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Unruptured intracranial aneurysms and arteriovenous malformations are frequently discovered incidentally on neuroimaging, presenting complex decisions around monitoring, referral, and treatment. This episode highlights key risk factors for rupture, the role of imaging in evaluation, and practical approaches to triage and management, including when specialist intervention is warranted. In this episode, Gordon Smith, MD, FAAN, speaks with Edgar Samaniego, MD, FAAN, authors of the article "Unruptured Intracranial Aneurysms and Arteriovenous Malformations" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Smith is a Continuum® Audio interviewer and a professor and chair of neurology at Kenneth and Dianne Wright Distinguished Chair in Clinical and Translational Research at Virginia Commonwealth University in Richmond, Virginia. Dr. Samaniego is a professor of neurology, neurosurgery, and radiology and the director of the vascular neurology fellowship at the University of Iowa in Iowa City, Iowa. Additional Resources Read the article: Unruptured Intracranial Aneurysms and Arteriovenous Malformations Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @GordonSmithMD Guest: @esamaniego Full episode transcript available here Dr Smith: Have you ever ordered an MRI of the brain and found a coincidental unruptured aneurysm or perhaps an arteriovenous malformation? If so, are you up to speed on how to manage this common situation, how to monitor, when to refer, and how to counsel your patients? If your answers to these two questions are yes and or no, then please keep listening.  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 Smith: This is Dr. Gordon Smith. Today, I'm interviewing Dr. Edgar Samaniego about his article on unruptured intracranial aneurysms and arteriovenous malformations. This article appears in the June two thousand twenty-six Continuum issue on cerebrovascular disease. Edgar, welcome to the podcast, and maybe you can briefly introduce yourself to our listeners.  Dr Samaniego: Yeah. Thank you, Gordon. So, I'm an interventional neurologist. I'm practicing at the University of Iowa. I've been in Iowa for the last ten years. I'm originally from Ecuador. Did my residency in Wisconsin, and then I went to Stanford for neuro critical care and stroke. And then I did my neurointerventional fellowship at the Baptist Cardiac and Vascular Institute in Miami.  Dr Smith: You're a triple threat in the world of vascular and critical care, which I want to get to later. But your article's really great. I'll admit one of the first things I do when I read an article for Continuum Audio is I see how long it is. I saw yours was as long as the rest, and I was a little surprised because this sounded like a simple topic. But having read it, it's anything but simple. This is really important and complex stuff. I wonder if maybe you can orient our listeners to the importance of this. We frequently find unruptured aneurysms or vascular malformations on brain imaging that we order for something else. I mean, how common is that, and why do you think our listeners need to be particularly attentive to our conversation today?  Dr Samaniego: It's pretty frequent that we see patients with unruptured brain aneurysms. A lot of times, you know, we do imaging like CT angiograms, or magnetic, resonance angiography. Patients come to the ER with headaches, and we find an unruptured aneurysm. And you know, the question always comes, "What should we do with this aneurysm that we found?" We know that a lot of these aneurysms will not rupture, but the caveat is that when they rupture, like fifty percent of these patients may die or have bad outcomes. So, it's always a puzzling question, you know. What should we do with the aneurysm?  Dr Smith: Well, thanks, Edgar. I mean, this is certainly something that I come across. I'm glad to hear that other people struggle with this as well. What actually is the prevalence of aneurysms in the general population? How common is this?  Dr Samaniego: It's more common than what we think, you know. The, the estimates talk about like one in every fifty people have a brain aneurysm, and about every eighteen minutes an aneurysm will rupture. In the United States, there's approximately thirty thousand ruptures per year. So, there's a significant number of, of patients affected by brain aneurysms. And, and the key thing is that affects usually younger patients who are in the most productive years of their lives. So that's why it shouldn't be ignored, and once we find an aneurysm, we have to have all the information for triaging and deciding on treatment of these aneurysms.  Dr Smith: Well, it's a great way to begin our conversation. I mean, this is not a rare problem. It's a common problem, and there's actually a really great section of the article I'll refer people to about medical malpractice and the importance of recognizing and dealing with this thoughtfully. It's an empowering section, not a scary one, but this is important for our listeners to know about. Pretty high-stakes stuff. Maybe you can orient listeners like me or maybe simple neuromuscular people. What different types of aneurysms are there?  Dr Samaniego: That's the interesting question because there's multiple types of aneurysms, and there is a whole spectrum of aneurysm. When we say aneurysm, you can be talking about a fusiform versus a saccular aneurysm. We tend to classify them based on shape, also location. But the two main classifications for brain aneurysms will be saccular, which, you know, has a sac kind of morphology shape, and then you have the fusiform aneurysms. Those are the main morphological classifications. Then on top of that, you have two other subtypes that you see quite often. The one that we see is mycotic aneurysms that is like a misnomer because it's not a fungal aneurysm. It's just an infectious aneurysm that most of the time we see on the setting of endocarditis. These behave a little bit different than the typical saccular or fusiform aneurysms. And then also you have other more rare types of aneurysms like blister aneurysms that are sometimes located in the anterior wall of the carotid artery. So, you know, within this spectrum, we have those main aneurysms. The typical aneurysms, which can be fusiform or saccular, and also the more atypical, which can be mycotic and also blister-like aneurysms.  Dr Smith: I wonder if you might comment a little bit on the relevance of the type of aneurysm, fusiform, saccular, blister, and then location on rupture risk or prognosis.You have a really great figure about anatomic classification in the article actually that I encourage everyone to check out when they hopefully read it. But what do these characteristics imply for risk?  Dr Samaniego: Yeah. This is very complex question because, you know, entails different characteristics of aneurysms such as shape, the location, morphology. So, we know that some locations, for example, the anterior communicating artery has a high risk of rupturing as opposed to patients such as the part of ophthalmic aneurysm, which are usually located at the origin of the ophthalmic artery in the internal carotid artery. So, by risk of rupturing, the highest risk is usually the anterior communicating. Then you have posterior communicating artery aneurysms, which are usually located in the internal carotid artery, but because of their proximity to the origin of the posterior communicating artery, they're called posterior communicating artery aneurysms. Then you have the posterior circulation aneurysms on top of risk of rupturing is the top of the basilar artery location. Those three are the highest risk for rupturing: ACOM, PCOM, and top of the basilar. In terms of morphology, I always tell my patients, you know, if it's like a nice-looking aneurysm that has this rounded shape is a benign morphology. If you have the aneurysm that's having these Mickey Mouse ears that has these blebs or daughter sacs, those are aneurysms that usually scare us because those are the ones that usually rupture. So that's another criteria, morphology. And then the other criteria would be size. There is this magnificent study called ISUIA, which was published several years ago, and basically what it demonstrated was that aneurysms that are seven millimeters or larger are more likely to rupture versus smaller aneurysms. So those are the three criteria that I'm looking into when talking to patients about morphology, location, size, and the, the shape or morphology of the aneurysm.  Dr Smith: So, let's say a general neurologist or comprehensive neurologist practicing in a community setting in a rural area orders a, let's just say a CT or CTA for a patient with a TIA and finds what looks like an aneurysm. What's the next step in terms of imaging? What's the best next step? I mean, there are a bunch of different imaging modalities. Do you get an MRA? Is it time-of-flight, contrasted? You know, when do you get a DSA and so forth?  Dr Samaniego: Yeah. The first thing to do is to better characterize the aneurysm. Order of more accurate imaging that we can obtain without being invasive with a diagnostic cerebral angiogram. The rest will be a magnetic resonance angiography with contrast that, you know, gives you really good detailed information about the aneurysm. Similar in terms of quality and precision will be a CT angiography. The caveat there is with CT angiography is that, you know, you use radiation, and the patient has to get iodine. And then under those two, you will have a time-of-flight magnetic resonance angiography, which doesn't use any contrast, but then you lose a little bit of quality in terms of the imaging and some morphological features you might miss. So usually what we do in my practice, I don't wanna do a diagnostic cerebral angiogram, and somebody has to refer an unruptured aneurysm. I try to do CT angiogram as a baseline, see how the aneurysm looks, and then for follow-up, I usually do magnetic resonance an- angiograms with with contrast. If there is a concern that the aneurysm has some dangerous features like it's irregular in shape, it's, it's larger, it's in one of these high-risk locations, might be better just to refer the, the patient to a specialist for a diagnostic cerebral angiography.  Dr Smith: So, you know, there are these scales that you talk about in the article. There's phases in the UIATS that are used to predict rupture risk and guide decision-making. Are these scales that general neurologists or non-vascular neurologists can use to guide care? I'm thinking of like Chad-Baskin, ASBAD, which, you know, all our residents know about. Should we all be familiar with these scores?  Dr Samaniego: I think they're very helpful in the sense that it will give us some guidance. Some of the characteristics of the scale might be up- outdated. For example, like ancestry. Although it's been described more in Japanese and Finnish populations, and North American, not as much as these two other populations. We do see a lot of aneurysms in people from North America and other backgrounds. For example, one of the biggest critiques for the phases is that doesn't take into account smoking history. Smoking that we know is a risk factor. And the other critiques for phases is that, for example, if you are older than seventy years old, you will score one point, which will increase your risk of aneurysm rupturing. Having said that, we do see like tons of aneurysms on younger patients, actually the most productive years of their lives that they rupture. So, it gives you some parameters like the presence of hypertension, the size, as I said, seven or larger, previous history of subarachnoid hemorrhage, and the location of the aneurysm. But it doesn't take into account other factors like smoking or morphological features of the aneurysm. Dr Smith: Now, you mentioned size. I'd like to maybe go back and talk about a case from your article, which I found really impactful. For our listeners, this is a sixty-four-year-old woman who had a five-millimeter ACOM aneurysm. She was imaged serially, didn't change over the time period, and then two years later ruptured with devastating consequence, right? And so that's a small aneurysm. Most aneurysms, I guess, are small aneurysms. I just wonder, when you see a patient like that, how do you handle the discussion regarding risk? And how do you decide when to refer them for an intervention?  Dr Samaniego: Yeah. It's always puzzling when we see these smaller aneurysms. And this example is a typical example of a patient that doesn't follow the rule of seven or larger aneurysm size for rupturing. We see that quite often on aneurysms located in the anterior communicating artery. Just this last week, I treated two patients with similar characteristics, with smaller aneurysms, like average size between four and five, that rupture, and both were located in the anterior communicating artery. So, we know that there is definitely a linear relationship between size and risk and rupture, but we do see a lot of patients that have smaller aneurysms, like three, four, five millimeters that rupture, and we don't really understand very well the, biology of these aneurysms. So, when we see these aneurysms, we try to maximize the characterization of the aneurysm with better imaging, try to see the morphology. And usually when an aneurysm is discovered, what we do for follow-up is a six-month follow-up with some type of imaging, CTA, MRA with contrast, and see if there's has been any change in, on the aneurysm.  Dr Smith: So, is it fair to say that a knowledgeable non-vascular neurologist can safely manage these patients, follow them over time using what they learned from reviewing your article, identify patients who have higher risk aneurysms based on the characteristics you summarize, and refer them to a tertiary center? When I get these, it's easy for me to have our vascular neurosurgeon see them or a vascular neurologist, right? But in a community where you may not have ready access to that subspecialist, is it still important to get all of these patients to a tertiary center? Are there select instances where a community-based general neurologist can follow them and then refer if there's change in size, for instance?  Dr Samaniego: Yeah. I think that everything else that we do in neurology, it's important to do some type of triage in referring some of these patients for further studying and  expert opinion. I think age and size of the aneurysm, age of the patient and size of the aneurysm are huge factors. For example, if we have an older patient in their nineties and has incidentally found two-millimeter aneurysm in a low-risk location like the parathalmic, that patient probably needs to be seen locally. I don't think merits a full workup. As opposed to a younger patient with a three-millimeter aneurysm located in the ACOM. I think that type of patient probably needs to be referred to a tertiary s-stroke center for workup. I mean, most of the time what's gonna happen is that if it's a small aneurysm with benign characteristics, you know, it's gonna be seen by the specialist and they're gonna determine some type of follow-up, which can be done locally.  Dr Smith: So maybe we can pivot a little bit and talk about AVMs, if that's okay. What's your approach to a coincidentally discovered AVM, right? I mean, presumably, we need to think about symptomatic AVMs a little differently, I would think. So maybe we can start with the same scenario we've been talking about. You get an imaging study for something else, and, well, we find an AVM. What's the approach to that situation?  Dr Samaniego: Yeah. AVMs are fascinating vascular lesions because they're very complex, they're very heterogeneous. If we're talking about the morphological features with aneurysms, this, in the case of AVMs, is way more complex in terms of location size. The complexity added to AVMs is that you have a feeding artery, you have a nidus, and then you have draining veins. So, all of these can be very heterogeneous. In case of AVMs, I think those definitely need to be referred to a tertiary center because the management of AVMs is multidisciplinary, even in the tertiary centers. You know, we don't have a magic wand that will say, you know, all these AVMs need to be treated this way. Sometimes they don't even need to be treated because we know from some studies that just watching them will be good enough.  Dr Smith: You raised management of AVMs. Maybe we can go back and talk a little bit about what's the latest in management of aneurysms. You manage aneurysms from soup to nuts and as an endovascular interventional neurologist. What's the latest in management of aneurysms?  Dr Samaniego: The latest is that, which falls within management, is that we have tools that they have not really been validated a hundred percent because we're still understanding the biology of some of these aneurysms. But high-resolution MRI will help us to define if there is some enhancement of the aneurysm. There is the thought that if there is enhancement after the administration of contrast, might be more of an inflammatory process. So that can be used for management, triage, and follow-up of some of these aneurysms. In terms of endovascular treatment, it has been really a revolution of how we treat these lesions. You know, we have a lot of new devices, better catheters to access the aneurysms.There is devices that you can place inside the aneurysm sac and it'll completely shut down flow into the aneurysm. There is other special stents called flow diverters that can take the flow away from the aneurysm and bypassing the aneurysm. So, all of these things have really revolutionized how we treat them. Having said that, you know, there's always a risk with any of these procedures, and that's why we gotta be mindful when we decide to treat these patients with unruptured incidentally found aneurysm.  Dr Smith: I've got just one more question, Edgar, which I kind of led with. You've got training as a vascular neurologist, a neurointensivist, and an interventional neurologist. And you know, Ralph Sacco, as you probably know, used to like to talk about the neurologist, and part of the neurologist was interventional. I wonder what wisdom you have to trainees that are listening to us right now who might be interested in pursuing a career as a neuroendovascular neurologist. What wisdom do you have for them about how to go about doing that?  Dr Samaniego: It has been really rewarding to be part of this process and evolution of treating a stroke and aneurysms and AVMs because I remember when I was a resident at the University of Wisconsin, we only had, like, thrombolysis and only one device for, retrieving some of these clots. But now we have, like, 10 different devices. We have two different indications or two, two different thrombolytics. So, my best advice for trainees that want to pursue neuroendovascular is to get engaged early on, understand very well the biology and the thought process because it's not only a technical field. You have to have really good judgment on when to do and when not to do the procedure, and try to find mentorship. You know, there is a lot of neurointerventional neurologists out there right now. Having a good mentor will really facilitate your career choices and getting into training.  Dr Smith: Well, Edgar, thanks so much. What an exciting conversation. It's just another great example of how exciting neurology is these days. Many exciting advances and innovations, and we just scratched the surface. I encourage all of our listeners to read the article. It's actually really, really informative. So, thank you very much.  Dr Samaniego: Thank you so much, Gordon.  Dr Smith: Again, today I've been interviewing Dr. Edgar Samaniego about his article on unruptured intracranial aneurysms and AVMs. This article appears in the June 2026 issue of Continuum on Cerebrovascular Disease. Be sure to check out other Continuum Audio episodes from this and other issues, and thanks to you, our listeners, for joining us today.  Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use 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.

CardioNerds (Drs. Apoorva Gangavelli, Jenna Skowronski, and Hannah Every) discuss the continuum of prevention and heart failure with Drs. Anu Lala and Martha Gulati. Grounded in a clinical case of a 55-year-old woman with uncontrolled hypertension, type 2 diabetes, and obesity who is on the trajectory toward heart failure, this episode unpacks a paradigm-shifting framework from a joint HFSA/ASPC Scientific Statement. The discussion explores how prevention should not be siloed from heart failure management but rather integrated across a patient’s lifespan—from primary prevention in at-risk individuals, to secondary prevention in those with established heart failure, to tertiary prevention in patients with advanced therapies such as LVADs and heart transplantation. The experts highlight the importance of aggressive risk factor management, biomarker-guided screening, the AHA’s Life’s Essential 8, and the need for multidisciplinary collaboration and systems-level change to shift heart failure care from reactive to proactive. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls Systemic inflammatory diseases are associated with an elevated CVD risk that has significant implications for early detection, risk Heart failure prevention is a continuum, not a checkpoint. Prevention applies at every stage—from at-risk (Stage A) through advanced/post-transplant care—and every clinical encounter is an opportunity to intervene. The AHA’s Life’s Essential 8 (diet, physical activity, nicotine exposure, sleep, BMI, blood lipids, blood glucose, blood pressure) forms the foundation at every stage. Hypertension carries the highest population-attributable risk for heart failure of any modifiable risk factor. In the Framingham Heart Study, 91% of patients with newly diagnosed HF had pre-existing hypertension. The SPRINT trial demonstrated a 38% reduction in HF incidence with intensive blood pressure targets (30 ng/L or NT-proBNP >125 ng/L) identify individuals at heightened risk for progression to symptomatic HF. The ACC/AHA/HFSA guidelines give a Class IIa recommendation for natriuretic peptide screening in at-risk patients. Urine albumin-to-creatinine ratio (UACR) is an underutilized screening tool that provides additional insight into CKM risk. The heart failure label does not close the prevention window—it accentuates it. Secondary prevention through GDMT optimization (quadruple therapy in HFrEF) and continued risk factor management remains critical. Tertiary prevention extends to post-LVAD and post-transplant patients, where hypertension, diabetes, obesity, and CKD management remain essential to long-term outcomes. Show notes For a comprehensive review, please review the full HFSA/ASPC Joint Scientific Statement: Lala A, Beavers C, Blumer V, et al. The Continuum of Prevention and Heart Failure in Cardiovascular Medicine. J Card Fail. 2026;32:75-105. doi:10.1016/j.cardfail.2025.06.013 1. What is the “continuum of prevention” framework, and how does it differ from traditional approaches to heart failure prevention? Historically, prevention and heart failure management have been treated as separate disciplines—primary prevention handled by preventive cardiologists and treatment managed by heart failure specialists. This joint HFSA/ASPC Scientific Statement reframes prevention as a dynamic, continuous process that spans a patient’s entire lifespan, regardless of HF stage or ejection fraction. The framework maps onto the ACC/AHA HF staging system: Primary prevention targets Stage A (“at risk”) and Stage B (“pre-HF”) patients to reduce the burden of incident HF. Secondary prevention targets Stage C (symptomatic) and Stage D (advanced) patients to reduce the impact of established HF through GDMT optimization and ongoing risk factor management. Tertiary prevention encompasses risk factor management in patients with LVADs or heart transplants—populations where hypertension, diabetes, and obesity still drive outcomes. The Central Figure of the statement illustrates that Life’s Essential 8 (blood pressure and lipid control, diabetes management, exercise, sleep, smoking cessation, weight management, and diet/nutrition counseling) forms the foundation at every stage, with pharmacologic and device-based therapies layered on top as disease progresses (Figure) 2. How do traditional risk factors drive heart failure, and what should clinicians prioritize? Hypertension carries the greatest population-attributable risk for HF. In the Framingham Heart Study (N=5,143), HTN was associated with a 2- to 3-fold increased risk of HF, with a population-attributable risk of 39% in men and 59% in women. The SPRINT trial showed a 38% reduction in HF incidence and 25% reduction in the primary composite outcome with intensive BP targets (30 ng/L or NT-proBNP >125 ng/L) are associated with heightened risk for progression to symptomatic HF. In the ARIC study, incorporating NT-proBNP reclassified 20% of older adults without HF into Stage B. Factors that affect interpretation include age, sex, obesity (lower values), and CKD (higher values). High-sensitivity cardiac troponin (hs-cTn): Concentrations above the 99th percentile are now included in the definition of Stage B HF. Troponin testing may complement natriuretic peptides, particularly when BNP/NT-proBNP values are ambiguous. Risk scores: The PCP-HF equation predicts 10-year HF risk using traditional risk factors plus QRS duration. The AHA PREVENT score incorporates HF risk calculation and includes markers of kidney function (albuminuria, eGFR), though it may underestimate risk in men and Black adults. The CKM syndrome staging framework (Stages 0–4) provides a holistic approach to assessing systemic cardiovascular-kidney-metabolic risk. 4. What are the key nontraditional risk factors and cross-cutting themes in heart failure prevention? Genetics: Pathogenic cardiomyopathy variants exist in ~1 in 200 individuals in the general population. The HFSA and ACMG recommend cascade testing to identify at-risk family members. Polygenic risk scores for dilated cardiomyopathy show a 3.8-fold risk for DCM in the top 10th percentile compared with the median. Sex-specific considerations: Women have 2.8 times the odds of developing HFpEF, while men have similarly increased odds of HFrEF. A complete obstetric/gynecologic history is essential—preeclampsia is associated with a 4-fold increased risk of HF. Peripartum cardiomyopathy requires intentional screening in high-risk populations. Cardiotoxic exposures: Clinicians should be aware of medications that cause direct myocardial toxicity (e.g., anthracyclines, trastuzumab, tyrosine kinase inhibitors). A team-based approach with pharmacists can help optimize medication selection and risk factor modification. Social determinants of health: Environmental exposures (air pollution, arsenic, lead, cadmium), food insecurity, financial instability, and limited healthcare access contribute to HF risk and progression. Equity-focused, risk-based prevention strategies are needed. Psychological health: Depression is common in HF and independently associated with worse outcomes. Screening with brief questionnaires (e.g., PHQ-2) is recommended. Meditation, spirituality, and holistic wellness approaches remain underutilized. 5. What systems-level and policy changes are needed to move the needle on heart failure prevention? Multidisciplinary HF prevention clinics that bring together preventive cardiologists, HF specialists, endocrinologists, nephrologists, dietitians, pharmacists, exercise physiologists, and genetic counselors are advocated by the statement. EHR-embedded risk stratification could proactively flag patients on a trajectory toward HF—analogous to sepsis alerts or fall risk flags—enabling earlier intervention, particularly for patients who may not reach a cardiologist. Cardiac rehabilitation remains underutilized, particularly in HFrEF (Class 2b recommendation) and HFpEF (not yet covered by Medicare). The HF-ACTION trial showed quality-of-life benefits, and the REHAB-HF trial showed particular benefit in older patients with HFpEF. Policy priorities include expanding insurance coverage for preventive screening and novel therapies (SGLT2i, GLP-1 RAs, nsMRAs), reducing clinical inertia through team-based care models with closer follow-up intervals, and ensuring equitable access to evidence-based therapies across diverse populations. Digital health and AI hold promise for personalized risk prediction, remote monitoring (e.g., wearable devices, implantable PA pressure monitors), and virtual cardiac rehabilitation to overcome access barriers. Figure  Lala A, Beavers C, Blumer V, et al. The continuum of prevention and heart failure in cardiovascular medicine: a joint scientific statement from the Heart Failure Society of America and the American Society for Preventive Cardiology. J Card Fail. 2026;32(1):75-105. doi:10.1016/j.cardfail.2025.06.013) References Key references are bolded. Lala A, Beavers C, Blumer V, et al. The continuum of prevention and heart failure in cardiovascular medicine: a joint scientific statement from the Heart Failure Society of America and the American Society for Preventive Cardiology. 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Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2022;387(12):1089-1098. doi:10.1056/NEJMoa2206286 Filippatos G, Anker SD, Agarwal R, et al. Finerenone reduces risk of incident heart failure in patients with chronic kidney disease and type 2 diabetes: analyses from the FIGARO-DKD trial. Circulation. 2022;145(6):437-447. doi:10.1161/CIRCULATIONAHA.121.057983 Solomon SD, McMurray JJV, Vaduganathan M, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-1485. doi:10.1056/NEJMoa2407107 Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389(24):2221-2232. doi:10.1056/NEJMoa2307563 Deanfield J, Verma S, Scirica BM, et al. Semaglutide and cardiovascular outcomes in patients with obesity and prevalent heart failure: a prespecified analysis of the SELECT trial. Lancet. 2024;404(10454):773-786. doi:10.1016/S0140-6736(24)01498-3  Kosiborod MN, Abildstrøm SZ, Borlaug BA, et al. Semaglutide in patients with heart failure with preserved ejection fraction and obesity. N Engl J Med. 2023;389(12):1069-1084. doi:10.1056/NEJMoa2306963 Ndumele CE, Neeland IJ, Tuttle KR, et al. A synopsis of the evidence for the science and clinical management of cardiovascular-kidney-metabolic (CKM) syndrome: a scientific statement from the American Heart Association. Circulation. 2023;148(20):1636-1664. doi:10.1161/CIR.0000000000001175 Khan SS, Matsushita K, Sang Y, et al. Development and validation of the American Heart Association’s PREVENT equations. Circulation. 2024;149(6):430-449. doi:10.1161/CIRCULATIONAHA.123.067626 Khan SS, Ning H, Shah SJ, et al. 10-year risk equations for incident heart failure in the general population. J Am Coll Cardiol. 2019;73(19):2388-2397. doi:10.1016/j.jacc.2019.02.057 Bozkurt B, Fonarow GC, Goldberg LR, et al. Cardiac rehabilitation for patients with heart failure: JACC expert panel. J Am Coll Cardiol. 2021;77(11):1454-1469. doi:10.1016/j.jacc.2021.01.030 Packer M. Leptin-aldosterone-neprilysin axis: identification of its distinctive role in the pathogenesis of the three phenotypes of heart failure in people with obesity. Circulation. 2018;137(15):1614-1631. doi:10.1161/CIRCULATIONAHA.117.032474 Lala A, Tayal U, Hamo CE, et al. Sex differences in heart failure. J Card Fail. 2022;28(3):477-498. doi:10.1016/j.cardfail.2021.10.006 Bozkurt B, Coats AJS, Tsutsui H, et al. Universal definition and classification of heart failure. Eur J Heart Fail. 2021;23(3):352-380. doi:10.1002/ejhf.2115 Hershberger RE, Givertz MM, Ho CY, et al. Genetic evaluation of cardiomyopathy—a Heart Failure Society of America practice guideline. J Card Fail. 2018;24(5):281-302. doi:10.1016/j.cardfail.2018.03.004 Levine GN, Cohen BE, Commodore-Mensah Y, et al. 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Spend enough time around federal retirement and the acronyms start flying — and it starts to feel too late to ask what they mean. Charles and Marcus decode the alphabet soup in plain English: FERS (and RAE/FRAE), CSRS and CSRS Offset, TSP, FEHB, FSA, FEGLI, MRA, VSIP/VERA/DRP, SRS, SCD, OPM, ORA, AUO/LEAP, the SF forms, and CSA. Grab the free Acronyms Cheat Sheet in the description.Fill out the form and download the cheat sheet here: https://perspectivefunnel.co/682642d22275ec003bfa6626/6a445b182446fd510fd3af9b/Chapters:0:00 The Acronyms You're Afraid to Ask About2:03 FERS (RAE / FRAE)4:24 CSRS & CSRS Offset5:37 TSP6:23 FEHB & Open Season8:53 FSA10:04 FEGLI11:25 MRA12:44 VSIP, VERA & DRP14:24 SRS18:00 SCD, OPM & ORA23:06 AUO & LEAP25:00 SF Forms27:30 CSA + Free Cheat SheetCTA: Apply for a Retirement Consultation: https://perspectivefunnel.co/682642d22275ec003bfa6626/691df07396253e003c42b434/?ps_hello=Disclaimer: Educational only; not advice. Verify with OPM/TSP.gov. Advisory services through CD Financial LLC dba CD Financial (CA); insurance through CD Financial & Insurance Services LLC.Support the show

The Tunisian-born, American-based singer and activist Emel Mathlouthi, who records simply as Emel, became famous when her song "Kelmti Horra" became the anthem of the Arab Spring uprising some fifteen years ago. Since coming to the States, Emel has released a series of albums united by the themes of freedom, struggle, and community. Sonically, though, her songs have varied from dark electronica to North African-inflected pop to haunting and artful ballads. Her 2024 album, MRA, lifts up women and spotlights the fight against [the] patriarchy, and veers into more pop and hip hop than ever before. Emel and her band play live, in-studio.  Set list: 1. footsteps 2. Nar 3. Massive Will Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

Which acronym tripped you up the longest — FERS, FEGLI, SRS, or MRA? Drop it below

Choosing a federal retirement date is a major decision, and understanding how MRA, age 60, and age 62 affect eligibility and benefits can make the process clearer.In this presentation, Benchmark Financial Group discusses considerations you may want to review when evaluating your retirement timeline, such as:How your decisions affect decades of incomeEligibility and benefitsHow to get started on your retirement plan---------------------------------------------------------------Connect with Benchmark Financial Group:Website | ⁠https://bfgkc.com⁠LinkedIn | ⁠https://www.linkedin.com/company/benchmark-financial-group-llc⁠Facebook | ⁠https://www.facebook.com/BenchmarkFinancialGroupLLC⁠Benchmark Financial Group is located at 10975 Benson Dr., Suite 500, Overland Park, KS 66210, Corporate Woods Building 12. You can contact us by visiting our website at ⁠https://bfgkc.com⁠, calling 913.227.4224, or emailing David at david.raetz@bfgkc.com.Securities and Advisory Services are offered through CreativeOne Securities, LLC. Member FINRA/SIPC and an Investment Advisor. Benchmark Financial Group, LLC, and CreativeOne Securities are not affiliated companies.#federalemployees #federalbenefits #federalretirement #benchmarkfinancialgroup #planyourfederalretirement

CORE RESOURCES: Rutherford's Vascular and Endovascular Therapy 10th Edition, Chapters 88, 89, 91, and 94 Atlas of Vascular Surgery and Endovascular Therapy 2nd Edition, Chapter 9 ADDITIONAL RESOURCES: Audible Bleeding Episodes Holding Pressure - Carotid Endarterectomy: https://www.audiblebleeding.com/2024/02/27/holding-pressure-carotid-endarterectomy/ Holding Pressure Case Prep - Endovascular Basics: https://www.audiblebleeding.com/2023/04/23/holding-pressure-case-prep-endovascular-basics/ Videos TCAR Technical Video: https://jnis.bmj.com/content/14/8/842 Articles Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease:  https://www.jvascsurg.org/article/S0741-5214%2821%2900893-4/fulltext Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system: https://www.jvascsurg.org/action/showPdf?pii=S0741-5214%2816%2931862-6 Referenced Studies ROADSTER-1 https://pubmed.ncbi.nlm.nih.gov/30611582/ ROADSTER-2 https://pubmed.ncbi.nlm.nih.gov/32811386/ https://pubmed.ncbi.nlm.nih.gov/35381327/ TCAR Surveillance Project https://jamanetwork.com/journals/jama/fullarticle/2757579?utm_source=openevidence&utm_medium=referral https://pubmed.ncbi.nlm.nih.gov/36172943/   OUTLINE:   CAROTID ARTERY DISEASE 1. Pathophysiology/etiology Carotid artery disease is primarily driven by atherosclerotic plaque deposition.  Risk factors: hypertension, hyperlipidemia, diabetes, smoking, and advanced age. Nonatherosclerotic etiologies: fibromuscular dysplasia, carotid dissection, vasculitic disease, carotid webs, and trauma. When the endothelium is damaged, monocytes migrate to the site and differentiate into macrophages that take up oxidized LDL particles to become foam cells. Meanwhile, an inflammatory response occurs where activated platelets release thromboxane A2, platelet derived growth factor, and inflammatory cytokines that promote further platelet aggregation and vascular inflammation. Smooth muscle cells migrate and proliferate, forming the structural framework of the atheroma.  Within the lesion, necrotic debris and lipid accumulate, creating a vulnerable plaque. Plaque rupture exposes this material to the bloodstream, serving as a nidus for thrombus formation which can lead to ischemic events. Carotid bifurcation is particularly prone to plaque formation due to turbulent blood flow. Embolization of plaque from this area can result in TIA or ischemic stroke.  2. Presentation Patients are often asymptomatic and stenosis is incidentally found on imaging.  Symptomatic patients present with neurologic symptoms including unilateral motor and sensory loss, aphasia (difficulty finding words), dysarthria (difficulty speaking), amaurosis fugax (temporary monocular vision loss due to embolus to the ophthalmic artery), transient ischemic attacks Physical exam findings may be notable for auscultation of a carotid bruit. Patients may also have evidence of retinal artery embolization on fundoscopic examination (Hollenhorst plaque) or asymptomatic cerebral infarction.  3. Diagnosis USPTF recommends against screening for asymptomatic carotid artery stenosis.  In patients with no risk factors, SVS recommends against screening for asymptomatic carotid artery stenosis. However, they do recommend screening for asymptomatic clinically significant carotid bifurcation in certain groups of patients with multiple risk factors.  These risk factors include patients with clinically significant peripheral vascular disease, patients 65 and older with history of CAD, smoking, hypercholesterolemia, and patients prior to coronary artery bypass.  Relevant findings on physical exam or imaging findings may warrant screening, but screening is not recommended for the presence of neck bruit alone without other risk factors, as this finding has a low sensitivity and specificity for detecting clinically significant carotid artery stenosis.  Carotid duplex ultrasound: first-line imaging modality for both screening and initial evaluation of stenosis, noninvasive, low-cost CTA: rapid, high-resolution, three-dimensional imaging of vascular anatomy, risk of contrast and radiation exposure MRA: high-quality, three-dimensional imaging without radiation or contrast, expensive with longer acquisition time, can overestimate stenosis in severe disease DSA/angiography: gold standard, expensive, invasive, not generally recommended for routine diagnostic evaluation or screening 4. Classification Carotid artery stenosis is classified by degree of luminal narrowing. NASCET method: standard in current practice. Compares the minimal residual lumen at the point of greatest stenosis to the diameter of the normal distal internal carotid artery.  Classification of stenosis: Mild: 70 bpm, and ACT >250 seconds to optimize cerebral perfusion and minimize thrombotic risk. Clamp the carotid artery just proximal to the arterial sheath to establish active flow reversal.  Flow controller settings: Low setting High setting Flow-stop button: allows for temporary cessation of flow (used when we inject contrast).  Confirm flow reversal via two different ways:  The first way is to stop flow to the venous return sheath with the stopcock, clearing the line with hep saline injection, and then opening the stopcock and seeing the blood returning to the controller in a reverse fashion. The second way is to perform an angiogram with a small amount of contrast injection while holding the flow-stop button. Using the angio we want to make sure that contrast is flowing retrograde in the cervical ICA thereby confirming flow reversal.    Carotid artery stenting, balloon angioplasty, and completion angiogram At this point, a standard carotid angioplasty and stenting procedure is performed. ENROUTE transcarotid Neuroprotection System device:  inner diameter of 8F and an outer diameter of 10F Has its own carotid artery stent system but is also compatible with all FDA-approved carotid stents.  Final angiogram is performed to confirm stent position, vessel patency, and absence of complications including vasospasm at the distal end of the stent and filling defects from protrusion of atheromatous material through the stent    Cessation of flow reversal and sheath removal Allow the flow reversal to run for a few minutes after the final balloon angioplasty to clear any debris.  Antegrade flow is restored by releasing the carotid clamp and closing the stopcocks on the neuroprotection system.  The patient is auto-transfused the blood from the flow line back to the venous system.  As the arterial access system is removed and the puncture site is closed with the U-stitch.  IV protamine is administered to reverse the heparin. Standard closure is performed at the incision site. Meanwhile, hemostasis is achieved after removal of the femoral vein sheath with brief manual compression.  Postop care/complications Postop care All patients after a TCAR should be monitored in the ICU setting for 24 hours, as an embolic stroke, hypotension with or without bradycardia, or hypertension can occur.  Should a TIA or stroke be observed, a carotid duplex scan and CT angiogram should be immediately obtained to assess the stent site and the presence of an embolic or thrombotic filling defect, dissection, or occlusion.  Dual antiplatelet therapy: continue for 45 days to 12 months Aspirin and statin therapy: continued indefinitely Surveillance duplex imaging: 4 weeks, 6 months, and 12 months, and annually thereafter. Postop complications Hematoma Stroke Myocardial infarction Cerebral hyperperfusion syndrome Sudden and excessive increase in cerebral blood flow to previously hypoperfused brain tissue is met with vasculature that cannot constrict appropriately from chronic vasodilation Leads to breakthrough hyperperfusion. This results in cerebral edema, intracerebral hemorrhage, and neurological symptoms.  Cranial nerve injury Hypoglossal nerve (CN XII) injury: ipsilateral tongue deviation. It is the most commonly injured cranial nerve.  Vagus nerve (CN X) injury: hoarseness and possible vocal cord paralysis.  Glossopharyngeal nerve (CN IX) injury: soft palate dysfunction.  Recurrent laryngeal nerve injury: voice hoarseness and inability to cough as it innervates all of the voice box muscles except for the cricothyroid muscle Marginal mandibular nerve injury: ipsilateral lip droop, injury is rare in TCAR.  Stent restenosis Pseudoaneurysm Access site infection

Pregnancy and the postpartum period are critical windows of increased stroke risk, driven by physiologic changes such as hypercoagulability and blood pressure fluctuations. This episode highlights key warning signs, including headache and hypertension, along with practical guidance on evaluation, management, and risk reduction to improve outcomes for pregnant and postpartum patients. In this episode, Kait Nevel, MD, speaks with Michelle H. Leppert, MD, author of the article "Pregnancy and Stroke Risk" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Leppert is an associate professor of neurology at Tufts Medical Center in Boston, Massachusetts. Additional Resources Read the article: Pregnancy and Stroke Risk 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: @humich Full episode transcript available here Dr Nevel: The time during and around pregnancy is often thought of as a very joyful time, full of hope. But for some, medical complications such as stroke can lead to devastating disability and sometimes even death. Today, we're going to learn about pregnancy and postpartum stroke, including stroke risk evaluation and best practices in management and risk reduction to help our pregnant and peripartum patients reduce stroke risk and achieve best possible outcomes.  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. Michelle Leppert about her article on pregnancy and stroke risk. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Michelle, welcome to the podcast, and please introduce yourself to the audience.  Dr Leppert: My name is Michelle Leppert. I'm a stroke neurologist, and I currently work at the Tufts Medical Center in Boston, Massachusetts.  Dr Nevel: Thank you so much for being here, Michelle, and I'm looking forward to talking to you about your article. I always love starting with the question, what's the most important takeaway from your article for the practicing neurologist?  Dr Leppert: I think in this article, I'm trying to highlight that during pregnancy and especially postpartum, there's a heightened risk of stroke for women, and that's important for clinical neurologists to understand that this is a particularly vulnerable time for the population that we take care of. I think that one of the few of the things that could be informing this heightened stroke risk are the physiological changes that women undergo during pregnancy. So, that includes coagability, where there's an increased likelihood of clotting, and also the cardiovascular adaptations, including increased cardiac output and having an increased cardiac volume. And all of these mechanisms all contribute to the increased risk of strokes around pregnancy and postpartum.  Dr Nevel: Great. Thanks for that. What are some of the unique aspects of stroke types in etiology in pregnancy that we should be aware of?  Dr Leppert: When we think of strokes overall, generally the majority of our strokes are ischemic. So, for the overall population, about eighty-seven percent of strokes are ischemic, while the remainder are hemorrhagic. However, interestingly, during pregnancy, what we're seeing is about half of our strokes become hemorrhagic strokes, and now only a half of our strokes are ischemic, and this is in contrast to what we see in the overall population. One of the reasons is because pregnancy is associated with preeclampsia, and preeclampsia increases the risk of hemorrhagic stroke during pregnancy.  Dr Nevel: Can you tell us just more about headache in general in pregnancy and association of headache with secondary causes of headache and how that relates to stroke risk in this patient population? It seems like in this patient population that when somebody has a headache, we need to be very careful in our headache questions and evaluation.  Dr Leppert: Yeah. And I think the most concerning symptom that we're finding in this population is headaches, and the reason is because headaches is one of the clinical signs of having preeclampsia, which dramatically increases your risk of having a stroke, and especially a hemorrhagic stroke. So just to back up, we can talk about blood pressure for a little bit and some of the pathophysiologic changes during pregnancy. What most people may not know is that there's a dramatic vascular expansion that occurs during pregnancy. And somewhere during the second trimester, your blood pressure is actually the lowest. So, it can drop below pre-pregnancy levels and make your blood pressure appear low for the baseline. However, during the third trimester, as the baby is growing, there is increased vascular volume. The blood pressure starts to increase. We're seeing some of the highest prevalence of blood pressures, which is a sign for preeclampsia, and headaches develop during that third trimester, and particularly during the time around delivery and postpartum. And one of the most concerning signs, the most common sign of preeclampsia is having a headache. So, I think that with any patient that's presenting with a headache, especially during the third trimester or after delivery, that we really need to pay attention and take their blood pressure. That's one of the easiest clinical indicators that something could be going very wrong. Some of the other red flags clinically that we look for in headaches is that acute onset of a severe headache. That headache quality is different from what they usually have. Any woman with focal neurological symptoms associated with their headache, kind of excessive nausea and vomiting that's not characteristic for them. Not getting any relief with medications, and then lastly, checking that blood pressure is very important.  Dr Nevel: And what are the thoughts on blood pressure management in this patient population? I know that there is a little bit of difference in guidance in some of the obstetric societies on how we should manage blood pressure in this patient population. And then, is there anything beyond blood pressure management that we should be thinking about doing for this patient population to reduce their stroke risk?  Dr Leppert: I think that's a good question, and I hadn't really understood that this could be an area of controversy, cause my practice is mostly in stroke, and for most of adult population, the guidelines for blood pressure is very clear. We treat everybody over 130/80. If you're elderly, then your blood pressure limit might be a little higher. However, there's disagreement in the OBGYN guidelines from the American guidelines to the European guidelines. So, what the current American guidelines suggests is that if you have a history of chronic hypertension, then we would want your blood pressure treated during pregnancy below 140/90. However, if you don't have a history of chronic hypertension, then we allow the blood pressure to be higher and then it's an acute intervention if it's anything over 160. One of the issues with this strategy that is concerning is we had just mentioned that the pathophysiology of a pregnancy where you have the lowest blood pressure in that second trimester, and so your blood pressure may be abnormally good. [laughs] And it appears that it's better than your baseline. And so, by the OBGYN definition, any gestational blood hypertension is considered at 20 weeks and later. Sometimes these blood pressures are masked in some women who are pregnant. I think regardless of the controversy and what the practice should be, the focus is that most of the strokes are happening actually peripartum and postpartum, right? So, the woman's no longer pregnant. It is these time periods of the highest risk that we wanna make sure that the blood pressure is controlled. So, after the woman delivers the baby, we're no longer, you know, hampered by the whatever is chronic or gestational. We should be treating that blood pressure to 140/90. I think that not focusing on the controversy until the science catches up is probably what we should do. But like, really, the message here is that we should be checking women around the time of delivery and also postpartum, that we can't forget about their blood pressures postpartum, cause it actually doesn't peak until day five after they deliver the baby.  Dr Nevel: Does knowing that, that blood pressure peaks around day five, do you think that that should impact how we counsel patients in checking their blood pressure at home? Cause most women at day five are home. They're not still in the hospital.  Dr Leppert: Yeah, I think that's a really good point. One of the best interventions has been having a blood pressure at home for pregnant women. So even during their pregnancy and then postpartum, allow them to check their blood pressures, cause there's... Most of the cases, to be honest, that I've seen of preeclampsia and intracranial hemorrhage has happened postpartum. And I think what's unfortunate is that the woman is at home, they're distracted cause they have a newborn baby. They have a headache. They're just taking some Tylenol. And then if you have that blood pressure cuff readily accessible, that's a, a really easy way for them to check and notice that, hey, the blood pressure's too high, they have to go into the hospital.  Dr Nevel: Yeah, absolutely, and it's not just like a headache because you're sleep deprived and have a newborn. It's a headache that you need to pay attention to. Okay, maybe we could talk a little bit now about evaluation when we are suspicious of potential stroke. What do we need to know about imaging modalities and safety considerations of imaging in this patient population?  Dr Leppert: Yeah, that's a great question. I think when I was training, it was fairly controversial to give a pregnant woman MR contrast with gadolinium during their pregnancy. And as I was researching for this article, actually there's not definitive evidence that that is harmful for the fetus. However, in general, for the acute evaluation of patients during pregnancy, we're recommending using the CAT scan and then a CT angiogram. And then if the acute evaluation is not necessary, then an MRI. And if we need vessel imaging, you can employ an MRA time-of-flight study. That doesn't require the gadolinium contrast. However, one thing that I learned from this article that I thought was really interesting was the use of abdominal shielding. So, you're scanning someone's brain. I always thought, "Hey, doesn't it make sense to put a lead shield over the abdomen?" It turns out the lead shield actually interferes with the automatic calibration of the CT machine, so studies have found that actually increases the dose of radiation that the fetus is exposed to. So, it's much better when we're doing acute evaluations to not shield the abdomen, and really the only thing that can help reduce the radiation dose is the duration of the study. So, what we would recommend is if you want a rapid CT angiogram, rapid CT head, go ahead and obtain it. But if you don't need extra sequences, like a delayed phase of the CT angiogram, then to avoid that and reduce the exposure. Dr Nevel: I'm so glad that you talked about that because I was shocked when I read that in your article that we shouldn't be using abdominal shielding in pregnant women. I had no clue. I thought that that was, like, something that we absolutely should do. So, I found that really interesting. Thank you for that. So, any special considerations for acute stroke intervention or management in pregnancy in the postpartum phase, especially things like thrombolysis and thrombectomy?  Dr Leppert: Yeah. So, I think that as our evidence is getting better for thrombectomy, I would be more judicious about using IV thrombolysis, especially around the time of delivery, cause there is some evidence that it can be associated with postpartum hemorrhage. Patient selection, I think, is key here. So, women who have disability associated with their stroke, and then women who aren't candidates for thrombectomies are still candidates for IV thrombolysis. But understanding that this is a little bit of an unchartered territory for us, and only using IV thrombolytics when we think that there is a big benefit to be had.  Dr Nevel: Can you talk a little bit more about RCVS and PRESS in pregnancy and some of the overlap that we see in this patient population and its relationship to preeclampsia? It seems like there's a lot of interconnections there, and I thought that that was pretty interesting in your article.  Dr Leppert: Right now, the thinking is that RCVS and PRESS are on the same spectrum of pathology, and we think that it has something to do with the autoregulation of vascular resistance in the posterior circulation of the brain. We're not sure what triggers this, but there is something about pregnancy that classically we'll see this postpartum RCVS phenomenon. It likely has to do also with blood pressure that we're seeing. So really classically we think of this, like, thunderclap headache. You see vasospasms on imaging that is transient, that are kind of the classical signs of RCVS. But I think that we're still not completely sure what triggers it, but it's a very well-described clinical phenomenon.  Dr Nevel: Great. Thank you. Could you share a little bit about migraines in pregnancy and stroke risk? [laughs] I also thought that this also a segment of your article that caught my attention because migraines are so common. What's the association of migraine, pregnancy, and stroke risk?  Dr Leppert: Yeah. So that's a very complicated association. So, we know that migraines are associated independently with strokes, and especially people with migraines with aura. However, migraines are also highly associated with PFOs, right? And during pregnancy, what we see is that there is a hypercoagulability state, and so we see lots more DVTs, we see more PEs associated with women during pregnancy. So potentially, because migraineurs also are more likely to have PFOs, they could be presenting with more cardioembolic, kind of paradoxical emboli from these thrombus. But I'm not quite sure that we know why migraines in and of itself, especially with migraines with aura, lead to strokes. And especially during pregnancy, I'm not sure because we have very little understanding about pathophysiology of pregnancy while having migraines with aura also leads to more strokes, or that risk is really just associated with PFOs. So, I think that we need to think about that a lot more. The recommendation is a baby aspirin if you have some of these risk factors for preeclampsia, any vascular risk factors, and including migraines with aura during pregnancy. And we think that baby aspirin is relatively safe, especially starting around the 12 to 16-week period.  Dr Nevel: So just to clarify, in a woman who's pregnant, who's 12 weeks or beyond in their pregnancy and who has migraine with aura, is that a patient that we should consider aspirin for them to reduce their stroke risk?  Dr Leppert: I think you can. I am not sure that there is a specific recommendation. I think that, like, a conversation with your OBGYN is, you know, a good idea. But we do recommend that baby aspirin for women, um, above 35 years old because it's considered advanced maternal age. And then we recommend baby aspirin with women with a history of hypertension, multiple gestations, diabetes, renal disease, autoimmune disease. So, I definitely think that is something to consider.  Dr Nevel: Yeah. Interesting. Okay, great. Thank you for that. When someone has a stroke and they're pregnant again, what are some strategies for secondary stroke prevention? And you mentioned some of the primary risk reduction, but are there any others that you haven't mentioned yet other than aspirin and blood pressure control for primary prevention? Dr Leppert: Yeah, absolutely. So, I think that it's important to plan ahead. So, for women who are thinking about getting pregnant after they've had a stroke, one of the tenets of stroke neurology is trying to figure out why the first stroke happened. So, I feel like before getting pregnant, it's great to have a very thorough stroke workup so that you understand what the risk factors were and that those risk factors are controlled. One of the interventions, one of the only interventions that's, has evidence in young people with strokes is PFO closure. So, if you do have a stroke from a PFO, we recommend you get that closed prior to your pregnancy because then hopefully even given the hypercoagulability of pregnancy, there's some protection against another embolic stroke.  Dr Nevel: Another really interesting part of your article that I did not know before I read it was about the risk of cardiovascular disease long term in women who have had stroke during pregnancy. Could you talk a little bit more about that?  Dr Leppert: What we understand is that gestational diabetes and gestational hypertension sets you up for having diabetes and hypertension later on in life, and it's really developing the actual diabetes to the hypertension that increases your risk of strokes. So, what's really an important takeaway for providers is that after women develop gestational diabetes or they have gestational hypertension or they develop preeclampsia, it's very important for their primary or their neurologist to be very vigilant of these risk factors developing so that they can be modified before the women are at higher risk for strokes. And the reason why we think this happens is because pregnancy is like a stress test for your body. And so, the fact that you've developed the gestational diabetes or the gestational hypertension kind of already suggests that you're more likely and more vulnerable to developing these traditional risk factors later on.  Dr Nevel: That makes sense. Thank you for that. What do you think is a common misconception about stroke in pregnancy?  Dr Leppert: When I was earlier in my training, it kind of felt like having a stroke during pregnancy was being struck by lightning. It was really random. There was nothing you could do. It just happened to people. And I think as I learned more in my career, and especially researching for this article, I'm kind of shocked and disturbed by how much of the strokes in pregnancy we can actually prevent. Through management and monitoring of blood pressure for women. And so, I do think that it does our patients a disservice if we think that these are rogue events. But really, it might be a sign of the failure of our health system where we're not taking care of women around their delivery and postpartum and being more vigilant about their blood pressure and more vigilant about the clinical signs that they're developing.  Dr Nevel: Yeah, I really got that from your article, how important it is to monitor for blood pressure and other risk factors, and that that continues after the baby's born. Thank you so much for that, and thank you for talking with me today about your article about stroke and pregnancy. Again, today I've been interviewing Dr. Michelle Leppert about her article on pregnancy and stroke risk. This article appears in the June 2026 Continuum issue on cerebral vascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. And thank you so much 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.

In dieser Folge sprechen wir über aktuelle Veröffentlichungen der Europäischen Kommission und von Team NB sowie über Themen rund um benannte Stellen, harmonisierte Normen und den Vorschlag zur Änderung der MDR und IVDR. Dabei werfen wir insbesondere einen Blick auf die Stellungnahme des Bundesrats. Gemeinsam mit Prof. Dr. Handorn diskutieren wir zudem die Reform des Produkthaftungsrechts, ihre Neuerungen und die Auswirkungen auf den Medizinproduktesektor. Außerdem gehen wir auf das Stabilisierungsgesetz sowie das MRA mit der Schweiz ein.

Witam Państwa, nazywam się Jarosław Drożdż, pracuję w Centralnym Szpitalu Klinicznym Uniwersytetu Medycznego w Łodzi, skąd nagrywam podcast Kardio Know-How. W tym odcinku omawiam kolejną część badań opublikowanych podczas kongresu HFA 2026.  Kiedy studiowałem medycynę, digoksyna była jednym z podstawowych leków stosowanych w kardiologii, szczególnie w niewydolności serca i migotaniu przedsionków, a w Niemczech stosowano ją jeszcze odważniej niż w Polsce, często rozpoczynając terapię od dużych dawek nasycających. Już wtedy zastanawiała mnie zarówno różnica w podejściu do dawkowania między krajami, jak i praktyczna możliwość prawidłowego realizowania przez pacjentów skomplikowanych schematów leczenia opartych na zmiennych dawkach zależnych od masy ciała, funkcji nerek i czasu potrzebnego do uzyskania odpowiedniego stężenia leku. W Klinice Chorób Wewnętrznych prof. Krzemińskiej-Pakuły stosowaliśmy znacznie bardziej zachowawcze dawkowanie, ale i tak podstawową tabletką była dawka 0,25 mg, dziś praktycznie wyparta przez znacznie mniejsze dawki. Punktem zwrotnym okazało się opublikowane 20 lutego 1997 roku w NEJM badanie DIG: https://www.nejm.org/doi/full/10.1056/NEJM199702203360801, obejmujące ponad 6,5 tysiąca pacjentów z niewydolnością serca i frakcją wyrzutową poniżej 45%, obserwowanych przez pięć lat. Badanie pokazało, że digoksyna nie zmniejsza śmiertelności całkowitej, choć początkowo krzywe przeżycia rozchodziły się na korzyść leku, natomiast wyraźnie redukowała liczbę hospitalizacji oraz zaostrzeń niewydolności serca, co dziś mogłoby zostać uznane za sukces kliniczny z punktu widzenia złożonych punktów końcowych. W kolejnych analizach zauważono jednak, że korzyści występowały głównie przy niższych stężeniach digoksyny we krwi, najlepiej w zakresie 0,5–0,9 ng/ml, podczas gdy wyższe stężenia wiązały się ze wzrostem śmiertelności, szczególnie u kobiet. Dodatkowo niemal wszystkie współczesne badania nad digoksyną odbywają się już w zupełnie innym świecie terapeutycznym, w którym standardem są β-adrenolityki, MRA, ARNI i flozyny, czego nie było w czasach badania DIG. Najnowsze dane z badania DECISION oraz równolegle opublikowanej metaanalizy i analiz odstawienia digoksyny sugerują, że lek nadal może zmniejszać ryzyko zaostrzeń niewydolności serca, choć wpływ na śmiertelność całkowitą pozostaje nieistotny statystycznie: https://jamanetwork.com/journals/jama/article-abstract/2848972 oraz https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag385/8674856. Szczególne zainteresowanie wzbudziły obserwacje pokazujące nawet siedmiokrotny wzrost ryzyka zaostrzenia niewydolności serca po nagłym odstawieniu wcześniej stosowanej digoksyny, choć były to analizy krótkoterminowe oparte jedynie na sześciotygodniowej obserwacji. Dlatego w 2026 roku nadal pozostaję zwolennikiem „wielkiej piątki” nowoczesnej terapii niewydolności serca, a po digoksynę sięgam ostrożnie — głównie u pacjentów z migotaniem przedsionków, niewydolnością serca i utrzymującą się tachykardią mimo wysokich dawek β-adrenolityków, stosując małe dawki, kontrolując stężenie leku i unikając interakcji z amiodaronem oraz innymi lekami przeciwarytmicznymi. Szczegółowy TRANSKRYPT do odcinka.Podcast jest przeznaczony wyłącznie dla osób z profesjonalnym wykształceniem medycznym.

Tonight on Veritas our special guest is Damien Kross. And I want you to pay attention, because this one is different. This one comes with field notes.It begins on a night shift. A quiet night in an enclosed courtyard at a conference center on Puget Sound in Washington State. Damien was bored. He was a night shift worker, a writer, a black belt, and a former Special Police Officer with presidential security detail experience. He was not hunting for anything. He was looking at the sky.He spotted what looked like a satellite. And in a moment he describes as something a five-year-old would do, he grabbed a flashlight, pointed it at the sky, and waved. The object stopped. It changed color, altered its path, and sent something back that he still struggles to describe: a feeling. A brief, clear sense of surprise coming from the object, aimed directly at him.That was 2016. What followed was nine years of the most disciplined and rigorously documented contact investigation I have ever read.He did not go public immediately. He went to the doctor. Then specialists: MRI, MRA, CAT scans, EEG, psychological evaluations. He wanted to rule himself out before saying a word to anyone. While he was doing that, lights started appearing on his work security cameras, across the Sound on Maury Island. Lights that responded to his flashlight. Lights that matched colors he chose. Then lights that matched colors he only thought about before reaching for his flashlight.He built tests for that. He named the recurring lights. He logged their personalities. And he documented the night that two constellation clusters rearranged themselves in the sky above him in answer to a prayer he did not expect to be answered.This is a preview. Members hear the full interview and the complete archive at https://veritas7.com/subscribeveritasplus.php

Tonight on Veritas our special guest is Damien Kross. And I want you to pay attention, because this one is different. This one comes with field notes. It begins on a night shift. A quiet night in an enclosed courtyard at a conference center on Puget Sound in Washington State. Damien was bored. He was a night shift worker, a writer, a black belt, and a former Special Police Officer with presidential security detail experience. He was not hunting for anything. He was looking at the sky. He spotted what looked like a satellite. And in a moment he describes as something a five-year-old would do, he grabbed a flashlight, pointed it at the sky, and waved. The object stopped. It changed color, altered its path, and sent something back that he still struggles to describe: a feeling. A brief, clear sense of surprise coming from the object, aimed directly at him. That was 2016. What followed was nine years of the most disciplined and rigorously documented contact investigation I have ever read. He did not go public immediately. He went to the doctor. Then specialists: MRI, MRA, CAT scans, EEG, psychological evaluations. He wanted to rule himself out before saying a word to anyone. While he was doing that, lights started appearing on his work security cameras, across the Sound on Maury Island. Lights that responded to his flashlight. Lights that matched colors he chose. Then lights that matched colors he only thought about before reaching for his flashlight. He built tests for that. He named the recurring lights. He logged their personalities. And he documented the night that two constellation clusters rearranged themselves in the sky above him in answer to a prayer he did not expect to be answered.

In dieser Folge sprechen wir über aktuelle Veröffentlichungen der Europäischen Kommission und von Team‑NB sowie über den Vorschlag zur Änderung der MDR und IVDR. Dabei werfen wir insbesondere einen Blick auf das Thema Sampling und die stärkere Rolle der EMA. Gemeinsam mit Prof. Dr. Gassner diskutieren wir zudem die regulatorische Einordnung von Breakthrough Medical Devices. Außerdem gehen wir auf die Antwort von Kommissar Várhelyi auf parlamentarische Anfragen sowie auf das MRA mit der Schweiz ein.

Chris Holman welcomes back William "Bill" Hallen, President and CEO of Michigan Retailers Association, Lansing, MI. Welcome Bill. Remind the Michigan business community about the Michigan Retailers Association (MRA) and what were some highlights of 2025? What highlights MRA's focus in 2026? From a retailer's perspective, what happens on Main Street when trade and tariff policies become inconsistent or unpredictable? How important is Michigan's trade relationship with Canada to your members, and what risks do retailers face if that relationship weakens? Why did the Michigan Retailers Association decide to join the Michigan Smart Trade Alliance, and what does “smart, consistent trade policy” really mean for small businesses and consumers? » Visit MBN website: www.michiganbusinessnetwork.com/ » Subscribe to MBN's YouTube: www.youtube.com/@MichiganbusinessnetworkMBN » Like MBN: www.facebook.com/mibiznetwork » Follow MBN: twitter.com/MIBizNetwork/ » MBN Instagram: www.instagram.com/mibiznetwork/ Six prominent Michigan business groups join nonpartisan coalition to promote smart, consistent trade policies Groups representing businesses and retailers join the Michigan Smart Trade Alliance to showcase the importance of effective trade and tariff policies LANSING, Michigan — Six groups that represent retailers, health care providers, manufacturers, and other businesses across Michigan are supporting efforts by the Michigan Smart Trade Alliance (MISTA) to promote smart and consistent trade policy to help grow Michigan's economy and lower costs for families. The Michigan Retailers Association, the Midwest Independent Retailers Association, the Michigan Osteopathic Association, the Midland Business Alliance, the Lansing Regional Chamber of Commerce, and the Northern Michigan Chamber Alliance have joined MISTA in supporting trade policies that provide consistency for manufacturers, protect our relationship with Canada, and help to create new jobs. “To thrive in our global economy, retailers and small businesses need consistency and predictability,” said Bill Hallan, CEO of Michigan Retailers, which represents more than 5,000 businesses operating 15,000 stores across the state. “We support the Smart Trade Alliance's mission of creating an open dialogue aimed at securing supply chains and steadying important trading relationships.” “We support MISTA's effort to foster a constructive dialogue on consistent trade and tariff policies, recognizing the vital role these policies play in Midland's economy and the broader Great Lakes Bay Region,” said Tony Stamas, president and CEO of the Midland Business Alliance, an organization that represents more than 3,000 businesses and is dedicated to cultivating a strong and diverse economy around Midland. Other organizations that have joined MISTA's coalition are the Midwest Independent Retailers Association, the Michigan Osteopathic Association, the Lansing Regional Chamber of Commerce, and the Northern Michigan Chamber Alliance. The members represent growing momentum in Michigan to create a space to discuss and advocate for consistent, straightforward trade policies, which help small business owners as well as farmers, the automotive industry and retailers better compete in an international economy. “We are not surprised these groups have joined and more are on the way. There is widespread agreement with our mission of elevating the voices of families, farmers, job creators and entrepreneurs who want a space to talk about the importance of consistent trade and tariff policy,” said John Sellek, a spokesman for MISTA. “Michigan's employers and manufacturers rely on smart, consistent trade and tariff policies to compete globally and plan for a successful future.” Additional information is available online at www.smarttradealliance.com. The website offers the opportunity to sign a pledge to show support for efforts to promote smart, fair trade and tariff policies. # # #

Join us for another episode in our Secret Lives series of podcasts, where we delve into the science behind some of the everyday tools and equipment we use in the field of vascular surgery. In this episode, we will be taking a look at what is probably one of the most fearfully complicated pieces of equipment out there, the Magnetic Resonance Imaging or MRI scanner. A true marvel of applied physics and engineering that combines super-conducting magnets and radio-frequency to produce some of the most detailed medical imaging available. We will also take a look at how MR angiography works and how to interpret those grainy MRA images. No need to get confused with those T1 and T2 imaging sequences anymore; All will be explained! With Justin Woolgar.

Episode 212: Managing HFpEFHyo Mun and Jordan Redden (medical students) explain how to manage HFpEF with medications and touch some basics about nonpharmacologic treatments. Dr. Arreaza asks insightful questions to guide the discussion. Written by Hyo Mun, MSIV, American University of the Caribbean; and Jordan Redden, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Treatment of HFpEFArreaza: Mike, if you had to name the one therapy everyone with HFpEF should be on, what is it?Mike: That's easy! SGLT-2 inhibitors. This is the one slam-dunk we have in HFpEF. Empagliflozin (Jardiance) or dapagliflozin (Farxiga) should be started in essentially every patient with HFpEF, and it doesn't matter if they have diabetes or not.Jordan: And that's worth repeating, because people still think of these as “diabetes drugs.” They're not anymore. In HFpEF, SGLT-2 inhibitors reduce heart-failure hospitalizations, improve symptoms, improve quality of life, and even reduce cardiovascular death.Dr. Arreaza: They're also simple. Empagliflozin 10 mg daily or dapagliflozin 10 mg daily. No titration, no drama. The effectiveness of these meds was established around 2019 with DAPA-HF and later with DELIVER. These were trials thatdemonstrated that dapagliflozin reduces worsening heart failure and cardiovascular events across the full spectrum of heart failure, from reduced to preserved ejection fraction, independent of diabetes status.Mike: And the number needed to treat is about 28 to prevent one heart-failure hospitalization. That's excellent for a disease where we historically had almost nothing that worked.Jordan: They're also safe in chronic kidney disease down to an eGFR of about 25, which makes them even more useful in this population.Dr. Arreaza: Alright. We got SGLT-2 inhibitor, what's next?Mike: Volume management. Loop diuretics are still the backbone of symptom control in HFpEF. If the patient is volume overloaded, you diurese, and you diurese aggressively.Jordan: The goal is euvolemia. Dry weight, no edema, no orthopnea, no waking up gasping for air. A lot of these patients end up needing chronic oral loop diuretics to stay there.Dr. Arreaza: Something to remember: HFpEF patients don't tolerate congestion well, and being “a little wet” is not benign. Let's move into RAAS inhibition. Where do ARBs and ACE inhibitors fit in?Mike: Between ARBs and ACE inhibitors, ARBs are the winners in HFpEF. They actually reduce heart failure hospitalizations—drugs like candesartan, losartan, valsartan. ACE inhibitors? Not so much. They showed minimal benefit in older HFpEF patients, which is why we go with ARBs instead.Jordan: But a lot of clinicians get nervous about ACE inhibitors and ARBs because of kidney function, so it's worth talking through how these drugs actually work in the kidney.Dr. Arreaza: Yes, misunderstanding may lead to unnecessary drug discontinuation.Jordan: Under normal conditions, the afferent arteriole brings blood into the glomerulus, and the efferent arteriole is constricted by angiotensin II. That constriction keeps pressure high in the glomerulus and maintains filtration.Mike: Here's what happens with an ACE inhibitor: you block angiotensin II, the efferent arteriole relaxes, glomerular pressure drops, and GFR dips slightly. Creatinine bumps up a little, and that scares people, but that's actually the whole point—that's how you get kidney protection long-term.Jordan: High intraglomerular pressure causes hyperfiltration injury and scarring over time. Lowering that pressure protects the kidney long-term. The short-term GFR drop is the price you pay for long-term benefits.Dr. Arreaza: So let's talk about CKD, because this is where people panic.Mike: Right. ACE inhibitors and ARBs are not contraindicated in chronic kidney disease. In fact, they're recommended even in advanced stages. They reduce progression to kidney failure by about a third.Jordan: The key is how you use them. Start low. Check creatinine and potassium one to two weeks after starting, then periodically. A creatinine rise up to 30% from baseline is acceptable. That's not kidney injury, that's physiology.Dr. Arreaza: And what about potassium creeping up?Mike: You adjust the dose or add a potassium binder. You don't just automatically stop the drug.Dr. Arreaza: Now there is one absolute contraindication everyone needs to know about! (board exam test)Jordan: Bilateral renal artery stenosis. This is the big one. In these patients, the kidneys are completely dependent on angiotensin II–mediated efferent constriction to maintain GFR. Take that away, and GFR collapses.Mike: Creatinine can jump dramatically within days. If you see a creatinine rise of 20% or more shortly after starting an ACE inhibitor, you should be thinking about bilateral renal artery stenosis and stopping the drug immediately.Dr. Arreaza: After revascularization, though, many patients can tolerate ACE inhibitors again, so this isn't always permanent. What about cardiorenal syndrome? That's where things get uncomfortable.Mike: It is uncomfortable, but cardiorenal syndrome isn't a contraindication. These patients have severe heart failure and kidney disease, and their mortality is actually higher than patients with heart failure alone.Jordan: ACE inhibitors still reduce mortality and slow kidney disease progression in this group. Studies show that stopping ACE inhibitors during acute heart-failure admissions increases in-hospital mortality three- to four-fold.Dr. Arreaza: So we are cautious, but we don't avoid it.Mike: Exactly. Start low, titrate slowly, monitor labs closely, accept up to a 30% creatinine rise. You only stop if kidney function keeps worsening, or potassium gets dangerously high.Dr. Arreaza: Alright. Let's move on. What about mineralocorticoid receptor antagonists… MRA?Jordan: Spironolactone or eplerenone might reduce hospitalizations in HFpEF, but the data is mixed. This is more of a “select patients” situation.Mike: And you have to watch potassium and kidney function carefully, especially if they're already on an ACE inhibitor or ARB.Dr. Arreaza: What about sacubitril-valsartan, also known as Entresto®?Mike: Entresto may help patients with mildly reduced EF roughly in the 45 to 57% range. It's not first-line for HFpEF, but in select patients, it's reasonable.Dr. Arreaza: Now let's clarify one of the biggest sources of confusion: beta blockers.Jordan: Beta blockers are not a treatment for HFpEF itself. They're only indicated if the patient has another reason to be on them, like coronary disease or atrial fibrillation.Mike: And timing really matters here. You absolutely do not start beta blockers during acute decompensated heart failure. Their negative inotropic effects can make things worse when patients are volume overloaded.Jordan: But, and this is critical, you also don't stop them if the patient is already taking one. Abrupt withdrawal causes a sympathetic surge and dramatically increases mortality.Dr. Arreaza: If a patient is admitted on a beta blocker, what do we do?Mike: Continue it at the same dose or reduce it slightly if they're really unstable. Once they're euvolemic and stable, you can carefully titrate up.Jordan: And watch for chronotropic incompetence. HFpEF patients often rely on heart-rate response to exercise, and beta blockers can worsen exercise intolerance.Dr. Arreaza: Beyond medications, HFpEF is really about treating comorbidities. Aerobic activity can be an initial strategy to improve exercise intolerance and has evidence of improving aerobic function and quality of life. Sodium restriction: improves symptoms, does not decrease risk of death or hospitalizations.Mike: Hypertension control is huge. For diabetes, the SGLT-2 inhibitors will perform double duty. For obesity, weight loss improves symptoms, and GLP-1 agonists like semaglutide are absolute gamechangers.Jordan: Don't forget sleep apnea, atrial fibrillation, and lifestyle. Exercise improves the quality of life, even if it doesn't change hard outcomes. Lifestyle is the main treatment. Dr. Arreaza: And when should you refer to cardiology?Mike: You should refer when the diagnosis isn't clear; symptoms are not responding to treatment, difficult volume management, end-organ dysfunction, or if you are concerned about advanced heart failure.Dr. Arreaza: So, it has been a great discussion. What is the takeaway?Mike: HFpEF treatment isn't about one magic drug -- it's about volume control, SGLT2 inhibitors, smart use of RAAS blockade, and aggressive management of comorbidities.Jordan: And it's understanding the physiology, so you don't withhold life-saving therapies out of fear.Dr. Arreaza: Well said. If you found this helpful, share it with a friend or colleague and rate us wherever you listen. This is Dr. Arreaza, signing off.Jordan/Mike: Thanks! Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Barzin A, Barnhouse KK, Kane SF. Heart Failure With Preserved Ejection Fraction. Am Fam Physician. 2025;112(4):435-440.Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation. 2022;145(18):e895-e1032.Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC expert consensus decision pathway on management of heart failure with preserved ejection fraction. J Am Coll Cardiol. 2023;81(18):1835-1878.Anker SD, Butler J, Filippatos G, et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med. 2021;385(16):1451-1461.Solomon SD, McMurray JJV, Claggett B, et al. Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2022;387(12):1089-1098.Pitt B, Pfeffer MA, Assmann SF, et al. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370(15):1383-1392.Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction. Lancet. 2003;362(9386):777-781.Solomon SD, McMurray JJV, Anand IS, et al. Angiotensin-neprilysin inhibition in heart failure with preserved ejection fraction. N Engl J Med. 2019;381(17):1609-1620.Kosiborod MN, Abildstrøm SZ, Borlaug BA, et al. Semaglutide in patients with heart failure with preserved ejection fraction and obesity. N Engl J Med. 2023;389(12):1069-1084.Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nat Med. 2022;28(3):583-590.Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from COVID-19. JAMA Cardiol. 2020;5(11):1265-1273.Basso C, Leone O, Rizzo S, et al. Pathological features of COVID-19-associated myocardial injury. Eur Heart J. 2020;41(39):3827-3835.Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615.Badve SV, Roberts MA, Hawley CM, et al. Effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in adults with estimated GFR less than 60 mL/min per 1.73 m². Ann Intern Med. 2024;177(8):953-963.Navis G, Faber HJ, de Zeeuw D, de Jong PE. ACE inhibitors and the kidney: a risk-benefit assessment. Drug Saf. 1996;15(3):200-211.Textor SC, Novick AC, Tarazi RC, et al. Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease. Ann Intern Med. 1985;102(3):308-314.Hackam DG, Spence JD, Garg AX, Textor SC. Role of renin-angiotensin system blockade in atherosclerotic renal artery stenosis and renovascular hypertension. Hypertension. 2007;50(6):998-1003.Ronco C, Haapio M, House AA, et al. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52(19):1527-1539.Prins KW, Neill JM, Tyler JO, et al. Effects of beta-blocker withdrawal in acute decompensated heart failure. JACC Heart Fail. 2015;3(8):647-653.Jondeau G, Neuder Y, Eicher JC, et al. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure hospitalizED for a decompensation episode. Eur Heart J. 2009;30(18):2186-2192.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Dr. Alanna Morris-Simon, Senior Medical Director for US Medical Affairs at Bayer, describes the symptoms and diagnostics used to classify heart failure and the key at-risk populations for this condition. The rapidly evolving landscape of heart failure treatments now includes the Bayer drug KERENDIA, a non-steroidal MRA approved to reduce cardiovascular death and heart failure in adults with an ejection fraction of 40% or more. This drug is part of an emerging trend to treat multiple related conditions simultaneously  and could prevent the onset of heart failure and treat established heart failure. Alanna explains, "At a basic level, heart failure is a clinical syndrome, and that's important. I'm actually a heart failure cardiologist as well. And so this is important because patients have to have signs and symptoms. And those signs and symptoms really result from the heart being unable to either fill with blood properly or squeeze that blood out in a way that meets the body's demands. Either way, patients experience the same symptoms, and those include symptoms like swelling and weight gain, shortness of breath, either at rest or with activity, fatigue, abdominal swelling and bloating, loss of appetite, as well as other symptoms."   "If a doctor or a clinician suspects a diagnosis of heart failure, 99.99% of the time, they'll start by ordering an echocardiogram or a heart ultrasound. Of course, the guidelines tell us to get a chest X-ray, get labs, those sorts of things. But really, we make the diagnosis for the most part based on the results of an echocardiogram because that echocardiogram allows us to visualize how the heart is pumping. It allows us to classify the type of heart failure so that if we see that the squeeze of the heart is impaired, we call that heart failure with reduced ejection fraction. And that's when the ejection fraction or EF is 40% or less. If the EF is in the 41 to 49% range, we classify that as heart failure with mildly reduced ejection fraction. And if patients have an ejection fraction of 50% or greater, we call that heart failure with preserved ejection fraction or HFpEF."   "And we were excited that the FDA actually granted a priority review for KERENDIA because this really only occurs when the FDA recognizes that a treatment can fill a significant unmet need for a disease or a population of patients. And lo and behold, in July of 2025, finerenone was approved by the FDA under the trade name KERENDIA to reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in adults with an ejection fraction of 40% or more." #Bayer #Finerenone #Pharma #HeartFailure #HFpEF #HFmrEF #MRA #UnmetNeed #Cardiology #KERENDIA #FDA #CardiovascularHealth #MedicalBreakthrough #PatientCare #Innovation Bayer.com Download the transcript here

Dr. Alanna Morris-Simon, Senior Medical Director for US Medical Affairs at Bayer, describes the symptoms and diagnostics used to classify heart failure and the key at-risk populations for this condition. The rapidly evolving landscape of heart failure treatments now includes the Bayer drug KERENDIA, a non-steroidal MRA approved to reduce cardiovascular death and heart failure in adults with an ejection fraction of 40% or more. This drug is part of an emerging trend to treat multiple related conditions simultaneously  and could prevent the onset of heart failure and treat established heart failure. Alanna explains, "At a basic level, heart failure is a clinical syndrome, and that's important. I'm actually a heart failure cardiologist as well. And so this is important because patients have to have signs and symptoms. And those signs and symptoms really result from the heart being unable to either fill with blood properly or squeeze that blood out in a way that meets the body's demands. Either way, patients experience the same symptoms, and those include symptoms like swelling and weight gain, shortness of breath, either at rest or with activity, fatigue, abdominal swelling and bloating, loss of appetite, as well as other symptoms."   "If a doctor or a clinician suspects a diagnosis of heart failure, 99.99% of the time, they'll start by ordering an echocardiogram or a heart ultrasound. Of course, the guidelines tell us to get a chest X-ray, get labs, those sorts of things. But really, we make the diagnosis for the most part based on the results of an echocardiogram because that echocardiogram allows us to visualize how the heart is pumping. It allows us to classify the type of heart failure so that if we see that the squeeze of the heart is impaired, we call that heart failure with reduced ejection fraction. And that's when the ejection fraction or EF is 40% or less. If the EF is in the 41 to 49% range, we classify that as heart failure with mildly reduced ejection fraction. And if patients have an ejection fraction of 50% or greater, we call that heart failure with preserved ejection fraction or HFpEF."   "And we were excited that the FDA actually granted a priority review for KERENDIA because this really only occurs when the FDA recognizes that a treatment can fill a significant unmet need for a disease or a population of patients. And lo and behold, in July of 2025, finerenone was approved by the FDA under the trade name KERENDIA to reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in adults with an ejection fraction of 40% or more." #Bayer #Finerenone #Pharma #HeartFailure #HFpEF #HFmrEF #MRA #UnmetNeed #Cardiology #KERENDIA #FDA #CardiovascularHealth #MedicalBreakthrough #PatientCare #Innovation Bayer.com Listen to the podcast here

Da li je predsednik Srbije postao TikToker? U 223. epizodi Njuz Podkasta analiziramo nadrealni "duel" između Aleksandra Vučića i Bake Praseta. Dok predsednik pokušava da osvoji mlađu publiku na TikToku, mi se pitamo: da li je ovo promocija kocke i rijaliti kulture na državnom nivou? Osim viralnog spoja Vučića i Bake Praseta, bavimo se i drugim gorućim temama: Zašto RTS nije prenosio finale Novaka Đokovića i da li je Nole postao neprijatelj režima? Istražujemo i skandal u Petoj gimnaziji (slučaj "Dronka"), kontroverzni "Mrdićev zakon" koji preti pravosuđu, kao i aferu sa "kolačarom" iz redova SNS-a.

Dr. Mary Newport shares groundbreaking research analyzing cholesterol profiles across 40 years of studies, challenging conventional wisdom about saturated fat and heart health. We discuss her findings on MCT oil for brain health, the 288 caregiver reports showing cognitive improvements, and practical protocols for using coconut oil and ketones.Dr. Mary Newport, physician and Alzheimer's researcher, joins us to discuss her latest research that challenges decades of assumptions about coconut oil and saturated fat. In this interview, we explore: • Her comprehensive analysis of 26 studies spanning 40 years (984 lipid profiles) showing coconut oil's unexpected effects on cholesterol • The 288 caregiver reports documenting improvements in memory, cognition, and daily function • How medium-chain triglycerides (MCTs) may provide an alternative fuel source for aging brains • Practical protocols for incorporating coconut oil and MCT oil into your diet • The controversial history of dietary fat guidelines and the trans fat problem • Why the medical establishment has been slow to acknowledge ketone research Dr. Newport's work began with her husband Steve's dramatic response to coconut oil after his early-onset Alzheimer's diagnosis. Her research has since expanded to include hundreds of case reports and comprehensive lipid analysis.

Stroke risk doesn't begin suddenly it builds silently through inflammation and vascular damage. In Part 2, Dr. Ana Rosa explains why inflammation, insulin resistance, and unstable plaque are the true drivers of stroke risk, and why blockage percentage alone doesn't tell the full story. Learn how doctors use imaging like carotid ultrasound, MRI, and MRA to identify dangerous soft plaque early and how daily lifestyle habits can slow, stop, or even reverse vascular damage before it leads to stroke.

Friend of the pod Weeza AKA Australia's First Attractive Comedian AKA Elouise Eftos is back!! What better pair to talk about insecure men, and to break down some cooked r/MensRights posts? Babe, you're in for a treat. LINKS Vote for Dancing2 in the Hottest 100 https://www.abc.net.au/triplej/countdown/hottest100 Follow Elouise Eftos on IG @weezasqueeza See Elouise live https://linktr.ee/elouise Check out @itsalotpod on IG at https://bit.ly/itsalot-instagram Review the podcast on Apple Podcasts https://bit.ly/ial-review Follow LiSTNR Entertainment on IG @listnrentertainment Follow LiSTNR Entertainment on TikTok @listnrentertainment Get instructions on how to access transcripts on Apple podcasts https://bit.ly/3VQbKXY CREDITS Host: Abbie Chatfield @abbiechatfield Guest: Elouise Eftos @weezasqueeza Executive Producer and Editor: Amy Kimball @amy.kimballDigital and Social and Video Producer: Oscar Gordon @oscargordon Social and Video Producer: Justin Hill @jus_hillIt's A Lot Social Media Manager: Julia ToomeyManaging Producer: Sam Cavanagh Find more great podcasts like this at www.listnr.com/See omnystudio.com/listener for privacy information.

Download the Guide here: https://cdfinancial.com FREE 15-minute call: https://calendly.com/charlesdzama/complimentary-15-minute-phone-call-youtubeAre you truly ready to retire? This episode of the CD Financial Podcast dives into key questions about eligibility and financial management, helping you to understand the path to getting ready for retirement. We discuss essential aspects of retirement planning to ensure your financial planning is robust.Newsletter: https://cdfinancial.com/newsletterSocials:Instagram: https://instagram.com/cdfinancial.llc/Facebook: https://facebook.com/cdfinancialLinkedIn: https://linkedin.com/company/cd-financial

 Ted speaks with J. Irons of Miovic Reinhardt Associates, a Seattle-based design-build firm known for its deep commitment to craftsmanship, sustainability, and client-centered building. J. reflects on his early love of design, his path through Berkeley and the University of Washington, and how curiosity led him from architecture into business development and leadership.They explore the unique design culture of the Pacific Northwest — from biophilic buildings and civic responsibility to the influence of Seattle's natural beauty on the region's architectural identity. J. discusses the values that drive today's homeowners, including the desire for meaningful spaces, outdoor living, and wellness-focused environments.Ted and J. also examine how construction has evolved, the impact of rising costs, and why permitting delays remain one of the industry's biggest frustrations. J. offers perspective on improving efficiency, managing client expectations during long timelines, and how MRA approaches cost planning rather than cost cutting.The episode closes with a thoughtful discussion on AI: its misconceptions, its potential to enhance efficiency, and why human creativity, curiosity, and connection remain irreplaceable in the building process.TOPICS DISCUSSED01:30 Early Career & Path Into Architecture04:20 Curiosity, Sales & Becoming a Rainmaker08:10 Understanding Clients Through Deep Listening10:00 Childhood Creativity & Design Foundations14:00 Seattle's Design Culture & Regional Inspiration17:10 West Coast Mindset & Sense of Place21:00 Wellness, Balance & Human-Centered Spaces23:00 What Clients Value in Their Homes25:30 Outdoor Living & Modern Landscaping28:30 Evolution of Residential Construction30:10 Costs, Efficiency & Permitting Delays & System Challenges37:00 AI Misconceptions & Practical Uses47:20 Creativity, Curiosity & Human Value48:45 Human Connection & The Role of Sales CONNECT WITH GUESTJ. IronsWebsiteLinkedInInstagramKEY QUOTES FROM EPISODE"Alignment gives people the space to connect""People are yearning for connection""Engagement is about creating opportunities"

Novo Nordisk, the pharmaceutical company behind popular GLP-1 medications like Wegovy and Ozempic, recently announced that its phase 3, two-year trial examining GLP-1 medications for Alzheimer's failed to produce a significant reduction in disease progression.While these results are discouraging, they may have revealed something vital about Alzheimer's treatment.In this video, Dr. Bret Scher breaks down the recent failure of Novo Nordisk's evoke and evoke+ trials and what it teaches us about the limitations of a drug-only approach to Alzheimer's treatment.Key topics covered:Why GLP-1s may not be enough for Alzheimer'sThe link between glucose metabolism and brain energy failureHow ketones offer an alternative fuel for the brainEarly research on ketogenic therapy for cognitive impairmentWhy nutritional interventions deserve more scientific attentionWith Alzheimer's affecting millions and costing billions, it's time to shine a light on metabolic strategies that directly support brain energy, reduce inflammation, and improve cognitive function.

Tim and Guy are up against it. It's only the second watch and Guy fears the pair are in too deep a water already. That is a scary prospect for two men looking down the barrel of 12 more watches in just 4 short days. Let us gaze upon the beautiful cinematography and excellent acting of Joker 2 and marvel at how it stills somehow manages to be a really stinky film. Tim offers advice for his friends in the MRA community and swears to all Holy powers above that David Bowie most probably played The Sims.Support us, and watch these episodes early, ad-free and in video form (plus bonus content) at twioat.substack.com Hosted on Acast. See acast.com/privacy for more information.

In a small mining town in the Colorado Rockies, a man and his dog walked into the mountains and never returned. Less than a year later, another man working in the exact same location took interest in the disappearance from the year before. Soon he would follow the same trail and he too would vanish.  One mountain, two men, countless theories.SourcesFRNWH Unsolved Strange Outdoors CBSNEWS Chicago Tribune Historic Mysteries Colorado.gov MRA.orgSupport us on Patreon for as little as $1 a month, with benefits starting at the $3 tier!Follow us on Instagram at offthetrailspodcastFollow us on Facebook at Off the Trails PodcastIf you have your own outdoor misadventure (or adventure) story that you'd like us to include in a listener episode, send it to us at offthetrailspodcast@gmail.com  Please take a moment to rate and review our show, and a big thanks if you already have!**We do our own research and try our best to cross-reference reliable sources to present the most accurate information we can. Please reach out to us if you believe we have mispresented any information during this episode, and we will be happy to correct ourselves in a future episode.

In this listener mailbag episode, SLP grad students, clinicians, and private practice owners call the Minivan Meltdown line to share what's really happening behind the scenes in our field.First, a grad student with a repaired bilateral cleft lip and palate describes a supervisor who told her she “can't be a good SLP” because of her speech difference. Dr. Jeanette Benigas and Preston Lewis, SLP, break down discrimination in training, how CCC standards exclude disabled and Deaf clinicians, and why difference is not disorder.Next, a medical SLP who accidentally dropped her CCC in 2008 shares what happened when she kept her state license and kept working. We talk shame culture, confusion around the CCC, mutual recognition agreements, and why so many CCC “rules” fall apart under scrutiny.Finally, a private practice owner in Kentucky explains how pediatric F-codes (like F80) were treated as “mental health” diagnoses, triggering visit caps, mass denials, and 12–18 month reimbursement delays. We unpack F-code chaos, the Mental Health Parity Act, and why small practices shouldn't be the ones stuck fighting insurers.If you've ever been gaslit by a supervisor, confused by the CCC, or crushed by insurance games, this episode is your reminder: you're not the problem. The system is.Stop paying to track ASHA-approved CEUs. Save your money and set up for a FREE CEU/PDH tracker with Speech Therapy PD. While you are there, get $10 off a professional subscription with the code FixSLP10!

Pulsatile tinnitus — the perception of a rhythmic sound in sync with the heartbeat — can be a key indicator of underlying vascular or structural pathology. In this episode, JNIS new Editor-in-Chief Dr. Michael Chen speaks with Dr. Madhavi Duvvuri and Dr. Matthew Robert Amans, authors of Non-invasive imaging modalities for diagnosing pulsatile tinnitus: a comprehensive review and recommended imaging algorithm. They are both from the University of California San Francisco, USA. They discuss the current evidence base, highlight the strengths and limitations of non-invasive imaging techniques such as MRI, MRA, CT, and CTA, and outline a practical algorithm for streamlining diagnosis.    Please subscribe to the JNIS podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/4aZmlpT) or Spotify (https://spoti.fi/3UKhGT5). We'd love to hear your feedback on social media - @JNIS_BMJ.

Specijalna epizoda sa specijalnom gošćom! U goste nam je konačno stigla Iva Parađanin Lalić ( @tamponzona , Joj majko), a sa njom i priče o majčinstvu bez filtera, nerealnim očekivanjima i zašto se o teškim stranama roditeljstva premalo govori. Ali to nije sve! Spremili smo vam preporuke za svako raspoloženje: od "feel-good" serija koje će vam vratiti veru u život, do verovatno najmračnije i najteže drame koju smo ikada gledali. Prisetili smo se i naše opsesije španskim serijama iz '90-ih (Kralj stočara, seća li se ko?).

Heart failure remains a leading cause of hospitalization, prompting ongoing research into treatment strategies that improve outcomes for patients. A recent study explores the potential of combining an MRA agent and SGLT2 inhibitor, showing meaningful clinical benefit while also reinforcing the need for thoughtful patient selection and safety monitoring. Tune in to explore how this evidence may shape pharmacist-driven care and contribute to more confident, individualized treatment decisions.HOSTJoshua Davis Kinsey, PharmDVP, EducationCEimpactGUESTZachary Cox, PharmDProfessorLipscomb University College of PharmacyJoshua Davis Kinsey has no relevant financial relationships to disclose. Zachary Cox is a consultant for Roche, Reprieve Cardiovascular, Abiomed, Vectorious, Kestra Medical Technologies, and WhiteSwell. He was also a consultant for Lexicon Pharmaceuticals (ended 2025) and conducted research for AstraZeneca (ended 2024). All relevant financial relationships have been mitigated.  Pharmacists, REDEEM YOUR CPE HERE!CPE is available to Health Mart franchise members onlyTo learn more about Health Mart, click here: https://join.healthmart.com/CPE INFORMATION Learning ObjectivesUpon successful completion of this knowledge-based activity, participants should be able to:1. Describe the clinical evidence supporting the use of multiple drug classes in combination therapy for heart failure.2. Identify pharmacist considerations for evaluating patient-specific factors related to efficacy and safety of combination treatment approaches.0.05 CEU/0.5 HrUAN: 0107-0000-25-299-H01-PInitial release date: 10/20/2025Expiration date: 10/20/2026Additional CPE details can be found here.

Heart failure remains a leading cause of hospitalization, prompting ongoing research into treatment strategies that improve outcomes for patients. A recent study explores the potential of combining an MRA agent and SGLT2 inhibitor, showing meaningful clinical benefit while also reinforcing the need for thoughtful patient selection and safety monitoring. Tune in to explore how this evidence may shape pharmacist-driven care and contribute to more confident, individualized treatment decisions.HOSTJoshua Davis Kinsey, PharmDVP, EducationCEimpactGUESTZachary Cox, PharmDProfessorLipscomb University College of PharmacyJoshua Davis Kinsey has no relevant financial relationships to disclose. Zachary Cox is a consultant for Roche, Reprieve Cardiovascular, Abiomed, Vectorious, Kestra Medical Technologies, and WhiteSwell. He was also a consultant for Lexicon Pharmaceuticals (ended 2025) and conducted research for AstraZeneca (ended 2024). All relevant financial relationships have been mitigated.  Pharmacist Members, REDEEM YOUR CPE HERE! Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)CPE INFORMATIONLearning ObjectivesUpon successful completion of this knowledge-based activity, participants should be able to:1. Describe the clinical evidence supporting the use of multiple drug classes in combination therapy for heart failure.2. Identify pharmacist considerations for evaluating patient-specific factors related to efficacy and safety of combination treatment approaches.0.05 CEU/0.5 HrUAN: 0107-0000-25-299-H01-PInitial release date: 10/20/2025Expiration date: 10/20/2026Additional CPE details can be found here.Follow CEimpact on Social Media:LinkedInInstagram

On this episode of Together We Win, your hosts, President Steve Clark and VP Kerry Miller, sit down with Chef Eric Leblanc, MRA 2025 Chef of the Year and Culinary Director of Burtons Grill & Bar and Red Heat Tavern. From his early days in the kitchen to leading major restaurant operations, Eric's career is a masterclass in what a passion for the culinary world can achieve. He shares some of his favorite experiences along the way and gives us a behind-the-scenes look at exciting upcoming projects, including the opening of Burtons Grill & Bar's 24th location. You won't want to miss it!

Dubrovnik koji je postao kulisa, umiveno ustaštvo na ulicama Zagreba, potrošnja koja nadomješta ljudskost, majčinstvo o kakvom nije pristojno govoriti, banke kao sablasni stupovi naših života, emocije kakve ne viđamo u reklamama, a osjećamo ih tako snažno... To je svijet koji Maša Kolanović istražuje u svojoj novoj zbirci priča "Poštovani kukci". Autorica tekstom i crtežima oblikuje onaj sablasni i teško izrecivi višak materijalne strane ljudske egzistencije, dok smještanje priča u razdoblje tranzicije u Hrvatskoj dodatno pojačava njihov jezivi efekt. "Poštovane kukce" žanrovski bi se moglo opisati kao tranzicijsku gotiku, postsocijalističku zonu sumraka, jezivo stvarnosnu prozu… Mračno i apsurdne, a opet duboko intimne, snažne i društveno osjetljive priče. Nagrada Europske unije za književnost 2020. i Godišnja nagrada Vladimir Nazor 2020. Redateljica: Stephanie Jamnicky, dramatizacija: Kristina Kegljen

SLP fear is real, but facts are louder. In this Fix SLP Podcast episode, Dr. Jeanette Benigas, SLP, and Preston Lewis, MS/SLP, unpack the top fears heard daily: Praxis retakes, reinstating the ASHA CCC, supervision requirements, getting overlooked by misinformed employers, whether CCC status affects international portability via the Mutual Recognition Agreement (MRA) with the UK, Canada, Ireland, Australia, and New Zealand, and how employer education, not court battles, drives SLP autonomy and better jobs.This episode shows how to turn fear into facts: evaluating your local job market, approaching HR about removing CCC requirements, clarifying supervision rules, and proving that patient outcomes, not extra letters, define true competence in the field.Thank you to our sponsor, ⭐️ Informed Jobs, ⭐️ connecting SLPs with meaningful job opportunities and career resources to keep you informed and empowered. Explore more at informedslp.com. Just click the menu, then select "Jobs"!

Dr. Jeff Maki discusses current considerations for contrast enhanced MRA exams as well as liver imaging Claim your Credit Here This MR iCast episode is supported by Bracco Diagnostics Inc. through an unrestricted educational grant.

U najnovijoj epizodi Njuz Podkasta EP203 zaranjamo u epicentar haosa: otkriven je tajni plan Aleksandra Vučića za gašenje N1 i Nove S! Detaljno analiziramo ekskluzivni snimak koji je objavio KRIK i pitamo se da li je ovo kraj slobodnih medija u Srbiji. Pored toga, vraćamo se na uzavreli avgust i proteste "Srbija protiv nasilja". Komentarišemo najbizarnije trenutke – od Vučićeve povrede na staklu i tuče naprednjaka u Veterniku, do viralnih scena sa momkom sa fajtalicom. Zaranjamo u fenomen "Ćacilenda", analiziramo hapšenje Tome Mone i Vesićevu bolest, i ne zaobilazimo sramotu sa pismom Gardijanu. Na kraju, bavimo se opasnim napadom vlasti na Univerzitet i Filozofski fakultet i Đukinom idejom o pobedi "stranačke pešadije".

Inštitut za slovensko kulturo v Benečiji je kulturno in jezikovno središče zamejskih Slovencev v Italiji, ki prebivajo od Kanalske doline in Rezije do Terskih in Nadiških dolin. Ustanovljen je bil leta 2006 z namenom, da kot močna krovna organizacija omogoči bolj učinkovito uveljavljanje in ohranjanje slovenskega jezika in kulture v krajih, kjer je pripoved zgodovine v odnosu do Slovencev težka in mračna. “Prišel sem z dežja pod kap.” To preprosto reklo zgovorno označuje razmere v Benečiji takoj po drugi svetovni vojni. S temi besedami se začne knjiga Mračna leta Benečije, ki sta jo pod psevdonimom NAZ napisala duhovnika Marino Qualizza in Božo Zuanella. Knjiga o delovanju tajnih organizacij v Benečiji je izšla v italijanščini leta 1996 v Čedadu, slovenski prevod pa je Cankarjeva založba v Ljubljani objavila dve leti pozneje. Duhovnika sta bila za svoje delo preganjana na sodišču, pogum, s katerim sta prekinila molk, dolg desetletja, pa naj bi vplival tudi na njuni profesionalni karieri. Oba sta v visoki starosti umrla maja 2025. Ravno tisti mesec pa je Inštitut za slovensko kulturo v Benečiji izvolil novo vodstvo sedmih posameznic različnih generacij, vseh izredno dejavnih na raznih področjih življenja slovenske manjšine v Benečiji. Prvi večji dogodek so članice novega vodstva posvetile ravno umrlima duhovnikoma in lokalno skupnost pozvale k skupnemu branju njunih besed. Besedilo je bilo na voljo tako v slovenščini kot v italijanščini, branje pa je spodbudilo tudi marsikatero zgodbo starejših generacij, ki so ji lahko prisluhnili mladi, ki teh časov niso doživeli. Predstavnice vodstva smo povabili k pogovoru o tem, kako vidijo vlogo Inštituta za slovensko kulturo v regiji in širše ter položaju slovenske manjšine v sedanjih časih.

Send us a textGeorge Adams is in his 7th year as the Head Strength and Conditioning Coach at Madison-Ridgeland Academy. Adams oversees all aspects of the MRA athletics strength and conditioning program. Since arriving at MRA, Adams has been a part of eight state championships (three football, three boys' & girls' track and field, and two boys' basketball). He has served on the NHSSCA Mississippi Advisory Board since 2020, was named the 2022 Mississippi State Coach of the Year, and is now the Mississippi State Director for the association. Coach Adams has also served as a strength and conditioning coach with the Minnesota Vikings and at the following college athletic programs: Methodist University, Southern Miss, Marshall University, University of Georgia, Embry-Riddle Aeronautical University, and the University of Georgia. Periodization for high school sportsSpeed and agility drillsInjury prevention for teen athletesCoaching high school athletesWeightlifting technique youthStrength benchmarks for athletesIn-season vs offseason liftingAthletic performance podcastHigh school football trainingYouth performance traininghttps://youtube.com/@platesandpancakes4593https://instagram.com/voodoo4power?igshid=YmMyMTA2M2Y=https://voodoo4ranch.com/To possibly be a guest or support the show email Voodoo4ranch@gmail.comhttps://www.paypal.com/paypalme/voodoo4ranch

Join us on the Fireside Chat as we speak with Guy. He has been an MRA for a long time done a few small bits of advocacy here and there, wrote an article for AVFM and fancies himself as a social scientist but totally unqualified, kinda like a male version of Allison in that regard.

In this month's episode of Together We Win, MRA's President Steve Clark and VP Kerry Miller sit down with Kathi Turner, CEO of Turner's Seafood Grill & Market and the newest Chair of the Massachusetts Restaurant Association Board. Together, they discuss the evolution of the hospitality industry and the enduring importance of customer connection in an increasingly digital world. From embracing new technologies to staying rooted in people-first values, Kathi shares insights from her years of leadership and offers a thoughtful look at where the industry is headed. Whether you're leading a team or greeting guests at the door, this episode is a powerful reminder that success in hospitality still starts with human connection.

In this podcast, Ty J. Gluckman, MD, MHA, discusses the pivotal phase III FINEARTS-HF trial and how the treatment landscape is evolving for patients with heart failure (HF) with mildly reduced or preserved ejection fraction, including:The emerging role of mineralocorticoid receptor antagonists in HF careFinerenone's efficacy in reducing composite cardiovascular death and worsening HF events Why safety must be monitored, especially considering hyperkalemia riskWhere HF guideline recommendations lack compared with the current evidence PresenterTy J. Gluckman, MD, MHAMedical Director, Center for Cardiovascular Analytics, Research, and Data Science (CARDS)Providence Heart InstituteProvidence Health SystemPortland, OregonProgram page: https://bit.ly/448XcH0

Barron's Deputy Editor Ben Levisohn and Associate Editor Al Root are joined by MRA technical analyst John Kolovos to discuss the week's earnings, Tesla's robotaxi deadline, and what the charts say about the market right now. Learn more about your ad choices. Visit megaphone.fm/adchoices

On this week's episode, I'm discussing the Federal Employees Retirement System, or FERS, a program that covers nearly all civilian federal workers. If you're a federal employee curious about when you're eligible to retire, how your pension is calculated, what the Thrift Savings Plan offers, or how special early retirement and survivor benefits work, this episode is your go-to resource.  We're breaking down the three key components of FERS: your  Basic Benefit Plan (a pension), Social Security, and the Thrift Savings Plan, as well as important details like cost-of-living adjustments and tax considerations. Whether you're just starting your federal career or planning your retirement right now, you'll get practical insights to help you make the most of your retirement benefits. You will want to hear this episode if you are interested in... [00:00] I share an overview of how FERS provides federal employees' retirement benefits. [05:02] Your basic benefit plan is calculated using the highest average salary over three consecutive years, often the final service years. [09:52] Federal employees retiring at 55-57 receive a FERS supplement until age 62, calculated by years of service/40 times the estimated Social Security benefit. [11:41] Benefits include cost-of-living adjustments for those 62+ or in special roles, aligned with consumer price index increases. [14:52] FERS survivor benefits are available if the deceased had at least 10 years of service. What is FERS, and Who Does It Cover? As one of the most significant employment sectors in the United States, the federal government supports over 3 million workers, the majority of whom participate in the Federal Employees Retirement System (FERS). If you're a federal employee, understanding FERS is vital to planning a comfortable and financially secure retirement. The Federal Employees Retirement System (FERS) is the primary retirement plan for U.S. civilian federal employees hired after 1983. According to the Office of Personnel Management, FERS provides retirement income from three sources:   1. The Basic Benefit Plan (a pension). 2. Social Security. 3. The Thrift Savings Plan (TSP), similar to a private sector 401(k). FERS covers different federal professionals, from law enforcement and firefighters to engineers, analysts, and other administrative roles. Special provisions exist for high-risk positions such as air traffic controllers and certain law enforcement officers, which affect their benefit calculations and retirement age. When Can You Retire Under FERS? Retirement eligibility under FERS primarily depends on age and years of credible service. The key term here is Minimum Retirement Age (MRA), which varies based on birth year, from 55 for those born before 1948 to 57 for workers born in 1970 or later. Retirement options include:   Age 62 with 5 years of service. Age 60 with 20 years of service.  MRA with 30 years of service. MRA with 10 years of service (MRA+10), though benefits are reduced by 5% for each year under age 62. Early retirement is available in some situations, such as involuntary separations or major agency reorganizations. In those cases, eligibility can be as early as age 50 with 20 years of service or at any age with 25 years of service. Calculating Your Basic Pension Benefit The FERS pension is calculated using your “high-3” average salary, the highest three consecutive years of basic pay, usually your last three years. The formula generally provides 1% of your high-3 salary for each year of government service (increases to 1.1% if you retire at 62 or older with 20+ years). Special categories, like federal law enforcement or air traffic controllers, receive 1.7% for the first 20 years and 1% thereafter. For example: If you retire at 57 with 30 years of service and your high-3 average is $165,000:   - 30 years x 1% = 30%   - $165,000 x 30% = $49,500 annual pension The FERS Supplement Since some federal employees retire before they're eligible for Social Security (age 62), FERS includes a Special Retirement Supplement. This bridges the income gap until you can claim Social Security, calculated as:   Years of service ÷ 40 x age-62 Social Security benefit For example, with 30 years of service and a projected Social Security benefit of $2,500 per month, the supplement would be $1,875 per month from retirement until age 62. Understanding FERS is essential for federal workers considering retirement. Regularly reviewing your retirement strategy, estimating future benefits, and taking advantage of financial planning resources can help you maximize your retirement security.  Resources Mentioned Retirement Readiness Review Subscribe to the Retire with Ryan YouTube Channel Download my entire book for FREE  US Office of Personnel Management (OPM) FERS Information  Connect With Morrissey Wealth Management  www.MorrisseyWealthManagement.com/contact   Subscribe to Retire With Ryan  

Thank you for your wonderful and helpful videos on postponed retirement. The one question I have remaining is - I understand that if I retire at MRA and 10 that I cannot take my annuity without penalty until I am 62. Is there an option to continue with health benefits at time of resignation and not collect annuity until age 62 or do you have to start both at the same time? - Nancy  https://zurl.co/yidsG

Listener feedback, resistant hypertension, K-binders for MRA use in heart failure, nutritional epidemiology, and a positive study for vitamin D are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I Listener Feedback Califf editorial https://www.jacc.org/doi/10.1016/j.jaccas.2020.01.003 II Resistant HTN Positive Topline Results for Lorundrostat in Hypertension https://www.medscape.com/viewarticle/positive-topline-results-lorundrostat-hypertension-2025a100062e III K-Binding REALIZE K Trial https://doi.org/10.1016/j.jacc.2024.11.014 Packer Editorial https://doi.org/10.1016/j.jacc.2025.01.011 Diamond Trial EHJ https://doi.org/10.1093/eurheartj/ehac401 REALIZE K Commentary https://www.medscape.com/viewarticle/realize-k-new-potassium-binder-help-keep-spiro-board-2024a1000m2c IV Butter vs Plant-based Oils and Mortality JAMA-IM Study https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2831265 Is Red Meat Healthy? Multiverse Analysis Has Lessons Beyond Meat https://www.medscape.com/viewarticle/red-meat-healthy-multiverse-analysis-has-lessons-beyond-meat-2024a10008qv Cookbook Review https://doi.org/10.3945/ajcn.112.047142 V Vitamin D Impact Factor https://www.medscape.com/viewarticle/rare-win-vitamin-d-this-time-ms-2025a10005ul D-Lay trial https://jamanetwork.com/journals/jama/fullarticle/2831270 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

The following question refers to Sections 7.3.3 and 7.3.6 of the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure.The question is asked by Palisades Medical Center medicine resident & CardioNerds Academy Fellow Dr. Maryam Barkhordarian, answered first by UTSW AHFT Cardiologist & CardioNerds FIT Ambassador Dr. Natalie Tapaskar, and then by expert faculty Dr. Robert Mentz.Dr. Mentz is associate professor of medicine and section chief for Heart Failure at Duke University, a clinical researcher at the Duke Clinical Research Institute, and editor-in-chief of the Journal of Cardiac Failure. Dr. Mentz has been a mentor for the CardioNerds Clinical Trials Network as lead principal investigator for PARAGLIDE-HF and is a series mentor for this very Decipher the Guidelines Series. For these reasons and many more, he was awarded the Master CardioNerd Award during ACC22.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. American Heart Association's Scientific Sessions 2024As heard in this episode, the American Heart Association's Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It's a special year you won't want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!When registering, use code NERDS and if you're among the first 20 to sign up, you'll receive a free 1-year AHA Professional Membership! Question #39 Ms. Kay Lotsa is a 48-year-old woman with a history of CKD stage 2 (baseline creatinine ~1.2 mg/dL) & type 2 diabetes mellitus. She has recently noticed progressively reduced exercise tolerance, leg swelling, and trouble lying flat. This prompted a hospital admission with a new diagnosis of decompensated heart failure. A transthoracic echocardiogram reveals LVEF of 35%. Ms. Lotsa is diuresed to euvolemia, and she is started on carvedilol 25mg BID, sacubitril/valsartan 49-51mg BID, and empagliflozin 10mg daily, which she tolerates well. Her eGFR is at her baseline of 55 mL/min/1.73 m2 and serum potassium concentration is 3.9 mEq/L. Your team is anticipating she will be discharged home in the next one to two days and wants to start spironolactone. Which of the following is most important regarding her treatment with mineralocorticoid antagonists?ASpironolactone is contraindicated based on her level of renal impairment and should not be startedBSerum potassium levels and kidney function should be assessed within 1-2 weeks of starting spironolactoneCEplerenone confers a higher risk of gynecomastia than does spironolactoneDThe patient will likely not benefit from initiation of spironolactone if her cardiomyopathy is ischemic in origin Answer #39 ExplanationThe correct answer is B – after starting a mineralocorticoid receptor antagonist (MRA), it is important to closely monitor renal function and serum potassium levels.MRA (also known as aldosterone antagonists or anti-mineralocorticoids) show consistent improvements in all-cause mortality, HF hospitalizations, and SCD across a wide range of patients with HFrEF.