just a multivitamin. Regular menstrual cycles—but she's noticed they've been heavier recently.Jordan:Fatigue is a persistent sense of exhaustion that isn't relieved by rest. It's different from sleepiness or muscle weakness.Classification based on timeline:    •   Acute fatigue: less than 1 month    •   Subacute: 1 to 6 months    •   Chronic: more than 6 monthsThis patient's case is subacute—going on 3 months now.Dr. Arreaza:And we can think about fatigue in types:    •   Physical fatigue: like muscle tiredness after activity    •   Mental fatigue: trouble concentrating or thinking clearly (physical + mental when you are a medical student or resident)    •    Pathological fatigue: which isn't proportional to effort and doesn't get better with restAnd of course, there's chronic fatigue syndrome, also called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is a diagnosis of exclusion after 6 months of disabling fatigue with other symptoms.Michael:The differential is massive. So, we can also group it by systems.Jordan:Let's run through the big ones.Endocrine / Metabolic Causes    • Hypothyroidism: A classic cause of fatigue. Often associated with cold intolerance, weight gain, dry skin, and constipation. May be subtle and underdiagnosed, especially in women.    • Diabetes Mellitus: Both hyperglycemia and hypoglycemia can cause fatigue. Look for polyuria, polydipsia, weight loss, or blurry vision in undiagnosed diabetes.    • Adrenal Insufficiency: Think of this when fatigue is paired with hypotension, weight loss, salt craving, or hyperpigmentation. Can be primary (Addison's) or secondary (e.g., due to long-term steroid use).Michael: Hematologic Causes    • Anemia (especially iron deficiency): Very common, especially in menstruating women. Look for fatigue with pallor, shortness of breath on exertion, and sometimes pica (craving non-food items).     • Vitamin B12 or Folate Deficiency: B12 deficiency may present with fatigue plus neurologic symptoms like numbness, tingling, or gait issues. Folate deficiency tends to present with megaloblastic anemia and fatigue.    • Anemia of Chronic Disease: Seen in patients with chronic inflammatory conditions like RA, infections, or CKD. Typically mild, normocytic, and improves when the underlying disease is treated.Michael: Psychiatric Causes    • Depression: A major driver of fatigue, often underreported. May include anhedonia, sleep disturbance, appetite changes, or guilt. Sometimes presents with only somatic complaints.    • Anxiety Disorders: Mental fatigue, poor sleep quality, and hypervigilance can leave patients feeling constantly drained.    • Burnout Syndrome: Especially common in caregivers, healthcare workers, and educators. Emotional exhaustion, depersonalization, and reduced personal accomplishment are key features.Jordan: Infectious Causes    • Epstein-Barr Virus (EBV):Mononucleosis is a well-known cause of fatigue, sometimes lasting weeks. May also have sore throat, lymphadenopathy, and splenomegaly.    • HIV:Consider it in high-risk individuals. Fatigue can be an early sign, along with weight loss, recurrent infections, or night sweats.    • Hepatitis (B or C):Can present with chronic fatigue, especially if liver enzymes are elevated. Screen at-risk individuals.    • Post-viral Syndromes / Long COVID:Fatigue that lingers for weeks or months after viral infection. Often, it includes brain fog, muscle aches, and post-exertional malaise.Important: Chronic Lyme disease is a controversial term without a consistent clinical definition and is often used to describe patients with persistent, nonspecific symptoms not supported by objective evidence of Lyme infection. Leading medical organizations reject the term and instead recognize "post-treatment Lyme disease syndrome" (PTLDS) for persistent symptoms following confirmed, treated Lyme disease, emphasizing that prolonged antibiotic therapy is not effective. Research shows no benefit—and potential harm—from extended antibiotic use, and patients with unexplained chronic symptoms should be thoroughly evaluated for other possible diagnoses.Michael: Cardiopulmonary Causes    •   Congestive Heart Failure (CHF): Fatigue from poor perfusion and low cardiac output. Often comes with dyspnea on exertion, edema, and orthopnea.    •   Chronic Obstructive Pulmonary Disease (COPD): Look for a smoking history, chronic cough, and fatigue from hypoxia or the work of breathing.    •   Obstructive Sleep Apnea (OSA): Daytime fatigue despite adequate hours of sleep. Patients may snore, gasp, or report morning headaches. High suspicion in obese or hypertensive patients.Jordan:Autoimmune / Inflammatory Causes    •   Systemic Lupus Erythematosus (SLE): Fatigue is often an early symptom. May also see rash, arthritis, photosensitivity, or renal involvement.    •   Rheumatoid Arthritis (RA): Fatigue from systemic inflammation. Morning stiffness, joint pain, and elevated inflammatory markers point to RA.    •   Fibromyalgia: A chronic pain syndrome with widespread tenderness, fatigue, nonrestorative sleep, and sometimes cognitive complaints ("fibro fog").Cancer / Malignancy    •   Leukemia, lymphoma, or solid tumors: Fatigue can be the first symptom, often accompanied by weight loss, night sweats, or unexplained fevers. Consider when no other cause is evident.Michael:Medications:Common culprits include:    ◦   Beta-blockers: Can slow heart rate too much.    ◦   Antihistamines: Sedating H1 blockers like diphenhydramine.    ◦   Sedatives or sleep aids: Can cause grogginess and daytime sedation.    •   Substance Withdrawal: Fatigue can be seen in withdrawal from alcohol, opioids, or stimulants. Caffeine withdrawal, though mild, can also contribute.Dr. Arreaza:Whenever we evaluate fatigue, we need to keep an eye out for red flags. These should raise suspicion for something more serious:    •   Unintentional weight loss    •   Night sweats    •   Persistent fever    •   Neurologic symptoms    •   Lymphadenopathy    •   Jaundice    •   Palpitations or chest painThis patient doesn't have these—but that doesn't mean we stop here.Dr. Arreaza:Those are a lot of causes, we can evaluate fatigue following 7 steps:Characterize the fatigue.Look for organic illness.Evaluate medications and substances.Perform psychiatric screening.Ask questions about quantity and quality of sleep.Physical examination.Undertake investigations.So, students, do we send the whole lab panel?Michael:Not necessarily. Labs should be guided by history and physical. But here's a good initial panel:    •   CBC: To check for anemia or infection    • TSH: Screen for hypothyroidism    • CMP: Look at electrolytes, kidney, and liver function    • Ferritin and iron studies    • B12, folate    • ESR/CRP for inflammation (not specific)    • HbA1c if diabetes is on the radarJordan:And if needed, consider:    • HIV, EBV, hepatitis panel    • ANA, RF    • Cortisol or ACTH stimulation testImaging? Now that's rare—unless there are specific signs. Like chest X-ray for possible cancer or TB, or sleep study if you suspect OSA.Dr. Arreaza:Unaddressed fatigue isn't just inconvenient. It can impact on quality of life, affect job performance, lead to mood disorders, delay diagnosis of serious illness, increase risk of accidents—especially driving. So, don't ignore your patients with fatigue!Jordan:And some people—like women, caregivers, or shift workers—are especially at risk.Michael:The cornerstone of treatment is addressing the underlying cause.Jordan:If it's iron-deficiency anemia—treat it. If it's depression—get mental health involved. But there's also: Lifestyle Support: Better sleep hygiene, light physical activity, mindfulness or CBT for stress, balanced nutrition—especially iron and protein, limit caffeine and alcoholDr. Arreaza:Sometimes medications help—but rarely. And for chronic fatigue syndrome, the current best strategies are graded exercise therapy and CBT, along with managing specific symptoms. Beta-alanine has potential to modestly improve muscular endurance and reduce fatigue in older adults, but more high-quality research is needed.SSRI: fluoxetine and sertraline. Iron supplements: Even without anemia, but low ferritin [Anecdote about low ferritin patient]Jordan:This case reminds us to take fatigue seriously. In her case, it may be multifactorial—work stress, caregiving burden, and possibly iron-deficiency anemia. So, how would we wrap up this conversation, Michael?Michael:We don't need to order everything under the sun. A focused history and exam, targeted labs, and being alert to red flags can guide us.Jordan:And don't forget the basics—sleep, stress, and nutrition. These are just as powerful as any prescription.Dr. Arreaza:We hope today's episode on fatigue has given you a clear framework and some practical tips. If you enjoyed this episode, share it and subscribe for more evidence-based medicine!Jordan:Take care—and get some rest~___________________________Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:DynaMed. (2023). Fatigue in adults. EBSCO Information Services. https://www.dynamed.com (Access requires subscription)Jason, L. A., Sunnquist, M., Brown, A., Newton, J. L., Strand, E. B., & Vernon, S. D. (2015). Chronic fatigue syndrome versus systemic exertion intolerance disease. Fatigue: Biomedicine, Health & Behavior, 3(3), 127–141. https://doi.org/10.1080/21641846.2015.1051291Kroenke, K., & Mangelsdorff, A. D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome. The American Journal of Medicine, 86(3), 262–266. https://doi.org/10.1016/0002-9343(89)90293-3National Institute for Health and Care Excellence. (2021). Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: Diagnosis and management (NICE Guideline No. NG206). https://www.nice.org.uk/guidance/ng206UpToDate. (n.d.). Approach to the adult patient with fatigue. Wolters Kluwer. https://www.uptodate.com (Access requires subscription)Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

In this compelling episode of the Bendy Bodies Podcast, Dr. Linda Bluestein is joined by her longtime mentor and internationally respected EDS expert, Dr. Pradeep Chopra. Together, they tackle some of the most frustrating—and frequently misunderstood—questions surrounding hypermobile Ehlers-Danlos Syndrome (hEDS). From major flaws in the 2017 diagnostic criteria to the hidden surgical risks that could lead to serious complications like CCI (craniocervical instability), this conversation dives deep into clinical insights and lived experience. Listeners will also hear the surprising story of how Dr. Chopra helped inspire Dr. Bluestein to open her own practice. Whether you're a patient, parent, or provider, this episode just might change how you see joint hypermobility and connective tissue disorders forever. Takeaways Why men and boys may be getting overlooked by the current EDS diagnostic model The difference between dislocations and subluxations—and why that matters A surprising source of CCI: what your dentist, surgeon, and anesthesiologist may not know The 2017 criteria: well-meaning, but are they dangerously outdated? What every hypermobile patient should bring to their next surgery (yes, it's a hack) Want to follow along? Find the episode transcript here. References: Episode 70: https://youtu.be/BoRyQh12X2c Episode 71: https://youtu.be/yDT3JTzfiJk Episode 72: https://youtu.be/CYhnKkVjIxM Episode 73: https://youtu.be/2OxtZGNswfo Episode 77: https://youtu.be/d9A1aJB5GRo Episode 151: https://youtu.be/ho0rRcjUobI Perioperative Care in Patients with EDS by Linda Bluestein & Pradeep Chopra: https://www.scirp.org/journal/paperinformation?paperid=97524 Diagnostic Criteria: https://www.bendybodiespodcast.com/p/diagnostic-criteria-checklist/ The Incidence of Misdiagnosis in Patients with EDS: https://www.mdpi.com/2227-9067/12/6/698 Living Well with Orthostatic Intolerance by Peter C. Rowe: https://www.amazon.com/shop/hypermobilitymd/list/2LQLPARJY3CDS?linkCode=sl2&tag=onamzlindablu-20&ref_=aip_sf_list_spv_ofs_mixed_d 2023 Diagnostic Framework: https://www.ehlers-danlos.com/diagnosis/new-diagnostic-framework-for-pediatric-joint-hypermobility-v2/ Want more Dr. Pradeep Chopra?  Website: https://www.painri.com/ Contact Dr. Chopra's Office: snapa102@gmail.com Want more Dr. Linda Bluestein, MD? Website:  ⁠⁠https://www.hypermobilitymd.com/⁠⁠. YouTube: ⁠⁠⁠youtube.com/@bendybodiespodcast⁠⁠⁠  Instagram: ⁠⁠⁠https://www.instagram.com/hypermobilitymd/⁠⁠⁠  Facebook: ⁠⁠⁠https://www.facebook.com/BendyBodiesPodcast⁠⁠⁠  X: ⁠⁠⁠https://twitter.com/BluesteinLinda⁠⁠⁠  LinkedIn: ⁠⁠⁠https://www.linkedin.com/in/hypermobilitymd/⁠⁠⁠  Newsletter: ⁠⁠⁠https://hypermobilitymd.substack.com/⁠⁠⁠ Shop my Amazon store ⁠⁠⁠https://www.amazon.com/shop/hypermobilitymd⁠⁠⁠ Thank YOU so much for tuning in. We hope you found this episode informative, inspiring, useful, validating, and enjoyable. Join us on the next episode for YOUR time to level up your knowledge about hypermobility disorders and the people who have them. Join YOUR Bendy Bodies community at ⁠⁠https://www.bendybodiespodcast.com/⁠⁠. YOUR bendy body is our highest priority! Use this affiliate link for Algonot to get an extra 5% off your entire order: ⁠⁠https://algonot.com/coupon/bendbod/⁠⁠ Learn more about Human Content at ⁠⁠⁠http://www.human-content.com⁠⁠⁠ Podcast Advertising/Business Inquiries: ⁠⁠⁠sales@human-content.com⁠⁠⁠ Part of the Human Content Podcast Network FTC: This video is not sponsored. Links are commissionable, meaning I may earn commission from purchases made through links Learn more about your ad choices. Visit megaphone.fm/adchoices

In this compelling episode of the Bendy Bodies Podcast, Dr. Linda Bluestein is joined by her longtime mentor and internationally respected EDS expert, Dr. Pradeep Chopra. Together, they tackle some of the most frustrating—and frequently misunderstood—questions surrounding hypermobile Ehlers-Danlos Syndrome (hEDS). From major flaws in the 2017 diagnostic criteria to the hidden surgical risks that could lead to serious complications like CCI (craniocervical instability), this conversation dives deep into clinical insights and lived experience. Listeners will also hear the surprising story of how Dr. Chopra helped inspire Dr. Bluestein to open her own practice. Whether you're a patient, parent, or provider, this episode just might change how you see joint hypermobility and connective tissue disorders forever. Takeaways Why men and boys may be getting overlooked by the current EDS diagnostic model The difference between dislocations and subluxations—and why that matters A surprising source of CCI: what your dentist, surgeon, and anesthesiologist may not know The 2017 criteria: well-meaning, but are they dangerously outdated? What every hypermobile patient should bring to their next surgery (yes, it's a hack) Want to follow along? Find the episode transcript here. References: Episode 70: https://youtu.be/BoRyQh12X2c Episode 71: https://youtu.be/yDT3JTzfiJk Episode 72: https://youtu.be/CYhnKkVjIxM Episode 73: https://youtu.be/2OxtZGNswfo Episode 77: https://youtu.be/d9A1aJB5GRo Episode 151: https://youtu.be/ho0rRcjUobI Perioperative Care in Patients with EDS by Linda Bluestein & Pradeep Chopra: https://www.scirp.org/journal/paperinformation?paperid=97524 Diagnostic Criteria: https://www.bendybodiespodcast.com/p/diagnostic-criteria-checklist/ The Incidence of Misdiagnosis in Patients with EDS: https://www.mdpi.com/2227-9067/12/6/698 Living Well with Orthostatic Intolerance by Peter C. Rowe: https://www.amazon.com/shop/hypermobilitymd/list/2LQLPARJY3CDS?linkCode=sl2&tag=onamzlindablu-20&ref_=aip_sf_list_spv_ofs_mixed_d 2023 Diagnostic Framework: https://www.ehlers-danlos.com/diagnosis/new-diagnostic-framework-for-pediatric-joint-hypermobility-v2/ Want more Dr. Pradeep Chopra?  Website: https://www.painri.com/ Contact Dr. Chopra's Office: snapa102@gmail.com Want more Dr. Linda Bluestein, MD? Website:  ⁠⁠https://www.hypermobilitymd.com/⁠⁠. YouTube: ⁠⁠⁠youtube.com/@bendybodiespodcast⁠⁠⁠  Instagram: ⁠⁠⁠https://www.instagram.com/hypermobilitymd/⁠⁠⁠  Facebook: ⁠⁠⁠https://www.facebook.com/BendyBodiesPodcast⁠⁠⁠  X: ⁠⁠⁠https://twitter.com/BluesteinLinda⁠⁠⁠  LinkedIn: ⁠⁠⁠https://www.linkedin.com/in/hypermobilitymd/⁠⁠⁠  Newsletter: ⁠⁠⁠https://hypermobilitymd.substack.com/⁠⁠⁠ Shop my Amazon store ⁠⁠⁠https://www.amazon.com/shop/hypermobilitymd⁠⁠⁠ Thank YOU so much for tuning in. We hope you found this episode informative, inspiring, useful, validating, and enjoyable. Join us on the next episode for YOUR time to level up your knowledge about hypermobility disorders and the people who have them. Join YOUR Bendy Bodies community at ⁠⁠https://www.bendybodiespodcast.com/⁠⁠. YOUR bendy body is our highest priority! Use this affiliate link for Algonot to get an extra 5% off your entire order: ⁠⁠https://algonot.com/coupon/bendbod/⁠⁠ Learn more about Human Content at ⁠⁠⁠http://www.human-content.com⁠⁠⁠ Podcast Advertising/Business Inquiries: ⁠⁠⁠sales@human-content.com⁠⁠⁠ Part of the Human Content Podcast Network FTC: This video is not sponsored. Links are commissionable, meaning I may earn commission from purchases made through links Learn more about your ad choices. Visit megaphone.fm/adchoices

In today's episode we are discussing 2 journal club articles relating to risk factors of glaucoma with our Mayo Clinic colleague Dr Arthur Sit.   Long-Term Systemic Use of Calcium Channel Blockers and Incidence of Primary Open-Angle Glaucoma - Ophthalmology Glaucoma Relationship between Intraocular Pressure Fluctuation and Visual Field Progression Rates in the United Kingdom Glaucoma Treatment Study - PubMed Subscribe to the podcast:  https://MayoClinicOphthalmology.podbean.com Follow and reach out to us on X and IG: @mayocliniceye

Interview with Sameer Jauhar, PhD, author of Incidence and Nature of Antidepressant Discontinuation Symptoms: A Systematic Review and Meta-Analysis. Hosted by John Torous, MD. Related Content: Incidence and Nature of Antidepressant Discontinuation Symptoms

Interview with Sameer Jauhar, PhD, author of Incidence and Nature of Antidepressant Discontinuation Symptoms: A Systematic Review and Meta-Analysis. Hosted by John Torous, MD. Related Content: Incidence and Nature of Antidepressant Discontinuation Symptoms

Selon les règles du feng shui, la place de nos meubles aurait un impact sur notre santé et notre bien-être. Distribué par Audiomeans. Visitez audiomeans.fr/politique-de-confidentialite pour plus d'informations.

Welcome to episode 183 of Growers Daily! We cover: garlic rust and what to do about it, how to tell if your soil is healthy, and it's feedback friday! We are a Non-Profit! 

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Ce 216e épisode de Pos. Report reçoit deux marins qui, du 14 au 22 juin, disputeront le Tour de Bretagne à la voile entre Perros-Guirec et Quiberon, Alexis Loison (Groupe Réel) et Alexis Thomas (Wings of the Ocean).Nos deux invités commencent par évoquer cette épreuve qui fête cette année sa 15e édition, avec toujours le même format, à savoir qu'elle se court en double et par étapes. Alexis Loison, qui y a participé huit fois et l'a gagnée à deux reprises, avec Fred Duthil en 2029 puis Guillaume Pirouelle il y a deux ans, explique que la clé est la régularité, tandis qu'Alexis Thomas se souvient d'une première participation, en 2021, qui s'était terminée sur un caillou de l'Aber Wrac'h.Ils expliquent ensuite le choix de leurs co-skippers respectifs, Corentin Horeau pour le Normand, Malo Wessely pour le Rochelais, qui raconte au passage comment il est venu à la voile de compétition et au Figaro en particulier, sa famille étant très proche de celle des Levaillant père et fils (Jean-Baptiste et Arthur).Nous évoquons ensuite avec eux leur début de saison, marqué par une première victoire sur le circuit Figaro lors de la Solo Guy Cotten pour Alexis Thomas, qui l'explique notamment par un budget enfin à la hauteur de ses ambitions et l'arrivée de Romen Richard comme entraîneur du pôle de La Rochelle. Et même si la Transat Paprec s'est avérée frustrante (9e avec Pauline Courtois après avoir fait une partie de la course aux avant-postes), il estime avoir trouvé quelque chose en termes de vitesse, notamment au portant.Quant à Alexis Loison, il explique comment il “jongle” entre son travail à la voilerie Incidence et les navigations, notamment sur le nouveau JPK 1050 qu'il met actuellement au point. Nous enchaînons sur leur grand objectif de la saison, la Solitaire du Figaro, la 19e d'Alexis Loison, la 5e d'Alexis Thomas. Le premier présente le parcours et revient sur quelques souvenirs marquants, entre son unique victoire d'étape à Plymouth et la première du Figaro 3, en 2019.Diffusé le 10 Juin 2025Générique : Fast and wild/EdRecordsPost-production : Grégoire LevillainHébergé par Ausha. Visitez ausha.co/politique-de-confidentialite pour plus d'informations.

God orchestrates incidents in the journeys of people in order to actualise destiny

Featuring perspectives from Ms Kathryn M Lyle, Dr Ritu Salani, Ms Jaclyn Shaver and Dr Brian M Slomovitz, including the following topics: Introduction: Overview of Endometrial Cancer (0:00) First-Line Therapy for Advanced or Recurrent Endometrial Cancer (11:01) Role of Lenvatinib/Pembrolizumab in the Management of Progressive Advanced Endometrial Cancer (39:09) Novel Investigational Strategies for Newly Diagnosed Advanced Endometrial Cancer (1:00:15) Incidence and Management of HER2-Positive Endometrial Cancer (1:17:52) NCPD information and select publications  

Welcome to the podcast with Dr. Brendan McCarthy!   This episode takes you deep into the real-world practice of prescribing testosterone therapy for women. This is not a high-level overview—this is a nuts and bolts breakdown: ✅ Who it's for ✅ How it's dosed ✅ What labs to run ✅ What delivery methods are safest ✅ Why it's often done wrong—and how to get it right   With over 20 years of clinical experience, Dr. McCarthy shares the insights no seminar or textbook can offer, including the emotional and psychological challenges women face when beginning testosterone therapy, and the very real fears around side effects and community stigma.  

Welcome to the podcast with Dr. Brendan McCarthy!   In this episode we dive deep into one of the most misunderstood and debated topics in hormone health: testosterone replacement therapy (TRT) for women. You may have heard horror stories—or glowing reviews. But what's the truth? Dr. McCarthy discusses: - Why testosterone matters for women's health - How it affects brain chemistry, mood, bone density, and even breast tissue - Its role after estrogen-suppressing breast cancer treatments - The difference between safe and unsafe TRT - What your provider should be doing to monitor and manage it effectively   Dr. Brendan McCarthy founded Protea Medical Center in 2002. While he's been the chief medical officer, Protea has grown and evolved into a dynamic medical center serving the Valley and Central Arizona. A nationally recognized as an expert in hormone replacement therapy, Dr McCarthy s the only instructor in the nation who teaches BioHRT on live patients. Physicians travel to Arizona to take his course and integrate it into their own practices. Besides hormone replacement therapy, Dr. McCarthy has spoken nationally and locally before physicians on topics such as weight loss, infertility, nutritional therapy and more.   Citations: Popma, Arne, et al. "Cortisol moderates the relationship between testosterone and aggression in delinquent male adolescents." Biological psychiatry 61.3 (2007): 405-411 Likhtik, E., Stujenske, J. M., Topiwala, M. A., Harris, A. Z. & Gordon, J. A. Prefrontal entrainment of amygdala activity signals safety in learned fear and innate anxiety. Nat. Neurosci. 17, 106–113 (2014). Brannon, Skylar M., et al. "Exogenous testosterone increases sensitivity to moral norms in moral dilemma judgements." Nature Human Behaviour 3.8 (2019): 856-866.. * M.H.M. Hutschemaekers, R.A. de Kleine, M.L. Davis, M. Kampman, J.A.J. Smits, K. Roelofs,Endogenous testosterone levels are predictive of symptom reduction with exposure therapy in social anxiety disorder,Psychoneuroendocrinology,Volume 115,2020,104612 Barel, E, Abu‐Shkara, R, Colodner, R, et al. Gonadal hormones modulate the HPA‐axis and the SNS in response to psychosocial stress. J Neuro Res. 2018; 96: 1388– 1397. https://doi.org/10.1002/jnr.24259 * Buades-Rotger, M., Engelke, C., Beyer, F. et al. Endogenous testosterone is associated with lower amygdala reactivity to angry faces and reduced aggressive behavior in healthy young women. Sci Rep 6, 38538 (2016). https://doi.org/10.1038/srep38538 Ando, Sebastiano, et al. "Breast cancer: from estrogen to androgen receptor." Molecular and cellular endocrinology193.1-2 (2002): 121-128. Somboonporn, Woraluk, and Susan R. Davis. "Testosterone effects on the breast: implications for testosterone therapy for women." Endocrine reviews 25.3 (2004): 374-388. Donovitz, Gary, and Mandy Cotten. "Breast cancer incidence reduction in women treated with subcutaneous testosterone: testosterone therapy and breast cancer incidence study." European journal of breast health 17.2 (2021): 150. Glaser, Rebecca L., Anne E. York, and Constantine Dimitrakakis. "Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study." BMC cancer 19.1 (2019): 1271.   Thank you for tuning in and don't forget to hit that SUBSCRIBE button! Let us know in the COMMENTS if you have any questions or what you may want Dr. McCarthy to talk about next!   Check out Dr. Brendan McCarthy's Book! https://www.amazon.com/Jump-Off-Mood-...   -More Links- Instagram: www.instagram.com/drbrendanmccarthy TikTok: www.tiktok.com/drbrendanmccarthy Clinic Website: www.protealife.com

Featuring a slide presentation from Dr Matthew Matasar and related discussion from Dr Carla Casulo, Dr Matasar and Dr Laurie H Sehn, including the following topics: Overview of Chimeric Antigen Receptor (CAR) T-Cell Therapies for Relapsed/Refractory Follicular Lymphoma (FL) (0:00) Case: A man in his late 60s with relapsed FL who received axicabtagene ciloleucel (axi-cel) but experienced cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome and chronic cytopenia (3:50) Published Clinical Data Involving Axi-cel (10:24) Case: A man in his mid 60s with multiple comorbidities and progressive FL who received tisagenlecleucel (tis-cel) (15:34) Published Clinical Data Involving Tis-cel (19:47) Case: A woman in her late 40s with multiple comorbidities and refractory FL who received lisocabtagene maraleucel (liso-cel) after prior mosunetuzumab (22:43) Published Clinical Data Involving Liso-cel (26:05) Incidence and Management of Toxicities Associated with CAR T-Cell Therapy (27:48) Sequencing Considerations and Ongoing Trials Involving CAR T-Cell Therapy (30:35) Practical Considerations and Referrals for CAR T-Cell Therapy Administration (31:59) CME information and select publications

In this episode of the Science of Slink podcast, Dr. Rosy Boa delves into the intricacies of learning pole dance at home. With a background in pole dance since 2012 and instruction since 2018, she brings extensive experience and scientific insights to the discussion. The episode covers the effectiveness of home-based exercise supported by recent research, methods to maintain motivation, and strategies to avoid common injuries. Dr. Boa shares her 'pyramid of pole' framework to guide beginners through physical conditioning, technical learning, and artistic expression. The episode also explores how to adapt training routines to home environments, addressing space limitations, flooring types, and unique home dynamics like pets or kids. Finally, Dr. Boa highlights the importance of appropriate movement levels and offers specific recommendations for home pole dance practice, urging listeners to be patient and consistent in their training.Are you a pole nerd interested in trying out online pole classes with Slink Through Strength? We'd love to have you! Use the code “podcast” for 10% off the Intro Pack and try out all of our unique online pole classes: https://app.acuityscheduling.com/catalog/25a67bd1/?productId=1828315&clearCart=true Citations: McDonagh, S. T., Dalal, H., Moore, S., Clark, C. E., Dean, S. G., Jolly, K., ... & Taylor, R. S. (2023). Home‐based versus centre‐based cardiac rehabilitation. Cochrane database of systematic reviews, (10).Schutzer, K. A., & Graves, B. S. (2004). Barriers and motivations to exercise in older adults. Preventive medicine, 39(5), 1056-1061.Lee, J. Y., Lin, L., & Tan, A. (2019). Prevalence of pole dance injuries from a global online survey. The Journal of sports medicine and physical fitness, 60(2), 270-275.Nicholas, J., Weir, G., Alderson, J. A., Stubbe, J. H., Van Rijn, R. M., Dimmock, J. A., ... & Donnelly, C. J. (2022). Incidence, mechanisms, and characteristics of injuries in pole dancers: a prospective cohort study. Medical problems of performing artists, 37(3), 151-164.Dang, Y., Chen, R., Koutedakis, Y., & Wyon, M. A. (2023). The efficacy of physical fitness training on dance injury: a systematic review. International journal of sports medicine, 44(02), 108-116.Ambegaonkar, J. P., Chong, L., & Joshi, P. (2021). Supplemental training in dance: a systematic review. Physical Medicine and Rehabilitation Clinics, 32(1), 117-135.Bohm, S., Mersmann, F., & Arampatzis, A. (2015). Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports medicine-open, 1, 1-18.Chapters:00:00 Introduction to the Science of Slink Podcast02:24 The Benefits of Home-Based Pole Dance Training06:54 Building Physical Capacity for Pole Dance08:23 Cross Training and Injury Prevention14:09 Considerations for Home Pole Dancers18:00 Recommendations for Beginners21:20 The Science of Slink Membership23:21 Conclusion and Final Thoughts

Aujourd'hui, Antoine Diers, Fatima Aït-Bounoua et Jérôme Marty débattent de l'actualité autour d'Alain Marschall et Olivier Truchot.

Dr. Edmund Tsui interviews authors Dr. Muhammad Z. Chauhan and Dr. Krishna S. Kishor on the risk of uveitis among patients starting topical glaucoma therapy. From their Ophthalmology Glaucoma article, “Incidence of Uveitis Following Initiation of Prostaglandin Analogs versus Other Glaucoma Medications.” Incidence of Uveitis Following Initiation of Prostaglandin Analogs versus Other Glaucoma Medications. Chauhan, Muhammad Z.Amin, Sejal et al. Ophthalmology Glaucoma, Volume 8, Issue 2, 126 – 132.

This week on The Beat, CTSNet Editor-in-Chief Joel Dunning speaks with Dr. Mario Castillo-Sang, the Surgical Director of Mitral Valve and Heart Failure Therapies at St. Elizabeth Healthcare, Edgewood, Kentucky, USA, about totally endoscopic cardiac surgery. Chapters 00:00 Intro 01:17 Minimal Access Bedside Cardiac 04:37 Lung Cancer, Histological Subtype 09:29 TAVR vs SAVR, AS & CAD 12:22 Biopros TVR Outcomes 15:48 Mitral Annular Disjunction, MVR 18:47 Ozaki Technique, AV Reconst 20:46 Redo LVOT Reconst for Endocarditis 22:33 Totally Endoscopic ASD Closure TVR 24:08 Dr. Castillo-Sang, MI Bedside Endoscopy 40:51 Closing They explore key highlights from Dr. Castillo-Sang's CTSNet series Endoscopic Cardiac Surgery Series: The Swiss Army Knife Approach, his journey in performing endoscopic surgeries, and how he learned the techniques. Dr. Castillo-Sang shares the advantages of endoscopic surgery, as well as tips and recommendations for those wanting to learn this approach. He emphasizes the importance of the instruments he has worked with, detailing how these have improved over time. Additionally, they explore Dr. Castillo-Sang's involvement with the Endoscopic Cardiac Surgeons Club, discussing how he got involved and providing details about the club's upcoming annual meeting.   Joel also highlights recent JANS articles on the estimated worldwide variation and trends in incidence of lung cancer by histological subtype in 2022 and over time, transcatheter vs surgical aortic valve replacement in Medicare beneficiaries with aortic stenosis and coronary artery disease, long-term outcomes after bioprosthetic tricuspid valve replacement, and outcomes of patients with mitral annular disjunction undergoing mitral valve repair.  In addition, Joel explores aortic valve reconstruction using the Ozaki technique, redo LVOT reconstruction for endocarditis, and totally endoscopic ASD closure with tricuspid valve repair. Before closing, he highlights upcoming events in CT surgery.   JANS Items Mentioned  1.) Estimated Worldwide Variation and Trends in Incidence of Lung Cancer by Histological Subtype in 2022 and Over Time: A Population-Based Study  2.) Transcatheter vs Surgical Aortic Valve Replacement in Medicare Beneficiaries With Aortic Stenosis and Coronary Artery Disease  3.) Long-Term Outcomes After Bioprosthetic Tricuspid Valve Replacement: A Multicenter Study  4.) Outcomes of Patients With Mitral Annular Disjunction Undergoing Mitral Valve Repair  CTSNET Content Mentioned  1.) Aortic Valve Reconstruction—The Ozaki Technique  2.) Redo LVOT Reconstruction for Endocarditis  3.) Totally Endoscopic ASD Closure With Tricuspid Valve Repair  Other Items Mentioned  1.) Endoscopic Cardiac Surgery Series: The Swiss Army Knife Approach  2.) Endoscopic Cardiac Surgeons Club  3.) Mini Heart Valves   4.) Aortic Valve Replacement Series     5.) Career Center 6.) CTSNet Events Calendar  Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.

The average person spends up to 18 hours in their home. Therefore, our homes are not just places to rest. They're also environments that significantly impact our health and well-being.Spending so much time indoors makes it important to ensure our homes have as minimal harmful chemicals in the environment as possible. Our homes are often considered our safety nests, where we seek comfort and security, but they can also harbor hidden dangers if not properly maintained.That's why we're so glad to chat on IG Live with Alexandra Destler, Founder and CEO of SafetyNEST.SafetyNEST is an award-winning digital platform committed to providing the most credible information about the effects of toxic chemicals on prenatal and early childhood health in order to safeguard children's health and reduce the incidence of preventable diseases.During this Live, we're going to discuss overlooked environmental health factors in our homes, how they impact pregnancy outcomes, resources and tools people can use, and so much more!Learn more about SafetyNEST: https://www.mysafetynest.com/Get tested for BPA, phthalates, parabens, and other hormone-disrupting chemicals with Million Marker's Detect & Detox Test Kit: https://www.millionmarker.com/

Cori is a hard-working corporate employee who dutifully contributes to America's tax base. Nina is a low-income artist with Crohn's Disease whose medical expenses make her a net parasite, despite also paying taxes. After a surprise performance of improvised music by soda-can virtuoso Cori, we discuss tariffs, security, Medicaid, FICA, “maxing out contributions,” Incidence of Taxation, employment benefits, monetary incentives, distortions, the Tragedy of the Commons, suckers, rationalizations, population collapse/explosion, and episodic disability. Is art, work? How hard is it to be poor? Can air be privatized? Like Life itself, our tax/benefits system isn't fair, and it cannot go on forever. So a big Thank You to all American taxpayers who support unproductive, under-productive, post-productive, and ill members of society like your show-notes writer.Links:Leta Boylan testimonyTerminator 2: https://www.imdb.com/title/tt0103064/Tragedy of the Commons: https://en.wikipedia.org/wiki/Tragedy_of_the_commonsThe Economist on more people claiming entitlements: https://www.economist.com/britain/2025/04/02/the-tyranny-of-tiktokkers-who-turn-up Get full access to Heterodorx Podcast at heterodorx.substack.com/subscribe

Nonunion following naviculocuneiform (NC) joint arthrodesis is a well-recognized complication. Most studies reporting nonunion rates involve a limited number of cases or focus on a single disease entity. Moreover, there is variation between studies with regard to the number of articular facets included in the arthrodesis as well as the fixation construct used, with no clear evidence indicating how these factors influence union. This study, using the largest cohort to date, aims to investigate the nonunion rate following NC joint arthrodesis and to identify demographic and surgical factors associated with nonunion.   In conclusion, this study demonstrates a significant rate of nonunion following NC joint arthrodesis, exceeding that previously reported. We found that the rate of nonunion significantly increased in arthrodeses involving only the medial NC facet as compared to those including multiple NC facets.     Click here to read the article.

Join the conversation by letting us know what you think about the episode!According to the National Breast Cancer Foundation, 1 in 8 women will be diagnosed with breast cancer in her lifetime. Breast Cancer Facts & Stats 2024 - Incidence, Age, Survival, & More. Our guest, Erica Neubert Campbell is one of those women. Having lived through her mother's experience with breast cancer, Erica wasn't surprised when she was diagnosed with the same illness. In The Mastectomy I Always Wanted: A Breast Cancer Memoir, Erica takes us along with her from expectation to diagnosis to reconstruction and beyond. The end result is a resource for all of us - cancer warriors and survivors, their caregivers, and the people who love them.Where to find Erica Neubert Campbell:Website:  www.ericaneubertcampbell.comAmazon link:  https://amzn.to/4ck4Di1Facebook: https://www.facebook.com/erica.neubert/Instagram: https://www.instagram.com/erica.n.campbell/LinkedIN: https://www.linkedin.com/in/erica-neubert-campbell-936279/Support the showBe part of the conversation by sharing your thoughts about this episode, what you may have learned, how the conversation affected you. You can reach Raquel and Jennifer on IG @madnesscafepodcast or by email at madnesscafepodcast@gmail.com.Share the episode with a friend and have your own conversation. And don't forget to rate and review the show wherever you listen!Thanks!

Les accidents vasculaires cérébraux (AVC) constituent une préoccupation majeure en santé publique, avec plus de 120 000 cas recensés chaque année en France, entraînant environ 30 000 décès. Traditionnellement associés aux personnes âgées, les AVC touchent également des populations plus jeunes, une tendance mise en lumière par des études récentes.​Incidence des AVC selon l'âgeSelon le bulletin épidémiologique publié le 4 mars 2025 par Santé publique France, l'âge moyen des patients hospitalisés pour un AVC en 2022 était de 73,2 ans, avec une différence notable entre les sexes : 70,5 ans pour les hommes et 76,3 ans pour les femmes. La moitié des patients avaient plus de 75 ans au moment de l'AVC, et 25,4 % étaient âgés de moins de 65 ans. Ces chiffres illustrent que, bien que l'incidence des AVC augmente avec l'âge, une proportion significative touche des individus de moins de 65 ans. ​Le risque d'AVC augmente significativement avec l'âge, atteignant son maximum chez les personnes de 85 ans et plus. Augmentation des AVC chez les moins de 65 ansBien que le vieillissement de la population explique en partie l'augmentation globale des AVC, un "signal épidémiologique" préoccupant est observé chez les adultes de moins de 65 ans depuis une quinzaine d'années. Cette tendance suggère une hausse de l'incidence et des hospitalisations pour AVC dans cette tranche d'âge, nécessitant une attention particulière. ​Facteurs de risque chez les moins de 65 ansPlusieurs facteurs peuvent contribuer à cette augmentation chez les moins de 65 ans :​Hypertension artérielle : facteur de risque majeur d'AVC.​Diabète : augmente le risque de maladies vasculaires, y compris les AVC.​Tabagisme : endommage les vaisseaux sanguins et favorise les caillots.​Sédentarité et obésité : contribuent à l'hypertension et au diabète.​Consommation excessive d'alcool : peut entraîner une hypertension et des troubles du rythme cardiaque.​L'adoption de modes de vie sains, incluant une alimentation équilibrée, une activité physique régulière et l'arrêt du tabac, est essentielle pour réduire ces risques.​ConclusionBien que le risque d'AVC augmente avec l'âge, touchant principalement les personnes de plus de 75 ans, une proportion notable survient chez les moins de 65 ans. L'augmentation de l'incidence dans cette tranche d'âge souligne l'importance de la prévention et de la sensibilisation aux facteurs de risque modifiables, afin de réduire l'impact des AVC sur cette population. Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.

The diagnosis of cancer is rising in young adults (

In this episode of the Movement Logic Podcast, hosts Laurel Beversdorf and Dr. Sarah Court critically examine common beliefs surrounding spinal flexion exercises and osteoporosis, particularly from a yoga and Pilates perspective. They delve into two pivotal studies on exercise and fracture risk, both led by Dr. Mehrsheed Sinaki, a renowned specialist in physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minnesota.The first study, Postmenopausal Spinal Osteoporosis: Flexion versus Extension Exercises, is frequently cited on Pilates websites and in yoga and Pilates teacher trainings as evidence that spinal flexion is risky for individuals with osteoporosis—even during bodyweight exercises. However, despite its widespread use to justify movement restrictions, the study has notable methodological flaws. The second study, Stronger Back Muscles Reduce the Incidence of Vertebral Fractures: A Prospective 10-Year Follow-up of Postmenopausal Women, suggests that progressively overloaded back strengthening exercises can reduce fracture risk—even if the strengthening occurred only for a few years in the distant past. Yet, this study also has its own limitations.When viewed together, these studies present an intriguing contrast: one warns of the potential dangers of spinal flexion (even under low loads) based on weak evidence, while the other highlights the lasting protective benefits of strength training. Laurel and Sarah explore why bodyweight spinal flexion is often singled out as risky and question whether this caution is always justified.They also discuss the ethical implications and the boundaries of a movement teacher's scope of practice—particularly when making broad recommendations to avoid certain movements based on limited or flawed research. The hosts emphasize the importance of individualized context in exercise prescriptions, the need to follow medical guidance from a student's doctor, the evidence-backed benefits of strength training, and the necessity of empowering students with the autonomy to make informed movement choices.Get on the wait list for our Bone Density Course: Lift for LongevityFollow Movement Logic on Instagram00:56 Podcast Production & Content Creation01:33 Bone Density & Squat Depth02:20 Benefits of Full ROM Strength Training08:24 Is Spinal Flexion Dangerous for OP?10:00 Issues with Yoga/Pilates for OP Classes18:43 1984 Paper: Flexion vs. Extension for OP40:22 Flaws in the 1984 Study41:57 2002 Study: Stronger Back Muscles & Fractures43:03 2002 Study Design & Methods46:35 2002 Study Key Findings52:09 2002 Study Limitations56:30 Practical Takeaways01:06:15 Ethics for Movement Teachers01:17:43 ConclusionReferences:Episode 77: Make Dr. Loren Fishman Make SenseEpisode 92: Are You Getting Dexa Scammed? 1984 Sinaki paper 2002 Sinaki paper

In This Episode Kathleen investigates the connection between dietary fibre and cancer. Peter talks about future guests and our featured author. Increasing your intake of fibre can help with immune support, hormone health and overall metabolic stability. Furthermore, fibre has been shown in studies to help curb cancers such as gastric, ovarian and endometrial. If you're not used to high fibre, start slowly and gradually increase. This Week's Health Tip It's time for a Spring Clean – not just in your home but also your body and digestive system. Kathleen spoke about the Dr. Morse Herbal Health products that can help you do this. You can see all the products Kathleen mentioned on the Dr. Morse Herbal Health website. Use code Yakking Show for a 5% discount.  Mentioned On The Show Thea Trussler          www.petassistancetraining.com Logan Wright           www.grecogum.com Dr. Carol Remz        www.drcarolremz.com Dr. Mercola                 fibre consumption article Dr. Morse's episode          Video, audio and Spotify. Next Guest On the 1st of April we will explore the incredible benefits of mastic gum with Logan Wright, Co-Founder of Greco Gum. Mastic gum, harvested from the ancient Chios mastic tree, has been used for centuries for its oral health, jaw and facial muscle development, and gut health benefits. Featured Author. Our featured author this week is Eli LeClaire from episode 337 with her children's book “Adoption: A Beautiful Fulfillment of Life”. For parents of adopted children to help them prepare for the inevitable questions “Are you my mommy? Are you my daddy?” The Yakking Show is brought to you by Peter Wright & Kathleen Beauvais contact us to be a guest on our show. https://TheYakkingShow.com   peter@theyakkingshow.com    kathleen@theyakkingshow.com  Join our community today so you don't miss out on advance news of our next episodes. https://bit.ly/40GdxCG Yakking Show Affiliates Dr. Morse's Herbal Health Club Remedies https://bit.ly/3Oc2J8L  Science Driven Supplements - Circuguard & OxyBoost https://bit.ly/3VPzsV8  MyWayCBD https://bit.ly/4jFzmd0  BAM Metrics Exercise Equipment https://bit.ly/3SMnZom  B3 Sciences BFR bands  https://bit.ly/4g9HmzV  Chatterboss Virtual Assistants https://bit.ly/3Obmzlb  Follow us on social media Spotify   https://open.spotify.com/show/1N3yM4lUuBYGMByhwuUDVy  Facebook Group https://www.facebook.com/groups/480434235068451  FaceBook Page  https://www.facebook.com/theyakkingshow  Twitter  X   https://x.com/YakkingShow  Instagram  https://www.instagram.com/theyakkingshow/  Here are some of the tools we use to produce this podcast. Kit for sending emails and caring for subscribers Hostgator for website hosting. Podbean for podcast hosting Airtable for organizing our guest bookings and automations.   Clicking on some links on this site will let you buy products and services which may result in us receiving a commission, however, it will not affect the price you pay.            

Join JACC: Executive Associate Editor Mitsuaki Sawano, MD, FACC, and author Mats Lassen, MD discuss Dr. Lassen's study on the link between acute respiratory syncytial virus (RSV) infection and an increased incidence of cardiovascular events, particularly in older adults, using comprehensive nationwide data from Denmark. The findings, published in JACC and presented at ACC.25, highlight the need for heightened awareness among healthcare providers, potential adjustments in patient management during RSV season, and further research into whether RSV vaccines may help reduce cardiovascular complications. #jacc #jaccjournals #acc.25

Send us a textDeclining Incidence of Postoperative Neonatal Brain Injury in Congenital Heart Disease.Peyvandi S, Xu D, Barkovich AJ, Gano D, Chau V, Reddy VM, Selvanathan T, Guo T, Gaynor JW, Seed M, Miller SP, McQuillen P.J Am Coll Cardiol. 2023 Jan 24;81(3):253-266. doi: 10.1016/j.jacc.2022.10.029.PMID: 36653093 Free PMC article.As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

My guest is Dr. Roger Seheult, M.D., a board-certified physician in internal medicine, pulmonary diseases, critical care, and sleep medicine at Loma Linda University. We discuss the powerful benefits of light therapy, including infrared light, red light, and sunlight, for improving mitochondrial function in all the body's organs. We also explore ways to reduce the risk of influenza, colds, and other illnesses that affect the lungs, sinuses, and gut. Topics include the flu shot, whether handwashing truly prevents illness transmission, and treatments for long COVID and mold toxicity. We review the efficacy of N-acetylcysteine (NAC), the power of hydrotherapy for combating infections, and strategies for improving sleep and overall health. Additionally, we discuss air quality. This episode provides actionable, science-based tools for preventing and treating infectious illnesses. Read the full show notes for this episode at hubermanlab.com. Sponsors AG1: https://drinkag1.com/huberman Joovv: https://joovv.com/huberman Eight Sleep: https://eightsleep.com/huberman LMNT: https://drinklmnt.com/huberman Function: https://functionhealth.com/huberman Our Place: https://fromourplace.com/huberman Timestamps 00:00:00 Dr. Roger Seheult 00:02:16 Avoiding Sickness, Immune System, Tool: Pillars of Health, NEWSTART 00:08:03 Sponsors: Joovv & Eight Sleep 00:10:46 Sunlight, Mitochondria, Tool: Infrared Light & Melatonin 00:19:09 Melatonin Antioxidant, Reactive Oxygen Species (ROS)/Free Radicals 00:26:38 Infrared Light, Green Spaces, Health & Mortality 00:31:35 Infrared Light, Mitochondrial Dysfunction, Disease 00:38:46 Sunlight & Cancer Risk?, Tools: UV Light, Clothing & Sunlight Exposure 00:41:01 Sponsors: AG1 & LMNT 00:43:32 Sunlight, Incidence of Influenza or COVID 00:48:41 Tools: Sunlight Exposure Duration, Winter Months 00:55:18 Infrared Lamps?, Winter Sunlight Exposure; Obesity & Metabolic Dysfunction 00:59:48 Cloudy Days; Sunlight, Primitive Therapy, Hospitals 01:11:33 Sponsor: Function 01:13:21 Artificial Lights, Hospitals & Light Therapy?, ICU Psychosis 01:22:16 Sleep & Darkness, Tools: Eye Mask, Bathroom Navigation; Meals & Light 01:28:27 Influenza, Flu Shots, Swiss Cheese Model; Flu Shot Risks? 01:38:13 Masks?, Flu; Handwashing 01:42:16 Sponsor: Our Place 01:43:57 Water, Sodium; Innate Immune System, Fever & Hydrotherapy 01:53:46 Fever, Heat Hydrotherapy, Interferon & Immune System 01:58:25 Cold Hydrotherapy, Vasoconstriction & White Blood Cells 02:09:56 N-Acetyl Cysteine (NAC), Glutathione, White Clots, Flu, Covid 02:19:28 Tool: NAC Dose & Regimen; Mucous, Flu Symptoms 02:25:25 Zinc Supplementation, Copper; Exogenous Interferon 02:28:40 Eucalyptus Oil, Inhalation 02:32:22 Air, Smoking, Vaping, Nicotine Gum 02:36:49 Fresh Air, Forest Bathing, Tool: Go Outdoors 02:40:09 Nature vs Inside Environments, Dark Days/Bright Nights Problem 02:52:38 Long COVID, Mitochondrial Dysfunction, Intermittent Fasting, Sunlight 03:00:43 Covid & Varied Severity, Smell Loss Recovery 03:05:04 Mold Toxicity, Lungs, Germ vs Terrain Theory, Immunocompromised 03:11:46 Trust, Spirituality, Community, Faith; Forgiveness 03:19:46 Hospital Admission, Tool: Asking Questions 03:25:42 Zero-Cost Support, YouTube, Spotify & Apple Follow & Reviews, Sponsors, YouTube Feedback, Protocols Book, Social Media, Neural Network Newsletter Disclaimer & Disclosures

Title: Episode 4- Incidence, prevalence & Study Definitions Target Audience This activity is directed to physicians who take care of hospitalized children, medical students, nurse practitioners, and physician assistants working in the emergency room, intensive care unit, or hospital wards. Objectives: Upon completion of this activity, participants should be able to: 1.      Review incidence in research. 2.      Review prevalence in research. 3.      Review screening and how it pertains to research. Course Directors: Tony R. Tarchichi MD — Associate Professor, Department of Pediatrics, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC.) Paul C. Gaffney Division of Pediatric Hospital Medicine. No relationships with industry relevant to the content of this educational activity have been disclosed. Philana Lin M.D. MSc - University of Pittsburgh School of Medicine - Associate Professor in the Department of Pediatrics - Pediatric Infectious Disease Division Dr. Lin receives grant/research support from Pfizer (funds investigator initiated seroprevalance study on invasive pneumococcal infection), and NIH (Investigator initiated research on tuberculosis). Conflict of Interest Disclosure: No other planners, members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships to disclose. Accreditation Statement: In support of improving patient care, the University of Pittsburgh 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.  The University of Pittsburgh School of Medicine designates this enduring material activity for a maximum of 0.5 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.   Disclaimer Statement: The information presented at this activity represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses. Released 2/20/2025,  Expires 2/20/2028 The direct link to the course is provided below: https://cme.hs.pitt.edu/ISER/app/learner/loadModule?moduleId=25577&dev=true

Featuring a slide presentation and related discussion from Dr Surbhi Sidana, including the following topics: Key clinical data of FDA-approved chimeric antigen receptor (CAR) T-cell therapies (0:00) Real-world evidence evaluating utility of CAR T-cell therapies in the clinic (8:08) Impact of prior BCMA-targeted treatment on CAR T-cell therapy efficacy (12:55) Investigational CAR T-cell therapies in clinical development (15:08) Incidence and management of toxicities associated with CAR T-cell therapy (18:21) CME information and select publications

2/13/2025Seven Minute Summary1. High Dose vs. Low dose TXA in Adult deformity Surgery. JBJS. Dec 20242. Incidence of revision surgery and outcomes following surgery for spondylolisthesis. JNS. Jan 2025

Abdullah Al-Abcha, MD, social media editor of JACC: Cardiovascular Interventions, and Thomas Pilgrim, MD, MSc, discuss a recently published manuscript reporting the incidence, predictors, and clinical outcomes hemodynamic valve deterioration after transcatheter aortic valve replacement.

Tune in to learn about a key aspect of a pet's general wellness care that can significantly affect the incidence of systemic disease. Overlooking this key health concern can increase the incidence of kidney failure, congestive heart failure, and liver disease by 150%, as well as significantly increase the incidence of certain type of cancers. Send listener emails for consideration to be addressed by Dr. Roger on the air to comments@web-dvm.net. Follow Dr. Roger's Facebook posts (including new podcast episodes) by sending a friend request to his public profile, Roger Welton DVM. Dr. Roger Welton, aka "Dr. Roger," is a practicing veterinarian and highly regarded media personality through a number of platforms. He is the author of his top selling memoir ⁠The Man In The White Coat: A Veterinarian's Tail Of Love.⁠  In addition to this podcast, Dr. Roger has a global blog, ⁠The Web-DVM⁠, where he regularly posts articles. He is the CEO and chief attending veterinarian of  ⁠Premier Veterinary Care⁠ in Viera, FL.

Fliessend Fremdsprachen sprechen mit KI-Hilfe – das Ziel rückt näher. Ausserdem: Berner Forschende lüften eiskalte Klima-Geheimnisse aus der Zeit der Urmenschen. Und: Möglicherweise triggert das Coronavirus die vererbte Form der Diabetes. (00:00) Schlagzeilen (00:42) Mit KI-Hilfe Fremdsprachen sprechen Meta und andere Tech-Firmen versuchen sich daran, KI-basierte Dolmetscher zu entwickeln, die in Echtzeit übersetzen. Ganz ausgereift ist die Technologie noch nicht, finden Expertinnen, aber sie hat grosses Potential. (Sandro della Torre) (06:49) Meldungen Neue kommerzielle Rakete im Testflug / Weniger Tiefsee-Fischerei in EU-Sperrzonen / Horizon Europe wieder (fast) ganz offen für die Schweiz. (Anita Vonmont) (11:54) Uraltes Eis erzählt vom Klima vor über 1 Million Jahren Forschenden ist es gelungen, den bisher ältesten, kontinuierlich geschichteten Eisbohrkern zu bergen. Die darin eingeschlossenen Luftbläschen sollen Aufschluss geben darüber, wie die Atmosphäre auf dem Planeten Erde vor schätzungsweise 1.5 Mio Jahre zusammengesetzt war – und wie sie sich anschliessend im Verlauf der Jahre verändert hat. Von Anfang an mit dabei war ein Forschungs-Team der Universität Bern. Reportage aus dem Eislabor. (Cathrin Caprez) (18:21) Kann das Corona-Virus Diabetes triggern? Zur Zeit der Corona-Pandemie vermehrte sich die Neuansteckungsrate bei der vererbten, unheilbaren Form der Diabetes (Typ1) um das bis zu Zehnfache. Mittlerweile belegen mehrere Studien diese Korrelation klar. Dennoch muss noch genauer untersucht werden, ob das Corona-Virus Diabetes auslösen kann. (Mirjam Stöckel) Links: Ältestes Eis und Klima: beyondepica.eu/en/ Fliessend Fremdsprachen sprechen mit KI-Hilfe: nature.com/articles/d41586-025-00045-y Tiefseefischerei: science.org/doi/10.1126/sciadv.adp4353 Horizon Europe: snf.ch/de/PIgvZDNljXgiJ59U/news/horizon-europe-fuer-schweizer-forschende-wieder-offen?utm_source=newsletter&utm_medium=email&utm_content=lang-de&utm_campaign=snf-newsletter Diabetes und Corona: Studie 1: onlinelibrary.wiley.com/doi/10.1155/2023/7660985 Diabetes und Corona: Studie 2: jamanetwork.com/journals/jama/fullarticle/2809621 Diabetes und Corona: Studie 3: diabetesjournals.org/care/article/45/8/1762/139385/Incidence-of-Type-1-Diabetes-in-Children-and Mehr zum Wissenschaftsmagazin und Links zu Studien: srf.ch/wissenschaftsmagazin.

Guest: Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine. He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic.   Resources:  Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/ The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext  KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/    Outline: Steal Syndrome Definition & Etiology Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand. Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow.  Incidence and Risk Factors The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits. Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4  Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries' ability to vasodilate and adjust to decreased blood flow. Patient Presentation, Symptoms, Grading Steal syndrome is diagnosed clinically.  Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation. Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years. The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss.  There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow. Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5  Workup Duplex ultrasound can be used to analyze flow volumes. A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery. Upper extremity angiogram can identify proximal arterial lesions. Prevention Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter.  SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal. If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors, using the smaller end of the graft placed at the arterial anastomosis, although this has not yet been proven to reduce the incidence of steal.  Indications for Treatment Intervention is recommended in lifestyle-limiting cases of Grade II and all Grade III steal cases. If left untreated, the natural history of steal syndrome can result in chronic limb ischemia, causing gangrene with loss of digits or limbs. Treatment Options Conservative management relies on observation and monitoring, as mild cases of steal syndrome may resolve spontaneously. Inflow stenosis can be treated with endovascular intervention (angioplasty with or without stent) Ligation is the simplest surgical treatment, and it results in loss of the AV access. This is preferred in patients with repetitive failed salvage attempts, venous hypertension, and poor prognoses. Flow limiting procedures can address high volumes through the AV access. Banding can be performed with surgical cutdown and placement of polypropylene sutures or a Dacron patch around the vein or graft. The Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) technique employs a percutaneous endoluminal balloon inflated at the AVF to ensure consistency in diameter while banding Plication is when a side-biting running stitch is used to narrow lumen of the vein near the anastomosis. A downside of flow-limiting procedures is that it is often difficult to determine how much to narrow the AV access, as these procedures carry a risk of outflow thrombosis. There are also surgical treatments focused on reroute arterial inflow. The distal revascularization and interval ligation (DRIL) procedure involves creation of a new bypass connecting arterial segments proximal and distal to the AV anastomosis, with ligation of the native artery between the AV anastomosis and the distal anastomosis of the bypass. Reversed saphenous vein with a diameter greater than 3mm is the preferred conduit. Arm vein or prosthetic grafts can be used if needed, but prosthetic material carries higher risk of thrombosis. The new arterial bypass creates a low resistance pathway that increases flow to distal arterial beds, and interval arterial ligation eliminates retrograde flow through the distal artery.  The major risk of this procedure is bypass thrombosis, which results in loss of native arterial flow and hand ischemia. Other drawbacks of DRIL include procedural difficulty with smaller arterial anastomoses, sacrifice of saphenous or arm veins, and decreased fistula flow. Another possible revision surgery is revision using distal inflow (RUDI). This procedure involves ligation of the fistula at the anastomosis and use of a conduit to connect the outflow vein to a distal artery. The selected distal artery can be the proximal radial or ulnar artery, depending on the preoperative duplex. The more dominant vessel should be spared, allowing for distal arterial beds to have uninterrupted antegrade perfusion. The nondominant vessel is used as distal inflow for the AV access. RUDI increases access length and decreases access diameter, resulting in increased resistance and lower flow volume through the fistula. Unlike DRIL, RUDI preserves native arterial flow.  Thrombosis of the conduit would put the fistula at risk, rather than the native artery.  The last surgical revision procedure for steal is proximalization of arterial inflow (PAI). In this procedure, the vein is ligated distal to the original anastomosis site and flow is re-established through the fistula with a PTFE interposition graft anastomosed end-to-side with the more proximal axillary artery and end-to-end with the distal vein. Similar to RUDI, PAI increases the length and decreases the diameter of the outflow conduit. Since the axillary artery has a larger diameter than the brachial artery, there is a less significant pressure drop across the arterial anastomosis site and less steal. PAI allows for preservation of native artery's continuity and does not require vein harvest.  Difficulties with PAI arise when deciding the length of the interposition graft to balance AV flow with distal arterial flow. 2. Ischemic Monomelic Neuropathy Definition Ischemic monomelic neuropathy (IMN) is a rare but serious form of steal that involves nerve ischemia. Severe sensorimotor dysfunction is experienced immediately after AV access creation. Etiology IMN affects blood flow to the nerves, but not the skin or muscles because peripheral nerve fibers are more vulnerable to ischemia. Incidence and Risk Factors IMN is very rare; it has an estimated incidence of 0.1-0.5% of AV access creations.6 IMN has only been reported in brachial artery-based accesses, since the brachial artery is the sole arterial inflow for distal arteries feeding all forearm nerves. IMN is associated with diabetes, peripheral vascular disease, and preexisting peripheral neuropathy that is associated with either of the conditions. Patient Presentation Symptoms usually present rapidly, within minutes to hours after AV access creation. The most common presenting symptom is severe, constant, and deep burning pain of the distal forearm and hand. Patients also report impairment of all sensation, weakness, and hand paralysis. Diagnosis of IMN can be delayed due to misattribution of symptoms to anesthetic blockade, postoperative pain, preexisting neuropathy, a heavily bandaged arm precluding neurologic examination. Treatment Treatment is immediate ligation of the AV access. Delay in treatment will quickly result in permanent sensorimotor loss.   3. Perigraft Seroma Definition A perigraft seroma is a sterile fluid collection surrounding a vascular prosthesis and is enclosed within a pseudomembrane. Etiology and Incidence Possible etiologies include: transudative movement of fluid through the graft material, serous fluid collection from traumatized connective tissues (especially the from higher adipose tissue content in the upper arm), inhibition of fibroblast growth with associated failure of the tissue to incorporate the graft, graft “wetting” or kinking during initial operation, increased flow rates, decreased hematocrit causing oncotic pressure difference, or allergy to graft material. Seromas most commonly form at anastomosis sites in the early postoperative period. Overall seroma incidence rates after AV graft placement range from 1.7–4% and are more common in grafts placed in the upper arm (compared to the forearm) and Dacron grafts (compared to PTFE grafts).7-9 Patient Presentation and Workup Physical exam can show a subcutaneous raised palpable fluid mass Seromas can be seen with ultrasound, but it is difficult to differentiate between the types of fluid around the graft (seroma vs. hematoma vs. abscess) Indications for Treatment Seromas can lead to wound dehiscence, pressure necrosis and erosion through skin, and loss of available puncture area for hemodialysis Persistent seromas can also serve as a nidus for infection. The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines10 recommend a tailored approach to seroma management, with more aggressive surgical interventions being necessary for persistent, infected-appearing, or late-developing seromas.   Treatment The majority of early postoperative seromas are self-limited and tend to resolve on their own Persistent seromas have been treated using a variety of  methods-- incision and evacuation of seroma, complete excision and replacement of the entire graft, and primary bypass of the involved graft segment only. Graft replacement with new material and rerouting through a different tissue plane has a higher reported cure rate and lower rate of infection than aspiration alone.9     4. Infection Incidence and Etiology The reported incidence of infection ranges 4-20% in AVG, which is significantly higher than the rate of infection of 0.56-5% in AVF.11  Infection can occur at the time of access creation (earliest presentation), after cannulation for dialysis (later infection), or secondary to another infectious source. Infection can also further complicate a pre-existing access site issue such as infection of a hematoma, thrombosed pseudoaneurysm, or seroma. Skin flora from frequent dialysis cannulations result in common pathogens being Staphylococcus, Pseudomonas, or polymicrobial species. Staphylococcus and Pseudomonas are highly virulent and likely to cause anastomotic disruption. Patient Presentation and Workup Physical exam will reveal warmth, pain, swelling, erythema, induration, drainage, or pus. Occasionally, patients have nonspecific manifestations of fever or leukocytosis. Ultrasound can be used to screen for and determine the extent of graft involvement by the infection.   Treatments In AV fistulas: Localized infection can usually be managed with broad spectrum antibiotics.  If there are bleeding concerns or infection is seen near the anastomosis site, the fistula should be ligated and re-created in a clean field. In AV grafts: If infection is localized, partial graft excision is acceptable. Total graft excision is recommended if the infection is present throughout the entire graft, involves the anastomoses, occludes the access, or contains particularly virulent organisms Total graft excision may also be indicated if a patient develops recurrent bacteremia with no other infectious source identified. For graft excision, the venous end of the graft is removed and the vein is oversewn or ligated. If the arterial anastomosis is intact, a small cuff of the graft can be left behind and oversewn. If the arterial anastomosis is involved, the arterial wall must be debrided and ligation, reconstruction with autogenous patch angioplasty, or arterial bypass can be pursued. References   1. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and Characteristics of Patients with Hand Ischemia after a Hemodialysis Access Procedure. J Surg Res. 1998;74(1):8-10. doi:10.1006/jsre.1997.5206 2. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg. 1992;164(3):229-232. doi:10.1016/S0002-9610(05)81076-1 3. Valentine RJ, Bouch CW, Scott DJ, et al. Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg. 2002;36(2):351-356. doi:10.1067/mva.2002.125848 4. Malik J, Tuka V, Kasalova Z, et al. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access. 2008;9(3):155-166. doi:10.1177/112972980800900301 5. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35(3):603-610. doi:10.1067/mva.2002.122025 6. Thermann F, Kornhuber M. Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review. J Vasc Access. 2011;12(2):113-119. doi:10.5301/JVA.2011.6365 7. Dauria DM, Dyk P, Garvin P. Incidence and Management of Seroma after Arteriovenous Graft Placement. J Am Coll Surg. 2006;203(4):506-511. doi:10.1016/j.jamcollsurg.2006.06.002 8. Gargiulo NJ, Veith FJ, Scher LA, Lipsitz EC, Suggs WD, Benros RM. Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas. J Vasc Surg. 2008;48(1):216-217. doi:10.1016/j.jvs.2008.01.046 9. Blumenberg RM, Gelfand ML, Dale WA. Perigraft seromas complicating arterial grafts. Surgery. 1985;97(2):194-204. 10. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. doi:10.1053/j.ajkd.2019.12.001 11. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48(5):S55-S80. doi:10.1016/j.jvs.2008.08.067

You're the new intern on your first night of night float. First page, right off the bat – AFib with rates into the 150s. What's your next move?! Dr. Nathan Anderson takes the anxiety out of approaching Atrial Fibrillation in the post-operative patient. Join him and Dr. Elizabeth Maginot as they discuss this very common post-operative you're guaranteed to see on the wards.  Hosts:  - Dr. Nathan Anderson, Internal Medicine Associate Professor and Hospitalist, University of Nebraska  - Dr. Elizabeth Maginot, General Surgery Resident and BTK Surgical Education Fellow, University of Nebraska Medical Center, Twitter: @e_magination95 Learning Objectives:  - Discuss the underlying pathophysiological mechanisms that contribute to the development of atrial fibrillation in the postoperative setting.  - Critically approach the different management options for atrial fibrillation in the post-cardiac and non-cardiac surgery settings, including rate versus rhythm control, indications for cardioversion, and the role of anticoagulation.  - Identify common risk factors for atrial fibrillation in the post-operative setting.  - Discuss long-term management and follow-up strategies for patients who develop atrial fibrillation after surgery. References:  1. Bhave PD, Goldman LE, Vittinghoff E, Maselli J, Auerbach A. Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery. AmericanHeart Journal. 2012;164(6):918-924. doi:10.1016/j.ahj.2012.09.004 https://pubmed.ncbi.nlm.nih.gov/23194493/ 2. Gialdini G, Nearing K, Bhave PD, et al.. Perioperative Atrial Fibrillation and the Long-term Risk ofIschemic Stroke. JAMA. 2014;312(6):616. doi:10.1001/jama.2014.9143 https://pubmed.ncbi.nlm.nih.gov/25117130/ 3. Snow V, Weiss KB, LeFevre M, McNamara R, Bass E, Green LA, Michl K, Owens DK, Susman J, Allen DI, Mottur-Pilson C; AAFP Panel on Atrial Fibrillation; ACP Panel on Atrial Fibrillation.Management of newly detected atrial fibrillation: a clinical practice guideline from the AmericanAcademy of Family Physicians and the American College of Physicians. Ann Intern Med. 2003 Dec16;139(12):1009-17. doi: 10.7326/0003-4819-139-12-200312160-00011. PMID: 14678921. https://pubmed.ncbi.nlm.nih.gov/14678921/ 4. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. NewEngland Journal of Medicine. 2002;347(23):1825-1833. doi:10.1056/nejmoa021328 https://pubmed.ncbi.nlm.nih.gov/12466506/ Learn more about our Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship course and preview a full chapter here: https://app.behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  DOMINATE THE DAY