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Send us a textThis recording features audio versions of Month Year Journal of Vascular and Interventional Radiology (JVIR) abstracts:Optimal Timing of Percutaneous Cholecystostomy across Different Grades of Acute Cholecystitis: A Retrospective Cohort Study ReadGallbladder Cryoablation for Calculous Cholecystitis Initially Treated with Percutaneous Drainage: A Prospective Trial in High-Risk Patients ReadComparative Prognostic Utility of Updated Model for End-Stage Liver Disease Scores for Prediction of Early Mortality after Transjugular Intrahepatic Portosystemic Shunt Creation ReadLong-Term Outcomes of Angioplasty and Stent Placement for Portomesenteric Vein Obstruction following Hepatobiliary and Pancreatic Surgery ReadThe Impact of Chronic Kidney Disease on Amputation and Death Rates in Patients with Peripheral Artery Disease in the United States ReadPercutaneous Microwave Ablation of Small (

Idiopathic intracranial hypertension (IIH) is characterized by symptoms and signs of unexplained elevated intracranial pressure (ICP) in an alert and awake patient. The condition has potentially devastating effects on vision, headache burden, increased cardiovascular disease risk, sleep disturbance, and depression.  In this episode, Teshamae Monteith, MD, FAAN speaks with Aileen A. Antonio, MD, FAAN, author of the article “Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Antonio is an associate program director of the Hauenstein Neurosciences Residency Program at Trinity Health Grand Rapids and an assistant clinical professor at the Michigan State University College of Osteopathic Medicine in Lansang, Michigan. Additional Resources Read the article: Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Guest: @aiee_antonio Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Monteith: Hi, this is Dr Teshamae Monteith. Today I'm interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics.  Hi, how are you? Dr Antonio: Hi, good afternoon. Dr Monteith: Thank you for being on the podcast. Dr Antonio: Thank you for inviting me, and it's such an honor to write for the Continuum. Dr Monteith: So why don't you start off with introducing yourself? Dr Antonio: So as mentioned, I'm Aileen Antonio. I am a neuro-ophthalmologist, dually trained in both ophthalmology and neurology. I'm practicing in Grand Rapids, Michigan Trinity Health, and I'm also the associate program director for our neurology residency program. Dr Monteith: So, it sounds like the residents get a lot of neuro-ophthalmology by chance in your curriculum. Dr Antonio: For sure. They do get fed that a lot. Dr Monteith: So why don't you tell me what the objective of your article was? Dr Antonio: Yes. So idiopathic intracranial hypertension, or IIH, is a condition where there's increased intracranial pressure, but without an obvious cause. And with this article, we want our readers---and our listeners right now---to recognize that the typical symptoms and learning about the IIH diagnostic criteria are key to avoiding errors, overdiagnosis, or sometimes even misdiagnosis or underdiagnosis. Thus, we help make the most of our healthcare resources. Early diagnosis and management are crucial to prevent disability from intractable headaches or even vision loss, and it's also important to know when to refer the patients to the appropriate specialists early on. Dr Monteith: So, it sounds like your central points are really getting that diagnosis early and managing the patients and knowing how to triage patients to reduce morbidity and complications. Is that correct? Dr Antonio: That is correct and very succinct, yes. Dr Monteith: And so, are there any more recent advances in the diagnosis of IIH? Dr Antonio: Yes. And one of the tools that we've been using is what we call the optical coherence tomography. A lot of people, neurologists, physicians, PCP, ER doctors; how many among those physicians are well-versed in doing an eye exam, looking at the optic disc? And this is a great tool because it is noninvasive, it is high resolution imaging technique that allows us to look at the optic nerve without even dilating the eye. And we can measure that retinal nerve fiber layer, or RNFL; and that helps us quantify the swelling that is visible or inherent in that optic nerve. And we can even follow that and monitor that over time. So, this gives us another way of looking at their vision and getting that insight as to how healthy is their vision still, along with the other formal visual tests that we do, including perimetry or visual field testing. And then all of these help in catching potentially early changes, early worsening, that may happen; and then we can intervene more easily. Dr Monteith: Great. So, it sounds like there's a lot of benefits to this newer technology for our patients. Dr Antonio: That is correct. Dr Monteith: So, I read in the article about the increased incidence of IIH, and I have to say that I completely agree with you because I'm seeing so much of it in my clinic, even as a headache specialist. And I had a talk with a colleague who said that the incidence of SIH and IIH are similar. And I was like, there's no way. Because I see, I can see several people with IIH just in one day. That's not uncommon. So, tell me what your thoughts are on the incidence, the rising incidence of IIH; and we understand that it's the condition associated with obesity, but it sounds like you have some other underlying drivers of this problem. Dr Antonio: Yes, that is correct. So, as you mentioned, IIH tends to affect women of childbearing age with obesity. And it's interesting because as you've seen that trend, we see more of these IIH cases recently, which seem to correlate with that rising rate of obesity. And the other thing, too, is that this trend can readily add to the burden of managing IIH, because not only are we dealing with the headaches or the potential loss of vision, but also it adds to the burden of healthcare costs because of the other potential comorbidities that may come with it, like cardiovascular risk factors, PCOS, and sleep apnea. Dr Monteith: So why don't we just talk about the diagnosis of IIH? Dr Antonio: IIH, idiopathic intracranial hypertension, is also called pseudotumor cerebri.  It's essentially a condition where a person experiences increased intracranial pressure, but without any obvious cause. And the tricky part is that the patients, they're usually fully awake and alert. So, there's no obvious tumor, brain tumor or injury that causes the increased ICP. It's really, really important to rule out other conditions that might cause these similar symptoms; again, like brain tumors or even the cerebral venous sinus thrombosis. Many patients will have headaches or visual disturbances like transient visual obscurations---we call them TVOs---or double vision or diplopia. The diplopia is usually related to a sixth nerve palsy or an abducens palsy. Some may also experience some back pain or what we call pulsatile tinnitus, which is that pulse synchronous ringing in their ears. The biggest sign that we see in the clinic would be that papilledema; and papilledema is a term that we only use, specifically use, for those optic nerve edema changes that is only associated with increased intracranial pressure. So, performing of endoscopy and good eye exam is crucial in these patients. We usually use the modified Dandy criteria to diagnose IIH. And again, I cannot emphasize too much that it's really important to rule out other secondary causes to that increased intracranial pressure. So, after that thorough neurologic and eye evaluation with neuroimaging, we do a lumbar puncture to measure the opening pressure and to analyze the cerebrospinal fluid. Dr Monteith: One thing I learned from your article, really just kind of seeing all of the symptoms that you mentioned, the radicular pain, but also- and I think I've seen some papers on this, the cognitive dysfunction associated with IIH. So, it's a broader symptom complex I think than people realize. Dr Antonio: That is correct. Dr Monteith: So, you mentioned TVOs. Tell me, you know, if I was a patient, how would you try and elicit that from me? Dr Antonio: So, I would usually just ask the patient, while you're sitting down just watching TV---some of my patients are even driving as this happens---they would suddenly have these episodes of blacking out of vision, graying out of vision, vision loss, or blurred vision that would just happen, from seconds to less than a minute, usually. And they can happen in one eye or the other eye or both eyes, and even multiple times a day. I had a patient, it was happening 50 times a day for her. It's important to note that there is no pain associated with it most of the time. The other thing too is that it's different from the aura that patients with migraines would have, because those auras are usually scintillating and would have what we call the positive phenomena: the flashing lights, the iridescence, and even the fortification that they see in their vision. So definitely TVOs are not the migraine auras. Sometimes the TVOs can also be triggered by sudden changes in head positions or even a change in posture, like standing up quickly. The difference, though, between that and, like, the graying out of vision or the tunneling vision associated with orthostatic hypotension, is that the orthostatic hypotension would also have that feeling of lightheadedness and dizziness that would come with it. Dr Monteith: Great. So, if someone feels lightheaded, less likely to be a TVO if they're bending down and they have that grain of vision. Dr Antonio: That is correct. Dr Monteith: Definitely see patients like that in clinic. And if they have fluoride IIH, I'm like, I'll call it a TVO; if they don't, I'm like, it's probably more likely to be dizziness-related. And then we also have patient migraines that have blurriness that's nonspecific, not necessarily associated with aura. But I think in those patients, it's usually not seconds long, it's usually probably longer episodes of blurriness. Would you agree there, or…? Dr Antonio: I would agree there, and usually the visual aura would precede the headache that is very characteristic of their migraine, very stereotypical for their migraines. And then it would dissipate slowly over time as well. With TVOs, they're brisk and would not last, usually, more than a minute. Dr Monteith: So, why don't we talk about routine imaging? Obviously, ordering an MRI, and I read also getting an MRV is important. Dr Antonio: It is very important because, one: I would say IIH is also a diagnosis of exclusion. We need to make sure that the increased ICP is not because of a brain tumor or not because of cerebral venous sinus thrombosis. So, it's important to get the MRI of the brain as well as the MRV of the head. Dr Monteith: Do you do that for all patients' MRV, and how often do you add on an orbital study? Dr Antonio: I usually do not add on an orbital study because it's not really going to change my management at that point. I really get that MRI of the brain. Now the MRV, for most of my patients, I would order it already just because the population that I see, I don't want to lose them. And sometimes it's that follow-up, and that is the difficult part; and it's an easy add on to the study that I'm going to order. Again, it depends with the patient population that you have as well, and of course the other symptoms that may come with it. Dr Monteith: So, why don't we talk a little bit about CSF reading and how these set values, because we get people that have readings of 250 millimeters of water quite frequently and very nonspecific, questionable IIH. And so, talk to me about the set value. Dr Antonio: Right. So, the modified Dandy criteria has shown that, again, we consider intracranial pressure to be elevated for adults if it's above 250 millimeters water; and then for kids if it's above 280 millimeters of water. Knowing that these are taken in the left lateral decubitus position, and assuming also that the patients were awake and not sedated during the measurement of the CSF pressure. The important thing to know about that is, sometimes when we get LPs under fluoroscopy or under sedation, then these can cause false elevation because of the hypercapnia that elevated carbon dioxide, and then the hypoventilation that happens when a patient is under sedation. Dr Monteith: You know, sometimes you see people with opening pressures a little bit higher than 25 and they're asymptomatic. Well, the problem with these opening pressure values is that they can vary somewhat even across the day. People around 25, you can be normal, have no symptoms, and have opening pressure around 25- or 250; and so, I'm just asking about your approach to the CSF values. Dr Antonio: So again, at the end of the day, what's important is putting everything together. It's the gestalt of how we look at the patient. I actually had an attending tell me that there is no patient that read the medical textbook. So, the, the important thing, again, is putting everything together. And what I've also seen is that some patients would tell me, oh, I had an opening pressure of 50. Does that mean I'm in a dire situation? And they're so worried and they just attach to numbers. And for me, what's important would be, what are your symptoms? Is your headache, right, really bad, intractable? Number two: are you losing vision, or are you at that cusp where your optic nerve swelling or papilledema is so severe that it may soon lead to vision loss? So, putting all of these together and then getting the neuroimaging, getting the LP. I tell my residents it's like icing on the cake. We know already what we're dealing with, but then when we get that confirmation of that number… and sometimes it's borderline, but this is the art of neurology. This is the art of medicine and putting everything together and making sure that we care and manage it accordingly. Dr Monteith: Let's talk a little bit about IIH without papilledema. Dr Antonio: So, let's backtrack. So, when a patient will fit most of the modified Dandy criteria for IIH, but they don't have the papilledema or they don't have abducens palsy, the diagnosis then becomes tricky. And in these kinds of cases, Dr Friedman and her colleagues, when they did research on this, suggested that we might consider the diagnosis of IIH. And she calls this idiopathic intracranial hypertension without papilledema, IIHWOP. They say that if they meet the other criteria for modified Dandy but show at least three typical findings on MRI---so that flattening of the posterior globe, the tortuosity of the optic nerves, the empty sella or the partially empty sella, and even the narrowing of the transverse venous sinuses---so if you have three of these, then potentially you can call these cases as idiopathic intracranial hypertension without papilledema. Dr Monteith: Plus, the opening pressure elevation. I think that's key, right? Getting that as well. Dr Antonio: Yes. Sometimes IIHWOP may still be a gray area. It's a debate even among neuro-ophthalmologists, and I bet even among the headache specialists. Dr Monteith: Well, I know that I've had some of these conversations, and it's clear that people think this is very much overdiagnosed. So, that's why I wanted to plug in the LP with that as well. Dr Antonio: Right. And again, we have not seen yet whether is, this a spectrum, right? Of that same disease just manifesting differently, or are they just sharing a same pathway and then diverging? But what I want to emphasize also is that the treatment trials that we've had for IIH do not include IIHWOP patients. Dr Monteith: That is an important one. So why don't you wrap this up and tell our listeners what you want them to know? Now's the time. Dr Antonio: So, the- again, with IIH, with idiopathic intracranial hypertension, what is important is that we diagnose these patients early. And I think that some of the issues that come into play in dealing with these patients with IIH is that, one: we may have anchoring bias. Just because we see a female with obesity, of reproductive age, with intractable headaches, it does not always mean that what we're dealing with is IIH. The other thing, too, is that your tools are already available to you in your clinic in diagnosing IIH, short of the opening pressure when you get the lumbar puncture. And I need to emphasize the importance of doing your own fundoscopy and looking for that papilledema in these patients who present to you with intractable headaches or abducens palsy. What I want people to remember is that idiopathic intracranial hypertension is not optic nerve sheath distension. So, these are the stuff that you see on neuroimaging incidentally, not because you sent them, because they have papilledema, or because they have new headaches and other symptoms like that. And the important thing is doing your exam and looking at your patients. Dr Monteith: Today, I've been interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Thank you again. Dr Antonio: Thank you. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Send us a textThis recording features audio versions of June 2025 Journal of Vascular and Interventional Radiology (JVIR) abstracts:Comparison of Bypass Surgery versus Endovascular Interventions for Peripheral Artery Disease through Systematic Review and Meta-Analysis of Randomized Controlled Trials ReadThe Incidence and Consequences of Endovascular Technical Failure in Patients with Chronic Limb-Threatening Ischemia: Results from the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb-Threatening Ischemia (BEST-CLI) Trial ReadComparative Radiologic Response Assessment after Transarterial Chemoembolization, Percutaneous Ablation, and Multimodal Treatment: Radiologic-Pathologic Correlation in 81 Tumors ReadBreast Cancer Recurrence after Cryoablation in Patients Who Are Poor Surgical Candidates or Who Refuse Surgery ReadKetamine/Midazolam versus Fentanyl/Midazolam Sedation for Interventional Radiology Procedures: A Prospective Registry ReadPortal and Hepatic Vein Embolization versus Portal Venous Embolization Alone in Cirrhotic and Noncirrhotic Swine: A Pilot Study ReadAssessment of Catheter-Directed Thrombolysis and Histotripsy Treatment for Deep Vein Thrombosis ReadExpanding Global IR Outreach to Address Postpartum Hemorrhage in Kenya Using Geospatial Analytic Mapping ReadJVIR and SIR thank all those who helped record this episode. To sign up to help with future episodes, please contact our outreach coordinator at millennie.chen.jvir@gmail.com.  Host and audio Editor:Sonya Choe, University of California Riverside School of MedicineOutreach coordinator:Millennie Chen, University of California Riverside School of MedicineAbstract readers:Marc Attalla, University of California Riverside School of MedicineAgnes Manish, Loma Linda University School of MedicineClare Necas, Western University of Health Sciences, College of Osteopathic MedicineGavin Shu, University of California San Francisco School of MedicineMark Oliinik, Loma Linda University School of MedicineAbhisri Ramesh, George Washington School of Medicine and Health SciencesAndrew Sasser, University of Miami Miller School of Medicine Sakeena Siddiq, Western University of Health Sciences, College of Osteopathic MedicineSIR thanks BD for its generous support of the Kinked Wire.Read more about about interventional radiology in IR Quarterly magazine or SIR's Patient Center.Support the show

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.

When Dr. John Lewis discovered the incredible benefits of polysaccharides on improving cognitive function, reducing inflammation, and improving overall well being, he changed the direction of his career.   Dr. Lewis is a leader in clinical research, a former Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine, and is currently the Founder and President of Dr Lewis Nutrition.  You can reach Dr. Lewis at his websites https://drlewisnutrition.com/ and https://dailybraincare.comSome of the highlights Dr. Lewis shares:"Health Care" means taking care of our health everyday - it's not just treating symptoms with pharmaceuticals The United States has spent over 4.5 Trillion dollars on a "Health Care" system that brings unsatisfactory resultsNutrition is the most effective tool to care for our health and well beingHow a 12 month study on Alzheimer patients showed that adding certain polysaccharides improved cognitive function and quality of lifeAre all sugars bad?  No some types are beneficial for our well beingMonosaccharides (one sugar) like high fructose syrup harm our bodyDisaccharides (two sugars) like sucrose or table sugar harm our bodyPolysaccharides (many sugars) like those found in aloe vera and rice bran benefit the body in multiple waysResearch shows that polysaccharides improve cognitive function and reduce chronic inflammation70-80% of Americans are overweight or obeseOur best health care plan is to eat well and supplement proper nutritionHow our immune system is like the conductor of an orchestra keeping our organs and systems balanced and regulatedOur body wants to be healthyWe don't have to wait for a diagnosis of cancer, diabetes, heart disease, Alzheimer's, or other chronic illness to act - prevention is keyAnd more Please share, subscribe, leave a rating and review, visit the Linda's Corner website at lindascornerpodcast.com and/or follow on youtube, facebook, instagram, and pinterest @lindascornerpodcast. Thanks!Also please visit the Hope for Healing website at hopeforhealingfoundation.org for free resources to increase happiness, build confidence and self esteem, improve relationships, manage stress, and calm feelings of depression and anxiety.   Become the champion of your own story as you overcome your challenges. 

Despite advances in epilepsy management, disparities and lack of inclusion of many people with epilepsy are associated with increased morbidity and mortality. Improving awareness and promoting diversity in research participation can advance treatment for underserved populations and improve trust. In this episode, Teshamae Monteith, MD, PhD, FAAN speaks Dave F. Clarke, MBBS, FAES, author of the article “Diversity and Underserved Patient Populations in Epilepsy,” in the Continuum® February 2025 Epilepsy issue. Dr. Monteith is a Continuum® Audio interviewer and an 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. Clarke is the Kozmetsky Family Foundation Endowed Chair of Pediatric Epilepsy and Chief or Comprehensive Pediatric Epilepsy Center, Dell Medical School at the University of Texas at Austin in Austin, Texas. Additional Resources Read the article: Diversity and Underserved Patient Populations in Epilepsy 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, 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 Monteith: This is Dr Teshamae Monteith. Today I'm interviewing Dr Dave Clarke about his article on diversity and underserved patient populations in epilepsy, which appears in the February 2025 Continuum issue on epilepsy. So why don't you introduce yourself to our audience? Dr Clarke: Sure. My name is Dr Dave Clarke, as alluded to. I'm presently at the University of Texas in Austin, originating from much farther south. I'm from Antigua, but have been here for quite a while working within the field in epilepsy surgery, but more and more getting involved in outreach, access to care, and equity of healthcare in epilepsy. Dr Monteith: And how did you get involved in this kind of work? Dr Clarke: That's an amazing question. You know, I did it in a bit of a inside out fashion. I initially started working in the field and trying to get access to persons in the Caribbean that didn't have any neurological care or investigative studies, but very quickly realized that persons around the corner here in Texas and wherever I've worked have had the exact same problems, getting access via fiscal or otherwise epilepsy care, or geographically getting access, with so few having neurologists close at hand. Therefore, I started working both on a regional, national, and it transcended to a global scale. Dr Monteith: Wow, so you're just everywhere. Dr Clarke: Well, building bridges. I've found building bridges and helping with knowledge and garnering knowledge, you can expand your reach without actually moving, which is quite helpful. Dr Monteith: Yeah. So why don't you tell us why you think this work is so important in issues of diversity, underserved populations, and of course, access to epilepsy care? Dr Clarke: Sure, not a problem. And I think every vested person in this can give you a different spiel as to why they think it's important. So, I'll add in a few facts pertaining to access, but also tell you about why I think personally that it's not only important, but it will improve care for all and improve what you believe you could do for a patient. Because the sad thing is to have a good outcome in the United States presently, we have over three hundred epilepsy centers, but they have about eight or nine states that don't have any epilepsy centers at all. And even within states themselves, people have to travel up to eight hours, i.e., in Texas, to get adequate epilepsy care. So that's one layer. Even if you have a epilepsy center around the corner, independent of just long wait times, if you have a particular race or ethnicity, we've found out that wait may be even longer or you may be referred to a general practitioner moreso than being referred to an epilepsy center. Then you add in layers of insurance or lack thereof, which is a big concern regardless of who you are; poverty, which is a big concern; and the layers just keep adding more. Culture, etcetera, etcetera. If you could just break down some of those barriers, it has been shown quite a few years ago that once you get to an epilepsy center, you can negate some of those factors. You can actually reduce time to access and you can improve care. So, that's why I'm so passionate about this, because something could potentially be done about it. Dr Monteith: That's cool. So, it sounds like you have some strategies, some strategies for us. Dr Clarke: Indeed. And you know, this is a growth and this is a learning curve for me and will be for others. But I think on a very local, one-to-one scale, the initial strategy I would suggest is you have to be a good listener. Because we don't know how, when, where or why people are coming to us for their concerns. And in order to judge someone, if they may not have had a follow-up visit or they may not have gotten to us after five medications, the onus may not have been on that person. In other words, as we learned when we were in medical school, history is extremely important, but social history, cultural history, that's also just as important when we're trying to create bridges. The second major thing that we have to learn is we can't do this alone. So, without others collaborating with us outside of even our fields, the social worker who will engage, the community worker who will discuss the translator for language; unless you treat those persons with respect and engage with those persons to help you to mitigate problems, you'll not get very far. And then we'll talk about more, but the last thing I'll say now is they have so many organizations out there, the Institute of Medicine or the International League Against Epilepsy or members of the American Epilepsy Society, that have ways, ideas, papers, and articles that can help guide you as to how better mitigate many of these problems. Dr Monteith: Great. So, you already mentioned a lot of things. What are some things that you feel absolutely the reader should take away in reading your article? You mentioned already listening skills, the importance of interdisciplinary work, including social work, and that there are strategies that we can use to help reduce some of this access issues. But give me some of the essential points and then we'll dive in. Dr Clarke: OK. I think first and foremost we have to lay the foundation in my mind and realize what exactly is happening. If you are Native American, of African descent, Hispanic, Latinx, geographically not in a region where care can be delivered, choosing one time to epilepsy surgery may be delayed twice, three, four times that of someone of white descent. If you are within certain regions in the US where they may have eight, nine, ten, fourteen epilepsy centers, you may get to that center within two to three years. But if you're in an area where they have no centers at all, or you live in the Dakotas, it may be very difficult to get to an individual that could provide that care for you. That's very, very basic. But a few things have happened a few years ago and even more recently that can help. COVID created this groundswell of ambulatory engagement and ambulatory care. I think that can help to mitigate time to get into that person and improving access. In saying that, there are many obstacles to that, but that's what we have to work towards: that virtual engagement and virtual care. That would suggest in some instances to some persons that it will take away the one-to-one care that you may get with persons coming to you. But I guarantee that you will not lose patients because of this, because there's too big a vacuum. Only 22% of persons that should actually get to epilepsy centers actually get to epilepsy centers. So, I think we can start with that foundation, and you can go to the article and learn a lot more about what the problems are. Because if you don't know what the problems are, you can't come up with solutions. Dr Monteith: Just give us a few of the most persistent inequities and epilepsy care? Dr Clarke: Time to seeing a patient, very persistent. And that's both a disparity, a deficiency, and an inequity. And if you allow me, I'll just explain the slight but subtle difference. So, we know that time to surgery in epilepsy in persons that need epilepsy surgery can be as long as seventeen years. That's for everyone, so that's a deficiency in care. I just mentioned that some sociodemographic populations may not get the same care as someone else, and that's a disparity between one versus the other. Health equity, whether it be from NIH or any other definition, suggests that you should get equitable care between one person and the other. And that brings in not only medical, medicolegal or potential bias, that we may have one person versus the other. So, there's a breakdown as to those different layers that may occur. And in that I'm telling you what some of the potential differences are. Dr Monteith: And so, you mentioned, it comes up, race and ethnicity being a major issue as well as some of the geographic factors. How does that impact diagnosis and really trying to care for our patients? Dr Clarke: So again, I'm going to this article or going to, even. prior articles. It has been shown by many, and most recently in New Jersey, that if you're black, Hispanic, Latin- Latinx, it takes you greater than two times the time to surgery. Reduced time to surgery significantly increases morbidity. It potentially increases mortality, as has been shown by a colleague of mine presently in Calgary. And independent of that, we don't look at the other things, the other socially related things. Driving, inability to work, inability to be adequately educated, the stigma related to that in various cultures, various countries. So, that deficit not only increased the probability of having seizures, but we have to look at the umbrella as to what it does. It significantly impacts quality of life of that individual and, actually, the individuals around them. Dr Monteith: So, what are some of these drivers, and how can we address them, or at least identify them, in our clinic? Dr Clarke: That's a question that's rather difficult to answer. And not because there aren't ideas about it, but there's actually mitigating those ideas or changing those ideas we're just presently trying to do. Although outlines have been given. So, in about 2013, the federal government suggested outlines to improve access and to reduce these inequities. And I'll just give you a few of them. One of those suggestions was related to language and having more improved and readily available translators. Something simple, and that could actually foster discussions and time to better management. Another suggestion was try to train more persons from underserved populations, persons of color. Reason being, it has been shown in the social sciences and it is known in the medical sciences that, if you speak to a person of similar culture, you tend to have a better rapport, you tend to be more compliant, and that track would move forward, and it reduces bias. Now we don't have that presently, and I'm not sure if we'll have that in the near future, although we're trying. So then, within your centers, if you have trainings on cultural sensitivity, or if you have engagements and lectures about how you can engage persons from different populations, those are just some very simple pearls that can improve care. This has been updated several times with the then-Institute of Medicine in 2012, 2013, they came out with, in my mind, a pretty amazing article---but I'm very biased---in which they outline a number of strategic initiatives that could be taken to improve research, improve clinical care, improve health equity through health services research, to move the field forward, and to improve overall care. They updated this in 2020, and it's a part of the 2030 federal initiative not only for epilepsy, but to improve overarching care. All of this is written in bits and pieces and referenced in the article. To add icing on top, the World Health Organization, through advocacy of neurological groups as well as the International League Against Epilepsy and the AES, came out with the Intersectoral Action Plan on Epilepsy and Other Neurological Diseases, which advocates for parallel improvement in overall global care. And the United States have signed on to it, and that have lit a fire to our member organizations like the American Epilepsy Society, American Academy of Neurology, and others, trying to create initiatives to address this here. I started off by saying this was difficult because, you know, we have debated epilepsy care through 1909 when the International League against Epilepsy was founded, and we have continually come up with ways to try and advance care. But this have been the most difficult and critical because there's social dynamics and social history and societal concerns that have negated us moving forward in this direction. But fortunately, I think we're moving in that direction presently. That's my hope. And the main thing we have to do is try to sustain that. Dr Monteith: So, you talked about the importance of these global initiatives, which is huge, and other sectors outside of neurology. Like for example, technology, you spoke about telemedicine. I think you were referring to telemedicine with COVID. What other technologies that are more specific to the field of epilepsy, some of these monitorings that maybe can be done? Dr Clarke: I was just going to just going to jump on that. Thank you so much for asking. Dr Monteith: I have no disclosures in this field. I think it's important and exciting to think how can we increase access and even access to monitoring some of these technologies. That might be expensive, which is another issue, but…. Dr Clarke: So, the main things in epilepsy diagnosis and management: you want to hear from the patient history, you want to see what the seizures look like, and then you want to find ways in which to monitor those seizures. Hearing from the patient, they have these questionnaires that have been out there, and this is local, regional, global, many of them standardized in English and Spanish. Our colleagues in Boston actually created quite a neat one in English and Spanish that some people are using. Ecuador has one. We have created someone- something analogous. And those questionnaires can be sent out virtually and you can retrieve them. But sometimes seeing is believing. So, video uploads of seizures, especially the cell phone, I think has been management-changing for the field of epilepsy. The thing you have to do however, is do that in a HIPAA-compliant way. And several studies are ongoing. In my mind, one of the better studies here was done on the East Coast, but another similar study, to be unnamed, but again, written out in the articles. When you go into these apps, you can actually type in a history and upload a video, but the feed is not only going to you, it may be going to the primary care physician. So, it not only helps in one way in you educating the patient, but you educate that primary care physician and they become extenders and providers. I must add here my colleagues, because we can't do without them. Arguably in some instances, some of the most important persons to refer patients, that's the APPs, the PAs and the nurse practitioners out there, that help to refer patients and share patients with us. So, that's the video uploads they're seeing. But then the other really cool part that we're doing now is the ambulatory world of EEGs. Ceribell, Zeto, to name of few, in which you could potentially put the EEG leads on persons with or without the EEG technologist wirelessly and utilize the clouds to review the EEGs. It's not perfect just yet, but that person that has to travel eight hours away from me, if I could do that and negate that travel when they don't have money to pay for travel or they have some potential legal issues or insurance-related issues and I could read the EEG, discuss with them via telemedicine their care, it actually improves access significantly. I'm going to throw in one small twist that, again, it's not perfect. We're now trying to monitor via autonomic features, heart rate movement and others, for seizures and alert family members, parents, because although about 100,000 people may be affected with epilepsy, we're talking about 500,000 people who are also affected that are caregivers, affiliates, husbands, wives, etcetera. Just picture it: you have a child, let's say three, four years old and every time they have a seizure- or not every time, but 80% of times when they have a seizure, it alerts you via your watch or it alerts you in your room. It actually gives that child a sense of a bit more freedom. It empowers you to do something about it because you can understand here. It potentially negates significant morbidity. I won't stretch it to say SUDEP, but hopefully the time will come when actually it can prevent not only morbidity, but may prevent death. And I think that's the direction we are going in, to use technology to our benefit, but in a HIPAA-compliant way and in a judicious way in order to make sure that we not only don't overtreat, but at the end of the day, we have the patient as number one, meaning everything is vested towards that patient and do no harm. Dr Monteith: Great. One thing you had mentioned earlier was that there are even some simple approaches, efficiency approaches that we can use to try and optimize care for all in our clinics. Give me what I need to know, or do. Give me what I need to do. Dr Clarke: Yeah, I'll get personal as to what we're trying to do here, if you don't mind. The initial thing we did, we actually audited care and time to care delivery. And then we tried to figure out what we could do to improve that access and time to care, triaging, etcetera. A very, very simple thing that can be done, but you have to look at costs, is to have somebody that actually coordinates getting persons in and out of your center. If you are a neurologist that works in private practice, that could potentially be a nurse being associated directly one-and-one with one of the major centers, a third- or fourth-level center. That coordination is key. Educate your nurses about epilepsy care and what the urgent situations are because it will take away a lot of your headache and your midnight calls because they'll be able to know what to do during the day. Video uploads, as I suggested, regardless of the EMR that you have, figure out a way that a family could potentially send a video to you, because that has significantly helped in reducing investigative studies. Triaging appropriately for us to know what patients we can and cannot see. Extenders has helped me significantly, and that's where I'll end. So, as stated, they had many neurologists and epileptologists, and utilizing appropriately trained nurse practitioners or residents, engaging with them equally, and/or social workers and coordinators, are very helpful. So hopefully that's just some low-hanging fruit that can be done to improve that care. Dr Monteith: So why don't you give us some of your major takeaways to how we can improve epilepsy care for all people? Dr Clarke: I've alluded to some already, but I like counts of threes and fives. So, I think one major thing, which in my mind is a major takeaway, is cultural sensitivity. I don't think that can go too far in improving care of persons with epilepsy. The second thing is, if you see a patient that have tried to adequately use medications and they're still having seizures, please triage them. Please send them to a third- or fourth-level epilepsy center and demand that that third- or fourth-level epilepsy center communicate with you, because that patient will eventually come back and see you. The third thing---I said three---: listen to your patients. Because those patients will actually help and tell you what is needed. And I'm not only talking about listening to them medication-wise. I know we have time constraints, but if you can somehow address some of those social needs of the patients, that will also not only improve care, but negate the multiple calls that you may get from a patient. Dr Monteith: You mentioned a lot already. This is really wonderful. But what I really want to know is what you're most hopeful about. Dr Clarke: I have grandiose hopes, I'll tell you. I'll tell you that from the beginning. My hope is when we look at this in ten years and studies are done to look at equitable care, at least when it comes to race, ethnicity, insurance, we'll be able to minimize, if not end, inequitable care. Very similar to the intersectoral action plan in epilepsy by 2030. I'll tell you something that suggests, and I think it's global and definitely regional, the plan suggests that 90% of persons with epilepsy should know about their epilepsy, 80% of persons with epilepsy should be able to receive appropriate care, and 70% of persons with epilepsy should have adequately controlled epilepsy. 90, 80, 70. If we can get close to that, that would be a significant achievement in my mind. So, when I'm chilling out in my home country on a fishing boat, reading EEGs in ten years, if I can read that, that would have been an achievement that not necessarily I would have achieved, but at least hopefully I would have played a very small part in helping to achieve. That's what I think. Dr Monteith: Awesome. Dr Clarke: I appreciate you asking me that, because I've never said it like that before. In my own mind, it actually helped with clarity. Dr Monteith: I ask great questions. Dr Clarke: There you go. Dr Monteith: Thank you so much. I really- I really appreciate your passion for this area. And the work that you do it's really important, as you mentioned, on a regional, national, and certainly on a global level, important to our patients and even some very simple concepts that we may not always think about on a day-to-day basis. Dr Clarke: Oh, I appreciate it. And you know, I'm always open to ideas. So, if others, including listeners, have ideas, please don't hesitate in reaching out. Dr Monteith: I'm sure you're going to get some messages now. Dr Clarke: Awesome. Thank you so much. Dr Monteith: Thank you. I've been interviewing Dr Dave Clarke about his article on diversity and underserved patient populations in epilepsy, which 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 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.

Many patients with epilepsy are unable to acheive optimal seizure control with medical therapy. Palliative surgical procedures, neurostimulation devices, and other nonpharmalogical treatments can lead to a meaningful reduction in seizures and improved outcomes. In this episode, Teshamae Monteith, MD FAAN, speaks with Daniel Friedman, MD, MSc, author of the article “Surgical Treatments, Devices, and Nonmedical Management of Epilepsy,” in the Continuum® February 2025 Epilepsy issue. Dr. Montieth is a Continuum® Audio interviewer and an 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. Friedman is a professor (clinical) of neurology at NYU Grossman School of Medicine and Director of NYU Langone Comprehensive Epilepsy Center at NYU Langone Health in New York, New York. Additional Resources Read the article: Surgical Treatments, Devices, and Nonmedical Management of Epilepsy 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: @dfriedman36  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 Monteith: This is Dr Teshamae Monteith. Today, I'm interviewing Dr Daniel Friedman about his article on surgical treatments, devices, tools, and non-medication management of epilepsy, which appears in the February 2025 Continuum issue on epilepsy. Welcome to the podcast. How are you? Dr Friedman: I'm well, how are you? Dr Monteith: Thank you for your article. Dr Friedman: Thank you for the opportunity to talk today. Dr Monteith: Why don't you introduce yourself? Dr Friedman: So yeah, so I'm Dan Friedman. I am a professor of neurology here at NYU Grossman School of Medicine and I am the director of the NYU Comprehensive Epilepsy Center. I'm primarily an adult neurologist and I treat teens and adults with hard- difficult-to-treat epilepsy, including surgical treatments for epilepsy. Dr Monteith: And I know you see a lot of patients because I did my residency there. And so, when you graduate, you get a lot of it, like I think many, many residents. What inspired you to choose epilepsy as a profession? Dr Friedman: I came to neurology through my interest in neuroscience. I was a neuroscience undergraduate. I was very interested in the brain and brain function. Particularly, I was interested in how neurons communicate and organize to entrain and rhythms and that encode information. And through that interest and through my experiences in the laboratory, I actually became interested in how they do that in pathological circumstances like seizures. And so, I started reading about epilepsy, and then when I started seeing patients with epilepsy, you know, I decided this is the specialty for me for a lot of reasons. One is it combines inpatient and outpatient care. You get to establish long-term relationships with patients. For many of my patients, I'm probably the doctor that they see most often. You see people across the lifespan. And what I'm going to talk about today is for some people, you actually get to cure their disease, which at the time I was coming into neurology was something pretty rare. Dr Monteith: Yeah, that's great. Why don't you tell us, what were you thinking when you started writing the article? What did you set out to do? Dr Friedman: What I really wanted to do is to educate neurologists out there about the options that they have for their patients with epilepsy, especially those with difficult-to-treat or drug-resistant epilepsy, and give them the tools to communicate those options. Especially for them to understand the rationale, why we choose the interventions that we do as epileptologists, how to appropriately refer patients and have them be partners in that discussion with patients and families. One of the things that we have known for a long time is that the time to referral for things like epilepsy surgery is too long. You know, the average patient with drug resistant epilepsy who undergoes epilepsy surgery waits about twenty years. And for patients who could have curative therapy, you know, become seizure free, that's a lot of life years lost. If we can get patients to that potentially life-altering therapy earlier, that'd be great. Dr Monteith: Yeah, that is really impactful as you think about it. So why don't you tell us what the essential points of your article? Dr Friedman: The central point of my article is really that when patients have drug-resistant epilepsy, which means that our available anti-seizure medicines are not controlling their seizures to the degree that they need, there are other treatment options. Some of those are what we call curative, which means that they could stop their seizures entirely; and some of them are palliative, they could reduce the frequency or severity of seizures and improve quality of life and other outcomes. The other thing that I wanted to highlight was, in addition to these types of therapies, there are other tools we have at our disposal that can improve the quality of life and safety of our patients with epilepsy, including devices for seizure monitoring. Dr Monteith: And how do you define drug-resistant epilepsy? I feel like that could be a moving target. Dr Friedman: The International League Against Epilepsy actually set out to define it about a decade ago, and they defined it as patients who fail at least two appropriately selected anti-seizure medicines due to lack of efficacy. Then they're still having ongoing seizures. What does that mean? So, that means that the medicine that was chosen was appropriate for the type of seizures that they have, whether it's focal or generalized, and that it didn't work because of a lack of efficacy and not because of side effects. And we know from multiple studies that once patients fail two medications, the likelihood that the third, fourth, fifth, etcetera, medicine will control their seizures becomes smaller and smaller. It's not impossible, but the rates fall below five percent. And so we call those patients drug-resistant. Dr Monteith: So, it sounds like despite newer therapies, really things haven't changed in ten years. Dr Friedman: Yeah, unfortunately, at least when the concept was first investigated back in 2000 by Quan and Brody, they found that a third of patients were drug-resistant. When they went back in the mid-2010s to relook at these patients, despite the introduction of many new medications, the rate of patients who were drug-resistant was essentially unchanged. There may be therapies that are emerging or in development that may have better odds, but right now we don't really understand what makes people drug resistant and how we can target that. Dr Monteith: But you do raise a good point that this is about efficacy and not tolerability. And at least for some of the newer medications, they're better tolerated. If you stop the medicine because you had some side effect, that might change how that person has classified better-tolerated treatments. Dr Friedman: It's true. And better-tolerated treatments, you can potentially use higher doses. One of the things that is not in the definition of drug-resistant epilepsy, but as a practicing neurologist, we all know, is that the patients have to take the medicine for it to be effective. And unfortunately, they have to take it every day. And if the medicine makes them feel bad, they may choose not to take it, present to you as drug-resistant, when in reality they may be drug-sensitive if you got them on medicine that doesn't make them feel bad. Dr Monteith: So why don't we talk about patients that are ideal candidates for epilepsy surgery? Dr Friedman: The ideal candidates for epilepsy surgery… and I'll start by talking about curative epilepsy surgery, where the goal of the surgery is to make patients seizure-free. The best candidates are patients who have lesional epilepsy, meaning that there is a visible MRI abnormality like a focal cortical dysplasia, hippocampus sclerosis, cavernoma in a part of the brain that is safe to resect, non-eloquent, and where you can safely perform a wide margin of resection around that lesion. It helps if they have few or no generalized tonic-clonic seizures and a shorter duration of epilepsy. So the ideal patient, the patient that if they came to my office, I would say you should get surgery right now, are patients with non-dominant temporal lobe epilepsy of a few years' duration. So as soon as they've shown that they're not responding to two medicines, those are the ideal patients to say, you would have the most benefit and the least risk from epilepsy surgery. We know from studies that patients with temporal lobe epilepsy do a little better with surgery. We know patients who have a visible lesion on MRI do better with epilepsy surgery. We know that patients who have infrequent secondarily generalized seizures do better. But all patients with drug-resistant epilepsy should be considered for some form of surgery because even if they're not candidates for a curative surgery, there may be some palliative options, whether it's surgical resections that lessen the severity of their seizures or neurostimulation devices that reduce the frequency and severity of seizures. Ideal candidates, the ones that you would push through sooner rather than later, are those who have the likelihood of the best outcomes and the least risk of neurocognitive decline. Dr Monteith: So, you mentioned that there may be other candidates that still benefit, although maybe not ideal. You mentioned neuromodulation. What other interventions are available? Dr Friedman: For patients who are not candidates for resective surgery, there are several neurostimulation options. There's vagus nerve stimulation, which has been around the longest. It is a device that is implanted in- under the skin near the clavicle and has a lead that goes to the left vagus nerve and delivers stimulation, electrical stimulation to the nerve. For reasons we don't fully understand, it can reduce the both the frequency and severity of seizures. Seldom does it make people seizure free, but the reduction in seizure frequency for many patients is associated with improved quality of life, reduced risk of injury, and even reduced rates of SUDEP. We also have two intracranial neurostimulation devices we use for epilepsy. One is the responsive neurostimulator. So, this is a device that- it has leads that are implanted directly into the seizure focus and sense electrocortical brain activity and deliver electrical stimulation to attempt to abort abnormal brain activity. So functioning kind of like a cardiac defibrillator for the heart, but for seizures in the brain. And because these devices have two leads, they can be used to treat people with more than one seizure focus---so up to two---or be used in patients who are not candidates for resection because their seizure focus is in language cortex, motor cortex, things that would be unable to resect. And the RNS has somewhat better efficacy in terms of percent reduction in seizures compared to the VNS, but obviously because it's an intracranial device, it's also a little riskier. It has more potential for neurosurgical adverse effects. There's also a deep brain stimulator for epilepsies, the same exact device that we use to treat movement disorders. We can implant in the thalamus, in either the anterior nucleus of the thalamus or now, for some patients, into the central median nucleus of the thalamus, and deliver open loop stimulation to treat epilepsy and reduce the frequency and severity of seizures as well. Unlike the RNS, you don't have to localize the seizure focus, so you don't need to know exactly where the seizures are coming from. And you could treat patients with multifocal epilepsy with seizures coming from more than two locations or even generalized seizures. Dr Monteith: So, it sounds like there are a lot of options available to patients. I think one of the things I find challenging is when we have patients that may have some cognitive dysfunction, especially in the hospital, and they've had some seizures that are very obvious, but then there are these, maybe, events that you wonder are seizures. So, what is the utility of some of these seizure detection devices? Dr Friedman: The development of seizure detection devices started out primarily with the observation that a majority of cases of sudden unexpected death and epilepsy, or SUDEP, occurred following tonic-clonic seizures. And there was a need to be able to monitor for convulsive seizures, especially that occur at night when people were otherwise unattended. And so, the first generation of devices that were developed came on the market, essentially detected convulsive seizures, and they alerted caregivers nearby who are able to come to the bedside, provide basic seizure first aid, turn people on the side. And theoretically all this---this hasn't been shown in studies---prevents SUDEP. And so, the ones that are currently available on the market are focused on the detection of convulsive seizures, mostly generalized tonic-clonic seizures, but some devices can also detect other seizures with very prominent motor components. What we don't have yet available to us, and what people are working on, are devices that detect nonconvulsive seizures. We know that patients who have focal impaired aware seizures are often amnestic for their seizures. They don't know they had a seizure if family members aren't there to observe them. They may never report them, which makes treating these patients very difficult. How do you quantify disease burden in your headache patients, for instance? You say, how many headache days did you have since we last met in the clinic? Your patients will be able to report on their calendar, this many days. Well, imagine if the patients had no awareness of whether or not they had a headache day. You wouldn't know if your therapy is working or not. In epilepsy, we need those types of devices which can tell us whether patients are having seizures they're unaware of, and that may be more subtle than convulsions. Dr Monteith: Oh, that'd be great for headache, too. You just gave me an idea, but that's the next podcast. So, you mentioned SUDEP, really important. How good are surgical interventions at reducing what we would think the prevalence of SUDEP? Dr Friedman: For me that is one of the primary motivations for epilepsy surgery in patients who are drug-resistant, because we know that if patients who are candidates for epilepsy surgery have high SUDEP rates. Estimates range from six to nine per thousand patients per year. If surgery is successful, their mortality rates go down to the general population level. It literally can be lifesaving for some patients, especially when you're talking about curative epilepsy surgery. But we also know that the biggest driver for SUDEP risk is tonic-clonic seizures and the frequency of those tonic-clonic seizures. So even our palliative interventions, which can reduce the frequency and severity of seizures, may also reduce the risk of SUDEP. So, we know in study- observational studies of patients with VNS and with RNS, for instance, the rates of SUDEP in patients treated with those devices are lower than expected for the drug-resistant epilepsy population. Dr Monteith: Let's talk a little bit about some of these prediction models. And you have a lot of great work in your article, so I don't want to get into all the details, but how do you use that in the real world? Do you communicate that with patients? How do you approach these prediction factors? Dr Friedman: There are two places where, I think, clinical prediction tools for epilepsy surgery have a role. One is, for me, in my clinic where I'm talking to patients about the risks and benefits for surgery, right? You want to be able to accurately communicate the likelihood that the surgery is going to give you the desired outcome. So patients and their families can make educated decisions, be weighing the risks and benefits. I think it's important to be realistic with patients because surgery, like- you know, any surgery is not without risk, both acute risks and long-term risks. You're removing part of the brain, and, you know, every part of the brain is important. That's where I use prediction tools. But I think it's also important for the general neurologist, especially trying to triage which patients you are going to be aggressive with referring to a comprehensive epilepsy center for evaluation. Where you may use your limited time and capital with patients to counsel them on surgical treatments. Where a healthcare system with limited resources prioritizes patients. So, there's a significant need for having prediction tools that only take the input that a general neurologist seeing a patient in the clinic would have at hand. You know, the history, an MRI, an interictal EEG. Dr Monteith: I guess part of that prediction model includes adverse outcomes that you're communicating as well. Dr Friedman: Certainly, for me, when I'm discussing surgery for the patient in front of me, I will use prediction models for adverse outcomes as well that are informed by the kind of surgery we're proposing to do, especially when talking about things like language dysfunction and memory dysfunction after surgery. Dr Monteith: So, you mentioned a lot of great advances, and certainly since I was a resident, which wasn't that long ago. Why don't you tell me how some of these interventions have changed your clinical practice? Dr Friedman: Thinking about epilepsy surgery, like other surgical specialties, there's been a move to more minimally invasive approaches. For instance, when I started as an epilepsy fellow fifteen years ago, sixteen years ago, most of our surgeries involve removing a large portion of the skull, putting electrodes on the brain, doing resections through big craniotomies which were uncomfortable and risky, things like that. We now do our phase two or intracranial EEG monitoring through small burr holes in the brain using robotically placed electrodes. For many of our patients, we can actually treat their epileptic focus with a laser that is targeted through a small catheter and MRI guidance. And patients are usually home in two days with, you know, a lot less discomfort. Dr Monteith: Well, that's great. I didn't expect that one, but I do think that translates to many areas of neurology. Really just this idea of meeting their goals and personalizing their care. My last question is, what out of these advances and what you know about the future of epilepsy, what makes you the most excited and what gives you the most hope? Dr Friedman: I think there are a lot of exciting things in epilepsy. Last count I heard, there's something like over a hundred biotech companies developing epilepsy therapies. So that gives me hope that people are still interested in meeting the unmet needs of patients with epilepsy. And some of these therapies are really novel. For instance, there's a trial of stem cell treatments for drug-resistant temporal lobe epilepsy that's ongoing now, where inhibitory interneuron progenitor cells are implanted in the brain and kind of restore the brain circuit disruptions that we see in some of these epilepsies. There are combinations of drug and device therapies or gene therapy and device therapies that are in development, which have a lot of promise, and I think we'll have much more precise and targeted therapies within the next decade. Dr Monteith: Awesome. I really appreciate our conversation, and thank you so much for your wonderful article. I learned a lot reading it. Dr Friedman: Thank you. Dr Monteith: Today I've been interviewing Dr Daniel Friedman, whose article on surgical treatments, devices, tools, and non-medication management of epilepsy 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 Teshmae 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.

In this episode, Patricia D. Jones, MD, MSCR; Mindie H. Nguyen, MD, MAS, AGAF, FAASLD; and patient advocate, Jennifer Wild, MS, RN, OCN, discuss practical strategies to overcome barriers to hepatitis B virus (HBV) care, including: Overcoming health insurance navigation Improving access to HBV care in immigrant communitiesDispelling HBV myths and stigmaSolutions to language barriersCommunity-based interventionsPresenters:Patricia D. Jones, MD, MSCRAssociate Professor of Clinical MedicineDirector of Clinical Operations-HepatologyDivision of Digestive Health and Liver DiseasesDepartment of MedicineUniversity of Miami Miller School of MedicineSylvester Comprehensive Cancer CenterMiami, FloridaMindie H. Nguyen, MD, MAS, AGAF, FAASLDProfessor of Medicine (GI & Hepatology,Liver Transplant)Professor of Epidemiology & Population Health(by Courtesy)Director of Hepatology ClerkshipFaculty Search LENS Advocates,Stanford Department of MedicineFaculty Fellow, Stanford Center for Innovationin Global HealthMember, Stanford Cancer Institute, Maternal &Child Health Research Institute, & Stanford Bio-CStanford, CaliforniaPast Chair: HBV SIG, The American Association for the Study of Liver Diseases (AASLD)28th President: The International Association for the Study of the Liver (IASL)Jennifer Wild, MS, RN, OCNClinical Nurse – GI Medical OncologyUCSF Cancer CenterSan Francsico, CaliforniaLink to full program: https://bit.ly/4j973TNDownloadable slides: https://bit.ly/3WQkIWlGet access to all of our new podcasts by subscribing to the CCO Infectious Disease Podcast on Apple Podcasts, Google Podcasts, or Spotify.

Dr. Rahul Iyengar is a dedicated physician and the Founder and CEO of Members Health Co., a membership-based primary care clinic in Nashville, TN. He earned his medical degree from the University of Miami Miller School of Medicine and completed his residency at Southern Hills Family Medicine Continuity Clinic. Dr. Iyengar's diverse life experiences and extensive training in primary care and physiology provide him with a unique platform to deliver exceptional patient care. Beyond medicine, he has a passion for art and design, having considered a career in architecture before pursuing healthcare. This creative interest is evident in his endeavors, such as designing his own clinic and crafting furniture. membershealthco.com nashvillelifestyles.com In this episode, we delve into Dr. Iyengar's innovative approach to preventative medicine and his commitment to enhancing patients' quality of life. Our discussion covers a range of topics, including: Principles of Blue Zones—regions known for longevity—and practical strategies to incorporate their habits into daily life.  Potential benefits and considerations of NAD+ therapy, a treatment gaining attention for its possible anti-aging and energy-boosting effects. Additionally, Dr. Iyengar shares insights on the importance of regular physical activity, quality sleep, and other lifestyle choices that contribute to long-term health and well-being. Join us as we uncover actionable tips and expert advice to help you proactively manage your health and set yourself up for a vibrant future.

In this episode, our special guest is Dr. John E. Lewis, a leading expert in nutrition and human health. As the founder of Dr. Lewis Nutrition and a former associate professor at the University of Miami Miller School of Medicine, Dr. Lewis shares his extensive research on the benefits of polysaccharides. Discover their surprising advantages for Alzheimer's disease, immune function, and overall health. Dr. Lewis also dives into his journey from competitive bodybuilding to groundbreaking clinical trials. Tune in to learn how polysaccharides, along with good nutrition and exercise, can contribute to... aging well.Learn more about Dr. Lewis and his work at https://drlewisnutrition.comBUY Dr. Lewis Nutrition Daily Brain Care on Amazon and support The Aging Well Podcast: https://amzn.to/3X4KypN

Today, I am blessed to have here with me Dr. Emily Rowe. She graduated from the University of Miami Miller School of Medicine in 2004 with a doctorate degree in medicine. After a brief time in the field of Internal Medicine, she became frustrated with the Western approach to illness. She realized that she was being trained to treat the symptoms of disease and its end-stage complications, while failing to address its root cause. Inspired to find a comprehensive and definitive way to heal her patients, she went back to school and completed her Master's Degree in Chinese Herbal Medicine and Acupuncture (Master of Oriental Medicine) in 2009.   She and her husband, Christopher M. Estes MD, opened the Miami Beach Comprehensive Wellness Center in 2017. In this episode, Dr. Emily takes us through the intricate web of factors that affect our health, often lurking beneath the surface. She sheds light on the challenges of maintaining health, emphasizing how elevated toxic burdens or chronic infections can impact the body's pathophysiology, leading to issues like hormone imbalances and irregular blood sugar. Dr. Emily draws intriguing connections between heavy metal toxicity and cardiovascular problems, highlighting the role of metals as conductors that can disrupt the heart's electrical conductivity system, contributing to conditions like hypertension and atrial fibrillation. Join us on this enlightening journey with Dr. Emily as she uncovers the hidden factors affecting our health and provides valuable insights for a holistic approach to well-being. Download your FREE seed oil allergy card here: http://www.seedoilcard.com  Join Ben Azadi's 90 day heavy metal detox program (12 spots available): https://ketokamp.clickfunnels.com/order-page-a  Links and Resources: Miami Beach Comprehensive Wellness Center: https://www.miamibeachcwc.com InfectoLab: https://infectolab-americas.com/ Dr. Emily on LinkedIn: https://www.linkedin.com/in/emily-rowe-md-ap-ifmcp-9949a330/ Follow Miami Beach Comprehensive Wellness Center Facebook: https://www.facebook.com/MiamiBeachComprehensiveWellnessCenter/ Instagram: https://www.instagram.com/miamibeachcwc/  

This episode features a fireside chat with ACS Past President Henri R. Ford, MD, MHA, FACS, who is the dean and chief academic officer at the University of Miami Miller School of Medicine. Dr. Ford talks about his humble beginnings, his passion for surgery, lessons learned, and leadership skills that have helped him become the world-renowned surgeon he is today. The program host is Dr. Mohsen Shabahang for the ACS Academy of Master Surgeon Educators.   Talk about the podcast on social media using the hashtag #HouseofSurgery.

In this episode, we dive into an exciting conversation about nutrition and its impact on overall health, particularly brain health, with special guest Dr. John Lewis. Dr. Lewis is a former Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. He's also a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association with over 180 peer-reviewed publications in scientific journals. Together, we'll explore key questions like: How does nutrition impact your health? What does good health really mean? What are polysaccharides, and why are they important? How can you find the motivation to live a healthier lifestyle? No matter your age or current health, there's valuable insight in this episode for everyone. With the growing focus on cognition and dementia, this is a conversation you won't want to miss. Find Dr. John Lewis: https://drlewisnutrition.com https://www.youtube.com/channel/UC5xvuUBaSGsAuSo4ZxhNR0A/featured https://www.instagram.com/drlewisnutrition/ https://www.facebook.com/profile.php?id=100085418756619 Resources: Get your free Better Mental Health Affirmations: Affirmationbonus.com About Dr. John Lewis: John E. Lewis, Ph.D. is the Founder and President of Dr Lewis Nutrition  (https://www.drlewisnutrition.com) and past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. He is also a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He is a lecturer for the Institute for Brain Potential. He has been the principal investigator of over 30 different studies in his research career. During that time, he either directly raised or indirectly supported raising over $23 million in grants, gifts, and contracts for research studies and clinical trials and educational programs for medical students. Much of his research has focused on evaluating the effects of nutrition, dietary supplementation, and exercise on various aspects of human health and disease. Dr. Lewis also embodies the model of health and wellness by eating a whole-food, plant- based diet for over 27 years, taking certain key dietary supplements, and through a rigorous, daily exercise training program. John has a passion for educating others about the value of nutrition, exercise, and health, and he will continue to study the application of clinical nutrition for the benefit of mankind.

In this episode, Dr. Soyona Rafatjah dives deep into the world of functional medicine, explaining how it connects the dots between different systems in the body. She discusses the critical role of gut health, toxins, inflammation, and nutrition in healing, offering insight into how modern medicine often overlooks these connections. From addressing common issues like gut permeability and IBS to exploring cutting-edge testing methods like PCR DNA analysis, this conversation uncovers practical and holistic approaches to healing. Learn more about how functional medicine can help you live a healthier, more optimized life!~About Dr. Sonoya Rafatjah~Dr. Soyona Rafatjah is a board-certified Family Medicine physician and the Medical Director & Co-Founder of PrimeHealth in Denver, CO. https://primehealthdenver.com/She earned her medical degree from the University of Miami Miller School of Medicine and completed her residency at Jackson Memorial Hospital in Miami, FL.Passionate about blending conventional medicine with personalized Functional Medicine, Dr. Rafatjah specializes in uncovering and treating the root causes of illness for lasting relief. Her expertise spans thyroid and digestive disorders, autoimmune conditions, hormone imbalances, health optimization & longevity, and more.

In this episode, Patricia D. Jones, MD, MSCR; Mindie H. Nguyen, MD, MAS, AGAF, FAASLD; and patient advocate, Jennifer Wild, MS, RN, OCN, discuss best practices in hepatitis B virus (HBV) care, including: 2023 CDC HBV screening recommendationsSummary of guideline recommendations for hepatitis delta virus (HDV) screening Use of HDV reflex testing to avoid loss to follow-up2024 WHO HBV treatment recommendations, including recommendations for pregnant persons Presenters:Patricia D. Jones, MD, MSCRAssociate Professor of Clinical MedicineDirector of Clinical Operations-HepatologyDivision of Digestive Health and Liver DiseasesDepartment of MedicineUniversity of Miami Miller School of MedicineSylvester Comprehensive Cancer CenterMiami, FloridaMindie H. Nguyen, MD, MAS, AGAF, FAASLDProfessor of Medicine (GI & Hepatology,Liver Transplant)Professor of Epidemiology & Population Health(by Courtesy)Director of Hepatology ClerkshipFaculty Search LENS Advocates,Stanford Department of MedicineFaculty Fellow, Stanford Center for Innovationin Global HealthMember, Stanford Cancer Institute, Maternal &Child Health Research Institute, & Stanford Bio-CStanford, CaliforniaPast Chair: HBV SIG, The American Association for the Study of Liver Diseases (AASLD)28th President: The International Association for the Study of the Liver (IASL)Jennifer Wild, MS, RN, OCNClinical Nurse – GI Medical OncologyUCSF Cancer CenterSan Francsico, CaliforniaLink to full program: https://bit.ly/4j973TNDownloadable slides: https://bit.ly/3WQkIWlGet access to all of our new podcasts by subscribing to the CCO Infectious Disease Podcast on Apple Podcasts, Google Podcasts, or Spotify.

Anti-amyloid therapies provide the first FDA-approved option to alter AD pathology, but an understanding of overall utility and value to patients remains in its infancy. In this episode, Teshamae Monteith, MD, FAAN, speaks with David S. Geldmacher, MD, FACP, FANA, author of the article “Treatment of Alzheimer Disease” in the Continuum® December 2024 Dementia 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. Geldmacher is a professor and Warren Family Endowed Chair in Neurology and the director of the Division of Cognitive and Behavioral Neurology, Department of Neurology, Marnix E. Heersink School of Medicine at the University of Alabama at Birmingham in Birmingham, Alabama. Additional Resources Read the article: Treatment of Alzheimer Disease Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Transcript 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 Monteith: This is Dr Teshamae Monteith. Today, I'm interviewing Dr David Geldmacher about his article on treatment of Alzheimer's disease, which appears in the December 2024 Continuum issue on dementia. Welcome to our podcast, Dr Geldmacher. How are you?  Dr Geldmacher: I'm very well, thank you. It's a pleasure to be here.  Dr Monteith: Yeah. So, why don't you introduce yourself to our audience? Dr Geldmacher: Sure. I'm David Geldmacher. I'm a professor of neurology at the University of Alabama in Birmingham and I lead the division of Cognitive and Behavioral Neurology.  Dr Monteith: So, I'm really excited about this, to personally learn, and I know that or neurology community is also really excited about this interview. So, why don't we start off with your main objective.  Dr Geldmacher: So, my main goal in the article was to review the FDA-approved pharmacologic treatments for dementia. There's lots of ways of thinking about treatment of dementia; psychosocial, caregiver support, and so forth. But I really wanted to focus on the issues of drug treatment because that's what has been our backbone for a long time and now has recently expanded.  Dr Monteith: Why don't we talk a little bit about, first of all, the boom in the field? What's that been like?  Dr Geldmacher: So, the big change in the field is over the last several years, we've had treatments become available that actually attack the underlying Alzheimer pathology, and that's new and different. For decades, we've been able to treat the symptoms of the disease, but this is the first time we've really been able to get to the root of the pathology and look toward removing amyloid plaques from the brain.  Dr Monteith: Let's step back a little bit and talk about the framework of diagnosis and how that leads into the therapeutic potential. I know you're going to dive into some of the biologics, but we should probably talk about the kind of holistic approach to considering the diagnosis. Dr Geldmacher: Sure. So, you know, when someone comes to the clinic with memory complaints, our question we have to ask is, is this neurologic origin, a structural origin like Alzheimer's disease or vascular dementia? Are there complicating factors, the software issues of mood disorders and sleep disorders and pain that can all magnify those symptoms? The clinical reasoning is a critical part of that, but in Alzheimer's disease, typically the problems revolve around difficulty forming new memories of events and activities, the episodic memory. And then it's often accompanied by changes in word finding and semantic knowledge. And those are the things that we look for in the clinic to really point toward an AD diagnosis. And then we support it with exclusion of other causes through blood work and identification of patterns of brain atrophy on MRI. And then most recently in the last couple of years, we've been able to add to that molecular imaging for amyloid with PET scans as well as, most recently, blood-based biomarkers for Alzheimer's pathology. So, it's really been a revolution in the diagnosis over these last several years.  Dr Monteith: And when approaching patients or populations of individuals, there seems to be a real full spectrum with looking at the societal burden, the biological impact, of course, risk factors of primary prevention, and now this whole area of brain health and secondary prevention. How do you kind of tie all of this together when talking to patients and family members?  Dr Geldmacher: Sure. So, the approaches for brain health apply to everyone. In basically every clinic visited, our brain aging and memory clinic, we reviewed lifestyle approaches to brain health like regular physical exercise, healthy diet, cognitive and social stimulation. And those are fundamental to the approach to everyone, whether they have cognitive impairments that are measurable or not. These are all things that are good for our brain health. And then, you know, focusing on the vascular risk factors in particular and working with the patient and their primary care team to ensure that lipids and blood sugar and blood pressure are all in good healthy ranges and being appropriately treated.  Dr Monteith: You know, there's this kind of whole considerations of clinically meaningful endpoints and clinical trials, and even when we're talking to our patients. What would you say the field has kind of identified has the best endpoints in helping patients? Would you call it impaired daily function? Is that like the best hard endpoint? Obviously, there are other things such as caregiver burden, but you know, how do you approach assessing patients? Dr Geldmacher: Defining the endpoints is very difficult. Typically, if we talk to patients and their families, they would like to have better memory or improve memory. How that applies in everyday life actually is daily function. And so, we focus very much on daily function. And when I talk about our therapies, whether they're symptomatic therapies or the new disease-modifying therapies, I really talk about maintenance of function and delays and decline or slowing of decline, helping to foster the person's independence in the activities that they have and be able to sustain that over the longer term.  Dr Monteith: And when thinking about diagnosis- and we're going to get into treatments, but when thinking about the diagnosis, and of course, it's full-spectrum from mild cognitive impairment to moderate and severe forms of dementia, but who should have CSF testing and PET imaging? Obviously, these are invasive, somewhat invasive and expensive tests. Should all people that walk in the door that have memory complaints? How do you stratify who should have tests? Dr Geldmacher: I think about this in a big funnel, basically, and the starting point of the funnel, of course, is the person with memory complaints. Then there's that neurologic reasoning. Are these memory complaints consistent with what we expect from the anatomy of Alzheimer's disease, with atrophy in in the hippocampus and temporal lobe? Do they have episodic memory loss or not? That first step is really trying to characterize, do the clinical patterns act like those of Alzheimer's disease or not? And then we follow the Academy of Neurology guidelines, looking for reversible sources of cognitive decline, things like B12 deficiency and depression, sleep disorders and the like, and try to exclude those. We start with structural imaging with everyone, and MRI, typically, that will help us understand vascular burden and patterns of atrophy, looking for things like mesial temporal atrophy or precuneus atrophy that are characteristic of Alzheimer's disease. If those things are all pointing in the direction of AD as opposed to something else, then typically before moving on to CSF or PET scan, we will use blood-based biomarkers, which are one of the big changes in the field in the last year or so, and there are now multiple panels of these available. The downside is they are typically not covered by insurance. On the other hand, they can really help us identify who is likely to have a positive PET scan or positive findings on CSF. We start to provide that counseling and information to the patient before they get to those more definitive tests. We can push people in the other direction. We can say, your blood-based biomarkers are negative or do not indicate AD as the most likely source of your condition now, so let's treat other things. Let's see what else we can focus on. The blood-based biomarkers are now, in our clinic at least, the critical choke point between the routine workout that we've always done on everyone and then the more advanced workup of proving amyloid pathology with CSF or a PET scan. Dr Monteith: How sensitive are those blood biomarkers and how early are they positive?  Dr Geldmacher: The sensitivity is generally pretty good, in the ninety plus percent range on average and it depends on which panel. And as you point out, when in the course of symptoms that they're done, we know that they become positive and presymptomatic or asymptomatic people. We're using these kinds of markers to screen people for prevention trials. So, I think when someone is symptomatic, they're a good indicator of the presence or absence of AD pathology. Now that doesn't mean the AD pathology is the sole cause of their symptoms. And so, we still need to think about those other things like sleep and mood and so forth. But they do point us in the in the direction of Alzheimer's change.  Dr Monteith: So why don't we talk about some of the more standard older treatments, and it's also important to leave with kind of some rational approach to when we start and what should we be counseling our patients on. So why don't we start with the older, you know, choline esterase inhibitors and then some of the MDA- I guess there's only one modulator, SEPTA modulator. Dr Geldmacher: So, I've been really fortunate in my career span, the time from the first of those symptomatic agents reaching the market in 1993 to seeing the disease modifying drugs enter the market now. I think most neurologists actually have entered practice after those clinical trials of the colon esterase inhibitors were published. So, one of my goals in this article was to review that primary data and what can we expect from those symptomatic drugs. We know that they are inconsistently effective in mild cognitive impairment, and the Academy of Neurology guidelines says there is not strong evidence to use them in mild cognitive impairment. But in mild AD and beyond, the cholinesterase inhibitors provide meaningful benefits. They delay decline, they can delay nursing home placement. They reduce overall costs of care. So, I think they provide real value. So, in the article I have reviewed what the data looked like on those. My approach is to start with oral Donepezil at five milligrams and increase it to ten in everyone who tolerates the five. If for whatever reason the oral Donepezil is not well tolerated, I'll switch to transdermal rivastigmine to help improve tolerability. There are very few head to head comparisons, but nothing suggests that one of the cholinesterase inhibitors is superior to the other for clinical outcomes, and there's no evidence to support conjoint use of more than one at a time. Should someone be showing decline then on typical cholinesterase inhibitor therapy - and people will, it's often delayed, but the decline will reemerge - then I will add the NMDA receptor, a modulator memantine and titrate that up to full dosing, either 10 mg twice a day for the conventional release or 22 mg extended release. And at that point we're sort of on maximal pharmacologic therapy for Alzheimer's disease. These agents can provide some benefit in other conditions, they're off-label except for Lewy body disease where rivastigmine is labeled. But they can provide benefit across different conditions. And there's some preliminary data, for instance, of acetylcholinesterase inhibitors being helpful in vascular cognitive impairment. So, I will use them, but I expect the greatest response when someone really does follow the patterns of Alzheimer's disease.  Dr Monteith: And you have a great chart, by the way, and nice figures looking at some of the meta-analyses on cognitive outcomes as well as functional outcomes. So, thank you for that.  Dr Geldmacher: In general, all of those tables favor treatment over placebo in the domains of cognition, daily function, neuropsychiatric symptoms. And it's that consistency of result that lets me know that we really are seeing a drug effect, that it's not a class effect with those, that we really are helping our patients. It's not like some studies are positive and some are negative. They are very consistently positive. Small magnitude, but consistently positive.  Dr Monteith: And I know we have a lot of patients coming in where, at least, their caregivers are complaining about agitation, and sleep is also a problem for others. And so how do you help that patient? I know you have a good algorithm that also you included in your article, but why don't you summarize how we should approach these symptoms? Dr Geldmacher: Sure. So, for nonpsychotic agitation, you know, just restlessness, wandering, pacing and so forth, my first choice is an off-label use of citalopram. And there is good clinical trials evidence to support that. if someone has psychotic agitation that is with delusions or hallucinations and so forth, I think we do need to move to the antipsychotic drugs. And the one drug that is now approved for treatment of agitation and Alzheimer's disease does fall into that antipsychotic category, along with its various black box warnings - and that's brexpiprazole. For many of our patients, getting coverage for that agent is difficult. It's not on many formularies. So, it is something I progress toward rather than start with. Similarly, for sleep, there is one approved agent for sleep, that's a dual orexin agonist. And it shows effectiveness, but can have some negative cognitive effects, and so I tend not to start with that either. My first choice when sleep is the primary issue for our patients with dementia is trazodone, and there are some small, limited studies for it's off-label used to enhance sleep. It's safe, inexpensive, often effective, and therefore it's my first choice. Dr Monteith: So, now let's get into the big conversations that everyone is having. Let's talk about the newer disease modifying anti amyloid therapies. Give us a summary dating back 2021 probably, although we can hold the preclinical work, but let's talk about what is available to our patients. Dr Geldmacher: Sure. And the development of anti-amyloid therapies goes all the way back to 1999. So, it's a pretty long course to get us to where we are today.  Dr Monteith: Yeah, that's why we limited that.  Dr Geldmacher: With that first approved agent with aducanumab in 2021, it received a limited or accelerated approval in FDA parlance. These agents, the aducanumab, lecanemab and donanemab, all approved, are known to remove amyloid pathology from the brain as measured by CSF and/or BIPET. They are amyloid lowering therapies, often called disease-modifying therapies. And across the agents there's some variable results. But if we look at the two with full approval, lecanemab and donanemab, they slow clinical progression by 25% to 35% on average. And that's measured by either cognitive measures or global measures or composite measures, but it's pretty consistent in that range of about one-third slowing. That makes it really difficult to discern in an individual patient, though, because there's so much variability in the progression of the disease already that it can be difficult to tell in one person that these drugs are working. They're also complex to use, so there's a qualification process that involves MRI to exclude things like a high tendency toward hemorrhage. It includes genetic testing for papal E4 status to help us understand the risk for complication, and then once-monthly or twice-monthly infusions with standardized schedule for MRI scanning. So, there's a lot that goes into managing these agents. And they are expensive, and we don't yet know their cost effectiveness. The cost effectiveness of the cholinesterase inhibitors was questioned when they first came out back in the 1990s, and it took five or ten years to really understand that they provided benefit to society and to individuals in those domains of quality of life and return on investment. And we're still learning about that with the disease modifying therapies.  Dr Monteith: So, two questions. One, the case that you presented was an individual having symptoms and kind of voiced their desire to be on these therapies. So, people are going to be asking, coming to clinic asking and then of course, they're going to be people that you select out. So, how do you make that decision to recommend this treatment for patients given the potential risk? Dr Geldmacher: We've got some really good guidance from appropriate use recommendation papers for aducanumab and lecanemab, and I'm expecting one from donanemab fairly soon. But the key is to identify individualized risks, and that involves knowing their APOE4 status, knowing their- whether they've had microhemorrhages in the brain previously, and then documenting that they really do have amyloid pathology with something like PET scan to establish those baselines. I talk to people about the burden of twice-monthly infusions or, now with donanemab, once-monthly infusions. And for instance, for someone who's got a working caregiver, getting to an infusion center twice a month can be a significant burden. And then if there are complications, frequent MRI scans and so forth. So, we talk about the burden of entering into this therapeutic pathway. The reality is that people who are qualified generally want it. I have relatively few folks who have said, no, these risks are more than I'm willing to accept. For decades my patients have said, anything you can do to slow this down, I'm willing to try. And now we're seeing that translated to reality with people willing to accept high-risk, high-cost treatments with the chance of slowing their individual progression.  Dr Monteith: And how do you select between the two treatments? Dr Geldmacher: So far that's been easy because donanemab's not readily available.  Dr Monteith: Outside of clinical trials, right?  Dr Geldmacher: Exactly. For prescription use, it's coming in - the first cases have now been infused - but it's not generally available. Nonetheless, what I will do for patients in this is look at the risk tables. So donanemab appears to have in general some higher rates of the Aria complications, amyloid-related imaging anomalies, and some people are going to be more risk tolerant of that for the payoff of potentially faster response. The donanemab trials restructured that. They did their first assessment of effectiveness. I had amyloid removal at six months and a significant proportion of people were eligible to discontinue treatment at six months because their amyloid was below treatable thresholds. So higher risk, perhaps faster action and fewer infusions for donanemab. Lecanemab we have more direct experience with, and between the two of them, the eighteen month outcomes are pretty much the same and indistinguishable. So are we in it for a quick hit, or are we in it for the long race? And different patients and different families will have differing opinions on where they want to accept that risk and burden and so forth. But so far, the data don't indicate a lot of difference in their longer-term outcomes. We still have plenty to learn.  Dr Monteith: And so, it sounds like, as you mentioned, we're looking at eighteen months out for kind of a hard outcome, and that there is a lot of variability in response rate. How are you tracking patients- you know about the imaging, so just in terms of clinical outcomes and efficacy?  Dr Geldmacher: Sure. So, for Medicare to reimburse on these treatments, people need to be enrolled in a registry program - and there are several of these, CMS runs one of their own. But the requirement for that is, every six months, to do cognitive and functional outcomes through the first two years. Cognitive outcomes are up to the clinician, but things like the mini mental state exam, the MoCA, are appropriate. In our own program, we use something we developed locally called the Alabama Brief Cognitive Screener. As for the cognitive outcomes and then for functional, we use an instrument called the General Activities of Daily Living Scale, but there are many other ADL scales that could be used as well. CMS does not mandate specific tests. Since the progression of the disease is variable to begin with, we don't really know how to interpret these results in reference to whether the drug is working, but I can tell a patient or a family member, your scores are stable, or, you have a decline of three points in this test. That's typical for this duration of illness. But there isn't a good way to know whether the drug is working in this person at this time, at least with our current levels of data.  Dr Monteith: So, I think we have to talk about health equity, and it sounds like Medicare is reimbursing for some of us. We look at different socioeconomic backgrounds, educational backgrounds, race, ethnicity. Not everyone is aware of these treatments. So, how do we get more patients to become aware of these treatments? And how do we get them to more people to help people? Dr Geldmacher: Yeah, I mean, that's- it's a major, major issue of inequity in our population. We've done some work at UAB looking at the flow of members of minority communities into memory clinics. So, we know that the overall population of, and I'll choose, for an example, blacks and African Americans, that they are represented a much higher rate in our overall UAB treatment population than they are in our memory clinic population. So, they're not even getting to us in the specialty clinic at the same rates as other segments of our population. We also know that blacks and African Americans in our population are not receiving PET scans as often as the overall treatment population. So yes, there are real, real problems with access. There are cultural issues behind this as well. And in many communities, a change in cognition, a loss of memory is an expected part of the aging process rather than recognized as a disease. So, people who come to us from minority communities are often further along in the course of cognitive and functional decline and beyond the point where they might qualify for the disease-modifying therapies, where early AD is the sort of defining boundary. So, I think more awareness and more screening in primary care settings, perhaps more community outreach to let people know that changes in memory that affect daily function are not normal as part of the aging process and should be evaluated for intervention. So, there's lots of places in our healthcare community where we could foster better outreach, better knowledge to get more folks access to the medicines. And this is before we even get to cost. Dr Monteith: Yeah, yeah. And obviously, there's some stigma as well.  Dr Geldmacher: That's right.  Dr Monteith: Really recognizing what the issues are and diving and asking those questions and funding research that asks those questions, as you mentioned, is really important. And then you have also a nice area where, you know, looking on the impact of treatments on caregiver-related outcomes, and of course ultimately want to keep patients out of nursing homes and prevent death. And so, can you talk a little bit about that? And, you know, mainly the caregiver burden.  Dr Geldmacher: So, my research in that area goes back a long way now. But I learned early in the course of therapy that many times the outcome that the family is noticing for symptomatic therapies is not a change in the patient's memory per se, but that there is less work involved in the caregiving. Less time is spent in direct caregiving roles. The patient may shadow less and because they have better independent cognition. I remember one family member once told me, the medicine you started is a godsend because now I can go to the bathroom by myself and he's not pounding on the door saying where are you, where are you. He's able to recall long enough that I'm in the bathroom that I have that moment of privacy. That was very meaningful to me to hear that. So. Dr Monteith: Cool. So why don't you just help us wrap this up and just give us, like, three main takeaway points that we should be getting out of your article? Dr Geldmacher: The three points that I would emphasize from my article is that the symptomatic therapies provide meaningful benefits and measurable, consistent, meaningful benefits. The second is that those benefits extend beyond things like cognitive test scores and into things like caregiver well-being and maintenance of independence in the home environment. And the third is that the disease-modifying therapies are an exciting opportunity to modify the pathology, but we still are learning about their cost effectiveness and their long-term benefit both to individuals and to society. But the only way we're going to learn that is by using them. And that was the experience that we gained from the symptomatic therapies that took use in the community for years before we really began to understand their true value. Dr Monteith: Thank you. That was excellent. And I put you on the spot, too.  Dr Geldmacher: No problem.  Dr Monteith: Again, today I've been interviewing Dr David Geldmacher, whose article on treatment of Alzheimer's disease 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 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 contentpub.com/AudioCME. Thank you for listening to Continuum Audio.

Lewy body dementia is a common cause of cognitive impairment in older adults but is often subject to significant delays in diagnosis and treatment, increasing the burden on patients and family caregivers. Understanding key features of the disease and use of biomarkers will improve recognition. In this episode, Allison Weathers, MD, FAAN, speaks with James E. Galvin, MD, MPH, author of the article “Lewy Body Dementia,” in the Continuum December 2024 Dementia issue. Dr. Weathers is a Continuum® Audio interviewer associate chief medical information officer at the Cleveland Clinic in Cleveland, Ohio. Dr. Galvin is a professor of neurology at the University of Miami Miller School of Medicine in Miami, Florida. Additional Resources Read the article: Lewy Body 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 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 Weathers: This is Dr Allison Weathers. Today I'm interviewing Dr James Galvin, author of Lewy body dementias from the December 2024 Continuum issue on dementia. Welcome to the podcast, Dr Galvin. Please introduce yourself to our audience.  Dr Galvin: Thank you, Allison. My name is Jim Galvin. I'm a neurologist, a professor of neurology at the University of Miami Miller School of Medicine. Dr Weathers: We're so happy to have you with me today. Thanks, Jim, for your time. And as you highlight right from the start in your really outstanding and comprehensive overview of this really complex topic, even though Lewy body dementia is the second most common cause of neurodegenerative dementia, it often goes unrecognized in clinical practice, resulting in really potentially lengthy diagnostic delays. So, this is a really important article for a neurologist and an important topic for our listeners. So, I'm thrilled we're having this conversation today. While I traditionally start by asking the authors what they feel is the most important clinical message of their article, I would love to actually start a step earlier in this conversation with you. Can you start us off by explaining what's actually meant when we say Lewy body dementia? Dr Galvin: Great. So, you know, I think this is a, this is an interesting concept. So, we're really talking about two diseases that have a shared common pathology. So, Parkinson's sees dementia and dementia with Lewy bodies. So, their shared pathology is a Lewy body and that's why they're often grouped together as the Lewy body dementias. And then there's arguments back and forth as to whether these are distinct diseases or sort of two ends of the same candle burning in different directions. So, Parkinson's dementia is a lot like what it sounds like. So, if someone has Parkinson's disease, then at some point later they develop a dementia. And so back in the 1800's when Parkinson's disease was like first described as an entity, we basically felt that cognition wasn't affected. But we now know that's not true. And so most patients with Parkinson's do have some cognitive symptoms and a large proportion of them will eventually develop dementia. Perhaps up to 80% of Parkinson's patients will develop a dementia. The flip side is the dementia with Lewy body picture. And these are people who present primarily with a cognitive behavioral syndrome that may or may not have parkinsonism. So, they will sometimes have bradykinesia. They rarely have a rest tremor. And so, these are the people that are very much in the delayed diagnosis group. The Parkinson's dementia is more whether the clinician is checking their cognition as part of their annual visit. The flip side is that the people with DLB are often misdiagnosed early on, but together, this is Lewy body dementia, which is the most common disease that many people have never heard of. Dr Weathers: That's a great tagline, I think, for the whole article and for this concept. So now that that we're all on the same page about what's meant when we use that the term, what would you want our listeners to walk away with as their one key takeaway from our conversation today? Dr Galvin: Well, I think the article makes several key points, but I think if I put those all together into a single key point, it would really be that the Lewy body dementias are underrecognized, they're underdiagnosed, yet it is very possible to make the diagnosis using the standardized clinical criteria. They're very, very, very specific. They lack a little bit in sensitivity. So, because other diseases sometimes can look like this, but they're really quite specific. So, if you're confident clinically that the person has Lewy body dementia, you're probably going to be right. And in today's world, we have tests available to help confirm our diagnosis. The world is changing. We can make these diagnosed with much more confidence and we have confirmatory diagnosis laboratory tests that can help us. Dr Weathers: I want to talk more about the diagnosis in one minute, but first, how common actually are dementia with Lewy bodies and Parkinson's disease dementia? Dr Galvin: That's a great question. I think one of the challenges, of course, we really don't know how many people have any disease because it's going to largely rely on how well people code the diseases in the medical record. So, if you look at the most common cause of dementia in the United States, it's really dementia not otherwise specified, right? But we believe it to be the second most common cause of dementia. The Lewy Body Dementia Association, about a decade ago, started to try to develop some estimates. So, we have an estimate about how many people roughly have Parkinson's disease and that about 80% of those individuals would go on to develop dementia. And we know from the dementia population that about 40% of those individuals coming to autopsy have Lewy bodies. So, when you start to put that all together, you can get a reasonable estimate of how many people likely have the disease. And then that can be expanded on an annual basis, just like the Alzheimer's Association uses, by extrapolating those estimates onto the census data. So, we estimate right now there are about 1.4 to 1.6 million Americans who are living with Lewy body dementia. That's less than the 6.8 million people who have Alzheimer's disease, but more than a lot of other common diseases. So, if you think about, again, I said before, it's the most common disease no one's ever heard of. You know, there are about a million people who have multiple sclerosis. There are about eight hundred thousand people who have a stroke. There are about seven hundred thousand people who have a brain tumor. There are two hundred and fifty thousand people who have muscular dystrophy. There are twelve thousand people who have ALS. But I think if you stopped clinicians or people in the street and say have you ever heard of ALS or muscular dystrophy, they would say yes. If you ask them if they've heard of Lewy body dementia, they would say no.  Dr Weathers: That's an excellent point. And I know over the years I think there's been some increased awareness. I think sadly with some of the celebrities that have been impacted, I think that did a lot to raise awareness. But I think you're right that it's still so less commonly recognized by the lay public, by non-neurologists, than so many other diseases that you mentioned. And I think that leads back well into my next question into something that we've already mentioned just a few times already in our short conversation, this unfortunate and very common delay in the diagnosis. Why? And you mentioned earlier that there are these, you know, clinical criteria, these now ancillary tests. So, what makes the diagnosis so challenging? What aspects in particular do you think that neurologists find to be the most challenging in diagnosing patients? What trips us up?  Dr Galvin: So, there's an old analogy, right, that, you know, if you'll be three blind men to an elephant and each of them are touching a different part of the elephant, they'll each think it's something different. So because Lewy body dementia has so many different diverse kind of symptoms, it would really depend on who's seeing the patient first. So, if a person presents predominantly with a memory cognitive disorder and they go see someone who specializes in memory disorders, they're highly likely to be called Alzheimer's disease. If they present predominantly with the movement problem, they're going to see a movement disorder person and be called Parkinson's disease. If they present with a behavioral disorder, they're going to go see a psychiatrist. Then they'll get diagnoses like, you know, geriatric schizophrenia or bipolar disease or major depressive disorder. If they present with the constitutional symptoms, which are very common and drive patients absolutely batty. So chronic constipation, REM sleep disorder, runny nose, you know, heat intolerance, urinary frequency, obstipation, and you know, they're going to be called all sorts of things. So, if you start thinking about this, who do you show up with first is going to guide how fast you can get a diagnosis. So, we interviewed at point over a thousand caregivers and what we found was there was about an eighteen month delay after seeing five to six doctors for the majority of patients, of which Lewy body dementia was misdiagnosed about 75% of the time for the initial diagnosis.  Dr Weathers: Wow, what a sobering statistic. And you spoke about the criteria and some of the ancillary tests. What can really help, do you think, kind of mitigate or prevent this misdiagnosis? What is your approach in your own patients?  Dr Galvin: Well, I think like every good clinician, not starting off with a preconceived notion of what the person has and trying to collect all the valuable information. So, one of the things I highlighted in the article was, while there are diagnostic criteria and people can follow diagnostic criteria, the truth is at your fingertips. You don't always sit and think about whether someone meets diagnostic criteria. So, in the first table in the article, we tried to really then put all the different common symptoms into buckets, right? Because people present like that. They say, well, I have this and I have this and I have this and I have this. Well, then you can start to think about, well, they have a cognitive symptom that's predominantly executive attention or visual perceptual in nature. And gee, they have constipation and heat intolerance and they say they can't smell quite as well as they once did, right, and they're having some disturbance in their sleep with excessive daytime sleepiness. Now you can start to say, well, even though that didn't fit the core and suggestive criteria, the fact is that spectrum of symptoms makes it much easier to begin to make a diagnosis. And so, it's investigative work. A lot of neurology is still investigative work. The old days, they used to say, we knew everything but could do nothing, but now we know everything and can do something about it. And so, I think it's really important that we try to apply this information in clinically useful ways. That was part of the gist of putting this Continuum article together was to try to present it not just as listing the diagnostic criteria, because you can get that anywhere, but how do you actually apply it in clinical practice? Dr Weathers: That's a great point. And that table that you referenced was really fantastic. And I know I say this a lot, but they're true. So, you know, many of the tables, the reference to Continuum, one I will certainly kind of come back to again, again, as an excellent point of care tool. So, I know in, in preparing for today and reading more about, about you and your areas of research that one of your particular areas of focus and expertise is in healthcare disparities, especially in the early detection of neurodegenerative dementias. What is the greatest inequity or disparity that you see in the diagnosis and treatment of patients with Lewy body dementia?  Dr Galvin: So, there's a couple things that are that are really interesting. So first, unlike Alzheimer's disease, which tends to be a little bit more female predominant, the Lewy body dementias are male predominant. It's about 1.6 men for everyone woman. So, it's going to be a different presentation. It's going to be largely men and their caregivers are largely going to be their spouses. So, you're going to see sort of a different person looking, you know, staring on the other side of the table to you. It's going to be largely a male. And the other thing that's really interesting is that almost all of the series, case series, case reports, clinical papers are in predominantly white populations. So, this lends to some interesting things. So, you know, is the disease less common in African Americans and other minority populations or are we just really bad at ascertaining the disease? You know, many of the case reports in Alzheimer's disease include African Americans. In fact, we know that African Americans may be at a twofold increased risk of developing Alzheimer's disease compared to nonHispanic whites, probably due to vascular risk factors. But in case series of Lewy body dementia, almost all the patients are non-Hispanic white. There also seems to be a higher risk in Asian populations, and in fact, some of the very earliest case reports were from Japan. Is this a case ascertainment problem or is this really a disparity in how the disease presents? And I think those are really important questions that still need to be asked. I know as researchers, we struggle to try to develop cohorts that could help us understand that. I would say in my twenty five years of seeing these patients, I would say the large percentage of them, and I've seen a lot of them, have been no-Hispanic white.  Dr Weathers: So, so definitely more research needed in this very important area. So, moving on to somewhat of a personal question, I always, this is such an honor. I always talk about that I get to have this time to sit down with the authors of these outstanding articles and learn not only more about their subjects, but about them as people. I had shared during my last interview that my paternal grandmother had Alzheimer's disease, and unfortunately also my maternal grandmother actually did as well. In preparing for this, I had listened to one of your previous interviews and learned that you also have a personal connection that led you to this subspecialty with several family members impacted. How has this connection inspired your research and your interactions with your patients?  Dr Galvin: Yeah, I mean, so my personal connection was that my maternal grandfather had Lewy body dementia. So, I grew up in a two family home in New Jersey. My grandparents lived on the second floor. We lived on the first floor. I wass very close to my grandparents. I'm still close to my grandmother, who's a hundred and three years old. But when I was a high junior in high school, my grandfather was driving me home from a swimming practice. I was thinner, fitter and more athletic at that point in my life, and he made the world 's slowest left hand turn and we were broadsided. So luckily no one was hurt. But I remember because I was sixteen at the time and just learning how to drive us, Grandpa, what happened? And he's like, oh, the car didn't react. Or, you know, he was blaming the car. And I didn't think much of it because, you know, I was sixteen years old. Sometime after that he was at work, and he was a greaser. So, he would climb through the machines at Colgate Palmolive and keep them all moving. And so, he was at work and he fell off a ladder and then broke his ribs. And in the emergency room, when my grandmother went to pick him up, the ER doctor turned to her and said, how long has your husband had Parkinson's disease? And she's like, what are you talking about? And then that was the first time that all of us had noticed his rest tremor. And the reason he turned the wheel so slow is because he was Bradykinetic. And so then over the next few years, he progressed in his motor symptoms. And then as I got into college, he developed the cognitive symptoms. And so, by the time I had finished medical school that was doing my residency, he was no longer oriented to time. So that even though I had finished medical school, I was in my neurology residency, I was married and with children, I was still in college at that time for him. So, he would always ask me, you know, have I heard anything from getting to medical school and the like. So, I got to watch this person who I grew up with go through all of the different stages of disease. And then eventually he developed lots of hallucinations. And although he was relatively immobile, he experienced a hallucination and jumped out of his chair, fell down, and broke his hip. And so, he underwent a hip replacement, being rather severely demented, and then passed away in the rehab hospital. As I was living this with my grandparents, the one thing that my grandfather, while he could still communicate, and that my grandmother continued to say to me, you know, up until fairly recently was, you know, what are you going to do about this? You know, we're counting on you to make a difference. And so, a lot of my research is really focused on how I can make a difference for people. One, to make sure they get diagnosed properly. Two that we would have something to offer the patient and the family. And three, we can provide hope that we are actually going to come away with effective treatments to make a difference in their lives. Dr Weathers: Well, that is really inspiring. And I think you have really done that in your work. I always like to end these conversations on a hopeful note. So, what are the developments that are on the horizon in terms of diagnosis and treatment of Lewy body dementia that you are most excited about?  Dr Galvin: Well, I think there are three things that are of great interest right now. I mean, there's lots of things, but I think three things of great interest are, one, on the diagnostic side is that we now have assays that allow us to assess synuclein in body fluids and body tissues. So, we can measure synuclein seeding assays in the spinal fluid and we can visualize Lewy bodies through skin biopsies. And that's a tremendous advance because we were really, really limited otherwise to using indirect evidence, and the only indirect evidence we had was abnormalities on DAT scanning. So, we're looking at dopamine deficiencies. But as I mentioned earlier, that's very abnormal in Parkinson's disease. But in dementia with Lewy bodies, it's a little more subtle. So, the extent of dopamine degeneration in- particularly in early DLB is limited. So, you have to look very carefully. If we're not doing quantitative DAT scan imaging, then you may miss those subtle changes. So, I think that being able to directly visualize either synuclein seeding or synuclein aggregation has really changed the game. Plasma assays, blood-based biomarkers are probably a little farther away because they're- the red blood cells have a lot of synuclein and so it interferes with the ability to get a good sensitive assay. But I do think in the next couple of years we will see PET ligands that also bind  synnuclein. So, I think diagnostically we're going to be able to provide better, earlier, and more precise diagnoses. From a treatment perspective, traditionally we've just borrowed medicines from other fields to treat symptoms, but there are a number of disease-modifying trials that are ongoing. I was fortunate to be the academic PI on two very large NIH grants where we test tested disease modifying medicines. Both of those studies are fully recruited and we should get a readout toward the end of 2024 or the beginning of 2025. So very, very excited about that. I also am fortunate to be MPI an NIH grant where we're just going to be testing the first inhuman synuclein vaccine. So very, very excited about the potential to offer disease-modifying medicines and to fulfill the promise that I made to my grandma and grandpa twenty years ago. And I think the third thing is that right now there's a little bit of like an emerging controversy about developing some integrated staging paradigms between the movement disorder world and the cognitive world. And so, while those paradigms are currently published, you know, not everybody agrees with them. But I think whether I like that staging paradigm now or not, the fact that we're coming together and trying to develop some unified staging paradigms, I think, is going to make a big difference in increasing the ability for clinicians to make early diagnoses that are more precise so that we can either get people into clinical trials or into clinical treatment protocols at the earliest possible time. And that's going to make all the difference in the world for the patients and their families.  Dr Weathers: I think that was a fantastic answer. Really, all really exciting things that I think are all, I normally, I say on the horizon. I'm thinking, you know, pretty far ahead. And I think the really wonderful thing is that all of these are either here now or very, very close to being here. So, definitely a very positive way to end this discussion. Well, Jim, thank you so much for taking the time to speak with me today. Dr Galvin: Thank you. This was wonderful. I hope the listeners found this enjoyable and interesting and read the Continuum issue. I think it's going to be the latest and greatest on what we know about the dementias.  Dr Weathers: Again, thank you again, Dr Galvin, for joining me on Continuum Audio. Again, today I've been reviewing Dr James Galvin, his article on the Lewy body dementias, dementia with Lewy bodies, and Parkinson's disease dementia appears in the December 2024 Continuum issue on dementia. 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.

Orofacial pain comprises many disorders with different etiologies and pathophysiologies. A multidisciplinary approach combining medication, physical therapy, and procedural and psychological strategies is essential in treating patients with orofacial pain. In this episode, Teshamae Monteith, MD, FAAN, speaks with Meredith Barad, MD; Marcela Romero-Reyes, DDS, PhD, authors of the article “Orofacial Pain,” in the Continuum® October 2024 Pain Management in Neurology 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. Barad is a clinical associate professor of anesthesiology, perioperative and pain medicine, and neurology and neurological sciences and codirector of the Stanford Facial Pain Program at Stanford Medicine in Stanford, California. Dr. Romero-Reyes is a clinical professor and director of the Brotman Facial Pain Clinic and Department of Neural and Pain Sciences at the University of Maryland in Baltimore, Maryland. Additional Resources Read the article: Orofacial 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 @ContinuumAAN Host: @headacheMD Guest: @meredith_barad facebook.com/continuumcme 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 Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. Today I'm interviewing Drs Meredith Barad and Marcela Romero-Reyes about their article on oralfacial pain, which appears in the October 2024 Continuum issue on pain management and neurology. Welcome to the podcast, ladies. How are you?  Dr Barad: Excellent.  Dr Romero-Reyes: Fine, happy to be here.  Dr Monteith: I am so happy to see you. I mean, I think both of you I've known for like ten years. Dr Romero-Reyes: Yeah.  Dr Barad: Yes.  Dr Monteith: So why don't you introduce yourselves? While I know you, our audience, some of them, may not know you.  Dr Romero-Reyes: I'm Dr Marcella Romero Reyes. I am a neuropathial pain specialist, clinical professor, and director of the Provident Special Pain Clinic here in the University of Maryland School of Dentist. Dr Monteith: Excellent.  Dr Barad: My name is Meredith Barad. I'm a clinical associate professor at Stanford and I work- I'm the codirector of our headache and facial pain clinic in the Stanford pain management clinic. Dr Monteith: Well, first of all, thank you for writing this article. It is extremely detailed and up-to-date and very informative. And in neurology, I think we don't get enough pain management. I'm interested in both of your backgrounds and, you know, what led you even to become an expert in this area? And both of you have complementary areas. I think we can see in the quality of this article. But why don't we start with you, Dr Romero-Reyes? Dr Romero-Reyes: Well, for me to get interested in orofacial pain, I will say more than an interest was like a calling that I wanted to take care of this patient population. So, as you know, my background is dentistry and at that time I was very interested in patients with complex medical issues. And was the time I was- I started to be interested in temporomandibular disorders. But what really picked completely my attention was the first time I saw a patient with trigeminal neuralgia. This was my last year in dental school. This patient already had, like, almost a full upper quadrant of teeth extracted where pain was not resolved. So when the patient came to us and I did my exam and, you know, and I triggered the pain, the sharp shoot electrical pain, that really broke my heart. And I took an x-ray and I didn't find anything that will explain it was something wrong until I talked to my professor and he said, no, this is medical. There's nothing wrong with it, with that tooth and needs to be, you know, followed with proper management and medication. And for me, that was like, wow, what a proper diagnosis and proper management can take care of these of these patients. And when the patient got better, that really said, oh, you know, I want to do this.  Dr Monteith: That's a crazy story. It's always that last patient of the day.  Dr Romero-Reyes: And you know, think about it, at least in dentistry at that time, I learned about trigeminal neuralgia from a book, right, my classes. But when you see the patient, this is it. That completely, you know, made me say yes, I want to study this.  Dr Monteith: Yeah. And unfortunately, that's not an uncommon scenario where patients with trigeminal neuralgia get, you know, their extractions and pain can sometimes be more complicated. What about you, Dr Barad? Dr Barad: Well, I guess I'm sort of like the opposite. So as a neurologist and a trained pain physician, I saw a lot of patients with neuralgic pain and headache pain, but I also saw many patients who would say, I have TMJ. And as, as Dr Romero has educated us, that's like saying I have shoulder or I have knee. But I quickly realized that I needed to work with a multidisciplinary team to really understand more about orofacial pain. It's not just neuralgic. There are other ideologies. And so that's how we started working together and that's how we practice in our clinic at Stanford. Dr Monteith: So, why don't you tell us about the objectives of this article? Dr Barad: I think our objectives were to help the neurologist broaden the differential diagnosis on facial pain to encompass below the nose, the oral cavity, the temporal mandibular joint. And to just think more broadly about facial pain and to understand some of the more recent diagnostic criteria that have been developed for facial pain and to- how to diagnose properly and how to begin treatment for some of the other conditions that are non-neurologic.  Dr Romero-Reyes: And I think I will ask about what Dr Barad say that also to bring awareness to the neurologist about the vast classification of oral facial pain disorder, craniofacial and orofacial. I think that was also a key thing too. And also, to show how well we can work together, you know, the multi-disciplinary management that is indicated for these cases. Dr Monteith: Cool. And you mentioned some of the new diagnostic criteria. I want to talk just briefly about the new international classification of orofacial pain, ICOP. When did that come out and what was the process there in really fine-tuning the diagnosis of orofacial pain disorders? Dr Romero-Reyes: So, in 2019 the orofacial head pain especially interest group of the International Association for the Study of Pain, the International Network for Orofacial Pain and Related Disorders methodology and the American Academy of Orofacial Pain and the International Headache Society. They partnered together to develop to develop this international classification of orofacial pain. And these, I think- it's such a great effort, you know, all the main people doing pain about this area, and goes very well together with the international classification of headache disorders. So, for example, you know, some disorders that International Classification of Headache Disorders doesn't present such as and the ICOP, International Classification of Orofacial Pain, presents, like the persistent idiopathic dental Viola pain. You have it in the ICOP. It's not, you know, mentioned in the in the International Classification of Headache Disorders, as well as, also we have the- I think it's item number five, the orofacial representations headache disorder or primary headache disorder. The ICOP gives you a nice, clean diagnostic criteria.  Dr Monteith: So, I guess I would ask Dr Barad with this classification in mind, how useful is it in neurology practice? And I know obviously you see patients with pain, but how useful even in managing patients with headache? Dr Barad: I think it's great because I've had a lot of dentists and ENT doctors who have started referring patients to me because they've realized that they've increased their awareness about orofacial pain and realized that pain in the sinuses, for example, accompanied by light sensitivity and sound sensitivity and rhinorrhea, may not be a recurrent monthly sinus infection. And so that kind of broadens our awareness of these of these disorders. And it's been, it's brought new patients into my clinic that we can help and treat. So that's been exciting.  Dr Monteith: And what about in the world of dentistry? Obviously, I think people in orofacial pain worlds are highly attuned to this, but I would hope this would hopefully have been disseminated into dentists and regular practice at C patients with trigeminal neuralgia. Dr Romero-Reyes: Going back for the, what you were discussing about the ICOP. So, it's what we're trying now as a new specialty. Well that we have been for the last four years, but finally in 2020 we have been recognized by the American Mental Association to disseminate this knowledge. But also, you know, can you imagine in in the realm in orofacial pain or dentistry have a patient with this recurrent pain, phonophobia, photophobia, throbbing dental pain is throbbing, but it's nothing wrong with your tooth. And that did they tell you that actually you have an orofacial or facial migraine or a neurovascular or facial pain. How crazy, right? And that is managed with migraines therapy. So it really, you know, to make you think like that. Wow, so these weird tooth things that used to come every week or these with facial pain, it's nothing to deal with, you know, with my teeth or any structure, you know, inside my mouth. Dr Barad: It sounds to me like what you're saying is that we've, this has encouraged patient education as well, not only interdisciplinary education, but really helping provide an explanation for the patient about what is going on with them. So rather than just getting sent away to another tertiary specialist, the patient is getting a more robust understanding of what's going on.  Dr Romero-Reyes: And going back to what you were saying about trigeminal neuralgia, you know, at least in dentistry also we're teaching now a new awareness like for two things, right? What about from the neurology setting? The patient has captured electrical pain. The trigger is intraoral. If it's pain inside your mouth, the first practitioner you're going to see who will be maybe the dentist that the dentist knows that could be a possibility of a disorder that doesn't deal with teeth, but also, it's important and we discussed that in our paper. What about that actually that weird trigger actually, it's not a general. What about if it's a cracked tooth has that singing sensation too. So, you see, it's two ways; one, to teach dentist to learn about this disorder and you know, we have learned, but you know, it's much more awareness now that this is great that, you know, these disorders you're not going to treat with dental procedures. Right? It's medical and vice versa, that the neurologist also has the awareness that oh, central trigger. Have you gone to the to the dentist? Have you checked that out? Dr Monteith: So what should neurologist know about dental sources of pain? Dr Barad: Well, maybe they should read the paper?  Dr Romero-Reyes: Yeah. Yeah, you need to read the paper. Yeah.  Dr Monteith: Top three, don't treat this with gabapentin.  Dr Romero-Reyes: Like well, dental pain is not going to be resolved with gabapentin. That would need to make a diagnosis if and you know it's that examination that come comes with a radiographic evidence that shows that maybe could be a cavity or could be a problem. You know in the in the practical tissues of the tooth that is given a symptomatology. Not only dental could be a lot of different disorders inside there now that can produce pain that also the readers can check our paper and learn about and see the wonderful interesting pictures that we have added there. Dr Monteith: Yeah. And so why don't we talk a little bit about TMD disorders and what is the new thinking around these conditions? Dr Romero-Reyes: Well, I will say for the last decade, maybe a little bit more has been a change in the evidence. They evidence based understanding of the theologia pathophysiologist and for mandibular disorders. Imagine that what's the shift in the in the paradigm that in dentistry prevails for a long, long time. That is that really focus and I will call it the pathological mechanistic point of view. What I mean by that I was focusing your bite, your occlusion, how the relation between in your maxilla mandible. That was the only issues that would create in temporomandibular disorders. So now we know that temporomandibular disorders are complex, are multifactorial and you need to understand them and see them within a biopsychosocial framework. And this dictate the main way to management for the primary way that we start will be conservative, reversible and basing evidence that the best evidence available that we have. Dr Monteith: And what about for trigeminal neuralgia? Is there newer kind of classification around trigeminal neuralgia? and what are some key points that we should consider when diagnosing these patients and treating these patients, Dr Barad?  Dr Barad: There haven't been any new diagnostic criteria, but I would say that there's been an increased awareness that classical trigeminal neuralgia is more likely than not related to neurovascular compression or we should say, maybe I should say neurovascular contact or compression. There is a developing grading system of that. That's an evolution as we speak. I think it's an exciting time for facial neuralgia because it's opened the door for us to look at other neuralgia also as vascular compressions and to think about how we can treat them with decompression or possibly with peripheral nerve stimulation or medicine or Botox. Or who knows what's the future is going to hold? But it is I think a change in the way we are thinking about the definition of neuralgia of, of trigeminal neuralgia in that is caused by a compression which is different than other neuralgia in other parts of the body. I should, I just want to classify there's about maybe ten twelve percent of people who present with classical trigeminal neuralgia who there is not evidence on imaging of a vascular contact or compression. But the majority of cases do seem to have some somewhere in the spectrum from contact to compression.  Dr Monteith: Even contact I find to be a bit vague sometimes say, well, thanks for letting me know that they're touching. But and then some of the neurosurgeons have different perspective when you open the patient up. So, I didn't know about the grading.  Dr Barad: Yeah, I think you've hit on it exactly like that is a big problem in the field right now. How do we understand what patients will be the best patients for surgery? And it used to be that you have the classical trigeminal neurologist symptomology plus some imaging that shows something versus nothing. And now we're getting into parsing out the imaging and trying to understand who's the best candidate for that with the imaging.  Dr Monteith: Dr Romero, anything to add?  Dr Romero-Reyes: No, that I agree about that, you know, and I think now maybe for the patients that I have seen with that, because under partial pain settings, sometimes we're the ones that, oh, actually what you have is trigeminal neuralgia idea, you know, so we start to have our small disciplinary management, but you know, when they come out, I already have an MRI doctor, but, and they say that these are compression, but what degree? And some patients that they don't have symptoms can have a compression. And I'm thinking maybe right that later on when we have more time and maybe nicer imaging, we're going to really find out or if it's the development angle is the measurement has some other characteristics, who knows. So, I think for trigeminal neuralgia, the things is still evolving, right? For our understanding. I have to help us to make a more- I will not say definitive diagnosis, but maybe some parameters will change in the future. Dr Monteith: So now we have a lot of people listening, international folks listening, and they always want some treatment, a tip, some clinical tips. So, can you give us a little bit of clinical insight to how to treat patients with trigeminal neuralgia and when you're seeing patients for second and third opinions, what might you see that may explain why their pain is not well controlled? We all get into interdisciplinary care, but in terms of pharmacology? Dr Barad: I think people are a little reluctant to use some of these medications that neuromodulating medications because, in general, it's an older population and they're rightly worried about falls and dizziness and confusion and low sodium. And so, I think they hesitate to go to the doses that are needed to help with pain control. So, a lot of our, my initial management is gingerly and gently titrating that to try to get to see if we can get control of the pain. Dr Monteith: Dr Romero?  Dr Romero-Reyes: I could add, for example, one thing that I in the realm of facial pain addition to pharmacology. Let's say that we have a patient with that intraoral trigger and we were able to localize that intraoral trigger. Sometimes we can even also use topical medication. And in the topical medication we can use, for example, an anticonvulsant, let's say gabapentin, oxcarbazepine for example, to add in the cream. And we use, we call it a neurosensory stent in my looks like a Nygard, but it's not a Nygard that can cover that area. So, the patient can add that cream very delimited in that area. And that helps, you know, can help with the pain sometimes. What we can find is that, at least in my, in my experience, and that when we add a topical, maybe we don't need to increase as much. The systemic medication, of course, depends from case to case.  Dr Monteith: So those are two great tips. Not being afraid to push those doses up in a safe manner and maybe with monitoring as well as of maybe utilizing more topicals. And I think we could probably hear a lot more from you on topicals at some other point. But thank you also for the table. I think it's, it's really nice the way all the treatments are laid out. So what other cranial neuralgia advances have there been? Dr Barad: I would say the main advancements have been in applying the knowledge that neurosurgeons have learned from microvascular decompression of the trigeminal nerve, to the glossopharyngeal nerve, to the geniculate nerve, and really trying to optimize imaging and optimize neurosurgical techniques to try to treat these neuralgias. If the patient has failed medicine, if the patient is a good candidate for surgery and if the patient desires that. Dr Monteith: Great. So now let's talk about multidisciplinary approaches. I know both of you are big fans of that, and you may do things a little bit differently at your institution, especially with your background. So maybe Dr Romero, do you want to tell us about your experience? And then we'll have Dr Brad. Dr Romero-Reyes: But in my experience from study management, let's say depend, of course, also the started we're talking about. But let's say for example about temporomandibular disorders, you know that for TMD is one of these overlapping pain conditions and we know that TMD is common with primary headache disorders, especially migraine. So, if we're able to utilize, you know, the expertise of neurologist specializing headache. With me, for example, or a facial pain person that is that is helping you manage a patient with this comorbidity. This is super effective because we know the presence of TMD in a migraineur can help the disorder to, to progress some more chronic form. So, you see, this is super important and effective to provide, you know, optimal care for the patient. For example, in the patients that I do see with neuralgias, like in addition to trigeminal neuralgia, let's say nervous intermediates neuralgia, that sometimes they can come to me like, oh, the pain is in my ear and my EMT or, or I think maybe it's my TMJ and for the pain is charged shooting inside the ear doesn't follow the for the diagnosis of temporomandibular disorders. And I can maybe help the patient to get a proper imaging or already penalize it with a neurologist to make sure. And maybe at least my way will be maybe I'm the one that can catch those disorders and help, you know, the patient to go for the next step. Dr Barad: I think Marcella, Dr Romero-Reyes, hit on a nice point that maybe this group is not as familiar with and that is that temporal mandibular dysfunction TMD is a, is one of the disorders that we call chronic overlapping pain conditions or COCPs. And those include headache. it's not, it's not specified fibromyalgia, irritable bowel syndrome, chronic pelvic pain and several other chronic pain syndromes. And they suggest a central sensitization to one's pain. And the way that we treat centrally sensitized pain is not just through medications, it's in a biopsychosocial framework because we see much higher rates of depression and anxiety in this group. And so, using a pain psychologist to help the patient develop coping strategies to help them manage their pain, using a physical therapist to help them learn this, the stretching exercises and using medications to help with not only with their pain syndrome, but also sometimes with their psych comorbidities. And then additionally, procedures sometimes play a role in the process to help usually turn down the pain. Interestingly, when we look at trigeminal neuralgia, we see much less overlapping pain disorders. It's much rarer to see somebody with TN who has other COCPs or the kind of chronic levels of depression and anxiety that we see in these patients. So, the approach is very different, and I think it requires the use of a multidisciplinary team to help guide the treatment pathways for these patients. Dr Monteith: Today, I've been interviewing Drs Meredith Barad and Marcelo Romero-Reyes, whose article on orofacial pain appears in the most recent issue of Continuum on pain management and 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.

How is 5G powering the use of AI to revolutionize life-saving solutions? Malcolm sits with T-Mobile for Business CMO Mo Katibeh, 3AM Innovations COO Ryan Litt, and the University of Miami Miller School of Medicine's Dr. Azizi Seixas to find out in this special episode of Revisionist History. Brought to you in partnership with T-Mobile for Business, and recorded live from the Mobile World Congress in Las Vegas.See omnystudio.com/listener for privacy information.

Join me and Dr. John Lewis, Founder and President of Dr Lewis Nutrition, as we dive deep into the fascinating world of polysaccharides. We're breaking down the myths about sugars and exploring how plant-based diets truly impact your health.  We'll also compare plant and animal proteins, clear up some common misconceptions about nutrients, and talk about what really matters when it comes to staying healthy—like nutrition, exercise, and sleep. This episode is packed with practical insights to help you make better choices for long-term health, so don't miss it! Key Takeaways: Polysaccharides like those found in aloe vera and rice bran are potent health-promoting substances, distinct from simple sugars notorious for spiking insulin and metabolic issues. Dr. John Lewis's groundbreaking research supports the use of a polysaccharide-based dietary supplement to improve cognitive and immune function in individuals with moderate to severe Alzheimer's disease. A plant-based diet offers crucial nutrients, casting doubt on the perceived necessity of animal proteins for sufficient nutrition. The mechanisms of aloe vera—notably its acute polysaccharide content—underpin its centuries-old reputation for soothing burns and other wounds. Dr. Lewis advocates for a holistic approach to health, encompassing plant-based diets, strategic supplementation, regular exercise, and adequate sleep.   More of  Dr. John Lewis: Dr. John E. Lewis has spent most of his career developing a unique approach as someone who “walks the walk” through all of his combined professional and personal experiences to attaining optimal health through nutrition, dietary supplements, and exercise. Throughout his research career, he has evaluated many different nutritional approaches to enhancing well-being, particularly for brain health, immune function, and counteracting aging. He can separate fact from fiction regarding how to utilize nutrition and dietary supplements to help you achieve and maintain optimal health. If you need a trusted source of information, products, and services, then look no further than Dr. Lewis and how he can help you achieve your health-related goals. Professional Career Dr. Lewis is past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine and the Founder and President of Dr Lewis Nutrition™. He is a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He has been the principal investigator of over 30 different studies on human health in his research career. During that time, he either directly raised or indirectly supported raising over $23 million in grants, gifts, and contracts for research studies and clinical trials and educational programs for medical students. In addition to his research, Dr. Lewis has been an invited national and international lecturer and guest speaker at conferences and as a guest on television shows. He is a well-known author with over 180 peer-reviewed publications in some of the world's leading scientific journals. He has also mentored many different students, from undergraduates to post-doctoral trainees, in not only how to conduct clinical research but to apply the principles of health promotion into daily practice. Research Interests Much of Dr. Lewis's research has focused on evaluating the effects of nutrition, dietary supplements, and exercise on various aspects of human health. He and his colleagues have been continually searching for ways to help people achieve and maintain health through natural treatments that align with our physiology. A primary stimulus for the origin of Dr Lewis Nutrition™ occurred after Dr. Lewis ran his landmark study on how an aloe polysaccharide multi-nutrient complex improved cognitive and immune functioning after 12 months in persons with moderate to severe Alzheimer's disease, leading to the creation of the dietary supplement, Daily Brain Care. Daily Brain Care showed clinically and statistically significant improvements in cognition according to the ADAS-cog cognition score and statistically significant improvements in inflammation (according to TNFα and VEGF), immune function (according to the CD4/CD8 ratio), and adult stem cells (according to CD14+ cells). His seminal publication from the study in the Journal of Alzheimer's Disease not only spurred him to leave academics and pursue a science-based business career, but also enabled him to be selected for a widely-acclaimed TEDxMiami talk. Website Instagram   Connect with me!: Website Instagram Facebook YouTube

Do You Need a Multivitamin? What Science Says About Brain Health and Memory Dr. Lewis is past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine and the Founder and President of Dr Lewis Nutrition™. He is a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He has been the principal investigator of over 30 different studies on human health in his research career. During that time, he either directly raised or indirectly supported raising over $23 million in grants, gifts, and contracts for research studies and clinical trials and educational programs for medical students. In addition to his research, Dr. Lewis has been an invited national and international lecturer and guest speaker at conferences and as a guest on television shows. He is a well-known author with over 180 peer-reviewed publications in some of the world's leading scientific journals. He has also mentored many different students, from undergraduates to post-doctoral trainees, in not only how to conduct clinical research but to apply the principles of health promotion into daily practice. www.georgebatista.com Green Vibrance: vibrance.georgebatista.com Wellness Resource: myvitaminresource.com Protonmail: Protonmail.georgebatista.com rumble.georgebatista.com Email: Wellnesstalk@protonmail.com

In this episode, hosts Mark and Jeff dive deep into the world of nutrition with Dr. John Lewis, a former academic turned dietary supplement entrepreneur. Dr. Lewis shares groundbreaking insights on the health benefits of polysaccharides derived from aloe vera and rice bran, discussing their potential to enhance cognitive function and overall wellness. We explore the challenges of securing funding for nutrition research, the pitfalls of the supplement industry, and the critical need for preventive health measures. Join us as we challenge conventional wisdom about diet and supplementation, and discover how these natural compounds could play a pivotal role in brain health and disease prevention.Dr. John E. Lewis is a leading expert in health and nutrition, dedicated to helping individuals achieve optimal well-being through nutrition, dietary supplements, and exercise. With a background as an Associate Professor at the University of Miami Miller School of Medicine, he founded Dr Lewis Nutrition™ to apply his extensive research experience to practical health solutions.As a Diplomate and Faculty Member of the Medical Wellness Association, Dr. Lewis has led over 30 studies, securing more than $23 million in funding for health research. He is a prolific author with over 180 peer-reviewed publications and a sought-after speaker at national and international conferences.Notably, Dr. Lewis conducted a landmark study on an aloe polysaccharide multi-nutrient complex, leading to the development of the supplement Daily Brain Care, which showed significant improvements in cognitive and immune function. Through Dr Lewis Nutrition™, Dr. Lewis continues to empower individuals to harness the benefits of nutrition and dietary supplements, promoting a vital message of health for those facing chronic health challenges.Connect with Dr. John Lewis: Instagram: @drlewisnutritionWebsite: drlewisnutrition.comShow sponsor RogersHood.com, detox from parasites, candida, heavy metals and toxins with code IDM to save 10%!Elevate your wellness with MK Supplements  premium beef organ capsules—nutrient-dense, non-GMO, and 100% pasture-raised.   Enjoy 30% off with code IDM and elevate your health naturally!Support the showFor more Informed Dissent visit our website at Informed Dissent Media Follow us on Social media @InformedDissentMedia

In this episode, hosts Mark and Jeff dive deep into the world of nutrition with Dr. John Lewis, a former academic turned dietary supplement entrepreneur. Dr. Lewis shares groundbreaking insights on the health benefits of polysaccharides derived from aloe vera and rice bran, discussing their potential to enhance cognitive function and overall wellness. We explore the challenges of securing funding for nutrition research, the pitfalls of the supplement industry, and the critical need for preventive health measures. Join us as we challenge conventional wisdom about diet and supplementation, and discover how these natural compounds could play a pivotal role in brain health and disease prevention.Dr. John E. Lewis is a leading expert in health and nutrition, dedicated to helping individuals achieve optimal well-being through nutrition, dietary supplements, and exercise. With a background as an Associate Professor at the University of Miami Miller School of Medicine, he founded Dr Lewis Nutrition™ to apply his extensive research experience to practical health solutions.As a Diplomate and Faculty Member of the Medical Wellness Association, Dr. Lewis has led over 30 studies, securing more than $23 million in funding for health research. He is a prolific author with over 180 peer-reviewed publications and a sought-after speaker at national and international conferences.Notably, Dr. Lewis conducted a landmark study on an aloe polysaccharide multi-nutrient complex, leading to the development of the supplement Daily Brain Care, which showed significant improvements in cognitive and immune function. Through Dr Lewis Nutrition™, Dr. Lewis continues to empower individuals to harness the benefits of nutrition and dietary supplements, promoting a vital message of health for those facing chronic health challenges.Connect with Dr. John Lewis: Instagram: @drlewisnutritionWebsite: drlewisnutrition.comShow sponsor RogersHood.com, detox from parasites, candida, heavy metals and toxins with code IDM to save 10%!Elevate your wellness with MK Supplements  premium beef organ capsules—nutrient-dense, non-GMO, and 100% pasture-raised.   Enjoy 30% off with code IDM and elevate your health naturally!Support the showFor more Informed Dissent visit our website at Informed Dissent Media Follow us on Social media @InformedDissentMedia

In this groundbreaking episode of The Midlife Makeover Show, host Wendy Valentine sits down with Dr. John E. Lewis, a leading expert in nutrition and dietary supplements. Dr. Lewis, founder and president of Doctor Lewis Nutrition and former associate professor at the University of Miami Miller School of Medicine, shares his revolutionary insights into the world of special polysaccharides derived from aloe vera and rice bran.   With over 30 studies and more than 180 peer-reviewed publications, Dr. Lewis unveils the life-changing effects these natural compounds have shown in clinical trials, particularly for conditions like Alzheimer's disease. Dr. Lewis explains how these polysaccharides can improve cognitive function, reduce inflammation, and enhance immune health, offering a new perspective on health and healing.   He recounts his journey into brain health, inspired by his encounter with Dr. Reg McDaniel, a pathologist who shifted his focus to nutrition after witnessing the incredible benefits of aloe vera. Together, they embarked on a mission to explore the potential of polysaccharides in treating various health conditions. Listeners will gain a deeper understanding of the complexities of sugars, the significance of polysaccharides, and their transformative impact on the body.   Dr. Lewis also shares compelling anecdotes from his clinical trials, including a remarkable story of cognitive improvement in Alzheimer's patients, underscoring the potential of these natural compounds to change lives. Discover how these groundbreaking findings could redefine approaches to health and nutrition, and learn how you can incorporate these powerful supplements into your daily routine for preventive and therapeutic benefits.  

Dr. John Lewis earned his BS in Business Administration from University of Tennessee, his MS in Exercise Physiology also from the University of Tennessee and then his PhD in Education and Psychological Studies from University of Miami in Coral Gables, Florida. In the 90's and early 2000's he grew in rank at the University of Miami Miller School of Medicine in various areas of research. I tracked him down in 2014 to find out more about his study titled “The Effect of an Aloe Polymannose Multinutrient Complex on Cognitive and Immune Functioning in Alzheimer's Disease”.RESOURCES:Get Daily Brain Care:https://drlewisnutrition.com/Visit the Show Blog Page:https://drhaley.com/reversing-alzheimers-diseaseSubscribe to Dr. Lewis on YouTube:https://www.youtube.com/channel/UC5xvuUBaSGsAuSo4ZxhNR0AGet Aloe from Haley Nutrition:https://haleynutrition.com/Who is Dr. Reg McDaniel:https://www.drreg.net/about/TIMESTAMPS:00:00 Intro Snip00:41 Introduce Dr. John Lewis01:40 How is it possible "Sugar Is Good For You"?04:07 What was the study "The effect of an aloe poly mannose multi nutrient complex on cognitive and immune functioning in Alzheimer's disease" about?04:25 Why aren't studies of this nature typically financed through organizations like NIH and Alzheimer's Association?10:33 Why a couple was willing to donate so much money to study nutrition for a disease process when even positive results would only amount to dietary recommendations11:25 A psychiatrists perspective that food could never help - only drugs work. (He was wrong!)12:10 Why doctors are so blind to the fact that nutrition plays such a large role in the allowance of and recovery from disease.13:00 Dr. Reg McDaniel's ("Reg") story about realizing how nutrition plays a role in disease and may even make the HIV viral load undetectable.16:50 How Dr. Wesley Calvin, a naturopath, had patients with HIV that became "HIV undetectable" by consuming aloe vera.20:30 How the psychiatrist that was part of the aloe multi-nutrient study came to realize that nutrition could make a difference.22:19 What was the product used in the study on cognitive health and Alzheimer's disease?23:37 how positive were the results of this study?23:56 What is the "ADAS-Cog"?24:55 What is the difference between clinically and statistically significant?28:41 What is the amount of product people had to have to get these positive results and is more better?29:53 Can you consumer more than is recommended?30:27 What is your theory on how the mechanism of the benefit was?31:07 What is the CD4 to CD8 ratio and how was it affected by the multi-nutrient complex used in your study?33:20 How did the polymannose multi-nutrient product affect stem cell production?35:10 What is neuroplasticity?37:10 What is the summary of benefits shown by this study?39:40 Product Reveal "Daily Brain Care" in the canister and capsules44:49 What are the special sugar molecules found in the "Daily Brain Care" products?52:00 The study done in the 30's showing mannose when given to rats that were in ketosis53:27 Dr. Robert LoPinto who mentioned Dr. John Lewis and his lecture at the FCA55:08 What is the principle investigator?55:43 What does "peer reviewed" mean?

Why should we use supplements? To answer this burning question, we spoke to Dr. John Lewis, a past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine and the Founder and President of Dr Lewis Nutrition™. He is a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He has been the principal investigator of over 30 different studies on human health in his research career. During that time, he either directly raised or indirectly supported raising over $23 million in grants, gifts, and contracts for research studies and clinical trials and educational programs for medical students. In addition to his research, Dr. Lewis has been an invited national and international lecturer and guest speaker at conferences and as a guest on television shows. He is a well-known author with over 180 peer-reviewed publications in some of the world's leading scientific journals. He has also mentored many different students, from undergraduates to post-doctoral trainees, in not only how to conduct clinical research but to apply the principles of health promotion into daily practice. In episode 497 of the Fraternity Foodie Podcast, we find out why Dr. Lewis chose the University of Tennessee in Knoxville, his best research discoveries at the University of Miami - Miller School of Medicine, some chronic diseases linked to poor nutrition and other modifiable habits, what is wrong with the dietary supplements already available on the market that made him want to start the business, how do you know what supplements you need, and what's in his whole-food, plant-based diet that he's been eating for over 27 years. Enjoy!

On today's episode, we speak with Dr. Yalini Vigneswaran and Dr. Kayla (Polcari) Councell about bariatric surgery, also known as weight-loss surgery. We discussed the impact of these surgeries on patient health, as well as some of the barriers our patients face in accessing these surgeries. We delve into some of the new weight loss medications on the market, and how patients can figure out what is best for them.Yalini Vigneswaran, MD, MS, is an advanced minimally invasive gastrointestinal surgeon at the University of Chicago who specializes in esophageal and gastric disorders, including motility disorders, esophageal and gastroesophageal junction cancers, reflux disease and paraesophageal hernias. She has specific clinical expertise in esophageal surgery, including minimally invasive esophagectomy for both benign and malignant disease. Additionally, Dr. Vigneswaran has expertise in bariatric surgery and performs various weight loss procedures. Dr. Vigneswaran conducts clinical and translational research and is committed to improving outcomes for patients with gastroesophageal disorders and patients undergoing weight loss surgery.Kayla (Polcari) Councell, MD, MPH, is a general surgery resident at the University of Chicago. She obtained her BS from the University of Notre Dame in Notre Dame, IN. She then completed medical school and her public health training at the University of Miami Miller School of Medicine, Miami, FL. She is expected to complete her general surgery residency training in 2027.“Deep Cuts: Exploring Equity in Surgery” comes to you from the Department of Surgery at the University of Chicago, which is located on Ojibwe, Odawa and Potawatomi land.Our senior producer is Tony Liu. Our producers are Alia Abiad, Caroline Montag, and Chuka Onuh. Our editor and production coordinator is Nihar Rama. The intro song you hear at the beginning of our show is “Love, Money Part 2” from Chicago's own Sen Morimoto off of Sooper Records. Our cover art is from Renaise Kim.A special thanks this week to Beth Gabryszak. We'd also like to thank all of our listeners for supporting the show. Let us know -- what have you most enjoyed about our podcast? Where do you see room for improvement? You can reach out to us on Instagram or X at @deepcutssurgery. Additionally, you can find more information at our website, https://deepcuts.surgery.uchicago.edu/.

Many autoimmune neuromuscular disorders are reversible with prompt diagnosis and early treatment. Understanding the potential utility and limitations of antibody testing in each clinical setting is critical for practicing neurologists. In this episode, Teshamae Monteith, MD, FAAN speaks with Divyanshu Dubey, MD, FAAN, author of the article “Autoimmune Neuromuscular Disorders Associated With Neural Antibodies,” in the Continuum® August 2024 Autoimmune Neurology 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. Dubey is an associate professor in the departments of neurology and laboratory medicine and pathology at the Mayo Clinic in Rochester, Minnesota. Additional Resources Read the article: Autoimmune Neuromuscular Disorders Associated With Neural Antibodies 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 Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. Today, I'm interviewing Dr Divyanshu Dubey about his article on autoimmune neuromuscular disorders associated with neural autoantibodies, which is part of the August 2024 Continuum issue on autoimmune neurology. Welcome to the podcast. How are you?   Dr Dubey: Hi, Dr Monteith. Thank you for inviting me to be a part of this podcast. I'm doing well.   Dr Monteith: Well, why don't you introduce yourself to the audience? And, call me Tesha.   Dr Dubey: I'm Divyanshu Dubey (please, call me Div). I'm one of the autoimmune neurology consultants here at Mayo Clinic Rochester. I'm an Associate Professor of neurology, as well as lab medicine and pathology. My responsibilities here are split - partly seeing patients (primarily patients with autoimmune disorders, including neuromuscular disorders), and then 50% of my time (or, actually, more than 50%), I spend in the lab, either doing research on these autoimmune disorders or reporting antibodies in a clinical setting for various antibody panels which Mayo's neuroimmunology lab offers.   Dr Monteith: That's a nice overlap of subspecialty area. How did you get into this work?   Dr Dubey: I think a lot of it was, sort of, by chance. Meeting the right people at the right time was the main, sort of, motivation for me. Initially, I trained in India for my medical school and didn't really got much exposed to autoimmune neurology in India. I think our primary concern in my training was sort of treating TB meningitis and cerebral malaria - that was my exposure to neurology, including stroke and some epilepsy cases. As a part of application for USMLEs and coming here to residency, I did some externships, and one of the externships was at Memorial Sloan Kettering Cancer Center, and that's when I worked a few weeks with Dr Posner and got introduced to the idea of paraneoplastic neurological syndrome working with him. And that sort of started - I wouldn't call it vicious cycle - but my interest in the area of autoimmune neurology and paraneoplastic neurological disorders, which subsequently was refined further through residency and fellowships.   Dr Monteith: That's interesting. I actually rotated through - I did a externship also at Sloan Kettering, and I had a clinic with Dr Posner. And I thought, at the time, he was such a rock star, and, like, I took a picture with him, and I think he thought it was insane. And I didn't go into autoimmune neurology. So, you know, interesting pathways, right?   Dr Dubey: Yes. And I think he's inspired many, many people, and sort of trained a lot of them as well.   Dr Monteith: So, why don't you tell us what you set out to do when writing this article?   Dr Dubey: So, I think, given my background and training in various subspecialties in neurology, I was, sort of, formally did fellowships in autoimmune neurology, as well as neuromuscular medicine. One of the areas in these areas that I focus on is in my clinical practice, as well as in my sort of lab work, is autoimmune muscular disorders - and that to, specifically, autoantibodies and their clinical utility for autoimmune muscular disorders. So, that's what I wanted to focus on in an article. When I was invited to write an article on autoimmune muscular conditions in general, I thought it was very difficult to pack it all in one chapter or one article, so I narrowed my focus (or tilted my focus) towards antibody-positive disorders and trying to understand how we as neurologists can firstly sort of identify these conditions (which may end up being antibody-positive) – and then, on the other hand, once we get these antibody results, how we can find the utility in them or find them useful in taking care of our patients. At the same time, I also wanted to kind of highlight that these antibodies are not perfect, they do have certain limitations – so, that's another thing I sort of highlighted in the article.   Dr Monteith: So, why don't we just start with a very broad question - what do you believe the role of autoantibodies is in the workup of neuropathies and then neuromuscular disorders? Obviously, when we think of myasthenia gravis, but there are some presentations that you may not necessarily think to first order autoantibody tests. So, what is the role, and where does it fit in the paradigm?   Dr Dubey: I think it's extremely crucial, and it's evolving as time goes on, and it's becoming more and more clinically relevant. Let's say three, four decades ago, the number of biomarkers which were available were very limited and only a handful - and there has been a significant increase in these biomarkers with growing utilization of newer techniques for discovery of antibodies, and more and more people jumping into this field trying to not only discover, but try and understand and validate these biomarkers (what they truly, clinically mean). These antibodies, like you pointed out, ones for myasthenia (such as acetylcholine receptor-binding antibodies, or MuSK antibodies), they can be extremely helpful in clinical diagnosis of these patients. We all know the importance of EMG in managing our patients with neuromuscular disorders. But, oftentimes, EMG nerve conduction studies are often not available at every center. In those scenarios, if you have antibodies with very high clinical specificity, and you're seeing a patient on examination whom you're seeing ptosis (fatigable ptosis), double vision, you're suspecting myasthenia, you send antibodies, and they come back positive. It brings you closer to the answer that may, in turn, require you to refer to a patient to a place where you can get high-quality EMGs or high-quality care. In addition to getting to the diagnosis, it also, sometimes, leads you in directions to search for what is the trigger. A good example is all these paraneoplastic neurological syndromes (which we started our conversation with), where once you find a biomarker (such as anti-Hu antibodies or CRMP5 antibodies) in a patient with paraneoplastic neuropathies, it can direct the search for cancer. These are the patients where, specifically, these two antibodies, small-cell lung cancer is an important cancer to rule out - they require CT scans, and if those are negative, consider doing PET scan – so, we can remove the inciting factor in these cases. And then, lastly, it can guide treatment. Depending upon subtypes of antibodies or particular antibodies, it can give us some idea what is going to be the most effective treatment for these patients.   Dr Monteith: I think paraneoplastic syndromes are a very good example of how autoantibodies can help guide treatment. But, what other examples can you provide for us?   Dr Dubey: Yeah, so I think one of the relatively recent antibody tests which our lab started offering is biomarkers of autoimmune neuropathies - these are neurofascin and contactin, and those are great examples which can target or guide your treatment. I personally, in the past, have had many CIDP patients before we were offering these testings, where we used to kind of start these patients on IVIG. They had the typical electrodiagnostic features, which would qualify them for CIDP. They did not show any response. In many of these cases, we tried to do sort of clinical testing or sort of research-based testing for neurofascin and contactin back in the day, but we didn't have this resource where we can sort of send the blood, hopefully, and within a week, get an answer, whether these patients have autoimmune neuropathy or not. Having this resource now, in some of these cases, even before starting them on IVIG, knowing that test result can guide treatments, such as considering plasma exchange up front as a first-line therapy, followed by rituximab or B-cell depleting therapies, which have been shown to be extremely beneficial in these conditions. And it is not just limited to neurofascin or contactin (which are predominantly IgG4-mediated condition), but the same concept applies to other IgG4-mediated diseases, such as MuSK myasthenia, where having an antibody result can guide your treatment towards B-cell depleting therapies instead of sort of trying the typical regimen that you try for other myasthenia gravis patients.   Dr Monteith: And you mentioned where I was reading that, sometimes, nerve conduction studies and EMG can be useful to then narrow the autoantibody profiles. Oftentimes, in the inpatient service, we order the autoantibodies much faster, because it's sometimes harder to access EMG nerve conduction studies - but talk about that narrowing process.   Dr Dubey: Yeah. And it goes back to the point you just made where we end up sending, sort of, sometimes (and I'm guilty of this as well), where we just send antibodies incessantly, even knowing that this particular patient is not necessarily likely to be an autoimmune neurological disorder, and that can be a challenge, even if the false-positive rate for a particular test is, let's say 1% - if you send enough panels, you will get that false-positive result for a particular patient. And that can have significant effects on the patient - not only unnecessary testing or imaging (depending on what type of antibody it is), but also exposure to various immunotherapies or immunosuppressive therapies. It's important to recognize red flags – and that's one of the things I've focused on in this article, is talking about clinical, as well as electrodiagnostic, factors, which make us think that this might be an autoimmune condition, and then, subsequently, we should consider autoantibody testing. Otherwise, we can be in a situation - that 1% situation - where we may be sort of dealing with a false-positive result, rather than a true-positive result. In terms of EMGs, I think I find them extremely useful, specifically for neuropathies, distinguishing between demyelinating versus exonal, and then catering our antibody-ordering practices toward specific groups of antibodies which are associated with demyelinating neuropathies (if that's what the electrophysiology showed) versus if it's an exonal pathology (considering a different subset of antibodies) - and that's going to be extremely important.   Dr Monteith: You're already getting to my next question, which is what are some of the limitations of autoantibody testing? You mentioned the false-positivity rate - what other limitations are there?   Dr Dubey: So, I think the limitations are both for seropositive, as well as seronegative, patients. As a neurologist, when we see patients and send panels, we can be in a challenging situation in both of those scenarios. Firstly, thinking about seropositives - despite the growing literature about neurology and antibodies, we have to be aware, at least to some extent, about what methodologies are being utilized for these antibody tests. And what I mean by that is knowing when you're sending a sample to a particular lab, the methodology that they're utilizing - is that the most sensitive, specific way to test for certain antibodies? We've learned about this through some of the literature published regarding MOG and aquaporin-4, which has demonstrated that these antibodies, which we suspect are cell surface antibodies, not only generate false-positive, but also false-negative results if they are tested by Western blots or ELISAs. Similar can be applied to some of the cell surface antibodies we are investigating on the autoimmune neuromuscular side (we have some sort of unpublished data regarding that for neurofascin-155). Secondly, it's also kind of critical when you're getting these reports to kind of have a look at what type of secondary antibodies are being utilized, an example being we talked about neurofascin-155, and I mentioned these are IgG4-predominant diseases, so testing for neurofascin IgG4 and knowing that particular patient is positive IgG4 rather than neurofascin pan-IgG. That's an important discrimination, and important information for you to know, because we have seen, at least in my clinical practice, that patients who are positive for neurofascin IgG4 follow the typical story of autoimmune neuropathies - the ones who are not (who are just neurofascin-155 IgG-positive), oftentimes can have wide-ranging phenotypes. The same applies to neurofascin-155 IgMs. And then (not for all antibodies, but for some antibodies), titers are important. A good example of that is a3 ganglionic receptor antibodies, which we utilize for when we're taking care of patients who have autoimmune dysautonomia - and in these cases, if the titers of the antibodies are below .2 nmol/L, usually, those don't have a high specificity for AAG diagnosis. So, I get referred a lot of patients with very low titers of a3 ganglionic receptor antibodies, where the clinical picture does not at all look like autoimmune autonomic ganglionopathy. So, that's another thing to potentially keep in mind. And then, on the seronegative front, it's important to recognize that we are still sort of seeing the tip of the iceberg as far as these antibodies or biomarkers are concerned, specifically for certain phenotypes, such as CIDP. If you look at the literature, depending upon what demographics we're looking at or sort of racial profiles we're looking at, the frequency of these autoimmune neuropathy biomarkers range from 5% to 20%, with much higher frequency in Asian patients - so, a good chunk of these diseases are still seronegative. In the scenario where you have a very high suspicion for an autoimmune neuromuscular disorder (specifically, we'll talk about neuropathies, because that's why we utilize tissue immunofluorescence staining on neural tissues), I recommend people to potentially touch base with that tertiary care lab or that referral lab to see if they have come across some research-based antibodies which are not clinically validated, which can give you some idea, some additional supportive idea, that what you're dealing with is an autoimmune neuromuscular disorder. So, we have to keep the limitations of some of these antibody panels and antibody tests in mind for both positive, as well as negative, results.   Dr Monteith: So, you've already given us a lot of good stuff, um, about titer seronegativity and false-positive rates. And, you know, also looking at the clinical picture when ordering these tests, utilizing EMG nerve conduction studies, give us a major key point that we can't not get when reading your article.   Dr Dubey: I think the major key point is we are neurologists first and serologists later. Most of these patients, we have to kind of evaluate them clinically and convince ourselves at least partly that this might be an autoimmune neuromuscular disorder before sending off these panels. Also, I find it useful to narrow down the phenotype, let's say, in a particular neuropathy or a muscle disease or a hyperexcitability syndrome. So, I have a core group of antigens, autoantigens, or autoantibodies, which I'm expecting and making myself aware of - things beyond that will raise my antenna - potentially, is this truly relevant? Could this be potentially false-positive? So, clinical characterization up front, phenotypic characterization upfront, and then utilizing those antibody results to support our clinical decision-making and therapeutic decision-making is what I've tried to express in this article.   Dr Monteith: And what is something that you wish you knew much earlier in your career?   Dr Dubey: It's a very challenging field, and it's a rapidly evolving field where we learn many things nearly every year, and, sometimes, we learn things that were previously said were incorrect, and we need to kind of work on them. A good example of that is initial reports of voltage-gated potassium-channel antibodies. So, back in the day when I was actually in my medical school and (subsequently) in my residency, voltage-gated potassium-channel antibodies were closely associated with autoimmune neuromyotonia, or autoimmune peripheral hyperexcitability syndromes. Now, over time, we've recognized that only the patients who are positive for LGI1 or CASPR2 are the ones who truly have autoimmune neuromuscular disorders or even CNS disorders. The voltage-gated potassium-channel antibody by itself, without LGI1 or CASPR2, truly doesn't have a very high specificity for neurological autoimmunity. So, that's one example of how even things which were published were considered critical thinking or critical knowledge in our field of autoimmune neuromuscular disorders has evolved and has sort of changed over time. And, again, the new antibodies are another area where nearly every year, something new pops up - not everything truly stands a test of time, but this keeps us on our toes.   Dr Monteith: And what's something that a patient taught you?   Dr Dubey: I think one of the things with every patient interaction I recognize is being an autoimmune neurologist, we tend to focus a lot on firstly, diagnosis, and secondly, immunotherapy - but what I've realized is symptomatic and functional care beyond immunotherapy in these patients who have autoimmune neurological disorders is as important, if not more important. That includes care of patients, involving our colleagues from physical medicine and rehab in terms of exercise regimen for these patients as we do immunotherapies, potentially getting a plan for management of associated pain, and many other factors and many other symptoms that these patients have to deal with secondary to these autoimmune neurological conditions.   Dr Monteith: I think that's really well said, because we get excited about getting the diagnosis and then getting the treatment, but that long-term trajectory and quality of life is really what patients are seeking.   Dr Dubey: Yeah, and as you pointed out, most of the time, especially when we are in inpatient service, or even when we're seeing the patients upfront outpatient, we are seeing them, sometimes, in their acute phase or at their disease not there. What we also have to realize is, what are the implications of these autoimmune neurological conditions in the long term or five years down the line? And that's one of the questions patients often ask me and how this can impact them even when the active immune phase has subsided - and that's something we are actively trying to learn about.   Dr Monteith: So, tell me something you're really excited about in your field.   Dr Dubey: I think, firstly (which is pretty much the topic of my entire article), is novel antibodies and new biomarker discoveries. That's very exciting - we are actively, ourselves, involved in the space. The second thing is better mechanistic understanding of how these antibodies cause diseases, so we can not only understand diseases, we can also try and understand how to target and treat these diseases - this is being actively done for various disorders. One of the disorders which continue to remain a challenge are T-cell mediated diseases, where these antibodies are just red flags or biomarkers are not causing the disease, but it's potentially the T-cells possibly attacking the same antigen which are causing disease process, and those are often the more refractory and harder-to-treat conditions. I'm hoping that with some of the work done in other fields (such as rheumatology or endocrinology for type one diabetes), we're able to learn and apply the same in the field of autoimmune neurology and autoimmune neuromuscular medicine. And then, the final frontier is developing therapies which are antigen specific, where you have discovered that somebody has a particular antibody, and if that antibody is pathogenic, can I just deplete that antibody, not necessarily pan-depleting the immune system. And there is some translational data, there's some animal model data in that area, which I find very exciting, will be extremely helpful for many of my patients.   Dr Monteith: So, very personalized targeted therapies?   Dr Dubey: Correct. Without having all the side effects we all have to kind of take care of in our patients when we start them on, let's say, cyclophosphamide, or some of these really, really, significantly suppressive immunosuppressive medications.   Dr Monteith: Well, thank you so much. I learned a lot from reading your article to prepare for this interview, but also just from talking to you. And it's clear that you're very passionate about what you do and very knowledgeable as well, so, thank you so much.   Dr Dubey: Thank you so much. Thank you for inviting me to do this. And thank you for inviting me to contribute the article.   Dr Monteith: Today, I've been interviewing Dr Divyanshu Dubey, whose article on autoimmune neuromuscular disorders associated with neural autoantibodies 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 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.

E366 – "Inner Voice: A Heartfelt Chat with Dr. Foojan Zeine." In this episode, Dr. Foojan Zeine chats with Dr. John E. Lewis, Ph.D., the Founder and President of Dr Lewis Nutrition™ (https://www.drlewisnutrition.com) and past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. He is also a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He is a lecturer for the Institute for Brain Potential. With over 30 different studies as the principal investigator in his research career, Dr. Lewis has extensive experience in evaluating the effects of nutrition, dietary supplementation, and exercise on various aspects of human health and disease, instilling confidence in his knowledge. In addition to his research, Dr. Lewis has been invited as a national and international lecturer at conferences and workshops and as a guest on television shows, where he discusses his research findings and provides guidance and recommendations as an expert in the health and wellness field. He has over 180 peer-reviewed publications in scientific journals, where his work has first appeared in print, including some of the leading scientific journals, such as AIDS and Behavior, American Journal of Clinical Nutrition, American Journal of Public Health, Journal of the International AIDS Society, Journal of Strength and Conditioning Research, Nutrition, and Cancer: An International Journal, Sports Medicine, Stroke, The Journal of Alternative and Complementary Medicine, and The Gerontologist. He has also mentored many students, from undergraduates to post-doctoral trainees, in conducting clinical research and applying the principles of health promotion into daily practice. His seminal publication in the Journal of Alzheimer's Disease from his Alzheimer's study not only spurred him to leave academics and pursue a science-based business career but also enabled him to be selected for a widely-acclaimed TEDx Miami talk (https://www.youtube.com/watch?v=rOJr0sxmxGI) about how dietary supplementation can improve brain health. Dr. Lewis not only embodies the model of health and wellness by following a whole-food, plant-based diet for over 27 years, taking key dietary supplements, and maintaining a rigorous, daily exercise training program, but he also has a fervent passion for educating others about the value of nutrition, exercise, and health. His commitment to studying the application of clinical nutrition for the benefit of mankind is unwavering, reassuring the audience of his expertise in the field. In this episode, we will be talking about his latest research on the nutritional value of the polysaccharides found in Aloe Vera. www.DrLewisNutrition.com

In EPISODE 173 OF GROWING OLDER LIVING YOUNGER we explore whether a whole food, plant-based diet and dietary supplements, particularly polysaccharides from aloe vera and rice bran, are optimal for health, in particular brain health. The founder and president of Dr Lewis Nutrition, Dr John Lewis, has a passion for educating others about the value of nutrition, dietary supplementation and exercise, for health. Dr Lewis is a past full time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. He is also a diplomate, faculty member and advisor of the Medical Wellness Association. He's been the principal investigator of over 30 studies focusing on the effects of nutrition, dietary supplementation and exercise on human health, with over 180 peer reviewed publications. Episode Timeline 0:01 Whole food, plant-based diet for health with Dr. Lewis 3:55 His transition from academia to a wellness business 13:34 The challenges in building a business  15:45 Understanding polysaccharides and their benefits 24:42 Plant-based dietary choices 31:26 The role of dietary supplements in brain health 37:10 Conclusions and key takeaways Schedule a free Wellness Discovery Call with Dr. Gillan Lockitch Learn about Dr. Lewis and Dr. Lewis Nutrition at the links below. Instagram:  https://www.instagram.com/drlewisnutrition Facebook:  https://www.facebook.com/profile.php?id=100085418756619 YouTube:  https://www.youtube.com/@drlewisnutrition LinkedIn:  https://www.linkedin.com/in/johnelewisphd X:  https://x.com/DrJohnELewis1 And if you have not already done so, please follow, rate and review this Growing Older Living Younger podcast.

Join us on an enlightening journey as we explore the future of medicine and how energy, fascia, and intuition are shaping the landscape of healing. In this episode, Emeritus Professor Carol Davis and Joanne delve into the exciting realm of integrative healing, highlighting the wellness revolution that emphasizes functional wellness and holistic health. Discover how intuitive healing and alternative medicine are becoming essential components in therapeutic and medical approaches, bridging the gap between materialistic science and physical therapeutics.We also discuss the role of fascia in our bodies and its significance in complementary therapies, as well as share insights into alternative modalities that enhance patient optimization. By embracing holistic therapies and intuitive practices, in the learning field, we can unlock new possibilities for health and vitality.Whether you're a professional therapist or just interested in alternative approaches to wellbeing or seeking to understand the synergy of energy and healing, this episode offers valuable insights into the journey towards integrative health. ABOUT CAROL DAVIS: Emeritus Professor, Carol M. Davis works at the Department of Physical Therapy, University of Miami Miller School of Medicine. Carol does research in Rehabilitation Medicine, Primary Care and Physiotherapy. Carol is also a potent voice in the growing field of fascia and fasciategrity. One of many publications is 'ACAPT First Annual Geneva R. Johnson Innovations in Physical Therapy Education Forum: Doctor of Physical Therapy (DPT): So What? Now What? Educating DPTs as Leaders to Meet Future Societal Needs'.SIGN UP TO THE JOANNE AVISON NEWSLETTER Simply scroll down to ‘Join Our Collective' and pop in your details. We DON'T spam and we DO respect privacy!FOLLOWING ON YOUTUBE?Why don't you start here: https://youtube.com/playlist?list=PL3Nb0JCvJRHKdZqF3PgHc9BaJnv33rU-u&si=vn4qiIAToTILqVmGMORE:My website - https://www.joanneavison.com/My course - https://myofascialmagic.com/My book: - https://amzn.to/3zF3SASInstagram - joanneavisonFREE ONLINE WEBINAR:Free Webinar - https://myofascialmagic.com/webinar-registration

Dr. John E. Lewis is past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine and the Founder and President of Dr Lewis Nutrition™. He is a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He has been the principal investigator of over 30 different studies on human health in his research career. He has also mentored many different students, from undergraduates to post-doctoral trainees, in not only how to conduct clinical research but to apply the principles of health promotion into daily practice.Dr. Lewis shares groundbreaking insights into the power of polysaccharides derived from aloe vera and rice bran. Dr. Lewis also highlights the importance of maintaining the bioactivity of these compounds during extraction and their significant benefits for cognitive and immune functions, particularly in individuals with Alzheimer's and multiple sclerosis.------------------------------------Join the Your Infinite Health Community! www.skool.com/your-infinite-healthTakeawaysIncorporate polysaccharides into daily routines.Minimize heat extraction.Take charge of your health.Connect with Dr. John Lewis:Instagram | X | Facebook | LinkedIn | YouTube Websites: https://drlewisnutrition.com/ | https://dailybraincare.com/ConnectDr. Trip Goolsby & LeNae Goolsby are the co-founders of the Infinite Health Integrative Medicine Center, and are also the co-authors of the book “Think and Live Longer”.

Our Brains, Cancer and Why Uric Acid Matter with guest expert David Perlmutter, MD.Board-Certified Neurologist | NY Times bestselling author of the Grain Brain book seriesYou may not realize this -- but uric acid (something I knew nothing about before my conversations with Dr. Perlmutter) is a something we should know about and care about. Yep, it actually plays a huge role in our health. Beyond that, uric acid is a major player when it comes to metabolic diseases and so much more.Wondered how it affects us? TUNE IN and let's uncover that together!In this episode, you will learn: Role of uric acid in metabolic diseasesHealth consequences of elevated uric acid levels (diabetes, cardiovascular disease, etc.)Five key supplements recommended for healthBenefits of using a continual glucose monitorHealth benefits of time-restricted eatingImpact of uric acid on chronic diseases like Alzheimer'sUric acid as an overlooked metabolic waste productImportance of lowering uric acid levels for health improvementSources of uric acid -- we delve into fructose, alcohol, purinesHistorical increase in uric acid levels and sugar consumptionUric acid's link to death rates and obesityLifestyle-related chronic degenerative conditionsEffects of dietary sodium on uric acid levels and weight gainNatural methods to lower uric acid (tart cherries, vitamin C, quercetin, coffee)Home testing for uric acid levels and its significanceAbout our guest expert: DR. DAVID PERLMUTTER, MD, FACN, ABIHMBoard-Certified Neurologist | NY Times bestselling author of the Grain Brain series of booksDr. Perlmutter is a Board-Certified Neurologist and six-time New York Times bestselling author.He serves on the Board of Directors and is a Fellow of the American College of Nutrition.Dr. Perlmutter received his M.D. degree from the University of Miami School of Medicine where he was awarded the Leonard G. Rowntree Research Award. He serves as a member of the Editorial Board for the Journal of Alzheimer's Disease and has published extensively in peer- reviewed scientific journals including Archives of Neurology, Neurosurgery, and The Journal of Applied Nutrition. In addition, he is a frequent lecturer at symposia sponsored by institutions such as the World Bank and IMF, Columbia University, Scripps Institute, New York University, and Harvard University and serves as an Associate Professor at the University of Miami Miller School of Medicine.Dr. Perlmutter's books have been published in 32 languages and include the #1 New York Times bestseller Grain Brain, The Surprising Truth About Wheat, Carbs and Sugar, with over 1 million copies in print. Other New York Times bestsellers include Brain Maker, The Grain BrainCookbook, The Grain Brain Whole Life Plan, and Brain Wash, co-written with Austin Perlmutter, M.D. He is the editor of The Microbiome and the Brain authored by top experts in the field and published in December 2019 by CRC Press. His latest New York Times bestselling book, Drop Acid, focuses on the pivotal role of uric acid in metabolic diseases.Links:Where to buy DROP ACID: https://www.drperlmutter.com/books/drop-acid/Facebook:

First up this week on the show, uncounted kilometers of fences are strung across the globe. Researchers know they interfere with wildlife migrations and sometimes make finding food and safety difficult for animals. But they don't know where all these fences are. Freelancer science journalist Christine Peterson joins host Sarah Crespi to discuss how artificial intelligence and aerial photos could help create fence inventories and eventually reopen spaces for native species.   Next, Azizi Seixas, interim chair of the University of Miami Miller School of Medicine's department of informatics and health data science and a professor in the department of psychiatry and behavioral sciences, discusses his review on decentralized randomized trials. Randomized, controlled trials based in a research center or centers have long been the gold standard for determining the effectiveness of a medical intervention. This week on the podcast, Seixas argues that distributed research designs with home-based measurements and reporting have the potential to speed up research, allow greater participation, and make the results of studies more equitable.   This week's episode was produced with help from Podigy.   About the Science Podcast   Authors: Sarah Crespi, Christine Peterson   About the Science Podcast: https://www.science.org/content/page/about-science-podcast Learn more about your ad choices. Visit megaphone.fm/adchoices

Are we getting too much sun exposure? Or not enough? This week, we're joined by Dr. Katherine Varman as she walks us through the complexity of sun exposure. Listen in as she discusses the different types of photoprotection, the importance of colorful foods, and how to rethink your relationship with the sun. Each Thursday, join Dr. Raja and Dr. Hadar, board-certified dermatologists, as they share the latest evidence-based research in integrative dermatology. For access to CE/CME courses, become a member at LearnSkin.com.   Want to know more about "Beyond Sunscreen: Topical Approaches to Sun Protection?" Join Dr. Varman at the 2024 Integrative Dermatology Symposium.   Katherine Varman, MD is a dermatologist who works in private practice in Northern California. She graduated from the University of Miami Miller School of Medicine, during which she completed an additional year as a Doris Duke Clinical Research Fellow at the University of North Carolina, Chapel Hill. After an intern year in Chattanooga, TN, she returned to UNC-CH for dermatology residency. Dr. Varman specializes in treating inflammatory skin conditions such as eczema and psoriasis with a unique blend of conventional and functional medicine practices. She also has a passion for photo-immunology and seeks to revitalize phototherapy as an indispensable tool in dermatology. She is also a homesteader and enjoys an active farm life with her husband and children.

In this episode, hosts Bruce Lesley and Messellech Looby chat with Dr. Glenn Flores, Professor and Chair of Pediatrics at the University of Miami Miller School of Medicine. Dr. Glenn Flores explains that the most important lesson in child health research and policy is that children are not little adults - they have vastly different anatomy and physiology depending on their age, which requires taking a developmental perspective. Dr. Flores also discusses several pressing health inequities that children face, caused by racial, financial, and geographic disparities. There is also a discussion of the current most pressing concerns facing child health, such as medicaid unwinding and the rise in mood disorders. Learn more about current challenges in children's healthcare: Blog: Children Are Not Little Adults: Ensuring Adequate Pediatric Emergency Care in U.S. Hospitals, By Bruce Lesley Webinar: 988 Suicide and Crisis Lifeline - One Size Does Not Fit All, By Averi Pakulis and Elaine Dalpiaz Blog: Nearly 5 Million Children Have Lost Health Care Due To “Unwinding,” By Abuko Estrada and Tim Smith To join the conversation, follow First Focus on Children on Instagram, LinkedIn, and Twitter. Send us comments on thoughts via email: SpeakingOfKids@firstfocus.orgFind us on Twitter/X: @SpeakingOfKids, @BruceLesley and @First_FocusWant to be a voice for kids? Become an Ambassador for Children here. To support our work and this podcast, please consider donating to First Focus on Children here. Hosted on Acast. See acast.com/privacy for more information.

Public Health Careers podcast episode with Harold Gil, MSPH

In this episode of The Glioblastoma AKA GBM Podcast, Dr. Ashish Shah, Assistant Professor of Neurological Surgery at the University of Miami Miller School of Medicine and Director of Clinical Trials and Translational Research within the University of Miami Brain Tumor Initiative, dives deep into his groundbreaking research on glioblastoma. Dr. Shah discusses a fascinating study revealing how fragments of a retrovirus, integrated into the human genome millions of years ago, are implicated in the proliferation and progression of glioblastoma, the most aggressive primary brain tumor. This episode explores how these findings from Dr. Shah's research at the Sylvester Comprehensive Cancer Center could revolutionize our understanding of glioblastoma and lead to novel treatment strategies. We also delve into the potential of antiretroviral agents and gene therapy as innovative approaches to target these viral fragments, opening new avenues for combatting this challenging cancer. Episode Sponsor: Novocure. Visit https://www.novocure.com/ to learn more. Trigger Warning: This episode includes discussions on medical conditions, cancer treatments, and genetic research. Visit to Learn More: For more information and support resources, visit GBMResearch.org. Disclaimer: The content discussed on The Glioblastoma AKA GBM Podcast is based on personal stories and experiences. It is not intended as medical advice. Always consult with healthcare professionals for medical guidance and treatment options.

In this episode, we sit down with Dr. John Lewis, a leading expert in nutritional research and the therapeutic potential of Aloe polysaccharides. Dr. Lewis shares insights from his groundbreaking studies on Alzheimer's disease, multiple sclerosis (MS), and the broader impacts of Aloe polysaccharides on immune function and brain health. Key Topics Discussed Understanding Aloe Polysaccharides What are Aloe polysaccharides? How are they extracted and formulated for nutritional supplements? Research on Alzheimer's Disease and Multiple Sclerosis Overview of Dr. Lewis's studies on Alzheimer's disease and MS. Impact of Aloe polysaccharides on cognitive function and disease progression. Immune System Modulation Effects of Aloe polysaccharides on CD4 to CD8 ratios. Regulation of key cytokines: TNF-alpha, VEGF, and BDNF. Balancing TH1 and TH2 responses. Brain Care Formulation Detailed discussion on the Brain Care formulation developed by Dr. Lewis. Clinical results and patient outcomes. Challenges in Nutritional Research Funding difficulties for nutritional and supplement research. Issues with the pharmacological model of placebo-controlled randomized double-blind trials. Why this model is challenging for evaluating supplements and nutritional interventions. Future Directions and Innovations Potential future applications of Aloe polysaccharides in other health conditions. Innovations in nutritional research methodologies. Key Takeaways Aloe Polysaccharides: Naturally occurring compounds with significant therapeutic potential, particularly in modulating immune function and supporting brain health. Clinical Research: Dr. Lewis's studies highlight the positive effects of Aloe polysaccharides on Alzheimer's disease, MS, and overall immune health. Nutritional Research Challenges: The current pharmacological model of clinical trials poses challenges for the study of supplements, necessitating new research approaches. Research References Studies on Alzheimer's disease and Aloe polysaccharides: Positive impacts on cognitive function and disease markers. Research on MS: Aloe polysaccharides and their role in managing symptoms and progression. Immune modulation: Detailed findings on CD4/CD8 ratios, cytokines (TNF-alpha, VEGF, BDNF), and TH1/TH2 balance. Dr. John Lewis provides compelling evidence on the health benefits of Aloe polysaccharides and underscores the need for innovative research methodologies in nutritional science. This episode offers valuable insights for anyone interested in the intersection of nutrition, immune function, and brain health.Connect with Dr. John Lewis Website: Dr. John Lewis Nutrition If you want to get Daily Brain Care visit our online curated range of cutting edge longevity and anti-aging supplements at  BIO John E. Lewis, Ph.D. is the Founder and President of Dr Lewis Nutrition™. Dr. John E. Lewis has spent most of his career developing a unique approach as someone who "walks the walk" through all of his combined professional and personal experiences to attaining optimal health through nutrition, dietary supplements, and exercise. Throughout his research career, he has evaluated many different nutritional approaches to enhancing well-being, particularly for brain health, immune function, and counteracting aging. He can separate fact from fiction regarding how to utilize nutrition and dietary supplements to help you achieve and maintain optimal health. If you need a trusted source of information, products, and services, then look no further than Dr. Lewis and how he can help you achieve your health-related goals. Professional Career Dr. Lewis is past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine and the Founder and President of Dr Lewis Nutrition™. He is a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association. He has been the principal investigator of over 30 different studies on human health in his research career. During that time, he either directly raised or indirectly supported raising over $23 million in grants, gifts, and contracts for research studies and clinical trials and educational programs for medical students. In addition to his research, Dr. Lewis has been an invited national and international lecturer and guest speaker at conferences and as a guest on television shows. He is a well-known author with over 180 peer-reviewed publications in some of the world's leading scientific journals. He has also mentored many different students, from undergraduates to post-doctoral trainees, in not only how to conduct clinical research but to apply the principles of health promotion into daily practice. Research Interests Much of Dr. Lewis's research has focused on evaluating the effects of nutrition, dietary supplements, and exercise on various aspects of human health. He and his colleagues have been continually searching for ways to help people achieve and maintain health through natural treatments that align with our physiology. A primary stimulus for the origin of Dr Lewis Nutrition™ occurred after Dr. Lewis ran his landmark study on how an aloe polysaccharide multi-nutrient complex improved cognitive and immune functioning after 12 months in persons with moderate to severe Alzheimer's disease, leading to the creation of the dietary supplement, Daily Brain Care. Daily Brain Care showed clinically and statistically significant improvements in cognition according to the ADAS-cog cognition score and statistically significant improvements in inflammation (according to TNFα and VEGF), immune function (according to the CD4/CD8 ratio), and adult stem cells (according to CD14+ cells). His seminal publication from the study in the Journal of Alzheimer's Disease not only spurred him to leave academics and pursue a science-based business career, but also enabled him to be selected for a widely-acclaimed TEDxMiami talk. Founding Dr Lewis Nutrition™ While Dr. Lewis still maintains an academic affiliation, he chose to leave a full-time research career to pursue his true passion of helping people achieve health through nutrition, dietary supplements, and exercise. His research in brain health and immune function was key in the creation of Daily Brain Care, but afterward he chose to shift into business where the opportunity to reach a larger audience is greater. Dr Lewis Nutrition™ is the vehicle through which Dr. Lewis leverages his many years of personal and professional work to spread a message of health that is so desperately needed, particularly for those who are afflicted with an all-too-common chronic disease, e.g., neurodegeneration, immune dysfunction, or cardiac and metabolic disorder. Dr. Lewis will continue to be a thought leader to help people utilize the power of nutrition and dietary supplements and learn how to take control of and optimize their health.         Personalised Health Optimisation Consulting with Lisa Tamati Lisa offers solution focused coaching sessions to help you find the right answers to your challenges. Topics Lisa can help with:  Lisa is a Genetics Practitioner, Health Optimisation Coach, High Performance and Mindset Coach. She is a qualified Ph360 Epigenetics coach and a clinician with The DNA Company and has done years of research into brain rehabilitation, neurodegenerative diseases and biohacking. She has extensive knowledge on such therapies as hyperbaric oxygen,  intravenous vitamin C, sports performance, functional genomics, Thyroid, Hormones, Cancer and much more. She can assist with all functional medicine testing. Testing Options Comprehensive Thyroid testing DUTCH Hormone testing Adrenal Testing Organic Acid Testing Microbiome Testing Cell Blueprint Testing Epigenetics Testing DNA testing Basic Blood Test analysis Heavy Metals  Nutristat Omega 3 to 6 status and more  Lisa and her functional medicine colleagues in the practice can help you navigate the confusing world of health and medicine . She can also advise on the latest research and where to get help if mainstream medicine hasn't got the answers you are searching for whatever the  challenge you are facing from cancer to gut issues, from depression and anxiety, weight loss issues, from head injuries to burn out to hormone optimisation to the latest in longevity science. Book your consultation with Lisa    Join our Patron program and support the show Pushing the Limits' has been free to air for over 8 years. Providing leading edge information to anyone who needs it. 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Lisa is constantly researching and interviewing the top scientists and researchers in the world to get you the best cutting edge supplements to optimize your life.   Subscribe to our popular Youtube channel  with over 600 videos, millions of views, a number of full length documentaries, and much more. You don't want to miss out on all the great content on our Lisa's youtube channel. Youtube   Order Lisa's Books Lisa has published 5 books: Running Hot, Running to Extremes, Relentless, What your oncologist isn't telling you and her latest "Thriving on the Edge"  Check them all out at  https://shop.lisatamati.com/collections/books   Perfect Amino Supplement by Dr David Minkoff Introducing PerfectAmino PerfectAmino is an amino acid supplement that is 99% utilized by the body to make protein. PerfectAmino is 3-6x the protein of other sources with almost no calories. 100% vegan and non-GMO. The coated PerfectAmino tablets are a slightly different shape and have a natural, non-GMO, certified organic vegan coating on them so they will glide down your throat easily. Fully absorbed within 20-30 minutes! No other form of protein comes close to PerfectAminos Listen to the episode with Dr Minkoff here:    Use code "tamati" at checkout to get a 10% discount on any of their devices.   Red Light Therapy: Lisa is a huge fan of Red Light Therapy and runs a Hyperbaric and Red Light Therapy clinic. If you are wanting to get the best products try Flexbeam: A wearable Red Light Device https://recharge.health/product/flexbeam-aff/?ref=A9svb6YLz79r38   Or Try Vielights' advanced Photobiomodulation Devices Vielight brain photobiomodulation devices combine electrical engineering and neuroscience. To find out more about photobiomodulation, current studies underway and already completed and for the devices mentioned in this video go to www.vielight.com and use code “tamati” to get 10% off     Enjoyed This Podcast? If you did, subscribe and share it with your friends! If you enjoyed tuning in, then leave us a review and share this with your family and friends. Have any questions? You can contact my team through email (support@lisatamati.com) or find me on Facebook, Twitter, Instagram and YouTube. For more episode updates, visit my website. You may also tune in on Apple Podcasts.  To pushing the limits, Lisa and team

Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. Patient-centered approaches and scientific methodologies can guide clinicians' prognostications. In this episode, Teshamae Monteith, MD, FAAN, speaks with Susanne Muehlschlegel, MD, MPH, FNCS, FCCM, FAAN, author of the article “Prognostication in Neurocritical Care,” in the Continuum® June 2024 Neurocritical Care 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. Muehlschlegel is a professor (PAR) in the departments of neurology, anesthesiology/critical care medicine and neurosurgery, division of neurosciences critical care at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Prognostication in Neurocritical Care 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: @SMuehlschMD Transcript Full 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, 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 Monteith: This is Dr Tesha Monteith, Associate Editor of Continuum Audio. Today, I'm interviewing doctor Susanne Muehlschlegel about her article on prognostication in neurocritical care, which is part of the June 2024 Continuum issue on neurocritical care. Well, Susanne, thank you so much for coming on the podcast, and thank you for writing that beautiful article. Dr Muehlschlegel: Thank you so much for having me. Excited to be here. Dr Monteith: Why don't we start with you just introducing yourself? Dr Muehlschlegel: Yeah, sure. My name is Susanne Muehlschlegel. I'm a neurointensivist at Johns Hopkins in Baltimore, Maryland. I have been a neurointensivist for about eighteen years or so. I worked previously at the University of Massachusetts and recently arrived here at Hopkins. Dr Monteith: Cool. So, what were you thinking about - What information did you want to convey - when you set out to write your article? Dr Muehlschlegel: Yeah. So, the article about neuroprognostication is really near and dear to my heart and my research focus, and I'm very passionate about that part. And as neurologist and neurointensivist, prognostication, you know, might be considered the bread and butter of what we're asked to do by families and other services, but as the article states, is that we don't usually do a great job (or physicians sometimes believe they do). But when you actually do research and look at data, it's probably not as good as we think, and there's a lot of room for improvement. And, so, the reason for this article really was to shine the light at the fact that I think we need to really make neuroprognostication a science, just like we make prediction models a science - and, so, that is the main topic of my research, as well as the article. Dr Monteith: So, we know about your interest in research in this area, but what got you into critical care to begin with? Dr Muehlschlegel: Yeah. It's, pretty much, a story of always being drawn to what's exciting and what others may want to avoid. So, in medical school, people were afraid of neurology and learning all the anatomy, and I just loved that and loved interacting with these patients. And then, in neurology residency, I was drawn to not just treating the brain and the spinal cord, but also the entire patient (so the lung and the heart and the interaction of all the organs). And then, naturally, I'm a little bit of an impatient person, and so I like the environment of the ICU of rapid change and always having to be on my toes. And so that's what drew me into neurocritical care. It was a very new field when I was training, and so, I was probably, you know, one of the, maybe, first- or second-generation neurointensivists. Dr Monteith: And it sounds like you're maybe okay with uncertainty and a lot of variability? Dr Muehlschlegel: Well, you know, neuroprognostication - I think everyone has to acknowledge that we cannot take away uncertainty, right? So, folks who pretend that they know for sure what's going to happen - I think the only time we can say that is in a patient who's braindead. But everyone else, we really don't know for sure, and all we can do is do the best to our ability to give a rough outlook - but we need to acknowledge uncertainty, that's for sure. Dr Monteith: So, can you just give us a few of the biggest causes of variability when it comes to withdrawing life-sustaining therapies in patients with severe acute brain injuries? Dr Muehlschlegel: So, that's the focus of quite some research. And, of course, there are many epidemiological factors, patient severity of disease, and, you know, how fast someone might arrive to the hospital, ethnic, racial, social demographic factors (and there's research on that), but when you adjust and control for all of those factors, variability remains. And so, what I've observed in my practice and what I also describe in the article is that maybe it's the way physicians describe prognostication or communicate with families, meaning there is potentially the chance for physician bias - that may also drive prognostication. And I can tell you from my own experience, what really drove me into this area is anecdotal experience that probably we've all had of other physicians kind of nihilistically prognosticating, thinking, you know, "This is going to be bad no matter what”, and not even wanting to try to provide aggressive care to patients. So, I think these what we call “self-fulfilling prophecies” we need to be very aware of. So, I think some of the variability may be driven by other factors other than family, patient, or health system factors. Dr Monteith: And you outline that really nicely in the article, so thank you for that. Why don't you just give us an example of a challenging case that maybe you're still thinking about today, that maybe happened years ago, that helps us understand what you go through? Dr Muehlschlegel: Yeah, I'll rephrase the case. I still have, you know, very vivid memories about this, but I tell my residents about this case. When I was a fellow, there was a young patient in his early forties, a father of several children, a young family man who had a big right MCA stroke and really was progressing to the point that it was clear that he needed a hemicraniectomy or he was going to die. Discussed this with my attending, who said I should consult neurosurgery. At the time, the neurosurgical service had a transition to practice service for these emergencies - and so, these were fairly young, chief residents or early-year attendings. And the person came in, went into the patient's room, and I didn't even know about it, and came out and then just said, “Family decided for CMO”. I was very surprised and shocked and was trying to understand how this happened, and this provider, all he said was, “Well, it's all how you put it to the family. I told him that he probably shouldn't be a vegetable. They didn't want him to be a vegetable, and so this was the only option.” And, so, I was very shocked, and the patient did progress to die within a few days. And, so, that was a dire example of how biased prognostication can drive families to maybe an unnecessary outcome. Dr Monteith: And what's CMO? Dr Muehlschlegel: I'm sorry. Comfort measures only - so, essentially, a withdrawal of life-sustaining therapies. Dr Monteith: Yeah. That is a good example of that and how our bias can inform families and maybe not with the exact amount of data to support that, as you outlined so nicely in your article. Dr Muehlschlegel: And I do want to emphasize, I don't want to generalize that all providers are like that, but it is an example that really still sticks in the back of my mind, and I think, you know, we need to shine a light at how we do this and how we do it right or wrong. Dr Monteith: And wouldn't it be nice to just have more objective measures (right?) to guide us? So why don't we talk about existing tools that are used to help guide neuroprognostication? Dr Muehlschlegel: Yeah, so I think, in general, we can break down prognostication to two pieces (and I outline that in the article as well). So, one is, kind of, a derivation of prognostication in the head of a physician or, you know, clinician – and what may go into that is how the patient presented, examination, radiology or other diagnostics, biomarkers, you name it. But, then the second part of it (that also is really important) is how we put it to the family, right? Because we can influence families in a way that we may not even be aware of, and I think we all have unconscious biases, and how we talk to families is really important and may drive what happens to the patient as well. So, I always say there's two pieces to that – so, first of all, how we come up with a prognosis, and then how we disclose that to the family. Dr Monteith: So how can we better handle uncertainty? Dr Muehlschlegel: So, we actually did some research on that and we asked stakeholders, "How do you want physicians to handle uncertainty?”. People are aware that no physician can be certain (again, other than in the case of brain death), and so families are very aware of that. And there's quite some data out there to suggest that if physicians have very absolute statements - you know, want to close the door by saying something very absolute - is that the optimistic bias in families goes up. So, the mistrust in what the physician is saying, coming up with their own (you know, “This is a fighter, and he or she is going to do better than what you're saying”) - and, so, I think, you know, there's no true answer to what's the absolute right way to do it, but some have suggested to maybe fully acknowledge that there is uncertainty. That's actually what families want you to do, based on some qualitative research we've done – is to say, “I do not have a crystal ball. There will be uncertainty”, but then to potentially go into a best/ worst-case scenario. But again, there, all we can do is give a best gross estimate and guess. And so, the work is not really clear at this point. There's research ongoing as to what should be the best way of doing it, but currently, that's what is suggested. Dr Monteith: And in your article, you spoke about some pretty innovative approaches, such as modeling, to help guide shared decision-making. And, so, you know, how reliable is that? Dr Muehlschlegel: That's a good point, right? So, that is up to statisticians or those who are inventing these new models. So, you know, in the old days we used logistic regression, maybe linear regression. Now, there are fancy machine-learning modeling and other Bayesian models that people use, and they certainly have some advantages that I outlined in the article. Bayesian models, for example, may use serial data as it comes in throughout the patient's hospital course - and that's kind of how we do it in real life. But, I think what's really important before we apply models is that we know that there's always outliers, and we don't know if this one patient might be the outlier, and that we need to validate these models, and most importantly, look at calibration. So, I talk in the article about how, you know, all models always report the what's called “area under the receiver-operating curve (the AUC)”, which is discrimination. But, what's actually more important for a model to be applied to a patient at the bedside is calibration, meaning how well does it actually predict a potential outcome. And, you know, there's a lot of research into that, that only maybe half of the papers that report on a new model actually report calibration - so, I think it's really important to pay attention to that (has the model been validated and calibrated before we actually use these models?). I think prediction models have definitely a important role. But, then again, as the article says, we also have to think about how we then apply that to the patient and how we do it in individual patients. Dr Monteith: And then, of course, there's some variability between institutions. Dr Muehlschlegel: That's for sure. You know, there's these systematic approaches or system-based cultures in certain institutions. And then, of course, you know, there's still this model of learning from a role model or a mentor or an attending - meaning you look at how this person does it and then you may adapt it to your own practice. I think we need to critically examine whether we need to continue with that kind of apprenticeship model of learning how to neuroprognosticate, or whether we need to have other educational ways of doing that. So, especially in the field of palliative care, there's a lot of education now around communication - and I think med students get that exposure, and residents may get that exposure, too - but I think we need to practice it and study it systematically, whether having a standardized approach to do this leads to more patient-congruent decisions. Dr Monteith: And, you know, we do have a lot of trainees, residents, and fellows that listen in. So, what are some key messages that you want to make sure gets conveyed? Dr Muehlschlegel: Key messages is that, I think, we need to move away from looking at a patient the first one or two weeks and then concluding that we will know what will happen to this patient in six months or a year or further down the line. I think there's not a lot of longitudinal studies out there now that show that patients actually probably do better than expected if they're allowed to live. And what I mean by that is many studies allow early withdrawal of life-sustaining therapies within the first three days or maybe two weeks - but if we actually allow these patients to live, people wake up more than we thought, people may do better than we thought. So, referring to the article, I discuss in detail some twelve-month data from the TRACK-TBI study or very interesting results from South Korea where withdrawal of life-sustaining therapies is forbidden by law. And, so, you can actually do a true natural-history study of what happens with these patients if you allow them to live. And, surprisingly, a lot of people that, you know, within the first two weeks were still comatose actually ended up waking up. And, I think it's really important to look at those studies and to continue to conduct those studies so that we know better what might happen. I always shudder a little bit when I hear, “We need an MRI in the first few days or first week for neuroprognostication”. And then I always question, “Well, what is it really going to tell you about that patient who clearly isn't brain dead and still has certain, you know, exam findings?” and “Shouldn't we just give those patients time?”. I think some of those were a bit too quick to provide poor prognostication if we really don't know. Dr Monteith: And, so, I want to know how did you get into research? You know, it can be competitive to get funding, grant funding - so, tell us about that in terms of, you know, your day-to-day, what's it like? And then, also, what makes you most excited about research happening in this area? Dr Muehlschlegel: Yeah, I mean, there's a lot of research happening in that area. I think there's a huge focus on biomarkers and models and all sorts of new diagnostic tools to predict outcome, big push over decades now to do large longitudinal epidemiological studies - and all of those are very, very important, you know. I just mentioned as an example, the TRACK-TBI study is one of many other examples. I'm also excited about doing research in the second part of neuroprognostication that I mentioned - the communication and disclosure part - and the potential of bias as we speak to families. So, I get very excited about that part. It's not easy to get funding, but I think what's important is to focus on the potential impact. And, of course, then you try to convince funders that this is important research that has to be done in addition to funding model development and large epidemiological studies. What my day-to-day looks like? Well, you know, we have several ongoing projects (I won't get into details on that), but to get involved would probably be the best time as a trainee - so, I have medical students working with us, residents and fellows (although their time can be limited). And then to continue to just be curious and ask questions. Dr Monteith: And what do you find most exciting about the work that you do? Just, kind of, overall? Dr Muehlschlegel: I mean, without a doubt, the potential impact, right? So, changing the field a little bit. I'm not claiming that my research is doing that - I hope it might. But, most importantly, it's the potential impact on families and patients. I think our goal is not to have less withdrawal of care (although, sometimes, I just think we need to give people more time), but I think it's important to focus and ask about what patients might want, and then really focus families onto that. I think that can be difficult, because patients don't always tell families what they would want or families want something different than what they know the patient might want - and so, we spend quite some time on that when we speak to families. And then, I also talk about the disability paradox. So, you know, at one point, the family might say, “Well, he would not want to live if he can't walk”, but then, patients, as they learn to live with this new normal, may actually later say, “Well, it's not as bad as I expected it to be, and I'm actually very happy to be alive, even if I'm not able to walk”. And so, that's something that others are doing research on, and that's also important to consider. Dr Monteith: Yeah, that's cool. Thinking about outside of the ICU, right? Dr Muehlschlegel: For sure. Yes. Dr Monteith: Great. Thank you so much for being on our podcast. I know that our listeners are going to really enjoy reading your article and all the thought that you put into that. Dr Muehlschlegel: Thank you so much for having me.   Dr Monteith: Again, today, we've been interviewing Dr Susanne Muehlschlegel whose article on prognostication in neurocritical care appears in the most recent issue of Continuum on 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 doctor Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, please consider subscribing to the journal. There's a link in the episode notes. We'd also appreciate you following the podcast and rating or reviewing it. AAN members, go to the link in the episode notes and complete the evaluation to get CME for this episode. Thank you for listening to Continuum Audio.

# 112 Nutrition for Brain Transformation: Health Secrets with Dr. John Lewis Ever wondered how your diet REALLY affects not just your body, but your brain health and overall quality of life? In this episode, we sit down with the esteemed Dr. John Lewis, founder and president of Dr. Lewis Nutrition, to explore the fascinating intersection of nutrition, supplementation, and human health. With a wealth of experience as a former associate professor and researcher at the University of Miami Miller School of Medicine, Dr. John has been at the forefront of over 30 studies examining the effects of nutrition and exercise on various aspects of human health. His work, with over 180 peer-reviewed publications in prestigious scientific journals, has shed light on the profound impact of diet and lifestyle choices on our well-being. Dr. John himself embodies the principles of health, following a whole food plant-based diet for over 26 years, supplemented with key dietary supplements, and maintaining a rigorous exercise regimen. His research has highlighted the importance of polysaccharides for brain health, immune function, and overall quality of life. Join us as we delve into Dr. John's passion for helping people achieve total transformation and learn how simple changes in diet and lifestyle can lead to profound improvements in health and well-being. Tune in to discover the science-backed secrets to a vibrant, healthy life, straight from the expert himself! Want to connect with Dr. John? Websites: www.drlewisnutrition.com and www.dailybraincare.com Instagram: @drlewisnutrition Twitter: DrJohnELewis1 Facebook: drlewisnutrition LinkedIn: linkedin.com/in/johnelewisphd Youtube: DrLewisNutrition The primary purpose of The Pretty Well Podcast being to educate. This content is for informational and educational purposes only. It is not intended to provide medical advice nor to take the place of such advice or treatment from a personal physician. By listening to this content, you agree to consult your own physician or qualified health professional regarding specific health questions. Neither Lisa Smith, The Pretty Well Podcast, nor any guest takes responsibility for possible health consequences of any person or persons following the information in this educational content. All listeners of this content, especially those who are pregnant or taking prescription or over-the-counter medications, should consult their physicians before beginning any nutrition, supplement, or lifestyle program. The Pretty Well Podcast is for private non-commercial use and our guests do not necessarily reflect any agency, organization, or company that they work for. In addition, opinions of interview guests do not necessarily reflect the opinions of Lisa Smith and/or The Pretty Well Podcast. This content is not guaranteed to be correct, complete, or up to date.

Dr. Lewis joins Something For Everybody this week. John E. Lewis, Ph.D. is past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine and the Founder and President of Dr Lewis Nutrition™. This conversation covers a range of topics including personal development, societal trends, the impact of money on health, and the importance of personal responsibility. It delves into the reasons for the rise in obesity, the influence of big pharma on society, and the role of nutrition in brain health. The discussion also highlights the significance of informed decision-making and the power of raw materials in supporting cellular function. - This Episode Brought To You By…  Shop For Everybody  Use code SFE10 for 10% OFF

Looking for the latest research in skin substitutes? You're in luck. Join Dr. Robert Kirsner as he discusses CAMPs or cellular, acellular, and matrix products. Learn about their application for chronic wounds, ulcers, conditions such as HS, and how you can use them in your clinic. Each Thursday, join Dr. Raja and Dr. Hadar, board-certified dermatologists, as they share the latest evidence-based research in integrative dermatology. For access to CE/CME courses, become a member at LearnSkin.com.   Robert Kirsner, MD PHD is Chairman and the endowed Harvey Blank Professor in the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery and Professor of Public Health Sciences at the University of Miami Miller School of Medicine. He is Chief of Dermatology at the University of Miami Hospital and Clinics and Jackson Memorial Hospital and directs the University of Miami Hospital Wound Center. His research interests include Wound Healing and Skin Cancer Epidemiology. Dr. Kirsner serves as one of 3 academic editors for the journal Wound Repair and Regeneration and on the editorial boards for a number of other journals in dermatology and wound healing. Dr. Kirsner serves in national leadership positions in both Wound Healing and Dermatology, including being Vice President of the American Academy of Dermatology and serving on the Wound Healing Society Board of Directors.   Sponsored by University of Miami Visit University of Miami's website for more information. 

Dr. Armando Hernandez-Rey is Conceptions Florida's medical director and triple-board certified in Reproductive Endocrinology and Infertility; Obstetrics and Gynecology; and Surgery. Dr. Armando Hernandez-Rey has over 24 years of experience in the medical field. He graduated from Universidad Autonoma de Ciencias Médicas de Centro America in 1998. He attended medical school at the University of Miami Miller School of Medicine for his specialization in Obstetrics and Gynecology. He specializes in treating patients with polycystic ovary syndrome (PCOS), recurrent pregnancy loss (miscarriage), and severe endometriosis. He is especially interested in fertility preservation (eggfreezing) for patients who must delay childbearing for personal or medical reasons, including cancer and systemic lupus erythematosus. Dr. Hernandez-Rey is an assistant clinical professor at the Herbert Wertheim College of Medicine at Florida International University and serves as an ad-hoc reviewer for the prestigious peer-reviewed journal, Fertility and Sterility. He has also published several articles and chapters in medical literature.   Website https://www.conceptionsflorida.com Instagram https://www.instagram.com/conceptionsflorida/ Facebook https://www.facebook.com/conceptionsfl Tiktok https://www.tiktok.com/@conceptionsflorida     For more information about Michelle, visit: www.michelleoravitz.com   The Wholesome FertilityFacebook group is where you can find free resources and support: https://www.facebook.com/groups/2149554308396504/   Instagram: @thewholesomelotusfertility   Facebook:https://www.facebook.com/thewholesomelotus/     Transcript:   Michelle (00:00) Welcome to the podcast, Dr. Hernandez -Ray.   Armando Hernandez-Rey MD (00:04) Thank you, Michelle. Thanks for the invitation. It's really an honor and a privilege to be on your show, on your podcast.   Michelle (00:09) Yes, well, I've heard a lot about you over the years because I've had a lot of patients go to you. And one of the things that I've heard is that you do really well with surgeries and fibroids and you're able to in and   but in a way that still preserves fertility. So that was one of the things that I've learned.   Armando Hernandez-Rey MD (00:32) Well, reproductive endocrinology and infertility as a subspecialty is a surgical subspecialty as is OB -GYN, which is a mandatory path to get to the infertility route. Unfortunately, a lot of the newer generation is not operating because they're not taught, not through no fault of their own, they're not taught. The reality is that it is...   Michelle (00:47) Mm -hmm.   Armando Hernandez-Rey MD (00:55) for a myriad of reasons this phenomenon has happened. Number one, the minimally invasive surgery tract has been developed where you have the person who's really just really perfected their obstetrical skills. And then you have the gynecologic oncology route and the pelvic urogynecology or pelvic reconstruction route and the minimally invasive surgical route. And a lot of the reproductive endocrinologists,   have said, you know what, I'm going to forego surgery and I'm going to refer it out. My personal philosophy, and this is in no way critical to absolutely anybody, it's just my own, is that I went into medicine to be a surgeon, I actually wanted to be an orthopedic surgeon. I ended up not liking it, I had a very bad fracture when I was in my teens playing competitive soccer, and I really had some PTSD from that fracture, so I just couldn't see myself doing   orthopedic surgery, but I somehow found my way towards OBGYN, absolutely loved it. And eventually towards the reproductive endocrinology route, which encompasses a lot of surgery, should you allow it. And so yes, like you said, fibroids are an important part of fertility. you, tubal reconstruction used to be much more important than it is now. People are more, are bypassing that route and going directly to in vitro fertilization.   Endometriosis, as I said, I was running a little bit late today. I was in a very, very complex endometriosis case with a patient with bilateral endometriomas and complete frozen pelvis and scar tissue. And, you know, just a little bit longer, I had to work with the colorectal surgeons to do some resection of the colon because it was, you know, endometriosis is such an awful, awful disease. So yes, to answer your question, I...   Michelle (02:41) Yeah.   Armando Hernandez-Rey MD (02:44) Absolutely love surgery. I think it's an integral part of the infertility journey to get a patient from being infertile to getting them to a high level of success with any sort of treatment. And hopefully it's more conservative than having to resort to artificial insemination or in vitro and with just surgery and corrective surgery, we can help the couple achieve a pregnancy.   Michelle (03:07) Yeah, and I think it's important because I think that a lot of people might not realize that there are certain people that specialize in this or have experience doing that, doing surgery and really getting in there because it is important to find somebody who's specialized if you have a complicated case.   Armando Hernandez-Rey MD (03:23) I think it's important. I think people feel well taken care of. Again, my perception, people feel well taken care of when everything is done in house. Meaning, you know, there's no messages that get lost as you refer a patient out who may have the minimally invasive surgery knowledge, but not necessarily the focus on infertility, reproductive endocrinology.   Michelle (03:33) Mm -hmm.   Armando Hernandez-Rey MD (03:50) specialist has and I think people feel comfortable with that.   Michelle (03:52) Yeah, absolutely. Because there's some people that will take out fibroids, but they're not doing it with fertility in mind. You know, for many women, it could just be just taking out fibroids, but you're doing these things with fertility in mind.   Armando Hernandez-Rey MD (04:07) There are many great surgeons out there that are not infertility specialists. You know, I want to make sure that I'm clear. I just think that I was, I always love surgery. I happen to do surgery and I feel my patients feel very comfortable with me doing the surgery and not being referred out. It's what I think. You know, the journey, the infertility journey is very complex. It requires a lot of a woman in particular more than the male and to be   Michelle (04:25) Yeah.   Armando Hernandez-Rey MD (04:36) you know, passed around, it gets complicated. And I think it's nice to be able to offer that service to patients.   Michelle (04:44) Yeah, for sure. And then you do specialize in miscarriages.   Armando Hernandez-Rey MD (04:49) Sure, I mean, I think we all really have a focus on on as you know, we're all specialized in miscarriages and and PCOS and all that there's some people that tend to see More miscarriage patients or they people will refer miscarriage patients to us We have a particular kind of focus on that, you know, I think a lot of it is   genetic, a lot of it is immunologic, a lot of it is just taking a holistic approach to things and not just focusing on one or the more common causes of infertility. And even now, I think that, you know, the use of supplements, which maybe 15 years ago was maybe considered some snake oil. Now, I think there's a lot of provocative data that has shown that supplements do work, in particular in   Michelle (05:18) Mm -hmm.   Armando Hernandez-Rey MD (05:44) cases with recurrent miscarriage. And now we have the ability to measure those levels and we are now ability to supplement those levels and they have tremendous impact positively on these patients.   Michelle (05:57) And what supplements have you seen help with miscarriages?   Armando Hernandez-Rey MD (06:02) Well, I think a lot of it has to do with what the cause of the miscarriages is. Oftentimes, believe it or not, miscarriages can alluded to fibroids, it could be anatomical, sub -mucosal myoma. Well, there's not gonna be any supplement that's gonna help with that. It's just purely the surgical route or the diminished ovarian reserve,   Michelle (06:07) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (06:29) cause for recurrent miscarriages, which is older women or ovaries that are behaving or eggs that are behaving older than what their chronological age would dictate, you have a higher chance for aneuploidy. And in those cases, there's a variable cocktail of supplements that we use, including ubiquinol, including N -acetylcysteine, including vitamin E, even melatonin has been shown to be very, very effective. And I can go on and on, even alpha lipoic acid.   Michelle (06:50) Mm -hmm.   Armando Hernandez-Rey MD (06:57) as well. There's some very nice studies coming out of Mayo Clinic that have shown that aflalipoic acid is very, very good for recurrent miscarriages. So again, things that we thought were, well, they can't hurt, now we know that they absolutely help.   Michelle (06:57) Yeah.   Right. Yeah. I mean, that's great because it just helps to know that there's something that people can do that really does make a difference. And it's not just like in theory with miscarriages when it comes to immunology. I'd love to talk about that because I know that that's a big one. Actually, I did see a study that showed that women who have are more sexually active, that their immune system calms down. It behaves differently in the luteal phase.   Armando Hernandez-Rey MD (07:31) Mm -hmm.   Michelle (07:44) so that it's able to receive life so that it's not seeing like the sperm as an invader the, yeah.   Armando Hernandez-Rey MD (07:50) So women that are more sexually active than others, it's probably a function of repeated antigen exposure, which is the more the woman is exposed to the antigens of the sperm, more there becomes an acquiescence by the immune system to be more receptive of that embryo. Because remember, the embryo is   Michelle (08:06) Mm -hmm.   Armando Hernandez-Rey MD (08:19) a haplotype, meaning it's half female, half the woman, half the mother, and half the male. And the only genes that the immune system of the mother has got to harbor the pregnancy are her own. And so oftentimes the immunologic processes are heightened because it does not recognize the male antigens that are formed part of the embryo in general. But as a whole, I mean, recurrent pregnancy loss,   Michelle (08:33) Mm -hmm. Right.   Armando Hernandez-Rey MD (08:47) is, is a small portion of the general population and, it's skewed towards advanced maternal age and advanced paternal age. so the immunologic component, while absolutely important, I think it's the one where we're still not a hundred percent sure how to absolutely treat it. Although supplementation and.   immune suppression definitely are known to work. It's the testing that I think we still need a lot more work in doing because you know people talk about NK cells and you know that was part of my thesis when I was a fellow. So we talk about NK cells and ANA and antiphospholipids and all of that and the reality is that these tests have very very   poor sensitivity in the realm of immunologic infertility or reproductive immunology. And so you may have COVID and then you can test positive or lightly positive for NK cells. And so I think that the overwhelming response by the treating physician is, well, they're positive, they must be immunologically incapable of handling a pregnancy. So therefore we should treat.   Michelle (09:40) Mm -hmm.   Armando Hernandez-Rey MD (10:04) with nowadays what we use as intralipids. Back in the day, we used to use IVIG that has kind of fallen by the wayside a little bit. I think it's better to treat empirically than to have someone treat or test for all of these different immune markers that really, really in the presence of immunology and reproductive immunology,   They have very low sensitivity. Now if you're treating or you're looking for lupus or rheumatoid arthritis or mixed collagen disorder or Sjogren's for sure, they are your go -tos every single time.   Michelle (10:44) And what about a PRP for ovaries? What has do you do offer that?   Armando Hernandez-Rey MD (10:50) ovaries. American study of reproductive medicine came out with a black box warning that they do not recommend PRP for ovaries. Now, PRP for recurrent implantation failure, poor lining development, there is some very robust data that there may be some room or benefit for this.   Michelle (10:57) okay.   Mm -hmm.   Armando Hernandez-Rey MD (11:14) And we do do offer that. We do not offer intra ovarian PRP because ASRM has a huge black box warning on this. It's a liability. The potential for infection is there. Tubo ovarian abscess have been reported, adhesions, periovarian adhesions, and with very little to no benefit whatsoever. I mean, the whole premise for it is that we are...   Michelle (11:16) Okay.   wow, okay, I didn't know that.   Mm -hmm.   Okay, got it.   Armando Hernandez-Rey MD (11:42) regenerating the follicle complex and therefore improving egg quality and that definitively has not been shown to be the case. Although anybody who suffers from that as I would be would be like, slide me up. But unfortunately, you know, it's very easy for us to fall prey to things that we desperately want without having the medical literature to corroborate it or back it up.   Michelle (11:49) Got it.   Right.   Got it. So that's actually showing to not necessarily be what a lot of people originally thought, but for the uterus, it has been shown to help.   Armando Hernandez-Rey MD (12:15) Yes, we are doing PRP installations and very select group of women with those diagnoses in particular. And.   Michelle (12:25) So who would be a good candidate? Somebody who's had failed transfers, inflammation.   Armando Hernandez-Rey MD (12:30) Yes, someone with very high quality embryos, high quality embryos that are not getting pregnant. Also patients, for example, patients who have adenomyosis that do not develop a nice lining, a thickened lining. Those have been shown. Our numbers are very small, you know, by no means.   Michelle (12:42) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (12:53) they are in the realm of what a randomized controlled trial should be. We're following the data from the randomized controlled trials and from the literature that's out there. So patients with adenomyosis who have poor lining development, recurrent implantation failure, so patients with euploid embryos, that means a normal embryo that's tested that looks to be high quality. Also, after a second implantation failure, we'll...   offer that to the patient as a possibility.   Michelle (13:19) Mm hmm. Got it. Awesome. And then also we were talking about Ozempic pre -talk. So I'd love to get your... Yes. Yeah. Ozempic babies.   Armando Hernandez-Rey MD (13:24) the topic du jour these days, right?   It's right. So as we were discussing, I mean, this, this phenomena is not really a phenomenon that's surprising at all. It is just a, a byproduct, a side effect of, of how the medication works and the effects that positive effects that I have on women with in particular, and ambulatory disorders, specifically polycystic ovarian syndrome, which is often tied to or associated with insulin resistance, obesity, sometimes even overt.   type 2 diabetes and the elevated levels of insulin, the elevated testosterone levels, they all work together to create this sort of environment within the ovary and the system of the female which creates an ovulatory disorder or dysfunction. And as a woman loses weight by virtue of the way that these GLP1s or glucocortes   Michelle (13:58) Mm -hmm.   Armando Hernandez-Rey MD (14:22) Glucagon like peptides work They're very successful. They're very good at number one slowing gastric emptying which in turn slows down the release of sugar into the blood system to the Number one number two it stops the the release of glucose produced by the liver and Number three increases insulin levels so increase insulin levels helps get the the   the sugar into the muscles out of the circulation and out of stimulating the ovaries and the theca cells to produce more androgens which then get produced produce more estrogen which then stops the hypothalamic pituitary ovarian axis from functioning correctly and as these levels drop patients automatically begin to have spontaneous ovulation if the system is working and the male has normal sperm and they're sexually active.   this is how the ozempic baby phenomena occurs. And what we discussed also is that the concern is of the downstream consequences of ozempic babies given that the current recommendations are to have at least a two month washout period before anybody starts to try to conceive.   Michelle (15:32) So two month washout means like really not trying anything. Yeah. And then also, I know like naturally, myonocytol is really helpful as well for insulin resistance. It might take a little longer. And then also metformin has been used as well.   Armando Hernandez-Rey MD (15:37) No exposure, right? No exposure.   Yeah. Yes. So, my own hospital is, is a, is a great product. my own hospital alone, although you will find oftentimes my, my own hospital with a D chimeric, hospital and really the literature shows that my own hospital by itself is the one that truly has the most benefit might be hard to find.   Michelle (16:06) Right, yeah.   Right because for a little while they said my own hospital and dechiro, but now they're going back to saying just my own ocital, correct?   Armando Hernandez-Rey MD (16:23) Yeah, well the way that it's normally found in the body is at a ratio of 20 to 1. And that's what those supplements show, 20 to 1. Although we know now that in the ovary it's almost 40 to 1 ratio of myoinocytol to D -chimeric, inocytol.   Michelle (16:30) Mm -hmm.   Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (16:49) Myo Inositol is actually not an essential vitamin, but it's considered like a vitamin, but it's in the category of B8 It's a glucose like peptide that basically helps to Help the system function by processing the circulating blood sugar in a way that's more physiologic and there by lowering insulin levels and thereby also helping tremendously with   Michelle (16:56) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (17:16) regularity of cycles and even spontaneous ovulation as well. And metformin obviously is medication that's been around for many, many years. It is somewhat of a controversial drug. It is an anti -aging drug even these days because we know that insulin levels are so profoundly toxic for aging for the muscle and for the system in general.   Michelle (17:29) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (17:45) And so we know it works, we know that it helps with the efficiency of insulin. And so it's certainly been used for many, many, many years in the presence of patients with polycystic ovarian syndrome. I would challenge people to be a little bit more meticulous about using it in patients who are the lean PCOS.   Michelle (18:11) Right.   Armando Hernandez-Rey MD (18:11) or the skinny PCOS or the ovulatory PCOS even though insulin levels have been shown to be higher, slightly higher in...   Michelle (18:19) So you're talking about being cautious with metformin, not necessarily myonositol. Yeah, yeah.   Armando Hernandez-Rey MD (18:22) Metformin, you also don't want very high levels of myelonostetal because they can be, you know, there is some quote unquote toxicity. I think the recommendations are up to four grams per day. I think all the recommendations are four grams per day in two divided doses, two grams in the morning and two grams at night. I've seen patients be on eight grams and 10 grams and toxicity really starts happening around the greater than 10 gram dose.   Michelle (18:29) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (18:52) I in our office we only use it, you know, what's recommended which is the four gram total per day two grams in the morning two grams at night and I don't think it's the end -all be -all I don't think it's you know treating anything in life is multi -pronged. It's not just one single thing perhaps but I definitely believe very wholeheartedly that it does assist in in adjunct treatment, although we certainly have patients put patients on on myocytil and combined with   Michelle (19:06) Yeah. Right.   Armando Hernandez-Rey MD (19:20) diet and exercise and have been able to achieve pregnancies on their own, which is obviously what we want instead of having to go through treatments.   Michelle (19:27) That's great. I mean, I will say that I was very surprised this past year. two different patients came from different, different places, not yours, it was other doctors, but I think the nutritionist there suggested metformin when they did not have insulin resistance or PCOS for egg quality.   Armando Hernandez-Rey MD (19:47) Yeah, I'm not familiar with any studies that have shown that have improved that. In fact, when I was a fellow, we were, just as I was coming into fellowship, where I trained, Rutgers was involved with a very well known and publicized study, it's called the PP COAS study, which looked at patients on placebo versus metformin alone versus metformin with Clomid, sorry.   placebo versus clomid versus clomid with metformin and there was no difference in pregnancy rates or anything else. I'll go one step further with them going back to the myonocytol. It has even been shown to decrease the rates of gestational diabetes and so in our patients with PCOS with who are you know   Michelle (20:18) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (20:39) Stage one, type one obesity, type two, we'll continue them on the myonostetal throughout the pregnancy and when they leave us and go to their OB -GYN, in our referral letter back, we'll say that we're recommending for her to continue on myonostetal because there have been improvements in sugar levels and glycemic control and reduction in gestational diabetes overall.   Michelle (20:54) Yeah, that's good to know.   another big one is vitamin D. A lot of people, even though we're in Florida here, we have a lot of sun. A lot of people are very deficient in vitamin D.   Armando Hernandez-Rey MD (21:11) Yeah, What it is is a combination of things. Number one, we're not as sun exposed as you think we are. You know, we're always in a car, we're always indoors, it's very hot. And yes, we go out to the beach and there is a lot of sun, but we become very, very sensitive to the sun and to the untoward effects of the sun.   Michelle (21:17) Mm -hmm.   Armando Hernandez-Rey MD (21:35) So we protect ourselves tremendously. That's number one. Number two is that I think the levels are set higher than what the average person can sustain with just diet and sun exposure. And actually the recommendations now in the infertility world that when you order a vitamin D from Quest, they'll tell you that the levels are, you want them at   Michelle (21:38) Mm -hmm.   Armando Hernandez-Rey MD (22:04) definitively above 20 Certainly above 30 and now recently now the recommendations are that for them to go above 40 and and and Yeah, I'm not yeah, so I heard I've read 40 I it was a Paper that came out of Either the Lancet or   Michelle (22:11) Yes, yep, I've been hearing that or even 50. Yeah.   Armando Hernandez-Rey MD (22:27) or fertility necessarily, anyone, one of, that they recommend now for vitamin D levels to be above 40. So that's really hard. I mean, I work really hard. I take a lot of vitamin D and I'm just barely scraping like 50. You know, I take about 5 ,000 units a day, which is what we're recommending nowadays, 5 ,000 units of vitamin D. And I take that every single day and I barely scratch,   Michelle (22:38) Mm -hmm.   Yeah.   Armando Hernandez-Rey MD (22:56) you know, 45, 50 every time I get an average check. So I'm not getting as much sun as I think I am, number one. I am out fairly often. I do play some golf, not enough. And yet it's not enough. So definitely supplementation's important.   Michelle (23:03) Mm -hmm.   Yeah, magnesium is also important. That's another thing. It's to not be deficient in magnesium because magnesium plays an important role of our absorption of D, which, you know, obviously doing this, I learned, I was like, that's might be deficient magnesium and be taking a lot of D and then their body's not processing, which is why it's important sometimes even in foods, foods have everything. So like,   even beef liver, you know, from Chinese medicine perspective is so beneficial because it has iron, but it has it in a combination of nutrients that helps the body absorb it.   Armando Hernandez-Rey MD (23:46) Yeah, B6, B12 are incredibly important for iron absorption as well. So all of these things are extremely important. Everything is all intertwined and we're just learning about this. And for us, I've really gotten grabbed hold of this whole longevity thing, hence my aura ring and all of this. And...   Michelle (23:57) It is.   Yeah.   Armando Hernandez-Rey MD (24:09) I'm just trying to apply a lot of the things that we know today work for longevity medicine and anti -aging principles to the infertility world because it's all intertwined. It's all intertwined.   Michelle (24:16) Yeah.   without a doubt. It's funny because that you say that because I always say it's pretty much anti aging. Yeah.   Armando Hernandez-Rey MD (24:26) Yeah, totally, totally. They're even coming up with a way to stop menopause.   Michelle (24:36) wow. How?   Armando Hernandez-Rey MD (24:37) which is extremely interesting. Believe it or not, recombinant antimullerian hormones.   Michelle (24:42) How is that? Explain that.   Armando Hernandez-Rey MD (24:46) So the way that antimullerine, the function of antimullerine hormone at the level of the ovary is that it stops follicular recruitment. That's why women with PCOS have higher AMHs and therefore they have higher egg counts and higher, they tend to go into menopause later on, et cetera. That's because they have high levels of antimullerine hormone. So by reproducing or creating it in the laboratory and then from an early stage,   This is in its infancy, by the way, okay? So this is, yeah, this company, I believe she's a Harvard scientist, biochemist or something, who's coming up. My point is that, listen, that it's all intertwined, aging and even in menopause, for God sakes. Now I've been doing this for so long that I now,   Michelle (25:18) It's new.   Mm -hmm.   Armando Hernandez-Rey MD (25:39) seeing menopausal patients who were like, you know, listen, you took care of my baby, you're a reproductive metachronologist, you understand the science, will you treat me? And, you know, like, and I realized, like, somewhere, some women got like, they got a some bad luck thrown their way because, you know, with the WHI results and the way they were interpreted, they made hormones bad. And somewhere along the way, someone said,   It's okay for women to suffer from menopause, just suck it up. Like it's not okay. That's not okay. That's not okay. And so if you start from very early on and, you know, and, and really practice what you preach, which is healthcare and not sick care, which is what we practice in the United States, you know, we're just very, we, we're not proactive. We're reactive to when a patient is sick instead of early intervention, early screening and all of that.   Michelle (26:25) Yeah, absolutely.   Armando Hernandez-Rey MD (26:30) And that goes for the infertility world and that goes for a woman's long reproductive life extending past menopause. I think we still have a lot of challenges to overcome, but I think that we're heading in the right direction. Sorry to digress a little bit. I went off on a tangent there for a second.   Michelle (26:43) Yeah, for sure. no, it's okay. But you know what? I love the passion and I love that, that, you know, ultimately is great. It's important, very important, because it's true. And I agree a lot with what you just said, that we should be proactive when it comes to healthcare. I mean, really when it comes to so many things and something else that I...   that I read, it was an animal study. It was a study on, I believe it was like, I don't remember which kind of animal it was. I think it was like either sheep or cows or some form of those where they actually gave them oxytocin right before IUI. And that improved the chances of the conception rates, which I thought was very interesting because I think that that's one of the things with IUI that's missing because obviously you're taking away the connection.   that is usually there when you're just under natural circumstance. And I thought it was interesting because I was looking into it for something else to understand from a Chinese medicine perspective, because they have this heart -uterusconnection, that connection, the bonding. And so what I found was interesting too is that oxytocin increases around ovulation and after intercourse. And usually what they look at it as its role is usually for labor.   not so much conception. So I was just going to kind of like pick your brain on that. Any thoughts on that?   Armando Hernandez-Rey MD (28:13) Well, I mean, oxytocin is secreted at the time of... I'm not sure of ovulation, I didn't know that. But definitely at the time of...   Michelle (28:21) or it increases around that time, like right before ovulation in the cycle, a woman cycle.   Armando Hernandez-Rey MD (28:27) What we know that it's involved is at the time of orgasm. And so this may promote uterine contractility, which is what is used for intrapartum, to promote contractility of the uterus, to promote descent and eventual delivery. And we know that it's intimately involved in orgasm, we're seeing.   Michelle (28:33) Mm -hmm.   Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (28:55) during intercourse and orgasm and so with you know the projection of with the secretion of oxytocin and it causing uterine contractility obviously not at the same level that it does during labor but at smaller amounts then I can see how there could be a role for oxytocin in artificial insemination.   Michelle (29:18) even in fertility in general and because it's got to be there for a reason why would the body produce it around that time?   Armando Hernandez-Rey MD (29:25) Well, yeah, I guess, but it's either IUI or IVF and we definitely don't want oxytocin during the IVF cycle.   Michelle (29:33) Right, because you don't want to contract, right?   Armando Hernandez-Rey MD (29:35) Right, because we're transferring an embryo where there should not be any oxytocin. And you can have the most beautiful embryo, but if you screw up the embryo transfer, through no fault, just because it's a difficult transfer for a myriad of reasons, and you cause uterine contractility, then there's a high likelihood of pregnancy not occurring during that time.   Michelle (29:57) Right. I think it would be an interesting thing to look into for IUI. There might be something to it, because if it works with animals, and the animals obviously have similar certain functions that we do, mammals, that seems like an interesting thing.   Armando Hernandez-Rey MD (30:10) Yeah.   I think there's not going to be a lot of resources put into improving IUI, to be honest with you. IUI, I think it is what it is. And I mean, I think the majority of research is going to go to improving even more IVF rates, because I think ultimately patients are going to want to go more.   Michelle (30:22) Mm -hmm. Yeah.   Armando Hernandez-Rey MD (30:40) towards IBF, no matter how hard we try to say, hey, listen, there's this option or this option or this option. It's more become a more of an instant gratification society. Number one, number two, people are waiting longer. So therefore they're more pressed for time, if you will. And I think there will be less of a motivation to go down a treatment option that frankly,   Michelle (30:48) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (31:07) You know, has a low pregnancy rate.   Michelle (31:09) Right. And then my other question is, what are your, thoughts about a lower intensity cycle?   like lower amounts of hormones for older women. In some cases I've heard it might be a little better. you do? Yeah, yeah.   Armando Hernandez-Rey MD (31:24) We use it all the time. Yeah, we use it all the time. I think it's...   a very successful option in cases with severely diminished ovarian reserve. I think that the senescent ovary does not do well with high impact medication or high doses of medication separately, but you know, jointly the medication costs are exorbitant and you end up having the same number of eggs that are mature, that get fertilized with a mini stent protocol as you do with   Michelle (31:38) Okay.   Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (31:59) a high dose regimen.   Michelle (32:02) Okay, so you've seen good success with that.   Armando Hernandez-Rey MD (32:06) Well, I mean, not good success because generally these cases are, we've seen success. Let's call it that. Because the patients that you're treating with these medics, with this protocol are patients who are POI, you know, premature ovarian insufficiency, diminished ovarian reserve, poor egg quality, high rate maniploidy. So these are your poor responders essentially. And they're very...   Michelle (32:12) Yeah, okay.   Mm -hmm. Mm -hmm.   Armando Hernandez-Rey MD (32:34) specific factors that propel a woman to have success with this protocol compared to her twin sister with almost the same testing who doesn't do as well.   Michelle (32:47) Got it. And then lastly, we talked about this in the pre -talk, let's talk about marijuana and sperm, data is showing. Yeah.   Armando Hernandez-Rey MD (32:55) I don't do it myself, but I have no problem with people that do. What the data has shown that we're just becoming more and more familiar because the overwhelming number of people who are using cannabis and open about it, which is the second part, which was very difficult to conduct studies because it was so people were ostracized. They were looked at.   not the wrong way and seen as in the fringe. And now it's, you know, it's so mainstream. but so now we're, we're keenly aware, of patients were able to analyze them and what we know without a shadow of a doubt that the potency of the cannabis that's being produced these days is anywhere between eight to 12 times more potent than I think I use the joke of the guys at Woodstock back in the sixties, right?   Michelle (33:21) Mm -hmm.   Mm -hmm.   Armando Hernandez-Rey MD (33:46) where everybody was getting pregnant and everybody was high on life, all of those things. And then what we've also known, which I did mention, is that using the vape pens, whatever types of inhalers as opposed to the traditional joint, if you will, increase the potency of that by a factor of two to three. The cannabis that was already potent to begin with.   Michelle (34:08) Yeah.   Right.   Armando Hernandez-Rey MD (34:14) So what you're seeing in males in particular, and I'm not sure that the literature is so complete on the female aspects, are that we're seeing a high levels of fragmentation. And what fragmentation is, is imagine that sperm is like an Amazon box. And inside that box, there's a porcelain doll that's wrapped in these packing cubes. They're held very, very tight. And under...   Michelle (34:26) Mm -hmm.   Armando Hernandez-Rey MD (34:40) The best of circumstances, those packing cubes are wound so tight, packed so tight that nothing, if I kick the box off the Amazon truck, nothing is gonna happen to the porcelain doll. Well, as fragmentation occurs and it happens under natural conditions and old guys like me, you know, patients who, occupational hazards, firefighters, exposed to toxins, a lot of people who use fertilizers, et cetera, et cetera.   you see high levels of fragmentation. I'm talking about DNA fragmentation. And so what we're seeing is high levels of fragmentation at the level of the DNA of the sperm, which has significant effects on embryo quality, embryo development, and pregnancy rates, and high levels of aneuploidy, which is abnormal embryos. So,   Michelle (35:10) So you're talking about DNA fragmentation. Yeah. Yeah.   Mm -hmm.   Armando Hernandez-Rey MD (35:33) You know, I'm not here to like, you know, slap you on the wrist and say don't smoke weed, but really that's what you're facing. And we know that this happens in women with cigarette smoking. Like this is a well -known cause of an accelerated transition to perimenopause. You know, 65 % of women who smoked a pack a day for greater than 15 years will go into menopause before the age of 40, assuming they started before their 20s. That's a pretty...   Michelle (35:40) Bye.   Mm -hmm.   Armando Hernandez-Rey MD (36:03) ominous number, actually. Thankfully, not many women smoke these days, cigarettes anyway. So I guess the results of cannabis on females is yet to be elucidated, but we definitely have some pretty compelling evidence in terms of the male data that show that it can have detrimental or deleterious effects on sperm quality and not necessarily on numbers.   Michelle (36:04) Yeah.   Mm -hmm.   right, which is what people look at usually when I mean, that's like the, the analysis is always on numbers shape and, numbers shape it. Yeah. And morphology and they won't necessarily look at the DNA fragmentation. That's actually not something that REIs usually initially look at.   Armando Hernandez-Rey MD (36:33) Exactly.   the thesis in morphology.   is done in a well not initially unless there's comorbid situations or things that raise your red flags. For example, advanced paternal age, we always do it. Particularly in egg donor cycles, right? Because patients will be like, well, I'm using an egg donor and why don't I have bad energy? Well, because your husband could be 70 or 60 and   Michelle (37:11) Yeah.   Armando Hernandez-Rey MD (37:14) And then their fragmentation is completely elevated and through the roof. So yeah. So, you know, firefighters, occupational hazards.   Michelle (37:18) Right. So, yeah, it's important. It's important for people to hear this because they can go in and say, the semen analysis was perfect. But that, like what you just said, is not really checked. So they may not, in a healthy, like, younger guy.   Armando Hernandez-Rey MD (37:35) It's not as nuanced as we once thought it was.   Michelle (37:38) Yeah. Yeah. Interesting. It's, it's fun. It's always fun for me to talk to our, our ease, you know, just to get, to pick your brain and get your thoughts. and you're my neighbors. So it's pretty cool.   Armando Hernandez-Rey MD (37:50) That's right. Thank you very much for the invitation. This was really fun. We spoke about a wide array of different topics here. So this was really nice to connect this way.   Michelle (37:53) Yeah.   Yeah.   Yeah, for sure. And I know that a lot of people are going to be like, this is interesting information. Cause I know that what you just mentioned, a lot of it is not common knowledge. people don't know automatically hear about this or really know to think about asking about it. So, so I appreciate all your information, all your good, good data. And, for people who would like to work with you or in town, how can they find more about you?   Armando Hernandez-Rey MD (38:27) Well, we are at Conceptions Florida. We have two offices in Merritt Park, Coral Gables and one in Miramar and hopefully soon also in Boca. And I'm there Armando Hernandez -Ray, MD I'm sure. Easy to find these days on Google, but I'm happy to help in any way that we can. We've been doing this for a long time, quite successfully, thankfully. And we take a lot of pride, humbly speaking, but probably also.   in having a good footprint in South Florida and the infertility world and trying to offer the best care possible.   Michelle (39:01) Awesome. Well, this was such a pleasure and thank you so much for coming on today.   Armando Hernandez-Rey MD (39:05) Thank you, Michelle.    

In 2011, the Food and Drug Administration held a hearing to review a drug previously approved for the treatment of metastatic breast cancer. The hearing was fraught with concerns over the drug's safety competing with cancer patients who felt they were alive because of the drug. Dr. Mikkael Sekeres was on the panel receiving testimony, and weighing what he heard against the long history of the FDA to make sure drugs are safe AND effective. Mikkael Sekeres is a professor of medicine and chief of the division of Hematology at the Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine. He earned a master's and medical degree in clinical epidemiology from the University of Pennsylvania School of Medicine before completing his postgraduate training at Harvard University. He has served as Director of the Leukemia Program and Vice-chair for Clinical Research at the Cleveland Clinic Cancer Center. Sekeres' new book, “Drugs and the FDA,” is set in the context of the FDA's 2011 trial for the drug Avastin. There, he examines the ways the FDA became the sole authority on medicine in the United States and the process of approving drugs.See omnystudio.com/listener for privacy information.

Contrary to popular belief, not all sugars are harmful to your health. Polysaccharides, a type of complex carbohydrate, highlight how certain sugars can be beneficial. Found in foods such as whole grains, vegetables, and legumes, these long-chain carbohydrates play essential roles in maintaining good health and strengthening the immune system. Join us in today's episode on polysaccharides with Dr. John E. Lewis, where we explore the subject of sugars, anti-nutrients, misconceptions, and more. Meet our guest John E. Lewis, Ph.D., is the Founder and President of Dr Lewis Nutrition™ and a former Associate Professor at the University of Miami Miller School of Medicine. He is a Diplomate, Faculty Member, and Advisor of the Medical Wellness Association and lectures for the Institute for Brain Potential. With over 180 peer-reviewed publications, Dr. Lewis has led more than 30 research studies, raising over $23 million in grants and contracts. His research focuses on the impact of nutrition, dietary supplements, and exercise on health. Dr. Lewis' work on Alzheimer's disease led to his widely acclaimed TEDxMiami talk. A proponent of a whole-food, plant-based diet and rigorous exercise, he is dedicated to advancing clinical nutrition for better health. Thank you to our partners Outliyr Biohacker's Peak Performance Shop: get exclusive discounts on cutting-edge health, wellness, & performance gear Ultimate Health Optimization Deals: a roundup article of all the best current deals on technology, supplements, systems and more Gain mental clarity, energy, motivation, and focus with the FREE Outliyr Nootropics Mini-Course The simple, guided, and actionable Outliyr Longevity Challenge helps you unlock your longevity potential, slow biological aging, and maximize your healthspan Key takeaways It's ignorant to say that sugar is bad Depending on their characteristic, sugar has a very different effect on us than what is commonly believed In any type of degeneration, chronic systemic inflammation is involved Polysaccharides tamper down and control chronic inflammation Immune function is highly related to cardiovascular function If you don't protect yourself with a healthy lifestyle, you're speeding up cardiovascular disease in your body Neurodegeneration is linked to a poor immune system Links Watch it on YouTube: https://youtu.be/Nw9RMm6ecuc Full episode show notes: mindbodypeak.com/160 Connect with Nick on social media Instagram Twitter YouTube LinkedIn Easy ways to support Subscribe Leave an Apple Podcast review Suggest a guest Do you have questions, thoughts, or feedback for us? Let me know in the show notes above and one of us will get back to you! Be an Outliyr, Nick

John E. Lewis, Ph.D. is the Founder and President of Dr Lewis Nutrition™ and past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. He is also a Diplomat, Faculty Member, and Advisor of the Medical Wellness Association.  He is a lecturer for the Institute for Brain Potential.  He has been the principal investigator of over 30 different studies in his research career. During that time, he either directly raised or indirectly supported raising over $23 million in grants, gifts, and contracts for research studies and clinical trials and educational programs for medical students. Much of his research has focused on evaluating the effects of nutrition, dietary supplementation, and exercise on various aspects of human health and disease. In addition to his research, Dr. Lewis has been an invited national and international lecturer at conferences and workshops and as a guest on television shows, where he discusses the findings of his research and provides guidance and recommendations as an expert in the field of health and wellness. He has over 180 peer-reviewed publications in scientific journals, where his work has first appeared in print, including some of the leading scientific journals, such as AIDS and Behavior, American Journal of Clinical Nutrition, American Journal of Public Health, Journal of the International AIDS Society, Journal of Strength and Conditioning Research, Nutrition and Cancer: An International Journal, Sports Medicine, Stroke, The Journal of Alternative and Complementary Medicine, and The Gerontologist. He has also mentored many different students, from undergraduates to post-doctoral trainees, in how to conduct clinical research and how to apply the principles of health promotion into daily practice.  His seminal publication in the Journal of Alzheimer's Disease from his Alzheimer's study not only spurred him to leave academics and pursue a science-based business career, but also enabled him to be selected for a widely-acclaimed TEDxMiami talk about how dietary supplementation can improve brain health. Dr. Lewis also embodies the model of health and wellness by eating a whole-food, plant-based diet for over 27 years, taking certain key dietary supplements, and through a rigorous, daily exercise training program. John has a passion for educating others about the value of nutrition, exercise, and health, and he will continue to study the application of clinical nutrition for the benefit of mankind. In this episode, we cover: - how he turned his love for learning into his career - what polysaccharides are and how they're beneficial for health - the benefits of polysaccharides on brain health - how taking care of your brain NOW sets you up for life ... and more! You can connect with him over on Instagram: @drlewisnutrition Or check out his website: drlewisnutrition.com You can learn more about me by following on IG @imperfectlypaigewellness or by checking out my blog, freebies, and offers on my website: https://imperfectlypaigewellness.com Please share with #PaigeTalksWellness to help get the word out about the show - and join the Imperfect Health Fam over on Facebook.

Dr. Perlmutter is a Board-Certified Neurologist and Fellow of the American College of Nutrition.  He received his M.D. degree from the University of Miami School of Medicine where he was awarded the Leonard G. Rowntree Research Award.  He has published extensively in peer-reviewed scientific journals and is a frequent lecturer at symposia sponsored by such medical institutions as Columbia University, Scripps Institute, New York University, and Harvard University.  He also serves as an Associate Professor at the University of Miami Miller School of Medicine. Dr. Perlmutter is the author of four New York Times bestselling books showing the connection between gut health and brain health, including Grain Brain, Brain Maker, The Grain Brain Cookbook, and his most recent book, The Grain Brain Whole Life Plan.  Dr. Perlmutter has also been interviewed on many nationally syndicated television programs including 20/20, Larry King Live, CNN, Fox News, Fox and Friends, The Today Show, Oprah, The Dr. Oz Show, and The CBS Early Show. He is also the recipient of numerous awards, including: the Linus Pauling Award for his innovative approaches to neurological disorders; the National Nutritional Foods Association Clinician of the Year award; the Humanitarian of the Year award from the American College of Nutrition; the Media Award from the American College of Nutrition; and the Healthy Living Award from The Invisible Disabilities Association. Related episodes: Ep 22 - Brigid Titgemeier on Functional Nutrition Ep 38 - Micronutrients and Quality Supplementation with Oliver Amdrup and Julius Heslet If you like this episode, please subscribe to Pursuing Health on iTunes and give it a rating or share your feedback on social media using the hashtag #PursuingHealth. I look forward to bringing you future episodes with inspiring individuals and ideas about health. Disclaimer: This podcast is for general information only, and does not provide medical advice.  I recommend that you seek assistance from your personal physician for any health conditions or concerns.

Have you heard of polysaccharides? This nutrient, found in aloe and rice bran can help with Alzheimer's and other chronic diseases! Give this episode a listen to learn more! On this week's episode, Jenn is joined by the Founder and President of Dr. Lewis Nutrition™, Dr. John Lewis. He has been studying polysaccharides for many years to help those struggling with chronic disease, Alzheimer's, concussion syndrome, and more. During the episode, Dr. Lewis talks about the importance and benefits of polysaccharides and what he has learned through years of research. Dr. Lewis talks about clinical trials with patients struggling with Alzheimer's and how aloe and polysaccharides helped change those patient's lives. This fascinating episode will leave you with a lot of great information to determine if aloe and rice bran are right for you.The Salad With a Side of Fries podcast is hosted by Jenn Trepeck, discussing wellness and weight loss for real life, clearing up the myths, misinformation, bad science & marketing surrounding our nutrition knowledge and the food industry. Let's dive into wellness and weight loss for real life, including drinking, eating out, and skipping the grocery store. IN THIS EPISODE: ●   [4:43] How Dr. Lewis went from being an all-natural bodybuilder to studying aloe.●   [9:00] What are polysaccharides, why are they important and where do they come from?●   [13:12] How did Dr. Lewis get the funding for his research projects?●   [16:10] What is the connection between polysaccharides and Alzheimer's? ●   [26:34] Is providing the missing nutrients that allow the body to function properly the tie with polysaccharides? ●   [28:01] What is happening in the research around TBI and concussion syndrome?●   [31:31] What is the difference between the polysaccharides in aloe and rice bran vs. other types of polysaccharides? ●   [33:42] How do consumers know that they are getting the right aloe? ●   [39:10] Dr. Lewis shares his final thoughts around polysaccharides. KEY TAKEAWAYS: ●   [12:04] It's difficult to get polysaccharides from food and this is where dietary supplements can come in and make a big addition to your daily routine. ●   [18:18] Genetic modification, all the herbicides, pesticides, etc. have really weakened the amount of nutrients in many common foods. ●   [30:46] Polysaccharides help to calm down inflammation and modulate or enhance immune function. QUOTES: [7:32] “She was a cancer patient who introduced me to the rice bran. It not only completely changed my career, it completely changed my life in the sense that it took me to a different level of having an appreciation and perspective on what mother nature provides to us, and then being able to utilize those particular nutrients or phytonutrients for health.” - Dr. John Lewis[17:44] “The body is intelligent enough to take a bunch of fructose or a bunch of glucose and mash all of those things together into polysaccharides, but our theory is that obviously is not the way or what our cells prefer. Otherwise, we wouldn't be ravaged with all these different chronic diseases today.” - Dr. John Lewis[23:45] “Very broadly speaking, we're talking about the ability for these polysaccharides to improve immune function, lower inflammation, improve adult stem cell production process, and then just generally improve overall quality of life.” - Dr. John Lewis[41:25] “For me, this is cradle-to-grave and all of the in between, there's no limitation on these polysaccharides in terms of how old you need to be, what your current health state is, if you have an existing health challenge or whatever, there's no limitation on that. There's been no documented problems with interacting with medications, in fact, they actually will help when you improve your nutrition status, they help your health status to be able to utilize things that you're maybe being treated for with disease.” - Dr John Lewis"Increasing our health status, giving our body the nutrients it's missing, creates the environment for health vs the environment for disease." - Jenn TrepeckRESOURCES:Become A Member of Salad with a Side of FriesJenn's Free Menu PlanA Salad With a Side of FriesA Salad With A Side Of Fries MerchA Salad With a Side of Fries InstagramGuest ResourcesDr. Lewis Nutrition's WebsiteDr. Lewis Nutrition's YouTubeDr. Lewis Nutrition's InstagramDr. Lewis Nutrition's FacebookDr. Lewis Nutrition's LinkedInBIODr, John Lewis is the Founder and President of Dr Lewis Nutrition™ and past full-time Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. He is also a Diplomat, Faculty Member, and Advisor of the Medical Wellness Association, and a lecturer for the Institute for Brain Potential. He has been the principal investigator of over 30 different studies in his research career. Much of his research has focused on evaluating the effects of nutrition, dietary supplementation, and exercise on various aspects of human health and disease.In addition to his research, he's an international lecturer at conferences and workshops and as a guest on television shows, with over 180 peer-reviewed publications in scientific journals, such as AIDS and Behavior, American Journal of Clinical Nutrition, American Journal of Public Health, Nutrition and Cancer: An International Journal, The Journal of Alternative and Complementary Medicine, and more. He embodies the model of health and wellness by eating a whole-food, plant-based diet for over 27 years, taking certain key dietary supplements, and through a rigorous, daily exercise training program. He has a passion for educating others about the value of nutrition, exercise, and health which brings him here to Salad with a Side of Fries.

In this episode of REJUVENAGING with Dr. Ron Kaiser, Dr. John Lewis joins Dr. Ron to delve into the integral role of nutrition, exercise, and dietary supplements in enhancing human health. With a rich background as an associate professor and a principal investigator of numerous studies at the University of Miami Miller School of Medicine, Dr. Lewis shares his journey from academia to launching a science-based business focused on nutritional supplements. His work primarily explores the impact of polysaccharides—complex sugars derived from plants like aloe vera and rice bran—on cognitive functions and overall health.Dr. Lewis explains his rigorous research, which led to significant findings in the improvement of cognitive functions in Alzheimer's patients through dietary supplementation, surpassing the outcomes from conventional medications. He passionately argues for the necessity of supplements in today's diet, especially those that cannot be sufficiently obtained from food alone, such as certain polysaccharides. Additionally, Dr. Lewis emphasizes a whole food, plant-based diet and discusses the transformative power of strength training alongside cardiovascular exercises to maintain physical and cognitive health.The conversation also covers the challenges of securing funding for research and the broader implications of his studies on Alzheimer's, highlighting the potential of polysaccharides in both preventing and addressing neurodegeneration. Dr. Lewis offers practical advice for incorporating effective nutritional strategies into daily life, advocating for a diet rich in diverse plant-based foods and critical supplements to optimize health at any age.Resourceshttps://www.drlewisnutrition.com https://www.facebook.com/people/Dr-Lewis-Nutrition/100085418756619/ https://www.instagram.com/drlewisnutrition/https://www.youtube.com/channel/UC5xvuUBaSGsAuSo4ZxhNR0Ahttps://dailybraincare.comDaily Brain Care on AmazonThe Complete Nutrition Guide to Cognitive Function For more info on Dr. Ron:https://www.drronkaiser.com/ Hosted on Acast. See acast.com/privacy for more information.