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Double vision is a symptom often experienced by patients with neurologic disease. An organized systematic approach to evaluating patients with diplopia needs a foundational understanding of the neuroanatomy and examination of eye movements and ocular alignment. In this episode, Teshamae Monteith, MD, FAAN, speaks with Devin Mackay, MD, FAAN, author of the article “Approach to Diplopia” in the Continuum® April 2025 Neuro-ophthalmology issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Mackay is an associate professor of neurology, ophthalmology, and clinical neurosurgery at Indiana University School of Medicine in Indianapolis, Indiana. Additional Resources Read the article: Approach to Diplopia Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Monteith: This is Dr Teshamae Monteith. Today I'm interviewing Dr Devin Mackay about his article on approach to diplopia, which appears in the April 2025 Continuum issue on neuro-ophthalmology. Welcome to the podcast. How are you? Dr Mackay: Thank you. It's great to be here. Dr Monteith: Congratulations on your article. Dr Mackay: Thank you. I appreciate that. Dr Monteith: Why don't you start off with introducing yourself to our audience? Dr Mackay: So, yeah, my name is Devin Mackay. I'm a neuro-ophthalmologist at Indiana University. I did my residency at what was used to be known as the Partners Healthcare Program in Boston, and I did a fellowship in neuro-ophthalmology in Atlanta. And I've been in practice now for about ten years. Dr Monteith: Oh, wow. Okay. Tell us a little bit about your goals when you were writing the chapter. Dr Mackay: So, my goal with the approach to double vision was really to demystify double vision. I think double vision is something that as trainees, and even as faculty members and practicing neurologists, we really get intimidated by, I think. And it really helps to have a way to approach it that demystifies it and allows us to localize, just like we do with so many other problems in neurology. Dr Monteith: I love that, demystification. So why don't you tell us what got you interested in neuro-ophthalmology? Dr Mackay: Yeah, so neuro-ophthalmology I stumbled on during a rotation during residency. We rotated in different subspecialties of neurology and I did neuro-ophthalmology, and I was just amazed by the exam and how intricate it was, the value of neuroanatomy and localization, the ability to take a complicated problem and kind of approach it as a diagnostic specialist and really unravel the layers of it to make it better. To, you know, figure out what the problem is and make it better. Dr Monteith: Okay, so you had a calling, clearly. Dr Mackay: I sure did. Dr Monteith: You talked about latest developments in neuro-ophthalmology as it relates to diplopia. Why don't you share that with our listeners? Dr Mackay: Yeah. So, you know, double vision is something that's really been around since the beginning of time, essentially. So that part hasn't really changed a lot, but there are some changes that have happened in how we approach double vision. Probably one of the bigger ones has been, we used to teach that with a, you know, patient over the age of fifty with vascular risk factors who had a cranial nerve palsy of cranial nerves 3, 4, or 6, we used to automatically assume that was a microvascular palsy and we just wouldn't do any more testing and we'd just, you know, wait to see how they did. And it turns out we're missing some patients who have significant pathologies, sometimes, with that approach. And so, we've really shifted our teaching with that to emphasize that it's a lot easier to get an MRI, for example, than it ever has been. And it can be important to make sure we're not missing important pathology in patients, even if they have vascular risk factors over the age of fifty and they just have a cranial nerve 3, 4, or 6 palsy. So that's been one change. Dr Monteith: Interesting. And why don't you tell us a little bit about the essential points that you want to get across in the article? Dr Mackay: Yeah. So, I think one is to have a systematic approach to double vision. And a lot of that really revolves around localization. And it even begins with the history that we take from the patients. There's lots of interesting things we can ask about double vision from the patient. For example, the most important thing you can ever ask someone with double vision is, does it go away when you cover either eye? And that really helps us figure out the first question for us as neurologists, which is, is it neurologic or non-neurologic? If it's still there when covering one eye, then it is not neurologic and that's usually a problem for an ophthalmologist to sort out. So that's really number one. And then if it is binocular double vision, then we get into details about, is it horizontal or vertical misalignment? Is it- what makes it better and worse? Is there an associated ptosis or other symptoms? And based on all of that, we can really localize the abnormality with the double vision and get into details about further testing if needed, and so forth. I also love that that approach really reduces our need to rely on things like neuroimaging sometimes when we may not need it, or on other tests. So, I think it really helps us be more efficient and really take better care of patients. Dr Monteith: So definitely that cover/uncover test, top thing there. Your approach- and you mentioned, are you really getting that history, and are there any other kind of key factors when you're approaching diplopia before getting into some of the details? Dr Mackay: Yeah, that's a good question. I think also having some basics of how to examine the patient, because double vision is such a challenging thing. A lot of us aren't as familiar with the exam toolkit, so to speak, of what you would do with a patient with double vision. And so, I go over in the article a bit about a Maddox rod, which is a handy little tool that I always keep in my pocket of my lab coat. It allows you to assign a red line to one eye and a light to the other eye, and you can see if the eyes line up or not. And you don't need any other special equipment, you just need the light in that Maddox rod. That really helps us understand a lot about the pattern of misalignment, which is really important for evaluating double vision. So, for example, if someone has a right 6th nerve palsy, I'll expect a horizontal misalignment of the eyes that worsens when the patient looks to the right and improves when they look to the left. And especially if it's a partial palsy, it's not always easy to see that just by looking at their eye movements. And having a way to really measure the eye alignment and figure out, is it worse or better in certain directions, is really essential to localization, I think, in a lot of cases. Dr Monteith: You caught me. I skipped over that Maddox rod part, even though you spent a lot of time talking about Maddox rods. Kind of skipped over it. So, you're saying that I need one. Dr Mackay: Everyone needs one. I've converted some of our residents here to carry one with them. And yeah, I realize it's a daunting tool at first, but when you have a patient with double vision and their eye movements look normal, I feel like a lot of neurologists are- kind of, their hands seem like they're tied and they're like, oh, I don't know, I don't know what to do at this point. And if you can get some more details with a simple object like that, it can really change things. Dr Monteith: So, we've got to talk to the AAN store and make sure that they have enough of these, because now there's going to be lots of… Dr Mackay: We're going to sell out on Amazon today now because of this podcast. Dr Monteith: Cyber Monday. So, let's talk about the H pattern. And I didn't know it had the- well, yeah, I guess the official name is “H pattern.” In medical school, I mean, that's what I learned. But as a resident and, you know, certainly as an attendee, I see people doing all sorts of things. You're pro-H pattern, but are there other patterns that you also respect? Dr Mackay: It depends on what you're looking for, I think. The reason I like the H pattern is because you get to look at upgaze and downgaze in two different directions. So, you get to look at upgaze and downgaze when looking to the left, and up- and downgaze when looking to the right. And the reason that matters is because vertical movements of the eyes are actually controlled by different eye muscles depending on whether the eye is adducted toward the nose or abducted away from the nose. And so that's why I love the H pattern, is because it allows you to see that. If you just have them look up and down with just a cross pattern, for example, then you really lose that specificity of looking at both the adduction and abduction aspects. So, it's not wrong to do it another way with, like, the cross, for example, but I just think there are some cases where we'll be missing some information, and sometimes that can actually make a difference. Dr Monteith: Well, there you have it. Let's talk a little bit about eliciting diplopia during the neurologic exam. What other things should we be looking out for? Dr Mackay: So, in terms of eliciting diplopia, it really starts with the exam and again, figuring out, are we covering one eye? And figuring out, is this patient still having double vision? It's tricky because sometimes the patients won't even know the answer to that question or they've never done it, they've never covered one eye. And so, if that's the case, I really make them do it in the office with me and it's like, okay, well, are we having double vision right now? Well, great, okay, we are, then we're going to figure this out right now. And we cover one eye and say, is it still double? And that way we can really figure out, are we monocular or binocular? That's always step one. And then if we've established that it's binocular diplopia, then that's when we get into the other details that I mentioned before. And then as far as other things to look for, we're always in tune to other things that are going on in terms of symptoms, like ptosis, or if there's bulbar weakness, or some sensory change or motor problem that seems to be associated with it. Obviously, those will give us clues in the localization as well. Dr Monteith: And what about ocular malalignment? Dr Mackay: Yeah. So ocular malalignment, really, the cardinal symptom of that is going to be double vision. And so, if a patient has a misalignment of the eyes and they don't have double vision, then usually that means either we're wrong and they don't have double vision, or they do have double vision and they, you know, haven't said it correctly. Or it could be that the vision is poor in one eye. Sometimes that can happen. Or, some patients were actually born with an eye misalignment and their brain has learned in a way to kind of tune out or not allow the proper development of vision in one eye. And so that's also known as amblyopia, also known as the lazy eye, some people call it. But that finding can also make someone not experience double vision. But otherwise, if someone's had normal vision kind of throughout their life, they'll usually be pretty aware of when they first notice double vision. It'll be an obvious event for them in in most cases. Dr Monteith: And then the Cogan lid twitch? Dr Mackay: Oh yes, the Cogan lid twitch. So, the Cogan lid twitch is a feature of myasthenia gravis. The way you elicit it is, you have the patient look down. I'm not sure there's a standardization for how long; you want to have it long enough that you're resting the levator muscle, which is the muscle that pulls the upper lid open. And so, you rest that by having them look down for… I usually do about ten or fifteen seconds. And then I have them look up to looking straight forward. And you want to pay careful attention to their lid position as their eye settles in that straight-forward position. What will happen with a Cogan's lid twitch is, the lid will overshoot, and then it'll come back down and settle into its, kind of, proper position. And what we think is happening there is, it's almost like a little mini “rest test” in a way, where you're resting that muscle just long enough to allow some of the neurotransmission to recover. You get a normal contraction of the muscle, but it fades very quickly and comes back down. And that's experienced as a twitch. Dr Monteith: So, the patient can feel it. And it's something you can see? Dr Mackay: Yeah, the patient may not feel it as much. It's usually it's going to be something that the clinician can see if they're looking for it. And I would say that's one of the physical exam findings that can be a hallmark of myasthenia gravis, but certainly not the only one. Some others that we often look for are fatigable ptosis with sustained upgaze. You have the patient look up for a prolonged time and you'll see the lid droop down. So that can be one. Ice pack test is very popular nowadays, and it has pretty good sensitivity and specificity for myasthenia. So, you keep an ice pack over the closed eyes for two minutes and you compare the lid position before and after the ice pack test. And in the vast majority of myasthenia patients, if they have ptosis, the ptosis will have resolved, or at least significantly improved, in those patients. And yet one more sign is, if you find the patient's eye with ptosis and you lift open the eye manually, you'll often see that the other eyelid and the other eye will lower down. So, I'm not sure there's a name for that, but that can be a helpful sign as well. Dr Monteith: Since you're going through some of these, kind of, key features of different neurologic disease, why don't you tell us about a few others? Dr Mackay: Yeah, so another I mentioned in the in the article is measurement of levator function, which is really a test of eyelid strength. And so, that can be helpful if we have- someone has ptosis, or we're not sure if they have ptosis and we're trying to evaluate that to see if it's linked to the double vision, because that really changes the differential if ptosis is part of the clinical situation. So, the way that's measured is you have a patient look down as far as they can. And you get out a little ruler---I usually use a millimeter ruler---and I set the zero of the ruler at the upper lid margin when they're looking down. So, I hold the ruler there, and then I ask the patient to look up as far as they can without moving their head. Where the lid position stops of the upper lid is the new point on the ruler. And so, you measure that and see how much that is. And so, a normal patient may have a value somewhere between, I don't know, twelve or thirteen millimeters up to seventeen or eighteen millimeters, probably, in most cases. Especially if there is an asymmetric lid position, if you find that the levator function is symmetric, then it tells you that the muscle is working fine and that the ptosis is not from the muscle. So then the ptosis may be from dehiscence of the lid margin from the muscle. And so, that's a really common cause of ptosis, and that's often age-related or trauma-related. And we can dismiss that as being part of the symptom constellation of double vision. So, it can be really helpful to clarify, is this a muscle problem, which you'd expect with myasthenia or a third nerve palsy, or is this a mechanical problem with the lid, which is non-neurologic and really should be dismissed? So that can be a really helpful exam tool. Dr Monteith: So, you're just now getting into a little localization. So why don't we kind of start from the most proximal pistol with localization. Give us a little bit of tips. I know they just got to read your article, but give us a few tips. Dr Mackay: So, in terms of most proximal causes, there are supranuclear causes of ocular misalignment. For example, a skew deviation would qualify as that. Anything that's happening from some deficient input before you get to the cranial nerve nuclei, that we would consider supranuclear. So, we also see that with things like progressive supranuclear policy and certain other conditions. And then there can be lesions of the cranial nerve nuclei themselves. So, cranial nerves 3, 4, and 6 all have nuclei, and if they're lesioned they will cause double vision in specific patterns. And then there's also another subgroup, which is known as intranuclear problems with eye alignment. And so, the most common of that is going to be intranuclear ophthalmoplegia. And so that's very common in patients with demyelinating disorders, or it can also happen with strokes and tumors and other causes. And then there's infranuclear problems, which are from the cranial nerve nuclei out, and so those would be the cranial nerves themselves. So that's where your microvascular palsies, any tumor pressing on the nerve in those locations can cause palsies like that, any inflammatory disorder along that course. Then as we get more distal, we get into the orbit, we have the neuromuscular junction---so, the connection between the nerve and the muscle. And of course, that's our myasthenia gravis. And there are rare causes, things like botulinum and tick borne illnesses and certain other things that are more rare. And then, of course, we get to the muscle itself, and there can be different muscular dystrophies, different things like myositis or inflammatory disorders of the orbit or even physical trauma. So, if a patient, you know, had a trauma in trapping an extraocular muscle, that can be a localization. So really, anywhere along that pathway you can have double vision. So, I love to approach it from that perspective to help narrow down the diagnostic possibilities. Dr Monteith: Okay, just like everything? Dr Mackay: Just like all of the rest of the neurology. See, it's not that scary. Dr Monteith: You know, and so, yeah. And then you do a lot more than, you know, a few cranial nerves, right? Dr Mackay: Right. That's right. There's a lot more to double vision than that. I think as neurologists, we get lost if it's not a cranial nerve palsy, we're like, oh, I don't know what this is. And if it's not myasthenia, not a cranial nerve palsy. But it's worth also considering that there are ophthalmologic causes of someone having double vision that we often don't consider. So maybe someone who was born with strabismus, or maybe they have a little bit of a tendency toward an eye misalignment that their brain compensates, for and then it decompensates someday and that now they have a little bit of double vision intermittently, so that those can be causes to consider as well. Dr Monteith: Yeah, well, we'll just have to, you know, request those records from forty years ago. No problem. Dr Mackay: That's right. Dr Monteith: Why don't you also give us a little bit of tip when we're on the wards and we want to teach either a medical student or a resident, or if it's a resident listening, may want to teach a junior resident and seem like a star when approaching a patient with diplopia. Give us some teaching pearls. Dr Mackay: Yeah. So, I would love people teaching more about this at the bedside. I'd say probably the first thing to do would be to equip yourself by recognizing what some of the pertinent questions are to ask someone with double vision. Those things would include, is the double vision worse when looking in a certain direction? Does the double vision go away or not when you cover one eye? What happens when you tilt your head one direction or the other? Is it intermittent or constant? What makes it better? What makes it worse? Those kinds of things can really help us narrow down the possibilities. And then the other thing would be to equip yourself with some tools for examining. And it doesn't have to be physical tools. These can actually be things like, you mentioned the cross-cover test or cover/uncover test. That's described in the article. And I think knowing how to do that properly, knowing how to examine the eye movements properly and how to check for subtle things like a subtle intranuclear ophthalmoplegia, which is also mentioned in the article, being familiar with those things can be a really useful exercise in allowing you to teach others later on. Dr Monteith: Cool. Why don't you tell us about some of the things you're most excited about in the field? Dr Mackay: One of the things about our subspecialty for so long is we really haven't had big data with, you know, big trials and all these things that all the stroke people have. And that's starting to change slowly. There's been, for example, the idiopathic intracranial hypertension treatment trial that was published back in, I think it was 2014. You know, of course we had the optic neuritis treatment trial, back a few decades ago now. Some of the exciting ones coming up, there's going to be a randomized controlled trial looking at different treatments for idiopathic intracranial hypertension that are surgically based. So, for example, comparing venous sinus stenting with optic nerve sheath fenestration. And so, figuring out, is there a best practice for surgical intervention for patients with IIH? So, we're starting to have more trials like that now than I think we've had in the past. And so, it's exciting to get to have an evidence base for some of the things that we recommend and do. Dr Monteith: And what about some of the treatment for diplopia? Like prisms, and where are we with some of that? Dr Mackay: Yeah, great. So, it's a pretty simple concept, but still kind of difficult in practice. I kind of say there are four different ways to treat double vision: you can ignore it, you can patch or cover one eye, you can treat with prisms, and you can treat with eye muscle surgery. And so, those are the main ways other than, of course, treating the underlying disorder if there's a disorder causing double vision. So those are the main ways to treat. In terms of knowing if someone's going to be a candidate for prism therapy, we also have to remember that prisms are really going to be most helpful for when someone's looking straight forward. So, we need to make sure that their double vision is happening when they look straight forward. So, for example, if they're only having double vision looking to the left or to the right, that patient may not benefit from prisms as much as someone who is having double vision when they look straight forward. So that's one thing I look for. And then strabismus surgery is something to be considered if someone is not tolerating prisms and they're not helping and their eye alignment is stable. So, if you think about it, if someone's eye alignment is changing a lot, you're probably not going to want to do surgery for that patient because it's going to keep changing after surgery. And so, if someone's eye alignment is stable for six months or more and they're not getting the benefit they'd like from prisms, then maybe referral to a strabismus surgeon might be something to consider. Dr Monteith: Great. And then, I guess another question is just popping up in my head selfishly. What are your thoughts about patients that get referrals for exercises? Say they have, like, a convergence efficiency or something causing diplopia, maybe after a concussion. Maybe there's not a lot of evidence, but what is your take on exercising? Dr Mackay: Yeah, excellent question. So, there actually is evidence for exercises for convergence insufficiency. So, we know that those do work. Now where exercises are probably not as helpful, or at least not- there isn't an evidence base for them, is really with just about every other kind of eye misalignment in adults. We hear a lot about eye movement therapies for concussion and barely any other acquired misalignment of the eyes as well. And really, the evidence really hasn't shown us that that's helpful; again, with the exception being convergence insufficiency. So, we know that an office-based vision therapy type program for convergence insufficiency does work, but of course it's kind of inconvenient. It can cost money that may or may not be covered by insurance. And so, there are difficulties even with doing that. And so, I often recommend that patients with convergence insufficiency at least try something called pencil push-ups, where they take a pencil at arm's length and they bring it in and exercise that convergence ability. You know, that's a cheap, easy way to try to treat that initially. So yeah, there can be some limited utility for eye muscle exercises in certain conditions. Dr Monteith: My one example. I was- it was fuzzy, but in a different way. So, what do you do for fun? I mean, it sounds like you like to see a lot of eyeballs? Dr Mackay: I do. I like to see a lot of eyeballs. Dr Monteith: When you're not doing these things, what do you do for fun? Dr Mackay: So, people ask me what my hobbies are, and I laugh because my hobby is actually raising children. Dr Monteith: Oh, okay! Dr Mackay: So, my wife and I have eight kids- Dr Monteith: Oh, wow! Dr Mackay: Ages three to thirteen. So, kind of doesn't allow me to have other things right now. I'm sure I'll have more hobbies later on, but no, I really love my kids. And I- they give me plenty to do. There's no shortage of- in fact, they were really, they were really excited about this podcast today. They're so excited that Dad gets to be on a podcast, and so I'm going to have to show this to them later. They're going to be thrilled about it. Dr Monteith: Excellent. Well, thank you so much for being on the podcast. Dr Mackay: Thank you. It's been my pleasure. Dr Monteith: Again, today I've been interviewing Dr Devin Mackay about his article on approach to diplopia, which appears in the most recent issue of Continuum on neuro-ophthalmology. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Papilledema describes optic disc swelling (usually bilateral) arising from raised intracranial pressure. Due to its serious nature, there is a fear of underdiagnosis; hence, one major stumbling points is correct identification, which typically requires a thorough ocular examination including visual field testing. In this episode, Kait Nevel, MD speaks with Susan P. Mollan, MBChB, PhD, FRCOphth, author of the article “Papilledema” in the Continuum® April 2025 Neuro-ophthalmology issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Mollan is a professor and neuro-ophthalmology consultant at University Hospitals Birmingham in Birmingham, United Kingdom. Additional Resources Read the article: Papilledema Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @DrMollan Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Nevel: Hello, this is Dr Kait Nevel. Today I'm interviewing Dr Susan Mollan about her article Papilledema Diagnosis and Management, which appears in the April 2025 Continuum issue on neuro-ophthalmology. Susie, welcome to the podcast, and please introduce yourself to our audience. Dr Mollan: Thank you so much, Kait. It's a pleasure to be here today. I'm Susie Mollan, I'm a consultant neuro-ophthalmologist, and I work at University Hospitals Birmingham- and that's in England. Dr Nevel: Wonderful. So glad to be talking to you today about your article. To start us off, can you please share with us what you think is the most important takeaway from your article for the practicing neurologist? Dr Mollan: I think really the most important thing is about examining the fundus and actually trying to visualize the optic nerves. Because as neurologists, you're really acutely trained in examining the cranial nerves, and often people shy away from looking at the eyes. And it can give people such confidence when they're able to really work out straightaway whether there's going to be a problem or there's not going to be a problem with papilledema. And I guess maybe a little bit later on we can talk about the article and tips and tricks for looking at the fundus. But I think that would be my most important thing to take away. Dr Nevel: I'm so glad that you started with that because, you know, that's something that I find with trainees in general, that they often find one of the more daunting or challenging aspects of learning, really, how to do an excellent neurological exam is examining the fundus and feeling confident in diagnosing papilledema. What kind of advice do you give to trainees learning this skill? Dr Mollan: So, it really is practice and always carrying your ophthalmoscope with you. There's lots of different devices that people can choose to buy. But really, if you have a direct ophthalmoscope, get it out in the ward, get it out in clinic. Look at those patients that you'd know have alternative diagnosis, but it gives you that practice. I also invite everybody to come to the eye clinic because we have dilated patients there all the time. We have diabetic retinopathy clinics, and it makes it really easy to start to acquire those skills because I think it's very tricky, because you're getting a highly magnified view of the optic nerve and you've got to sort out in your head what you're actually looking at. I think it's practice. and then use every opportunity to really look at the fundus, and then ask your ophthalmology colleagues whether you can go to clinic. Dr Nevel: Wonderful advice. What do you think is most challenging about the evaluation of papilledema and why? Dr Mollan: I think there are many different aspects that are challenging, and these patients come from lots of different areas. They can come from the family doctor, they can come from an optician or another specialist. A lot of them can have headache. And, as you know, headache is almost ubiquitous in the population. So, trying to pull out the sort of salient symptoms that can go across so many different conditions. There's nothing that's pathognomonic for papilledema other than looking at the optic nerves. So, I think it's difficult because the presentation can be difficult. The actual history can be challenging. There are those rare patients that don't have headache, don't have pulsatile tinnitus, but can still have papilledema. So, I think it- the most challenging thing is actually confirming papilledema. And if you're not able to confirm it, getting that person to somebody who's able to help and confirm or refute papilledema is the most important thing. Dr Nevel: Yeah, right. Because you talk in your article the importance of distinguishing between papilledema and some other diagnoses that can look like papilledema but aren't papilledema. Can you talk about that a little bit? Dr Mollan: Absolutely. I think in the article it's quite nice because we were able to spend a bit of time on a big table going through all the pseudopapilledema diagnoses. So that includes people with shortsightedness, longsightedness, people with optic nerve head drusen. And we've been very fortunate in ophthalmology that we now have 3D imaging of the optic nerve. So, it makes it quite clear to us, when it's pseudopapilledema, it's almost unfair when you're using the direct ophthalmoscope that you don't get a cross sectional image through that optic nerve. So, I'd really sort of recommend people to delve into the article and look at that table because it nicely picks out how you could pick up pseudopapilledema versus papilledema. Dr Nevel: Perfect. In your article, you also talk about what's important to think about in terms of causes of papilledema and what to evaluate for. Can you tell us, you know, when you see someone who you diagnose with papilledema, what do you kind of run through in terms of diagnostic tests and things that you want to make sure you're evaluating for or not missing? Dr Mollan: Yeah. So, I think the first thing is, is once it's confirmed, is making sure it's isolated or whether there's any additional cranial nerve palsies. So that might be particularly important in terms of double vision and a sixth nerve palsy, but also not forgetting things like corneal sensation in the rest of the cranial nerves. I then make sure that we have a blood pressure. And that sounds a bit ridiculous in this day and age because everybody should have a blood pressure coming to clinic or into the emergency room. But sometimes it's overlooked in the panic of thinking, gosh, I need to investigate this person. And if you find that somebody does have malignant hypertension, often what we do is we kind of stop the investigational pathway and go down the route of getting the medics involved to help with lowering the blood pressure to a safe level. I would then always think about my next thing in terms of taking some bloods. I like to rule out anemia because anemia can coexist in a lot of different conditions of raised endocranial pressure. And so, taking some simple blood such as a complete blood count, checking the kidney function, I think is important in that investigational pathway. But you're not really going to stop there. You're going to move on to neuroimaging. It doesn't really matter what you do, whether you do a CT or an MRI, it's just getting that imaging pretty much on the same day as you see the patient. And the key point to that imaging is to do venography. And you want to rule out a venous sinus thrombosis cause that's the one thing that is really going to cause the patient a lot of morbidity. Once your neuroimaging is secure and you're happy, there's no structural lesion or a thrombosis, it's then reviewing that imaging to make sure it's safe to proceed with lumbar puncture. And so, we would recommend the lumbar puncture in the left lateral decubitus position and allowing the patient to be as calm and relaxed as possible to be able to get that accurate opening pressure. Once we get that, we can send the CSF for contents, looking for- making sure they don't have any signs of meningitis or raised protein. And then, really, we're at that point of saying, you know, we should have a secure diagnosis, whether it would be a structural lesion, venous sinus thrombosis, or idiopathic intracranial hypertension. Dr Nevel: Wonderful. Thank you for that really nice overview and, kind of, diagnostic pathway and stepwise thought process in the evaluations that we do. There are several different treatments for papilledema that you go through in your article, ranging from surgical to medication options. When we're taking care of an individual patient, what factors do you use to help guide you in this decision-making process of what treatment is best for the patient and how urgent treatment is? Dr Mollan: I think that's a really important question because there's two things to consider here. One is, what is the underlying diagnosis? Which, hopefully, through the investigational save, you'll have been able to achieve a secure diagnosis. But going along that investigational pathway, which determines the urgency of treatment, is, what's happening with the vision? If we have somebody where we're noting that the vision is affected- and normally it's actually through a formal visual field. And that's really challenging for lots of people to get in the emergency situation because syndromes of raised endocranial pressure often don't cause problems with the visual acuity or the color vision until it's very late. And also, you won't necessarily get a relative afferent papillary defect because often it's bilateral. So I really worry if any of those signs are there in somebody that may have papilledema. And so, a lot rests on that visual field. Now, we're quite good at doing confrontational visual fields, but I would say that most neurologists should be carrying pins to be able to look at the visual fields rather than just pointing fingers and quadrants if you're not able to get a formal visual field early. It's from that I would then determine if the vision is affected, I need to step up what I'm going to do. So, I think the sort of next thing to think about is that sort of vision. So, if we have somebody who, you know, you define as have severe sight loss at the point that you're going through this investigational pathway, you need to get an ophthalmologist or a neuro-ophthalmologist on board to help discuss either the surgery teams as to whether you need to be heading towards an intervention. And there are a number of different types of intervention. And the reason why we discuss it in the article---and we'll also be discussing it in a future issue of Continuum---is there's not high-class evidence to suggest one surgery over another surgery. We may touch on this later. So, we've got our patients with severe visual loss who we need to do something immediately. We may have people where the papilledema is moderate, but the vision isn't particularly affected. They may just have an enlarged blind spot. For those patients, I think we definitely need to be thinking about medical therapy and talking to them about what the underlying cause is. And the commonest medicine to use for raised endocranial pressure in this setting is acetazolamide, a carbonic anhydrous inhibitor. And I think that should be started at the point that you believe somebody has moderate papilledema, with a lot of discussion around the side effects of the medicine that we go into the article and also the fact that a lot of our patients find acetazolamide in an escalating dose challenging. There are some patients with very mild papilledema and no visual change where I might say, hey, I don't think we need to start treatment immediately, but you need to see somebody who understands your disease to talk to you about what's going on. And generally, I would try and get somebody out of the emergency investigational pathway and into a formal clinic as soon as possible. Dr Nevel: Thank you so much for that. One thing that I was wondering that we see clinically is you get a consult for a patient, maybe, who had an isolated episode of vertigo, back to their normal self, completely resolved… but incidentally, somebody ordered an MRI. And that MRI, in the report, it says partially empty sella, slight flattening of the posterior globe, concerns for increased intracranial pressure. What should we be doing with these patients who, you know, normal neurological exam, maybe we can't detect any definite papilledema on our endoscopic exam. What do you think the appropriate pathway is for those patients? Dr Mollan: I think it's really important. The more neuroimaging that we're doing, we're sort of seeing more people with signs that are we don't believe are normal. So, you've mentioned a few, the sort of partially empty sella, empty sella, tortuosity of the optic nerves, flattening of the globes, changes in transverse sinus. And we have quite a nice, again, table in the article that talks about these signs. But they have really low sensitivity for a diagnosis of raised endocranial pressure and isolation. And so, I think it's about understanding the context of which the neuroimaging has been taken, taking a history and going back and visiting that to make sure that they don't have escalating headache. And also, as you said, rechecking the eye nerves to make sure there's no papilledema. I think if you have a good examination with the direct ophthalmoscope and you determine that there's no papilledema, I would be confident to say there's no papilledema. So, I don't think they need to necessarily cry doubt. The ophthalmology offices, we certainly are having quite a few additional referrals, particularly for this, which we kind of called IIH-RAD, where patients are coming to us for this exclusion. And I think, in the intervening time, patients can get very anxious about having a sort of MRI artifact picked up that may necessarily mean a different diagnosis. So, I guess it's a little bit about reassurance, making sure we've taken the appropriate history and performed the examination. And then knowing that actually it's really a number of different signs that you need to be able to confidently diagnose raised ICP, and also the understanding that sometimes when people have these signs, if the ICP reduces, those signs remain. You know, we're learning an awful lot more about MRI imaging and what's normal, what's within normal limits. So, I think reassurance and sensible medical approach. Dr Nevel: Absolutely. In the section in your article on idiopathic intracranial hypertension, you spend a little bit of time talking about how important it is that we sensitively approach the topic of potential weight loss for those patients who are overweight. How do you approach that discussion in your clinic? Because I think it's an important part of the holistic patient care with that condition. Dr Mollan: I think this is one of the things that we've really listened to the patients about over the last number of years where we recognize that in an emergency situation, sometimes we can be quite quick to sort of say, hey, you have idiopathic endocranial hypertension and weight loss is, you know, the best treatment for the condition. And I think in those circumstances, it can be quite distressing to the patient because they feel that there's a lot of stigma attached around weight management. So, we worked with the patient group here at IIH UK to really come up with a way of a signposting to our patients that we have to be honest that there is a link, you know, a strong evidence that weight gain and body shape change can cause someone to fall into a diagnosis of IIH. And we know that weight loss is really effective with this condition. So, I think where I've learned from the patients is trying to use language that's less stigmatizing. I definitely signpost that I'm going to talk about something sensitive. So, I say I'm going to talk about something sensitive and I'm going to say, do you know that this condition is related to body shape change? And I know that if I listen to this podcast in a couple of years, I'm sure my words will have changed. And I think that's part of the process, is learning how to speak to people in an ever-changing language. And they think that sort of signpost that you're going to talk about something sensitive and you're going to talk about body shape change. And then follow up with, are you OK with me talking about this now? Is it something you want to talk about? And the vast majority of people say, yes, let's talk about it. There'll be a few people that don't want to talk about it. And I usually come in quite quickly, say, is it OK if I mention it at the next consultation? Because we have a duty of care to sort of inform our patients, but at the same time we need to take them on that journey to get them back to health, and they need to be really enlisted in that process. Dr Nevel: Yeah, I really appreciate that. These can be really difficult conversations and uncomfortable conversations to have that are really important. And you're right, we have a duty as medical providers to have these conversations or inform our patients, but the way that we approach it can really impact the way patients perceive not only their diagnosis, but the relationship that we have with our patients. And we always want that to be a positive relationship moving forward so that we can best serve our patients. Dr Mollan: I think the other thing as well is making sure that you've got good signposts to the professionals. And that's what I say, because people then say to me, well, you know, kind of what diet should I be on? What should I be doing? And I say, well, actually, I don't have professional experience with that. I'm, I'm very fortunate in my hospital, I'm able to send patients to the endocrine weight management service. I'm also able to send patients to the dietetic service. So, it's finding, really, what suits the patient. Also what's within licensing in your healthcare system to be able to provide. But not being too prescriptive, because when you spend time with weight management professionals, they'll tell you lots of different things about diets that people have championed and actually, in randomized controlled trials, they haven't been effective. I think it's that signpost really. Dr Nevel: Yeah, absolutely. So, could you talk a little bit about what's going on in research in papilledema or in this area, and what do you think is up-and-coming? Dr Mollan: I think there's so much going on. Mainly there's two parts of it. One is image analysis, and we've had some really fantastic work out of the Singapore group Bonsai looking at a machine learning decision support tool. When people take fundal pictures from a normal fundus camera, they're able to say with good certainty, is this papilledema, is this not papilledema? But more importantly, if you talk to the investigators, something that we can't tell when we look in is they're able to, with quite a high level of certainty, say, well, this is base occupying lesion, this is a venous sinus thrombosis, and this is IIH. And you know, I've looked at thousands and thousands of people's eyes and that I can't tell why that is. So, I think the area of research that is most exciting, that will help us all, is this idea about decision support tools. Where, in your emergency pathway, you're putting a fundal camera in that helps you be able to run the image, the retina, and also to try and work out possibly what's going on. I think that's where the future will go. I think we've got many sort of regulatory steps and validation and appropriate location of a learning to go on in that area. So, that's one side of the imaging. I think the other side that I'm really excited about, particularly with some of the work that we've been doing in Birmingham, is about treatment. The surgical treatments, as I talked about earlier… really, there's no high-class evidence. There's a number of different groups that have been trying to do randomized trials, looking at stenting versus shunting. They're so difficult to recruit to in terms of trials. And so, looking at other treatments that can reduce intracranial pressure. We published a small phase two study looking at exenatide, which is a glucagon-like peptide receptor agonist, and it showed in a small group of patients living with IIH that it could reduce the intracranial pressure two and a half hours, twenty-four hours, and also out to three months. And the reason why this is exciting is we would have a really good acute therapy---if it's proven in Phase III trials---for other diseases, so, traumatic brain injury where you have problems controlling ICP. And to be able to do that medically would be a huge breakthrough, I think, for patient care. Dr Nevel: Yeah, really exciting. Looking forward to seeing what comes in the future then. Wonderful. Well, thank you so much for chatting with me today about your article. I really enjoyed learning more from you during our conversation today and from your article, which I encourage all of our listeners to please read. Lots of good information in that article. So again, today I've been interviewing Dr Susie Mollan about her article Papilledema Diagnosis and Management, which appears in the most recent issue of Continuum on neuro-ophthalmology.Please be sure to check out Continuum episodes from this and other issues. And thank you to our listeners for joining us today. Thank you, Susie. Dr Mollan: Thank you so much. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Yep, you read that title correctly. This is a very different and super interesting chat with Dr. Bill about.. well, you read the title. So many interesting factors, considerations, research options, medical possibilities and stories to come out of this woman's fascinating superpower. Enjoy. **Bill Sullivan, Ph.D., is the author of 'Pleased to Meet Me: Genes, Germs, and the Curious Forces That Make Us Who We Are'. He is an award-winning professor at the Indiana University School of Medicine, where he studies genetics and infectious disease. He's also a much-loved regular on TYP.authorbillsullivan.comSee omnystudio.com/listener for privacy information.

Stand Up is a daily podcast that I book,host,edit, post and promote new episodes with brilliant guests every day. Please subscribe now for as little as 5$ and gain access to a community of over 700 awesome, curious, kind, funny, brilliant, generous souls Check out StandUpwithPete.com to learn more Dr. Aaron E. Carroll is President & CEO of AcademyHealth. A nationally recognized thought leader, science communicator, pediatrician, and health services researcher, he is a passionate advocate for the creation and use of evidence to improve health and health care for all.  Before joining AcademyHealth, Dr. Carroll was a Distinguished Professor of Pediatrics and Chief Health Officer at Indiana University, where he also served as Associate Dean for Research Mentoring and the director of the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University School of Medicine. He earned a B.A. in chemistry from Amherst College, an MD from the University of Pennsylvania School of Medicine, and an M.S. in health services from the University of Washington School of Public Health, where he was also a Robert Wood Johnson Clinical Scholar. Dr. Carroll's research focused on the study of information technology to improve pediatric care, decision analysis, and areas of health policy including cost-effectiveness of care and health care financing reform. He is the author of The Bad Food Bible and the co-author of three additional books on medical myths. In addition to having been a regular contributor to The New York Times and The Atlantic, he has written for many other major media outlets and is co-Editor-in-Chief at The Incidental Economist, an evidence-based health policy blog. He also has a popular YouTube channel and podcast called Healthcare Triage, where he talks about health research and health policy. Join us Thursday's at 8EST for our Weekly Happy Hour Hangout!  Pete on Blue Sky Pete on Threads Pete on Tik Tok Pete on YouTube  Pete on Twitter Pete On Instagram Pete Personal FB page Stand Up with Pete FB page All things Jon Carroll  Follow and Support Pete Coe Buy Ava's Art  Hire DJ Monzyk to build your website or help you with Marketing Gift a Subscription https://www.patreon.com/PeteDominick/gift

Dr. Misty Shields guides us through this great paper out on Cancer (ACS) on the TOP advances in Small Cell Lung Cancer. Small cell lung cancer (SCLC) remains a leading cause of cancer mortality, with its aggressive nature and frequent relapse leading to poor outcomes. In recent years, immunotherapy has provided some survival benefits, and in 2024, key breakthroughs have significantly improved patient outcomes. Notable advances include the use of consolidative durvalumab immunotherapy for limited-stage SCLC, new insights into timing immunotherapy with radiation, and promising treatments such as the bispecific T-cell engager tarlatamab and antibody-drug conjugates. Precision medicine approaches, like neuroendocrine subtyping, may guide future treatments, while advocacy efforts, such as the Small Cell SMASHERS group @SCLCSMASHERS , offer new support for patients with this historically stigmatized disease.​Misty Dawn Shields MD PhD (Presenter and first author) Department of Medicine, Division of Hematology/Oncology, Indiana University School of Medicine, Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA

Stand Up is a daily podcast that I book,host,edit, post and promote new episodes with brilliant guests every day. Please subscribe now for as little as 5$ and gain access to a community of over 700 awesome, curious, kind, funny, brilliant, generous souls Check out StandUpwithPete.com to learn more GET TICKETS TO PODJAM II In Vegas March 27-30 Confirmed Guests! Professor Eric Segall, Dr Aaron Carroll, Maura Quint, Tim Wise, JL Cauvin, Ophira Eisenberg, Christian Finnegan and The Ladies of The Hue will all join us!   Dr. Aaron E. Carroll is President & CEO of AcademyHealth. A nationally recognized thought leader, science communicator, pediatrician, and health services researcher, he is a passionate advocate for the creation and use of evidence to improve health and health care for all.  Before joining AcademyHealth, Dr. Carroll was a Distinguished Professor of Pediatrics and Chief Health Officer at Indiana University, where he also served as Associate Dean for Research Mentoring and the director of the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University School of Medicine. He earned a B.A. in chemistry from Amherst College, an MD from the University of Pennsylvania School of Medicine, and an M.S. in health services from the University of Washington School of Public Health, where he was also a Robert Wood Johnson Clinical Scholar. Dr. Carroll's research focused on the study of information technology to improve pediatric care, decision analysis, and areas of health policy including cost-effectiveness of care and health care financing reform. He is the author of The Bad Food Bible and the co-author of three additional books on medical myths. In addition to having been a regular contributor to The New York Times and The Atlantic, he has written for many other major media outlets and is co-Editor-in-Chief at The Incidental Economist, an evidence-based health policy blog. He also has a popular YouTube channel and podcast called Healthcare Triage, where he talks about health research and health policy. Join us Thursday's at 8EST for our Weekly Happy Hour Hangout!  Pete on Blue Sky Pete on Threads Pete on Tik Tok Pete on YouTube  Pete on Twitter Pete On Instagram Pete Personal FB page Stand Up with Pete FB page All things Jon Carroll  Follow and Support Pete Coe Buy Ava's Art  Hire DJ Monzyk to build your website or help you with Marketing Gift a Subscription https://www.patreon.com/PeteDominick/gift      

Nonepileptic events are prevalent and highly disabling, and multiple pathophysiologic mechanisms for these events have been proposed. Multidisciplinary care teams enable the efficient use of individual expertise at different treatment stages to address presentation, risk factors, and comorbidities.   In this episode, Kait Nevel, MD, speaks with Adriana C. Bermeo-Ovalle, MD, an author of the article “A Multidisciplinary Approach to Nonepileptic Events,” in the Continuum® February 2025 Epilepsy issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Bermeo-Ovalle is a professor and vice-chair for Faculty Affairs in the Department of Neurological Sciences at Rush University Medical Center in Chicago, Illinois. Additional Resources Read the article: A Multidisciplinary Approach to Nonepileptic Events Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Full episode transcript available here Dr. Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Nevel: Hello, this is Dr Kait Nevel. Today I'm interviewing Dr Adriana Bermeo about her article on a multidisciplinary approach to nonepileptic events, which she wrote with Dr Victor Petron. This article appears in the February 2025 Continuum issue on epilepsy. Welcome to the podcast, and please introduce yourself to our audience. Dr Bermeo-Ovalle: Hello Dr Neville, it's a pleasure to be here. Thank you very much for inviting me. My name is Adriana Bermeo and I'm an adult epileptologist at Rush University Medical Center in Chicago, and I am also the codirector of the NEST clinic, which is a treatment clinic for patients with nonepileptic seizures within our level four epilepsy center. Dr Nevel: Wonderful. Well, thank you so much for being here, and I can't wait to talk to you about your article and learn a little bit about NEST, maybe, during our conversation, and how you approach things. To start us off talking about your article today, could you share with us what you think is the most important takeaway from your article for the practicing neurologist? Dr Bermeo-Ovalle: Wonderful. There's some messages that I would like people to get from working with patients with functional neurologic disorders in general. The first one is that functional neurologic disorders are very common in presentation in the neurologic clinic, almost no matter what your practice of self-specialty care is. The second is that for people who treat patients primarily with seizures or epilepsy, they account for between 5 to 10% of our patients in the clinic, but about 30% of our patients in our epilepsy monitoring unit because the seizures typically do not respond to anti-seizure medication management. Also, that in order to diagnose them, you don't need to have a neuropsychological stress already be available for the patient or the clinician. And the most important thing is that there are available treatments for these patients and that there are options that we can offer them for them to have less seizures and to be more integrated to whatever activities they want to get integrated. Dr Nevel: Wonderful. What do you think a practicing neurologist might find surprising after reading your article? Dr Bermeo-Ovalle: I think still many neurologists feel very hopeless when they see patients with these conditions. They do not have very good answers right away for the patients, which is frustrating for the neurologist. And they don't think there's too much they can do to help them other than send them somewhere else, which is very difficult for the neurologist and is crushing to the patients to see these doctors that they're hoping to find answers to and then just find that there's not much to do. But what I want neurologists to know is that we are making strides in our understanding of the condition and that there are effective treatments available. And I hope that after reading this and engaging with this conversation, they will feel curious, even hopeful when they see the next patient in the clinic. Dr Nevel: Yeah, absolutely. I find the history of nonepileptic seizures really interesting and I enjoyed that part of your article. How has our understanding of nonepileptic seizures evolved over the centuries, and how does our current understanding of nonepileptic seizures inform the terminology that we use? Dr Bermeo-Ovalle: Yeah. The way we name things and the way we offer treatment goes along to how we understand things. So, the functional seizures and epileptic seizures were understood in ancient times as possession from the spirits or the demons or the gods, and then treatments were offered to those kind of influences and that continues to happen with functional seizures. So, we go through the era when this was thought to be a women-only condition that was stemming from their reproductive organs and then treatments accordingly were presented. And later on with Charcot and then Freud, they evolved to even conversion disorders, which is one understanding the most conversion disorders, which is one of the frameworks where this condition has been treated with psychotherapy, psychoanalytic psychotherapy. And in our current understanding, we understand functional neurologic disorders in general as a more like a connection, communication network disorder, between areas of the brain that modulate emotional processing and movement control. And therefore, our approach these days is much more geared towards rehabilitation. You know, I think that's the evolution of thinking in many different areas. And as we learn more, we will be acquiring more tools to help our patients. Dr Nevel: Yeah, great. Thanks so much for that answer. Just reading the historical information that you have in your article, you can imagine a lot of stigma with this diagnosis too over time, and that- I think that that's lessening. But I was wondering if you could talk about that a little bit. How do we approach that with our patients and loved ones, any stigma that they might feel or perceive from being diagnosed with nonepileptic seizures? Dr Bermeo-Ovalle: Thank you for asking that question. Stigma is actually an important problem even for people living with epilepsy. There's still a lot of misunderstanding of what epilepsy is and how it affects people, and that people living with epilepsy can live normal, healthy lives and do everything they want to do with appropriate treatment. And if a stigma is still a problem with epilepsy, it is a huge problem for patients living with functional neurologic symptoms in general, but particularly with functional seizures or nonepileptic seizures. Because the stigma in this population is even perpetuated by the very people who are supposed to help them: physicians, primary care doctors, emergency room doctors. Unfortunately, the new understanding of this condition has not gotten to everybody. And these patients are often even blamed for their symptoms and for the consequences of their symptoms and of their seizures in their family members, in their job environment, in their community. Living with that is really, really crushing, right? Even people talk about, a lot about malingering. They come back about secondary gain. I can tell you the patients I see with functional seizures gain nothing from having this condition. They lose, often, a lot. They lose employment, they lose ability to drive. They lose their agency and their ability to function normally in society. I do think that the fight- the fighting of stigma is one that we should do starting from within, starting from the healthcare community into our understanding of what these patients go through and what is causing their symptoms and what can we do to help them. So there's a lot of good work to be done. Dr Nevel: Absolutely. And it starts, like you said, with educating everybody more about nonepileptic seizures and why this happens. The neurobiology, neurophysiology of it that you outlined so nicely in your article, I'm going to encourage the listeners to look at Figure 1 and 4 for some really nice visualization of these really complex things that we're learning a lot about now. And so, if you don't mind for our listeners, kind of going over some of the neurobiology and neurophysiology of nonepileptic seizures and what we're learning about it. Dr Bermeo-Ovalle: Our understanding of the pathophysiology of functional neurologic seizure disorder is in its infancy at this point. The neurobiological processes that integrate emotional regulation and our responses to it, both to internal stimuli and to external stimuli and how they affect our ability to have control over our movement---it's actually amazing that we as neurologists know so little about these very complex processes that the brain do, right? And for many of us this is the reason why we're in neurology, right, to be at the forefront of this understanding of our brain. So, this is in that realm. It is interesting what we have learned, but it's amazing all that we have to learn. There is the clear relationship between risk factors. So, we know patients with functional neurologic symptom disorder and with functional seizures, particularly in many different places in the world with many different beliefs, relationship to their body, to their expression of their body, have this condition no matter how different they are. And also, we know that they have commonalities. For example, traumatic experiences that are usually either very strong traumatic experiences or very pervasive traumatic experiences or recurrent over time of different quality. So, we are in the process of understanding how these traumatic experiences actually inform brain connectivity and brain development that result in this lack of connections between brain areas and the expression of them, and that result in this kind of disorder. I wish I can tell you more about it or that I would understand more about it, but I am just grateful for the work that has been done so that we can understand more and therefore have more to offer to these patients and their families and their communities that are support. Dr Nevel: Yeah, absolutely. That's always the key, and just really exciting that we're starting to understand this better so that we can hopefully treat it better and inform our patients better---and ourselves. Can you talk to us a little bit about the multidisciplinary team approach and taking care of patients with nonepileptic seizures? Who's involved, what does best practice model look like? You have a clinic there, obviously; if you could share with us how your clinic runs in the multidisciplinary approach for care of these patients? Dr Bermeo-Ovalle: The usual experience of patients dealing with functional seizures, because this is a condition that has neurological symptoms and psychiatric symptoms, is that they go to the neurologist and the neurologist does not feel sufficiently able to manage all the psychiatric comorbidities of the condition. So, the patient is sent to psychiatry. The psychiatry really finds themselves very hopeless into handling seizures, which is definitely not their area of expertise, and these patients then being- “ping-ponging” from one to the other, or they are eventually sent to psychotherapy and the psychotherapist doesn't know what they're dealing with. So, we have found with- and we didn't come up with this. We had wonderful support from other institutions who have done- been doing this for a longer time. That bringing all of this specialty together and kind of situating ourselves around the patient so that we can communicate our questions and our discrepancies and our decision between who takes care of what without putting that burden on the patient is the best treatment not only for the patient, who finally feels welcome and not burden, but actually for the team. So that the psychiatrist and the neurologist support the psychotherapist who does the psychotherapy, rehabilitation, mind the program. And we also have the support and the involvement of neuropsychology. So, we have a psychiatrist, a neurologist, social worker, psychotherapist and neuropsychology colleagues. And together we look at the patient from everywhere and we support each other in the treatment of the patient, keeping the patient in the middle and the interest of the patient in the middle. And we have found that that approach has helped our patients the best, but more importantly, makes our job sustainable so that none of us is overburdened with one aspect of the care of the patient and we feel supported from the instances that is not our most comfortable area. So that is one model to do it. There's other models how to do it, but definitely the interdisciplinary care is the way to go so far for the care of patients with functional neurologic symptom disorders and with functional seizures or nonepileptic seizures in particular. Dr Nevel: Yeah, I can see that, that everybody brings their unique expertise and then doesn't feel like they're practicing outside their, like you said, comfort zone or scope of practice. In these clinics---or maybe this happens before the patient gets to this multidisciplinary team---when you've established a diagnosis of nonepileptic seizures, what's your personal approach or style in terms of how you communicate that with the patient and their loved ones? Dr Bermeo-Ovalle: It is important to bring this diagnosis in a positive term. You know, unfortunately the terminology question is still out and there's a lot of teams very invested into how to better characterize this condition and how to- being told that you don't have something is maybe not that satisfying for patients. So, we are still working on that, but we do deliver the diagnosis in positive terms. Like, this is what you have. It's a common condition. It's shared by this many other people in the world. It's a neuropsychiatric disorder and that's why we need the joint or collaborative care from neurology and psychiatry. We know the risk factors and these are the risk factors. You don't have to have all of them in order to have this condition. These are the reasons why we think this is the condition you have. There is coexisting epilepsy and functional seizures as well. We will explore that possibility and if we get to that conclusion, we will treat these two conditions independently and we- our team is able to treat both of them. And we give them the numbers of our own clinic and other similar clinics. And with that we hope that they will be able to get the seizures under better control and back to whatever is important to them. I tell my trainees and my patients that my goals of care for patients with functional seizures are the same as my patients with epileptic seizures, meaning less seizures, less disability, less medications, less side effects, less burden of the disease. And when we communicate it in that way, patients are very, very open and receptive. Dr Nevel: Right. What do you think is a mistake to avoid? I don't know if “mistake” is necessarily the right word, but what's something that we should avoid when evaluating or managing patients with nonepileptic seizures? What's something that you see sometimes, maybe, that you think, we should do that differently? Dr Bermeo-Ovalle: I think the opportunity of engaging with these patients is probably the hardest one. Because neurologists have the credibility, they have the relationship, they have- even if they don't have a multi-disciplinary team all sitting in one room, they probably have some of the pieces of this puzzle that they can bring together by collaborating. So, I think that missing the opportunity, telling the patient, this is not what I do or this is not something that belongs to me, you need to go to a mental health provider only, I think is the hardest one and the most disheartening for patients because our patients come to us just like all patients, with hopes and with some information to share with us so that we can help them make sense of it and have a better way forward. We as neurologists know very well that we don't have an answer to all our patients, and we don't offer zero seizures to any of our patients, right? We offer our collaborative work to understand what is going on and a commitment to walk in the right direction so that we are better every day. And I do think wholeheartedly that that is something that we can offer to patients with functional seizures almost in any environment. Dr Nevel: Yeah, absolutely. And using that multidisciplinary approach and being there with your patient, moving forward in a longitudinal fashion, I can see how that's so important. What do you find most challenging and what do you find most rewarding about caring for patients with nonepileptic seizures? Dr Bermeo-Ovalle: The thing that I find more challenging are the systemic barriers that the system still places. We discuss with the patients, what is the right time to go to the emergency room or not? Because the emergency room may be a triggering environment for patients with functional seizures and it may be a place where not everybody is necessarily attuned to have this conversation. Having said that, I never tell any of my patients not to go to the emergency room because I don't know what's happening with them. As a matter of fact, we're getting a lot of information on high mortality rates in patients with functional seizures, and it's not because of suicide and is probably not related to the seizure. Maybe this is---you know, this is speculation on my part---that is because they get to more severe conditions in other things that are not the functional seizures because they just experienced the healthcare system as very hostile because we are very in many instances. So, navigating that is a little bit difficult, and I try to tell them to have the doctors call me so that I can frame it in a different way and still be there for them. But I can tell you this clinic is the most rewarding clinic of all my clinical activities. And I love with all my heart being an epileptologist and seeing my patients with epilepsy. But the number of times my patients with functional seizures say, nobody had ever explained this to me, nobody had ever validated my experience in front of my family so that I'm not- like, feel guilty myself for having this episode, I can't tell you how many times. And obviously patients who come to the nonepileptic seizure clinic already know that they come to the nonepileptic seizure clinic, so that- you can say it's a selection of patients that are already educated in this condition to come to the clinic. But I would love everybody to know managing this population can be enormously, enormously satisfying and rewarding. Dr Nevel: Especially for, I imagine, patients who have been in and out of the ER, in and out of the hospital, or seen multiple providers and make their way to you. And you're able to explain it in a way that makes sense and hopefully reduces some of that stigma maybe that they have been feeling. Dr Bermeo-Ovalle: And along with that, iatrogenic interventions, unnecessary intubations, unnecessary ICUs; like, so much. And I think, I have no superpower to do that other than understanding this condition in a different way. And by I, I mean all the providers, because I'm not alone in this. There's many, many people doing excellent work in this state. And we just need to be more. Dr Nevel: Yeah, sure. Absolutely. So, on that note, what's next in research, or what do you think will be the next big thing? What's on the horizon in this area? Dr Bermeo-Ovalle: I think the community in the functional neurologic disorder community is really hopeful that more understanding into the neurobiology of this condition will bring more people over and more neurologists willing to take it on. There was an invitation from the NIH, I think, about four or five years ago to submit proposals for research in this area in particular. So, all of those studies must be ongoing. I'm much more a clinician than a researcher myself, but I am looking forward to what all of that is going to mean for our patients. And for- I think there's other opportunities in that further understanding of the clinical manifestations of many other conditions, and for our understanding of our relationship with our patients. I feel we are more attuned to align with a disease that, when the experience of the patient- and with a disease like this, a condition like this one, we have to engage with the personal experience of the patient. What I mean by that is that we are more likely to say,  I'm an epileptologist, I'm an MS doctor, you know, and we engage with that condition. This condition, like, just makes us engaging with the symptom and with the experience of the person. And I think that's a different frame that is real and rounded into the relationship with our patients. So, I think there's so much that we can learn that can change practice in the future. Dr Nevel: Yeah. And as your article, you know, outlines, and you've outlined today during our discussion, that- how important this is for the future, that we treat these patients and help them as much as we can, that comes with understanding the condition better, because wow, I was really surprised reading your article. The mortality associated with this, the healthcare costs, how many people it affects, was just very shocking to me. So, I mean, this is a really important topic, obviously, and something that we can continue to do better in. Wonderful. Well, thank you so much. It's been really great talking to you today. Dr Bermeo-Ovalle: Thank you, Katie, I appreciate it too. Dr Nevel: So again, today I've been interviewing Dr Adriana Bermeo about her article on a multidisciplinary approach to nonepileptic events, which she wrote with Dr Victor Petron. This article appears in the most recent issue of Continuum on epilepsy. Be sure to check out Continuum audio episodes from this and other issues. And thank you to our listeners for joining today.  Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

In this episode of My DPC Story, Dr. Rachel Trupe, Dr. Adam Henry, and Dr. Luke Pittman from Valiant Primary Care share their journey into the world of Direct Primary Care (DPC). These three physicians, all trained at Indiana University School of Medicine, transitioned from three separate conventional healthcare system residencies to open their DPC practice in Zionsville, Indiana, seeking more autonomy and a better work-life balance. The episode highlights their motivations, including burnout from high patient volumes and scheduling challenges in traditional settings. By forming a partnership, they have successfully established a practice that prioritizes patient relationships and personalized care. The doctors discuss the misconceptions they initially had about DPC, the importance of understanding the financial model, and their strategies for rapid growth without significant marketing expenses. They also emphasize the value of having supportive partners and a shared vision, which has been crucial to their success. The episode serves as inspiration for physicians considering the DPC model, offering insights into the potential benefits for both doctors and patients, and reinforcing the supportive nature of the DPC community. Join the conversation to learn about the transformative power of DPC in redefining patient care.HINT: Learn about Hint's best-in-class billing, membership management software, all-in-one EMR, direct care ecosystem and free educational resources and tools at hint.com/startupFREE MARKET MEDICAL ASSOCIATION (FMMA) 4/9-11/25: Use code MYDPCSTORY for $800 off your FMMA Annual Conference registration! -> SPRUCE HEALTH: NEW USERS get 20% off your SPRUCE HEALTH paid plan with code: MARYAL20Support the showBe A My DPC Story PATREON MEMBER! SPONSOR THE PODMy DPC Story VOICEMAIL! DPC SWAG!FACEBOOK * INSTAGRAM * LinkedIn * TWITTER * TIKTOK * YouTube

In today's episode of THE MENTORS RADIO, Host Dan Hesse talks with former U.S. Vice President Dan Quayle, Chairman of Cerberus Global Investments and a member of the Firm's senior leadership team. Prior to joining Cerberus in 1999, he served as the 44th Vice President of the United States of America to President George H. W. Bush from 1989 through 1993. In 1976, Vice President Quayle was elected to the U.S. House of Representatives and re-elected in 1978. In 1980, he was elected to the U.S. Senate and was the youngest Senator from Indiana. He was re-elected to the U.S. Senate in 1986. Following his vice presidency, former Vice President Quayle authored three books, including Standing Firm: A Vice-Presidential Memoir, which was on The New York Times' Best Seller List for 15 weeks. He was a distinguished visiting professor at Arizona State University's Thunderbird School of Global Management for two years. He was also active for many years on the lecture circuit in the United States and internationally. He has served on numerous boards of directors for both private and public entities as well as charities. Former Vice President Quayle graduated from DePauw University and the Indiana University School of Law (Indianapolis). LISTEN TO the radio broadcast live on iHeart Radio, or to “THE MENTORS RADIO” podcast any time, anywhere, on any podcast platform – subscribe here and don't miss an episode! SHOW NOTES: VP DAN QUAYLE: BIO: https://en.wikipedia.org/wiki/Dan_Quayle BOOKS: Standing Firm: Dan Quayle, by Dan Quayle The American Family: Discovering the Values That Make Us Strong, by Dan Quayle and Diane Medved, Ph.D. Worth Fighting For, by Dan Quayle MORE: https://www.bakerinstitute.org/event/beyond-ballot-conversation-dan-quayle 

The COVID pandemic has complicated everything from school to work to grocery shopping. The need to physically distance from people not in our homes has made it difficult to maintain friendships or causal relationships while being stuck at home with a significant other for months on end can make even the biggest house seem tiny. COVID's impact on relationships and sex is the focus of this episode of Stats and Stories with guest Debby Herbenick. Herbenick is a sex educator, sex advice columnist, author, research scientist, children's book author, blogger, television personality, professor, and human sexuality expert in the media. Dr. Herbenick is a professor at the Indiana University School of Public Health and was lead investigator of the National Survey of Sexual Health and Behavior.

Dr. Ashton-Lazaroae is a pediatrician who takes the issue of gender ideology and it's harms to children, families and communities very seriously.She was a panel speaker in October of last year at The Christian Post's seminar "Unmasking Gender Ideology" speaking on topics including:I'm super grateful to have her on "I'm Glad You Said That" today. Hope you can tune in.Dr. Ashton-Lazaroae has practiced general pediatrics since 1996. She received her medical degree from Indiana University School of Medicine and completed a general pediatrics residency at Vanderbilt University Children's Hospital. She is a member of the American Academy of Pediatrics, the Northern Virginia Pediatric Society and the Christian Medical and Dental Society. She recently joined the American College of Pediatricians and assisted with launching the Biological Integrity website. She was commissioned as a Colson Fellow in 2022, after completing a teaching practicum "Transgenderism: Unraveling the Confusion."Support the show

Dr. Armin Feldman's Pretrial Prelitigation Medical Legal Consulting Coaching Program will teach you to build your own nonclinical consulting business as a valued consultant to attorneys without doing med mal cases or expert witness work. Armin will teach you everything from business concepts to the medicine involved when launching your new consulting business during one year of unlimited coaching. For more information go to nonclinicalphysicians.com/mlconsulting/ Learn the business and management skills you need by enrolling in the University of Tennessee Physician Executive MBA program at nonclinicalphysicians.com/physicianmba. Get the FREE GUIDE to 10 Nonclinical Careers at nonclinicalphysicians.com/freeguide. Get a list of 70 nontraditional jobs at nonclinicalphysicians.com/70jobs.                                                                                                 =============== Dr. Megan Leivant received her medical degree from the Indiana University School of Medicine and training in internal medicine residency at McGaw Medical Center of Northwestern University. After practicing internal medicine for ten years, she transitioned to a medical director position for a life insurance company. She now works as VP and Medical Director with another firm. During today's interview, Megan shares what led her to change careers, how she landed her first life insurance job, and advice for others wanting to pursue this career. She lists resources for those wishing to learn more before pursuing a career in life insurance medicine and explains that board certification in the field is available. She also discusses the duties and lifestyle of a life insurance medical director, opportunities for advancement, and the differences between direct and reinsurance companies. Finally, she explains that the intellectual stimulation, ongoing learning, and application of medical knowledge keep her excited about working in this industry. You'll find links mentioned in the episode at nonclinicalphysicians.com/new-life-insurance-medicine-career/

GLP-1 drugs like Ozempic, Wegovy, and Mounjaro have opened doors for people to lose weight. Should everyone have the option to take it? Those arguing “yes” say obesity needs to be treated using every available tool, especially for people for whom diet, lifestyle changes, and exercise aren't enough. Those arguing “no” are concerned about its side effects and the risks if people don't take them as directed. Now we debate: should prescription weight loss drugs be available for all?    Arguing Yes: David Allison, Obesity Researcher; Dean and Distinguished Professor at the Indiana University School of Public Health-Bloomington  Arguing No: Stuart W. Flint, Associate Professor of the Psychology of Obesity at the University of Leeds    Emmy award-winning journalist John Donvan moderates  Learn more about your ad choices. Visit podcastchoices.com/adchoices

High phosphorus (hyperphosphatemia) is a common complication caused by chronic kidney disease. Join us for this NKF Live to learn more about why this happens and how to successfully manage high phosphorus in CKD. During this program, you will hear a kidney doctor, a clinical pharmacist, and a person living with high phosphorus discuss important information to know about when managing high phosphorus.   Dr. Jay Wish is Professor of Clinical Medicine at Indiana University School of Medicine in Indianapolis and Chief Medical Officer for Outpatient Dialysis at Indiana University Health.  He is past president of the National Forum of ESRD Networks, served on the Board of Directors of the Renal Physicians Association and the American Association of Kidney Patients and was the recipient of the latter's Visionary Award in 2005. He has over 150 articles, reviews, and book chapters published, particularly in the areas of ESRD quality oversight/improvement, accountability, anemia management and vascular access. Dr. Katie Cardone is an associate professor at Albany College of Pharmacy and Health Sciences in Albany, NY. She is a clinical pharmacist with a clinical practice and research program focused on improving care in patients with kidney disease in outpatient nephrology and dialysis. She co-led the publication of pharmacy practice standards for pharmacists caring for people with kidney disease. She is a member of the Board of Pharmacy Specialties Ambulatory Care Pharmacy Council and is a fellow of the National Kidney Foundation, the American Society of Nephrology, and the American College of Clinical Pharmacy. Quenton Turner Gee has been on in-center hemodialysis for about 2 years. He was diagnosed with Stage 4 CKD in 2020. After a battle with COVID-19, it quickly progressed to end-stage kidney disease. Since starting on dialysis, he's been advocating for mental health and policies improving access to transplants and kidney innovations.   Additional Resources: Phosphate Lowering Agents High Phosphorus Information NKF Peers   Do you have comments, questions, or suggestions? Email us at NKFpodcast@kidney.org. Also, make sure to rate and review us wherever you listen to podcasts.

