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Damon Cunningham sits down with the dynamic D'Kia Anderson, the breakout star of Tyler Perry's Beauty in Black on Netflix, to unpack her journey from Baltimore to Hollywood's brightest screens. Known for her fiery portrayal of Leslie in Beauty in Black and scene-stealing roles in Hacks, The Big Bang Theory, and Dutch II: Angel's Revenge, D'Kia opens up about navigating the industry, the challenges of playing complex characters, and what it's really like working with Tyler Perry.From her early days as a daycare worker on Grey's Anatomy to becoming a fan favorite on Netflix, D'Kia shares behind-the-scenes stories, the grind of auditioning, and how she balances authenticity with the demands of the spotlight. Plus, she dishes on her upcoming projects—including Happy Anniversary and Peripheral—and why mental health advocacy in the Black community fuels her passion off-screen.Expect laughs, raw honesty, and maybe a few surprises as Damon and D'Kia dive deep into the art of acting, resilience, and the power of saying yes to the right roles. Don't miss this electrifying conversation!Stream this episode of Two Mics Up—where stars tell their stories unfiltered.-Featured Guest Star: D'Kia AndersonSocial Media IG: @dkiaanderson #twomicsup #tylerperry #beautyinblack #talkshow #dkiaanderson #movietalks #celebritytalkshow
Con un constipado que me tiene casi sin voz, intento hablarte de la sere The Peripheral.ENLACES DE INTERÉSSerie The Peripheral en Amazon Prime VideoINFORMACIÓN Y DATOS DE CONTACTOTwitter: @SansaTwitwww.podcrastinando.eswww.unicorn-st.comwww.genide.comwww.wintablet.infoGrupo Telegram Unicorn SThttp://bit.ly/GrupoTelegramUnicornSTSuscríbete a Podcrastinando, el feed que contiene todos mis podcast (Unicorn ST & Ya Te Digo)https://feedpress.me/sospechososPodcrastinandoPodcast asociado a la red de SOSPECHOSOS HABITUALES.Suscríbete con este feed: https://feedpress.me/sospechososhabitualesPodcast grabado con:Dispositivo: ThinkPad X230 TabletMicro: Behringer XM8500Mesa de mezclas e interfaz: Yamaha AG06 Aplicación de grabación y edición: Reaper
Con un constipado que me tiene casi sin voz, intento hablarte de la sere The Peripheral.ENLACES DE INTERÉSSerie The Peripheral en Amazon Prime VideoINFORMACIÓN Y DATOS DE CONTACTOTwitter: @SansaTwitwww.podcrastinando.eswww.unicorn-st.comwww.genide.comwww.wintablet.infoGrupo Telegram Unicorn SThttp://bit.ly/GrupoTelegramUnicornSTSuscríbete a Podcrastinando, el feed que contiene todos mis podcast (Unicorn ST & Ya Te Digo)https://feedpress.me/sospechososPodcrastinandoPodcast asociado a la red de SOSPECHOSOS HABITUALES.Suscríbete con este feed: https://feedpress.me/sospechososhabitualesPodcast grabado con:Dispositivo: ThinkPad X230 TabletMicro: Behringer XM8500Mesa de mezclas e interfaz: Yamaha AG06 Aplicación de grabación y edición: Reaper
Con un constipado que me tiene casi sin voz, intento hablarte de la sere The Peripheral.ENLACES DE INTERÉSSerie The Peripheral en Amazon Prime VideoINFORMACIÓN Y DATOS DE CONTACTOTwitter: @SansaTwitwww.podcrastinando.eswww.unicorn-st.comwww.genide.comwww.wintablet.infoGrupo Telegram Unicorn SThttp://bit.ly/GrupoTelegramUnicornSTSuscríbete a Podcrastinando, el feed que contiene todos mis podcast (Unicorn ST & Ya Te Digo)https://feedpress.me/sospechososPodcrastinandoPodcast asociado a la red de SOSPECHOSOS HABITUALES.Suscríbete con este feed: https://feedpress.me/sospechososhabitualesPodcast grabado con:Dispositivo: ThinkPad X230 TabletMicro: Behringer XM8500Mesa de mezclas e interfaz: Yamaha AG06 Aplicación de grabación y edición: Reaper
Con un constipado que me tiene casi sin voz, intento hablarte de la sere The Peripheral.ENLACES DE INTERÉSSerie The Peripheral en Amazon Prime VideoINFORMACIÓN Y DATOS DE CONTACTOTwitter: @SansaTwitwww.podcrastinando.eswww.unicorn-st.comwww.genide.comwww.wintablet.infoGrupo Telegram Unicorn SThttp://bit.ly/GrupoTelegramUnicornSTSuscríbete a Podcrastinando, el feed que contiene todos mis podcast (Unicorn ST & Ya Te Digo)https://feedpress.me/sospechososPodcrastinandoPodcast asociado a la red de SOSPECHOSOS HABITUALES.Suscríbete con este feed: https://feedpress.me/sospechososhabitualesPodcast grabado con:Dispositivo: ThinkPad X230 TabletMicro: Behringer XM8500Mesa de mezclas e interfaz: Yamaha AG06 Aplicación de grabación y edición: Reaper
Welcome to Season 2 of the Orthobullets Podcast. Today's show is Core, where we review Core Knowledge for Orthopaedic Surgeons. This episode will cover the topic of Peripheral Nerve Injury & Repair, from our Hand section at Orthobullets.com. Follow Orthobullets on Social Media:FacebookInstagram TwitterLinkedInYouTube
In today's episode, David Cruz e Silva talks with Justinas Milasauskas, an investment manager at Willgrow, a single-family office based in Lithuania. Justinas explains how Willgrow approaches venture investments worldwide, focusing on US and European early-stage managers. He shares the family office's history, reasons for getting into venture, and how they think about manager selection, covering everything from ticket sizes to fund-of-funds benefits. It's a great look at how an LP outside the traditional financial hubs can still build a global venture portfolio.In this conversation, Justinas also reveals the importance of balancing conviction with consistent due diligence, highlighting why his team benchmarks managers against top peers worldwide. He talks about how they stay disciplined by maintaining a structured watchlist, stacking GPs based on strategy fit, and investing across multiple vintages. It's an honest, behind-the-scenes view of how a first-generation family office grows its exposure to private markets while keeping that entrepreneurial spirit front and center.Chapters: 03:02 WillGrow's Investment Strategy and Focus04:31 The Background and Experience of Justinas08:39 Building a Convincing Strategy for Sourcing09:45 The Role of Senior Advisors and Fund of Funds12:09 The Importance of Diversification and Long-Term Commitment13:56 Understanding WillGrow's Investment Approach14:28 Investment Strategy and Risk Profiles18:10 Active vs Passive Investment Approach20:54 Biggest Learnings in Venture Investing22:43 The Importance of Proper Benchmarking23:53 Diversification Across Funds and Vintages28:03 The Role of Stack Ranking in Investment Decisions34:47 Overcoming Barriers to Access in Venture Investing42:45 The Value of Fund of Funds43:48 Book Recommendation: Leading by Alex Ferguson
In which we discuss the Battle of New Market (May 15, 1864), as we continue our look at the collapse of Ulysses S Grant's peripheral strategy in Virginia in the spring of 1864. Learn more about your ad choices. Visit megaphone.fm/adchoices
Passend zu den ersten Blumenknospen, Sonnenstrahlen und Frühlingsgefühlen, beschäftigen sich Sinja und Boris in dieser Folge mit der Liebe. Dabei fragen sie sich nicht nur, wie wir romantische Liebe ausleben können, sondern auch, welche weiteren Formen der Liebe es gibt und wie sich diese im Alltag fördern lassen. Umfrage: Wie gefällt dir Verstehen, fühlen, glücklich sein? Erzähle es uns hier. Hintergründe und Studien:Lenz, K.: Soziologie der Zweierbeziehung. Eine Einführung, Opladen: Westdeutscher Verlag 1998.Reddy, W. M. (2019). The making of romantic love: Longing and sexuality in Europe, South Asia, and Japan, 900-1200 CE. University of Chicago Press. Link zum Buch Bogaert, A. F. (2004). Asexuality: Prevalence and associated factors in a national probability sample. The Journal of Sex Research, 41(3). Link zur Studie Prause, N., & Graham, C. A. (2007). Asexuality: Classification and characterization. Archives of Sexual Behavior, 36(3). Link zur Studie Hudson NW, Lucas RE, Donnellan MB. The Highs and Lows of Love: Romantic Relationship Quality Moderates Whether Spending Time With One's Partner Predicts Gains or Losses in Well-Being. Pers Soc Psychol Bull. 2020 Apr;46(4):572-589. doi: 10.1177/0146167219867960. Epub 2019 Aug 13. PMID: 31409247. Link zur Studie Jacobson, E., Wilson, K., Kurz, A., & Kellum, K. (2018). Examining self-compassion in romantic relationships. Journal of contextual behavioral science, 8, 69-73. Link zur Studie Barraza, J. A., Alexander, V., Beavin, L. E., Terris, E. T., & Zak, P. J. (2015). The heart of the story: Peripheral physiology during narrative exposure predicts charitable giving. Biological psychology, 105, 138-143. Link zur Studie Dainton, M., Stafford, L., & Canary, D. J. (1994). Maintenance strategies and physical affection as predictors of love, liking, and satisfaction in marriage. Communication Reports, 7(2), 88-98. Link zur Studie Ogolsky, B. G., & Bowers, J. R. (2013). A meta-analytic review of relationship maintenance and its correlates. Journal of Social and Personal Relationships, 30(3), 343-367. Link zur Studie Jacobs Bao, K., & Lyubomirsky, S. (2013). Making it last: Combating hedonic adaptation in romantic relationships. The Journal of Positive Psychology, 8(3), 196-20 Link zur Studie
In which we look at the collapse of Grant's peripheral strategy in Virginia. We talk about the Battle of Cloyd's Mountain on May 9, 1864. Learn more about your ad choices. Visit megaphone.fm/adchoices
G.I. Joe Chronicles - Outpost: Episode 15Title: G.I. Joe A Real American Hero - Sunbow G.I. Joe Cartoon: S1.E25 - E28Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. On this Episode of the Outpost Jim the Joe Junkie, George the Quartermaster of the Outpost are joined by Jason Keene to discuss 4 Classic Episodes of the Sunbow G.I.Joe Cartoon. They talk about Roaming Reptiles, a Grown man that uses toys to play with his Captors, Galactic Graffiti and a Super Germ that doesn't like to eat its Fruits. Let's not forget about the Military Surplus where they discuss some amazing G.I.Joe Sticker sets. Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.comLet us know what you think!Leave a comment by sending an email to: contact@longboxcrusade.comThis podcast is a member of the LONGBOX CRUSADE NETWORK:LINKTREE: https://linktr.ee/longboxcrusadeFollow on TWITTER: https://twitter.com/LongboxCrusadeFollow on INSTAGRAM: https://www.instagram.com/longboxcrusadeLike the FACEBOOK page: https://www.facebook.com/LongboxCrusadeSubscribe to the YouTube Channel: https://goo.gl/4LkhovSubscribe on Apple Podcasts at:https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2orhttps://anchor.fm/s/e9b9020/podcast/rssThank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost!#gijoe #gijoearealamericanhero #gijoearah #gijoetoys #gijoecommunity #gijoenation #gijoe
G.I. Joe Chronicles - Outpost: Episode 15Title: G.I. Joe A Real American Hero - Sunbow G.I. Joe Cartoon: S1.E25 - E28Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. On this Episode of the Outpost Jim the Joe Junkie, George the Quartermaster of the Outpost are joined by Jason Keene to discuss 4 Classic Episodes of the Sunbow G.I.Joe Cartoon. They talk about Roaming Reptiles, a Grown man that uses toys to play with his Captors, Galactic Graffiti and a Super Germ that doesn't like to eat its Fruits. Let's not forget about the Military Surplus where they discuss some amazing G.I.Joe Sticker sets. Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.comLet us know what you think!Leave a comment by sending an email to: contact@longboxcrusade.comThis podcast is a member of the LONGBOX CRUSADE NETWORK:LINKTREE: https://linktr.ee/longboxcrusadeFollow on TWITTER: https://twitter.com/LongboxCrusadeFollow on INSTAGRAM: https://www.instagram.com/longboxcrusadeLike the FACEBOOK page: https://www.facebook.com/LongboxCrusadeSubscribe to the YouTube Channel: https://goo.gl/4LkhovSubscribe on Apple Podcasts at:https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2orhttps://anchor.fm/s/e9b9020/podcast/rssThank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost!#gijoe #gijoearealamericanhero #gijoearah #gijoetoys #gijoecommunity #gijoenation #gijoe
Welcome to the Dr. Shawn Baker Podcast. In today's episode, we are joined by Dr. Andrew Koutnik, a leading researcher in the field of biomedical sciences with a strong background in exercise physiology. Dr. Koutnik shares his insights as a type one diabetic who has dedicated his career to researching this condition, particularly the effects of low-carb and ketogenic diets on exercise performance and diabetes management. In this discussion, we dive into the controversial claims surrounding the potential for low-carb and carnivore diets to prolong the honeymoon period in type one diabetes. Dr. Koutnik provides a comprehensive overview of the current treatment landscape, including the promising developments in immunomodulatory drugs and their potential to extend the honeymoon period for patients. We also explore the significance of glycemic control and its relation to long-term health outcomes for diabetics, comparing the roles of technology and diet in managing blood glucose levels. Dr. Koutnik shares his personal experience and knowledge, drawing on ten years of data from his own life to illustrate the impact of a low-carb diet on diabetic health over the long term. Main website: https://andrewkoutnik.com/ Social Media: https://x.com/akoutnik https://www.instagram.com/andrewkoutnikphd/ https://substack.com/@andrewkoutnikphd http://youtube.com/@andrewkoutnikphd Timestamps: 00:00 Trailer 01:15 Introduction 06:42 Historical diabetes diets: early low-carb treatment 09:11 Barriers in curative therapies 13:15 Glycemic control in type 1 diabetes 1 06:40 Glycemic control crucial in type 1 diabetes 18:54 Insulin dose impact on type 1 diabetes 22:45 Peripheral insulin resistance in type 1 diabetes 26:52 Exercise for insulin sensitivity boost 27:40 Exercise regularly for insulin sensitivity 33:41 Low-carb diets and prediabetes 35:41 Endurance exercise and insulin resistance 37:42 Nutrition change resolves symptoms 43:56 Protein's impact on type 1 diabetes 45:17 Optimizing insulin kinetics for protein 48:35 Increased protein intake for jiu-jitsu 53:40 Ketogenic diet's cardiovascular impact 54:37 Where to find Andrew Join Revero now to regain your health: https://revero.com/YT Revero.com is an online medical clinic for treating chronic diseases with this root-cause approach of nutrition therapy. You can get access to medical providers, personalized nutrition therapy, biomarker tracking, lab testing, ongoing clinical care, and daily coaching. You will also learn everything you need with educational videos, hundreds of recipes, and articles to make this easy for you. Join the Revero team (medical providers, etc): https://revero.com/jobs #Revero #ReveroHealth #shawnbaker #Carnivorediet #MeatHeals #AnimalBased #ZeroCarb #DietCoach #FatAdapted #Carnivore #sugarfree Disclaimer: The content on this channel is not medical advice. Please consult your healthcare provider.
BUFFALO, NY — March 12, 2025 — A new #research paper was #published in Aging (Aging-US) on February 25, 2025, Volume 17, Issue 2, titled “Epidemiology and genetic determination of measures of peripheral vascular health in the Long Life Family Study.” Researchers from multiple institutions, led by first author and corresponding author Deidra R. Fricke from the University of Pittsburgh, studied the genetic and lifestyle factors that influence peripheral artery disease (PAD), a condition that restricts blood flow to the legs. Their findings suggest that people from families with exceptional longevity have a lower risk of PAD, possibly due to inherited genetic traits or healthier lifestyle habits. Peripheral artery disease is a common but often undiagnosed condition that affects millions worldwide. It increases the risk of heart disease, stroke, and mobility issues. This study conducted using data from the Long Life Family Study (LLFS), found that individuals from long-lived families have significantly better vascular health than the general population. “Peripheral artery disease (PAD) is a major contributor to morbidity in older adults.” The researchers analyzed over 3,000 participants, including 1,090 long-lived individuals, their 1,554 children, and 362 spouses. Among the oldest participants (average age 89), about 18% had PAD. However, among their children (average age 60), only 1% had PAD—far lower than the expected 12% found in other studies. This finding suggests that certain protective factors, whether genetic or lifestyle-related, help maintain healthier arteries in these families. In the study, key risk factors for PAD were identified, including aging, high blood pressure, smoking, and hypertension medication use. Interestingly, unlike in other studies, high cholesterol and diabetes were not major risk factors in this group. This data further supports the idea that long-lived families may have genetic protective factors that contribute to better vascular health. In addition to lifestyle factors, the study found four genomic regions linked to PAD risk. Three of these were new discoveries, while the fourth was similar but not identical to previously published findings. These genetic markers may help scientists better understand why some individuals are more likely to develop PAD and how to prevent it. “We identified four genomic sites that may harbor variants associated with protection from PAD.” This research highlights the value of studying long-lived families to unlock the secrets of healthy aging and vascular health. Understanding what helps them maintain better artery function could lead to new strategies for preventing PAD, heart disease, and other age-related conditions. Paper DOI: https://doi.org/10.18632/aging.206204 Corresponding author: Deidra R. Fricke — der94@pitt.edu Keywords: aging, ankle-brachial index, peripheral arterial disease, heritability, genomewide linkage analysis, genomewide association study Subscribe for free publication alerts from Aging - https://www.aging-us.com/subscribe-to-toc-alerts About Aging-US The mission of the journal is to understand the mechanisms surrounding aging and age-related diseases, including cancer as the main cause of death in the modern aged population. The journal aims to promote 1) treatment of age-related diseases by slowing down aging, 2) validation of anti-aging drugs by treating age-related diseases, and 3) prevention of cancer by inhibiting aging. (Cancer and COVID-19 are age-related diseases.) Please visit our website at https://www.Aging-US.com and connect with us: Facebook - https://www.facebook.com/AgingUS/ X - https://twitter.com/AgingJrnl Instagram - https://www.instagram.com/agingjrnl/ YouTube - https://www.youtube.com/@AgingJournal LinkedIn - https://www.linkedin.com/company/aging/ Pinterest - https://www.pinterest.com/AgingUS/ Spotify - https://open.spotify.com/show/1X4HQQgegjReaf6Mozn6Mc MEDIA@IMPACTJOURNALS.COM
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode1006. In this episode, I'll discuss a review article on the safety of peripheral vasopressors and hypertonic saline. The post 1006: Any Port in a Storm (For a Little While At Least) – The Safety of Peripheral Vasopressors and Hypertonic Saline appeared first on Pharmacy Joe.
Chapters 00:00 Introduction to Circadian Rhythms and Skeletal Muscle 02:52 Understanding the Circadian Clock 06:12 Dysregulation of Circadian Rhythms 09:06 Impact of Inflammation on Circadian Clocks 12:00 Peripheral Clocks and Their Independence 15:06 Exercise Timing and Performance 18:06 Feeding Patterns and Circadian Rhythms 21:00 Chronotypes and Individual Differences 23:59 Caffeine and Its Effects on the Clock 27:02 Adaptation of Circadian Clocks in Extreme Conditions 29:58 Alcohol's Impact on Circadian Function 31:01 The Impact of Circadian Clocks on Muscle and Tendon Health 36:34 Aging and Its Effects on Circadian Rhythms 40:47 Injury and Circadian Clocks: Understanding the Connection 43:10 The Role of Nutrition and Feeding Patterns 48:29 Circadian Disruption and Metabolic Health 51:50 Practical Applications for Maintaining Healthy Clocks Takeaways Circadian clocks are molecular timers found in every cell. The clock regulates metabolism and gene expression based on time of day. Dysregulation can lead to health issues like increased glucose levels. Peripheral clocks can operate independently of the central clock. Exercise timing can enhance performance and adaptation. Feeding patterns should align with activity for optimal health. Chronotype influences individual preferences for sleep and activity. Caffeine affects the sympathetic nervous system but doesn't phase shift the clock. Alcohol can disrupt circadian function and health. Adaptation of clocks can occur even in extreme light conditions. Circadian clocks significantly influence muscle and tendon health. Disruption of circadian rhythms can lead to metabolic issues. Aging affects the ability of circadian clocks to regulate gene expression. Inactivity does not stop circadian clocks, but it affects their function. Nutrition timing is crucial for maintaining healthy circadian rhythms. Exercise can enhance the function of circadian clocks in muscles. Understanding the communication between muscle and tendon is vital for rehabilitation. Time-restricted feeding may extend lifespan and improve health. Research on circadian rhythms can inform strategies for injury recovery. Maintaining a consistent activity and feeding schedule supports clock health. Karyn's profile: https://physiology.med.ufl.edu/profile/esser-karyn/ Karyn's Linkedin: https://www.linkedin.com/in/karyn-esser-a187333 Notes: https://jackedathlete.com/podcast-129-circadian-rhythms-with-karyn-esser/
Today's Song of the Day is “Peripheral Lover” from Gordi's album Like Plasticine, out May 30.
G.I. Joe Chronicles - Outpost: Episode 14Title: G.I. Joe A Real American Hero Marvel Comics - Issues: 24-27 (1983-1984)Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. Join Jim The Joe Junkie, Pat "DJ Kristatos" Sampson and Special Guest, Doug Dellow as they explore the Imprisonment and Escape of Cobra Commander. They discuss the New Joes and Cobras, a Battle in the Swamplands of the Everglades. And let's not forget the Intriguing and Mysterious Origin of Snake-eyes.Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.comLet us know what you think!Leave a comment by sending an email to: contact@longboxcrusade.comThis podcast is a member of the LONGBOX CRUSADE NETWORK:LINKTREE: https://linktr.ee/longboxcrusadeFollow on TWITTER: https://twitter.com/LongboxCrusadeFollow on INSTAGRAM: https://www.instagram.com/longboxcrusadeLike the FACEBOOK page: https://www.facebook.com/LongboxCrusadeSubscribe to the YouTube Channel: https://goo.gl/4LkhovSubscribe on Apple Podcasts at:https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2orhttps://anchor.fm/s/e9b9020/podcast/rssThank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost!#gijoe #gijoearealamericanhero #gijoearah #gijoetoys #gijoecommunity #gijoenation #gijoe
G.I. Joe Chronicles - Outpost: Episode 14Title: G.I. Joe A Real American Hero Marvel Comics - Issues: 24-27 (1983-1984)Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. Join Jim The Joe Junkie, Pat "DJ Kristatos" Sampson and Special Guest, Doug Dellow as they explore the Imprisonment and Escape of Cobra Commander. They discuss the New Joes and Cobras, a Battle in the Swamplands of the Everglades. And let's not forget the Intriguing and Mysterious Origin of Snake-eyes.Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.comLet us know what you think!Leave a comment by sending an email to: contact@longboxcrusade.comThis podcast is a member of the LONGBOX CRUSADE NETWORK:LINKTREE: https://linktr.ee/longboxcrusadeFollow on TWITTER: https://twitter.com/LongboxCrusadeFollow on INSTAGRAM: https://www.instagram.com/longboxcrusadeLike the FACEBOOK page: https://www.facebook.com/LongboxCrusadeSubscribe to the YouTube Channel: https://goo.gl/4LkhovSubscribe on Apple Podcasts at:https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2orhttps://anchor.fm/s/e9b9020/podcast/rssThank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost!#gijoe #gijoearealamericanhero #gijoearah #gijoetoys #gijoecommunity #gijoenation #gijoe
Listener Chloe's Dead Letter starts out talking about the infamous Greyfriars Kirkyard. One of the earliest topics on the main show here at Astonishing Legends. It quickly transitions to her visit to the Edinburgh underground vaults and an unsettling experience she had there on a ghost tour. The Astonishing Dead Letter Office - Where Your Stories Die to be Told https://en.wikipedia.org/wiki/Greyfriars_Kirkyard https://astonishinglegends.com/al-podcasts/2016/12/8/ep-003-greyfriars-kirkyard-halloween-special?rq=greyfriars https://en.wikipedia.org/wiki/Edinburgh_Vaults
In this episode, we explore peripheral nerve blocks (PNBs), which are a cornerstone of pain management in surgical care. PNBs offer targeted pain relief by blocking nerve signals, reducing the need for systemic analgesics, and enhancing recovery times. From their mechanism of action to nursing priorities, we cover everything you need to know to confidently care for patients receiving PNBs. In this episode, you will learn: What is a Peripheral Nerve Block? Learn about the benefits of PNBs, including reduced opioid use, faster recovery, and suitability for high-risk patients. How They Work: Understand how local anesthetics like ropivacaine and bupivacaine block sensory, motor, and sympathetic nerves in sequence. When They're Used: Common surgeries utilizing PNBs, such as knee replacements, carpal tunnel repair, and shoulder procedures. How They're Administered: Single-shot vs. continuous infusion techniques, including the use of portable pumps like the Ambit pump or elastomeric devices. Medications: Local anesthetics and adjuvants like epinephrine, dexamethasone, and clonidine that enhance the block's efficacy. Complications to Watch For: Learn about local anesthetic systemic toxicity (LAST) to nerve trauma and post-op safety risks. