Podcasts about mri

A new MP3 sermon from Generations Radio is now available on SermonAudio with the following details: Title: An Interview with the Inventor of the MRI – A Blessing From God Speaker: Kevin Swanson Broadcaster: Generations Radio Event: Radio Broadcast Date: 12/4/2024 Length: 33 min.

A pragmatic and organized approach is needed to recognize patients with symptomatic Alzheimer Disease in clinical practice, stage the level of impairment, confirm the clinical diagnosis, and apply this information to advance therapeutic decision making. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Gregory S. Day, MD, MSc, MSCI, FAAN, author of the article “Diagnosing Alzheimer Disease,” in the Continuum December 2024 Dementia issue. Dr. Berkowitz is a Continuum® Audio interviewer associate chief medical information officer at the Cleveland Clinic in Cleveland, Ohio. Dr. Day is an associate professor in the Department of Neurology at Mayo Clinic Florida in Jacksonville, Florida. Additional Resources Read the article: Diagnosing Alzheimer Disease Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @AaronLBerkowitz Guest: @GDay_Neuro Full episode transcript available here Dr Jones: This is Doctor Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Berkowitz: This is Dr Aaron Berkowitz, and today I have the pleasure of interviewing Dr Gregory Day about his article on Alzheimer disease, which appears in the December 2024 Continuum issue on dementia. Welcome to the podcast, Dr Day. Would you mind introducing yourself to our audience?  Dr Day: Thanks very much, Aaron. I'm Gregg Day. I'm a behavioral neurologist at Mayo Clinic in Jacksonville, Florida, which means that my primary clinical focus is in the assessment of patients presenting typically with memory concerns and dementia in particular. Dr Berkowitz: Fantastic. Well, as we were talking about before the interview, I've heard your voice many times over the Neurology podcast and Continuum podcast. I've always learned a lot from you in this rapidly changing field over the past couple of years, and very excited to have the opportunity to talk to you today and pick your brain a little bit on this very common issue of evaluating patients presenting with memory loss who may have concerns that they have dementia and specifically Alzheimer disease. So, in your article, you provide a comprehensive and practical approach to a patient presenting for evaluation for possible dementia and the question of whether they have Alzheimer disease. The article is really packed with clinical pearls, practical advice. I encourage all of our listeners to read it. In our interview today, I'd like to talk through a theoretical clinical encounter and evaluation so that I and our listeners can learn from your approach to a patient like this. Let's say we have a theoretical patient in their seventies who comes in for evaluation of memory loss and they and/or their family are concerned that this could be Alzheimer disease. How do you approach the history in a patient like that? Dr Day: It's a great way to approach this problem. And if you're reading the article, know that I wrote it really with this question in mind. What would I be doing, what do we typically do, when we're seeing patients coming with new complaints that concern the patient and typically also concern those that know the best? So be that a family member, close friend, adult child. And in your scenario here, this seventy year old individual, we're going to use all the information that we have on hand. First off, really key, if we can, we want to start that visit with someone else in the room. I often say when talking to individuals who come alone that there's a little bit of irony in somebody coming to a memory assessment alone to tell me all the things they forgot. Some patients get the joke, others not so much, but bringing someone with them really enhances the quality of the interview. Very important for us to get reliable information and a collateral source is going to provide that in most scenarios. The other thing that I'm going to start with, I'm going to make sure that I have appropriate time to address this question. We've all had that experience. We're wrapping up a clinical interview, maybe one that's already ran a little bit late and there's that one more thing that's mentioned on the way out the door: I'm really concerned about my memory or I'm concerned about mom 's memory. That's not the opportunity to begin a memory assessment. That's the opportunity to schedule a dedicated visit. So, assuming that we've got someone else in the room with us, we've got our patient of interest, I'm going to approach the history really at the beginning. Seems like an easy thing to say, but so often patients in the room and their caregivers, they've been waiting for this appointment for weeks or months. They want to get it out all out on the table. They're worried we're going to rush them through and not take time to piece it together. And so, they're going to tell you what's going on right now. But the secret to a memory assessment, and particularly getting and arriving at an accurate diagnosis that reflects on and thinks about cause of memory problems, is actually knowing how symptoms began. And so, the usual opening statement for me is going to be: Tell me why you're here, and tell me about the first time or the first symptoms that indicated there was an ongoing problem. And so, going back to the beginning can be very helpful. This article is focused on Alzheimer disease and our clinical approach to the diagnosis of Alzheimer disease. And so, what I'm going to expect in a patient who has a typical presentation of Alzheimer disease is that there may be some disagreement between the patient and the spouse or other partners sitting in the room with me about when symptoms began. If you've got two partners sitting in the room, maybe an adult child and a spouse, there may be disagreement between them. What that tells me is at the onset, those first symptoms, they're hard to pin down. Symptoms typically emerge gradually in patients with symptomatic Alzheimer disease. They may be missed early on, or attributed or contributed to other things going on in the patient's time of life, phase of life. It's okay to let them sort of duke it out a little bit to determine, but really what I'm figuring out here is, are we talking about something that's happened across weeks, months or more likely years? And then I'm going to want to listen to, how did symptoms evolve? What's been the change over time? With Alzheimer disease and most neurodegenerative diseases, we expect gradual onset and gradual progression, things becoming more apparent. And at some point, everyone in the room is going to agree that, well, as of this state, there clearly was a problem. And then we can get into talking about specific symptoms and really begin to pick that apart the way that we traditionally do in any standard neurological assessment. Dr Berkowitz: Fantastic. And so, what are some of the things you're listening for in that history that would clue you in to thinking this patient may indeed be someone who could have Alzheimer's disease and going to require a workup for that diagnosis? Dr Day: It's pretty common when I have new trainees that come to clinic, they just head into the exam room and they sort of try to approach it the way that we would any patient in the emergency department or any other clinical scenario. The challenge with that is that, you know, we're taught to let the patient speak and we're going to let the patient speak - open-ended questions are great - but there's only so many questions you need to sort out if someone has a memory problem. And memory is really only one part, one component, of a thorough cognitive evaluation. And so, I'm going to help by asking specific questions about memory. I'm going to make sure that there is memory challenges there. And whenever possible, I'm going to solicit some examples to back that up, add credibility and sort of structure to the deficits. I'm also going to choose examples that help me to understand how does this concern, or this complaint, how does that actually affect the patient in their day-to-day life? Is it simply something that they're aware of but yet hasn't manifested in a way that their partner knows about? Is it to a level where their partner's actually had to take over their responsibility? It's causing some difficulties, disability even, associated with that. That's going to be important for me as I try to understand that. So, I'll ask questions when it comes to memory, not just, you know, do you forget things, but do you manage your own medications? You remember to take those in the morning? Do you need reminders from your partner? What about appointments; health appointments, social appointments? Are you managing that on your own? Sometimes we need a little bit of imagination here. Partnerships, and particularly those who have been together for a long time, it's natural that different people are going to assume different responsibilities. And so, might have to say, Imagine that you went away for the weekend. Would you worry about your partner remembering to take their medications over that time frame? That can help to really solidify how much of an impact are these challenges having on a day-to-day basis. I may ask questions about events, something that they maybe did a couple of weeks ago. Is the patient likely to remember that event? Are they going to forget details? Maybe the most important of all, with each of these, when there's a yes or an affirmation of a problem, we want to be clear that this represents a change from before. We all have forgetfulness. Happens on a day-to-day basis, and we all pay attention to different details, but what we're concerned about and typically the reasons patients want to come and see us as neurologists is because they've noticed a change. And so, I'm going to focus in on the things that represent a change from before. After I've discussed memory, I think it's really important to talk about the other domains. So, how is judgment affected? Decision-making?  In a practical way, we often see that borne out in financial management, paying the bills. Not just paying them on time and consistently, but making wise choices when it comes to decisions that need to be made. You're out at a restaurant. Can you pay the bill? Can you calculate a tip? Can you do that as quickly and as efficiently as before? Are we starting to see a breakdown in decision-making abilities there? We can sometimes lump in changes in behavior along with judgment as well. The patient that you know, maybe isn't making wise choices, they've picked up the phone and given their social security number out to someone that was calling, seeming to be well-meaning. Or maybe they've made donations to a few more institutions than they would have otherwise? Again, out of- out of order. Again, something that could be atypical for any individual. Looking for behavioral changes along with that as well. And then I'm going to talk about orientation. What's their ability to recognize days of the week, date of the month? Do they get lost? Is there concerns about wayfinding? Thinking about that, which is really a complex integration of some memory, visuospatial processing, judgment, problem solving, as we look to navigate our complex world and find our way from point A to B. And then I like to know, you know, what are they doing outside of the home? What are they doing in the community? How are they maintaining their engagement? Do they go to the store? Do they drive? An important topic that we may need to think about later on in this patient 's assessment. And inside the home? What responsibilities do they maintain there? Are the changes in decision making, memory problems, are they manifesting in any lost abilities inside the home? Cooking being a potentially high-risk activity, but also using typical appliances and interacting with technology, in a way that we are all increasingly, increasingly doing and increasingly reliant on. And last but not least, you know, maybe the one that everyone wants to think about, well, I can still manage all of my own personal care. Well, good news that many of our patients who have early symptoms can manage their own personal care. Their activities of daily living are not the big problem. But we do want to ask about that specifically. And it's not just about getting in the shower, getting clean, getting out, getting your teeth brushed. Do you need reminders to do that? Do you hop in the shower twice because you forgot that you'd already been in there once during the day? And so, asking some more of those probing questions there can give us a little bit more depth to the interview and really does sort of round out the overall comprehensive history taking in a patient with a memory or cognitive concern. Dr Berkowitz: Fantastic. That was a comprehensive master class on how to both sort of ask the general questions, have you noticed problems in fill in the blank memory, judgment, behavior, orientation, navigation and to sort of drill down on what might be specific examples if they're not offered by the patient or partner to try to say, well, in this domain, tell me how this is going or have you noticed any changes because the everyone's starting from a different level cognitively based on many factors. Right? So, to get a sense of really what the change is in any of these functions and how those have impacted the patient's daily life. So, let's say based on the history, the comprehensive history you've just discussed with us, you do find a number of concerning features in the history that do raise concern for dementia, specifically Alzheimer's disease. How do you approach the examination? We have the MoCA, the mini-mental. We have all of these tools that we use. How do you decide the best way to evaluate based on your history to try to get some objective measure to go along with the more subjective aspects of the history that you've ascertained? Dr Day: And you're honing in on a really good point here, that the history is one part of the interview or the assessment. We really want to build a story and potentially and hopefully a consistent story. If there are memory complaints, cognitive complaints from history, from reliable- that are supported by reliable collateral sources, we're going to expect to see deficits on tests that measure those same things. And so, I think that question about what neuropsychological measures or particular bedside tests can we integrate in our assessment is a good one. But I'll say that it's not the end-all-be-all. And so, if you've got a spouse, someone that lives with an individual for twenty or thirty years, and they're telling you that they notice a change in daily activity and it's impairing their day to day function, or where there's been some change or some concern at work, that's going to worry me more than a low score on a cognitive test with a spouse saying they haven't noticed any day-to-day impact. And so, we're going to take everything sort of in concert and take it all together. And it's part of our job as clinicians to try to process that information. But often we're going to see corroborating history that comes from a bedside test. He named a few that our listeners are probably pretty familiar with. I think they're the most common ones that are used. The Mini-Mental State Exam, been in practice for a long time. All the points add up to thirty and seems to give a pretty good sample of various different cognitive functions. The Montreal Cognitive Assessment, another favorite; a little bit more challenging of a test, I think, if we're if we're looking at how people tend to perform on it. And like the MMSE, points add up to thirty and gives a pretty good sample. There are others that are out there as well, some that are available without copyright and easy for use in clinical practice. The Saint Louis Mental Status Exam comes to mind. All these tests that we're willing to consider kind of share that same attribute. They can be done relatively quickly. They should sample various different aspects of function. There should be some component for language reading, spoken, spoken word, naming items, something that's going to involve some kind of executive function or decision making, problem solving. Usually a memory task where you're going to remember a set of words and be asked to recall that again later. So, learn it, encode it, and recall it later on. And then a few other features, I mean, some of them, these tests, most of these tests use some sort of drawing tasks so that we can see visuospatial perception and orientation questions about date, time, location, sort of the standard format. Any of these tests can be used aptly in your practice. You're going to use the one that you're most comfortable with, that you can administer in a reasonable amount of time and that seems to fit with your patient population. And that's the nuance behind these tests. There are many factors that we have to take into account when we're picking one and when we're interpreting the test results. These tests all generally assume that patients have some level of traditional sociocultural education that is westernized for the most part. And so, not great tests for people that aren't well into integrated into the community, maybe newcomers to the United States, those that have English as a second, third, or fourth language, as many of our patients do. Statements like no ifs, ands, or buts may not be familiar to them and may not be as easy to repeat, recall and remember. And so, we want to weigh these considerations. We may need to make some adjustments to the score, but ideally, we're going to use these tests and they're going to show us what we expect and we're going to try to interpret that together with the history that we've already ascertained. When I obtain that history and I'm thinking about memory loss, I'm going to look at the specific domain scores. And so, if I'm using the mini mental state examination thirty point test, but three questions that relate to relate to recall. Apple, penny, table. And so, depending on how our patients do on that test, they could have an overall pretty good score. Twenty seven. Oh, that looks good. You're in the normal range according to many different status. But if I look at that and there's zero out of three on recall, they could not remember those three items, that may support the emergence of a memory problem. That may corroborate that same thing on the MoCA, which uses five-item recall, and other tests in those same parameters. I mentioned some other caveat cities testing. Are patients who are presenting with prominent language deficits important part of cognition. They can't get the words out. They can't frame their sentences. They may really struggle with these tests because a lot of them do require you to both understand verbal instructions and convey verbal instructions. People with prominent visual problems, either visual problems that come because of their neurodegenerative disease and so part of cognition, visual perceptual problems, or people who simply have low vision. Are there difficulties for that? These tests require many people to read and execute motor commands, to draw things, to follow lines and connect dots, all very difficult in that setting. And so, we have to be cautious about how we're interpreting test results in patients who may have some atypical features or may arrive with sort of preexisting conditions that limit our ability to interpret and apply the test to clinical practice.  Dr Berkowitz: Really fantastic overview of these tests, how to use them, how to interpret them. It's not all about the number. As you said, it depends if all the points are lost in one particular domain, that can be salient and then considering, as you said, the patient 's background, their level of education, where English falls in their first language, second, third or fourth, as you said, and then some of the aspects of the MoCA, right, are not always as culturally sensitive since it's a test designed in a particular context. So, let's say your history and exam are now concerning to you, that the patient does indeed have dementia. Tell us a little bit about the next steps in the laboratory neuroimaging evaluation of such a patient?  Dr Day: I've got a history of memory and thinking problems. I've got some corroborating evidence from bedside cognitive testing, a normal neurological exam. This is where we think about, well, what other tests do we need to send our patients for? Blood testing really can be pretty cursory for most patients with a typical presentation who have typical risk factors, and that can include a thyroid study and vitamin B12. So, measuring those in the blood to make sure that there's no other contributions from potential metabolic factors that can worsen, exacerbate cognitive function. And pretty easy to do for the most part, if patients have other things in their history, maybe they come from a high-risk community, maybe they engage in high risk behaviors, I may think about adding on other tests that associate with cognitive decline. We'll think about the role of syphilis, HIV, other infections. But generally, that's when it's driven by history, not a rule of thumb for me in my typical practice. But beyond the blood tests, neuroimaging, some form of structural brain imaging is important. A CT scan will get you by. So, if you have a patient that can't get in the scanner for one reason or another or won't get in the scanner, or you don't have easy access to an MRI, a CT scan can help us in ruling out the biggest things that we're looking for. That's strokes, hemorrhages, and brain masses. So other things that obviously would take us down a very different path, very different diagnosis and very different treatment approach. An MRI, though, is going to be preferred, not only because it gives us a much higher-resolution view, but also because it helps us to see sort of regional areas of atrophy. It's a sensitive scan to look for small vessel disease, tiny strokes, tiny bleeds, microhemorrhages that again might point towards meteorology for us. Of course, it's better at finding those small masses, whether they be metastasis or primary masses, that could give us something else to consider in our diagnostic evaluation. I get an odd question often from patients, well, can you see Alzheimer's disease on an MRI? And the true answer to that is no, you can't. Can we see the signs of Alzheimer's disease? Sure, in some patients, but really what we see on an MRI is a reflection of neurodegeneration. And so, we see evidence of tissue loss and typically in areas that are most often involved early on in Alzheimer's disease. The hippocampus, the entorhinal areas around the hippocampus, we may see atrophy there. We may see biparietal atrophy, and of course, as the disease progresses, we're going to see atrophy distributed throughout other areas of the brain. But if you're looking for atrophy, you've got to have a pretty good idea what's normal for age and what you expect in that patient population. So, I do encourage clinicians who are assessing patients routinely, look at your own images, look at the images for patients with and without cognitive impairment. So we develop a pretty good sense for what can be normal for age, and of course work with our colleagues in radiology who do this for a living and generally do an excellent job at it as well.  Dr Berkowitz: Perfect. So, you're going to look for the so-called reversible causes of dementia with serum labs, structural imaging to either rule out or evaluate for potential structural causes that are not related to a neurodegenerative condition or patterns of regional atrophy suggestive of a neurodegenerative condition, and maybe that will point us in an initial direction. But the field is rapidly expanding with access to FDG-PET, amyloid PET, CSF biomarkers, genetic testing for APOE 4, probably soon to be serum biomarkers. So, patients may ask about this or a general neurologist referring to your clinic may ask, who should get these tests? When should we think about these tests? How do you think about when to send patients for advanced imaging, CSF biomarkers, genetic testing for APOE 4? Dr Day: It's not that patients may ask about this. Patients will ask about this. And you've probably experienced that in your own world as well. They're going to ask about any of these different biomarkers. Certainly, whatever they've recently read or has been covered on television is going to be common fodder for consideration in the clinic environment. It's important to know what tests you can get, what reliable tests that you can get, and to know the differences between some of these tests when making a recommendation or weighing the pros and cons of doing additional testing. I think common practice principles apply here. Let's order tests that are going to change our next steps in some way. And so, if we have a patient, particularly a patient like the one that we've been talking about: seventy something year old, presenting with memory complaints, they're concerned, the family is concerned. We've got that history, physical exam, and now we may need to really hone in on the etiology. Well, I say may need because for that patient it may be enough to know, yeah, I agree, there's a problem here. And I can say it's an amnestic, predominant, gradual-onset progressive cognitive decline. This is probably Alzheimer disease based on your age. And maybe that's all they want to hear. Maybe they're not ready to pursue additional testing or don't see the value or need for additional testing because it's not going to change their perspective on treatment. In that case, it's okay to apply an often underrated test, which is the test of time. Recognizing this is a patient I can follow. I can see them in six months or twelve months, depending on what your clinic schedule allows. If this is Alzheimer disease, I'm going to expect further gradual progression that may affirm the diagnosis. We can think about symptomatic therapies for a patient like that, perhaps Donepezil as an early, early medication that may help with symptoms somewhat and we can leave it at that for the time being. But there's many scenarios where that patient or the family member says, look, I really need to know. We really want this answer. And as you pointed out, there are good tests and increasingly good tests that we have access to.  Dr Berkowitz: Well, that's a very helpful overview of the landscape of more precise diagnostic testing for Alzheimer disease specifically and how you think about which tests to order and when based on your pretest probability and the patient 's candidacy for some of these new potential therapies. To close here, as you said, treatment is discussed in another podcast. There's another article in this issue. So, we won't get into that today. But let's say you have gotten to the end of the diagnostic journey here. You are now convinced the patient does have Alzheimer's disease. How do you present that diagnosis to the patient and their family? Dr Day: I think here we're going to recognize that different styles align with different patients and families, and certainly different clinicians are going to have different approaches. I do tend to take a pretty direct approach. By the time that patients are coming to see me, they've probably already seen another neurologist or at least another physician who's maybe started some of the testing, maybe even built the foundation towards this diagnosis and shared some indications. Certainly, when they look up my profile before they come to see me, they know what I specialize in and so, they may even have done their own research, which has ups and downs in terms of the questions that I'll be faced with at that point in time. The way I like to start is first acknowledging the symptoms. And the symptoms that the patients have shared with me, recognizing if those symptoms are impacting daily life, how they impacted daily life, and usually using that information to synthesize or qualify the diagnosis. Is there cognitive impairment, yes or no? And at what level is that cognitive impairment? Is this mild cognitive impairment? Is this mild dementia? Is it maybe more moderate or severe dementia? So, using those terms directly with patients and explaining the meaning of them. But I then transition in relatively quickly to the important point of not leaving it at the syndrome, but actually thinking about the cause. Because it is cause that patients come to talk about. And if they don't say that directly, they say it in their next question, which is what are we going to do about it and how are we going to treat this? And so, I will use the information I have available at that time to suggest that based on your age, based on the history, the normal physical examination, the performance and the bedside testing that we've done. And hey, that's pretty normal structural imaging or imaging that only shows a little bit of atrophy in a few areas. I think that this condition is most consistent with symptomatic Alzheimer's disease, mild cognitive impairment due to Alzheimer's disease, or mild dementia due to Alzheimer's disease. And then I'll discuss the next options in terms of testing and try to get a feel of what our patients are thinking about when it comes to treatment. Do they want to be on the cutting edge with brand-new therapies that offer potential benefits but counterbalance by pretty substantial risks that warrant individualized discussions? Are they interested in symptomatic therapies? Would that be appropriate for them? And I can usually round out the discussion with advice that works for everyone. And that's where we talk about the importance of brain health. What are the other things that I should be doing, you should be doing, and our patients and their partners should be doing as well to maintain our brain in its best possible state as we hope that we all continue to age and look towards the future where we maintain our cognition as best as possible? And that is still the goal. Even when we're talking to patients who have neurodegenerative diseases that are working against our efforts, we still want to do what we can to treat other problems, to evaluate for other problems that may be contributing to decline and may be amenable to our management as well.  Dr Berkowitz: Well, thank you so much for taking the time to speak with us today. I've learned a lot from your very nuanced and thoughtful approach to taking the history, performing the examination, making sense of cognitive tests and how they fit into the larger picture of the history and examination, and thinking about which patients might be candidates for more advanced imaging as we try to make a precise diagnosis in patients who may be candidates and interested in some of the potential novel therapies, which we both alluded to a few times, but are deferring to another podcast that we'll delve more deeply into that topic in this series. So, thank you so much again, Dr Day. Again, I've been interviewing Dr Gregory Day from the Mayo Clinic, whose article on Alzheimer's disease appears in the most recent issue of Continuum on Dementia. Be sure to check out Continuum Audio episodes from this and other issues. And thank you so much to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

A new MP3 sermon from Generations Radio is now available on SermonAudio with the following details: Title: An Interview with the Inventor of the MRI – A Blessing From God Speaker: Kevin Swanson Broadcaster: Generations Radio Event: Radio Broadcast Date: 12/4/2024 Length: 33 min.

What if you could undergo a scan of of your whole body once a year to screen for any tumors, aneurysms, or any other medical abnormalities? On the surface, it sounds like a great idea, and indeed many companies are offering the opportunity to undergo whole body MRIs to catch medical findings before they become medical 'problems'. But is whole body MRI really all it's cracked up to be? Or can it also lead you down a rabbit hole chasing a diagnosis when nothing of consequence is to be found? Radiologist Dr. Matthew Davenport joins the podcast. Hosted on Acast. See acast.com/privacy for more information.

In this episode of Neuro Innovation Talks, Host John Murray interviews Professor Jacques Moret, MD, Professor and Consultant Interventional Neuroradiology and Honorary Chairman, NEURI center, Bicetre University Hospital, a pioneer in neurovascular intervention, as he reflects on the early challenges and groundbreaking innovations that shaped the field. Dr. Moret recounts the origins of balloon remodeling for brain aneurysm treatment, detailing the iterative process of developing this transformative technique and the critical role of collaboration with industry leaders. He highlights the technological and ethical considerations that informed his work, emphasizing the balance between innovation and patient safety. The conversation delves into his philosophy of mentorship, the significance of anatomical knowledge in neurointervention, and the importance of maintaining humanity in patient care. Dr. Moret also discusses the future of neurovascular treatment, advocating for MRI-compatible devices and real-time functional imaging to enhance procedural outcomes. Thank you to Confluent Medical Technologies for sponsoring this episode of Neuro Innovation Talks. To learn more about how Confluent Medical supports medical device companies, visit: www.confluentmedical.com. Special thanks to the following, the Neuro Innovation Talks podcast series would not be possible without their support: Joanna Colangelo, Mark Dickinson, Whitney Garrett, Tracy Murray, SYK, Dr. Christophe Cognard, Dr. Laurent Spelle, and Dr. Vitor Pereira Tune in and subscribe to the DeviceTalks Podcast Network wherever you get your podcasts and follow youtube.com/@DeviceTalks to never miss an episode. Thank you for supporting the Neuro Innovation Talks podcast!

For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:https://www.mycme.com/courses/questions-and-answers-on-amyloid-cardiomyopathy-and-polyneuropathy-9845SummaryIn this activity – which learners can review as a podcast or a webcast - Drs. Chafic Karam and Michelle Kittleson dive into five key questions from recent live-virtual broadcasts about transthyretin amyloidosis (ATTR). They discuss the role of cardiac MRI, biopsy, and genetic testing in diagnosing ATTR cardiomyopathy and polyneuropathy. They also explore treatment options, including silencing therapies and stabilizers, with insights into when patients should be referred for specialized care. The conversation emphasizes the importance of early diagnosis, collaborative care between neurologists and cardiologists, and the expanding therapeutic landscape for ATTR.Learning ObjectivesAt the conclusion of this activity, participants should be better able to:Describe the correct diagnostic algorithm for suspected ATTR, including interpretation of the monoclonal protein screen and indications for biopsy and genetic testing.Initiate appropriate management, including disease-directed therapy and appropriate cardiac care, or referral when indicated.This activity is accredited for CME/CE CreditAssociation of Black Cardiologists, Inc. (ABC) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.Association of Black Cardiologists, Inc. designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.This activity has been planned and implemented in accordance with the Accreditation Standards of the American Association of Nurse Practitioners® (AANP) through the joint providership of the National Association for Continuing Education (NACE) and ABC. NACE is accredited by the AANP as an approved provider of nurse practitioner continuing education. Provider number 121222. This activity is approved for 0.25 contact hours (which does not include hours of pharmacology).In support of improving patient care, this activity has been planned and implemented by Haymarket Medical Education (HME) and NACE. Haymarket Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.This knowledge-based activity JA4008232-9999-24-043-H01-P qualifies for 0.25 contact hours (0.025 CEUs) of continuing pharmacy education credits.For additional information about the accreditation of this program, please contact NACE at info@naceonline.com.Summary of Individual DisclosuresPlease review faculty and planner disclosures here.Disclosure of Commercial SupportThis educational activity is supported by an educational grant from Alnylam Pharmaceuticals, Inc., and an educational grant from AstraZeneca Pharmaceuticals.Please visit http://naceonline.com to engage in more live and on demand CME/CE content.

Hey Wealth Formula Nation, I've got something really exciting for you today—a chance to win a full-body MRI worth $2,500! This giveaway comes from my new podcast, Longevity Junky (that's junky with a Y). It's a fun, insightful show I co-host with actress Nikki Leigh, where we dive into cutting-edge advancements in health and longevity. […] The post Giveaway: $2500 Full-Body MRI appeared first on Wealth Formula.

Hey Sapio Fans, I've got something really exciting for you today—a chance to win a full-body MRI worth $2,500! This giveaway comes from my new podcast, Longevity Junky (that's junky with a Y). It's a fun, insightful show I co-host with actress Nikki Leigh, where we dive into cutting-edge advancements in health and longevity. This week's episode is all about full-body MRIs from Prenuvo, a groundbreaking technology that can identify over 500 conditions—including deadly cancers and brain aneurysms—before they pose a serious threat to your health. Here's how you can enter to win this $2,500 Prenuvo MRI scan for free: Go to Apple Podcasts and find the Longevity Junky podcast (that's "Junky" with a Y). Leave a five-star review for the podcast. Subscribe to the podcast. Take a screenshot of your review. Visit LongevityJunky.com (again, "Junky" with a Y). Send the screenshot of your review along with a brief explanation of why you'd like a full-body MRI. Winners will be announced in 2 weeks—stay tuned and good luck to everyone!

The December 2024 replay wraps up the year with five previously posted episodes on autoimmune neurology. The episode begins with Drs. Michael R. Wilson and John Pluvinage discussing transcobalamin antibodies. The episode leads into an interview with Dr. Andrew McKeon, who talks about paraneoplastic CAMKV autoimmune encephalitis. In the third episode, Dr. Maarten Titulaer discusses long-term outcomes and rehab in NMDAR encephalitis. The episode continues with Prof. Zsolt Illes discussing the mortality of patients with AQP4 antibody–seropositive neuromyelitis optica spectrum disorder compared with that in the general population. In the final episode, Drs. Marius Ringelstein and Ilya Ayzenberg discuss the effectiveness and safety of Eculizumab in routine clinical care. Podcast Links: Transcobalamin receptor Antibodies in Autoimmune Vitamin B12 Central Deficiency  Paraneoplastic CAMKV Autoimmune Encephalitis Long-Term Outcomes and Rehabilitation in Anti-NMDAR Encephalitis Mortality in a Danish NMO Cohort Eculizumab Use in Neuromyelitis Optica Spectrum Disorders Article Links: Transcobalamin Receptor Antibodies in Autoimmune Vitamin B12 Central Deficiency  Paraneoplastic Calmodulin Kinase-Like Vesicle-Associated Protein (CAMKV) Autoimmune Encephalitis  Long-Term Cognitive, Functional, and Patient-Reported Outcomes in Patients With Anti-NMDAR Encephalitis  Mortality of the Danish Nationwide AQP4 Antibody-Seropositive Neuromyelitis Optica Spectrum Disorder Patient Cohort  Eculizumab Use in Neuromyelitis Optica Spectrum Disorders: Routine Clinical Care Data From a European Cohort Disclosures can be found at Neurology.org.

In this episode of The Sports Medicine Project, we explore navicular stress fractures—a high-risk injury requiring a unique approach due to the bone's anatomy, biomechanics, and healing challenges. We cover: ​Anatomy and biomechanics of the navicular. ​Risk factors: young athletes, biomechanics, and bone health. ​Delayed diagnosis and the role of imaging (CT vs. MRI). ​The debate over blood supply and its impact on healing. ​Management strategies: non-weight-bearing protocols, surgery vs. conservative care. ​Rehabilitation and return-to-sport considerations. ​PMID: 8775123 ​PMID: 28110392 ​PMID: 39348218 ​PMID: 37489055 ​PMID: 33512847 This episode is for educational purposes only and should not be taken as medical advice. Support the show if it brought you value. The only thing we want to do the money is crate a better show and better resources https://www.patreon.com/SportsMedicineProject?utm_campaign=creatorshare_creator 00:00 Welcome to Season Two 04:31 Bilateral Insertional Achilles Tendinopathy 22:05 Better Subjective Questioning 28:27 Neck of Femur Stress Fracture 31:39 Understanding Navicular Stress Fractures 32:35 Introduction to Navicular Stress Fractures 35:06 Incidence of Navicular Stress Fractures 35:15 Who Gets Navicular Stress Fractures? 36:57 Time to Diagnosis of Navicular Stress Fractures 38:20 Anatomy of the Navicular 41:46 Biomechanics of the Navicular 45:18 Risk Factors for Navicular Stress Fractures 50:27 Foot Stiffness and Navicular Stress Fractures 55:28 Diagnostic Tests for Navicular Stress Fractures 01:00:11 Differential Diagnosis for Navicular Stress Fractures 01:01:24 Understanding Mid-Foot Pain and Injuries 01:02:57 Blood Supply to the Navicular 01:03:32 Do Naviculars Have Blood Flow? 01:06:25 Healing Variability and Factors Affecting Recovery 01:09:49 Imaging of Navicular Stress Fractures 01:14:00 Differential Diagnoses Not to Miss 01:14:55 Management Strategies for Navicular Stress Fractures 01:14:58 Müller-Weiss Syndrome 01:15:14 Management of Navicular Stress Fracture

Welcome to a couple of rad techs, where Chaundria dives into the fascinating world of radiology and answers your burning questions in a lively Q&A session. This episode highlights the distinction between radiologic technologists and radiologists, clarifying that while techs take the images, it's the radiologists who interpret them. Chaundria emphasizes the importance of choosing accredited programs for aspiring radiologic technologists, detailing how to navigate the educational landscape and the significance of understanding accreditation for career success. From discussing the realities of working in the field to offering guidance on pay negotiations for new grads, she shares valuable insights that can help shape your career in medical imaging. With a playful tone and a wealth of experience, Chandria makes the intricate world of radiology accessible and engaging for everyone.Chaundria's live Q&A session serves as a comprehensive guide to understanding the role of radiologic technologists, dispelling myths, and providing valuable insights for aspiring professionals in medical imaging. She begins by defining the core responsibilities of radiologic technologists, emphasizing their expertise in capturing images using various technologies, including ultrasound and MRI, while clarifying the distinction between their roles and those of radiologists. This foundational understanding is crucial for anyone considering a career in this field, as it highlights the collaborative nature of healthcare and the importance of each role within the patient care continuum.Throughout the session, Chaundria addresses key questions from her audience about educational pathways and the importance of accreditation. She passionately advocates for prospective students to thoroughly research programs, ensuring they choose accredited institutions that will prepare them for licensure and employment. Her practical advice includes checking the reputation of schools, understanding their accreditation status, and assessing the qualifications of educators. This emphasis on education reflects her commitment to ensuring that future radiologic technologists are well-prepared to meet the challenges of the profession.Chaundria's insights extend beyond education as she tackles the realities of entering the job market. With a blend of humor and realism, she discusses the pay scales for new graduates, particularly in regions like Florida, where the allure of sunny beaches can affect salary expectations. She encourages new professionals to prioritize gaining experience and advancing their education over immediate salary gains, highlighting the long-term benefits of investing in their careers. By the end of the session, Chaundria leaves her audience not only informed about the intricacies of radiologic technology but also inspired to pursue their passions with confidence and clarity.Takeaways: Radiologic technologists are not radiologists and do not interpret medical images. To become a radiologic technologist, you must complete an accredited educational program. When choosing a radiologic technology program, ensure it is accredited by ARRT for licensing. A career in radiology can include various specialties, offering room for growth and advancement. Negotiating salary as a new grad should consider experience, education, and benefits offered. Networking through professional societies is essential for career development in radiology. Links referenced in this episode:arrt.orgCompanies mentioned in this episode: ARRT JRCERT Emory University School of Medicine University of Alaska radiology, radiologic technologist, medical imaging, ultrasound, MRI, CT scan, radiology schools, radiologic...

In this episode, Andy Baynes, former Apple, Next and Google Executive, and CEO and co-founder of GT Life Sciences, shares his journey from Silicon Valley innovator to leader in AI and data science. We explore the challenges and opportunities of working with massive datasets, the critical need for robust data strategies, and how AI is reshaping healthcare—like democratising MRI access and improving early diagnoses. Andy also delves into the evolving role of design in AI, from intuitive user interfaces to choreographing seamless experiences across industries. Discover how the fusion of data, design, and AI is driving transformative change in healthcare, technology, and beyond.See omnystudio.com/listener for privacy information.

BUFFALO, NY - November 27, 2024 – A new #editorial was #published in Oncotarget's Volume 15 on November 12, 2024, entitled “Persistence landscapes: Charting a path to unbiased radiological interpretation.” In this editorial, Yashbir Singh, Colleen Farrelly, Quincy A. Hathaway, and Gunnar Carlsson from the Department of Radiology, Mayo Clinic (Rochester, MN), introduce persistence landscapes, a mathematical method designed to address biases in medical imaging and artificial intelligence (AI). Persistence landscapes build on persistence images, which track how patterns in data appear and disappear across different scales. By transforming this complex data into simpler, more manageable forms, persistence landscapes create a format that is easy to analyze and compare. This makes it a valuable tool for identifying and correcting biases in medical imaging. Medical imaging plays a critical role in healthcare, but it is not perfect. Biases, caused by differences in equipment, technology, or even the patient population, can lead to inaccurate diagnoses. Persistence landscapes offer a way to identify and fix these hidden issues. "[...] persistence landscapes have the potential to play a crucial role in identifying and mitigating biases in radiological practice, whether these biases stem from demographic factors, equipment variations, or the limitations of AI algorithms.” Persistence landscapes are particularly effective at reducing random noise in medical images while preserving important details. This makes it easier for clinicians and researchers to focus on the most meaningful parts of an image. The method also improves AI tools by addressing common problems, such as when models are too focused on specific details or when they miss important information. Additionally, persistence landscapes also simplify the integration of data from different scan types, like positron emission tomography (PET) and magnetic resonance imaging (MRI), without introducing new errors. Despite its potential, the use of persistence landscapes in real-world medical imaging comes with challenges. It requires powerful computers to process large data, which can be costly and time-consuming, and expert interpretation for meaningful use. Better tools are needed to make this method more accessible for clinicians. While integrating this method into clinical settings will take effort, the benefits could be transformative. With further research and refinement, persistence landscapes hold enormous promise for advancing equitable healthcare. “Persistence landscapes represent a powerful new tool in our ongoing efforts to achieve unbiased and accurate radiological interpretation.” DOI - https://doi.org/10.18632/oncotarget.28671 Correspondence to - Yashbir Singh - singh.yashbir@mayo.edu Video short - https://www.youtube.com/watch?v=kq1pEhZvLXc Subscribe for free publication alerts from Oncotarget: https://www.oncotarget.com/subscribe/ About Oncotarget Oncotarget (a primarily oncology-focused, peer-reviewed, open access journal) aims to maximize research impact through insightful peer-review; eliminate borders between specialties by linking different fields of oncology, cancer research and biomedical sciences; and foster application of basic and clinical science. Oncotarget is indexed and archived by PubMed/Medline, PubMed Central, Scopus, EMBASE, META (Chan Zuckerberg Initiative) (2018-2022), and Dimensions (Digital Science). To learn more about Oncotarget, please visit https://www.oncotarget.com and connect with us: Facebook - https://www.facebook.com/Oncotarget/ X - https://twitter.com/oncotarget Instagram - https://www.instagram.com/oncotargetjrnl/ YouTube - https://www.youtube.com/@OncotargetJournal LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Spotify - https://open.spotify.com/show/0gRwT6BqYWJzxzmjPJwtVh MEDIA@IMPACTJOURNALS.COM

Happy Thanksgiving week from your two best friends that never call! This week as the holidays approach we talk about a Christmas themed restaurant in NYC that's a rip off, childrens "theater" performances, microplastics, and how terrifying it is if your kid has to go into an MRI machine. Eat a ton of Turkey and tell a friend about NNT! ++RATE AND REVIEW++ Need advice? Have a funny story?  Email us at nevernottiredpod@gmail.com Follow Casey and Ahri for all NNT updates! https://www.instagram.com/casefaceb/ https://www.instagram.com/theycallmeahri/  

On today's Justice Team Podcast, we host Greg Staudenberg, an innovator in the medical imaging space. Greg discusses his work with Invigorate, a company set to transform medical diagnostics for both healthcare and legal applications. Discover how their new CT technology provides highly detailed 3D images in just one minute, surpassing traditional MRI scans and improving case outcomes for personal injury lawyers.

Dr. Refky Nicola talks with Dr. Wendy VanBuren and Dr. Priyanka Jha about advances in endometriosis imaging, focusing on ultrasound, MRI, and the role of T1 and T2 sequences in diagnosis and reporting. Radiology State-of-the-art Review:Endometriosis Imaging Interpretation and Reporting. VanBuren et al. Radiology 2024; 312(3):e233482.

In this week's episode, Dr. Brian Feeley and Dr. Drew Lansdown tackle one of the most talked-about topics in professional football: quarterback shoulder injuries. Listen as the duo dives into the anatomy, mechanics, and recovery process for these critical injuries. As the NFL season progresses past the 60% mark, this conversation is not only timely but also crucial for fans, athletes, and anyone interested in the intersection of sports and medicine.

Check out this week's QuadCast where we highlight the reduced toxicity of reduced-margin MRI-guided prostate SBRT, the response rate of double hit lymphoma to radiation, the inappropriate radiation services denial rate of Medicare Advantage plans, and more! Check out the website and subscribe to the newsletter! www.quadshotnews.com Founders & Lead Authors: Laura Dover & Caleb Dulaney Podcast Host: Sam Marcrom

Mind bending podcast!!!  Brain scans that prove Jennifer is IN ANOTHER ZONE!!!  Jennifer was invited by a lab up in Marin County to do some EEGs of her brain, based upon the fact that she'd had a number of events, broken bones over the years.  She went up to a brain scan lab in Marin where they mapped her brain - doing a baseline scan while she was "not thinking of anything" - and then while doing a session with someone in the office, but looking straight ahead. The results are dramatic and mind bending.  The results show that when Jennifer is "doing a session" (in trance, or as I call it "bypassing the filters on the brain") she's in full DELTA state - the equivalent of being in a deep sleep, or as shown in the scans of monks who are in a trance or doing meditation.   From an AI definition of the Theta vs. Delta state: There are various levels of awareness and sleep as recorded by science - theta state, delta state, etc. Theta and delta waves are both types of brain waves that occur during sleep, but they have different frequencies and are associated with different stages of sleep: Theta waves These waves are associated with the initial stages of non-REM sleep, and are characterized by a frequency of 3–8 Hz and an amplitude of 50–100 µV. Theta waves are associated with deep relaxation, creativity, intuition, and visualization. Delta waves These waves are associated with deep, slow-wave sleep, and are characterized by a frequency of 0.5–3 or 4 Hz and an amplitude of 100–200 µV. Delta waves are associated with physical healing and regeneration, reduced stress and anxiety, and dreamless sleep.  Electroencephalography (EEG) is the primary tool used to measure brainwaves during sleep." It's as if Jennifer is "sound asleep" while we're doing these sessions, while she's working with law enforcement, while working with her clients.  Her brain is "In another dimension" so to speak - not the awake mind that we associate with daily living. Also worth noting; as the video of a Parkinson's patient (on this page - Coleman Hough) during hypnosis showed, during the hypnosis session she lost her symptoms; she stopped shaking and spoke normally.  (As if she was asleep, while consciously speaking.)  As noted, people with brain issues (Parkinsons, Tourette's) don't shake or have tics while they're sleeping.  It's only in the Theta state that the shaking returns (as evidenced in the session with Coleman, all the shaking returned when she was "counted down." In the research from Dr. Greyson ("AFTER") he talks about filters on the brain, that "block information not conducive to survival."  Dr. Wambach talks about the same filters in her book "Reliving Past Lives." The point is - if people can use meditation (and Coleman told us from the flipside that both meditation and hyperbaric oxygen therapy can help) to bypass the filters, why not use that as a tool for healing? It's uncanny that Jennifer has these scans, and as noted in the podcast, a scientist at the University of Pennsylvania is doing EEG/MRI scans of mediums. (Dr. Beauregard's BRAIN WARS has some MRI data in his research.) Luana Anders is our moderator on the flipside, LuanaAnders.com - passed in 1996, was pals with Tina Turner, both SGI Buddhists.  So Tina stops by to say hello.  (And Jennifer has had a client who has spoken with Tina as well.) So HAPPY THANKSGIVING. Each week Jennifer and I have no idea what we're going to talk about, and each week we go further and farther into the flipside to learn new information. Stay tuned! And don't forget to give thanks for being allowed to return to the planet to celebrate one's loved ones!  They are not gone, they're just not here. When you toast them, do so in present tense.

Promises To Keep. In 25 parts, edited from the works of FinalStand. Listen and subscribe to the ► Podcast at Connected.. Note to readers: There is a bit of mangling of the Iliad going on. My apologies to Homer and the countless singers before him who carried the Iliad down through the dark centuries until the Greeks figured out how writing works. “Never judge a friend by what they give, but of how much of themselves they give.” (From the floor of Katrina's office) First thoughts,  I was on the floor where I had fallen, surrounded and being manhandled in the tenderest way. That was a romantic means of relating to my mummification. Those little Band-Aids that had been applied when I woke up from my coma had failed the 'Cáel is a Smeckle-head' test. All the crud they had pumped into my system and amperage they had channeled through my muscles was not the same as eating and exercise. Having a sexual romp with two ladies? My Goddess made plans for my body that my caloric bank account couldn't afford, thus me passing out. Unlike my time with Miyako and Estere, I had a feeling my two sofa-buddies were ovulating. Fatherhood was on the way. How my infant would survive the continuous poisonous assault on the augur's lymphatic system was beyond me. Her guardian, let's just say I dealt with sneaky bitches/Dot on a regular basis and leave it at that. "He is awake," Tadêfi alerted the room. "You must leave so I can deliver my message to him in the privacy he requested." "I am almost done," a different Amazon voice stated. She was the medico dealing with my wounds. By the aroma, she had slathered on two coats of the healing goo that was becoming as comfortable to my nostrils as my soap-on-a-rope. A few more rounds of adhesive tape and the exodus from the room began. I hadn't opened my eyes because I was unprepared for the looks of anger, disappointment and concern surely leveled my way. The door shut and my eyes opened. "The Conqueror, the Champion, the Friendless and the Foe have all escaped the Land of the Endless Black Sands and returned to the Sunlit Realm," Tadêfi whispered upon my lips. Huh? That was it? Seriously, four freaking titles without, And here came the rest, faces. Faces with eyes and eyes with a purpose. Names, not names I wanted to hear at the moment. Bad fucking news all around. It couldn't be something helpful like the identity of the next High Priestess, No, that would be good fucking news. Okay, time to turn this frown upside down. I could make this work for me. How, I wasn't sure. "Thank you," I responded to Tadêfi's plea of understanding. Outside of having impregnating sex with me, the Sex-Master, Timothy was going to Nerf-shoot me for that, she'd endured spiritual, mental and physical grief and torment to be with me here today. She waited, kneeling beside my head. "Kiss me," I requested. It was a moist act, full of compassion and understanding. I racked my mind for the names and their importance. "Who was Shammuramat?" "I don't know, but this helps, right?" Tadêfi expressed her need to make the reward for the sacrifices to make sense. Five dead sister-augurs. They had to find that son-of-a-bitch! "Tadêfi, we are back in the fight," I grinned. "You and your sisters have given the Host a mighty weapon in the upcoming struggle." I knew that to be true because I knew who and where the Conqueror was, I knew he wasn't ready to be revealed, his enemies were closing in and he was ignorant of that fact. I was going to have to rain on his parade to save his life. The five augurs hadn't died futilely. The Weave of Fate had shielded the man and it took the augers' fanatical devotion to cut the threads and expose the truth the Host needed most. The Champion, hell, I knew who he was. I chuckled. Tadêfi was confused. The Champion was coming to kill me, me and a bunch of other Amazons, because blood feuds tend to run both ways. The Foe. He was easy enough. Granddad. The Bastard just wouldn't stay dead. I had a clue to what was going on now. I wasn't sure how useful that knowledge would be. Still, knowledge is knowledge. That thing crawling around inside my brain? No help there. That left Shammuramat. That name was familiar. Even when I finally placed it, I didn't understand her role in things. Why her? "Krasimira," I called out. I struggled to sit up and with Tadêfi's help, I did so. The Keeper and two guardians entered as well. One, Sikia, hovered over her companion/augur. "What is the link between Shammuramat and the Host?" I inquired. I saw no recognition in the Keeper's eyes. "She was the first ever "independent" queen of a nation-state, Assyria." Krasimira sat on the sofa and retrieved her tablet from inside her robes. She began working with the electronic history of the Amazon race. "9th Century BCE," I added. Slowly others migrated back into the room. Buffy, Katrina (not good and not happy), Elsa (really not good) and Desiree. Pamela leaned against the door sill, neither in nor out. Katrina sat behind her desk. The phone came out and whispered conversations began in earnest. I had shoved us straight into a war which looked like a free for all at the moment. No one trusted anyone. No one could afford to. I had to change that. The only saving grace was that it appeared no Secret Society had planned for the Protocols to abruptly end a week and a half ago. "Ah, I found it," Krasimira spoke up. Because I'm me, it was at that moment I finally realized that someone had put me in my biking shorts in an effort to provide me a modicum of modesty, with the benefit of blood being smeared on the inside. "She abandoned the Host, she was put under a death sentence for killing her twin sister who was chosen to lead House Anat over her." "Anat?" I queried. "The other dead First House," Krasimira sighed. "They were renowned for their berserkers. Some would drape themselves in the entrails of their enemies in the midst of battle to increase their ferocious appearance." "Oh, how sweet, what was Ishara known for?" I was surprised I'd never asked. "Ishara were the emissaries of the Host," Krasimira informed me. With the Amazon practice of killing embassies sent their way, the extinction of my house made much more sense. "What does this mean?" Desiree took charge of matters since Katrina was still busy on the phone. In a few short weeks, Desiree's prestige had definitely increased. Katrina was her sister in more than name now. "Where to begin,  Fine, why don't we refer to the Mycenaeans by their proper Amazon name?" Everyone but Buffy was glancing about nervously. "You used the name, didn't you?" Elsa rubbed the bridge of her nose, dreading the response. "Yes, " I answered. "Because no one warns him of shit," Pamela huffed. "You assume an Amazon education with no basis in reality. You act like he grew up with our fairy tales and phantasmal histories. Everyone in this room, but Buffy," she acknowledge my First, "knew he spoke our language and the accompanying risk. Still, no one warned him." "You didn't warn him," Desiree skewered Pamela with a glance. "Not my job, Buttons," Pamela chuckled. "I relish the rest of you being made to look like idiots too much to be useful to Cáel unless it really matters. So he invoked an ancient malediction. What is the worst that could happen?" "I'm going to make a huge deductive leap, am I the reason the Achaean hero Ajax and his boys are back from the dead and coming after us for some Ako-level vengeance?" I groaned. (That's the 47 Ronin for us Westerners) Silence. "That's not your fault, Sport," Pamela snorted. "Mano-man, was I a dumbass for doing nothing. I'll take the blame for that one ladies. Damn Cáel, you would have to pick the Unconquered One, wouldn't you?" "Who is this guy and why does he hate us?" Buffy interjected. Pause. "Our ancestors poisoned his wine so that, in his angry haze, he mistook his own men for his enemies and slaughtered them all, back during the Trojan War. Afterwards, he committed suicide in anguish over his crime, Death opened his eyes at the last, he saw our treachery and managed to curse us as he died," Krasimira informed the lot of us. "And my using that word brought him back? That sounds, weak," I grunted. "The word would not have been enough," Tadêfi comforted me. "There must have been some sort of rift in the curtain of Reality that allowed the others to slip through. I don't understand how, oh no," she gasped as the pieces came together. "I'm willing to believe that was the price of doing business," I petted Tadêfi's cheek. "Please enlighten us," Elsa grumbled. "I need to find the Earth  and  Sky ambassador and set up a new meeting. Using what Tadêfi has gifted me with and the sacrifice of her fellow augurs, I can secure an alliance for us if only I can make up for the whole stunt Troika played," I grinned. "Any ideas?" "We could call them," Pamela produced my phone. "Seems some lady named Hana Sulkanen has been trying for days to get in touch with you. She hunted down the owner of the necklace, they talked about your current physical state, courtesy of Odette, and the owner of the necklace has expressed a continued interest in meeting you, and only you. It would appear that they really don't trust the rest of our merry little band since your first disappearance." Hana, and here I had killed her step-brother, the one she despised. An unexpected benefit of civil discourse, my People's chance of survival had doubled. Pamela lobbed my phone and I caught it. "What of the other two?" Tadêfi pushed down on my euphoria. "Was the Foe dead as well?" A quick look at Pamela told me she knew the answer to that. "The Foe is complicated," I lied. "His return was an inevitability, so we count that as a draw. The Champion, bad news. Let's put Shammy in the 'maybe' column and the Conqueror is a win for our side." A Berserker Queen, fresh from the Underworld, who we were honor-bound to kill,  or the 'other lost heir to a dead House' that was going to make us cobble together some nonsense to bring her back into the fold. If I wasn't the male leader of a spiritually significant All-Girls social club/paramilitary outfit, I might have been daunted by my prospects of achieving the latter. "The thing going on inside your head?" Elsa asked. That explained her presence. My mental capacity was still suspect. Was I still me? Could I flip out with no warning? "It is still there. I still have no idea what happened to me, or what the results might be. This means I'm going into battle wounded and that's that," I stated. "Are you acting in the best interest of the Host," Elsa studied me. "I am not sure," I confessed after half a minute's introspection. "So many of you are fuck-nuts; I'm not sure what acting responsible is for this set," I added jokingly. "As it stand, you lack the authority to pass judgment on me, Elsa. I promise you that if I feel I'm losing control, I will turn myself in." "Saint Marie would feel better if you stayed here," Elsa insisted. "Is the SD declaring war on House Ishara?" Buffy rose to the challenge. "We (by that she meant my fellow Isharans) have discussed the matter and talked to our best neuroscientist. She cannot definitively tell us Cáel isn't Cáel, so there is no reason to constrain him." Whoa. In our best prospect's educated opinion I was not-not me. Legions of English teachers weren't going to like that. "I have the answer for that," Katrina spoke up. "I owe Cáel and I would pay that debt now. He expressed a desire to see my niece, Aya. Do you still wish that Cáel Ishara?" "More than ever, but the Council is meeting," I sighed. "Buffy is your (dead word spoken), your apprentice," Katrina suggested. "Appoint someone to stand with her." That was more than good advice. Buffy was a woman and, to those who knew of her, as fierce an Amazon as ever lived. That was what Katrina was telling me without telling me. "I choose Daphne Pile, if she will accept, to stand by Buffy's side," I announced. Buffy would need someone who was passionate for my cause and who spoke Old Kingdom Hittite. Buffy still didn't, and the chance of the Council speaking English on her behalf was non-existent. "That is Daphne of House Cotyttia," Pamela corrected me. Who Cotyttia was? I had no idea. I was stupid to think Daphne's actual Amazon surname was Pile. Daphne wasn't even around. Executive Services was functioning fine without me and that meant Daphne had a work queue. "The Thracian Goddess of Sex, Orgies, War and Slaughter," Krasimira gracefully filled in my ignorance. Another whoa, why wasn't she my matron goddess? Tadêfi hauled off and slapped me. The action seemed to take everyone, Tadêfi included, by surprise. "I don't know why I did that," Tadêfi wailed out in despair. I did. It didn't take telepathy to figure out what I had been thinking. To prove my point, Pamela laughed. I cupped Tadêfi's jaw. "Worry not," I cooed. "I had that coming, Dot Ishara," I dodged another one, "isn't happy with me right now." Recall, Tadêfi was hooked up to an old-fashioned party line with the Beyond. "Animaniacs," Pamela snorted. "I so love you. It is my deep and abiding pleasure to have you as my Grandson." "I'm not your grandson," I countered. "Well, I say you are. Now be quiet and accept the shame," Pamela's eyes danced with amusement. "That makes me, Daphne and Brielle incest," I pointed out. "Amazons don't have an incest taboo," Pamela retorted. Duh. They are all women, no chance of seven fingered, Cyclops babies. "Ah, women, misunderstanding and pain, Buffy, would you check out Quebec and see if I'm still wanted in that province for bestiality. It could be important later," I commanded. "Bestiality?" only one woman failed to mutter, sputter or exclaimed. "The complainant in question is not that pissed at you anymore," Katrina's rolodex mind kicked in. "I believe she expressed a desire to question you about some missing accoutrements though." My splitting headache meant I had to think about that, ah yes, her dress uniform. It was/had been Canada Day, thus her having an official function and thus me cheating with the girl from across the hall in the Mountie's bed. I'm an idiot alright and my ability to keep an eye on the clock needs improvement. My last image of her, frothing at the mouth (she was a tad more possessive than I had anticipated) as she screamed out insults in Quebecois French concerning my lineage, personality failings and the treasured parts of my anatomy. She punctuated various parts of that deranged episode by hurling articles of her clothing over the border at me as I turned (once I had good Ole US soil/pavement under my feet) and tried to get us back together. Yes, I had them, just not in my Box of Failed Romances. Acting on hopes of reconciliation, I had the uniform dry cleaned, placed in a dress bag, and the boots polished; both currently occupying space in my closet. At least the Alburgh-Noyan Crossing guards (it is a dual Canadian-American post) appreciated me evading/begging forgiveness long enough for them to see her in only her bra and panties. I imagine they didn't normally get much excitement there. "Katrina, " I began. "Yes, Maya forgives you too, though she scored an 'At Risk' for reliability. Anais sounded genuine," Katrina related. Anais was the Mountie. Maya was the Guyane Française university student from across the hall, the one I was caught cheating with. I had told her I was Anais's brother. Maya was also a super-exceptional cook. "Cáel Ishara, who are these women we are talking about?" Sikia demanded. 'We', that didn't take long. We were now a 'we', which in Amazon meant 'male, you're my property'. "I have a sideline job as an Amway distributor," I replied. "I give crappy customer service." "You give awesome customer service," Katrina riposted. "That's the problem." "Sikia, you are not the first Amazon Cáel has stuck his dick into. You are probably not the tenth," Elsa dripped with frustration. Quick count: Rhada, Buffy, Oneida and Gael, I was only going to count the penile-vaginal penetrations. "They are only numbers five and six, thank you very much," I defended myself. "So much for your 'intern, no sex' policy," Desiree muttered. "Cut me some slack, I work with stone-cold, Olympic level athlete foxes 24/7," I griped. "I am a sexual being too, I have needs." "What about the 'End of Internship' hunting shindig?" Desiree pulled a flawless 'Katrina'. "Oh, it is still on. With my 'do or die' learning curve, it is going to be so much more fun," I grinned. "And, okay, no more Amazon sex until then, sorry Rachel." "Except for house members," Buffy insisted. "No exceptions," Elsa demanded. "I'll keep an eye on him," Pamela resolved the issue. "No more Amazon boinking for him." She was such a liar. She was also a highly accomplished liar because everyone bought it. On with my life. Stage one: exit Katrina's office. Done deal, no problems. Stage two: set up meeting with the Earth  and  Sky. They wanted to meet on their ground. Since I was the uncertain factor in these negotiations, I agreed. I was bringing one, Pamela raised four fingers, four people with me. Who? Outside of Pamela, I had no idea. Stage three: going to medical and putting on my business suit, it was a new one and very, very nice. I was moving up into serious majestic magnate territory. I also picked up buddy number two, FBI Special Agent Virginia Maddox. Why had I chosen a federal agent to accompany me to a meeting between two secret societies? I hadn't a clue. Sometimes you have to roll with these things. In the lobby, I picked up number three, Delilah, Mom's MI-6 operative/baby-sitter. Compassionate, caring people were surrounding me all the time. It gave me this sensation of a 'down home' environment no matter where I went, if down home was Gaza, or Donetsk. I think my entourage/lifestyle observation teams had grown to encompass six cars. I was in no condition for riding my bike, so that recourse was denied me. Taxi? One, most were hard-working stiffs like my family who didn't deserve to be caught in a noontime, drive-by assassination attempt. Besides, with my luck I'd meet the guy from Qatar again, the one with the sister with cute eyes. That reminded me, I gave Nicole a call. "How are you doing?" she quickly inquired. "Good," I lied to a past master of shattering perjury. Pause. "I'm surrounded by girls with guns, tailed by your clients, some part of a Federal Task force and some people who I don't know yet. Hold on." I put my hand over my phone. "Delilah, are you packing heat?" I asked softly. She opened her jacket revealing paired revolvers in shoulder holsters. I didn't recognize them so the Brit gave me the 4-1-1. "Ruger Alaskans," she grinned. Bing! Now I recalled them. The girl who taught me to shoot once read some reviews of that beast on her laptop while I gave her a slow, passionate screw from behind. She became all hot and bothered, wiggling, squirming and generally having a grandiose time with my cock deep within. I repeat, this girl really loved guns, a huge cerebral G-spot for her. Oh yeah, the Ruger Alaskan is what you get if you are worried about Grizzly bears popping their heads through the tent flaps late at night. Delilah was probably packing 4 80's. Her guns would turn 250 kilograms of pissed off ursine into an excellent throw-rug in about two shots. In an urban environment,  well, maybe she thought the New York Giants were actually giants, or something like that. Two were overkill, unless you expected someone needing to borrow one. "Just checked. I remain the only one unarmed in my personal carnival of carnage, " my words trailed up to an unintelligible mumble. I was mumbling because suddenly four handguns were casually offered up for my use (Tiger Lily was holding one over her shoulder as she drove), in the same way you'd offer up some Nicorette to a man jonesing for a smoke. Rachel was kind enough to hand me my familiar Glock-22 and Ruger 38 caliber with their accompanying holsters. Two spare clips followed, then I stashed the lot. I scratched my calf. It took me a second to realize I was reaching for my pistol. No, not the one at my hip, or my ankle, but the one, in my boot? "Now that you've been handed firearms of dubious origin, can I get back to questioning you," the FBI agent intruded upon my ruminations. "We were discussing that list of people that are visiting a morgue instead of a court room. What can you tell me?" "Bye Nicole. Miss you. Being interrogated by a blonde FBI lady with a whips scar on her eyebrow and eyes that could scare a badger back into its hole. Later," I cut of my lawyer's fierce demand that I keep my mouth shut. "Nothing useful that wouldn't implicate myself and others in a criminal conspiracy," I answered her. "There is no way I'd name anyone else I suspect of involvement. I feel no guilt over what has happened, so no remorseful confession, and that is based on my belief that cosmic justice has been achieved." "You can't create lists of people for execution," Maddox persisted. "That negates the whole justice system and the principle of innocent until proven guilty." Wow! Except for the two of us, every other person in the car snorted their derision of Maddox's presumptive naiveté. "Do you even believe the tripe spilling from your pie-hole?" Delilah mocked Maddox. "I'm in law enforcement. That means I enforce the laws, not interpret them, or choose which ones I want to obey and which ones to ignore," Virginia fought back. "Love, that's crap and you know it. You are an agent of the US government. You bomb, drone-strike, overthrow lawfully elected governments and assassinate in your nation's best interests," Delilah countered. "You selectively enforce your Constitution when it suits you." "I'm law enforcement, not the military or foreign affairs. Know the difference," Maddox glared. "The pay master is the same,  you willingly collect your thirty pieces of silver; get off your high horse because you are in the shat now, Agent Maddox. I haven't known this crowd an hour and I know for a fact that you are the only US citizen onboard," Delilah chortled. "I don't know their bleeding nationality, but I doubt it is on the UN Charter." Maddox turned to me. "That was succinct and rather accurate," I murmured. "Special Agent Maddox, I have the sneaking suspicion that you are with us because FP (federal prosecutor) Castello feels you can handle this, Umm, unusual set of circumstance. I promise you this, it is going to get worse." "Why don't we test this quaint theory?" FBI Lass challenged us. "Jail, bail, and I'm waking up in Rio de Janeiro in two days," I sighed. "I have a few thousand in the bank, live in a hole and own my father's home, when it clears probate. Only you know I'm flight risk. A dozen people will vouch/lie about my character and that's that. All you've succeeding in doing is making enemies when you need friends." "There is still a matter of multiple people dead under suspicious circumstance," she said. "Imagine for a second that Cáel admits to creating a hit list," Pamela began. "He would never give up the names of the other people involved. He didn't kill anyone, or say 'kill them'. Now what? You still have an abysmal case to put before a judge. Add to that, the mitigating factor of a raped girl. You get to break her down until she's a cooperating witness because she's the only one who can provide you with Cáel's motive," my mentor continued. "Good for you and your team. She gets to betray the man who tried to save her. Cáel promised horrific retribution if any of those in the now-dead crowd hurt her. That is rather unlike him, he normally forgives when given the least excuse. I don't give a damn about women's rights, or the rights of rape victims. I really could give a shit about human rights for that matter. Wronging me is the surest way to early retirement. It is not a matter of strong versus weak, or right versus wrong. What matters to me is who I can trust. I don't know you, thus I don't trust you. I trust your government to be so much chicken shit. I base this on the lack of public torture and execution. I want the families of dying criminals paraded in front of those cock-suckers before the condemned finally perish in agony. I want to see thieves get their forearms hacked off, trial by combat, and respect for your elders. I want to see public officials being sacrificed upon the altar of Jehovah when they leave office. I want to see a system of justice with a soul, not law books thicker than an aircraft carrier's hull. A government 'of the People, by the People, for the People' should be the sole guiding force for your culture and we both know that's never going to happen. I admire your soldiers; not because they are brave and combat effective, they are. I admire them because they are fighting and dying for elected officials and a population that can't locate Afghanistan, or Iraq on a map, can't tell the difference between a Sikh and a Muslim, and thinks 'Pashtun' is an exotic piece of furniture. I admire them because they are better human beings despite you, not because of you," Pamela was coming to her crescendo. "Basically you people, by that I mean most of the human race, are dangerous in your idiocy, arrogance and pride in your ignorance. Not one of you should be allowed to use weapons, or play with fire. For you, unrestricted voting is a crime right up there with inventing, disease prevention, bilingualism and anything that perpetuates your educational system." "Lady, why are you so angry with the world?" Maddox studied Pamela intensely. I wished her luck with divining and then unwrapping that lady's mind. "I hold dear to my heart anyone's hunger to learn, honesty when it hurts and love no matter what the cost, so I find myself alone most of the time," Pamela grinned. "Above even those, I adore humor in the face of ridicule, condemnation and adversity. You can dodge bullets and parry knives. Humor always strikes home," she finished. "It is the perfect weapon." "Liar," I smiled. "You like high performance automobiles too." Did she? I didn't know. "Only with a 2X4 pressing the accelerator as it races toward the lip of a canyon," Pamela bantered back, "with Ursula K. Le Guin strapped in the back seat." "Who?" I inquired. "She's an author. I take exception to some of her work and unwillingness to appreciate the fusion of exceptional feminine characteristics with power positions," Pamela answered. "And your critique of her life's work is an exploding car at the bottom of a cliff?" I smiled. "Starting uncontrolled wildfires and littering, two of my favorite activities," she laughed. "I'll stick with blondes and brunettes, and red- and raven-haired, bald has its own appeal, green and purple have their own kink going on, " I joked. "Wait! We were talking about people being murdered and you two are cracking jokes?" Maddox rumbled. "I had a dream about tying them together with nylon cord and tossing them off the back ramp of a transport aircraft, and watching them fall, and fall," Rachel sighed dreamily. "Atta girl," I play-punched Rachel's shoulder. "What is your part in all of this?" Maddox turned to Rachel. "I'm the head of his bodyguard detail," Rachel gave her confession of the damned. "And you want to kill him, " Virginia struggled to keep up. "Given time, you will too," Rachel promised. "According to his pre-employment records, only one woman he's had a sexual relationship with hasn't wanted to at least hurt him," glaring at me, "badly." "The nun doesn't want me dead!" I vocally protested. "It is so wrong that you are proud that of over 200 women you've slept with, TWO have not, at some point in knowing you, wanted to maul you and one of those is in the 'forgiving' business," Rachel chastised me. Virginia had an answer for my madness. Her phone came out and she hit speed-dial, work. "Ms. Castello, this is Special Agent Maddox, do you have a moment?" Virginia calmly asked when she finally wrangled my current-favorite fed's attention. "You do now? Thank you. I'd like to know what the fuck have you done to me? This assignment is nuts. Either I'm part of some elaborate prank, or I'm in an S U V with escapees from the looney bin." Ten seconds later Maddox gave me the phone. "Stop it. I've upheld my end of the bargain, so behave," Javiera ordered. Man, she'd shot me straight to the core and we hadn't even slept together yet. Clever, clever girl. "Yes Ma'am," I swore. "I'll do my best to buffer Special Agent Maddox from the truth." "I'll have to accept that," Javiera conceded. "Give Maddox the phone back." A brief conversation later and Maddox was no better off than when she started. Thankfully we parked in front of the Kazakhstan Consulate in New York, giving us all an excuse to face facts. Maddox was feeling compelled to ask questions she didn't want the answers to, and that we didn't want to answer. Saved by work. "Kazakhstan Consulate? Why are we here?" both Virginia and Rachel asked. "Oh! This is going to be good," Pamela leaned forward excitedly. "Change the course of human history," I answered with a great deal of confidence I didn't feel. See, I had knowledge critical to the Earth  and  Sky. That knowledge was also something they wanted kept compartmentalized, so they might take exception to it being possessed by an outsider. Oh,  so that's why Pamela earlier insisted on four ladies being with me, so we could shoot our way out if things turned ugly. I hugged my mentor. "Thank you, Pamela." "You are coming along nicely, Mr. Potter," Pamela patted my cheek. "Your praise leaves me suspicious, Professor Snape. Besides, if I'm going to die, it helps me to know you'll go first ." "That was uncalled for," Pamela chided me. It was the 'Snape' role she rejected. "Snape gave up his life for Harry, Dumbledore died for Draco," I countered. "Well, let's hope it doesn't come to that," Pamela shone with joy and pride. "You act like I have a choice," I sighed. "Touché," Pamela nodded. "I see what you mean about these two," Maddox addressed Rachel. "Oh my God," Delilah laughed. "You wove Harry Potter into a life and death conversation and it made sense. I am probably going to die, but I'll die knowing I have lived." "Not you too?" Maddox glared at Delilah. Rachel just shook her head. We exited the car, settled ourselves out. Rachel took point, Delilah took one flank while Pamela took the other. By happenstance, I ended up in the middle, yeah right, with Virginia covering my back. "You stay here," Pamela put a hand on Rachel's shoulder. "You'll need to lead the team in if someone 'pumps up the volume'." Interesting euphemism for 'when people start killing people'. "What are we doing today?" Miyako 'appeared'. She'd been walking down the sidewalk toward us, the Kazak Consulate was a townhouse, but her presence hadn't registered. "I require your pledge of silence on what is to transpire. No death is intended," I stated calmly to Miyako. "I didn't know you were versed in ninja contracts, much less spoke Japanese?" Miyako responded. Blink. "I didn't know I spoke it either, " I mumbled. "No sweat," Pamela tried to hustle us along. "He's a quick study." Yeah. I didn't feel it apropos to point out I hadn't heard myself speaking Japanese, or understood that my words had some secret meaning. "How important is this to my people?" Miyako asked. Now that I was paying attention to it, I could make out that she was speaking in her native tongue. "If they don't think we can be trusted to not speak of what is to transpire for a week, they are going to kill us," I related my suspicions. "My mind and heart are joined in this decision." "I give you my pledge," Miyako nodded. She looped her arm in mine. "Does anyone care to enlighten me?" Maddox prodded. Whoa. It seemed that, beside me and Miyako, only Pamela spoke Japanese. "Special Agent Maddox, no matter what, don't give up your gun, when we say run, run, and shoot to kill because they will be trying to kill us," I informed her. "Does the term 'extraterritoriality' mean anything to anyone here?" Maddox snapped. Her nervousness was totally understandable. I stopped at the top of the steps, looking over my shoulder. I nodded. Pamela, Delilah and Miyako nodded as well. "Hold on, I can't believe I'm saying this. Does anyone have a back-up I can use?" Maddox groaned. Rachel quick-stepped forward and handed over a 22 automatic pistol then a spare clip with a smooth, practiced motion that suggested that SD swapped weapons all the time. Maddox didn't miss the casualness of the gesture. The firearm and magazine disappeared. "Fine, we will never discuss the laws we just butchered, ever, and if I die and any of you make it out alive, I will seek revenge at whatever cost FROM WHEREVER I AM," FBI girl growled. "One of us," Pamela smirked at me as I touched the doorbell. It opened promptly. We weren't on a crowded street, we were on their stoop and a security camera was pointed right at us. We were invited in and two rather Caucasian-looking gentlemen (Kazaks are a mixed bag of Turks and Cumans) were waiting with the doorman. They looked tough in that they took personality lessons from saddle leather. "You will place your weapons there," the more charismatic of the two spoke up. He was pointing to a side table that looked large enough for the task. "No," was the most courteous response I could muster. He didn't look surprised. He didn't look much like he was breathing, or blinking either. "Go," he pointed to the door. I looked to Pamela. "Well, that didn't take long," I grinned. I felt out the necklace under my shirt and pulled it over my head. "Please return this to its owner in the spirit it was given." He took it. The doorman opened the door and out we went. Rachel was back in our GL550, using the door as possible cover. She said we could take our seats and away we rolled. Maddox looked apoplectic. She had prepared herself for the Wild, Wild West, not a doe-see-doe at the door. In her mind, I had wound her up for nothing. My phone rang. "Cáel Ishara, there seems to have been a diplomatic miscommunication," a male native Turkish-speaker said in heavily accented English. "The person you are meeting must be approached in the spirit of peace." "No, I understood you perfectly," I assured him. "We aren't the Brownies, or the Girl Scouts, Buddy. I don't know, or trust you and you don't know, or trust me, yet. I will compromise though. I will respect your traditions. I will enter your home unarmed. In turn, everyone in the building will line up outside on the street except for the person I'm supposed to meet. Is that acceptable?" Pause. "Do you hate these people, or like them?" Maddox grumbled. "With you, I can't quite tell." "That would not be acceptable," the man finally responded. "Perhaps an alternative. You come in, alone yet armed." "Nope. Due to the efforts of people far smarter than me, I know pretty much who I am meeting, so I am either very rude, insane, or bear a message that is worth my life," I countered. "Your personal safety is guaranteed," was the counter-offer. "That is a false promise, not because you lack honor, or respect for me, but because you are from a wise and noble lineage with a historical propensity of cutting to the heart of any problem." By that, I meant they'd cut my heart out. "What I expect is for every one of you to hold the future of the Earth  and  Sky above any such concepts as personal promises, hospitality, and honor. I am even putting my faith in your willingness to put the survival of the Earth  and  Sky over your own well-being," I riposted. "If the message is so crucial, you should be willing to come alone," back at me. "It isn't important to me," I stated. "Listen, a war is about to break out. Unless we both want to be found all alone in the outhouse masturbating when the headsman comes, one of us has to blink. Today, it is you. Tomorrow you may be able to return the favor and mess with my head." Pause. "Your koumiss is getting warm." "We'll be right there. We apologize for the delay. Traffic is murder these days, or a close facsimile thereof," I gave a little back in the humility department. "Tiger Lily, " "On it, Ishara, Wakko Ishara. I've been circling the block," Tiger Lily had anticipated my antics. Sure, I acted like I had no game plan, but I never wasted people's time. Maybe if I developed an actual game plan I could do even better. "Wakko Ishara?" it was Delilah's and Maddox's turn to share a 'what the?' moment. "May I explain the sacred names?" Rachel requested of me. "I have a feeling these two might become a fixture." "By all means, Rachel. Our trust runs deep," I trusted Rachel with more than my life; I trusted her with my future. "Wakko, as in you're the nutty one?" Delilah made a stab at our arcane nomenclature. If you use small words does that make it gnomenclature? Pamela winked at me, psychic twin grandmother powers activate! "We need complementary rings," Pamela remarked. Sweet! "Cáel Ishara is differentiated as Wakko Ishara, Ishara, first of House Ishara, is Yakko Ishara, and, " Rachel began. "The Animaniacs? Your code names are the Warner Brothers and their sister Dot?" Maddox gasped. "You are beyond nuts." "And the Goddess Ishara is named, by House Ishara and House Ishara alone," Rachel made some warding appeal against divine punishment, "as Dot Ishara." Maddox's face shown with disbelief. "Following Cáel Ishara into battle has been one of my greatest pleasures," Rachel stared at Maddox. "I never knew insanity could be so liberating, or that laughing at death could be such an aphrodisiac." "When did you two go into battle?" Delilah wondered. "In a morgue, fighting to retrieve the body of his fallen father so that our enemies could not desecrate it," Rachel explained. Ah, the walls of Troy, fighting over the spoils of the dead. "You mean when I face-planted?" I grinned at Rachel. "Even without a weapon, your instincts were good, forcing our enemy to commit to multiple angles of coverage even though your efforts were foiled by a footing failure. Your rushing their leader was even more heroic in that you were unarmed and using your body as a decoy, knowing your enemy's superior skill would stop him from shooting you," Rachel smiled my way, sex. "Let me get this straight," Miyako finally spoke up. "You charged an enemy unarmed then stumbled and failed. They were armed?" "Yes, with a 3 57 Magnum revolver and a 10 gauge sawed-off automatic shotgun, in tight confines and close range, oh, and no cover." Maddox replied, then to me, "I read the report." "Then you repeated the action a few minutes," Miyako. "Less than a minute later," Maddox clarified. "A minute later, wow! You are as fearless as we've heard. Please don't die before we have a baby," Miyako gave me a quick hug. If you cover a zeppelin with uranium paint, can it still fly, or does it sink to the center of the Earth? Ninja babies, We had returned to the stairs at the Consulate. This time the door swung open upon our approach. "Is there some drug you are all taking to bask in this shared fantasy life?" Maddox mumbled. "One of us," Pamela retorted. "One of us." "One of us," I joined in. It helped cut the tension. The bodyguards were present right where we'd them last time. They ushered us up the stairs to a second floor sitting room that ate up half the floor. There were two men there; radiating that subtle assurance that a half-dozen killers were close by. The man standing was Iskender, the E and S emissary from Dad's funeral. I broke all decorum, strode to the man, locked arms, hugged him tight and patted him on the back. "Thank the spirits you are here," I whispered, "all this lack of dick is making me a bit stir-crazy." "Ah, yes, it is good to see you again too," Iskender imparted as we broke our embrace. His boss, the guy on the sofa, shot me and my Kyrgyz buddy a sharp look. The Main Man was clearly Mongolian and must have thought blank, white walls exhibited too much empathy. "Koumiss," the boss offered. I sipped it from a simple, yet regal drinking mug that probably hit the kiln 200 years ago. "Mare, or yak?" I inquired as I handed the cup around. Iskender came first, but it was clearly my intention that we all partake. It was more a matter of the host's pledge of sanctuary than me wanting to share the koumiss. It tasted like thin, lightly chilled, bitter beer with a vanilla-almond milk shake-chaser. "Mare, of course. Please sit," he offered. He defined the suggestion by slipping off the sofa onto the layered carpet rug. He was semi-reclined, so we followed suit. "We should pray for the protection of the spirits," was the suggestion that wasn't a suggestion. It was his itinerary. He clapped his hands and from beyond a curtained partition came this really sensual Mongolian chick carrying a large brass bowl. She flicked her eyes at me and an instant connection was formed. She liked to bark like a dog under the full moon, okay, I'm not sure where that came from. "Nice woman," I told the leader. "She looks like she has seen many winters." Whoa! Where the fuck did that come from? I got a shocked reaction from Iskender. The Leader looked pissed, if a flake of paint on the white wall indicated anger. The girl blushed like what I said was an incredible turn on. "She is my daughter," the Leader pointed out. Way past swallowing my foot. My ankle was tasty. "My name is Oyuun Tömörbaatar. My faithful Iskender, you know. This is my daughter T. Sarangerel. She is studying at N Y U and is not entertaining marriage proposals at this time," he slapped down his boundaries. Somehow 'I only want to sleep with her' didn't sound like the right response. Wait! Saying his 'daughter had many winters' was a marriage bargaining opening move. What the fuck! "What I meant was that surely many men have died trying to come before you," I back-pedaled. More happy looks from the daughter. More paint peeling from the dad. Pamela made sure more koumiss was going around. Getting drunk could hardly hurt at this juncture. Sarangeral placed the bowl between us. It was filled with clear, cold water undoubtedly collected from a mountain-fed glacier. "Let us cleanse our hands in the water so that we may speak with clarity," O. Tömörbaatar said. We dipped our fingers and, for a second, I saw him. Not 'O', but HIM. "It is good to finally meet you Ferko Ishara Cáel Nyilas," the man said. My Spidey senses told me he was feeling less 'good' about this meeting every second. "How can your people and mine better get along?" 'Let me impregnate your daughter', would probably get my skull split open. "No time for that," I replied. "I know where HE is. The Seven Pillars have found a way to search the Weave and are closing in. You must act with haste." Whether it was disbelief, or old schooled Ku Chun in the art of gambling, the older man gave no outward reaction. "Where is he?" O. Tömörbaatar asked in a gentle tone. "I can do you one better," I steeled myself for the unknown forces I was invoking. I put my hands on the bowl's lip and looked in. Several seconds later, he did as well. For a moment, nothing. It was like a ripple in reverse. The first earth tremor I barely noticed. The ripples grew and grew until I felt the whole row of townhouses would come crashing down. Wind snapped the locks on the windows, flinging them wide open and tearing at the curtains like streamers in a hurricane. Then we saw HIM clearly. HE stopped driving this old, beat-up Peugeot and was pulling to the side of a desolate stretch of highway. HE could sense something yet couldn't pinpoint the source of his unease. We definitely got the impression this wasn't his first taste of this experience, the Seven Pillars. He was young, maybe my age. He looked like an educated man turned vagabond/boundless traveler. HIS eyes, his eyes had a depth that were a microcosm of what I'd glimpsed in Ishara, Dot Ishara's unshielded glance when we first met. All lingering doubts vanished in my mind. "I know that place," O T muttered, his eyes fixated on the only feature in the vacant expanse, a road sign, in Chinese. Yikes. "I know that place." The image faded. Our meeting venue was intact. Whatever I felt transpire, I had shared with O. Tömörbaatar alone. "You have work to do," I stated as I cleared my throat. "I will leave you to it." I stood. "What do you wish for this gift?" O T reached out and touched my sleeve. "When the time comes, maybe you can help us," I replied. "A man who asks for nothing can expect anything," O T smiled for the first time. "Go." I did not take a fear-free breath until the cars started up and we pulled away. He'd let us live. Even with that priceless piece of magical insight, he'd let us live. "I'm still stunned we got out alive," I sighed. "I wasn't really sure he'd take the news as well as he did." No one said anything for a minute. "Why would he have killed us?" Delilah inquired. "You, I understand. I don't know what you communicated to that young lady, but the old guy wasn't happy about it. He was going to kill us over that?" Pause. "What did the rest of you see and hear?" I looked around the cabin. Pamela appeared worried. "I didn't know you spoke Chagatai," Miyako smiled at me. "You are full of surprise. I only caught a word, or two, and none of it made sense." "MRI," I groaned. "Magnetoencephalography," Pamela said in the same breath. "Mine is better, Boyo." "What is going on?" Rachel upped her alertness level. "We need to take Cáel to a hospital that has a Magnetoencephalography device," Pamela insisted. "He's spontaneously speaking languages he didn't know moments earlier, " Maddox put things together first. The rest nodded at her assessment. "We'll need to have his records from Havenstone sent over as a baseline." Poor Virginia, the absurdity of my life was sucking her in. "I'll call Katrina," Rachel informed us. I was a mental case once more. At least my input was still being solicited. "How many guns do you have on you?" Pamela zinged me. The answer was obvious, two. My Glock and my back-up. That didn't seem right. "Ah, two?" I responded. "Yeah, something is happening to your muscle memory as well," Pamela shook her head. "What exactly does that mean, and what's wrong with Cáel's brain?" Delilah studied the group. "It means he could spontaneously pull out his gun and start shooting us?" Pamela confessed her uncertainty. "I don't know. We'd better figure out which impulses are his guiding light right now before that happens." "I don't even know how to begin reporting this," Maddox muttered. "Cheer up. Our Cáel is still currently in charge. Did you appreciate how he lured in that young Mongolian girl? That's classic Cáel," Pamela comforted the crowd. I was saved from a straightjacket because I was a 'Playa'. (Meadowlands Medical Center in far off New Jersey) I'm not political. For me, that means I am completely and utterly dedicated to whatever doctrine that the cutest political campaigner in front of me endorses. Fifteen minutes on the internet and you can fake it like a pro. Be careful to be with the winning team when the results come in. Nothing makes a political chick go wild like sneaking into the candidate's office and screwing her on the newly elected/re-elected figure's desk. Let her scream out her idol's name. Odds are neither of you will be welcomed back afterwards anyway. Why politics now? Javiera called some people. I had a sneaking suspicion that someone I knew and trusted got in touch with my 'Aunts' as well. All I knew for sure was the Hospital's Administrator's phone began ringing off the hook and I'd become the hospital's number one priority. The hospital staff was visibly irritated with the clout raining down on their heads for about an hour. Once they digested my Havenstone records, all of that changed. Holy 'Published in The New England Journal of Medicine', someone had drilled a micro-surgical hole in my skull in the middle of a wrestling match with no resulting cerebral scarring. THEN this unknown device shot into my skull with pinpoint accuracy and pumped a ghastly amount of energy into my cerebrum. They were fascinated. They were so fascinated I heard two medical technicians mutter about where the Zombie Survival Guide could be found. They triple checked my vital signs, again. I was still as much alive as when I checked myself in. There was a rumor that a fire ax disappeared from a stairwell close by, but not one confessed to the deed. I was speaking in languages I had no reason to know? They were surprised I could contain my mouth drool. It was somewhat disheartening to hear three seasoned physicians discuss what probable scenarios could explain me still being in a non-vegetative state,  or alive for that matter. Some poor nurse had to ask. "Do you feel an unnatural, interest in human brains?" she whispered when she though no one was close by. "I'm not sure what you mean," I whispered back. "I always respect a woman's intelligence. Sex is a cerebral passion. What's the point if you can't communicate with your partner?" Pamela slapped me upside my head. That disturbed just about everybody else in the vicinity and my mentor was promptly exiled from the room. I was curious about what havoc she was perpetrating on this establishment. My condition had gotten her past all the heavy security and I knew without seeing that someone high ranking had misplaced their ID badge. Maybe Pamela was the love-child of Batman and Cat woman. Before you think that's comic fanboy talk, recall what my life was like at that moment. Tests ensued. The staff decided that Havenstone employed a bunch of quacks and snake charmers. Two hours later, they found out they were wrong. Larger battery of tests, same results. I was the second coming of Christ, back from the dead, or a zombie living in a convincing state of denial. Some folks wouldn't let that go. Pamela had proved to be prophetic. Her pet gizmo finally provided a new picture of what my neural pathways were up to. If there is any doubt, 'I've never seen that before' is not what you want to hear one of North America's experts in the field of neuroscience say. The first educated opinion was that I suffered from chronic traumatic encephalopathy, that meant I was hit in the head a lot. Normally that diagnosis comes in the midst of an autopsy. I was having paralytic seizures. They had me juggle a squeeze-ball, then two and finally three. My perfect performance frustrated them. Women find relatively simple carnival tricks to be seductive. Pluck a card from a girl's bra gets you both to some dark corner, hungrily looking for the rest of the deck, I speak from experience. Next up at bat: 'I was possessed', I shit you not. Holistic medicine was right on board with the team. Was I influenced by a supernatural power? Yes I was. So claimed the majority of people on Earth. Did I receive specific instructions? Yes, and so did practitioners of Voodoo/Vodun on three continents. I added that I attempted to evade said instructions when I could. Did I have 'evil' impulses to hurt myself, or others? Huh? For starters, my matron goddess was more of a 'fucker' than a 'fighter' and her instructions were always suitably vague, the same way a Philosophy professor would give you a ten word pointless sentence on Friday and expect you to have a 250 page doctrine on Monday morning. That hit home. Too many normally smart people take a philosophy class in college hoping for an easy-A. Some teachers love dissolving those delusion, sitting back and watching your hopes and dreams of task-free weekends go down the drain. The more obscure the discipline, the more perverse the desire. That is why you always pick a teacher of the opposite gender (if in doubt, use a gay/lesbian test) and keep 'sex for grades' on the menu. Was I suffering from optical illusions, or phantom noises? Straight to the point, yes, I saw and talked with ghosts. So did the Long Island Medium, the casts of Ghost Hunters, Paranormal Witness plus George Anderson and Chip Coffey. To my credit, I didn't do it for profit, or in order to influence people. Was I seeing ghosts now? I was in hospital, so odds weren't bad. I had every non-ghost raise their left hand. No ghosts. Was my paranormal dementia pre- or post-brain trauma? Did seeing a college student being called before his class and successfully accused of plagiarism on his senior thesis, turning him into one of the Restless Dead count? No? My 'disputed' abilities were all post-college employment, thank you very much. Did the ghosts possess me/tell me to do things? I was not possessed and, discounting sexual bondage and my current work venue, had never been possessed. From my limited exposure, ghosts wanted to not be alone in the afterlife, to be guided to a final resting place with others of their kind/family/friends. None had taught me languages, asked me to steal something, or kill anyone. Had any done so, I would have denied them. Such actions were immoral and I could still freely differentiate between right and wrong. I preferred to commit wrong on my own initiative and making me do good was a chore most sane people abandoned after a few days. I took a Rorschach test. The results were predictable because I had taken old 'R' several times before. Just like every other time, I'd mixed up sexual innuendo with a psychological test to seduce the test-giver,  everything reminded me of intercourse. I changed it up with this girl. I gave her numbers. Sometime after I was long gone, they were going to figure out the ink blots were numbered after whichever erotic positions from the Kama Sutra I was reminded of at the time. I knew that wasn't being helpful and I was certain I wasn't a brain specialist. I also knew Rorschach wasn't the key to solving my woes. Final remaining hypothesis, I was utilizing 30 % of my brain capacity with three independent patterns emerging, not the usual 5 %. For that to work, my brain had to be oozing out my ears because brains generate a terrific amount of heat. My temperature was a steady 37.3 C (99 F) and my ear channels were free of obstruction. Hey man, cleaning your ears is quick and easy. Don't risk turning off a date with misfortunately located ear-hair and wax. How was my brain shedding the heat? Their solution, let's do a Spinal Tap. No way. I'd seen that band and they were all extremely fucked up, even for old guys. I wasn't going down that road. They insisted. I suggested that I consent to the procedure with the condition that I received no pain killers/sedatives of any kind and I got to grab and hold onto the testicles of my two, current, least favorite doctors. When they realized I was deadly serious and immovable on the issue, they came up with a new plan, no Spinal Tap. Gutless sissies. Into this vacuum of information, a brainstorm emerged (besides my inexplicable one). They would talk to me, no more interrogations, an actual verbal exchange. They couldn't come over and start flapping their gums like some punk rock band with no talent. They were suddenly worried about 'concerning' me and 'agitating my unstable state'. I pray to Goddess Ishara that one day soon they play back the tapes of their early hours working on me and pay close attention to my facial expressions of shock, horror, fear and depression as they clearly and openly talked about me as if I was the Fiji Mermaid. But hey, a few of them were kinda cute, so in the final analysis all that emotional trauma worked its way out. Hospital highlights: (Understand, I was lying on a table while various specialists prodded and talked about me as if I wasn't there. To strike back at reality, I throbbed my penis every time this cute Parasitologist looked at it. Finally ) Female Chief of Neurosurgery: "Did anyone think to study changes in is body's nervous system?" (Guilty looks all around) Neuro Surgeon: "What are all these needle marks?" Havenstone Medico, "Those are muscle stimuli insertion sites. They kept his musculature from atrophying while he was in a coma." Neuro Surgeon: "Let me get this straight. This man had a lightning bolt go off in his head and part of your healthcare regimen was to run a constant current of electricity throughout the rest of his body." (Scathing looks at the Medico from everyone else, jackals) HM: "He has retained excellent muscle tone." Neuro Surgeon: "Have you even taken the Hippocratic Oath?" HM: (offended) "Of course not, he's Greek." Neuro Surgeon: "What does my patient being Greek have to do with anything?" HM: "Not him (pointing at me). Hippocrates, he was a Greek. Cáel is Magyar/Irish Gaelic." Neuro Surgeon: "Helpful, that's not. He seems to have a great deal of bruises and scarring, some of it certainly received over an extensive period of time. Is this your work?" HM: (in a positive note) "No. It has not been my pleasure to spar with Cáel yet." Neuro Surgeon: "Isn't he a bit, big for you?" &

Thank you for joining us for our 2nd Cabral HouseCall of the weekend! I'm looking forward to sharing with you some of our community's questions that have come in over the past few weeks…   Tina: Hi! I'm a huge fan of your podcast and almost finished with my Level 1 certification. Every year, I complete the Big 5 and gut tests and work with a Level 2 IHP. I diligently follow all the protocols, and all of my hormones are balanced, but I'm still struggling with a few symptoms. I was diagnosed with Raynaud's, the bottoms of my hands and feet have been persistently yellow for 20 years. I take liver support supplements and receive glutathione IVs. Additionally, I suffer from a constant nasal drip. I've been using a neti pot with citracidal drops and have completed all of the detoxes. I do sauna, dry brushing, lymphatic drainage massages, and weekly vibration plate. Can I get rid of the raynauds, yellow hands & feet and nasal drip? What else can I do to get rid of this? Thanks     Mya: Hi Dr. Cabral! Thank you for all you do and educating us on becoming the healthiest version of ourselves! I have been struggling with gut issues for quite a long time, with the biggest issue being extreme stomach pain and bloating. I decided to do further gut testing and found out I have extreme leaky gut, very low levels of beneficial bacteria, low sIgA levels, and low butyrate as well. No dysbiosis, or SIBO or candida. The issue is that I can NOT handle any prebiotics (even PHGG), no probiotics (except sacchromyces boulardii), and have extreme histamine intolerance. How do I fix the low beneficial bacteria and leaky gut if I can't handle pro & prebiotics and have a limited diet (I get extreme stomach pain and immune reactions when I try to add them in).     Sophie: I am an active 42-year-old woman who has a generally healthy lifestyle. I have been experiencing heart palpitations a few to several hours after exercise in the late afternoon or evening. Symptoms include a dramatical increase in my HR and shortness of breath. Medical professionals have diagnosed non-sustained ventricular tachycardia. Blood tests returned normal results for my kidneys, thyroid and electrolytes and further tests confirmed no heart disease. I have been prescribed beta blockers, which Doctors said may resolve the VT, while I await an MRI scan. What test you would recommend to get to the root cause of the problem? What are your thoughts on beta blockers? Are there any natural herbs/tablets I could take instead of the beta blockers?     Mark: Hi Stephen. Your podcast has saved my life and I am forever greatful. Thankyou. What's your opinion on a newish discovered fat C15? The brand is fatty15 and seems that it could replace fish oil. What's are your thoughts on this fat? Thankyou.     Tanna: Hello, my family and I are suffering from mold toxicity, orchard spray poison and a rain barrel that is flooding over. We have recently relocated to get out of mold and orchard spray and need to replace our furniture. Is there a non toxic brand of furniture that you would recommend? Specifically fabric couches?   Thank you for tuning into this weekend's Cabral HouseCalls and be sure to check back tomorrow for our Mindset & Motivation Monday show to get your week started off right!   - - - Show Notes and Resources: StephenCabral.com/3215 - - - Get a FREE Copy of Dr. Cabral's Book: The Rain Barrel Effect - - - Join the Community & Get Your Questions Answered: CabralSupportGroup.com - - - Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - Get Your Question Answered On An Upcoming HouseCall: StephenCabral.com/askcabral - - - Would You Take 30 Seconds To Rate & Review The Cabral Concept? The best way to help me spread our mission of true natural health is to pass on the good word, and I read and appreciate every review!  

Ghislaine Boddington aspires to be interconnected with an AI digital companion that advises and supports her, keeps her healthy and represents her around the world. A twin that could live on after her death, or for as long as someone pays the subscription. In practical terms, a digital bio-twin is made up of continuously measured multiple biological signals from your body. These might include your heartbeat, breath, temperature and muscle tension, as well as food intake, exercise and mental health - all fed into an avatar body. By combining AI and, for example, scanning our bodies and faces, cloning our voice and mannerisms, our virtual twin will become more and more like us. In a journey that involves an MRI heart scan, dancing in a Belgium basement and a discussion about digital death, Ghislaine learns how to build her own digital twin.

In this episode, Ben Azadi, author of Ketoflex and host of the Metabolic Freedom Podcast, outlines a seven-step diet plan to reduce visceral fat in 14 days. The first step is to lower insulin levels by swapping carbohydrates for protein and fat. Ben emphasizes that carbohydrates cause the highest blood insulin response compared to protein and fat. He suggests replacing common high-carbohydrate foods, such as oatmeal, cereal, bread, fruit, and potatoes, with cauliflower rice, eggs, red meat, and vegetables. The second step is to stop snacking between meals to avoid disrupting metabolism and preventing the body from burning visceral fat. The third step is to incorporate sprints into a workout routine three times a week, as high-intensity interval training activates hormones that promote fat burning. The fourth step is to eliminate or limit alcohol consumption, as alcohol prioritizes detoxification over fat burning and increases appetite. The fifth step is to walk at least 7,000 steps a day, particularly after meals, to blunt blood sugar spikes and reduce insulin production. The sixth step is to practice intermittent fasting on an 18/6 schedule to lower insulin levels, increase human growth hormone, and promote cellular cleaning through autophagy. The final step is to get 90 minutes of deep sleep each night to activate fat-burning hormones and accelerate fat loss. Ben also recommends measuring visceral fat through a DEXA scan or, more accurately, an MRI. 

49ers Update: Brock Purdy has undergone an MRI. NYG releases Daniel Jones.

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In this fascinating episode, we're joined by Dr. Dayan Goodenowe, a visionary neuroscientist and founder of Prodrome Sciences, to explore the groundbreaking potential of plasmalogens in restoring health and optimizing longevity. Dr. Goodenowe's work is transforming how we approach chronic conditions, such as Alzheimer's, Parkinson's, autism, multiple sclerosis (MS), long COVID, and cardiovascular issues. We discuss the role of plasmalogens, Prodrome Sciences' advanced diagnostic tools, and how his Restorative Health Centre is making these innovations accessible for proactive health management. Episode Highlights 1. What Are Plasmalogens, and Why Are They Essential? Dr. Goodenowe explains the critical role of plasmalogens, unique lipids that maintain cell membrane integrity, support the immune system, and regulate oxidative stress. These lipids, particularly abundant in the brain and heart, are essential for neuron function, immune resilience, and cardiovascular health. Research shows that low levels of plasmalogens are linked to neurodegenerative diseases, immune dysfunction, and other chronic conditions, positioning plasmalogens as a key factor in preventive and restorative health. 2. Prodrome Scan: Personalized Health Insights Through Plasmalogen Measurement The Prodrome Scan, a pioneering health assessment tool developed by Dr. Goodenowe, measures plasmalogen levels to detect potential deficiencies early on. This scan provides practitioners and individuals with insights into the body's biochemical state, allowing them to address risks for conditions like cognitive decline, heart disease, and immune system issues. By identifying these risks ahead of time, the Prodrome Scan empowers users to take proactive steps to preserve health and delay or prevent disease onset. 3. How Plasmalogens Impact Neurodegenerative Conditions  In neurodegenerative conditions such as Alzheimer's and Parkinson's, plasmalogen levels are typically depleted. Dr. Goodenowe explains how supplementing with plasmalogen precursors can protect neuron membranes, reduce oxidative damage, and improve brain function, potentially slowing or reversing disease progression. His products, Prodrome Glia (Omega-9) and Prodrome Neuro (Omega-3), are designed to target both glial cells and neurons, offering holistic support for cognitive and neurological resilience. 4. Advanced Imaging and Diagnosis at the Restorative Health Centre Dr. Goodenowe's Restorative Health Centre takes health assessment and intervention to a new level by offering advanced MRI imaging, which includes proprietary scans for brain health. This cutting-edge imaging allows for detailed visualization of brain structures, which, combined with plasmalogen measurements, provides unparalleled insights into brain health and early indicators of neurodegenerative conditions. By integrating these advanced diagnostic tools, the centre allows for early, precise intervention, tailored to each person's needs. 5. Training Practitioners in Restorative Medicine Dr. Goodenowe's work goes beyond patient care; he is dedicated to educating healthcare practitioners on the science of plasmalogens and restorative health. Prodrome Sciences offers an in-depth training program for practitioners to understand, interpret, and apply the Prodrome Scan and other tools in clinical practice. By training practitioners, Dr. Goodenowe is expanding the reach of this groundbreaking science, equipping professionals with knowledge and tools to better serve their patients with targeted, science-backed interventions. 6. Applications Beyond Brain Health:  Cancer, Autism, Long COVID,  Dr. Goodenowe discusses the broader applications of plasmalogens beyond brain health, including in conditions like autism, where they support neural connectivity, and long COVID, where they strengthen immune function and resilience. Plasmalogens have anti-inflammatory properties that can aid recovery from chronic viral infections and help support the immune system in its defense against future challenges. He also discusses plasmalogens in cancer. 7. Cardiovascular Benefits of Plasmalogens  In addition to neurological and immune health, plasmalogens play a protective role in cardiovascular health. Plasmalogen supplementation supports heart cell function, improves lipid metabolism, and helps maintain the integrity of arterial walls, reducing the risk of cardiovascular events. Dr. Goodenowe explains how Prodrome Glia's Omega-9 plasmalogens can be especially beneficial for heart health. 8. Phosphatidylcholine and Mitochondrial Support for Enhanced Cellular Health   Dr. Goodenowe emphasizes the importance of phosphatidylcholine and mitochondrial health as complementary strategies for cellular resilience. Phosphatidylcholine strengthens cell membranes, while mitochondrial support through targeted nutrients enhances energy production, reducing cellular stress and aging markers. 9. How Plasmalogens Fit Into the Larger Picture of Restorative Health Throughout the interview, Dr. Goodenowe illustrates a unique perspective on health by focusing on restoration rather than simply managing symptoms. By measuring biomarkers like plasmalogens, we can intervene before symptoms manifest, thereby preventing the onset of chronic diseases and supporting longevity. Key Takeaways: Plasmalogens - are essential for cellular and neurological health, with depletion linked to many chronic conditions. Prodrome Scan - is a groundbreaking tool that assesses plasmalogen levels, enabling early intervention. Restorative Health Centre - offers advanced MRI imaging and personalized diagnostics for comprehensive health assessment. Prodrome Glia and Prodrome Neuro - supplements provide tailored plasmalogen support for glial and neuronal health. Dr. Goodenowe's practitioner training program brings the science of plasmalogens to a wider audience, equipping clinicians to improve patient outcomes. Links:  You can find out more about Dr Goodenowe at drgoodenowe.com and www.prodrome.com Practitioner training:  https://prodrome.com/pages/prodrome-practitioners   To buy your plasmalogens go to https://prodrome.com/vrszjgeo and use Code LisaT25 to get 25% off your purchases.      BIO   Dr. Goodenowe is a PhD neuroscientist, biochemist, synthetic organic chemist, inventor, and clinical research expert. In 1999, he invented and patented a revolutionary ion cyclotron resonance mass spectrometry technology that, for the first time in history, made it possible to comprehensively monitor human biochemistry. Using this advanced technology, Dr. Goodenowe analyzed blood samples from tens of thousands of persons of all ages, of all races, and from multiple countries. The biochemistry of healthy persons was compared to persons suffering from disease. A diverse range of over 20 diseases from autism to dementia, and from colon cancer to heart disease was studied. The biochemistry of young versus old, and all-cause mortality was studied. This research led to his discovery that early mortality and each human disease has a biochemical prodrome. These discoveries led to an extensive patent portfolio of diagnostic tests for the early detection and screening of diseases such as specific cancers (colon, pancreatic, ovarian, breast, lung, prostate, and many more), autism, multiple sclerosis, Parkinson's, ALS, Alzheimer's, dementia, bipolar disease, schizophrenia, unipolar depression, cardiovascular disease, and others. Dr. Goodenowe created the ProdromeSCAN™ blood test which measures all of the key prodrome biomarkers and offers advanced laboratory test interpretation training for health practitioners.       Personalised Health Optimisation Consulting with Lisa Tamati Lisa offers solution focused coaching sessions to help you find the right answers to your challenges.   Topics Lisa can help with:  Lisa is a Genetics Practitioner, Health Optimisation Coach, High Performance and Mindset Coach. She is a qualified Ph360 Epigenetics coach and a clinician with The DNA Company and has done years of research into brain rehabilitation, neurodegenerative diseases and biohacking. She has extensive knowledge on such therapies as hyperbaric oxygen,  intravenous vitamin C, sports performance, functional genomics, Thyroid, Hormones, Cancer and much more. She can assist with all functional medicine testing. Testing Options Comprehensive Thyroid testing DUTCH Hormone testing Adrenal Testing Organic Acid Testing Microbiome Testing Cell Blueprint Testing Epigenetics Testing DNA testing Basic Blood Test analysis Heavy Metals  Nutristat Omega 3 to 6 status and more  Lisa and her functional medicine colleagues in the practice can help you navigate the confusing world of health and medicine . 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In this episode of the Pacey Performance Podcast, Rob is speaking to Bryan Heiderscheit, Fearghal Kerin and Emidio Pacecca. The topic of this conversation is all around MRI and its use in athlete performance profiling. MRI scans are usually thought of an expensive tool that is used when an athlete gets injured. But in this episode we break down those barriers and disciver how they can be used, through technology like Springbok Analytics, in other ways to improve performance and mitigate injury risk with healthy athletes. First we discuss MRI and what it actually is. Bryan gives us some great examples of where it can be used and why. Fearghal and Emidio then give us some amazing insights from the world of elite sport on how MRI scans are actually being used. But most importantly, they give us the real key information which is what we do with the information once we have it. If you're trying to reduce injury risk and optimise performance, check out this episode.

For certain diagnoses and patients who meet clinical criteria, neuromodulation can provide profound, long-lasting relief that significantly improves quality of life. In this episode, Aaron Berkowitz, MD, PhD, FAAN speaks with Prasad Shirvalkar, MD, PhD, author of the article “Neuromodulation for Neuropathic Pain Syndromes,” in the Continuum® October 2024 Pain Management in Neurology issue. Dr. Berkowitz is a Continuum® Audio interviewer and a professor of neurology at the University of California San Francisco in the Department of Neurology and a neurohospitalist, general neurologist, and clinician educator at the San Francisco VA Medical Center at the San Francisco General Hospital in San Francisco, California. Dr. Shirvalkar is an associate professor in the Departments of Anesthesia and Perioperative Care, Neurological Surgery, and Neurology at Weill Institute for Neurosciences at the University of California, San Francisco in San Francisco, California. Additional Resources Read the article: Neuromodulation for Neuropathic Pain Syndromes 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: @AaronLBerkowitz Guest: @PrasadShirvalka Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor in Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors, who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Prasad Shirvalkar about his article on neuromodulation for painful neuropathic diseases, which appears in the October 2024 Continuum issue on pain management in neurology. Welcome to the podcast, and if you wouldn't mind, please introducing yourself to our listeners.  Dr Shirvalkar: Thanks, Aaron. Yes, of course. So, my name is Prasad Shirvalkar. I'm an associate professor in anesthesiology, neurology and neurological surgery at UCSF. I am one of those rare neurologists that's actually a pain physician.  Dr Berkowitz: Fantastic. And we're excited to have you here and talk to you more about being a neurologist in in the field of pain. So, you wrote a fascinating article here about current and emerging neuromodulation devices and techniques being used to treat chronic pain. And in our interview today, I'm hoping to learn and for our listeners to learn about these devices and techniques and how to determine which patients may benefit from them. But before we get into some of the clinical aspects here, can you first just give our listeners an overview of the basic principles of how neuromodulation of various regions of the nervous system is thought to reduce pain? Dr Shirvalkar: Yeah, I would love to try. But I will promise you that I will not succeed because I think to a large extent, we don't understand how neuromodulation works to treat pain, to describe or to define neuromodulation. Neuromodulation is often described as using electrical stimuli or a chemical stimuli to alter nervous system activity to really influence local activity, but also kind of distant network activity that might be producing pain. On one level, we don't fully understand how pain arises, specifically how chronic pain arises in the nervous system. It's a huge focus of study from the NIH Heal Initiative and many labs around the world. But acute pain, which is kind of when you stub your toe or you burn your finger, is thought to be quite different from the changes over time and the kind of plasticity that produces emotional, cognitive and sensory dimensions. Really what I think is its own disease, chronic pain, of which there are multiple syndromes when we use neuromodulation, either peripheral nerve stimulation or electrical spinal cord stimulation. One common or predominant theory actually comes from a paper in science from 1967 and people still use it, foundational theory and it's called the gate control theory. Two authors, Melzack and Wall, postulated that at the spinal level, there are, there's a local inhibitory circuit or, you know, there's a local circuit where if you provide input to either peripheral nerves or either spinal cord ascending fibers that to kind of summarize it, there's only so much bandwidth, you know, that nerves can carry. And so that if you literally pass through artificial signals electrically, that you will help gate out or block natural pathological but natural pain signals that might be arising from the periphery or spinal cord. So, you know, one idea is that you are kind of interfering with activity that's arising for chemical neuromodulation. The most common is something known as intrathecal drug infusion drug delivery ITTD for that we quite literally put a catheter in the spinal fluid, you know, at the level of the dorsal horn neurons that we think are responsible for perpetuating or creating the pain. Where's the pain generator? And you really, you can infuse local anesthetic, you can infuse opioids. And what's nice is you avoid a lot of systemic side effects and toxicity because it goes right to the spinal cord, you know, by infusing in the fluid. So there's a couple of modalities, but I will say just, like maybe all of our living experience, pain is in the brain. And so, we don't really understand, I would say, what neuromodulation is doing to the higher spinal or brain levels. Dr Berkowitz: Fascinating topic. And yeah, very interesting to hear both what our current understanding is that some of our current understanding is based on data that's 60 years old and that we're actually probably learning about pain by using these modulation techniques, even though we don't really understand how they might be working. So interesting feedback loop there as well as in as in the as in this land. So, your article very nicely organizes the neuromodulation techniques from peripheral to central. So, encourage our listeners to check out your article. And first before we get into some of the clinical applications, just to give the listeners the lay of the land, can you sort of lay out the devices and techniques available for treating pain at each level of the neuroaxis? We'll get into some of the indications in patient selection in a moment, but just sort of to lay out the landscape. What's available that you and your colleagues can use or implant at different levels when we're thinking of referring patients too? Dr Shirvalkar: Absolutely. So, starting from the least invasive or you know, over the counter patients can purchase themselves a TENS machine. Many folks listening to this have probably tried a TENS machine in the past. And the idea is that you put a couple of pads, at least two. So you have like a dipole or you have a positive and a negative lead and you basically inject some current. So, the pads are attached to a battery and you can put these pads over muscle. If you have areas where myofascial pain or sore muscles, you can put them, frankly, over nerves as well and stimulate nerves that are deeper. Most TENS machines kind of use electrical pulses that occur at different rates. You change the rates, you can change the amplitude and patient can kind of have control for what works best. Then getting slightly more invasive, we can often stimulate electrically peripheral nerves. To do this we implant through a needle, a small wire that consists of anywhere from one electrical contact to four or even eight electrical contact. What I think is particularly cool, like TENS, which is transcutaneous electrical nerve stimulation that goes through the skin. Peripheral nerve stimulation aims to stimulate nerves, but you don't have to be right up against the nerve. So, yeah. We typically do this under an ultrasound and you can visualize a nerve like the sciatic nerve, peroneal nerve, or you know, even if someone has an ulnar or a neuropathy, you know, that's the compression. There's a role obviously for surgery and release, but if they have predominantly pain, it's not related to a mechanical problem per se, you could prevent a wire from a peripheral nerve stimulator as far as one centimeter from a nerve and it'll actually stimulate that that modulated and then, you know, kind of progressing even more deeply. The spinal cord stimulation, SCS, it's probably the most ubiquitous or popular form of neuromodulation for pain. People use it for all kinds of diseases. But what it roughly involves is a trial period, which is a placement of either two cylindrical wires, not directly over the spinal cord, but actually in the epidural space, right? So, it's kind of like when you get an epidural injection or doing labor and delivery, when women get epidural catheters, placing spinal cord stimulator leads in that same potential space outside the dura, and you're stimulating through the dura to actually target the ascending dorsal column fibers. And so, you do a trial period or a test drive where the patients get these wires put in. They're coming out of the skin, they're connected to a battery, and they walk around at home for about a week, take careful notes, check in with them, and they keep a diary or a log about how much it helps. Separately. I will say it's hard to distinguish this, the placebo effect often, but you know, sometimes we want to use the placebo effect in clinical practice, but it is a concern, you know, with such invasive things. But you know, if the trial works well, right, you basically can either keep the leads where they are and place a battery internally. And it's for neurologists. You're familiar with deep brain stimulation. These devices are very similar to DVS devices, but they're specifically made for spinal cord stimulation. And there's now like seven companies that offer manufacturers that offer it, each with their own proprietary algorithm or workflow. But going yet more invasive, there is intrathecal drug delivery, which I mentioned, which involves placement of the spinal catheter and infusion of drug into spinal fluid. You could do a trial for that as well. Keep a patient in the hospital for a few days. You've all probably had experience with lumbar drains. It's something real similar. It just goes the other way. You know, you're infusing drugs, and it could also target peripheral nerves or nerve roots with catheters, and that's often done. And last but not least, there's brain stimulation. Right now, it's all experimental except for some forms of TMS or transcranial magnetic stimulation, which is FDA approved for migraine with aura. There are tens machine type devices, cutaneous like stimulators where you can wear on your head like a crown or with stickers for various sorts of migraines. I don't really talk about them too much in in the article, but if there's a fast field out there for adjunctive therapy as well,  Dr Berkowitz: Fantastic. That's a phenomenal overview. Just so we have the lay on the land of these devices. So, from peripheral essentially have peripheral nerve stimulators, spinal cord stimulators, intrathecal drug delivery devices and then techniques we use in other areas of neurology emerging for pain DBS deep brain stimulation and TMS transcranial magnetic stimulation. OK let's get into some clinical applications now. Let's start with spinal cord stimulators, which - correct me if I'm wrong - seem to be probably the most commonly seen in practice. Which patients can benefit from spinal cord stimulators? When should we think about referring a patient to you and your colleagues for consideration of implantation of one of these spinal cord stimulator devices?  Dr Shirvalkar: So, you know, it's a great question. I would say it's interesting how to define which patients or diagnosis might be appropriate. Technically, spinal cord stimulators are approved for the treatment of most recently diabetic peripheral neuropathy. And so, I think that's a really great category if you have patients who have been failed by more conservative treatments, physical therapy, etcetera, but more commonly even going back, neuropathic low back pain and neuropathic leg pain. And so, you think about it and it's like, how do you define neuropathic pain. Neuropathic pain is kind of broadly defined as any pain that's caused by injury or some kind of lesion in the somatosensory nervous system. We now broaden that to be more than just somatosensory nervous system, but still, what if you can't find a lesion, but the pain still feels or seems neuropathic. Clinically, if something is neuropathic, we often use certain qualitative descriptors to describe that type of pain burning, stabbing, electric light, shooting radiates. There's often hyperpathia, like it lingers and spreads in space and time as opposed to, you know, arthritis, throbbing dull pain or as opposed to muscle pain might be myofascial pain, but sometimes it's hard to tell. So, there aren't great decision tools, I would say to help decide. One of the most common syndromes that we use spinal cord stimulation for is what used to be called failed back surgery syndrome. We never like to, we now try to shy away from explicitly saying something is someone has failed in their clinical treatment. So, the euphemism is now, you know, post-laminectomy syndrome. But in any case, if someone has had back surgery and they still have a nervy or neuropathic type pain, either shooting down their legs and often there's no evidence on MRI or even EMG that that something is wrong, they might be a good candidate, especially if they're relying on long term medications that have side effects or things like full agonist opioids, you know that that might have side effects or contraindication. So, I would say one, it's not a first line treatment. It's usually after you've gone through physical therapy for sure. So, you've gone through tried some medications. Basically, if chronic pain is still impacting your life and your function in a meaningful way that's restricting the things you want to do, then it it's totally appropriate, I think, to think about spinal cord stimulation. And importantly, I will add a huge predictor of final court stimulation success is psychological composition, you know, making sure the person doesn't have any untreated psychological illness and, and actually making sure their expectations going in are realistic. You're not going to cure anyone's pain. You may and that's, you know, a win, but it's very unlikely. And so, give folks the expectation that we hope to reduce your pain by 50% or we want you to list personally, I like functional goals where you say what is your pain preventing you from doing? We want to see if you can do X,Y, and Z during the trial period. Pharmacostimulation right now. Yeah. Biggest indication low back leg pain, Diabetic peripheral neuropathy. There is also an indication for CRPS, complex regional pain syndrome, a lesser, I'd say less common but also very debilitating pain condition. For better or worse. Tertiary quaternary care centers. You often will see spinal cord stem used off label for neuropathic type pain syndromes that are not explicitly better. That may be for example, like a nerve injury that's peripheral, you know, it's not responding. A lot of this off label use is highly variable and, you know, on the whole at a population level not very successful. And so, I think there's been a lot of mixed evidence. So, it's something to be aware about.  Dr Berkowitz: That's a very helpful framework. So, thinking about referring patients to who have most commonly probably the patients with chronic low back pain have undergone surgery, have undergone physical therapy, are on medications, have undergone treatment for any potential psychological psychiatric comorbidities, and yet remain disabled by this pain and have a reasonable expectation and goals that you think would make them a good candidate for the procedure. Are those similar principles to peripheral nerve stimulation I wasn't familiar with that technique, I'm reading your article, so are the principles similar and if so, which particular conditions would potentially benefit from referral for a trial peripheral nerve stimulation as opposed to spinal cord stimulation?  Dr Shirvalkar: Yeah, the principles are similar overall. The peripheral nerve stimulation, you know, neuropathic pain with all the characteristics you listed. Interestingly enough, just like spinal cord stim, most insurances require a psychological evaluation for peripheral nerve stim as well. And we want to make sure again that their expectations are reside, they have good social support and they understand the kind of risks of an invasive device. But also, for peripheral nerve stem, specifically, if someone has a traumatic injury of an individual peripheral nerve, often we will consider it seeing kind of super scapular stimulation. Often with folks who've had shoulder injuries or even sciatic nerve stimulation. I have done a few peroneal nerve stimulations as well as occipital nerve stimulation from migraine, so oxygen nerve stimulation has been studied a lot. So, it's still somewhat controversial, but in the right patient it can actually be really helpful. Dr Berkowitz: Very helpful. So, these are patients who have neuropathic pain, but limited to one peripheral nerve distribution as opposed to the more widespread back associated pains, spine associated pains. Dr Shirvalkar: Yeah, Yeah, that's right. And maybe there's one exception actually to this, which is brachial plexopathy. So, you know, folks who've had something like a brachial plexus avulsion or some kind of traumatic injury to their plexus, there is I think good Class 2 evidence that peripheral nerve stem can work. It falls under the indication. No one is as far as to my knowledge, No one's done an explicit trial, you know PNS randomized controlled trial. Yeah, that's, you know, another area one area where PNS or peripheral nerve stems emerging is actually, believe it or not in myofascial low back pain to actually provide muscle stimulation. There are some, there's a company or two out there that seeks to alter the physiology of the multifidus muscle, one of your spinal stabilizer muscles to really see if that can help low back pain. And they've had some interesting results.  Dr Berkowitz: Very interesting. You mentioned TENS units earlier, transcutaneous electrical nerve stimulation as something a patient could get over the counter. When would you encourage a patient to try TENS and when would you consider TENS inadequate and really be thinking about a peripheral nerve stimulator?  Dr Shirvalkar: Yeah, you know TENS we think of as really appropriate for myofascial pain. Folks who have muscular pain, have clear trigger points or taught muscle bands can often get relief from TENS If you turn a TENS machine up too high, you'll actually see muscle infection. So, there's an optimal level where you actually can turn it up to induce, like, a gentle vibration. And so folks will feel paresthesia and vibrations, and that's kind of the sweet spot. However, I would say if folks have pain that's limited or temporary in time or after a particular activity, TENS can be really helpful. The unfortunate reality is TENS often has very time-limited benefits - just while you're wearing it, you know? So, it's often not enduring. And so that's one of the limitations. Dr Berkowitz: That's helpful to understand. We've talked about the present landscape in your article, also talk a little bit about the future and you alluded to this earlier. Tell us a little bit about some off label emerging techniques that we may see in future use. Who, which types of patients, which conditions might we be referring to you and your colleagues for deep brain stimulation or transcranial magnetic stimulation or motor cortex stimulation? What's coming down the pipeline here?  Dr Shirvalkar: That's a great question. You know, one of my favorite topics is deep brain stimulation. I run the laboratory that studies intracranial signals trying to understand how pain is processed in the brain. But, believe it or not, chronic pain is probably the oldest indication for which DBS has been studied. the first paper came out in 1960, I believe, in France. And you know, the, the original pivotal trials occurred even before the Parkinson's trial and so fell out of favor because in my opinion, I think it was just too hard or too difficult or a problem or too heterogeneous. You know, many things, but there are many central pain syndromes, you know, poststroke pains, there's often pains associated with Parkinson's disease, epilepsy, or other brain disorders for which we just don't have good circuit understanding or good targets. So, I think what's coming down the pipeline is a better personalized target identification, understanding where can we stimulate to actually alleviate pain. The other big trend I think in neuromodulation is using closed loop stimulation which means in contrast to traditional electrical stimulation which is on all the time, you know it's 24/7, set it and forget it. Actually, having stimulation respond or adapt to ongoing physiological signals. So that's something that we're seeing in spinal cord stem, but also trying to develop in deep brain stimulation and noninvasive stimulation. TMS is interestingly approved for neuropathic pain in Europe, but not approved by the FDA in the US. And so I think we may see that coming out of pipeline broader indication. And finally, MR guided focused ultrasound is, is a kind of a brand new technique now. You know, focused ultrasound lesions are being used for essential tremor without even making an incision in the skull or drilling in skull. But there are ways to modulate the brain without lesioning. And, you know, I think a lot of research will be emerging on that in the next five years for, for pain and many other neuronal disorders. Dr Berkowitz: That's fascinating. I didn't know that history that DBS was first studied for pain and now we think of it mostly for Parkinson's and other movement disorders. And now the cycle is coming back around to look at it for pain again. What are some of the targets that are being studied that are thought to have benefit or are being shown by your work and that of others to have benefit as far as DBS targets for, for chronic pain? Dr Shirvalkar: You know, that's a great question. And so, the hard part is finding one target that works for all patients. So, it may actually require personalization and actually understanding what brain circuit phenotypes do you have with regards to your chronic pain and then based on that, what target might we use? But I will say the older targets. Classical targets were periaqueductal gray, which is kind of the opioid center in your brain. You know, it's thought to just release large amounts of endogenous opioids when you stimulate there and then the ventral pusher thalamus, right. So, the sensory ascending system may be through gait control theory interferes with pain, but newer targets the answer singlet there's some interest in in stimulating there again, it doesn't work for everybody. We found some interesting findings with the medial thalamus as well as aspects of the caudate and other basal ganglion nuclei that we hopefully will be publishing soon in a data science paper.  Dr Berkowitz: Fantastic. That's exciting to hear and encourage all of our listeners to check out your article. That goes into a lot more depth than we had time to do in this short interview, both about the science and about the clinical indications, pros and cons, risks and benefits of some of these techniques. So again, today I've been interviewing Dr Prasad Shirvalkar, whose article on neuromodulation for painful neuropathic diseases appears in the most recent issue of Continuum on pain management in neurology. Be sure to check out Continuum Audio episodes from this and other issues. And thank you again to our listeners for joining today.  Dr Shirvalkar: Thank you for having me. It was an honor. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

James is flying solo in this episode while Mai Ling is traveling and he brings us a fascinating conversation with our guest, Professor Mark Cook, a Melbourne-based Consultant Neurologist who specializes in the treatment of epilepsy. James talks with Mark about what prompted his desire to work in epilepsy research specifically, the impact that epilepsy has on a person's life, the effects of MRI technology in epilepsy treatment, and the value of getting involved with people outside your specialty. This interview is jam-packed with interesting information and valuable takeaways for your own endeavors.

Dr. Rick Helmich tells us about the role of functional MRI in understanding the circuits of tremor. The conversation starts with a description of his most famous theory on the pathophysiology of Parkinsonism tremor ('dimmer-switch' hypothesis) and moves towards other forms of tremors, such as dystonic, Holmes and essential and even physiological tremor.

In this episode, we discuss the case of a 15-year-old girl who presents with progressive headache, nausea, vomiting, and difficulty ambulating. Her condition rapidly evolves into altered mental status and severe hydrocephalus, leading to a compelling discussion about the evaluation, diagnosis, and management of hydrocephalus in pediatric patients.We break down the case into key elements:A comprehensive look at acute hydrocephalus, including its pathophysiology and causesEpidemiological insights, clinical presentation, and diagnostic approachesManagement strategies, including temporary and permanent CSF diversion techniquesA review of complications related to shunts and endoscopic third ventriculostomyKey Case Highlights:Patient Presentation:A 15-year-old girl with a 3-day history of worsening headaches, nausea, vomiting, and difficulty walkingAltered mental status and bradycardia upon PICU admissionCT scan revealed severe hydrocephalus without a clear mass lesionManagement Steps in the PICU:Hypertonic saline bolus improved her mental status and pupillary reactionsNeurosurgery consultation recommended MRI and close neuro checksInitial management included dexamethasone, keeping the patient NPO, and hourly neuro assessmentsDifferential Diagnosis:Obstructive (non-communicating) vs. non-obstructive (communicating) hydrocephalusConsideration of alternative diagnoses like intracranial hemorrhage and idiopathic intracranial hypertensionEpisode Learning Points:Hydrocephalus Overview:Abnormal CSF buildup in the ventricles leading to increased intracranial pressure (ICP)Key distinctions between obstructive and non-obstructive typesEpidemiology and Risk Factors:Congenital causes include genetic syndromes, neural tube defects, and Chiari malformationsAcquired causes: post-hemorrhagic hydrocephalus (e.g., from IVH in preemies), infections like TB meningitis, and brain tumorsClinical Presentation:Infants: Bulging fontanelles, sunsetting eyes, irritabilityOlder children: Headaches, vomiting, papilledema, and gait disturbancesManagement Framework:Temporary CSF diversion via external ventricular drains (EVD) or lumbar cathetersPermanent interventions include VP shunts and endoscopic third ventriculostomy (ETV)Complications of Shunts and ETV:Shunt infections, malfunctions, over-drainage, and migrationETV-specific risks, including delayed failure years post-procedureClinical Pearl:Communicating hydrocephalus involves symmetric ventricular enlargement and is often linked to inflammatory or post-treatment changes affecting CSF reabsorption.Hosts' Takeaway Points:Dr. Pradip Kamat emphasizes the importance of timely recognition and intervention in hydrocephalus to prevent complications like brain herniation.Dr. Rahul Damania highlights the need for meticulous neurological checks in PICU patients and an individualized approach to treatment.Resources Mentioned:Hydrocephalus Clinical Research Network guidelines.Recent studies on ETV outcomes in pediatric populations.Call to Action:If you enjoyed this discussion, please subscribe to PICU Doc On Call and leave a review. Have a topic you'd like us to cover? Reach out to us via email or on social media!Follow Us:Twitter: @PICUDocOnCallEmail: