Podcasts about mollan

Idiopathic intracranial hypertension (IIH), a condition of increased intracranial pressure (ICP), causes debilitating headaches and, in some, visual loss. The visual defects are often in the periphery and not appreciated by the patient until advanced; therefore, monitoring visual function with serial examinations and visual fields is essential. In this episode, Kait Nevel, MD speaks with John J. Chen, MD, PhD, and Susan P. Mollan, MBChB, PhD, FRCOphth, authors of the article “Treatment and Monitoring of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Chen is a professor of ophthalmology and neurology at the Mayo Clinic in Rochester, Minnesota. Dr. Mollan is an honorary professor of metabolism and systems science in the department of neuro-ophthalmology at University Hospitals Birmingham in Birmingham, United Kingdom. Additional Resources Read the article: Treatment and Monitoring 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: @IUneurodocmom Guests: @chenmayo, @DrMollan Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Nevel: Hello, this is Dr Kate Nevel. Today, I'm interviewing Drs John Chen and Susan Mollan about their article on treatment and monitoring of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics. Drs Chen and Mollan, welcome to the podcast. And please, could you introduce yourselves to the audience? Dr Chen: Hello, everyone. I'm John Chen, one of the neuro-ophthalmologists at the Mayo Clinic. Thanks for having us here. Dr Mollan: Yeah, it's great to be with you here. I'm Susan Mollan. I'm a consultant neuro-ophthalmologist in Birmingham, England. Dr Nevel: Wonderful. So great to have you both here today, and our listeners. To start us off, talking about your article, can you share with us what you think is the most important takeaway from your article for the practicing neurologist out there? Dr Chen: Yeah, so our article talked about the treatment and monitoring of IIH. And I think one takeaway point is, IIH is becoming much more prevalent now that there's this worldwide obesity epidemic with obesity having- essentially being the largest risk factor for IIH other than female. It's really important to monitor vision because vision loss is often peripheral vision loss at first, which the patient may be completely unaware of. And so, it's important to pair up with an ophthalmologist so you can monitor the papilledema of the visual fields and make sure they don't get permanent vision loss. And in the article, we also talk about- there's been changes in the treatment of severe IIH, where traditionally, we used VP shunts; but there's been a trend toward using more venous sinus stenting in addition to the traditional surgeries. Dr Nevel: Great, thank you. I think probably most of our listeners or a lot of neurologists out there have a pretty good understanding of kind of the basics of the IIH. But can you kind of just go over a few key characteristics of IIH, and maybe some things that are less commonly known or things that are maybe just been kind of better understood over the past decade, perhaps? Dr Mollan: Yes, certainly. I think, as Dr Chen said, it's because this condition is becoming more prevalent, people recognize it. I think it's- we like to go back to the diagnostic criteria so that we're making a very accurate diagnosis. So, the patients may come in to the emergency room with, say, papilledema that's been identified elsewhere or crashing headaches. And it's important to go through that sort of diagnostic pathway, taking a blood pressure, taking a full blood count to make sure the patient is anemic, and then moving forward with that confirmation of papilledema into urgent neuroimaging, whether it's CT or MRI, but including venography to exclude a venous sinus thrombosis. And then if you have no structural lesion that's causing the raised ICP, it's moving forward with your lumbar puncture and carefully checking those pressures. But the patients may not only have crashing headache, they often have pulsatile tinnitus and neck pain. I think some of the features that we're now recognizing is the systemic metabolic effects that are unique to IIH. And so, there's an increased risk of cardiometabolic disease that's over and above what is conferred by obesity. Also, our patients have a sort of maternal health burden where they get impaired fertility, gestational diabetes and preeclampsia. And there's also an associated mental health burden, amongst other things. So we're really starting to understand the spectrum of the disease a bit more. Dr Nevel: Yeah, thank you for that. And that really struck me in your article, how important it is to be aware of those things so that we're making sure that we're managing our whole patient and connecting them with the appropriate providers for some of those other issues that may be associated. For the practicing neurologist out there without all the neuro-ophthalmology equipment, if you will, what should our bedside exam focus on to help us get maybe an early but accurate picture of the patient's visual function when we suspect IIH to be at play, perhaps before they can get in with the neuro-ophthalmologist? Dr Chen: Yeah, I think at the bedside you can still check visual acuity and confrontational visual fields, you know, with finger counting. Of course, you have to know that those are, kind of, crude kind of ways of screening. With papilledema, oftentimes the visual acuity is intact. And the confrontational visual fields aren't as sensitive as automated perimetry. Another important thing will be to do your direct ophthalmoscope and look at the amount of papilledema. If it's grade one or two papilledema on the more mild side, it's actually not vision threatening. It's the higher degrees of papilledema that can cause rapid vision loss. And so, if you look in and you see grade one papilledema, obviously you need to do the full workup, the MRI, MRV, lumbar puncture. But in terms of rapidly getting to an ophthalmologist to screen for vision loss, it's not going to be as important because you're not going to have vision loss at that low grade. If you look in and you see this rip-roaring papilledema, grade five papilledema, that patient is going to be at very severe risk of vision loss. So, I think that exam, looking at the optic nerve can be very helpful. And of course, talking to the patient about symptoms; is there decreased vision Is there double vision from a sixth nerve palsy? Are there transient visual obscurations which would indicate at least a higher degree of papilledema? That'd be helpful as well. Dr Nevel: Great, thank you. And when the patient does get in with a neuro-ophthalmologist, you talk in your article and, of course, in clinical practice, how OCT testing is important to monitor in this condition. Can you provide for the listeners the definition of OCT and how it plays a role in monitoring patients with IIH? Dr Mollan: Sure. So, OCT is short for optical coherence tomography imaging, and really the eye has been at the forefront of OCT alone. Our sort of cardiology colleagues are catching up on the imaging of blood vessels. But what it allows us to do is give us really good cross-sectional, anatomical-level changes that we can see both in the retina and also at the optic nerve head. And it gives us some really good measurements. It's not so good at sort of saying, is this definitely papilledema or not? That sort of lower end of disc elevation. But it is very good at ruling out what we call the pseudopapilledema. So, things like drusens or these other little masses we find underneath the optic nerve head. But in terms of monitoring, because we can longitudinally take these images and the reproducibility is pretty good at the optic nerve head, it allows us to see whether there's direct changes: either the papilledema getting worse or the papilledema getting better at the optic nerve head. It also gives us some indication of what's going on in the ganglion cell layer complex. And that can be helpful when we're thinking about sort of looking at structure versus function. So, ophthalmologists in general, we love OCT; and we spend much more time nowadays looking at the OCT than we really do the back of the eye. And it's just become critical for patients with papilledema to be able to be very accurate from visit to visit to see what's changing. Dr Nevel: How do you determine how frequently somebody needs to see the neuro-ophthalmologist with IIH and how often they need that OCT evaluation? Dr Chen: Once the diagnosis of IIH is made, how often they need to be seen and how frequent they need to be seen depends on the degree of papilledema. And again, OCT is really nice. You can quantify it and then different providers can actually use the same OCT numbers, which is super helpful. But again, if it's grade three papilledema or higher, or article thickness of 200 or higher, I tend to follow them a little bit more closely, trying to treat them more aggressively. Try to get the papilledema down into a safer zone. If it's grade one or two papilledema, we see them less frequently. So, my first visit might be three months out. They come with grade five papilledema, I'm seeing them within a few days to make sure that's papilledema's come down quickly because we're trying to decide, are they going to need surgery or not? Dr Nevel: Yeah, great. And that's a nice segue into talking a little bit about how we treat patients with IIH after the diagnosis is confirmed. And I'd like to just point out you have a very lovely figure in your article---Figure 5-6,---that I'd like to direct our listeners to read your article and check out that figure, which is kind of an algorithm on how we think about the various treatment options for patients who have IIH, which seems to rely a lot on the degree of presence of papilledema and the presence of vision disturbance. Could you maybe walk us through a little bit about how you think about the different treatment options for patients with IIH and when more urgent surgical intervention might be indicated? Dr Mollan: Yeah, sure. We always find it quite hard in any medical specialty to write these kind of flow diagrams because it's really an individual we're looking at. But these are kind of what we'd say is “broad brushstrokes” into those patients that we worry about, sort of, red disease in those patients, more amber disease. Now obviously, even those patients that may not have severe papilledema, they may have crashing headaches. So, they may be an urgent referral themselves because of that. And so, it's nice to try and work out which end of the spectrum you're working with. If we think of the papilledema, Dr Chen's already laid out the sort of lower end of the prison's scale---our grades one, our grades two---that we're less anxious about. And those patients, we would definitely be having discussions about medical management, which includes acetazolamide therapy; but also thinking about weight management. And it may well be that we talk a little bit further about weight management, but I think it's helpful to sort of coach those conversations after you've made a definite diagnosis. And then laying out the risk that's caused, potentially, the IIH in an individual. And then having a sort of open conversation with them about what changes they can have in their lifestyle alongside thinking about medical therapy. There's some patients with very low levels of papilledema that we decide not to put on medicines initially. As patients progress up that papilledema grade, we're definitely thinking about medical therapy. And our first line from the IIH treatment trial would be using acetazolamide, but we need to be thinking about using appropriate dosing. So, a lot of the patients that I see can be sent to me with very low doses that may be inappropriate for that person. In the IIHTT they used up to four grams daily in a divided dose. And you do need to counsel your patients when you're putting them on acetazolamide because of the side effects. You've got quite a nice table in this article about the side effects. I think if you get the patient on board, that they understand that they will experience side effects, that is helpful because they will expect it, and then possibly tolerate it a bit better. Moving through to that area where we're more anxious, that visual-threatening papilledema. As Dr Chen said, it's sort of like you look in and it's sort of “blood and thunder” in there. And you need to be getting on and encouraging the ophthalmologist to get a formal assessment of the visual field. It's very difficult to determine exactly the level at which- and we talk about the mean deviation in a lot of our research studies. But in general, it's a combination of things: the patient's journey to get to you, their symptoms, what's going on with the visual field, but what's also happening at the OCT. So, we look in and we see that fluid is seeping towards the fovea. We get very anxious, and those patients may not even have enough time for a rapid escalation of acetazolamide. It may well be at the first presentation, which we would term, like, fulminant; that we'd be thinking about surgical intervention. And I think before I stop, the other thing to say is, the surgical landscape is really changing. So, we're having some good studies coming out in terms of stenting. And so, there is a sort of bracket where it may well be that we are thinking about neuroradiological intervention in an earlier case. They may not quite be at that visual-threatening stage, but they may be resistant to medical treatments. Dr Nevel: Thank you for that. What do you think is a potential pitfall or a mistake to avoid, if you will, in the management of patients with IIH? Dr Chen: I think it's- in terms of pitfalls, I think the potential pitfalls I've seen are essentially patients where we don't necessarily create a good patient physician relationship. Where they don't have buy-ins on the treatment, they don't have buy-ins to come back, and they're lost to follow-up. And these patients can be dangerous, because they could have vision threatening papilledema and if not getting the appropriate treatment---and if they're not monitoring the vision---this can lead to poor outcomes. So, I've definitely seen that happen. As Dr Mollan said, you really have to tell them about the side effects from the medications. If you just take acetazolamide, letting them know the paresthesias and the changes in taste and some of these other side effects, they're going to immediately stop the medication. Again, and these medications do work, proven in the IIH treatment trial. So again, I think that patient-physician relationship is very important to make sure they have appropriate follow up. Dr Nevel: The topic of weight loss in this patient population can be tricky, and I know I talked with Susie in a prior interview about how to approach this topic with our patients in a sensitive and compassionate manner. Once this topic is broached, I find many patients are looking for advice on strategies for weight loss, or potentially medications or other interventions. How do you prioritize or think about the different weight loss strategies or treatments with your patients, and how do you think about the way that you recommend these different treatments or not? Dr Mollan: Yeah. I think that's a really great question because we sort of stray here into a specialty that we have not been trained in. One thing I definitely ask my patients: if they've been on a weight loss journey before, and what's worked for them and what's not worked for them. And within our different healthcare systems, we have access to different tiers of weight management approaches. But for the person sitting in front of me, that possibly there may be a long journey to access more professional care, it's about understanding. iIs there things that are free, such as, we have some apps in the National Health Service which are weight management applications where they can actually just start putting in their calories, their daily calorie intake. And those apps can be quite helpful and guiding in terms of targeting areas, but also informing the patient of what types of foods to avoid in their diet and what types of foods to include in their diet. And with some of the programs that are completely complementary, they also sometimes add on things about exercise. But I think it is a really difficult thing to manage as, say, an ophthalmologist or a neurologist, mainly because it's not our area of expertise. And I think we've all got to find, in our local hospitals and healthcare systems, those pathways where the patients may be able to access nutritional support, and sort of behavioral lifestyle therapy support, all the way through to the new medications for weight loss; and also for some people, bariatric surgery pathways. It's a tricky topic. Dr Nevel: So how should we counsel our patients about what to expect in the future in terms of visual outcomes? Dr Chen: I think a lot of that depends on the degree of papilledema when they present. If a patient comes in with grade five papilledema, that fulminant IIH that Dr Mollan had mentioned, these patients can have very severe vision loss. And even if we treat them very aggressively with high-dose medications and urgent surgical interventions, sometimes they can have permanent vision loss. And so, we counsel them that, you know, there's a strong chance that they're going to have a good amount of vision loss. But some patients, we're very surprised and we get a lot of vision back. So, we kind of set expectations, but we're cautiously optimistic that we can get vision back. If a patient presents with more mild papilledema like grade one or two papilledema, they're most likely not going to have any permanent vision loss as long as we're treating them, we're monitoring their vision, they're coming to their follow-ups. They tend to do very well from a vision perspective. Dr Nevel: That's great, thank you. And you know, ties into what you said earlier about really making sure that, you know, we create good- as with any patient, but good physician-patient relationships so that they, you know, trust us and they come to follow up so we can really monitor their vision appropriately. What do you think is going on in research in this area that's exciting? What do you think one of the next breakthroughs or thing that we need to understand the most about treatment and monitoring of IIH? Dr Chen: I think surgically, venous sinus stenting is going to probably take over the bulk of surgeries. We still need that randomized clinical trial, but we have some amazing outcomes with venous sinus stenting. And there's many efforts on randomized clinical trials for venous sinus stenting. So we'll have those results soon. From a medical standpoint, Dr Mollan can actually say, actually, more about this. Dr Mollan: I completely agree. The GLP-1 receptor agonists, the twofold prong approach: one is the weight loss where these patients, you know, have significant weight loss to put their disease into remission; and the other side of it is whether certain GLP-1s have the ability to reduce intracranial pressure. So, a phase 2 study that we undertook here in Birmingham did show that we were able to reduce intracranial pressure, but we don't think it's a class effect. So, I think the sort of big breakthrough will be looking at novel therapies like xenotide and other drugs that, say, work on the proximal kidney tubule. Are they able to reduce intracranial pressure directly? And I think we are on the cusp of a real breakthrough for this disease. Dr Nevel: Great. Thank you so much for chatting with me today. And I really learned a lot, appreciated the opportunity. I hope our listeners learned something today, too. So again, today I've been interviewing Drs John Chen and Susan Mollan about their article on treatment and monitoring 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 us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

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

For en stund siden fikk jeg en henvendelse fra en lytter: Vedkommende hadde ingen særlig erfaring med teltlivet, men planla et månedslangt teltopphold i marka neste vår. En slik plan avstedkommer gjerne en rekke spørsmål – spesielt rundt utstyr. Det slo meg at dette var et fint tema for en episode. Dermed tok jeg kontakt med Christer Værdahl og Charlotte Mollan som gjerne delte sine synspunkter rundt saken. Resultatet ble en prat jeg tror mange kan ha nytte av, enten du skal på din første telttur eller om du har mer erfaring.Bli med i turlaget på PatreonBesøk min kommersielle samarbeidspartner Barents Outdoor ASKjøp episode 200 på LPDu finner dagens gjester på Instagram som @charl8mo og @friogvill Hosted on Acast. See acast.com/privacy for more information.

Series 5 new episode is out now! Our host, leading Headache Specialist Dr Katy Munro discusses Idiopathic intracranial hypertension (IIH) with Professor Alex Sinclair and Dr Susan Mollan. Idiopathic intracranial hypertension (IIH), also known as benign intracranial hypertension or Pseudotumor cerebri, is a rare condition with an unknown cause or causes. The condition is associated with raised fluid pressure around the brain. Expert guests: Professor Sinclair is a Professor of Neurology at the University of Birmingham, and Head of the Metabolic Neurology Research Group. She is an international figure in translational research in Idiopathic Intracranial Hypertension (IIH), headache and traumatic brain injury. Dr Susan Mollan, is an Honorary Professor at the University of Birmingham and a Consultant Neuro-ophthalmologist at University Hospitals Birmingham. She is an International Senior Examiner for the Royal College of Ophthalmologists. If you have any questions/comments or any topics you would like us to cover in our future episodes email: info@nationalmigrainecentre.org.uk.   WE ARE A CHARITY Please help us keep going in the following ways: Please donate to help us continue to release new episodes: https://www.justgiving.com/campaign/headsup    Links mentioned in the episode 1. https://www.iih.org.uk/ 2. https://www.nhs.uk/conditions/intracranial-hypertension/  

Jim Sharpe talks to Kari Mollan about what people can expect at airports over the next few weeks.   See omnystudio.com/listener for privacy information.

In this week's episode we sit down with Dennis Mollan, founder of Protone Pedals. He and I get into what it's to run a boutique pedal company, what it's like working with “famous” artists, and the strange story of how we met! protonepedals.com

Serdar Tuncer ile “Biri Bir Gün” kendine has tarzıyla kaldığı yerden devam ediyor. Bu bölümde Serdar Tuncer "Bir Ok Attım Kebap Oldu" hikayesini anlatıyor. Her hafta birbirinden farklı hikayelerle izleyicilerini kıssadan hisse almaya davet eden Serdar Tuncer bu hafta "Bir Ok Attım Kebap Oldu" hikayesini anlatıyor. Serdar Tuncer'in Biri Bir Gün'de anlattığı hikaye; Hikaye bu ya, yıllarca çocuğu olmayan bir şark sultanının nihayetinde bir oğlu olur. Fakat çocuk şehzadelik çağına gelmesine rağmen her ne kadar eğitim verilirse verilsin bir türlü devlet yönetimi ile ilgilenmez. Üstüne üstlük her defasında yeni konular bulur, olur olmaz yerlerde izahı oldukça güç yalanlar uydururmuş. Yalanlarının itibarı da giderek azalmaya başlarmış. Sonunda oğlunun bu durumuna çok üzülen ve kahırlanan sultan, buna bir hal çaresi bulmak için ülkenin en ünlü mollasını huzuruna çağırır. Mollaya, tehditvari bir şekilde; oğluna gereken eğitimi vermesi ve en azından söylediği yalanları akla uygun bir hale getirip, oğlunun halk nezdinde gülünç duruma düşmesini önlemek için kendisini eğitmesini ister. Bunun için kendisine iki yıl süre verir; aksi halde mollanın başını vuracağını söyler. Aradan geçen iki yılın ardından sultan, tüm halkı bir meydana toplar ve artık eğitiminden kuşku duymadığı oğlunu onlara takdim eder. Amacı şehzadenin iki yıl içinde kat ettiği mesafeyi ahalisine göstermek. Herkesin hazır bulunduğu bu ortamda şehzade: “Bir ok attım kebap oldu” der. Topluluk; “Amma da attın!” demeye başlayınca, molla hemen imdada yetişir: “Niye atıyormuş ki? Birlikte ava çıkmıştık, şehzademiz havada uçan kuşa okuyla nişan aldı, attı vurdu. Ok kuşla birlikte yere düşerken kayaya çarptı. Çeliğin kayaya çarpması ile sürtünmeden ateş çıktı. Vurulan kuş da bu ateşe düştü, böylelikle de pişmiş oldu ve de nihayetinde kebap oldu.” Topluluk bu izah karşısında pes etmiş ve şehzadeyi dinlemeye devam etmiş. Mollanın bu harika izahı şehzadeyi aşka getirmiş ve daha büyük bir bomba patlatmış: “Bir ok attım göl oldu.” Ahali bu laftan da bir şey anlamamış ve yine molla ortaya atılmış ve de bir açıklama daha yapmış: “Ey ahali! Şehzademiz veciz konuşmaya devam ediyor, dilerseniz ben açıklayayım. Bir gün kırlarda gezinirken, bir de ne görelim! Büyük bir kaya parçası gölün yatağını kapatmış, göl kurumak üzere. Şehzademiz hemen bir ok attı ve kayayı tam ortasından vurup parçaladı ve göl yine suyla doldu.” Bu açıklamanın ardından halk sevinç içinde ve yüzler tebessümlü, şehzade ise gurur içinde. Bir müddet sonra alkışlar biter ve şehzade yine söze başlar: “Bir ok attım, aşure oldu.” Ahali yine hiç vakit kaybetmeden gözlerini mollaya çevirir. Ancak molla bakmış bu söz hiç de içinden çıkılır bir söz değil. Ve bu sözün izah edilecek bir yönü de yok. Yerinden doğrulur ve Sultan'ın huzuruna varıp el etek öper ve boynunu bükerek: “Hünkârım, işte kılıç, işte kelle. Haydi kebap meselesini hallettik, sel meselesini de hallettik. Bu aşure de nereden çıktı. Suyu bulsak şeker lazım, şekeri bulsak buğday lazım… Onu da bulsak nohut vs. lazım bunların hepsini ben nasıl bir araya getireyim. Boynum kıldan ince, lakin ben de öğrenmek istiyorum, şu şehzade parçasına bir sorun bakalım; bir ok atar da nasıl aşure olur diye?” Gelin, Beraber Yürüyelim...

Welp......Dennis Mollan of Pro Tone Pedals swears a lot,  chats up branding and more.  And honestly... it is all about knobs.  http://protonepedals.com/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/40ish/support

Varför är det är så viktigt att läsa med sitt barn? Vilka böcker funkar bäst? Barnhälsovårdspsykolog Malin Bergström samtalar med bibliotekarien Therese Flodqvist om barn och böcker. Lyssna också på: BVCpodden 101: Corona, små barn och läsglädje: Här är bästa boktipsen (https://bvcpodden.fireside.fm/101) Här är Thereses boktips: 0-2 år Toto Tittut (Emma Virke) Imse vimse spindel (Catarina Kruusval) Kika genom hålet! Färger Räkna med hajar (Sarah Sheppard) Gustav och snåla glasstanten (Peter Cohen, Olof Landström) Ticke tack! (Lennart Hellsing, Lena Sjöberg) Mollan och mormor (Lena Andersson) Titta Hamlet (Barbro Lindgren, Anna Höglund) Allt det här (Ulf Stark, Linda Bondestam) Död (Stina Wirsén) 2-3 år Tesslas mamma vill inte! (Åsa Mendel-Hartvig, Caroline Röstlund) Tesslas pappa vill inte! (Åsa Mendel-Hartvig, Caroline Röstlund) Ellens boll (Catarina Kruusval) 3-5 år Hej och hå kläder på (Stina Kjellgren, Lotta Geffenblad) Ester Arg och Daisy Galej (Anna Platt, Maria Källström) Det är en gris på dagis (Johanna Thydell, Charlotte Ramel) Alla tre inne på förskolan Ärtan (Maria Nilsson Thore) Nämen Benny (Barbro Lindgren, Olof Landström) Bodils kalas (Lene Due Jensen) Sabelles röda klänning (Marina Michaelido-Kadi, Daniela Stamatiadi) Adjö, herr Muffin (Ulf Nilsson, Anna-Clara Tidholm) Ebbe och ägget (Petra Nilsson, Linn Gustafsson) Malla handlar (Eva Eriksson) Lill-Gruffalon (Julia Donaldson, Axel Scheffler, översättning Lennart Hellsing) Det var det fräckaste! (Werner Holzwarth, Wolf Erlbruch) Special Guest: Therese Flodqvist.

«Mener du det? Var det virkelig sånn?», det var iallefall reaksjonen min til mange av historiene som Astrid Mollan (69) hadde på lager. Bare se for deg følelsen av å stå foran tre gråhåra, gamle menn, og spørre om lov til å ta abort (28:27). Bare tanken av at det ikke er ditt valg er jo rimelig absurd. For i denne episoden snakker vi mye om kvinners rolle i samfunnet, og hvordan det har vært opp gjennom tidene. I dag ser hun på iPaden som det artigste leiketøyet hun har hatt, men som student i Trondheim måtte hun gå 30-40 minutter inn til byen for å kunne ringe familien hjemme i Kristiansund. En stooor takk til Ambolt Audio som hjalp til med lydmiksen her, og ikke minst til alle dere som støtter meg på Patreon, blant annet Linn og Kine, dere gjorde denne turen mulig.

In collaboration with many different specialists, professions and patient representatives, Mollan et al (2018) have developed the first ever guidelines for the investigation and management of idiopathic intracranial hypertension (IIH). Senior author, Dr Alexandra Sinclair (University of Birmingham) discusses these with the JNNP podcast editor, Elizabeth Highton. Read the full guidelines here: https://jnnp.bmj.com/content/89/10/1088 Access the Practical Neurology infographic summary here: https://pn.bmj.com/content/early/2018/08/28/practneurol-2018-002009

Our fourth episode lends itself well to our previous Questionable Moment, "Where is the Pedal Industry heading?" To answer that question and much more, we are joined by Dennis Mollan of Pro Tone Pedals. Since starting his company about 15 years ago, he has carved a path in a segment of the pedal market that may have seemed obscure at one time. That is no longer the case. Plus, as usual, we have a few other things up our sleeve. Highlights of the podcast include: 00:40 Setting the Stage 02:45 Questionable Moments 05:00 Dennis Mollan Interview 33:55 The Value Shot Thanks for listening and we look forward to hearing from you!

"I am here for one purpose and it is to uncover and heal all the ways that I am blocking the love that is always here. My work is about helping people begin to love themselves by realizing their magnificence. You can't begin to love God if you don't first love yourself. As I love myself more, I have more capacity to love others and God." - Renee Mollan-Masters Renée Mollan-Masters, MA, teaches people that YOU ARE SMARTER THAN YOU THINK. Her internationally renowned book, teaching program and new online Journey helps people discover their best way to learn and how to maximize it. Renee's own journey began when she was working on producing a parenting show for PBS and encountered the research done by Harvard's Dr. Howard Gardner and his book Frames of Mind. Everything that she had ever learned or experienced about learning and memory came together in that moment. Renée earned her Master's Degree in Speech Pathology from California State University, Fullerton. She has always been gifted at applying research and was acknowledged for such by the faculty when she was awarded Outstanding Senior Clinician in her senior year. While serving as a Speech Pathologist for the Fountain Valley School District, she developed a reading perception lab, which became a model program for the state of California. Visit www.youaresmarterthanyouthink.com Get the OFF TO WORK CD by Sister Jenna.  Like America Meditating & follow us on Twitter  

Renée Mollan-Masters, Author/Developer of You Are Smarter Than You Think.......... Could it be that we all learn in slightly different ways, and for each of us to tap into our full potential, it might mean to simply find the method of learning that is best for you? Renee will show us the way. Website: www.youaresmarterthanyouthink.com LinkedIn: yastyt@mind.net Twitter: yastyt@mind.net Facebook: You Are Smarter Than You Think

Francis Jackson is an attorney who specializes in disability law for those seeking veterans disability benefits and social security disability benefits.  A founding partner of Jackson & MacNichol. He most recently appeared as a guest of Ben Glass on the “Consumer Advocate” show discussing benefits for veterans and social security disability benefits and how his practice allows him to make a difference in the lives of people facing disabilities.  He has also been quoted in USA Today and is listed in Cambridge Who's Who.  Mr. Jackson was  honored by the National Academy of Best Selling Authors with a "Quilly" award for his contribution as a joint author to the Amazon best selling book, "Protect and Defend" Renée Mollan-Masters author of the book " You Are Smarter Than You Think" John Lewis Mealer an Arizona born and raised life-long tinkerer and mechanic turned engineer and developer. After spending 25 years researching Arizona for clean industrial development and having party-politics shut him down time after time, John opted to run for Governor and repair what the parties have destroyed.  John spent years in the construction industry, implementing the use of kit homes made from alternative building materials such as hemp, hay, e-crete and other cost effective solutions for homeowners on a budget. His passion for racing, engineering, and early American automobiles influenced the Mealer Automobile, a prototype 25 years in the making. John holds multiple patents in conjunction with his design, including a non-fossil fuel powered regenerative energy system which has ultimately become the power source for the flagship Mealer Automobile

You may never have heard of Pro Tone pedals, but they're making noise in both the rock and metal worlds. Behind every great guitar is a set of pedals and […] The post Podcast Episode 4: Dennis Mollan of Pro Tone Pedals appeared first on CreativeLive Blog.

Kvällens gäst är Anna Rydell. Vi pratar bl.a. om Duran och Mollan, nyårsrevy och Revy-SM. www.duranomollan.se www.rydellarna.se

Kvällens gäst är Anna Rydell. Vi pratar bl.a. om Duran och Mollan, nyårsrevy och Revy-SM. www.duranomollan.se www.rydellarna.se

Hot and fresh minimal house set.Enjoy! Oto Kami Original quality here : http://rapidshare.com/files/375475040/My_House_is_your_house.mp3 souncloud.com/otokami Tracklist: 1 D - 3rd_Eye_Original_Mix masomenos 2 Blow It - Original Mix Lemos 3 la_mezcla_original_mix michel_cleis 4 Blu (Original Mix) Pirupa 5 Trump And Horns Mollan 6 Speaking Inside (Original Mix) Alessandro Sensini 7 Chano Matthias Tanzmann 8 Dont Stop (Original Mix) Ilario Alicante 9 Alma De Dios (Loko Remix) Aki Bergen 10 Burujava(Original_Vibes_Mix) Stefano Noferini

In this podcast, Pipes and PT chat with Dennis Mollan about inspiration, rock stars and designing killer pedals priced for mere mortals.  Also, we get old-school with our GOW, ponder nonguitarists,  and announce a new contest!