Informal care partners are essential to the care of people living with dementia, but they often experience significant burden and receive minimal training, support, and resources. Multicomponent interventions can mitigate burden and other negative consequences of caregiving. In this episode, Gordon Smith, MD, FAAN speaks with Angelina J. Polsinelli, PhD, ABPP-CN, author of the article “Care Partner Burden and Support Services in Dementia” in the Continuum® December 2024 Dementia issue. Dr. Smith is a Continuum® Audio interviewer and professor and chair of neurology at Kenneth and Dianne Wright Distinguished Chair in Clinical and Translational Research at Virginia Commonwealth University in Richmond, Virginia. Dr. Polsinelli is an assistant professor of clinical neurology at the Indiana University School of Medicine in Indianapolis, Indiana. Additional Resources Read the article: Care Partner Burden and Support Services in Dementia Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @gordonsmithMD Full interview transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Smith: This is Dr Gordon Smith. Today, I've got the great pleasure of interviewing Dr Angelina Polsinelli about her article on care partner burden and support services in dementia. This article appears in the December 2024 Continuum issue, which is on dementia. Ange, welcome to the podcast. And maybe you can begin by just introducing yourself to our audience?  Dr Polsinelli: Yeah. Well, thank you for having me. I'm very excited to be here. I'm Ange Polsinelli. I'm a neuropsychologist at Indiana University School of Medicine, where I work in the Department of Neurology. I also work with the Longitudinal Early Onset Alzheimer's Disease study that's led by Liana Apostolova. And I also do some work with the Outreach, Recruitment and Engagement Core of the Indiana Alzheimer's Disease Research Center. This topic that we're going to talk about today is extremely near and dear to my heart. Dr Smith: Well, thanks for joining me. And of course, IU is a powerhouse for Alzheimer's and basketball, in that order. So, we're really excited to have you. I'd like to get right into it. I'll emphasize, we were chatting a little bit about this, Ange, before we started recording, that your topic today is so important for all of us. And I think, you know, this is a podcast that not only neurologists listen to, but students and, and I think increasingly members of the lay public. And this conversation is going to be very important for neurologists and our neurology learners. But I lost my grandmother to Alzheimer's disease. I lost my uncle just in the last week. So, this touches all of us. So, I'm really excited. And then with that in mind, I wanted to begin with a statistic that- you can correct me if I misunderstood it, but it really blew my mind. And that is across the world, as I understand it, care partners provide one hundred and thirty three billion hours of care for people living with dementia yearly, which is pretty staggering. But what's really amazing is that by 2030 that number is expected to go to one point four trillion hours, which I couldn't grab my mind around it. So, I figured I'd try and determine how many years of person work is that and if my math is right, that's almost a hundred and sixty million person years of worth caring for people with dementia yearly across the world. One, are those numbers right? Did I get it right? And then, assuming so, can you put a human face or experience to these numbers?  Dr Polsinelli: Yeah, unfortunately those numbers are correct. And with our increasing aging population across the world, that's why you're getting that, you know, exponential increase in care per hours, compounded by the fact that the majority of the caregiving that happens is not done by doctors, physicians, but it's done by these informal care partners, these family members, these friends, these siblings, children, who are providing these really important services and unfortunately not being trained to do this, doing it largely on their own in a lot of respect. But again, these are people who are loved ones of the person living with dementia. There are a variety of kinships, as I mentioned, siblings, children, spouses, friends; and all sorts of age ranges as well. A large majority of them being spouses, and then the second largest majority being children. So, kind of a sandwich generation of people who are caring for parents with Alzheimer's or dementia and then caring for children as well. Dr Smith: Yeah, I was actually struck by the statistic that a quarter of caregivers or so called sandwich caregivers; in other words, they're taking care of a parent and a child. But listen to what you said. But just to call it out, two-thirds of care partners are women, which is a striking statistic.  Dr Polsinelli: Absolutely. Women are not only more likely to have dementia, but they are also more likely to be the care partners of somebody who has dementia. And so, the research shows, too, that if you're a care partner, you're at higher risk of developing dementia yourself. So, there's a lot of risk for women when it comes to dementia, development of dementia, but also that the burden and the majority of care needs that are that are supported by women as well. Dr Smith: Right. And there's a lot to unpack in that observation, and maybe we can come back to that. But I wonder if you might talk to us a little bit about the risk of dementia in women caregivers. That's really striking. Is there any thought regarding mechanism for that? Why is that the case? Is it a shared risk factor? Is it cause and effect? What's the story?  Dr Polsinelli: So, there are - this is kind of a dissociable or different - kind of two aspects to this, this question. There's the fact that women are at higher risk for developing dementia in general. I think the researchers feel sort of out about why exactly that is. It's not just that women are at higher risk or more likely to develop dementia because they're living longer than men, but there's probably some hormonal aspects of their higher risk factor for dementia. But then there's the other aspect of it too, is that as caregivers, caregivers are at higher risk of developing dementia. And because caregivers tend to be women, that increases or compounds the risk for women as well. We know with caregiving, particularly with someone who's living with dementia, there's more risk of developing things like depression, high stress, health problems, psychological distress, and all of these things increase somebody 's risk for developing dementia as well. Dr Smith: So, I wonder if you might talk a little more, Ange, about what you mean by burden? I think we have in our mind what that is. But in reading your article, there's a lot of- a lot more to it than may meet the eye. Dr Polsinelli: Yeah, it is a more complicated, I guess, topic or terminology that's gone through several iterations over the course of doing research into burden. But when we think about burden, it's really a kind of a combination of both objective experiences and subjective experiences. And these objective, subjective experiences fall into the categories of physical burden, emotional burden, psychological burden. So, there's a lot of different areas of life in which someone can experience burden. But really, it's a combination of factors of both the objective experience, lived experience, and the person 's perception of that experience or what they're dealing with. I should also mention that it appears to be more of that subjective experience or that perception that people have of their objective experience of stressors or burden. That really does determine the person's response to that, if whether they actually perceive their lived experience as being burdensome.  Dr Smith: One of the things I found really interesting was the societal and cultural context surrounding this, that there are different cultural expectations and societal dynamics, both in the nature of the burden care partners may feel and how they're viewed. I wonder if you could talk about that? I think it's something that it would seem all of us need to be attuned to as we're working with our patients and their families.  Dr Polsinelli: Yeah, this is a topic we could talk for a very long time on. I will try and- I will try not to kind of provide too much of a, or too lengthy of a response. But what we know now is basically that our models of stress and burden that we have typically used or historically used do not incorporate a lot of factors of cultural identity of social and structural determinants of health factors. And so, what we understand now is that stress and the way that people perceive burden is influenced by so many other factors than just kind of an experience and a perception. Because that perception is influenced by so many factors, including, as you mentioned, cultural factors that include how society's familial expectations for us, cultural expectations for us, as well as what our resources are that are determined by, again, structural and social determinants of health, what our community resources are. They're just a lot of different factors that go into how somebody perceives their ability to cope with, again, this kind of life-altering diagnosis that their loved one has received and them being the person who is caring for them through that. Dr Smith: Your article actually goes through in some detail the types of burdens and what drives the burden. And that changes over time. And so I wonder if maybe you can talk a little bit about what the specific natures of the burden are from the caregiver perspective. I mean, what  sort of tasks there are, you know, from the many of us who take care of patients, we still don't know unless we've been in the room or in the home watching this happen. So maybe you can describe that for those of our listeners who maybe haven't lived through this?  Dr Polsinelli: Yeah, absolutely. I will say upfront that the caregiving experience is going to be different for every single person. And again, kind of dependent on some of those factors that I mentioned before. So, it's going to look different for most people. It's also going to look different through the dementia journeys. The experiences and the requirements earlier on in dementia are going to be a vastly different than what occurs later on when dementia is in the more late stage, moderate or severe stages of the disease. Those care responsibilities absolutely change over the spectrum of that time as well. We know that early on the stage of disease, primary care partner might be spending forty plus hours a day. So, a full-time- or not a day. I'm sorry, a week. So, a full time job carrying it. But that number increases up to a hundred and fifty or so hours per week once the person is more advanced in their disease. So, I say that because the number of hours, I think, make all, like- putting that into perspective of somebody having a full time, multiple full time jobs, basically providing care, I think is really important. But the responsibilities of the care partner are going to range from everything from just helping the person early on in terms of managing finances or managing them, making sure they're reminding them to take their medications, scheduling their medical appointments for them, maybe taking over all of the driving to get them to their appointments or to get them to family outings and things like that. They're going to be the ones that's going to be the most responsible for reminding people to do something: to eat, to maybe stay on track for a recipe or something that they are making. So, kind of being the eyes and ears for this person right away, basically right at the beginning, even early stages. And then that progresses over time to the person who is caregiving, who is doing potentially everything for this person. So that means helping them use the restroom when they need to, helping them shower. So, there's a physical component to the caregiving as well as that- sort of what we call instrumental support in terms of organizing medical appointments and things like that. They're just basically doing it all for that person.  Dr Smith: So, what about a busy clinician who has half an hour to see a dementia patient follow up? Kind of hard to- in these days, you know, we've got, you know, these new therapies to think about as well. What advice do you have to neurologists and other professionals caring for patients? Dr Polsinelli: Yeah. And I think neurologists, I mean, we all have limited time. And I know neurology in particular is like primary care, has even more constrained time. I think one of the biggest things that neurologists can do is really check in with the care partner. So, take a moment to check in with the care partner who's there with the person with dementia to see how are they doing. You're looking for signs of burden or stress, so things like physical complaints like headaches or stomach ache, mentioning feeling burnt out or overwhelmed, maybe feeling depressed or something like that. There's also some short kind of questionnaires that you could give care partners prior to an appointment that they could fill out. You could kind of get a sense of where is this person at this point and then help connect them potentially to some resources that might be available. And I would refer people to that article that has a list of resources in there that you could just basically print out and give to somebody.  Dr Smith: Yeah, I was going to make the same point, Ange. Your article is a treasure trove of information. And you know, I'm certainly, I keep all of these on file, as you might imagine, but I'm keeping it in hand for future use. One of the things you talk about that really hit home for me among many is the idea of self-care, and I think sometimes the best care partners are susceptible to burnout because they they're so dedicated. You made the airplane oxygen mask metaphor, which I love. So maybe you can talk about what airplane oxygen masks have to do with dementia care and what advice you have for us and helping our patient's care partners take care of themselves? Dr Polsinelli: Yeah, absolutely. Self-care is the number one thing I tell care partners to do. It's also one of the hardest things for care partners to do. Like you mentioned, there is a deep, generally speaking, a deep love and caring for the person with who is living with dementia. And the focus becomes on them. And understandably so, the care partners sort of loses focus on themselves and making sure that they're doing okay. So I oftentimes use this oxygen airplane metaphor for people, which is basically, you know, when you're in an airplane and if there's some kind of pressure change in an airplane, they always tell you, put your oxygen mask on first before you help somebody else because you're not going to be any good to anybody if you're passed out. In the airplanes, the pressure changes, you know. You need to be available. you need to be getting what you need in order to help somebody else. So, I think that metaphor, that analogy really works well in dementia care is you need to be- the care partner needs to be caring for themselves and replenishing themselves in order to be the best care partner they can be for their loved one.  Dr Smith: Another challenge that, it strikes me as shared between people living with dementia and their care partner is that of social isolation and loneliness, right? If you're working a hundred and fifty hours a week doing anything, you don't have time to care for yourself or very hard to engage in social connections. And one of the loud messages I think I heard from your article is the power of social connectedness, both in terms of resilience and in many different ways. I wonder if you can talk a little bit about loneliness? And I just reflect that in a postpandemic world, this is probably a bigger issue than it was four years ago or four years and three months ago. Dr Polsinelli: Yeah, absolutely. Loneliness and social isolation was a big problem before, and it's even worse now is when I'm hearing from my patients. What I'm seeing in the literature is this postpandemic time is even more has been even more isolating and more problematic for people, but this social network cannot be, as you said, it cannot be overstated in terms of the importance for people. So that social network is important for not only providing potential instrumental care - so that practically care that care partners can use can lean on other people to come into the home to do things for the person living with dementia so the care partner can go practice self-care or go do those errands that need to be done - but also the emotional support as well that social networks can provide for people. And also, you know, social networks for not just the person, the care partner, but for the person living with dementia as well. We know that social engagement in particular is really good for brain health. I mean, we don't think about it, but social engagement is a very cognitive activity. And so, it helps give the brain a bit of a workout. So that social network is important for a lot of different reasons, and understandably a lot harder to maintain in this sort of postpandemic world as well. Dr Smith: As our time starts to come to- close to a close, we're not done yet, but I think we're probably going to have to start winding up. I wonder if we could pivot to something positive and then talk about the joy in this. And by that, I mean you describe and I think we've witnessed relationships and caring, caregiving situations that, as challenging as they are, provides fulfillment and the connection one has with a loved one or sort of that social aspect. Are there things that- predictive of that kind of positivity, and are there ways that we as professional caregivers for patients and their families can facilitate that? Dr Polsinelli: Yeah, there are. There are a couple of things. So, one of which is basically the quality of relationship between the care partner and the person living with dementia already. So that's the quality of that relationship. The better the quality of that relationship, the more likely it is that the care partner will experience more meaning and fulfillment and joy associated with caregiving, kind of outweighing that burden. But the additional piece of that is the more resources, the more mastery they feel about their caregiving or care partnering abilities, the more competent they feel and their ability to do good by the person, their loved one, the person living with dementia, the more likely they are to find that role fulfilling and meaningful. And I think that's where neurologists and other providers can kind of come in as helping people make sure that they have those resources that they are connecting to places where they can learn skills for giving appropriate care so that they can feel confident in what they're doing. There's the preexisting relationship piece that matters a lot. But I think that there's a lot of modifiability that neurologists have, too, in making a positive impact on the care partner and the person living with dementia. Dr Smith: That's really great advice, Ange. And I definitely will refer our listeners yet again to your article, which is a compendium of useful advice about this, both in terms of the text itself and in tables that provide lists of resources, websites, books, organizations, good case examples. It's a home run and I hope all of our listeners check it out. I'd like to wind up by talking a little bit about your work. And as I understand it, you obviously are very passionate about this topic, but you have specific interests in caregiver burden and underserved and marginalized communities. And then, we've touched on this, but this is a huge percentage of our population. And when you look out globally, it's even bigger than that. Tell us about what you're working on. And then maybe following that, what's the future look like? Where are we going to see advances in this in the coming years?   Dr Polsinelli: So just a really quick kind of brief history is that I've worked in dementia for almost twenty years or so now. And what I've consistently seen is when you give care partners good supports and education and resources, there are better outcomes for them and their families. The unfortunate thing is, a lot of these really great interventions and things that we have are not necessarily really accessible by a lot of people, but particularly not accessible by those living in underserved communities. The last few years in particular, I've really shifted into wanting to better understand that and better understand how do we provide culturally and socially appropriate interventions and education for these care partners and their families. With the current research project that I'm working on, we're looking at better understanding the needs of care partners of people who have early onset Alzheimer's disease, specifically from Black and African American individuals and other underrepresented groups. Again, the idea of this is to understand the needs before building an intervention for these groups, and I'm very excited about it. I know that there are lots of really great people who are working in this area, including Dr Dilworth Anderson and Kalisha Bonds Johnson, doing really fabulous work in this area. So, and building on what they're doing as well. In terms of what the future holds, one, I think we absolutely need to, we have lots of really great care partner interventions out there that have been lots of research going on, but it's not really transitioning into the clinical sphere. It's really kind of staying in that research sphere. So, I think it's really important that we get some implementation scientists who are taking those interventions and moving them into the clinical sphere, into the sort of like everyday, how do these actually work for people sphere. And then similar to some of this conversation we're having in terms of serving, making sure our interventions and making sure that our resources are appropriate and accessible for underserved communities, we really need to be taking a look at what these communities need rather than kind of saying, this is what's available. Kind of, hopefully this works for you. Speaking with these communities, engaging stakeholders and understanding what are the needs in these groups so that we can provide the appropriate resources, the appropriate interventions, the appropriate supports for care partners and people living with dementia. Dr Smith: And I'm just thinking, imagine what this looks like with effective treatments for Alzheimer's disease, that slow progression. And you know, that's going to make the caregiving even more important, it seems to me. But there's an opportunity to make it a better rewarding and a better-supported system as we develop these new therapies. So, this is a, like a Clarion call for learners listening that they should all become dementia neurologists and neuropsychologists like here. Thank you. That was outstanding. Say, Ange, I want to thank you a lot for a really engaging conversation. This fulfilled every hope I had coming into it. I was really excited to talk to you. I always love talking to neuropsychologists, but I think again, this is really useful for neurologists, learners, people who are nonneurologists everyone. And so, thank you very much. I've learned a lot and I really would encourage everyone to check out the article.  Dr Polsinelli: Well, thank you so much for having me on and giving me the opportunity to talk about the stuff that is really important to me and, I think, to most of us out there. So, hopefully people find the article and the resources in there useful and, and thanks again for having me.  Dr Smith: I'm sure they will. Again, today I've been interviewing Dr Angelina Polsinelli, whose article on care partner burden and support service in dementia appears in the most recent issue of Continuum, which is on dementia. Be sure to check out Continuum audio episodes from this and other issues. And thanks to you, our listeners, for joining us today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Stand Up is a daily podcast that I book,host,edit, post and promote new episodes with brilliant guests every day. Please subscribe now for as little as 5$ and gain access to a community of over 700 awesome, curious, kind, funny, brilliant, generous souls Check out StandUpwithPete.com to learn more GET TICKETS TO PODJAM II In Vegas March 27-30 Confirmed Guests! Professor Eric Segall, Dr Aaron Carroll, Maura Quint, Tim Wise, JL Cauvin, Ophira Eisenberg, Christian Finnegan and More! Dr. Aaron E. Carroll is President & CEO of AcademyHealth. A nationally recognized thought leader, science communicator, pediatrician, and health services researcher, he is a passionate advocate for the creation and use of evidence to improve health and health care for all.  Before joining AcademyHealth, Dr. Carroll was a Distinguished Professor of Pediatrics and Chief Health Officer at Indiana University, where he also served as Associate Dean for Research Mentoring and the director of the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University School of Medicine. He earned a B.A. in chemistry from Amherst College, an MD from the University of Pennsylvania School of Medicine, and an M.S. in health services from the University of Washington School of Public Health, where he was also a Robert Wood Johnson Clinical Scholar. Dr. Carroll's research focused on the study of information technology to improve pediatric care, decision analysis, and areas of health policy including cost-effectiveness of care and health care financing reform. He is the author of The Bad Food Bible and the co-author of three additional books on medical myths. In addition to having been a regular contributor to The New York Times and The Atlantic, he has written for many other major media outlets and is co-Editor-in-Chief at The Incidental Economist, an evidence-based health policy blog. He also has a popular YouTube channel and podcast called Healthcare Triage, where he talks about health research and health policy. Join us Thursday's at 8EST for our Weekly Happy Hour Hangout!  Pete on Blue Sky Pete on Threads Pete on Tik Tok Pete on YouTube  Pete on Twitter Pete On Instagram Pete Personal FB page Stand Up with Pete FB page All things Jon Carroll  Follow and Support Pete Coe Buy Ava's Art  Hire DJ Monzyk to build your website or help you with Marketing     Gift a Subscription https://www.patreon.com/PeteDominick/gift

In this episode, three HPNA Diversity, Equity, Inclusion, & Belonging (DEIB) Committee members reflect on their lived experience- how positionality impacts the way they show up to their work as hospice and palliative care clinicians and researchers and how they've shifted from cultural competency toward cultural responsiveness. Together, these experts discuss how our knowledge and actions must evolve in the face of new information, and how we can foster a healthcare environment that not only acknowledges but celebrates individual identity and culture. Whether you're a clinician, researcher, or anyone passionate about making healthcare more equitable, this conversation provides valuable insight into how we can all "do better" by truly seeing each person as they are.   Nancy Dias, PhD, RN, MSN, FPCN® Nancy Dias is an Associate Professor in the Nurse Science Department at the College of Nursing. Her work experience in nursing includes both experiences in the United States and internationally (India and Oman) as a clinician, educator, administrator, and a researcher. She completed her PhD at Duke University School of Nursing and a 1-year T32 post-doctoral fellowship from Indiana University School of Nursing. As a researcher, she has a niche for a very significant and innovative aspect of pediatric palliative care services that includes caregiver health outcomes, their bereavement processes, social and structural determinants of health, and innovative technology. Her academic initiatives have focused on transforming educational curriculum to integrate a nursing curriculum with a goal “charting a path to achieve health equity”. Her entrepreneurial skills are exemplified through her role as a co-founder of the Indo-American Evidence based practice Academy and development of an innovative app for bereaved families. She has received several research grants and among many awards, she is the recipient of the Research Nurse of the Year Award 2020, from North Carolina Nurses Association. She has also been recognized with several other awards including, East Carolina University College of Nursing Outstanding Faculty award (2022), Outstanding Mentor award from Sigma Theta Tau's Beta Nu chapter (2024). She was inducted as the Fellow in Palliative Care Nursing in 2024. She has international collaborations with nurses in India and Egypt and mentors these nurse scientists with whom she shares common research and scholarship interest. She has several publications and presentations done locally, nationally, and internationally.  Adrienne Jones-Adamczyk, MBE, RN, ACNP-BC ACHPN®, HEC-C Adrienne Jones-Adamczyk MSN, MBE, RN, ACNP-BC, ACHPN®, HEC-C is a Senior Clinical Ethics Specialty Program Director for Banner Health. She has more than 14 years of experience as a board-certified Acute Care Nurse Practitioner and is an Advanced Certified Hospice and Palliative Care Nurse. She has spent her career in Neuroscience, Palliative Medicine, Home Hospice, and Hospice GIP settings. The clinical conundrums and ethical dilemmas of the COVID-19 pandemic inspired her to continue her education in bioethics, and she obtained a Master of Bioethics degree in May 2023 from Harvard Medical School. She continues her work in equity and human flourishing as an active member of the HPNA Diversity, Equity, Inclusion, and Belonging Committee. Katherine Doyon, PhD, MED, RN, CHPN® Kate Doyon is an assistant professor at Boise State University, School of Nursing. She serves on HPNA's Diversity, Equity, Inclusion, and Belonging Committee and Research Advisory Committee and is a former co-chair of the Emerging Scholars Special Interest Group. She is a certified hospice and palliative care nurse and volunteers on the CHPN® Credentialing Committee. She is a member of the most recent Cambia Sojourns Leadership scholars' program. Kate is passionate about mentoring the next generation of hospice and palliative care nurse scientists and mentors several nurse scholars. She is the recipient of the HPNF Research Scholar Award, the first author of the section on health equity for the HPNA Research Agenda and a reviewer for palliative care journals and conferences including the Annual Assembly of Hospice and Palliative Medicine. Through her advocacy, mentorship, and research of equitable hospice and palliative care, Dr. Doyon exemplifies the highest standards of HPNA's commitment to compassionate care.   

Although Alzheimer disease (AD) is the most common neurodegenerative cause of dementia, other etiologies can mimic the typical amnestic-predominant syndrome and medial temporal brain involvement. Neurologists should recognize potential mimics of AD for clinical decision-making and patient counseling. In this episode, Kait Nevel, MD, speaks with Vijay K. Ramanan, MD, PhD, an author of the article “LATE, Hippocampal Sclerosis, and Primary Age-related Tauopathy,” in the Continuum December 2024 Dementia issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Ramanan is a consultant and assistant professor of neurology in the Division of Behavioral Neurology at Mayo Clinic College of Medicine and Science in Rochester, Minnesota. Additional Resources Read the article: LATE, Hippocampal Sclerosis, and Primary Age-related Tauopathy Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: IUneurodocmom Guest: @vijaykramanan Full episode transcript available here Dr Jones: This is Dr Lyle Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum 's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Nevel: This is Dr Kait Nevel. Today I'm interviewing Dr Vijay Ramanan about his article he wrote with Dr Jonathan Graff-Radford on LATE hippocampal sclerosis and primary age-related tauopathy, which appears in the December 2024 Continuum issue on dementia. Welcome to the podcast. Vijay, can you please introduce yourself to the audience? Dr Ramanan: Thanks so much, Kait. I'm delighted to be here. So, I am a cognitive neurologist and neuroscientist at the Mayo Clinic in Rochester, Minnesota. I have roles in practice, education and research, but amongst those I see patients with cognitive disorders in the clinic. I help direct our Alzheimer's disease treatment clinic and also do research, including clinical trial involvement and some observational research on genetics and biomarkers related to Alzheimer's and similar disorders. Dr Nevel: Great, thanks for that. So, I'd like to start off by talking about why is LATE hippocampal sclerosis, why is this important for the neurologist practicing in clinic to know about these things? Dr Ramanan: That's a great question. So, if we take a step back, we know that degenerative diseases of the brain are really, really common, and they get more and more common as we get older. I think all neurologists, and in fact most clinicians and large swaths of the general public, are well aware of Alzheimer's disease, which is the most common degenerative cause of cognitive impairment in the population. But there are non-Alzheimer's degenerative diseases which can produce cognitive difficulties as well. And it's important to be aware of those disorders, of their specific presentations and their implications, in part because it's always a healthy thing when we can be as precise and confident about diagnosis and expectation with our patients as possible. I'll look to the analogy of a patient presenting with a myelopathy. As neurologists, we would all find it critical to clarify, is that myelopathy the result of a compressive spondylotic change? The result of an inflammatory disorder, of a neoplastic disorder, of an infectious disorder? It's critical to guide the patient and choose appropriate management options based on the cause of their syndrome. It would potentially harm the patient if you treated an infectious myelopathy with steroids or other immune-suppressant drugs. So, a similar principle holds in cognitive neurology. I accept with humility that we can never be 100% crystal clear certain about things in medicine, just because when you think you got it all figured out there's a curveball. But I want to get as close to that 100% as possible. And recognizing that disorders like LATE or PART can mimic the symptoms, sometimes even the imaging features of Alzheimer's disease. I think it's critical to have heightened awareness of those disorders, how they look, to be able to apply appropriate counseling and management options to patients. I think this becomes particularly critical as we move into an era of disease-specific, and sometimes disease-modifying, therapies, where applying a choice of a treatment option could have significant consequences to a patient if the thing you're treating isn't the thing that the drug is trying to accomplish. So, having awareness and spreading awareness about some of these non-AD causes of cognitive difficulty, I think, is a big mission in the field.  Dr Nevel: Yeah, that makes total sense. And kind of leaning into this, you know, trying to differentiate between these different causes of late-life amnestic cognitive impairment. You know, I'll point out to the listeners today to please read your article, but in addition to reading your article, I'd like to note that there's a really nice table in your article, Table 6-1, where you kind of go through the different causes of amnestic cognitive impairment and the different features that better fit with diagnosis X, Y, or Z, because I think it's a really nice table to reference and really easy to look at and reference back to. But on that note, what is your typical approach when you're seeing a patient in clinic, have a new referral for an older patient presenting with a predominantly progressive amnestic-type features? Dr Ramanan: Excellent question. And this is one that I think has relevance not just in a subspecialty memory clinic, but to all the clinicians who help to diagnose and manage cognitive disorders, including in primary care and general neurology and others. One principle that I think it's helpful to keep in our minds is that in cognitive neurology, no one data point takes precedence over all the others. We have a variety of information that we can gather from history, from exam, from imaging, from fluid biomarkers. And really the fun, the challenge, the reward is in piercing together that information. It's almost like being a lawyer and compiling the evidence, having possibilities on your list and raising and lowering those possibilities to get as close to the truth as you can. So, for patients with a cognitive syndrome, I think the first plank is in defining that syndrome. As you mentioned, if I'm seeing someone with a progressive amnestic-predominant syndrome, I first want to make sure, are we talking about the same thing, the patient, the care partner, and I?  Can often be helpful to ask them for some examples of what they see, because sometimes what patients may report as memory troubles may in fact reflect cognitive difficult in other parts of our mental functioning. For example, executive functioning or naming of objects. And so helpful to clarify that in the history to get a sense of the intensity and the pace of change over time, and then to pair that with a good general neurologic exam and some type of standardized assessment of their cognitive functioning. At the Mayo Clinic, where partial to the short test of mental status. There are other ways to accomplish that, such as with an MMSE or a MoCA. If I understand that the syndrome is a progressive amnestic disorder, Alzheimer's disease is the most common cause of that presentation in older adults, it deserves to be on my differential diagnosis. But there might be some other features in the story that could raise or lower those mimics on my list. So, in patients who are, say, older than the age of seventy five, disorders like LATE or PART start to rise higher on the likelihood for me, in particular if I know that their clinical course has been more slow brewing, gradually evolving. And again, most degenerative disorders we expect to evolve not over days or weeks, but over many months to many years. But in comparison with Alzheimer's disease, patients with LATE or with PART would be expected to have a little more slow change where maybe year over year they or their care partners really aren't noticing big declines. Their daily function is relatively spare. There might not be as much involvement into other non-memory cognitive domains. So, these are some of the pieces of the story that can help to perhaps isolate those other non-AD disorders on the list as being more likely and then integrating, as a next level, diagnostic testing, which helps you to rule in and rule out or support those different causes. So, for example, with LATE there can be often out of proportion to the clinical picture, out of proportion to what you see on the rest of their imaging or other profiles, very predominant hippocampal and medial temporal volume loss. And so that can be a clue in the right setting that you may not be dealing with Alzheimer's disease or pure Alzheimer's disease, but that this other entity is there. So, in the big picture, I would say being systematic, recognizing that multiple data points being put together helps you get to that confident cause or etiology of the syndrome. And in particular, taking a step back and thinking about big picture factors like age and course to help you order those elements of the differential, whether AD or otherwise. Dr Nevel: Great, thanks. In your article, you talk about different imaging modalities that can be used, as you mentioned, you know, just another piece of the puzzle, if you will, to try and put together what may be going on with the patient, and recognizing that some of these imaging techniques are imaging is special imaging, not available in a lot of places.  You know, and maybe other diagnostic type tests that could be helpful in differentiating between these different disorders may not be available, you know, for the general neurologist practicing in the community. So, what do you suggest to the general neurologist maybe practicing somewhere where they don't have access to some of these ancillary tests that could assist with a diagnosis?  Dr Ramanan: Critical question. And here I think there's not likely to be one single answer. As with most things, awareness and recognition is a good place to start. So, some of those clues that I mentioned earlier about the clinical course, about the age, the- we're talking about clinical setting there. So, comfort with and understanding that the clinical setting can help you to be more confident about, for example, LATE or PART being present in contrast to AD. That's important information. It deserves to be part of the discussion. It doesn't necessarily need other tests to have value on its own. A second piece is that tests help, in some cases, to rule in and rule out causes for cognitive difficulty. As part of a standard cognitive evaluation, we would all be interested in getting some blood tests to look for thyroid dysfunction or vitamin deficiencies. Some type of structural head imaging to rule out big strokes, tumors, bleeds. Head CT can accomplish some of that perspective. It's ideal if a brain MRI can be obtained, but again, keeping in mind, what's the primary goal of that assessment? It's to assess structure. Occasionally you can get even deeper clues into a syndrome from the MRI. For example, that very profound hippocampal or medial temporal atrophy. So, increasing awareness amongst clinicians throughout our communities to be able to recognize that change and put it in the context of what they see in other brain regions that can be affected by Alzheimer's or related disorders. For example, the parietal regions can be helpful. And recall that MRI can also be helpful in assessing for chronic cerebrovascular disease changes. This is another mimic that shows up in that table that you mentioned. And so multiple purposes can be satisfied by single tests. Now, you're absolutely right that there are additional test modalities that, perhaps in a subspecialty clinic at an academic medical center, we're very used to relying on and finding great value on; for example, glucose PET scans or sometimes fluid biomarkers from the blood or from the spinal fluid. And these are not always as widely available throughout our communities. Part of the challenge for all of us as a field is therefore to take the expertise that we have gathered in more subspecialty settings and tertiary care settings and translate and disseminate that out into our communities where we need to take care of patients. That's part of the challenge. The other challenge is in continued tool and technological development. There's a lot of optimism in our field that the availability of blood-based biomarkers relevant for Alzheimer's disease may play a part in helping to address some of the disparities in resource and access to care. You can imagine that doing a blood test to give you some high-quality information, there are going to be less barriers to doing that in many settings compared to thinking about a lumbar puncture or a PET scan, both in terms of cost to the patient as well as infrastructure to the clinicians and the care team. So I'm optimistic about a lot of those changes. In the meantime, I think there are, through both clinical evaluation and some basic testing including structural head imaging, there are clues that can help navigate these possibilities. Dr Nevel: So, let's say you have your patient in clinic, you've done your evaluation, maybe gotten some ancillary testing, and you highly suspect either LATE or PART. How do you counsel those patients and their families? How do you manage those patients moving forward who you really suspect don't have, you know, some sort of co-pathology? Dr Ramanan: So, it's- I think it's helpful to remember when patients are coming to see us, either they or the people around them have noticed an issue. And very likely it's an issue that's been brewing for a little while. I think it can be very valuable, very helpful for patients to have answers. What's the cause for the issue? Once you have answers, even if sometimes those answers are not the most welcome things or the things that you'd be looking forward to, answers give you an opportunity to grab hold of what's going on, to define a game plan. So, understanding there is a degenerative disease there, it sheds light on why that individual had had memory symptoms over the years. And it gives them a general expectation that over time on an individualized basis, but generally expecting gradually over many months to many years, there may be some worsening in some of those symptoms helps them to plan and helps them to make the adaptations that are a-ok and great to make to just help you to do the things you want to do. As much as I can, I try to put the focus here closer to how we would view things like high blood pressure or high cholesterol. Those are also chronic issues that tend to be more common as we get older, tend to get more troublesome as we get older. The goal is, know what you're dealing with and take the combination of lifestyle modifications, adaptations in your day-to-day and maybe medications to keep them as mild and as slow-changing as possible. With something like LATE, we don't have specific medication therapies to help support cognitive functioning at this time. There's a lot of hope that with additional research we will have those therapies. But even so, I think it's an important moment to emphasize some of those good healthy lifestyle habits. Staying mentally, socially and physically active, getting a good night's sleep, eating a healthy, balanced diet, keeping good control of vascular risk factors, all of that is critical to keeping the brain healthy, keeping the degenerative disease as mild and slow-brewing as possible. And understanding what some of the symptoms to expect could be. So, with LATE the syndrome tends to be very memory-predominant. There may be some trouble with maybe naming of objects or perhaps recall of emotionally salient historical knowledge, world events, but you're not expecting, at least over the short to medium term, huge intervening on other cognitive functioning. And so that can be helpful for patients to understand. So, the hope is once you know what what you're dealing with, you understand that the disease can look different from person to person. Having a general map of what to expect and what you can do to keep it in check, I think, is the goal. Dr Nevel: I agree with you 100% that it really can be helpful even if we can't, quote unquote, fix it, that for people, family, the patient have a name for what they have and kind of have some sort of idea of what to expect in the future. And they may come in thinking that they have Alzheimer's or something like that. And then, so, to get that information that this is going to be a little different, we expect this to go a little bit differently then it would if you had a diagnosis of Alzheimer's, I can see how that would be really helpful for people.  Dr Ramanan: I completely agree. And here's another challenge for us in the field when most patients have heard about Alzheimer's disease and many have perhaps even heard of dementia with Lewy bodies or frontotemporal dementia, but may not have heard of things like LATE. And they're not always easy to go online or find books that talk about these things. Having a name for it and being able to pair that with patient-friendly information is really critical. I see our appointments where we're sharing those diagnosis and making initial game plans as an initial foray into that process.  Dr Nevel: Yeah, absolutely. What is the greatest inequity or disparity that you see in taking care of patients with progressive amnestic cognitive impairment? Dr Ramanan: Yeah, great question. I think two big things come to mind. The first, you hinted at very well earlier that there are disparities in access to care, access to diagnostic testing, access to specialists and expertise throughout our communities. If we want diagnostics and therapeutics to be broadly applicable, they do need to be broadly available. And that's a big challenge for us as a field to work to address those disparities. There's not going to be one single cause or contributor to those iniquities, but as a field, I'm heartened to see thought and investment into trying to better address those. Another big weakness, and this is not just limited to cognitive neurology, it's a challenge throughout neurology, is that too many of our research studies are lacking in diversity. And that impacts our biological and pathophysiological understanding of these disorders. It also impacts our counseling and management. Again, if we want a new drug treatment to be broadly applicable throughout all of the patients that we take care of, we need to have data which guides how we apply those treatments. And so again, I'm heartened. This is a big challenge. It's a long standing challenge. It will take deep and long standing committed efforts to reverse. But I'm heartened that there are efforts in the field to broaden clinical trial enrollment, broaden observational research enrollment, and again, broaden access to tools and expertise. As a neurologist, I got into this field because I want to help people, use my expertise and my training to help people. These are steps that we can take to make sure that that help is broadly applicable throughout everybody in our communities. Dr Nevel: Yeah, absolutely. So, kind of segueing from you mentioning research and how we can better include patients in research. What do you think the next breakthrough is going to be? What do you think the next big thing is going to be in these disorders? What do we still need to learn? Dr Ramanan: There's a lot. I think for LATE and PART, the development of specific biomarkers would be top of the agenda. Now, biomarkers are by their nature imperfect. Even with Alzheimer's disease, where in comparison, we know quite a lot. We have a variety of imaging and fluid biomarkers that we can use to support or rule out a diagnosis. There are nuances in how you interpret those biomarkers. Patients can have signs of amyloid plaques in their brain and have completely normal cognition. They may be at risk for developing cognitive trouble due to Alzheimer's disease in the future, but it's one piece of the puzzle. Patients can have the changes of Alzheimer's disease amyloid plaques and tau tangles in the brain. We can confirm that through biomarkers. But at the end of the day, their cognitive syndrome might be driven by something else. Maybe it's Lewy body disease, maybe it's LATE, maybe it's a combination of factors. So, integrating and interpreting those biomarkers is challenging. But I do think, again, from the standpoint of giving patients answers with a diagnosis, having those biomarkers is really critical to just kind of closing the loop. It will also be critical to have those biomarkers as we're assessing for treatment response. So, for example, patients who may have coexistent Alzheimer's disease and LATE, I don't think we know the answer fully as to how likely they are to benefit from, say, newer antiamyloid monoclonal antibodies for Alzheimer's disease in the setting of that second pathology. So, wouldn't it be great if, similar to an oncologic setting where you engage in a treatment and then you're tracking two or three or four plasma measures and you're tracking tumor size with imaging, if we had this multimodal ability to track neurodegenerative pathology through biomarkers? I think that'll be a critical next step. And so, filling out that for non-Alzheimer's diseases, including LATE and PART, I think is item number one on the agenda. Dr Nevel: Wonderful, thank you so much. I really appreciate you taking the time to chat with me today about your article. I really enjoyed our conversation, certainly learned a lot. Dr Ramanan: Thank you so much, Kait. Love talking with you. And again, it was an honor to write this article. I hope it's helpful to many out in the field who take care of patients with cognitive issues.  Dr Nevel: Yeah, I think it will be. So again, today I'm interviewing Dr Vijay Ramanan about his article that he wrote with Dr Jonathan Graff-Radford on LATE hippocampal sclerosis and primary age-related tauopathy, which appears in the most recent issue of Continuum on dementia. Be sure to check out Continuum audio episodes from this and other issues. And thank you, Vijay, and thank you to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Dr. Brandi Bolling is a triple-board-certified psychiatrist and pediatrician specializing in ADHD and autism spectrum disorders. With nearly a decade of experience and approximately 20,000 patients seen, she empowers mothers and educators to support children with ADHD through her concierge practice, speaking engagements, and annual ADHD summit. Dr. Brandi earned a neuroscience degree from Vanderbilt University, an MD from Meharry Medical College, and completed her triple board residency at Indiana University School of Medicine. Passionate about mental health awareness, she engages audiences via media, panels, keynotes, and her weekly Facebook livestream, *Focus on It Friday*.   Listen to this Parenting With Impact episode with Dr. Brandi Bolling about ADHD and autism. Here is what to expect on this week's show: Dr. Brandi points out subtle signs such as dark eyes and unique staring behaviors in children with autism that may go unnoticed Dr Brandi explains embracing a spectrum-based understanding is essential, particularly when dealing with cases where ADHD coexists with autism. Dr. Brandi discusses the importance of celebrating children's uniqueness regardless of their diagnoses.   Connect with Dr. Brandi: Website:  http://www.rbpsychiatry.com/meet-the-team Facebook:  https://www.facebook.com/DrBrandiB Focus On It Fridays:  https://www.facebook.com/DrBrandiB/videos   Links Mentioned: Website:  http://www.rbpsychiatry.com/meet-the-team Facebook:  https://www.facebook.com/DrBrandiB Focus On It Fridays:  https://www.facebook.com/DrBrandiB/videos “Autism Spectrum Disorder: Putting the Pieces of the Puzzle Together”:  https://www.facebook.com/profile/100063686375210/search/?q=autism Shine: Understanding ADHD So Your Child Can Be a Star!:  https://www.amazon.com/exec/obidos/ASIN/164484379X/?tag=im0ea3-20 Recommended treatment for ADHD: https://impactparents.com/help-for-parents/recommended-treatment/ Parenting Through Denial:  https://impactparents.com/blog/anxiety/parenting-denial/ Keys to Parenting Autism: Education, Coaching & You!:  https://youtu.be/HUtbvMo4kbk Missed Diagnosis: Autism In Girls:  https://www.youtube.com/watch?v=Mz-CRQTOnHk Improving Practices, Diagnosis, and Treatment of ADHD:  https://www.youtube.com/watch?v=RlARVMSmk6U What Your Kids Want You To Know About ADHD:  https://youtu.be/eZ1DbKYSQxM Raising a Child with ADHD: Keeping Focus on What Matters:  https://youtu.be/Bsjr6BErTAc   Get your FREE copy of 12 Key Coaching Tools https://impactparents.com/gift   Connect with Impact Parents: Instagram: https://www.instagram.com/impactparents/ @impactparents Facebook: https://www.facebook.com/ImpactParent @impactparent LinkedIn: https://www.linkedin.com/company/impactparents/ @impactparents X (fkaTwitter): https://twitter.com/ImpactParents @impactparents Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode, we sit down with Dr. Laura Vater,  board certified Gastrointestinal Oncologist at Indiana University Simon Comprehensive Cancer Center and physician advocate. She shares her journey into medicine, how she started writing, and became a physician advocate at all levels of medical education. Dr. Vater is board certified in Internal Medicine and Medical Oncology, and is currently an Assistant Professor of Clinical Medicine at the Indiana University School of Medicine. She is also the founding director of the Young-Onset Colorectal and Gastrointestinal Cancer Program at IU and co-founder of the narrative medicine program, Writing for Wellness. She was inducted into the Gold Humanism Honor Society in 2018 and is a member of the Pegasus Physician Writers at Stanford University. She has developed a wellness behavior tool for patients and clinicians (called the SMILE Scale) and has published several narrative medicine essays and peer-reviewed publications. Besides being a writer, Dr. Vaah-ter is a TEDx and commencement speaker, mother, and advocate for patients and healthcare workers. She believes that patients should be treated as whole human beings and that clinicians deserve the same. We explore the topics of humanism in medicine, compassion, the importance of physician wellness and mental health, burnout in healthcare, and the nuances of medical care both in the clinic and at the institutional level. For further reference follow Dr. Laura Vater on Instagram @doclauravater and at https://www.lauravater.com/.  Episode produced by: Nikita Ganeshan Episode recording date: 11/15/2024 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate

Jon Hartley and Brad Gerstner discuss Brad's career, free markets, investing in technology, industrial policy, the CHIPS and Science Act, and baby equity investment accounts. Recorded on November 1, 2024. ABOUT THE SPEAKERS: Brad Gerstneris the founder and CEO of Altimeter Capital, a tech investment firm based in Silicon Valley, that manages both public and VC investment portfolios. Started in 2008, Altimeter manages over $15bn of investments across its public equity fund and venture capital funds. Brad is also the founder of Invest America, a non-profit that is spearheading research into the creation of private investment accounts for the 3.7 million children born each year in America, unlocking economic mobility for the next generation. Born in Indiana, he studied at Wabash College, Oxford University, Indiana University School of Law and Harvard Business School. He practiced securities law and served a term as Indiana deputy secretary of state before returning to HBS. Jon Hartley is a Research Assistant at the Hoover Institution and an economics PhD Candidate at Stanford University, where he specializes in finance, labor economics, and macroeconomics. He is also currently a Research Fellow at the Foundation for Research on Equal Opportunity (FREOPP) and a Senior Fellow at the Macdonald-Laurier Institute. Jon is also a member of the Canadian Group of Economists, and serves as chair of the Economic Club of Miami. Jon has previously worked at Goldman Sachs Asset Management as well as in various policy roles at the World Bank, IMF, Committee on Capital Markets Regulation, US Congress Joint Economic Committee, the Federal Reserve Bank of New York, the Federal Reserve Bank of Chicago, and the Bank of Canada.  Jon has also been a regular economics contributor for National Review Online, Forbes, and The Huffington Post and has contributed to The Wall Street Journal, The New York Times, USA Today, Globe and Mail, National Post, and Toronto Star among other outlets. Jon has also appeared on CNBC, Fox Business, Fox News, Bloomberg, and NBC, and was named to the 2017 Forbes 30 Under 30 Law & Policy list, the 2017 Wharton 40 Under 40 list, and was previously a World Economic Forum Global Shaper. ABOUT THE SERIES: Each episode of Capitalism and Freedom in the 21st Century, a video podcast series and the official podcast of the Hoover Economic Policy Working Group, focuses on getting into the weeds of economics, finance, and public policy on important current topics through one-on-one interviews. Host Jon Hartley asks guests about their main ideas and contributions to academic research and policy. The podcast is titled after Milton Friedman‘s famous 1962 bestselling book Capitalism and Freedom, which after 60 years, remains prescient from its focus on various topics which are now at the forefront of economic debates, such as monetary policy and inflation, fiscal policy, occupational licensing, education vouchers, income share agreements, the distribution of income, and negative income taxes, among many other topics. For more information, visit: capitalismandfreedom.substack.com/

BUFFALO, NY- December 4, 2024 – A new #research paper was #published in Aging (listed by MEDLINE/PubMed as "Aging (Albany NY)" and "Aging-US" by Web of Science) Volume 16, Issue 21 on November 22, 2024, entitled, “The effects of young and aged, male and female megakaryocyte conditioned media on angiogenic properties of endothelial cells.” Researchers Murad K. Nazzal, Hanisha L. Battina, Nikhil P. Tewari, Sarah L. Mostardo, Rohit U. Nagaraj, Donghui Zhou, Olatundun D. Awosanya, Saveda K. Majety, Sue Samson, Rachel J. Blosser, Ushashi C. Dadwal, Patrick L. Mulcrone, and Melissa A. Kacenaat from Indiana University School of Medicine and Richard L. Roudebush Veterans' Administration Medical Center, have uncovered how certain bone marrow cells, called megakaryocytes (MKs), promote the growth of new blood vessels (angiogenesis) to aid in bone healing. Their findings help explain why healing slows with age and offer insights into potential treatments to accelerate fracture recovery in older adults. Broken bones are common in older adults, and slower healing can lead to complications and longer hospital stays. Accelerating the healing process could significantly improve the quality of life for millions. In this study, researchers investigated the effects of substances secreted by MKs, collected from young and older male and female mice. These substances, known as conditioned media (CM), were tested for their ability to stimulate the growth and function of endothelial cells (EC), which form the building blocks of blood vessels. Blood vessels play a critical role in healing by delivering oxygen and nutrients to damaged areas, making angiogenesis a vital part of the recovery process. The results showed that CM from younger MKs mice was more effective at helping blood vessels grow. Interestingly, MKs from female mice performed better than those from males, regardless of age. For example, substances from female MKs mice boosted blood vessel growth by over 115% and significantly improved the movement of cells needed for healing. The researchers also studied changes in genes related to blood vessel growth, and found that aging affects how these genes work. These changes may explain why older people heal more slowly after breaking a bone. “An understanding of which factors regulate which mechanisms of EC functionality may allow for isolation of one or a few factors that influence EC migration changes with aging, resulting in the development of targeted therapy to improve EC migration, subsequent angiogenesis, and fracture healing.” In conclusion, this research paves the way for developing new therapies to help older individuals recover from fractures more quickly, reducing pain and improving mobility. One potential approach could involve creating treatments that replicate the effects of MKs from younger individuals or isolating the specific substances that promote blood vessel growth. This represents an important step toward addressing the growing challenge of delayed healing in an aging population. DOI - https://doi.org/10.18632/aging.206077 Corresponding authors - Patrick L. Mulcrone - pamulcro@iu.edu, and Melissa A. Kacena - mkacena@iupui.edu About Aging-US The mission of the journal is to understand the mechanisms surrounding aging and age-related diseases, including cancer as the main cause of death in the modern aged population. The journal aims to promote 1) treatment of age-related diseases by slowing down aging, 2) validation of anti-aging drugs by treating age-related diseases, and 3) prevention of cancer by inhibiting aging. (Cancer and COVID-19 are age-related diseases.) Please visit our website at https://www.Aging-US.com​​. MEDIA@IMPACTJOURNALS.COM

Dr. Craig Svensson is a Dean Emeritus of Pharmacy and Professor of Medicinal Chemistry and Molecular Pharmacology at Purdue University, as well as an Adjunct Professor of Pharmacology and Toxicology at the Indiana University School of Medicine. He is also an elected Fellow of the American Association for the Advancement of Science and the American Association of Pharmaceutical Scientists. He's the authored over a hundred scientific publications and several books, including When the Hurt Won't Heal and the mini-book, Recreational Drug Use: A Biblical Perspective. He lives in West Lafayette, IN, and he's been married to his beautiful bride for 40 years.  To find out more about Dr. Craig, you can visit his website: http://www.craigsvensson.com or email him at svensson@purdue.edu . ------------------------------------------------   If you want to help us transform the lives of even MORE MEN for God's glory, please take a minute to leave us a helpful REVIEW on iTunes: http://www.rmcpodcast.com and SHARE this podcast with any young man (or men) you're mentoring or discipling. And make sure you don't miss an interview episode by signing up for our Man-to-Man eNewsletter at http://www.RealMenConnect.com, and grab your FREE copy of the Real Men Victory Tracker.    Talk with Dr. Joe 1-on-1: Are you stuck? Want to go to get your faith, marriage, family, career and finances back on track?  Then maybe it's time you got a coach. Every CHAMPION has one. Schedule an appointment to chat with Dr. Joe on how we can help you spiritually love and lead your family better and become the hero of your home.   Dr. Joe takes on only a few Breakthrough Calls each week to help you with your faith, marriage, work, and financial challenges.  The call is FREE, but slots are limited to ONE call only.  NO RESCHEDULES.  Just click on the link below and select the BREAKTHROUGH CALL option to set up an appointment: http://TalkwithDrJoe.com  If no slots are available, please check back in a week.   Also join us on: Join the Real Men 300: http://www.RealMen300.com Facebook Group: http://www.realmenuniversity.com/ YouTube: http://www.RealMenTraining.com Facebook: @realdrjoemartin Instagram: @realdrjoemartin Twitter: @professormartin

In this episode, Dr. Bill Sullivan (our favourite award-winning professor, author and science superstar from the Indiana University School of Medicine), tells us about being evolutionarily equipped for predators and dangers that no longer exist, and what impact that kind of hypervigilance can have on our mind, body, emotions and in general terms, our health. We also chat about status hierarchy (it's been around for millennia) and our need to feel superior, important and valued. We learn that stoics and philosophers were talking (and teaching) about the human condition thousands of years before psychology was a thing. We discuss the concept of wealth being about much more than money and the connect (or disconnect) between the states of our external (physical) and internal (non-physical) worlds. And in one of my proudest TYP achievements, after dropping the F bomb around the very moral and articulate Dr. Bill a thousand times over numerous episodes, today he walked through the swearing door for the first time. I should be ashamed. I'm not.authorbillsullivan.comSee omnystudio.com/listener for privacy information.

Co-hosts Anne Chappelle and David Faulkner speak with William J. Sullivan, PhD, Showalter Professor of Pharmacology & Toxicology and Professor of Microbiology & Immunology with the Indiana University School of Medicine, about toxic parasites lying dormant in your brain and the power and importance of science communication.About the GuestBill Sullivan, PhD, has been studying the intracellular parasite Toxoplasma gondii since he was a graduate student in the laboratory of Dr. David Roos at the University of Pennsylvania in 1994. He completed postdoctoral fellowships with Dr. Chuck Smith at ELANCO (a division of Eli Lilly, Co.) and Dr. Sherry Queener at the Indiana University School of Medicine. He became an Assistant Professor at the Indiana University School of Medicine in 2003. Dr. Sullivan is now the Showalter Professor of Pharmacology & Toxicology and Microbiology & Immunology at the Indiana University School of Medicine.Dr. Sullivan's lab studies cellular signaling and the regulation of gene expression in a fascinating protozoan parasite called Toxoplasma gondii. Toxoplasma causes congenital birth defects as well as opportunistic infection in HIV/AIDS, cancer chemotherapy, and heart transplant patients. There is also emerging evidence that this parasitic infection may be linked to neurological disorders, such as schizophrenia and behavior modification. While the acute stage of toxoplasmosis can be treated, the ability of the parasite to convert into latent tissue cysts prevents eradication of the infection from the patient. Unfortunately, if immunity wanes, the patient can relapse and suffer additional episodes of life-threatening acute infection. Additionally, toxoplasma is a serious threat to some wildlife and livestock.Send SOT thoughts on the episodes, ideas for future topics, and more.

On Today's episode of Transforming Healthcare with Dr. Wael Barsoum, we're honored to have Dr. R. Michael Meneghini, the CEO and founder of the Indiana Joint Replacement Institute (IJRI) and the newly named Chief Market Development Officer at Healthcare Outcomes Performance Co. (HOPCo). With over 19 years of experience, Dr. Meneghini is a nationally and internationally recognized expert in joint replacement. His expertise spans primary and partial hip and knee replacements, revision surgeries, outpatient joint replacements, and advanced computer-assisted surgical techniques. Additionally, he co-founded M2 Orthopedic Partners, a private-equity backed orthopedic management company. Dr. Meneghini's impressive educational journey began at Rose-Hulman Institute of Technology, where he graduated Magna Cum Laude in engineering. He earned his medical degree from Indiana University, completed his orthopedic surgery residency at Rush University Medical Center in Chicago, and pursued a fellowship in complex hip and knee replacement at the Mayo Clinic. Before founding IJRI, he led the Indiana University Health Hip and Knee Center for over a decade. Throughout his distinguished career, Dr. Meneghini has received numerous accolades, including the Coventry Award at the Mayo Clinic, the Early Career Achievement Award from Indiana University School of Medicine, and the Career Achievement Award from Rose-Hulman Institute of Technology. In 2020, he attained the academic rank of Professor in Clinical Orthopaedic Surgery at Indiana University School of Medicine. Dr. Meneghini is also a prolific researcher, having authored over 200 peer-reviewed journal articles and book chapters. His commitment to advancing the field extends to his roles on the executive boards of the Knee Society, Mid-American Orthopaedic Association (MAOA), the International Orthopedic Education Network (IOEN), and the American Association of Hip and Knee Surgeons (AAHKS), where he will serve as President in 2025. Join us as we delve into Dr. Meneghini's extensive expertise, innovative contributions, and vision for the future of orthopedic surgery. Welcome, Dr. Meneghini!

When it comes to money, we're often taught to play it safe. Hold on to what we have, avoid taking too many risks, and trust that our money will grow where we're advised to put it.  What if that advice isn't really in your best interest? Here's the issue: simply holding on to your money without a plan for strategic growth can leave you vulnerable—especially during times of tragedy. Imagine believing you're financially secure, only to discover you're not prepared for life's unexpected challenges. While we can't stop life's hardships, wouldn't it be empowering to know your finances are secure, no matter what happens? Being your own bank offers that control, turning even difficult situations into moments of opportunity and resilience. How can we ensure our family's future is protected? Can positivity emerge from tragedy? And how does becoming your own bank help create this financial safety net? In this episode, James Miles, owner of a Residential Assisted Living and Memory Care home in Carmel, Indiana, joins me to discuss how becoming your own bank can offer support in tough times. He shares his personal experiences with tragedy and how financial preparedness helped him navigate it.    Things You'll Learn In This Episode  -Going back to the fundamentals Many people skip over the basic but important fundamentals of investments. How can fundamentals help us understand what we're doing and the risk of doing it all? -The age-old money mindset Outdated mindsets can negatively influence important money decisions and kill new opportunities. How can you break free from traditional money beliefs to make more informed and flexible financial decisions? -The bare minimum won't cut it Settling for minimal insurance coverage can leave you vulnerable when you truly need it, so it's essential to invest in adequate protection. How can investing in better insurance coverage save you from future financial risks?   Guest Bio James Miles, based in Carmel, IN, is the Owner and Operator of Willow Haven Senior Homes. With experience from Indiana University School of Medicine and Charles Schwab, James now dedicates his career to providing compassionate residential assisted living and memory care. His "feels like family" approach ensures that seniors needing care have a comforting home, while their families can rest assured knowing their loved ones are well cared for. Growing up in a family that cared for his mentally handicapped uncle, James understands firsthand the challenges of caregiving. This personal experience drives his mission to offer respite for families, freeing them from guilt and stress, and giving them peace of mind. Find James on LinkedIn @James Miles Donate to the Willow Haven Senior Homes State Supreme Court Defense GoFundMe here https://www.gofundme.com/f/willow-haven-senior-homes-zoning-legal-defense  Email shawna@chrisnaugle.com with proof of your $ amount donated and Chris will match your donation.   About Your Host From pro-snowboarder to money mogul, Chris Naugle has dedicated his life to being America's #1 Money Mentor. With a core belief that success is built not by the resources you have, but by how resourceful you can be. Chris has built and owned 19 companies, with his businesses being featured in Forbes, ABC, House Hunters, and his very own HGTV pilot in 2018. He is currently founder of The Money School™, and Money Mentor for The Money Multiplier. His success also includes managing tens of millions of dollars in assets in the financial services and advisory industry and in real estate transactions. As an innovator and visionary in wealth-building and real estate, he empowers entrepreneurs, business owners, and real estate investors with the knowledge of how money works. Chris is also a nationally recognized speaker, author, and podcast host. He has spoken to and taught over ten thousand Americans delivering the financial knowledge that fuels lasting freedom.  

In this podcast episode, Dr. Robert Whitfield, a board-certified plastic surgeon specializing in breast implant illness (BII), and Dr. Mithun Sinha, a PhD scientist, discuss the complexities of Breast Implant Illness. Dr. Whitfield shares his clinical experiences and emphasizes the importance of understanding the symptoms and experiences of women affected by Breast Implant Illness and Dr. Sinha provides scientific insights into the role of fatty acids, bacteria, and biofilm formation concerning breast implants, explaining how these factors contribute to symptoms like fatigue and brain fog. Be sure to tune in to hear more! Show Highlights: Role of Fatty Acids in Cell Structure (00:01:51) The importance of fatty acids in cellular stability and protection Interaction of Fatty Acids and Implants (00:03:20) Discussion on how fatty acids interact with breast implants and surrounding tissue Formation of 10 Home and Biofilms (00:05:20) Dr. Sinha describes how oleic acid transforms into 10 Home, linked to bacterial biofilms. Scar Capsule and Bacterial Colonization (00:06:40) Exploration of how the scar capsule provides a habitat for bacteria to form biofilms Historical Perspective on Surgical Techniques (00:12:40) Dr. Whitfield shares his experience with surgical techniques for patients with breast implant illness. Importance of Research on BII (00:13:41) Lack of attention to women suffering from BII and the need for better care Introduction to Oxaliplatin Home Research (00:14:54) Dr. Sinha introduces his new paper on oxaliplatin home and its link to inflammation Oxidation and Its Effects on the Body (00:16:04) Dr. Sinha explains how oxidation increases during stress and exercise, affecting health Potential Biomarkers for BII Symptoms (00:17:38) Discussion on identifying biomarkers to predict and assess symptoms in BII patients Characterizing Bacterial Contamination (00:19:54) Dr. Whitfield discusses the need to characterize bacterial contamination in patients with implants. Read Dr. Mithun Sinha's paper in The Aesthetic Surgery Journal. Oxylipins in Breast Implant–Associated Systemic Symptoms (https://academic.oup.com/asj/article/44/10/NP695/7690705) Bio. Mithun Sinha, PhD Dr. Sinha is an Assistant Professor in the Division of Plastic Surgery, Department of Surgery at the Indiana University School of Medicine. His laboratory specializes in the field of bacterial biofilm research. The investigations are focused on implant-associated complications due to biofilms and wound healing complications. These include breast implant-associated systemic immunological manifestations, dental implant-associated peri-implantitis, and orthopedic implant-associated osteomalacia. Studies also include wound healing studies exploring host-biofilm-mediated metabolites. His laboratory explores the development of implant-based biomaterials for their anti-biofilm properties. Over the years, he has actively collaborated with surgeons and chemical and material science engineers. He has been continually funded by NIH and currently have two active grants from NIH as PI (R01 and R21). He has also served/serving on 4 NIH grants as Co-Investigator. He has published 45 articles in peer-reviewed journals, with a Google Scholar citation of 2600+ and an h-index of 20. Seven of his publications have been cited 100+ times. A recent study from his lab on breast implant-associated immunological complications published in the Journal of Clinical Investigation (PMID: 38032740) has received editorial-type commentary from the peer community (PMID: 38299590). In addition to being a researcher, he has served as a reviewer for 15+ peer-reviewed journals. He also serves as Associate Editor for the journal RNA Biology and as an ad-hoc member of the NIH study section and Plastic Surgery Foundation (PSF) study panels. Connect with Dr. Whitfield: Podcast (https://podcasts.apple.com/gb/podcast/breast-implant-illness/id1678143554) Spotify (https://open.spotify.com/show/1SPDripbluZKYsC0rwrBdb?si=23ea2cd9f6734667) TikTok (https://www.tiktok.com/@drrobertwhitfield?_t=8oQyjO25X5i&_r=1) IG (https://www.instagram.com/breastimplantillnessexpert/) FB (https://www.facebook.com/DrRobertWhitfield) Linkedin (https://www.linkedin.com/in/dr-robert-whitfield-md-50775b10/) X.com (https://x.com/rjwhitfield?lang=en) Read this article (https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/implant-reconstruction/illness/breast-implant-illness) Shop Dr. Whitfield's Solutions (https://drrobssolutions.com) SHARP (https://www.harp.health) NVISN Labs (https://nvisnlabs.com/) Get access to Dr. Rob's Favorite Products below: Danger Coffee (https://dangercoffee.com/pages/mold-free-coffee?ref=ztvhyjg) - Use our link for mold-free coffee. JASPR Air Purifier (https://jaspr.co/)- Use code DRROB for the Jaspr Air Purifier. Echo Water (https://echowater.com/)- Get high-quality water with our code DRROB10. BallancerPro (https://ballancerpro.com) - Use code DRROBVIP for the world's leader in lymphatic drainage technology. Ultrahuman (https://www.ultrahuman.com/ring/buy/us/?affiliateCode=drwhitfield)- Use code WHITFIELD10 for the most accurate wearable.

In this podcast episode, Dr. Robert Whitfield, a board-certified plastic surgeon specializing in breast implant illness (BII), and Dr. Mithun Sinha, a PhD scientist, discuss the complexities of Breast Implant Illness. Dr. Whitfield shares his clinical experiences and emphasizes the importance of understanding the symptoms and experiences of women affected by Breast Implant Illness and Dr. Sinha provides scientific insights into the role of fatty acids, bacteria, and biofilm formation concerning breast implants, explaining how these factors contribute to symptoms like fatigue and brain fog. Be sure to tune in to hear more! Show Highlights: Role of Fatty Acids in Cell Structure (00:01:51) The importance of fatty acids in cellular stability and protection Interaction of Fatty Acids and Implants (00:03:20) Discussion on how fatty acids interact with breast implants and surrounding tissue Formation of 10 Home and Biofilms (00:05:20) Dr. Sinha describes how oleic acid transforms into 10 Home, linked to bacterial biofilms. Scar Capsule and Bacterial Colonization (00:06:40) Exploration of how the scar capsule provides a habitat for bacteria to form biofilms Historical Perspective on Surgical Techniques (00:12:40) Dr. Whitfield shares his experience with surgical techniques for patients with breast implant illness. Importance of Research on BII (00:13:41) Lack of attention to women suffering from BII and the need for better care Introduction to Oxaliplatin Home Research (00:14:54) Dr. Sinha introduces his new paper on oxaliplatin home and its link to inflammation Oxidation and Its Effects on the Body (00:16:04) Dr. Sinha explains how oxidation increases during stress and exercise, affecting health Potential Biomarkers for BII Symptoms (00:17:38) Discussion on identifying biomarkers to predict and assess symptoms in BII patients Characterizing Bacterial Contamination (00:19:54) Dr. Whitfield discusses the need to characterize bacterial contamination in patients with implants. Read Dr. Mithun Sinha's paper in The Aesthetic Surgery Journal. Oxylipins in Breast Implant–Associated Systemic Symptoms (https://academic.oup.com/asj/article/44/10/NP695/7690705) Bio. Mithun Sinha, PhD Dr. Sinha is an Assistant Professor in the Division of Plastic Surgery, Department of Surgery at the Indiana University School of Medicine. His laboratory specializes in the field of bacterial biofilm research. The investigations are focused on implant-associated complications due to biofilms and wound healing complications. These include breast implant-associated systemic immunological manifestations, dental implant-associated peri-implantitis, and orthopedic implant-associated osteomalacia. Studies also include wound healing studies exploring host-biofilm-mediated metabolites. His laboratory explores the development of implant-based biomaterials for their anti-biofilm properties. Over the years, he has actively collaborated with surgeons and chemical and material science engineers. He has been continually funded by NIH and currently have two active grants from NIH as PI (R01 and R21). He has also served/serving on 4 NIH grants as Co-Investigator. He has published 45 articles in peer-reviewed journals, with a Google Scholar citation of 2600+ and an h-index of 20. Seven of his publications have been cited 100+ times. A recent study from his lab on breast implant-associated immunological complications published in the Journal of Clinical Investigation (PMID: 38032740) has received editorial-type commentary from the peer community (PMID: 38299590). In addition to being a researcher, he has served as a reviewer for 15+ peer-reviewed journals. He also serves as Associate Editor for the journal RNA Biology and as an ad-hoc member of the NIH study section and Plastic Surgery Foundation (PSF) study panels. Connect with Dr. Whitfield: Podcast (https://podcasts.apple.com/gb/podcast/breast-implant-illness/id1678143554) Spotify (https://open.spotify.com/show/1SPDripbluZKYsC0rwrBdb?si=23ea2cd9f6734667) TikTok (https://www.tiktok.com/@drrobertwhitfield?_t=8oQyjO25X5i&_r=1) IG (https://www.instagram.com/breastimplantillnessexpert/) FB (https://www.facebook.com/DrRobertWhitfield) Linkedin (https://www.linkedin.com/in/dr-robert-whitfield-md-50775b10/) X.com (https://x.com/rjwhitfield?lang=en) Read this article (https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/implant-reconstruction/illness/breast-implant-illness) Shop Dr. Whitfield's Solutions (https://drrobssolutions.com) SHARP (https://www.harp.health) NVISN Labs (https://nvisnlabs.com/) Get access to Dr. Rob's Favorite Products below: Danger Coffee (https://dangercoffee.com/pages/mold-free-coffee?ref=ztvhyjg) - Use our link for mold-free coffee. 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Peripheral neuropathic pain is primarily influenced by the biology and pathophysiology of the underlying structures, peripheral sensory nerves, and their central pathways. In this episode, Kait Nevel, MD speaks with Miroslav Bačkonja, MD, an author of the article “Peripheral Neuropathic Pain,” in the Continuum October 2024 Pain Management in Neurology issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Bačkonja is the clinical director in the Division of Intramural Research at the National Institutes of Health in Bethesda, Maryland. Additional Resources Read the article: Peripheral Neuropathic Pain Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor in Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Nevel: Hello, this is Dr Kait Nevel. Today I'm interviewing Dr Miroslav Backonja about his article on peripheral neuropathic pain, which appears in the October 2024 Continuum issue on pain management and neurology. Welcome to the podcast.  Dr Backonja: Thank you.  Dr Nevel: Misha, can you please introduce yourself to the audience? Dr Backonja: Yes, I'm Miroslav Backonja, but everybody calls me Misha. So everybody knows me by that. I'm a training neurologist, and I also have training as well as certification in pain management. And most of my practice has been where neurology meets the pain, which is neuropathic pain. I spend some time basic science lab and then transition into clinical research. And I was in academia for a couple of decades and was most recently recruited by NCCIH National Center for Complementary and Integrated Health and have been there for two and a half years now.  Dr Nevel: That's wonderful. I would love to hear more about your career at the NCCIH, a little bit and what you do in your role now, and how that came to be. Dr Backonja: Yeah, I was recruited to help and provide clinical support to efforts at NCCIH in the phenotyping of pain and neurologists who've done research in quantitative sensory assessment and other quantitative means of assessment of pain. Coming to NIH was very rewarding and quite of a learning experience. After six months being there, I've discovered that NIH is the biggest secret in plain sight. They say in the plain sight because it's public institution and everything is open to public and it's a secret because we don't think about it. This is in particular in reference to biomedical research training, including clinical trainings. So, I would encourage everybody to think of NIH as a place to spend some time and learn. There are wonderful research opportunities as well as educational opportunities. Vast library of presentations, green rounds and different other types of courses - some of them open to public, and some of them are up to FAS, which is a foundation of advances in science education by discovering. I feel like being back in school and having fun.  Dr Nevel: That's wonderful. Can you share with us a little bit about how you became interested in peripheral neuropathy and pain management of peripheral neuropathic pain?  Dr Backonja: It actually goes back to my residency and fellowship. And actually, you know, I had the luck of being exposed to a couple of clinicians who actually became my mentors. First was Jose Ochoa, who was one of the first people to quote from a small fiber, C fiber specifically, and he also was pioneered in quantitative sensory testing. And the other one was Charles Cleland, who was a psychologist and who pioneered assessment of patient symptoms, developing the Brief Pain Inventory is one of the tools. That actually peaked my interest in the topic of pain and once when I started learning about pain, what is the kind of mysterious experience of humans' pain, turns out that we have learned a lot of science about the pain and can make the pain very accessible. And I hope some of this will come to the chapter that we've provided.  Dr Nevel: Thank you for sharing that. I think of peripheral neuropathy and I think most neurologists think of peripheral neuropathy as one of the bread-and-butter diagnosis within our field. For the practicing neurologist out there who might be listening, what do you think is the most important takeaway from your article that maybe they don't already know about peripheral neuropathic pain? Dr Backonja: When it comes to peripheral neuropathy and peripheral neuropathic pain, it goes back to my early experience and still holds the truth. Neuropathies don't kill people, they just maim them. They create- cause lots of disability and if you add a pain to it, it can be quite disabling. In some regards, it has been neglected the area of development in neurology in terms of scientific discoveries, although things are changing quite rapidly as of recently. Main take home messages, and especially when it comes to a sensory neuropathies and painful neuropathies, is that it's one of the skills that has not been well researched and then not well communicated to the vaccine neurologist in terms of what to do with it. But most neurologist sensory symptoms are just like a noise because, especially when it comes to pain and prosthesias and allodynia and hyperalgesias, like, what is that like? It's just not knowing what to make of it. Frequently associated also with emotional components in terms of the people are either depressed because of persistence of pain or anxious, not knowing what's going on. And that really can create quite a bit of a challenge in terms of what to do with it. But once anybody who's interested learns the fact that sensory neuropathies and fever neuropathies as well could be as well and is easily diagnosed by a neurologist who pays a little bit of attention and gains some skills in assessing not only negative sensory phenomena, because that's what he as a neurologist get trained to detect and quantify sensory deficits as well as motor deficits and loss reflexes. Also, if you pay attention to positive sensory phenomena, which is part of the repertoire of symptoms that patients with neuropathic pain experience, it's not whether patients would have either positive sensory phenomena like prosthesia and pain or negative sensory phenomena. Actually, they have all of them. And that's kind of puzzling for many patients. And lots of times, very patients say, like, how can I hurt when I don't feel like, let's say, like most commonly it's lower extremities. Like I don't feel my feet, but it hurts. I mean, how come? Oh, that's a cardinal feature of neuropathic pain, neuropathic painful neuropathy. Dr Nevel: Yeah, thanks for that. You know, I really thought that your Table 3-1 was really nice. It kind of lists through the common causes of peripheral neuropathic pain and just demonstrates the diversity of the different etiologies or other conditions that can cause neuropathic pain. And so, I encourage the listeners to review that table. But, on that topic, can you share with us what you think are the most important components of evaluating patients with neuropathic pain to maybe come to a diagnosis, to find what the underlying etiology or driver is?  Dr Backonja: When it comes to painful neuropathies, there are actually two problems you have to solve. So, don't forget that part. The first one is finding a pathological theology. Why a person has a neuropathy, what kind of neuropathy. And then second is, what's the nature of the sensory problems? What's the nature of the sensory symptoms, specifically pain, levodenia and hypogesia. So, figuring out the theology of the B12 deficiency or diabetic painful neuropathy, you can relatively quickly or hopefully one would relatively quickly come to that at theological diagnosis. But then the second part is the diagnosis of symptoms. What's the underlying metaphysiology of that. And again, just reminding colleagues that the specific sensory phenomena such as thermal hyperalgesia is now well established to be due to what's called peripheral sensitization of C fibers, which are the small unmyelinated fibers, expressed TP 1 receptors. So, patients who will report that taking a hot shower is very painful. An example of that or when conducting sensory exam and applying if you come to the point of examining the perception of warm and hot and patient affords the pain. That's just the hallmark of the C hurtful sensitizations to C fibrous sensitization. On the other hand, if somebody has mechanical ordinia like putting the shirt on hurts, putting the socks hurts. Well, that's evident to central sensitization. These are the simple, relatively simple but symptoms or signs that could have implication if those patients with central sensitization are more than likely to benefit from medications that restore descending inhibition, such as tricyclic antidepressants or SNRI's. And so just paying attention to that, it gives a clinician being a clinician or a neurologist, like, let me consider prescribing medication that have central A acting properties. Or if it's purpose sensitization, something we have like a sodium channel blocking property, things of that sort. Actually, there are some other strategies such as antagonist TRPV1receptors, the capsaicin base. Those are the kind of things that can help a neurologist kind of take the evaluation of painful neuropathies to the next level. Dr Nevel: Yeah, the- by getting a careful history and exam, that can influence what treatment you prescribe to patients. Understanding whether it's central or peripheral. On the topic of treating patients and talking with patients and evaluating them, what do you think is most important to counsel our patients about who we are treating for neuropathic pain? Dr Backonja: Number one: by getting good history and exam. Well, really in the coming to specific diagnosis is huge relief to the patients who thinks many themselves that they're just going nuts are crazy because nobody else understands these symptoms. So, validation in terms they have a real problem. Second important step is that for the most patients, there is probably reasonable degree of therapeutic interventions that can lead to relief of pain. And also, with applying the integrative approaches with complementary medicine is that patients are given tools to deal with what is otherwise underlying problem. Those two steps make a huge difference.  Dr Nevel: Absolutely. What's the most challenging aspect about managing patients with peripheral neuropathic pain? Dr Backonja: Actually, there are a couple. Number one thus far: we do not have a cure for any other neuropathies or painful neuropathies. So that's one of the big disappointing things one would need to communicate to the patient. The second challenge is actually the therapies that actually for neuropathic pain. There's a half a dozen- yeah, half a dozen FDA approved treatment. One thing that's interesting characteristic that all of them prove proven efficacy in clinical trials. If you scratch the surface, you find out that only 40% of patients obtain 30% pain relief. So, it's a rare patient that gets 100% pain relief, and even those, too, get what we call clinically significant, and then in studies, basically significant benefit. It's only partial penalty. But for the most those who do get the benefit, pain goes down probably enough for them to get some a semblance of normality in terms of having some control over the symptoms and their function. It's then the third challenge is really working through those available therapies to find what works for individual patients because we're not at the point yet where for example, other fields like oncology, you can quickly through the means of biomedical and other evaluation come to the patient specific therapy. So, at this point in time you're far from that. What we end up doing with when it comes to management for painful neuropathies is a trial. Sometimes patients say, well, trial and error. I would say, well, it's a treatment trials. We try one thing at a time, assess the risks and benefits and then there was many treatments that carry the benefit. If you carry it on when once, when they don't or if there's adverse events, side effects, we discontinue them. And then most of the patients end up with a combination of pharmacological and now pharmacological treatments and most of them can get some semblance of symptoms control. Dr Nevel: I really appreciate your point on preparing our patients and you know, expectations and things like that and working with them and looking for things that may help. But also having an understanding that the likelihood of complete pain relief is maybe not a super high chance of complete pain relief.  Dr Backonja: But if you're going back to the kind of preparing patients, it's a good to acknowledge or give a chance to express themselves because many times they patients are confused because they have symptoms that are confusing to them. And so just to have them express it. And for example, my alma mater, we developed the color paint drawing where the different sensory qualities are presented by different colors. And then on the body diagram, patients draw where they have symptoms. And this is probably one of the rare examples where you can literally see a pain because these neurologists can recognize the patterns. You can see the pattern of the motor, right, is multiplex or radiculopathy or the list goes on and on. So, this is one of the kind of tools that's very simple, but gives the patients another way to communicate because lots of times they really have difficulties expressing themselves. Dr Nevel: Right. So, the opposite of the most challenging, can you share with the listeners what you find the most rewarding about taking care of patients with peripheral neuropathic pain? Dr Backonja: What is rewarding is that with some work- and again, it's not easy work because it does require multiple visits and multiple assessments and the reassessments, most patients can get control over their symptoms to the point of coming to beginning some of the functional improvement and aspects of quality of life like sleep and work, they are definitely rewarding and most of the time it's fairly obvious. And again, pain management is definitely a team sport where really, it's important to gauge colleagues. Most of the places don't have what I have had when I was in academic institutions, easy access to health psychologist or physical therapist. Most communities do have those specialties. And many patients actually benefit from things that are what's considered a complementary medicine, such as Tai chi or yoga. And actually, in my practice, Tai chi was probably most common prescription for my patients because, as I tell them, there are multiple benefits. Number one: one of the risks of patients, especially prophyl neuropathies and lower extremities, is a loss of proprioception. Again, even those who have a reasonable preserved proprioception over welding, noise of pain actually makes the problem walking the at risk of falling. Actually, Tai chi one gets improvement in balance. There's also medicating component to it. So, mindfulness medication is kind of built in it and that all kind of gives the patients a better control of symptoms. So, some of those interventions are easily accessible in community. So, it's, again, it's a patient education that really takes important part. Dr Nevel: Yeah. And that Tai chi is maybe one of the answers to the next question that I have for you. But as the clinical director of the Division of Intramural Research at the National Center for Complementary and Integrative Health, I have to ask you, Misha, what sort of integrative and complementary type interventions do you counsel your patients about, maybe beyond Tai chi, and which ones do you think are the most helpful? Dr Backonja: To clarify, the NIH patients I see are all admitted per protocol. Actually, NIH has the largest research hospitals called clinical NIH Clinical Centre, which has a hospital and clinics. All the patients that come to our program, they come per protocol for the most part. They come for specific investigations. At the moment, we do not have intramural treatment protocols, although in near future one of my goals is to establish that. The NIH funds- 90% of funding from NIH goes extramurally to academic institutions and other healthcare organizations and so on, and only 10% goes for intermural research. So, what we do is much smaller in scope, much more focused. So, what do we support NCCIH actually support extramurally full range of anything from probiotics, research in microbiome related to health and pain all the way to interventions such as mindfulness meditation? Intramurally, once when patients come for protocol, we evaluated and it's unavoidable to be a question. So, what do we do now? What recommendations do we make? Again, we don't- with the present time, we have treatment protocols and then, most of the time, what I can do is provide recommendations to the patients when they go back to the treating community, to the treating providers. It's usually a fairly comprehensive list including pharmacological and non-pharmacological accommodations for those who have had experience with pharmacology. Sometimes I can just say yes, continue or change or whatever. But then when it comes to additional complementary accommodations, they always provide information. For example, why do I recommend Tai chi? Or, what's the benefit of yoga and why would one want to try to learn trying to behavioral therapy or mindfulness meditation? What's the benefit of turmeric and some other components of what's called anti-inflammatory diet and what's the rationale behind all of that? So rather than just giving a list of recommendations and leaving it that, I try to engage patients in terms of having to understand why something is recommended, whether the fits with their expectations and what fits with their lifestyle and so on. Dr Nevel: Yeah. So, what's coming up, what's next in painful peripheral neuropathy? What do you think is exciting? Where do you foresee some breakthroughs in this field? Dr Backonja: Probably what will make the most difference is application of some of the really molecular biology tools that are being applied to peripheral neuropathy. So hopefully one of these days you'll have a cure for neuropathy and pain and anything would come to that will be probably interaction between a nervous system and an immune system, in particular neuroinflammation. That's kind of my bias. They're probably that's- well, the answer will be, but many painful neuropathies - actually every painful neuropathy, because they come from, as a result, specific pathologies - are different in a sense of trajectory natural course that will have to be first addressed. And again, depending on the underlying disease and molecular biology of that and genetics of it will determine that. But on the other hand, there are some common denominators, as we talked, when it comes to painful neuropathies, which is drivers of peripheral and central sensitization. And maybe one of these days, we'll find what are those drivers and how to change the system so it does not produce pain and other associated symptoms. Dr Nevel: So once again, today I've been interviewing Dr Miroslav Misha Backonja, whose article on peripheral neuropathic pain appears in the most recent issue of Continuum on pain management in neurology. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining us today. And thank you, Misha, so much for talking with me today about your article. I encourage all of the listeners to read it. It was very comprehensive and just really wonderful to read. Dr Backonja: Thank you. Enjoyed it. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Armando Contreras is the National president and CEO of United Cerebral Palsy Inc. The organization has 55 affiliates, 53 of which are here in the United States and two are in Canada. Armando grew up in East Los Angeles and then attended college at the University of Southern California where he obtained a degree in Business Administration. Later he secured a Master's degree in Divinity from the University of San Francisco.   Armando has worked both in the for profit world as well as for and with several nonprofit organizations. He tells us about all his life adventures including being a cancer survivor now for ten years.   Mr. Contreras and I have a great discussion about his vision for UCP which this year is celebrating its 75th anniversary. Along the way, UCP expanded services beyond just working with persons with Cerebral Palsy. As he explains, the same kinds of services required by people with CP also apply to persons with Downs and Autism.   I hope what Armando discusses with me inspires you as much as it did me. Please let me know what you think.     About the Guest:   Armando A. Contreras is the President and CEO of the Washington, D.C. and Vienna, Virginia-based United Cerebral Palsy Inc., one of the nation's leading health associations providing vital services and advocating for the inclusion of people living with neurodevelopmental disabilities, such as cerebral palsy, autism, and Down syndrome via its 55 affiliates (53 in the U.S. and two in Canada).   A native of Los Angeles, Armando's professional career includes having served as CEO of UCP of Central Arizona, President and CEO of the Arizona Hispanic Chamber of Commerce (AZHCC), Director of the Arizona Registrar of Contractors, and Executive Director of the Council on Small Business under former Arizona Gov. Janet Napolitano.   He was featured in Activator Magazine's March 2021 issue (“A Servant Leader's Faithful Journey”). In November 2016, Arizona Business Magazine recognized him as a top CEO in the nonprofit health sector. In 2015, Armando was named one of the most Influential Minority Business Leaders in Arizona. He was also the featured CEO in the December 2013 issue of Arizona Business Magazine, and the Phoenix Business Journal awarded him a Champions in Diversity award in 2012. Armando was a special guest on The Hill newspaper's virtual Disability Summit, featuring policymakers, business and nonprofit leaders discussing ways to increase employment across the disability community.   Armando attended the Harvard School of Business Strategic Perspectives in Nonprofit Management program. In May 2001, he was honored to meet with President George W. Bush to discuss faith-based and community initiatives during a White House gathering on the topic.   Today, Armando serves on the Board of SourceAmerica. He is a former member of the Bishop's Finance Committee of the Catholic Diocese of Phoenix, and he recently completed a term serving as a member of the Board of Directors of the Kino Border Initiative, a binational organization that promotes U.S.-Mexico border and immigration policies that affirm the dignity of the human person.   Armando earned a bachelor's degree in business administration from the University of Southern California and a master's degree in theology from the University of San Francisco. He also received certificates from the Indiana University School of Philanthropy and Harvard University.   He and his wife, Norma Contreras, live in Phoenix, where they are active in the community, particularly contributing their time and talents to faith-based social justice issues. The couple has three adult children and a grandson with another grandson on the way.       About the Host:   Michael Hingson is a New York Times best-selling author, international lecturer, and Chief Vision Officer for accessiBe. Michael, blind since birth, survived the 9/11 attacks with the help of his guide dog Roselle. This story is the subject of his best-selling book, Thunder Dog.   Michael gives over 100 presentations around the world each year speaking to influential groups such as Exxon Mobile, AT&T, Federal Express, Scripps College, Rutgers University, Children's Hospital, and the American Red Cross just to name a few. He is Ambassador for the National Braille Literacy Campaign for the National Federation of the Blind and also serves as Ambassador for the American Humane Association's 2012 Hero Dog Awards.   https://michaelhingson.com https://www.facebook.com/michael.hingson.author.speaker/ https://twitter.com/mhingson https://www.youtube.com/user/mhingson https://www.linkedin.com/in/michaelhingson/   accessiBe Links https://accessibe.com/ https://www.youtube.com/c/accessiBe https://www.linkedin.com/company/accessibe/mycompany/   https://www.facebook.com/accessibe/       Thanks for listening!   Thanks so much for listening to our podcast! If you enjoyed this episode and think that others could benefit from listening, please share it using the social media buttons on this page. Do you have some feedback or questions about this episode? Leave a comment in the section below!   Subscribe to the podcast   If you would like to get automatic updates of new podcast episodes, you can subscribe to the podcast on Apple Podcasts or Stitcher. You can subscribe in your favorite podcast app. You can also support our podcast through our tip jar https://tips.pinecast.com/jar/unstoppable-mindset .   Leave us an Apple Podcasts review   Ratings and reviews from our listeners are extremely valuable to us and greatly appreciated. They help our podcast rank higher on Apple Podcasts, which exposes our show to more awesome listeners like you. If you have a minute, please leave an honest review on Apple Podcasts.       Transcription Notes:   Michael Hingson ** 00:00 Access Cast and accessiBe Initiative presents Unstoppable Mindset. The podcast where inclusion, diversity and the unexpected meet. Hi, I'm Michael Hingson, Chief Vision Officer for accessiBe and the author of the number one New York Times bestselling book, Thunder dog, the story of a blind man, his guide dog and the triumph of trust. Thanks for joining me on my podcast as we explore our own blinding fears of inclusion unacceptance and our resistance to change. We will discover the idea that no matter the situation, or the people we encounter, our own fears, and prejudices often are our strongest barriers to moving forward. The unstoppable mindset podcast is sponsored by accessiBe, that's a c c e s s i capital B e. Visit www.accessibe.com to learn how you can make your website accessible for persons with disabilities. And to help make the internet fully inclusive by the year 2025. Glad you dropped by we're happy to meet you and to have you here with us.   Michael Hingson ** 01:21 Welcome to another edition of unstoppable mindset where inclusion, diversity and the unexpected meet, and I won't go through all that again, it's inclusion because that means we include disabilities. Diversity typically doesn't, but the unexpected is what we get to deal with a lot as well. It's all fun, and we're glad that you're able to be here with us, wherever you happen to be. Our guest today is Armando Contreras, who is the president of United Cerebral Palsy, Inc, and I'm really anxious to hear more about that keeps keeps him, and I think a lot of us busy, and there's a lot of good stories and very relevant things to talk about regarding that. So let's get to it, Armando, I want to thank you and really appreciate you being here. Michael,   Armando Contreras ** 02:06 it's such a pleasure, and really it's an honor that I can be here on your show. So thank you for the kind invitation. Well, you   Michael Hingson ** 02:15 are. You're certainly most welcome, and Armando is one of those people who came to us again because of Sheldon Lewis here at accessibe, and he's he's keeping us busy, which is a good thing, and he's probably working on getting Armando to use accessibe, unless you already are with UCP. I haven't checked the website lately. Well, we   Armando Contreras ** 02:33 have. So we've already put in that, I believe, a plugin, and some of our affiliates are actually using accessibe as well,   Michael Hingson ** 02:43 which is cool, and it does a lot to help, which is, of course, what it's all about. Because accessibe, using AI, is able to do a lot of the work with the AI widget, not all, but a lot that needs to be done. So it's really great that you guys are using it, and I appreciate that and thank you for it, or on behalf of all of us at accessibe, yeah,   Armando Contreras ** 03:04 you're welcome. Well,   Michael Hingson ** 03:06 why don't we start as I love to do at the beginning? Why don't tell us a little bit about kind of the early Armando growing up and all that sort of stuff? Yes, so might as well,   Armando Contreras ** 03:18 yeah, the early Armando, growing up, was in East Los Angeles, in East LA so my father had a disability for most of his life. He had a he was in a car accident, and the doctors had said he would never work again. And right about that time when he had that car accident. I was born. I was the first, the oldest of three and my brother Louis and my sister Elizabeth. So life really changed for him, because he was middle class entrepreneur in Mexico, while he was American citizen. Then when he married my mom, then they moved over to Los Angeles, and eventually East Los Angeles, and that's where I grew up. I grew up pretty much in, you can say, in poverty. And while we were in a neighborhood called in Barrio, it's just a neighborhood of of, really, for the most part, a lot of good people. Our neighbors were fantastic, and we knew each other. So that was kind of like the beginning of many years of really, you know, experiencing disabilities with my dad and seeing what he had gone through. And it was a it was a tough, really. It was a tough. It was tough growing up, let me put it to you that way, for for many reasons. So then later, I got involved with the Catholic Church, Saint Lucy. Catholic Church in Los Angeles or a small town called City terrace, and that kind of that really changed a lot for me, as far as getting involved with community issues, getting involved in helping people, getting involved in connecting with the kind of the local issues that were happening in the city of Los Angeles, because those priests, those Catholic priests, were very involved in that, in ministries, and they went outside of the ministries to help community members, regardless if they were Catholic or not, what. And prior to that, I got involved as a musician. So I was a trumpet player, and I played trumpet at St Lucy's church for about 23 years. But then that that did something, something of sort of a miracle for me, because when I applied after going to a junior college in Los Angeles College, and then I applied to a dream university, USC, so the University of Southern California, and I think one of the big reasons that I got in was because of my community involvement, so that that led to a full scholarship, and that was quite the blessing for me, because there was no way that that we can afford me going to a private university. So, you know, that's kind of like, in the nutshell, my my upbringing, otherwise I would be here three days, you know,   Michael Hingson ** 06:30 yeah, what year? What years were you at USC,   Armando Contreras ** 06:34 I was there. I was there in 8085 through 87 ish, around that time? Yeah, around that that time? Yeah, I graduated in 87   Michael Hingson ** 06:46 that's that's much beyond my favorite USC football game, which was, how was it? I think Notre Dame was leading SC 24 to nothing at the end of the first half. You know, the game, I can tell by the end, it was 55 to 24 USC, which is the way it should be.   Armando Contreras ** 07:07 You know, SC had his great moments, and sc has had their challenging moments. Has Yeah. So, you know, last year, it could have been a better year for us. But, you know, we look to the future. And like I always say, don't fight on. So fight on   Michael Hingson ** 07:23 is right. My wife did her graduate work at SC I've never been to a football game there or anywhere, and one of these days, I'd love to go, but she just passed away in November of 2022 we were married for 40 years, but I've already been an SC fan before I married her, and one of my favorite SC stories is that the day we got married, we arrived at the church, and it was supposed to be a wedding that would pack the church. A lot of people wanted to come and see us get together, but the wedding was supposed to start at four o'clock, and like the church was less than half full on about 412 suddenly the doors opened, and this whole crowd came in, and the wedding went forward, only about 15 minutes late. Later, we tried to find out what it was that kept people away for so long. And what we heard was everyone was in their cars waiting for the end of the USC Notre Dame game. And since SC one, it was that God clearly was on our side.   Armando Contreras ** 08:25 I love that. Yeah, it's a great story. And my my sister, condolences for loss.   Michael Hingson ** 08:31 Well, thank you. You know she her body was just slowing down. She was in a wheelchair her whole life, and just in 2022, things were kind of catching up. And as I say, the spirit tends to move ahead of the body sometimes, and that's what happened. But she's watching somewhere, and if I misbehave, I'll hear about it. I'm not at all worried I'm going to try to be a good kid. But that's great that she did go to USC, and you said something else. I think that's really interesting to me, and that is that where you grew up, people were very nice and very friendly. And I think that is so often true, and a lot of times people stray into some of these areas and they think it's going to be horrible, and they they look for the worst, and they find it because they're not looking for the best. They're not looking to try to find friendly people and and it's so unfortunate that too many, too many times, we don't really look for the best in people. And unfortunately, then it comes out.   Armando Contreras ** 09:34 Well, you know, I I could only say great things about East LA and the barrio that I, that I grew up in, were there elements in there? Of course, sure you were, we were about a block away from from the gang activity, and you just had a choice, right? And thanks to my parents that were super strict, they didn't, they didn't allow me to make those kind of choices when I was younger. You know. To join the gangs, but that element was in front of you, you know, and some of them, some of the folks I still know today, some of them that were in gangs and stuff, now they've settled down. They have families, but I just have to say that there was a sense of community there where I grew up, even, even, or despite the elements that were around us. So yes, do I hear the negativity when they somebody mentions East Los Angeles? Yes, but I could, I have to say that even though we grew up in poverty and even though there was a lot of challenges for us as a family, I I really cherish the neighbors that were there. When I remember that the kind of those gatherings, we had nothing. So there was no we played, you know, with just a regular basketball or something. There was no communication via a cell phone or anything like that. Yeah. So, you know, I have only good things to say. And part of my upbringing there today, I realized that wow, I was I was working on a strategic plan without even knowing what a strategic plan was back in the day. Yeah.   Michael Hingson ** 11:17 Do you think that today it's harder, or there's more of that kind of activity, or is it just that people are now having their attention drawn more to it, and again, still, I think all too often deal with it in such a negative way. But do you think it's worse than it was?   Armando Contreras ** 11:36 I mean, if we're talking about, if we're talking about gang activity. I mean that still, I think, is just as prominent that today, unfortunately, than what it was this as it was back. You know, when I grew up in the night, in the 60s, I believe that leaders, community leaders, our representatives, really have to invest into communities, invest in education, invest in in jobs, right? Because people, naturally, some of them, will start looking for a way of making a living, and they may choose a different route. In addition to that, gangs and they become a family. So, you know, parents do need to, you know, also be aware of what their kids are doing, and support them and and nurture them and show them love, right? And because, if you really get to the bottom of it, and you start speaking to a gang member, she or he, there's underlining problems, and maybe comes from family. You know, there could be so many things that are happening, but I truly have a vision that that someday there's going to be more funds invested into communities like East Los Angeles, because a lot of great people come out of there, and I'm not talking about myself, but there's just a lot of good people, good hearted people, that really like to help their neighbor and others. When   Michael Hingson ** 13:10 I was selling in New York, when still living in California, and would go back and spend days at a time, I stayed at a particular hotel in midtown Manhattan, Near Time Square, and if I went out at night, every so often, somebody would come up and he would say, I'm one of the guardian angels. You're familiar with them? Yes. And he said, I'm with guardian angels. I want to walk with you. And I said, you know, you don't need to. And he said, I want to. And I didn't mind, but what I always felt and and experienced was if I treated people right, if I treated people like people, if I was I was treated like someone, and I didn't really need to fear any of the other kinds of things. Now, I'm sure there were crazies around, but in general, I really do think that if we would be a little bit more open to just accepting and not fear so much those things that we don't understand, or those kinds of communities that we're not as knowledgeable about, and I'm not so much thinking of the gangs, but just all the other communities, like East LA and watts and so on, we would be a whole lot better off, and we would learn to get along with people better.   Armando Contreras ** 14:31 I totally agree with that. I think it's building relationships, right, and getting to help and getting to know, you know, folks from different ethnicities, people with different abilities, right? It all comes together. Here is that, knowing them, respecting them, listening for understanding, and then building a friendship, right? And collaborating together. Um. For the betterment of humanity. That's what I believe, where it's at, and everybody has an opportunity to do that.   Michael Hingson ** 15:08 Yeah, and I just think that we, we, we somehow also need to get the politics out of providing the funds. And I don't know, it's just people have locked themselves into some very hard political decisions sometimes that that don't help the process at all.   Armando Contreras ** 15:26 Yeah? Michael, so yes, yes. Part of it is yes, taking out the politics, but the other part of it is bringing in the politics right? Is letting our our representatives, our public officials, and on the local level, on the municipality level, state level, on the federal level, to bring them in and know what the issues are, because we're all part of the fabric of society. Yeah, all somehow we do give, and we do contribute, and I don't, I don't care what ethnicity, what religion you are, if you if you have a disability, if you don't have a disability, we're all part of the society, and I believe that our representatives really need to know that and how we contribute in a very big way.   Michael Hingson ** 16:16 I think the biggest part is they need to be open to listening to hear that some do, some don't. And I am a firm believer in the fact that over time, all the issues that we need to deal with will get dealt with.   Armando Contreras ** 16:30 I believe so too, and I think those that those that don't listen to communities, for whatever reason it is that eventually somebody in their family or them may end up in that situation themselves, and then, you know, they'll begin to have that lived experience. But while they've had a chance to make a difference, and if they ignore it, then there was a window of opportunity for them to do something.   Michael Hingson ** 17:01 Yeah, well, and, and if they choose to ignore that again, I believe that things will will happen to deal with that, whatever it is, and hopefully it it doesn't a negative, horrible thing that has to happen to make them realize it. But I think in some cases, that has been what has occurred. But I have a lot of faith in the human race. Yes, so do I. Well, so you, what was your degree in from USC?   Armando Contreras ** 17:29 It was in business administration.   Michael Hingson ** 17:32 Ah. And did you go to any football games?   Armando Contreras ** 17:35 I did, yeah, good   Michael Hingson ** 17:36 for you. My wife did too. Yeah.   Armando Contreras ** 17:38 And, and most recently, most recently, I've gone to the last two USC UCLA games. So last year, it was great. It was fantastic. We were at the Rose Bowl at, you know, in UCLA territory this year, not so good. We were so good, not so good. We were at home at the Coliseum. And, you know, it didn't, it didn't work at a while, but it was a fun game. I   Michael Hingson ** 18:04 don't know, what do you think of the coach?   Armando Contreras ** 18:07 Um, I think that he's good, and I think that he will continue to be successful this year, this next year. I think it will be better this year. Yeah, I think so. And they got this young, this young man that showed up at the at the bowl game. I'm trying to remember Miller. I think it was Miller, and it was his name, and he showed up. He was a he, he did a fantastic job. And I do see a great future for him at USC and perhaps in in the in the NFL.   Michael Hingson ** 18:40 Well, it'll be fun. I know they got a new defensive coordinator and that they needed, so we'll, we'll see how it goes. But we won't bore everyone with football and our likes, but it's nevertheless, it's part of the world. So there you go, but then you went on to the University of San Francisco, right?   Armando Contreras ** 19:01 I did. So that was a few years later, and I graduated, I believe, in 2004 and I it was, it was something that drew me, and it was an opportunity for me to get a degree in Theology at a Jesuit university. So at that time, I was working for a faith based Catholic organization, a national organization called the National Catholic council for Hispanic ministry. And what we looked at overall in the United States were the issues of upper mobility for Hispanic Catholics for immigrants, or for our sisters and brothers that are immigrants, the issues that are happening with Hispanic families, education was a huge thing. You know, how do we how do we move, you know, our children that from, you know, grammar school to. Catholic high schools and perhaps Catholic universities were, yeah, unfortunate. Unfortunately, I have to say, is that there's not a whole lot of access, and we're the backbone of the Catholic Church, right? Because it's so expensive. So those were the things that that we were part of, and one of the opportunities that came about was attending the University of San Francisco and and I received, you know, I earned a degree in theology, master's degree, yes,   Michael Hingson ** 20:32 well, let's go back a little bit. So you graduated from SC then what did you do?   Armando Contreras ** 20:37 Well, then I had several jobs after that. I worked for a nonprofit in Los Angeles that helped people get jobs. And then after that, I believe, I went into a construction company as a contract administrator. I was here for maybe a year and a half or so, and then I went on for whatever reason I was interested in real estate. So then I worked for a corporation that did mortgage loans. And in that I met a gentleman who had his own real estate company, and then we decided to start our own real estate company. So I did that for about seven, seven years, and then I I got hired to work with this nonprofit, the National Catholic council that I just mentioned a little bit ago. I was there for about 10 and a half years. So I had I had a chance to travel around the nation and to meet with Hispanic Catholic leaders, lay leaders. I got to meet with religious orders of men and women from Jesuits, Franciscans, many other different orders. So it was, it was really a insightful time for me in those 10 and a half years about our church. And then after that, we moved from Los Angeles to Phoenix. And shortly after that, I got hired. Let's see here. I'm trying to remember the I got hired by governor Janet Napolitano, but I was her small business advocate, and in about 11 months, I moved into being a deputy director of a one of her departments, the Arizona register of contractors, and soon after that, I was on her cabinet. So I was honored to serve under Janet Napolitano when she moved to Washington, DC, because President Barack Obama appointed her as Secretary of Homeland Security. Then I moved on to the Hispanic Chamber of Commerce, here Arizona, Hispanic Chamber of Commerce. And then about a year later, then that's where I had folks come to me and said, there's an organization here that is the United Cerebral Palsy association of central Arizona. And I said, Well, I'm going to maybe put the word out and see who might be interested in that position, which was a CEO position. And then they said, No, we're looking for somebody like you. So to make a long story short, I got hired. And that was really a beginning of of a lot of things. I got hired not because I had the clinical background, or the researcher background, or that I had been involved with disabilities. I got hired so then I can take take that organization to another level, where they wanted to increase the revenues, they wanted to increase their brand awareness. They wanted to make sure that we had stronger collaborations in the community in Arizona, in in Phoenix, and that's why I got hired, to make sure that we enhance that to benefit the children and adults that we were serving.   Michael Hingson ** 24:05 Well. So what do you think about the differences since you've been in a position to have done both working in the for profit corporate kind of world, as opposed to working in the the nonprofit sector? That's,   Armando Contreras ** 24:21 that's Michael. That's a really interesting question, because there are similarities,   Michael Hingson ** 24:27 I know, and I've done the same thing. I've worked for both as well. Well,   Armando Contreras ** 24:31 look, you know, I'm working for a nonprofit, and those that are going to be listening to this, that are CEOs are working in development for both for profits and nonprofits. There's not a whole there's not a big difference there. Because we strive to be sustainable, like a for profit. We strive to look at years to come, because we want to be around and help people in the next 1015, 75, Years which we we're celebrating this year, our 75th anniversary. So part of our responsibility as a leader, as a president and CEO, is really looking beyond the years that you're going to be there. You can, you can serve for one year, 10 years, 20 years, 30 years. But really the i i truly believe that the test is, once you leave, will that organization continue to survive because of what you put together? So to answer your question, a lot of similarities between a for profit and a non profit. However, at the end of the day, the mission for us is to not make a profit, but to be sustainable so we can continue our life saving work   Michael Hingson ** 25:49 and for not, not for profits. Nonprofits generally tend to work more in an arena where they're trying to make a social difference. And although they're they're still selling products. The products are different. They're oftentimes less tangible, although a lot of the services that that they provide, like UCB, UCP provides and so on, end up being very tangible, but still there's there's an intangibility, but still, I agree with you that the reality is that they're very similar. Development is extremely similar to what a for profit company does. And in reality, when you're in development, you're in sales, and when you're in sales, you're in development, it's just that people have come up with two words for the same thing, but they're so similar in what you ultimately are trying to get from them, and ultimately, how you present to people who you want to be your customers or your donors, is so much the same as well.   Armando Contreras ** 27:00 Yeah, I agree with you, Michael, so in development, because I also have a background in fundraising, it's aligning with the folks that have the same vision and that would want to contribute for an impact that's happening in society. So with United Cerebral Palsy and our affiliates are providing direct services to children and adults with cerebral palsy and many other conditions. So there are people that are very, very generous, but I have to say that in the world of philanthropy now, donors are becoming a lot more informed, and they want to make sure that the dollar that they're going to donate, that it's going to go a long way. Yeah, so obviously they're looking at at administrative costs versus your program program costs, right? And that's a good thing. I encourage the philanthropic community to do that, to do their research and to pick those nonprofits in the United States or maybe around the world that are really making a huge impact. Michael, we we serve 100 and approximately 155,000 children and adults on an annual basis, and this is our affiliates that are working day in and day out to provide those services, vital services, life saving services, and services that maybe other organizations don't or people don't want to do. So those are the things that that people that are going to invest their return is really what's happening in the lives of 1000s and hundreds of 1000s of people. Many,   Michael Hingson ** 28:45 many years ago, I remember watching a little bit of a telethon. It was actually on Channel 13 out here, kcop, and it was back in what had to be the early to mid 80s, I think, and it was a telethon put on by the Society for the Prevention of blindness, which I don't even know whether they're around anymore, but at the end of the telethon, they had raised, I think, like $200,000 it was a local, Just independent television station doing it. But what we learned was that 95% of the cost of the telethon went to pay for it, and that the organization only ended up with about 5% of that $200,000 which is, of course, a real problem.   Armando Contreras ** 29:39 It is so like I mentioned before, is that today you're having more informed donors, right, that are looking at that ratio, right? Yeah, how much of their dollar is going to go to actual services, right? Versus cost for putting on a. For putting like you mentioned, a telethon today, there's not a whole lot of telethons going on. Have a million channels, but back in the day, I remember the channels 13, 574, and maybe 11 nine. Yeah, 11 nine. So there was a few more today. What do you have? 234, 100, and then more and all of that. There's other ways that I certainly believe that that can be as impactful and less expensive than the telethons. But sure, you bring up a really good point, is that if you're going to, if you're a donor, if you're a philanthropist, if you really want to have your money change people's lives, they have to do some homework. Yeah, they have to look at that nonprofit and to make sure that 90% of your dollars not going into it, and 90% is not going into it, administrative expenses. It   Michael Hingson ** 30:55 may well be that that 90% works or maybe a little bit less. You're spending a little bit more money on administration, if you can justify it, to say, but look out of that we are able to reach more people and thus get more money. But I do think it's, it's a it's a tight rope.   Armando Contreras ** 31:20 Yeah, I definitely agree with that, that you have to be strategic when you're out fundraising and your your case statement really has to be where it's so compelling that and then showing the data and and and bringing children and adults to tell their story, right of how their lives have been changed. Those are the storytelling is really part, one part, or a major part, of development and fundraising.   Michael Hingson ** 31:56 Well, tell us a little bit about UCP, the history and so on, if you would to inform more people about it.   Armando Contreras ** 32:02 Well, one, you know, I'm, I'm so excited to share with everybody that we're celebrating our 75th anniversary, right? Uh, 75 years of providing vital services, right? 75 years of having our direct service professionals, the folks that are working at home, under the home community based services. We have we have pre Ks, the different therapies that are out there. We have group homes, we have transportation, we have employment. There's so many things that we're bringing to the community. But it started in 1949 right? It started with concerned citizens and concerned parents, that they felt that in that time, which was a totally different world for people with disabilities, that they felt that something more had to happen, that no more can society or the doctors or people in authority can say, would your kids have to go to an institution no matter if they had Down syndrome? Well, maybe autism wasn't. Were so prevalent back then, maybe not as prevalent, but cerebral palsy, spinal bifid, all of that that their kids suddenly were taken away from their home.   Michael Hingson ** 33:22 Well, my parents were told by our doctors that they should send me to a home when it was discovered I was blind, and my parents rejected that, which was very fortunate, but   Armando Contreras ** 33:32 yeah, and good for your parents. And that's how it started, right? I think, I think a lot of nonprofits started in that way, but back in 1949 that's when a group of parents got together and said, we have to do something more right. Then today, we've evolved where we're in the disability world, there's greater access than there was before, there's more inclusion than there was before, right? We're trying at least that used because UCP national and our affiliates, we're trying to help people be more independent, if it's through legislation, research, therapies, everything that we're trying to do. And we're very we're very centric to those issues that are out there, and we're trying to make a huge difference. So what I'm looking at is, I'm looking at another 75 years and that United Cerebral Palsy. One we're trying to in here. Four goals. One is brand awareness. Also let folks know about our 75th year anniversary. But one of the bigger things Michael that is the challenge for us is that United Cerebral Palsy serves children and adults with cerebral palsy and other conditions, so we're trying to bring that message out. And figuring out, how can we let the community know that if your child has Down syndrome autism, that we are there providing vital services for for them as well. The next goal is development, or what we just spoke about, connecting with the philanthropic community, because we, while a lot of our affiliates rely on government funding and reimbursement, I believe that there's another level that we have to engage with, and that's the philanthropic community right. There are millions and millions of dollars. Michael, I go to this to a an event called the heckling event in Orlando, I've been going there for now five years, and those professionals that are working with Planned Giving, some of them will come to me and say that their clients don't know where to give their money to. That's why we're present there, and that's why other profits are there too, as well. Is that we need to educate the community that that you can actually invest in something that's going to bring back this return of investment, but more of a humanity return, and something that's going to be great for society. The other goal that we have is advocacy. So we're known throughout the federal government, the Biden administration, as well as the Trump administration community, communicated with us, especially during COVID So we had communications with the White House. We still do. We're engaged at the Congress and Senate level with various representatives and senators to make sure that they create legislation that's going to be beneficial for our for the for the disability community, and that we don't ever go back to the institutions that that would be their only option. Unfortunately, Michael, today, there's still institutions that exist, not as many as before, but there's still institution the last goal we have is to grow our footprint, not only nationally, but but internationally. So we're having discussions locally, in places that were not present, to grow our footprint, to see how we can collaborate. We're also having, I'm having conversations with people on the global level, like the International cerebral palsy society, like aacpdm, the Academy for cerebral palsy. I've been invited twice, once, well, I got invited last year to the International Congress on cerebral palsy in Mexico City, I got invited again. I was their president, and I gave a speech. And I got invited again this year, in March, I'll be in medida Yucatan at an international congress again, and that brings a lot of awareness for us, brand awareness, and the main thing is really collaboration. So I kind of touched upon some of the some of the goals, Michael, and some of the things that important things and vital things that our affiliates are doing. So if there's, if there's something else that you want me to elaborate, I'd be glad, more than glad to do. So how are   Michael Hingson ** 38:19 you working toward creating more and better brand awareness to the general population?   Armando Contreras ** 38:27 Well, one of the things that we're doing, given that we have this window of opportunity that we're celebrating our 75th year, and that begins in that started in February, and we'll go all the way through January 31 is that one, we have a lot of partners out there that are doing things like you're doing access to be right, that invited me on this program. And that's one of the beautiful things that in social media, it's not it's not very expensive for us to be out there. So we're using the media vehicles such as LinkedIn, Facebook and the others that are out there. And we're also using YouTube to spread the message out there. So we're we're also sharing the stories of our affiliates and their accomplishments and the people that are being served, the parents and their children, so they can share those great stories that sometimes are miracle stories because of the people that are serving them and providing quality services, care and love. So that's one vehicle. The other one is that I I was on 26 I traveled to 26 locations last year, so I'm also providing that message out there. And then within our affiliate network, they're also doing marketing, and they're doing. Brand awareness as well. So it's a whole it's really this whole core nation that we want, not only the nation, no, but globally. Let the people know who is you at UCP and United Cerebral Palsy,   Michael Hingson ** 40:16 what caused UCP to add in as part of the services that are provided, services for people with downs and autism, as opposed to just UCP   Armando Contreras ** 40:32 or UCP. Yeah, so if I go back to when I was at the local United Cerebral Palsy the UC central Arizona. It just happened to be that the programs, the same programs that were provided for children and adults with cerebral palsy, also were beneficial to other conditions. I'm not a researcher, but when there's a breakthrough in cerebral palsy or in autism or in a different condition, they try to see if that same breakthrough will help people with different conditions. What we do know is that the therapies that are being offered to children and adults with cerebral palsy, those same types of therapies are also impactful to other conditions. So what was happening is that, then parents started to to, I guess, the word went out, and what we have across the board in the United States is that we have a high percentage of non cerebral palsy clients, or we'll call them family members, that are are getting services because that's much needed. One Michael is like respite, like respite care. You know any, any family can use that rest, that respite care, no matter what the condition is. So if you're offering that, then you can offer it to the disability community, a broad range of of people that have various conditions,   Michael Hingson ** 42:13 which makes perfect sense, because a lot of the care that needs to be provided is very similar. Well, or is the same? Yes, well, you know, you, I understand, had a an involvement with cancer, and you survived that. How has that affected you and in your attitude? Because, clearly, you're a very sensitive person and very much involved in community and family and helping people. But what, what was the whole situation with you in cancer?   Armando Contreras ** 42:42 You know, I think it's that. I think that's, it's the experience that all people go through when they first hear that you have cancer, right? First thought is, are you going to survive? You know, the first, first thing that comes to you is that it's, it's terminal, right? You're not going to get through it. You know this when you hear news like that, and you know, maybe it's the same as parents hearing that their child has cerebral palsy or disability, you know, you just, you just, it's a scary moment. It's a scary time. So what? Yeah, it was a difficult time for me and for my family, especially, I think my family knowing that I had transitional carcinoma, high grade, and it was a it was a tumor in my bladder that was nine and a half centimeters. I haven't really talked about it a lot, but it's been 10 years. So February, when I had seen that as a suggestion, like you want to talk about that, my first thought was, No, I think I'm going to skip it. But a few seconds later, I said, maybe it's time for me to share with the community, because it's been 10 years since I was diagnosed so and I'll try to make this short, I got diagnosed huge tumor. They had asked me if I wanted that tumor to be taken out, otherwise I could die. And I said, of course. So they took out the tumor. I had a brilliant surgeon that did that. And then after that, they basically said to me that if I don't, if I don't do radical surgery, taking out my bladder, taking out some lymph nodes, my prostate, that I wouldn't live very long, that I had really, like a 35% chance or less to live. So I had said that I wanted to put a pause on this rush, and that perhaps there's an option out there, perhaps there was another way, because I knew that billions of dollars have been raised for cancer. And maybe because this is a whole new journey for me, that the cure was somewhere out there. Well, after going to five different doctors for second opinions, they all said the same to me, that I only had one choice, and that choice radical surgery. And even after that, even after that, I was still I was confused, I was scared, but I was still. There was a pause that I felt that maybe there was something out there. So thanks to my sister, she really saved my life. She connected me with the scientists that she was researching, and that scientist said, you know, I only, I've only done lab studies on this particular oil called frankincense oil. I haven't done any clinical studies, and today, Michael, there's still no clinical studies on frankincense oil. So I started doing that three months after they they took the tumor out. I had 20 more tumors come back in my bladder. But they were small. They were lesions. So I just asked them to scrape, scrape them. The doctors were furious with me. I get it. I mean, that was, that was a protocol. I totally get it, you know. But something, people say that I had a lot of courage. I'm not sure if it was, like just something, it could have been something was telling you. I mean, I definitely there was a lot of prayer during that time. Yeah, a lot of prayer happening at that time. I just couldn't see myself dying, and I didn't want that to happen. So just to kind of, like, kind of close on this is that when those 20 tumors came back, they scraped them. They were supposed to be a lot more coming back, or it was going to invade my body. Three months later, I had nothing, absolutely nothing. Three months after that, I had six lesions come back, and that was March of 2015, so it's been nine years since the last reoccurrence. It's been 10 years since I was diagnosed, and I get checked very often. Once a year in the beginning, I would go in and get checked every three months. So it's been quite the miracle. But I have to say, this is that one I changed. I had changed my diet at the time for about four and a half years, I was strictly doing a lot of juicing, no sugar, a lot of prayer, a lot of family love, a lot of support. I did the frankincense oil. So I think in a comprehensive way, that helped me, and that gave me another option. And I'm very grateful for that, and I'm very grateful that every day I wake up and I say to God, thank you for sparing me. But on the advocacy side, Michael, I just didn't leave it there. I've had conversations with with the with the University of Arizona, with the Arizona State University, with Cancer Centers of America, with St Joseph's Hospital, with my alma mater, USC, and the last conversation I had was with Georgetown University, and these were top CEOs. And I was sharing my documentation, because I have it all there. But sadly, I have to say that they're not interested. They're not interested in a cure, and I'll continue to pursue it when the opportunity continues on, but it's only my story, and I didn't want to leave it where. Well, Lord, thank you so much. You know it never came back, so thank you. No, I have a responsibility to figure out some ways, somehow, that my my story, can turn into a clinical study, and that someday, and maybe not in my my time, that there's going to be an option for millions of people that will contract cancers. So that's my story in a nutshell. Thank you for asking.   Michael Hingson ** 49:04 So what did the frankincense oil actually do? I assume that you feel it was a very significant part of your ability to deal with it.   Armando Contreras ** 49:12 Yeah, it's a good question, because medically, I can't tell you, because we haven't done right? Yeah, we haven't done clinical studies. And I've been, I've been asking these universities and these hospitals and these cancer firms, you know that are out there, and said, Why don't we do the clinical studies so you can so you can see exactly what it did. I can't tell you that what it did. The only thing I can tell you is that is that as they, as they as they took samples of the cancerous tumors. So you had the big tumor, and then the 20 small tumors, and then you had the six lesions that, according to the scientists, dr, dr Lynn, HK Lynn, what he did see is that the cancer cells were becoming less aggressive. And at the end, some of the cancer cells actually turn into good cells. Now, you know, people can believe that or not. I'm I'm okay with that. Sure, only thing I'm saying, Michael is that there should be, there should be clinical studies on this, because I believe it would save hundreds of 1000s of lives. What was it? We don't know. Was it the combination? Is it the combination of me juicing on a daily basis for four and a half years? Was it that, as a Catholic, you know, I was going through all the different sacraments, prayers and healing masses? So I believe there was a holistic healing process. And then my family that was supporting me during a very difficult time,   Michael Hingson ** 50:49 sounds to me like it's time to write a book.   Armando Contreras ** 50:54 I've I've been asked many times, and I think when I think, when, when I feel that, that when I'm ready for that, that, yeah, that's that will happen.   Michael Hingson ** 51:03 Yes, you've got to, you've got to feel ready and feel that it's the right time. But that might be one way to bring visibility to it. Yes, well, you know, you you value family a lot. I understand that there are music connections in your family, has music always been a part of your life or   Armando Contreras ** 51:24 or, yeah, I think I think so. I think that. Well, I know so, because when I was the trumpet player, young trumpet player at St Lucy's Catholic Church, a few years later, my lovely wife, Norma, joined the choir. I didn't know she was married, but she joined the choir. And you know, we have this thing that she doesn't agree with me, but I say, hey, when I when I met you, when I seen you, was love at first sight. And and I said, but not for you. It took a while. And she says, no, no, but so So music, I was playing trumpet, normal was singing. And then later we got married, and then we had our first child. Was Andrea, Andrea Michelle, our daughter, our beautiful daughter, who's with child today, her and her husband, Fabian. So she knew that in our home there was a lot of music happening, and if it was church or at home. And then our second child, Armando, Michael, he started catching on a little bit, but we started to notice that he started to sing and sing right in tune. And then we said, hey, maybe there's something here. So his first recital in Los Angeles, he's saying pop by the Sailor Man and over the rainbow. And he did pretty good. So later he joined as a as a young child, you know, five years old, he joined the choir at St Lucy's. And then we moved. We moved from, we moved from Los Angeles over to Phoenix, Arizona, which was a great blessing being here. And we then were exploring how we can continue to support his talent. And he joined the Grammy Award winning Phoenix boys choir, and that's where he began to sing. Got to meet some wonderful people. They had wonderful directors there, and had a great experience. That experience led him to fall in love with the classics. Oh, there he began to be part of some of the local, local opera performances. So to make a long story short, Norma, my wife and I supported him. He went to the Cleveland Institute of Music, from there in vocals, and then from there, he went to the University of Missouri in Kansas City for his masters. And today he's a professional opera singer. He's a baritone. So it's it's been amazing. All our kids are amazing. I also have to mention that our youngest Andrew, Matthew. He went to Gonzaga University and then graduated from Lewis and Clark in clinical psychology. He's worked with a lot of kids with disabilities. He's a drummer and he's a guitar player. So yes, music is a big part of our family.   Michael Hingson ** 54:28 Well, it is getting to be that time of the year that Gonzaga will become visible again as we get back down to march madness. I actually, I actually had the pleasure of going up there once to speak and and I hadn't really known a lot about Gonzaga at the time, and they were the ones who told me, however, one always said, Where is Gonzaga? You know what? What kind of a place is it? And so I've kept up with it ever since, but it is kind of funny that their basketball team is good. Yeah.   Armando Contreras ** 54:59 Yeah, it's a, it's a beautiful place. It's a great Jesuit university. We, I, you know, he had a great experience. This is Andrew. He had a great experience out there. So, yes, I totally agree. Yeah, we had a chance to go out to Bob, trying to remember the city here. Spokane, yeah, yeah, yeah. Spokane, various times with him,   Michael Hingson ** 55:25 that's pretty cool. Well, so is he professionally doing music now? No, so,   Armando Contreras ** 55:30 So Andrew, our youngest, he's professionally now a clinical psychologist. Ah, yeah, now and now. Armando, Michael, he is a professional opera singer, right? And that's what he does. So, you know, his, his, one of his dreams, is going to be singing at the Metropolitan Ooh, we do see that perhaps happening within a year or two, because they he'll be, right? He'll be auditioning for that, probably very soon, and he's very young. He's just 34 years old.   Michael Hingson ** 56:03 So that'd be super What would you like people to know about the disability community in general, when we think about disabilities, you know, when there's so many prejudices, what would you like people to know and in terms of disabilities and how to maybe change attitudes, yeah,   Armando Contreras ** 56:23 well, they're definitely part of the fabric of society, and we, nobody, not me, or anybody else in in any organization, can speak for them. We need to allow for them and give them that opportunity and space to voice their concerns, to voice whatever joy they have, to voice things that we need to hear in our community. We have to provide while we're here in the United States, and there's been laws that have been enacted, enacted that laws now have to be updated. We have antiquated laws that do not even pay people with disabilities even minimum wage, right? So, so that we really have to be conscious of a community that is part of our society. We need to engage. Furthermore, we have to collaborate. We need them as public, public officials. They need to run for office, right? Some of them do. They have to be part of the decision making, decisions that are being made from all levels of government, all levels of corporation, all levels of nonprofits. And that's the way, that's the way I really see it. Is that, and we also have to have breakthroughs in research, right? What are some of the things that that we can do so we can those lives can be more that they would have more of a more access, right? That even if you go to certain states in the United States that I've been, there's not even accessibility for wheelchairs. And just speak about the airlines, right? How, how and why are people thinking in those corporations that a person that has a disability can easily go into their bathrooms. There's no way, right flying, especially if it's a long flight. So no, there's, there's been some great things Michael that have, that have evolved and happened through a collaboration of a lot of advocates, and a lot of them are self advocates, but we still have a long way to go.   Michael Hingson ** 59:08 Yeah, and I think that's absolutely true. So what is UCP Inc doing to celebrate its 75th anniversary? What kinds of plans do you have and where do you go from here?   Armando Contreras ** 59:19 Well, we do have a an annual conference coming up in Orlando, and this year in April. So that's a good thing for us, you know. But the bigger thing for us is to celebrate is really bringing that education, bringing that awareness of what we're doing, not only in here in the United States, but we also have affiliates in Canada. So as we celebrate, part of our celebration is educating the society about exactly what we do and please, you know, knock on our door for for help. So that's that's really part of it. The other part of it is acknowledge. Gene, the folks that started UCP back in 1949 right? Like the, like the golden sins, and also the housemans and many others that that have helped us get through the 75 years.   Michael Hingson ** 1:00:18 Yeah, well, it's, a great milestone to be able to celebrate 75 years, and I am sure that you, with your background, is very concerned about making sure that there is great sustainability for the future, which is really important and cool that you're thinking about that, because it's something that always needs to be with us in whatever we're doing. That's a good thing. Any kind of last thoughts that you have that you want to convey to people who are listening or watching us.   Armando Contreras ** 1:00:51 Yes, one is first, I want to share my gratitude for inviting me, Michael. And then second, please reach out to us the disability community. Please find us@ucp.org we may be in your backyard. If there are organizations out there that want to become an affiliate of United Cerebral Palsy, please reach out to us as well. We are here. We want to continue to be here for the next 75 years, so that our community can be part and be an inclusive part of our society. That we can bring that help, bring that independence, but we can continue to see those miracles, that children that we're told, and families that were told that they would never walk. I've seen them walk, and were physicians that said to a mom and dad that their child would never move or never speak, and I've seen them hug their parents and tell them that they love them, right? And we want to continue to make those miracles happen through therapies, through early detection, through early intervention, all these forms of of of a reach that we have through United Cerebral Palsy in the United States and Canada and and watched for us in the near future as we begin to go global, and that's really a vision that that I have. But and also, again, is that it's important to know that we know that I know that, Michael, you know that is that everybody is a fabric at society, some way, somehow, no matter their abilities. And that's really important, important message for people to know.   Michael Hingson ** 1:02:43 I agree. Well, I want to thank you for being here with us and conveying all this information, and I hope people will take it to heart and that they'll support UCP and and reach out and learn more about the organization and that you are doing, and will continue to do a lot to just help people in general, with disabilities, which is cool. I appreciate that, and I want to thank Go ahead. No, no.   Armando Contreras ** 1:03:10 I just wanted to thank and I also want to thank accessibe, right? That's how we got here. So I really thank them for what they're doing and providing. I love their model that they have. They have a for profit, a for profit model. However, the services that they, that they provide for nonprofits, are free, and that's that's amazing. So we're really happy with the services, the access services for websites, the accessibility that they're providing for people in the disability community to have that access. Well,   Michael Hingson ** 1:03:48 thank you, and we're excited about the time ahead and and I think that's that's a good thing, and we'll all work to make it happen. Well, I want to thank everyone who was listening and watching today. We really appreciate it. I hope that you'll give us a five star rating wherever you're observing our podcast. We value that. Love it. If you'd reach out to me, give me your thoughts, your opinions and Armando for you and for all of our guests, our listeners and so on today, if you know of anyone else who ought to be a guest on unstoppable mindset, please let us know. Provide introductions. We're always looking for guests. You can reach out to me directly at Michael H, i@accessibe.com that's m, I, C, H, A, E, L, H, I at accessibe, A, C, C, E, S, S, I, B, e.com, or go to our podcast page, www dot Michael hinkson.com/podcast, and Michael Hinkson is spelled M, I C, H, A, E, L, H, I N, G, S o, n.com/podcast, so we really do value all the thoughts and and information and suggestions that people provide. Yeah, as I think I've mentioned to many of you before, I also do travel and speak, especially after September 11, 2001 if anyone needs a speaker, please reach out. You can get me easiest at speaker at Michael hingson.com but however you do it, you've got all sorts of ways to reach out to me. Love to hear from you. And you know, once again, Armando, I want to thank you very much for being here, and thank you for all of your time today.   Armando Contreras ** 1:05:24 Michael, thank you many blessings to you and your family, and many blessings to everybody out there who is going to listen to this podcast interview.   Michael Hingson ** 1:05:39 You have been listening to the Unstoppable Mindset podcast. Thanks for dropping by. I hope that you'll join us again next week, and in future weeks for upcoming episodes. To subscribe to our podcast and to learn about upcoming episodes, please visit www dot Michael hingson.com slash podcast. Michael Hingson is spelled m i c h a e l h i n g s o n. While you're on the site., please use the form there to recommend people who we ought to interview in upcoming editions of the show. And also, we ask you and urge you to invite your friends to join us in the future. If you know of any one or any organization needing a speaker for an event, please email me at speaker at Michael hingson.com. I appreciate it very much. To learn more about the concept of blinded by fear, please visit www dot Michael hingson.com forward slash blinded by fear and while you're there, feel free to pick up a copy of my free eBook entitled blinded by fear. The unstoppable mindset podcast is provided by access cast an initiative of accessiBe and is sponsored by accessiBe. Please visit www.accessibe.com . AccessiBe is spelled a c c e s s i b e. There you can learn all about how you can make your website inclusive for all persons with disabilities and how you can help make the internet fully inclusive by 2025. Thanks again for Listening. Please come back and visit us again next week.

Learn the business and management skills you need by enrolling in the University of Tennessee Physician Executive MBA program at nonclinicalphysicians.com/physicianmba. Get the FREE GUIDE to 10 Nonclinical Careers at nonclinicalphysicians.com/freeguide. Get a list of 70 nontraditional jobs at nonclinicalphysicians.com/70jobs.                                                              =============== Dr. Tod Stillson earned his medical degree at the Indiana University School of Medicine. He then completed a Family Medicine Residency and a one-year fellowship focusing on Obstetrics at the Roanoke Memorial Hospital in Roanoke, Virginia. He has practiced Family Medicine in North Central Indiana for almost 30 years, initially as an employee of the local hospital. About 10 years ago he discovered he could practice under a professional services agreement with the hospital system, so he incorporated and began working as a mini-corporation. That opened up many opportunities for him resulting in more autonomy and a higher income. He has now created several resources to help educate other physicians about incorporating and contracting with employers in this new way. These include a book called Doctor Incorporated: Stop the Insanity of Traditional Employment and Preserve Your Professional Autonomy, a blog, a membership program, free e-books, and consultation services. This week's podcast is Part 1 of the 2-Part interview, which concludes with Episode 375 of the Physician Nonclinical Careers Podcast in one week. You will find all of the links mentioned in the episode at nonclinicalphysicians.com/win-as-a-micro-corporation/ 

Click here to send us a topic idea or question for Weekend Wisdom.Teens and sex are a scary topic for lots of parents. How can we impact our kids' decisions and what do we say? Join our conversation today with Dr. Debby Herbenick, a Provost Professor at the Indiana University School of Public Health-Bloomington, where she leads the National Survey of Sexual Health and Behavior. She is the author of Yes Your Kid: What Parents Need to Know About Today's Teens and Sex.In this episode, we cover:What do you believe a parent's role should be in sex education?How do you become an askable parent?How to talk with our kids about sex without sounding overly judgmental but also convey your values.5 minutes a week conversations.The importance of having high-quality books on puberty and sexuality around the house.When to start talking about sex with kids?How to talk with young people about consentImpact of technology (internet, social media, ubiquitous cell phones, etc.) on sexual development.What are reasonable parental rules surrounding technology usage?Taking and sharing sexual images--how common?How should parents even start talking with their child about nude images?At what age should we start this conversationHow to share the downsidePornography or sexually explicit mediaHow common do kids access porn, and at what ages?Is viewing porn bad for kids?At what age should parents start talking with kids about pornography?What should parents say about porn?How to keep our kids from viewing porn?How to respond if we catch our kid watching porn or know that they have viewed it?Having these discussions when we haven't had a lifetime of raising this child?Support the showPlease leave us a rating or review. This podcast is produced by www.CreatingaFamily.org. We are a national non-profit with the mission to strengthen and inspire adoptive, foster & kinship parents and the professionals who support them.Creating a Family brings you the following trauma-informed, expert-based content: Weekly podcasts Weekly articles/blog posts Resource pages on all aspects of family building

Basic knowledge of the common CNS manifestations of rheumatologic diseases and sarcoidosis is important. In the context of many systemic inflammatory diseases, CNS disease may be a presenting feature or occur without systemic manifestations of the disease, making familiarity with these diseases even more important. In this episode, Kait Nevel, MD speaks with Jennifer A. McCombe, MD, author of the article “Neurologic Manifestations of Rheumatologic Disorders,” in the Continuum® August 2024 Autoimmune Neurology issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. McCombe is an associate professor in the Division of Neurology, Department of Medicine at the University of Alberta, Edmonton in Alberta, Canada. Additional Resources Read the article: Neurologic Manifestations of Rheumatologic Disorders Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Guest: @Div_Dubey Transcript Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology.  Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME.   Dr Nevel: Hello. This is Dr Kait Nevel. Today, I'm interviewing Dr Jennifer McCombe about her article on neurosarcoidosis and neurologic involvement of rheumatological disorders, which appears in the August 2024 Continuum issue on autoimmune neurology. Welcome to the podcast, and I would love to have you introduce yourself to the audience.   Dr McCombe: Well, thank you, and thank you for having me. As you said, my name is Jen McCombe. I'm a neurologist in Edmonton, Alberta, Canada, where I spend kind of a third of my time in teaching roles (I coordinate the undergraduate block for our medical school there), I spend about a third of my time in a neuroinflammatory clinic in Edmonton, Alberta, and then about a third of my time doing clinical research.   Dr Nevel: Wonderful. Well, thank you so much for being here today and for chatting with me about your article on this topic.   Dr McCombe: Thank you for having me.   Dr Nevel: To start off, can you share with the listeners a little bit about your career path?   Dr McCombe: Absolutely. Yeah. So, I've had, uh, a bit of a circuitous career path. I did my medical school in Queens (which is in Eastern Canada, in Kingston, Ontario) and then went back to Edmonton, Alberta, for my residency (in Canada, we have a five-year residency program, so a little bit different than the US), but finished my residency and then did a master's degree in Public Health at Johns Hopkins while completing clinical research in HIV, actually, and did this thing we call the Clinical Scholar Training Program – so, kind of like a fellowship, but a little bit more, you know, research and academic-based. So, when I first started, I was focused more on neuroinfectious diseases, and that's kind of what my career path looked like at the time - but, actually, shortly after I finished my residency program, I also had my first child, and he, unfortunately, developed opsoclonus-myoclonus syndrome, and at the time (this was in 2010), it was a rather rare condition, so, I ended up finding myself having to become a bit of a neuroinflammatory disease specialist at the same time. So, at that point, I transitioned into working in the neuroinflammatory clinic with some mentorship but was getting all of the kind of weird and wonderful referrals and diagnostic dilemmas from my colleagues who recognized I kind of developed some expertise, and so decided (actually, mid-career) to take a sabbatical, and in 2021, completed a fellowship in autoimmune neurology at the Mayo Clinic. So, I finished that quite recently and then went back, and now I'm feeling much more, I guess, confident, too. Sometimes, you wonder about, you know, the choices you're making. I recognize most of the conditions I'm dealing with don't have, in fact, any evidence for their treatment, and that was confirmed when I went to the Mayo Clinic and found that, really, it was just trying to gain an understanding of the disease process to make a rational choice to medications and treatments. So, now, I'm back and kind of trying to focus a little bit more on some clinical research in that area since I've kind of solidified that expertise.   Dr Nevel: Wow. Well, thank you for sharing with us your career path and how, you know, unexpected life events kind of changed your interests or molded your interests (changed kind of the things that you became expert in, you know), and being fluid in your career path and willing to kind of take a break and reassess and get additional training. That's really inspiring to, I think, to me, and probably to a lot of listeners, that you can always, you know, develop more expertise in the more niche area or additional area no matter where you are in your stage of life or career path.   Dr McCombe: Yeah.   Dr Nevel: So, can you tell us a little bit more about - you know, you shared with us kind of autoimmune inflammatory disorders and how you became interested in that, neurosarcoidosis, specifically (you know the article focuses on that), and what's your background in neurosarcoidosis, how you became interested in that specifically and in neurologic manifestations of rheumatologic disorders?   Dr McCombe: I started in our neuroinflammatory clinic over a decade ago, and, you know, at the time, a lot of the expertise in any of these neuroinflammatory disorders was quite spread out over the country, and so, as I kind to alluded to before, often some of the more complicated patients where there wasn't necessarily clear-cut evidence or even, you know, a fellowship path to get there, I would end up getting referrals for - and so, I developed quite a cohort of patients with central nervous system primarily, but other types of neuroinflammatory and autoimmune neurologic diseases, and part of that cohort was a rather large (and still growing) group of patients with neurosarcoidosis. And so, I kind of developed some practical expertise, although, as you can see in the article (and as I'm sure you all know), the approach to the treatment is extremely variable. One of the most telling things is when we were at the Mayo Clinic, one of my co-fellows actually pulled all of the neurologists in neuroinflammation at all of the Mayo Clinic sites and asked them, you know, what is your treatment approach to a patient with neurosarcoidosis, and I think got twelve completely different responses as to the medications chosen and the length of time for the tapers and things like that. So, you know, it is very much a part of neurologic disease treatment that we still really don't have great evidence for, and although we do have some kind of rational choices that we can make based on other types of evidence, so -   Dr Nevel: Yeah.   Dr McCombe: And I enjoy working with patients with these types of diseases where we can kind of work together to come up with a treatment plan that makes sense for them and also makes sense based on whatever evidence we do have at this time.   Dr Nevel: Yeah. So, moving on to the article a little bit, knowing that this is a area of neurology where there's a lot of, you know, maybe personal expertise and experience but not a ton of data or evidence to necessarily guide our standardization to our treatments and approach, what do you think is the most important clinical takeaway from your article for our listeners?   Dr McCombe: Well, I mentioned before I coordinate the neuro block for our undergraduate program here, so I've developed over the years (I've been doing that for a number of years) a curriculum that's all based on, kind of, that approach to - and I like to do it that way because it's very practical. I like the students to be able to basically take their class notes and then go to the emergency department on their first shift as a clerk and, you know, use their approach to headache that I've developed for them to kind of take a clinical history and examine a patient with that sort of problem. And so, similar to that, I tried to do an approach to, you know, a couple of the more common presentations that would make you think of a rheumatologic condition or neurosarcoidosis in looking at the approach to CNS vasculitis and the approach to, uh, pachymeningitis - and these are difficult differentials for lots of neurologists, because it really relies on a lot of medicine knowledge, and we graduate from our residencies slightly more confident in our medicine knowledge, because we get a lot of that in our residencies. But as neurologists, as we go through our careers, we get much more confident in our areas of specialty, and at least for myself and many of my colleagues, much less confident in other things like general medicine. And so, it's difficult, because you have to face your areas of potentially less confident knowledge and really think about that in the differential - and so, I think, you know, I put those two big “approach to” sections in there, because they're the most relevant for the conditions that I was covering. But, I think also what I would say to a learner or a more experienced neurologist who might be reading the article, kind of pick out the little things that you might add to your own kind of approach to - you know, when you see that person with an ataxia, remember that Sjogren syndrome is one of the things you might consider that could be a treatable cause, or you want to see a sensory neuronopathy, don't just think paraneoplastic – again, Sjogren syndrome. So, kind of pick out those little pearls and add them to your approach to that patient that we all see, and I think that would be my biggest takeaway.   Dr Nevel: Yeah. Thank you. So, kind of like, keep this information from the article in mind so that you keep rheumatologic disorders in mind as a possibility when you're approaching a patient with whatever neurologic symptoms they're presenting with. So, what do you think is challenging? You kind of already mentioned a little bit, you know, just that it stretches us maybe into the medicine arena and so maybe stretches our medical knowledge, especially as we become more subspecialized or focused in neurology - but what is challenging about identifying, diagnosing neurologic symptoms as being related or due to an underlying rheumatologic disorder?   Dr McCombe: Absolutely. Yeah. Well, as you said, you know, it forces us to kind of face that medicine stuff that we might not be as comfortable with, but I think what else is challenging is that, sometimes, those medical clues aren't there. For the rheumatologic disorders for the most part, they are. Sjogren's is potentially a little bit different in that, potentially, the symptoms are less obvious or a little bit more subtle. But, in particular, with neurosarcoidosis, there's a distinct proportion of the patients that won't, in fact, have any systemic complications of their underlying disease, and so, you have to think about it even when the clues aren't there. That's why you have to add it to those kind of differential diagnoses where it might be considered, because those systemic clues that we all rely on when we do our review of systems and we ask about rashes and joint pain and lung issues, and these sorts of things may not be there - and so, you still have to think about it even when it might be completely isolated to the central nervous system.   Dr Nevel: What is our understanding of why some patients with rheumatologic disorders develop neurologic involvement? Do we have an understanding? Do we know why some patients do and some patients don't? I know that's, you know, kind of, uh - that's a tough question, but that was something that I thought of as I was reading your article, like, why does this happen to some people?   Dr McCombe: Absolutely. I mean, I think, potentially, it's a little bit more clear for some of them, like rheumatoid arthritis, because, typically, if you develop a CNS complication of this, it's, in fact, just because you've had the disease for a very long time, and often, it's uncontrolled, and so you think about the disease “spreading” now to the central nervous system - but for other conditions, like neurosarcoidosis, it is much less clear, and even if you look at the epidemiologic patterns for that, it makes it even more muddied in that in some populations, it appears that they develop more central nervous system disease, whereas in others, less. And so, why that is the case and why certain individuals might develop this complication of these diseases I think is yet to be seen.   Dr Nevel: Yeah, that's always the crux of things if we can figure out the why, then maybe we could prevent it, right?   Dr McCombe: Million-dollar question always.   Dr Nevel: Always. So, what do you find the most intriguing about neurologic involvement of rheumatologic disorders?   Dr McCombe: Well, I think one of the things that, really, I mean, for neurosarcoidosis in particular, so many patients do so well, and that's what I really like about it. You know, you see patients who present with an incredible burden of disease radiologically, and yet, don't look nearly as sick as they should when they're sitting in front of you. And then, you start them on therapies and some of them do so well, and even those with relatively devastating deficits, or moderate disease who do have neurologic symptoms, have a remarkable improvement in their neurologic symptoms with treatment. And so, that's always something that's quite rewarding when you get to see these patients in follow-up, and they're generally quite thankful because they're doing so well. And it's different from many of the neurologic diseases that we treat. I mean, in autoimmune neurology, we're lucky because we do have a number of diseases that are quite treatable and patients can have wonderful outcomes. But, you know, it's always scary when we see patients with devastating neurologic signs and it's great to see improvement with treatment. And so, that really draws me to it.   Dr Nevel: Yeah, absolutely. That's really rewarding when you're able to help somebody get better in such a profound way.   Dr McCombe: Mm hmm.   Dr Nevel: What is one common misconception about neurologic manifestations of rheumatologic disorders? Or what do you think is not well understood by treating clinicians?   Dr McCombe: I think probably one of the things I see the most is, sometimes, an undertreatment of the patient. And so, I see patients who, you know, other clinicians may have seen and have made the diagnosis, and perhaps it's a lack of confidence in the diagnosis and so they kind of want somebody else with a subspecialty to kind of confirm the diagnosis, but that treatment hasn't been initiated despite pathological confirmation on biopsy of another tissue. And these patients, like I alluded to before, they do well, but you need to treat them and you need to treat them adequately, and when their symptoms are quite impairing, you need to treat them adequately now. And so I think, sometimes, that delay in starting a second-line therapy and relying on steroids for too long - those sorts of things can really expose a patient to a lot of different side effects and to a lot of different complications that they may not have had, too. So, that's why I spent some time focusing on the treatment, because I think just gaining a little bit of comfort with some of these more common second-line medications is a good thing, because starting those early, I think, makes sense because you can really save the patient a lot. And then, the other thing, too, is that when you're using steroids, think about all of the systemic things that you're causing - think about the increased risk of infection and the fact that you need to prophylax for certain infections, think about bone health, think about protecting the lining of someone's stomach - so not only kind of thinking about your disease in isolation and what you need to do for treatment, but that you need to ensure that you're appropriately prescribing the patient all of the things they need to do to protect themselves during these times.   Dr Nevel: Yeah. I think that's so important. And I'm glad that you brought that up, because I think, unfortunately, many of us have seen a patient who ended up having PJP pneumonia (or something like that) because they weren't put on antibiotic coverage for prolonged steroid use or, you know, bone health - all of that is really important to think about. So, this may be entering a territory where there's no, you know, great evidence, but you mentioned, you know, starting kind of that maintenance or second-line agent - when do you decide to do that in patients? And maybe we can focus (since it gets a little broad), but, you know, in a patient with neurosarcoidosis, let's say - when you're starting the steroids, when do you decide, okay, this person is also going to need a maintenance therapy? Is that something that you do at the beginning when you're starting the steroids, or is that something that you think about later on depending on how their course goes?   Dr McCombe: Yeah. In my practice, I do it at the outset - again, because I'm quite focused on, you know, as soon as I get them on it, getting people off steroids - and so I start essentially almost all of my patients on it unless there's some other contraindication or complication to their disease. And because I deal with central nervous system complications in the vast majority of my patients, I'm starting a TNF-a inhibitor as well as methotrexate, and that's because I see a lot of patients with cord disease and significant brain disease, and so I want to treat them kind of more aggressively from the outset. And so, typically, they'll be on steroids, um, a TNF-a inhibitor, as well as methotrexate, and then I just back off, actually, as they do well. And so, I try to taper the steroids quite quickly over the course of just a number of weeks, or kind of two to three months at most. I maintain the TNF-a inhibitor, and then in some patients, depending on how they're doing, I might eventually stop the methotrexate. Some patients tolerate it so well that we don't for a number of months - other patients want to try to minimize their medications as quick as they can. So, that's my personal practice. In the province where I live, we don't have to worry about access to these medications, and so I understand that that might be an issue in some centers where people practice and have different access and different funding. Of course, I live in a country where we have universal healthcare, and in our province, I have very good access to these medications and they're funded from my patients regardless of socioeconomic status, and so I have the luxury of making these choices and I understand that other people might not, but that's my personal practice and I find it works quite well in the vast majority of patients.   Dr Nevel: Yeah. And you bring up a really good point that, you know, access to some of these medications for patients with CNS manifestations of sarcoidosis, neurosarcoidosis, sometimes can be challenging to treating the patient with medications that you feel like would be best for them. But that's wonderful that you don't have those access issues where you live. How long do you typically continue the TNF-a inhibitor in patients, since you mentioned, you know, tapering off the steroids, tapering off the methotrexate, potentially depending on patient tolerance and course. What's your approach to the TNF-a inhibitor?   Dr McCombe: Yeah, so, of course I follow them clinically, and then radiologically as well, and it's really satisfying if you can see the resolution of their symptoms as well as resolution of the abnormalities and the MRI, so I let that guide me a little bit. But, in most patients, I keep them on therapy for about one to two years, and then at that point, see if I can cease it in some patients. And I, again, continue to follow them radiologically and clinically after I cease it so that I can ensure that I'm catching their disease more quickly if it does come back and then can just reinitiate therapy, but in lots of patients you're able to stop the medication and they have persisting, kind of, disease freedom after that, and so they don't need to be on anything.   Dr Nevel: Yeah, great. And I'm almost hesitant to focus so much on neurosarcoidosis. (It was the rheumatologic manifestation that you talked about the most in your article.) I'm going to put in a plug for everybody to read your article so that they can read about neurologic manifestations of rheumatoid arthritis, Sjogren's, lupus, Behcet's - many more things. But focusing on neurosarcoidosis, it can be difficult in my experience to definitively diagnose, and people who have neurosarcoidosis particularly, and people who don't seem to have any systemic manifestations or, you know, imaging findings consistent with sarcoidosis - can you share your approach with us? And you outlined this in your article nicely, too, but your personal approach to patients with suspected neurosarcoidosis, and how you make that clinical decision to treat somebody with possible neurosarcoidosis, somebody who maybe you're not able to get pathologic evidence on?   Dr McCombe: Absolutely. Yeah, those ones are difficult. And, you know, whenever possible (as I mentioned in my article), I think pathological evidence of a diagnosis is important, because then when you find yourself a year down the road and a treatment path and you have uncertainty, it's much more difficult to consider continuing medications that can have quite a number of side effects when you're not absolutely certain about that diagnosis. But, in some patients, you know, I've had patients who might have nondiagnostic biopsies (if you attempt to do a biopsy), or they have disease in a site that really just isn't amenable to biopsy, or they have some other reason they can't have a biopsy. So, how I approach that is that, you know, if you think about possible neurosarcoidosis similar to any other nondiagnosed, you know, blow out-like lesion (for lack of a better term) in the CNS, if it's steroid-responsive, I think that kind of going down a path of treating it as a steroid-responsive lesion is kind of the approach that I take - so the diagnosis in the chart might be possible neurosarcoidosis, but in the back of my mind, I'm just thinking of kind of a steroid-responsive nondiagnostic or idiopathic lesion. So, I then follow that up typically with something like methotrexate (so, a more broader- spectrum immunosuppressant-type medication), and if the methotrexate is able to maintain the response that the steroids initiated, then eventually get them off the steroids. And so, you know, if I think about my patients that I've treated in the past, if they have a diagnosis of possible neurosarcoidosis, I probably don't start a TNF-a inhibitor as quickly in them, because in the back of my mind, I'm always wondering what type of inflammatory lesion this is, but that steroid responsiveness really helps me decide to start a second-line or maintenance therapy and then, typically, in those patients, as I mentioned, I'll start something like methotrexate a little bit more soon.   Dr Nevel: Yeah, great. Thanks for sharing that with us. So, what do you think comes next in this field? What excites you? Where do you think our next kind of development or understanding or breakthrough, whether it's diagnostic or treatment-wise?   Dr McCombe: I think, in the field, you know, any immunologic diseases, we've been really gaining a much better understanding of pathophysiology, and that's honestly what excites me the most, when you can know precisely what part of the immune system is at play here (whether it's, you know, complement-mediated or antibody-mediated) and then being able to then rationally choose medications based on a really clear understanding of the disease is something that I think is kind of novel in a way. For so many years, we would use kind of big broad-spectrum immunosuppression - even in multiple sclerosis, still, we use medications that, historically, we've found to be helpful - but we don't have a great understanding sometimes of why the medicines work. So, kind of going at it from the other way, where we're actually determining what is the exact pathophysiology of disease and then making a rational approach to a therapy, or choosing a therapy based on that, I think is what excites me the most, and I think we'll gain a better understanding of even a broader swath of diseases and be able to make those choices more often. That's what I like about this field.   Dr Nevel: Great. Well, thank you so much for sharing that - and looking forward to the future in this area of neurology. And thanks so much for talking with me today and sharing your story and your expertise and knowledge.   Dr McCombe: Well, thank you for having me. It's been fun.   Dr Nevel: And I encourage all the listeners to read your article. Again, today, I've been interviewing Dr Jennifer McCombe, whose article on neurosarcoidosis and neurologic involvement of rheumatologic disorders appears in the most recent issue of Continuum on autoimmune neurology. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today.   Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at Continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Stand Up is a daily podcast. I book,host,edit, post and promote new episodes with brilliant guests every day. Please subscribe now for as little as 5$ and gain access to a community of over 700 awesome, curious, kind, funny, brilliant, generous souls Read Dr Carroll piece we discuss What Obesity Drugs and Antidepressants Have in Common Dr. Aaron E. Carroll is President & CEO of AcademyHealth. A nationally recognized thought leader, science communicator, pediatrician, and health services researcher, he is a passionate advocate for the creation and use of evidence to improve health and health care for all.  Before joining AcademyHealth, Dr. Carroll was a Distinguished Professor of Pediatrics and Chief Health Officer at Indiana University, where he also served as Associate Dean for Research Mentoring and the director of the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University School of Medicine. He earned a B.A. in chemistry from Amherst College, an MD from the University of Pennsylvania School of Medicine, and an M.S. in health services from the University of Washington School of Public Health, where he was also a Robert Wood Johnson Clinical Scholar. Dr. Carroll's research focused on the study of information technology to improve pediatric care, decision analysis, and areas of health policy including cost-effectiveness of care and health care financing reform. He is the author of The Bad Food Bible and the co-author of three additional books on medical myths. In addition to having been a regular contributor to The New York Times and The Atlantic, he has written for many other major media outlets and is co-Editor-in-Chief at The Incidental Economist, an evidence-based health policy blog. He also has a popular YouTube channel and podcast called Healthcare Triage, where he talks about health research and health policy. Pete on Threads Pete on Tik Tok Pete on YouTube  Pete on Twitter Pete On Instagram Pete Personal FB page Stand Up with Pete FB page All things Jon Carroll  Follow and Support Pete Coe Buy Ava's Art  Hire DJ Monzyk to build your website or help you with Marketing

Guest: Debby Herbernick, Ph.D.  Dr. Debby Herbenick is an internationally recognized sexual and reproductive health professor, researcher, and educator. She is a Provost Professor at the Indiana University School of Public Health and director of the Center for Sexual Health Promotion. For more than 20 years, she has dedicated her efforts to understanding how people experience their bodies and sexual lives. Among her 200+ peer-reviewed scientific publications, she has published on population-level sexual health issues (including Zika knowledge and adolescent/young adult sexuality education), college sexual health, and changing sexual behavior trends. Dr. Herbenick has also developed and validated measurement scales to assess genital self-image (which can be thought of as how people feel about their genitals and is relevant to people's willingness to seek healthcare) as well as sexual pleasure. Sites & Socials: Center for Sexual Health Promotion Yes, Your Kids Because It Feels Good The Coregasm Workout Read My Lips Sex Made Easy Additional Sites: AASECT Sex Etc. Dr. Candice Nicole ----more----

Strangulation, often misnamed "choking" (that's when something's stuck in your throat, not when someone's pressing on it), is trending in the sex lives of college-age kids, and that's a problem. Apparently, the thought is that if it's consensual, it's safe. Tell that to your brain cells that really need blood and oxygen at all times.  Dr. Debby Herbenick is a Provost Professor at the Indiana University School of Public Health and director of the Center for Sexual Health Promotion who's been studying sexual health and changing sexual behavior trends for the past two decades. She's also the author of Yes, Your Kid: What Parents Need to Know About Today's Teens and Sex and she has a lot to share on this topic. We need to talk about why young people are consenting to this and why some of them aren't—but think they need to just go along with it because it's become so normalized. And we need to talk about the risks. There is no safe way to strangle someone. Strangulation is the number one lethality indicator when abuse is present, and it's a pretty thin line between doing it for funsies and doing it for power and control.  You can read more in Amanda's story with Dr. Herbenick on DomesticShelters.org: "Being Choked During Sex Is Rising in Popularity Among Young People." And for more on talking to to your teen about sex, revisit Episode 13: Having the Sex Talk with Teens Featuring Shafia Zaloom.  Do you have a story you think we need to discuss or a guest we should have on? Visit us at ToxicthePodcast.com and tell us all about it.  As always, if you are experiencing abuse or domestic violence, please consider disclosing to someone you trust. You can also reach out to a trained domestic violence advocate—find one near you at DomesticShelters.org. We would so appreciate it if you could help us spread this conversation further by leaving us a review so the algorithm will suggest us to more people. We'd also love it if you could share your favorite episode with a friend, coworker, a random stranger in line at the grocery store, etc. Thank you, friend. 

We pulled out another favorite out this week - Dr. Zanotti's deep-dive on tracheostomy emergencies. Tracheostomies are common in ICU patients. Every intensivist should be capable of recognizing and providing initial management to potentially serious complications associated with tracheostomies. Dr. Zanotti is joined by Drs. Laura Bontempo and Sara Manning, emergency physicians and educators with a special interest in the topic. Dr. Laura Bontempo is an associate professor of emergency medicine and serves as Assistant Director for Faculty Development & Resident Education in the Department of Emergency Medicine at the University of Maryland Medical School. Dr. Sara Manning is an Assistant Professor of Clinical Emergency Medicine, in the Department of Emergency Medicine at the Indiana University School of Medicine. Additional Resources: Tracheostomy Emergencies. LJ Bontempo and SL Manning. Emerg Med Clin N Am 2019: pubmed.ncbi.nlm.nih.gov/30454773/ Link to Onepager on Tracheostomy Emergencies: onepagericu.com/trach-emergencies Bleeding Tracheostomy. Kenji Inaba MD. Presented at Essentials of EM: www.facebook.com/EssentialsofEM/v…163679590380038/ Book Recommendations: Who Moved my Cheese?: An A-Mazing Way to Deal with Change in Your Work and in Your Life. By Spencer Johnson, et al: amzn.to/3pq0CkR Where the Red Fern Grows. By Wilson Rawls: amzn.to/3AawH6a

Dr. Debby Herbenick wants us to know that today's trend for rough sex is different than what we might expect. Her research, as detailed in her book Yes, Your Kid: What Parents Need to Know About Today's Teens and Sex, shows a rise in aggressive and risky behavior, often lacking the crucial communication necessary between partners. Listen in as we unpack the rise in rough sex - specifically choking. We also discuss nude images, digital safety, and the importance of having conversations around all these topics with our teenagers and young adults. Dr. Debby Herbenick is a Provost Professor at the Indiana University School of Public Health-Bloomington, Director of the Center for Sexual Health Promotion, and an AASECT-certified sexuality educator. Her research focuses on women's sexual health, US population-representative research, as well as trends in sexual attitudes and behaviors. JOIN my Newsletter Community.FOLLOW on Instagram.VISIT my Website.

Are you emotionally intelligent? In this new episode Drs. Temara Hajjat and Jason Silverman sit down with Dr. Brian McFerron to review what emotional intelligence is, and how it applies to medical training, healthcare practitioners and everyone as individuals. We also discuss ways to improve and resources to consider.Dr. McFerron is the Director of the Fellowship Training Program for the Division of Pediatric Gastroenterology, Hepatology and Nutrition at Indiana University School of Medicine/Riley Hospital for Children. Dr. McFerron has clinical interest in pancreatic diseases and has been involved in clinical research involving acute recurrent and chronic pancreatitis, collaborating with colleagues nationally within the INSPPIRE consortium. He was awarded the NASPGHAN Terri Li Young Educator Award in 2022. Learning objectivesReview the components of emotional intelligence and how gaps in these components may presentDiscuss the importance of emotional intelligence in a variety of professional and personal domainsReview strategies for improving dimensions of emotional intelligence Episode linksLearning the Lasso WayHow to Use Emotional Intelligence as a Career CatalystAssessment of Medical Students' Emotional Intelligence Emotional Intelligence and Academic Performance in First and Final Year Medical StudentsThe Best Leaders Aren't Afraid to be Vulnerable (HBR)The Power of Vulnerability (TED Talk by Brené Brown)Support the Show.This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!As always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.Check out our merch website!Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes.Click here to support the show.

On episode 217, we welcome Bill Sullivan to discuss the burgeoning field of epigenetics, why genes are better thought of as dimmers rather than light switches, the antipsychiatry argument against mental illness and why all mental illnesses are organic, what we discovered about the microbiome, the Libet experiments and whether they cast doubt on free will, how genes and parasites affect personality development and change, why it's difficult for people to understand and accept genetic determinism, fraud in the field of medications purporting to affect gene expression, the ACE studies and their implications for mental health, and how identical twins can be reared in the same environment and exhibit different personalities. Bill Sullivan is the author of Pleased to Meet Me: Genes, Germs, and the Curious Forces That Make Us Who We Are (National Geographic Books), which has been translated into a dozen languages. Sullivan is the Showalter Professor at the Indiana University School of Medicine, where he studies infectious disease. He received his Ph.D. in Cell & Molecular Biology from the University of Pennsylvania and has published over 100 papers in scientific journals. An award-winning researcher, teacher, and science communicator, Sullivan has been featured in a wide variety of outlets, including CNN, Fox & Friends, CBS News, ESPN, The Doctors, New York Post, Wall Street Journal, TEDx, The Scientist, and many more. He has written popular science articles for National Geographic, Discover, Scientific American, Washington Post, WIRED, Psychology Today, The Conversation, and more. He is an editor and writer at PLOS SciComm, chairs the Editorial Advisory Board for ASBMB Today, and serves as a board member of the John Shaw Billings Medical History Society. Visit him at authorbillsullivan.com and on X/Twitter @wjsullivan. | Bill Sullivan | ► Website | https://authorbillsullivan.com ► Twitter | https://x.com/wjsullivan ► Linkedin | https://www.linkedin.com/in/billsullivanjr ► Pleased to Meet Me Book | https://amzn.to/3Lkp95L Where you can find us: | Seize The Moment Podcast | ► Facebook | https://www.facebook.com/SeizeTheMoment ► Twitter | https://twitter.com/seize_podcast ► Instagram | https://www.instagram.com/seizethemoment ► TikTok | https://www.tiktok.com/@seizethemomentpodcast ► Patreon | https://bit.ly/3xLHTIa  

What are the current smoking rates among LGBTQIA+ individuals compared to the general population? What unique barriers do LGBTQIA+ individuals face when trying to quit smoking? What are the recommended pharmacotherapies and behavioral interventions for smoking cessation? What training is needed for providers to deliver culturally affirmative smoking cessation treatment for LGBTQIA+ patients?  Dr. Rhonda Schwindt is an Associate Professor at The George Washington University School of Nursing. She is a nationally certified Psychiatric-Mental Health Nurse Practitioner with an active clinical practice specializing in LGBTQIA+ health, trauma, and treatment-resistant mood disorders. Dr. Schwindt earned a Doctor of Nursing Practice degree from Case Western Reserve University, a Master of Science in Nursing from Indiana University School of Nursing, a Bachelor of Arts from Purdue University, and a diploma in nursing from St. Elizabeth School of Nursing. Dr. Schwindt has a funded program of research focused on improving health outcomes for the LGBTQIA+ community. She led a team of researchers that examined barriers to, and facilitators of, smoking cessation and treatment utilization in the transgender and gender expansive population as well as studies exploring best practices for teaching graduate students how to provide affirming care. Dr. Schwindt has received international recognition as an outstanding graduate nurse educator and for clinical excellence in the care of persons living with serious mental illness.  Resources  Pride in Being Tobacco-Free  UCSF Smoking Cessation Leadership Center  Fenway Health  Trevor Project 

Medicare is betting that taking care of the caregiver will help dementia patients stay at home longer. Patients and their caregivers are often left to navigate the confusing world of dementia by themselves, but Medicare is launching a new program to change that.Guests:Malaz Boustani, MD, PhD, Founding Director, Sandra Eskenazi Center for Brain Care Innovation; Professor of Aging Research, Indiana University School of Medicine Rosanne Corcoran, Caregiver Liz Fowler, PhD, JD, Director of CMMI and Deputy Administrator, Centers for Medicare and Medicaid Services Cindi Hart, Caregiver Alex Olgin, Reporter/Producer, Tradeoffs Lauren Sullivan, Care Coordinator, Eskenazi Health Learn more and read a full transcript on our website.Want more Tradeoffs? Sign up for our free weekly newsletter featuring the latest health policy research and news.Support this type of journalism today, with a gift.Follow us on Twitter. Hosted on Acast. See acast.com/privacy for more information.

The critical care management of spontaneous subarachnoid hemorrhage (SAH) is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Recent trials are influencing practice and providing guidance for standardizing management. In this episode, Kait Nevel, MD speaks with Soojin Park, MD, FAHA, FNCS, author of the article “Emergent Management of Spontaneous Subarachnoid Hemorrhage,” in the Continuum June 2024 Neurocritical Care issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Park is an associate professor of neurology (in biomedical informatics) at Vagelos College of Physicians and Surgeons, Columbia University in New York, New York and medical director of critical care data science and artificial intelligence at NewYork-Presbyterian Hospital in New York, New York. Additional Resources Read the article: Emergent Management of Spontaneous Subarachnoid Hemorrhage Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @soojin_soojin Full episode transcript   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members, stay tuned after the episode to hear how you can get CME for listening.   Dr Nevel: This is Dr Kait Nevel. Today, I'm interviewing Dr Soojin Park about her article on emergent management of spontaneous subarachnoid hemorrhage, which is part of the June 2024 Continuum issue on neurocritical care. Welcome to the podcast. It's so great to be talking to you today.   Dr Park: Thank you so much, Kait. Nice to be here.   Dr Nevel: Before we get started, could you introduce yourself for the audience?   Dr Park: Sure. So, I am an Associate Professor of Neurology - also in Biomedical Informatics - at Columbia University here in New York City. I trained in vascular neurology and neurocritical care.   Dr Nevel: Great. And so, I always like to ask at the beginning of these interviews, you know, if we could take away one thing from your article — and this is specifically (I'll direct this) towards the neurologists out there that are covering inpatient consults and ER consults — and so, for our clinical neurologists listening out there, what is the most important thing that you think that they should take away from your article?   Dr Park: So, I guess the most important thing for the general neurologists out there is that it may have been a while since they were aware of some updates that have occurred. There are some recent trials that are influencing practice and will potentially influence practice in the next few years that readers should really know about, and it provides a little bit stronger guidance to drive more standardized management. There have been two recent guidelines published this year. But there remain several gray areas for management where you need to be a bit more nuanced, and so I'm hoping the article gives the readers a framework to deliver more expert care.   Dr Nevel: Yeah, and I really, of course, always urge the listeners to go back and read the article and reference the article, because I do think that you do that really nicely and are clear when there are things where there's more higher-level, evidence-based reasons for things and where there's, kind of, just more expertise and guidelines on certain things. So, could you tell the listeners a little bit more about yourself, what interests you about subarachnoid hemorrhage specifically, and how you approach that interest and clinical background in writing this article?   Dr Park: So, I mentioned that I trained in both vascular neurology and neurocritical care back when many people used to do that. As a result, I've trained or practiced in four different academic medical centers who have specialized neurointensive care units. And the patients with subarachnoid hemorrhage tend to have a substantial ICU length of stay, and the neurointensive care that we provide can have a very large impact on patient outcome. And what I saw, though (practicing across four different centers), was that the management of patients with subarach can be quite variable across institutions and across patients within institutions, and it's reflective of a couple of things. One, there's, like, complexity in detecting ischemia, even when your patient is a captive audience in their ICU room. Second, there's many clinical mimics that occur (the patients with subarachnoid hemorrhage, they have a risk for), such as hydrocephalus, seizure, and things like delirium. And then, finally, there's limitations in the technology that we even have available in terms of monitoring these patients. But, for me, it was this complexity and the variability of management that kind of posed an opportunity, and it really sparked my curiosity early on and has sustained me. So, I'm particularly interested in the role that, kind of, the complex analysis of existing monitoring technologies can play to improve outcome for patients with subarachnoid hemorrhage, and that's where the marriage of both being a neurointensive care physician and a biomedical informatics person comes in.   Dr Nevel: Yeah. That's really interesting, and I could see that, because I always felt, even during my training, that some of the management and, you know, what diagnostics were even ordered to follow patients throughout the ICU was expertise based and seemed to vary without a lot of really solid, again, high-level studies, guiding what was done. So how do you marry the bioinformatics with your interest in SAH?   Dr Park: Right. So, I have two grants on - basically, I guess you would say AI, but really data science - on how we can manage patients with bleeds, specifically ICH and subarachnoid hemorrhage and hydrocephalus. So, we use data that comes from the monitors and we process that in a multimodal fashion and apply signal processing and machine learning and we build predictive analytic tools. So, I'm very interested in this pipeline of developing clinical decision support (information that we don't really have), and we're trying to glean from all the data and turn it into information that clinicians might use. The problem in subarachnoid hemorrhage patients is that a lot of what we're looking for is subclinical - so, it's not quite obvious, either because you can't possibly be in the room to be constantly monitoring for it (and, currently, the best monitor is the human, is examination), but, specifically in patients who have disordered consciousness, even the examination can be somewhat limited, and that's where we rely upon some of our neuromonitors. So, my interest has come in taking those multimodal monitors - but even nonneurologic monitors (stuff about your physiology, like your heart rate and blood pressure, et cetera) - and able to find signals that might tell us that a patient is getting into a dangerous zone. So, that's what my research portfolio has been 100% about - it's about subarachnoid hemorrhage patients and trying to optimize management, both for prevention and intervening in a timely fashion.   Dr Nevel: Wow. That's really interesting and would be so wonderful, it sounds like, for this patient population, if, you know, something was able to be identified that you could easily monitor to kind of predict or catch things early. So, kind of segueing from that, what do you think are the most — and you outline these nicely in your article, and I'm going to reference the listeners to, I believe it's the first table (table 5-1) - but what are, just like in general, the most important initial steps a clinician should take when managing somebody with an aneurysmal subarachnoid hemorrhage?   Dr Park: So, I think it's sort of along the timeline. So, at the time of presentation of a patient with subarachnoid hemorrhage, the focus you should have should be really on differentiating the etiology of the subarachnoid hemorrhage. At the same time, if the patient has any coagulopathies, you should manage that coagulopathy reversal, blood pressure management, and then detection and management and treatment of hydrocephalus. That's first and foremost. But then there is a longer timeline of neurocritical care management, and that's really centered on prevention, detection, and treatment of delayed cerebral ischemia, and that can occur anytime from onset of subarachnoid hemorrhage to two to three weeks out. And then that period of neurocritical care is made challenging because you have early brain injury (which is the period of seventy-two hours after onset), cerebral edema, and then, like we talked about, disordered consciousness. This kind of knowing how to augment your management strategies with monitoring or imaging is really key.   Dr Nevel: Yeah. And you, you know, spend some time in your article really going through delayed cerebral ischemia really nicely. And I would love to hear your take on what is the most challenging aspects of delayed cerebral ischemia in both, you know, diagnosis and management - and you alluded to it a little bit earlier, I think, with some of your research, but I would love to hear you talk about that.   Dr Park: Yeah. And actually, this is probably one of - if there was a controversial area in this topic, it would be about this - because there does not seem to be one best way to operationalize how you either survey for, or monitor for, delayed cerebral ischemia. There has been, historically, a merging of these definitions of vasospasm and delayed cerebral ischemia, which are not the same thing.  And so, if you were to draw a Venn diagram, not all patients who have cerebral vasospasm end up having symptomatic or delayed cerebral ischemia, and not all patients who have delayed cerebral ischemia have any discernable vasospasm - and, so, to use the terms interchangeably leads to a little bit of confusion. I mentioned the clinical mimics - you know, the causes of which are myriad (could be delirium, or hydrocephalus, or early brain injury) - and so that also poses another challenge. And, so, what I always say is that delayed cerebral ischemia, sometimes - when you're thinking about it in the context of subarachnoid hemorrhage - is sometimes a retrospective diagnosis. And it really kind of came from a really earnest attempt to standardize what the community is talking about, so that we can better understand how to define (if you understand how to define it better, then you can tailor treatments, study treatments, you're talking about the same disease) - but we're still not there, and I think that's where a lot of the controversy or confusion comes from. My personal approach is really to focus on the symptomatology, so, if a patient has vasospasm - whether that is, you know, screened for with a transcranial Doppler (if your institution does use transcranial Dopplers, it might be a nice screening tool) - but the fact of the matter is that not all patients can get a transcranial Doppler every single day. You know, most of the institutions that I have worked in offer that technology Monday through Friday and not on holidays, not on weekends, and so you can't fully rely upon something like that. The advantage of it is that it has pretty high sensitivity but it does have a lower specificity (so it overcalls vasospasms), so to treat just based on a TCD would probably be erroneous. Not all people agree, but I think that's the majority of the sentiment - is that you should then be triggered to go look for confirmation with some neuroimaging and really potentially wait for symptoms so that it might be a trigger to optimize the patient in terms of volume and blood pressure, but not necessarily to treat. So, yeah, operationalizing that workflow of how do you trigger, you know, confirmatory neuroimaging, what type of neuroimaging you should then choose? This is where the variability exists. But, in general, I focus on symptomatology. The extra challenge comes in the patients who have disordered consciousness. And so, at an institution like mine, we do rely upon invasive neuromonitoring, and that's now called for in the guidelines as well.   Dr Nevel: And I imagine these are high-intensity situations where also I would suspect decisions, you know, need to be made quickly on some of these things that you're talking about, too.   Dr Park: That's right.   Dr Nevel: What do you think is a misconception - or maybe (I hate to call it a mistake, but for lack of a better term) like an easy mistake that one can make - when treating patients with aneurysmal subarachnoid hemorrhage?   Dr Park: Hmm, an easy mistake. I guess, you know, time is brain, so it's an opportunity to miss ischemia - or actually attribute everything to ischemia and ignore the possibility for things like seizure (so nonconvulsive seizures), a resurgence of more of a delayed hydrocephalus - and so, I think it's important as you're managing a patient not to get kind of pigeonholed into looking for one particular thing (only looking for delayed cerebral ischemia), but being really vigilant that there could be lots of different reasons for a neurological change of a patient. And so, timely monitoring - kind of figuring out the etiology of a change in neurological status - is really important. And then, also, on the flip side of that, is we're really good at being aggressive in both inducing hypertension or managing a patient (trying to prevent ischemia), we're not that great about starting to pull back - and so I think being vigilant about opportunities to reassess your patient's risk for ongoing ischemia and deciding when that period of risk is over and starting to peel back on therapies, because these patients are also at risk for the down sides of inducing hypertension, which is PRES - and we have seen that in patients, and, you know, the phenotype of that will look very much like ischemia.   Dr Nevel: Yeah, it's complicated because you're taking care of patients with often impaired consciousness who have a lot of symptoms that could represent many different diagnoses that you would treat very differently, so I could see that that might be easy to do to kind of fall into the mindset of thinking that it's definitely one thing without fully evaluating for everything. So, caring for patients with aneurysmal subarachnoid hemorrhage obviously can be really, you know, challenging from the medical perspective, but also from the perspective of, you know, communication with families, and families asking questions about prognosis and things like that (and you mentioned this in your article about prognostication a little bit) - and can you talk a little bit about our ability to prognosticate long-term outcomes for patients who are in that acute phase (maybe even early first, you know, couple of days or a week) with a subarachnoid hemorrhage?   Dr Park: I think one of the most rewarding aspects of caring for patients with subarachnoid hemorrhage is that these patients can look, really, very sick in the beginning, and they're quite complex to manage, but you can see some very impressive recovery. And from a neurointensivist perspective, seeing that recovery in kind of a rapid timeline is rare - and we get to see that in subarach patients. We see patients who just have refractory recurrent vasospasm and delayed cerebral ischemia getting all of the tools thrown at them and you're really kind of, you know, concerned that there seems to be no end - but there is this peak of that injury, and then after that window of secondary brain injury risk kind of resolves, the patient can very much recover (so seeing patients who look the sickest be able to leave and go home). I think there is a hidden cost to subarachnoid hemorrhage where, maybe on our gross measures of outcome, patients look great, but there are this hidden cost of social psychological outcome that is unmeasured the way that we are currently measuring it. And I think our field is getting better at adopting some of the ability to measure those kind of hidden costs, and we're able to see that, even a year out, patients are really not back to where they were before (even though on the scales we currently have, they do look great, right, in terms of motor function, and things like that) - so, I think as clinicians, we have to be sensitive to that. So, when we talk to families, we have to remain hopeful that they are going to have a remarkable potential recovery but prepare families that they really should be on the lookout for any opportunity to rehabilitate in all aspects of function.   Dr Nevel: Yeah. And you mentioned in your article that as we're moving into the future  - and even currently - that there is some focus on gathering more patient-reported outcomes for people who are, you know, out of the ICU back in their normal lives after subarachnoid hemorrhage (which speaks to this that you're talking about, that even if their motor function is normal, they may not be back to their normal lives). So, what is something you think that's really important that we've learned in the past ten years - I'll give it ten years, you can go back further, make that time frame shorter if you want, but about the past ten years - about subarachnoid hemorrhage's impact on patient care, and then what do you think we're going to learn in the next ten years that will impact the way we care for these patients?   Dr Park: So, you know, subarach - in terms of the literature that is forming, that has formed - like I said, the guidelines had not been updated for over a decade, and we're fortunate to have not just one, but two sets of guidelines from two professional societies that were published right next to each other this past year in 2023 - but the field is fast moving, so even after the publication of those guidelines, there was one of the first randomized controlled trials in the field to be published maybe a month or two after that (that was the early lumbar drain trial). So, the key areas that I think where the literature has really helped strengthen our practice in terms of bringing standardization is in the antifibrinolytics. And so, in that space, recently, there was a very nicely performed randomized controlled trial for early administration of antifibrinolytics. It's a practice that, even when I was training, was sort of based on old literature back when we used to treat subarachnoid patients very differently - so we were really kind of extrapolating from that literature into our practice, and we were all sort of just giving it uniformly to patients early on with the good intention to try to prevent rebleeding, (which we understood, prior to aneurysm securement, was a high source of morbidity/mortality). So, in trying to reduce that risk of rebleeding (which happens very early) as much as we could, we were giving it. But the length of treatment (you know, who should we give that medication to) was really kind of uncertain - and this recent randomized controlled trial really gave a definitive answer to this, which is that it probably makes no difference. It should be seen with a caveat, though, that the trial (like any trial) was a very specific population. So, it could probably be said that for patients who are secured very early, there's no role for antifibrinolytic therapy, but, potentially, for patients who may be in a lower-middle-income environment or lower-income environment or for whatever reason can't reach aneurysm securement within that seventy two-hour period - you could consider, you know, greater than twenty-four hours you should consider the use of antifibrinolytics - but largely has brought an end to uniform administration of antifibrinolytics. This is where that expert nuanced care comes to, right?   Dr Nevel: Mm-hmm.   Dr Park: Another area is, really, kind of something as basic as blood pressure management. I think we were taught very early on that we should be very rigorous, bring that blood pressure down - and so, I think, across all types of stroke now, we're realizing there is a little bit of nuance, right? You have to think about your patient, about prior existing renal failure, about prior existing chronic hypertension that's poorly controlled - and in subarachnoid hemorrhage, the additional impact of that early brain injury. If you have cerebral edema, you should be considering, do we really want to control our blood pressure that low? Because we might be inducing secondary brain injury from our presumed protective intervention. So, these types of things are being revisited - so, the language around that in the new guidelines is a little bit softer, and it does sort of refer more to, “let's consider the whole patient”.   Dr Nevel: Yeah, rather than making a blanket statement that doesn't apply to maybe everybody.   Dr Park: Yeah. And you also asked about future.   Dr Nevel: Yeah. Where do you think things are heading in the future? What's exciting in research, and if you had a crystal ball, what do you think we're going to figure out in the next ten years that's going to impact care?   Dr Park: Well, fortunately, for patients with subarachnoid hemorrhage and for people like me who are treating patients with subarachnoid hemorrhage, there's a lot going on. So, I mentioned lumbar drainage because there was a very nice trial that was published - I think we'll see in the next few years how much of that diffusion of innovation travels across the country in the world about the usage of this. There are some who point to prior studies that may have conflicting results and so want to wait and see it be validated. Others are pretty convinced, you know, by the quality of the study that was done and are trying to incorporate it into their protocols now. I think we're going to see more usage and more study of things like intravenous milrinone, early stellate ganglion blockade, intraventricular nicardipine, and even maybe optimized goals for cerebral perfusion or blood pressure - and this is for looking at a myriad of outcomes, including the prevention and treatment of vasospasm and ischemia, improving outcomes, and preventing infarction. There's also a lot to come about early brain injury (and I kind of talked about that). It's like a seventy-two-hour period window after subarachnoid hemorrhage, and it comprises processes like microcirculatory dysfunction, blood-brain barrier breakdown, and things like oxidative cascades, et cetera. While currently, there doesn't exist any practice besides, like, the nuance and expert determination of blood pressure goals prior to aneurysm securement, I think this will be an area that hopefully will become a target for intervention, because it has an independent and influential impact on poor outcomes for subarachnoid hemorrhage patients. So, watch the space.   Dr Nevel: Yes, absolutely. Looking forward to seeing what comes. Well, thank you so much for talking to me, Dr Park, and joining me on Continuum Audio.   Dr Park: It was my pleasure.   Dr Nevel: Again, today, I've been interviewing Dr Soojin Park, whose article on emergent management of spontaneous subarachnoid hemorrhage appears in the most recent issue of Continuum in neurocritical care. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining today.   Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice - and right now, during our spring special, all subscriptions are 15% off. Go to Continpub.com/Spring2024 or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members, go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

Men have many challenges to deal with when battling prostate cancer, including managing the side effects of their treatment.  One common issue men face after a radical prostatectomy is erectile dysfunction. As June is Men's Health Month, we are fortunate to have men's health expert Dr. Helen Bernie joining us today to provide a modern perspective on restoring erectile function post-prostatectomy through penile rehabilitation. Dr. Bernie is a board-certified and fellowship-trained urologist. She is the Director of Sexual and Reproductive Medicine, the Andrology Fellowship Program Director, and the Assistant Professor of Urology at the Indiana University School of Medicine, where she teaches medical students. She is passionate about men's health, cancer survivorship, and fertility preservation, and she treats all aspects of men's health, including male sexual dysfunctions and infertility. Dr. Bernie completed her residency in urology at the University of Rochester Medical Center and did a two-year fellowship in sexual and reproductive medicine at Memorial Sloan Kettering Cancer Centre and New York Presbyterian Weill Cornell Medical College. She has presented award-winning research on sexual medicine, testosterone replacement, prostate cancer, and male fertility. Stay tuned as Dr. Bernie shares her expert insights and practical advice on how men can reclaim their sexual health after prostate cancer treatment. Disclaimer: The Prostate Health Podcast is for informational purposes only. Nothing in this podcast should be construed as medical advice. By listening to the podcast, no physician-patient relationship has been formed. For more information and counseling, you must contact your personal physician or urologist with questions about your unique situation.   Show Highlights: How prostate removal or prostate cancer may affect men's sexual function How often does erectile dysfunction occur after a radical prostatectomy? Dr. Bernie shares some of the many options available for men to regain erectile function after a prostatectomy. Some of the barriers that exist in instituting penile rehabilitation Dr. Bernie shares her current approach to penile rehabilitation.  Why it is crucial for anyone diagnosed with prostate cancer or experiencing erectile dysfunction to find out what a penile rehabilitation program is and what it involves. Links:  Follow Dr. Pohlman on Twitter and Instagram - @gpohlmanmd  Get your free What To Expect Guide (or find the link on our podcast website)   Join our Facebook group  Follow Dr. Pohlman on Twitter and Instagram  Go to the Prostate Health Academy to sign up.  You can access Dr. Pohlman's free mini webinar, where he discusses his top three tips to promote men's prostate health, longevity, and quality of life here. Indiana University School of Medicine   Indiana University Andrology Fellowship Program Indiana University Urology Services

We are influenced by a lot in our early years that affect our sexual lives. Those who work on college campuses and teach human sexuality have noted that there is a rise in rough sex among the students. Some of what this rough sex involves is choking. Dr. Debby Herbenick has recognized how this can be problematic for many reasons, but one is that any constriction of breath can cause damage to our bodies and our brain. Her book, Yes, Your Kid helps parents navigate the necessary conversations that are needed in the home around sex and the exposure to porn. Often as parents we tend to think, “Not my kid.” However, the reality today is that with social media and 24 hour access to porn, this could very well be something your child has experienced or maybe thought about.  Dr. Herbenick is a Provost Professor at the Indiana University School of Public Health-Bloomington, Director of the Center for Sexual Health Promotion, and an AASECT-certified sexuality educator. Her newest book is “Yes Your Kid: What Parents Need to Know About Today's Teens and Sex” which has been highlighted in the New York Times and on CNN.com. Her research focuses on women's sexual health, US population-representative research, as well as trends in sexual attitudes and behaviors. She has published more than 200 peer-reviewed scientific articles related to sexual and reproductive health and serves as Principal Investigator of the award-winning National Survey of Sexual Health and Behavior, which has been ongoing since 2009. Dr. Herbenick's research, books, and expertise have been featured in the New York Times, Washington Post, Wall Street Journal, Vogue, NPR, CBC, the Tamron Hall Show, Tyra, Discovery Health, The Doctors, and in thousands of others media. Learn more: www.debbyherbenick.com www.linkedin.com/in/debbyherbenick www.debbyherbenick.com/books-media  

This episode of Audible Bleeding features Drs. Adam Johnson and Jeniann Yi, members of the Society for Vascular Surgery Health Information Technology Committee, to discuss the application of large language models in vascular surgery with two experts in the field, Dr. Andrew Gonzalez and one of his collaborators, Shantanu Dev.  The episode promises a conversation exploring machine learning and large language models with insights from the guests' diverse expertise in vascular surgery, health informatics, and artificial intelligence.   Dr. Andrew Gonzalez, an assistant professor in vascular surgery at Indiana University School of Medicine and also an SVS HITC committee member, has clinical and research interests in peripheral arterial disease and artificial intelligence applications for amputation prevention.   Shantanu Dev, a computer science PhD student at Ohio State, focusing on multimodal modeling for clinical applications in AI. Shantanu worked at PWC for eight years in their AI R&D division and co-owns Satsong Digital Health, an AI company addressing healthcare inequities and quality of care.   Relevant links: AI Revolution in Medince: GPT4 and Beyond by Peter Lee Artificial Intelligentce in Surgery: Understanding the Role of Ai in Surgical Practice by Dan Hashimoto Data Skeptic Podcast Deep Medicine: How Artificial Intelligence can make Helathcare Human Again by Eric Topel   Co-Hosts:   Dr. Jennian Yi is an Assistant Professor of Surgery at the University of Colorado. Dr. Adam Johnson is an Assistant Professor of Surgery at Duke University, and editor at Audible Bleeding. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

Stand Up is a daily podcast. I book,host,edit, post and promote new episodes with brilliant guests every day. Please subscribe now for as little as 5$ and gain access to a community of over 700 awesome, curious, kind, funny, brilliant, generous souls Today, the AcademyHealth Board of Directors announced their selection of nationally recognized thought leader, science communicator, pediatrician, and health services researcher, Aaron Carroll, M.D., M.S., as the next President and CEO of AcademyHealth. "Dr. Carroll is a fantastic choice to lead AcademyHealth into the next era of advocating for the use of evidence to improve the delivery of health care and to improve health for all," said chair of the AcademyHealth Board of Directors Lucy Savitz, Ph.D., M.B.A, professor in the University of Pittsburgh's Department of Health Policy and Management in the Graduate School of Public Health and Senior Innovation Advisor for the UPMC Insurance Division in their Center for High Value Health Care. "The board was especially impressed with Dr. Carroll's highly visible and impactful track record in translating complex research findings in a way to spark action as well as his passion for the development and mentoring of diverse research talent." Dr. Carroll is currently a Distinguished Professor of Pediatrics and Chief Health Officer at Indiana University. He is also Associate Dean for Research Mentoring and the past director of the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University School of Medicine. He earned a B.A. in chemistry from Amherst College, an M.D. from the University of Pennsylvania School of Medicine, and an M.S. in health services from the University of Washington School of Public Health, where he was also a Robert Wood Johnson Clinical Scholar. In addition, he previously served as Vice President for faculty development at the Regenstrief Institute, a medical research and development organization with expertise in electronic medical records and health care data integration. Dr. Carroll's research focuses on the study of information technology to improve pediatric care, decision analysis, and areas of health policy including cost-effectiveness of care and health care financing reform. The selection of Dr. Carroll further bolsters AcademyHealth's work to improve health and health care for all by moving evidence into policy and practice. He is an expert science communicator, the author of multiple books, a frequent contributor to the New York Times, co-editor-in-chief of The Incidental Economist, and his publications as well as his Healthcare Triage YouTube series and podcast have educated and entertained millions of readers and viewers.  "Today's challenges demand robust, inclusive evidence that tackles real-world issues. It's imperative that we communicate this knowledge in a manner that is comprehensible, trustworthy, and applicable," said Carroll. "AcademyHealth supports, amplifies, and represents the interests of a diverse and talented field that is perfectly positioned to answer that call. Stepping into this leadership role is a dream opportunity to work with some of the best minds in health research and policy and to make a real difference in American health care." Dr. Carroll assumes the role of President and CEO from Dr. Lisa Simpson, who will step down in March. Under Dr. Simpson's leadership, AcademyHealth made a public commitment to diversity, equity, inclusion, and accessibility, expanded its influence in Washington, and built robust portfolios of work to support innovation in data, workforce, research impact, and learning health systems.  "As a long serving AcademyHealth Board member, I am pleased that the selection committee was sensitive to the importance of choosing a leader who has demonstrated a commitment to evidence generation that advances the fight for health equity across all population groups” said Dr. Reed Tuckson, a cofounder of the Black Coalition Against COVID. "AcademyHealth and its stakeholder community of scholars have provided leadership and practical evidence-based guidance in this increasingly important field and I am confident that Dr. Carroll's leadership, intellect, and communication expertise will help advance this work into the future." Dr. Carroll will assume his new role on March 18, 2024. About AcademyHealth With nearly 3,000 individual and organizational members, AcademyHealth is the leading national organization serving the fields of health services and policy research and the professionals who produce and use this important work. Together with our members, we offer programs and services that support the development and use of rigorous, relevant and timely evidence to increase the quality, accessibility, and value of health care, to reduce disparities, and to improve health. A trusted broker of information, AcademyHealth brings stakeholders together to address the current and future needs of an evolving health system, inform health policy, and translate evidence into action. Learn more at www.academyhealth.org. The Stand Up Community Chat is always active with other Stand Up Subscribers on the Discord Platform.   Join us Thursday's at 8EST for our Weekly Happy Hour Hangout!  Pete on Threads Pete on Tik Tok Pete on YouTube  Pete on Twitter Pete On Instagram Pete Personal FB page Stand Up with Pete FB page All things Jon Carroll  Follow and Support Pete

Botox is a routine tool used in the cosmetic industry that has become increasingly popular. Is it a healthy medical procedure? What was it initially discovered for, and how has it developed over time? Dr. Eugene M. Helveston, a medical professional with many years of experience, sits down to enlighten us…   Dr. Helveston is an emeritus professor of ophthalmology, the founder of the section of Pediatric Ophthalmology, and the former Chairman of the Department of Ophthalmology at Indiana University School of Medicine. In January of 2024, he released Death to Beauty: The Transformative History of Botox, a book that walks readers through the intricate history of how the world's deadliest toxin (starting as a treatment for crossed eyes) became a routine tool for the cosmetic industry. In this discussion, we cover: How botox was used during its initial treatments.  What the primary toxin in botox is, and how it interacts with human cells.  How the cosmetic applications for botox were discovered and utilized. If you are ready to rethink success, beauty, and deadly bacteria, this podcast is certainly for you. Tune in now to broaden your perspective! You can find out more about Dr. Helveston and his other work here. Take advantage of a 5% discount on Ekster accessories by using the code FINDINGGENIUS. Enhance your style and functionality with premium accessories. Visit bit.ly/3uiVX9R to explore latest collection. Episode also available on Apple Podcasts: http://apple.co/30PvU9C

This episode is brought to you by Rupa Health, AG1, and Paleovalley. While the ketogenic diet is often thought of as a diet to help people lose weight, it has a much broader application with therapeutic benefits that help to reset metabolism and restore mitochondrial function. Researchers have found that a ketogenic diet can be a potent tool in cancer treatment as well as in neurodegenerative disorders and mental illness.In today's episode, I talk with Mark Sisson, Dr. Sarah Hallberg, Dr. Christopher Palmer, and Dr. Patrick Hanaway about how a ketogenic diet can be used as a treatment for serious health conditions.Mark Sisson is the founder of the popular daily health blog Mark's Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity.The late Dr. Sarah Hallberg was a medical director at Virta Health, a fellow of the Aspen Institute's Health Innovator Fellowship, and a member of the Aspen Global Leadership Network. She was also the Medical Director and founder of the Medically Supervised Weight Loss Program at Indiana University Health Arnett and an adjunct professor of clinical medicine at the Indiana University School of Medicine.Dr. Christopher Palmer is a psychiatrist and researcher working at the interface of metabolism and mental health. He is the Director of the Department of Postgraduate and Continuing Education at McLean Hospital and an assistant professor of psychiatry at Harvard Medical School. For over 25 years, he has held leadership roles in psychiatric education, conducted research, and worked with people who have treatment-resistant mental illnesses.Dr. Patrick Hanaway is a board-certified family physician and trained at Washington University. After 10 years as Chief Medical Officer at Genova Diagnostics, Dr. Hanaway became the Chief Medical Education Officer for the Institute for Functional Medicine. In 2014, Dr. Hanaway was the founding Medical Director of the Cleveland Clinic Center for Functional Medicine.This episode is brought to you by Rupa Health, AG1, and Paleovalley.Access more than 3,000 specialty lab tests with Rupa Health. You can check out a free, live demo with a Q&A or create an account at RupaHealth.com today.Head to drinkAG1.com/HYMAN to receive 10 FREE travel packs of AG1 with your first purchase.Paleovalley is offering my listeners 15% off their entire first order. Just go to paleovalley.com/hyman to take advantage of this deal.Full-length episodes of these interviews can be found here:Mark SissonDr. Sarah HallbergDr. Christopher PalmerDr. Patrick Hanaway Hosted on Acast. See acast.com/privacy for more information.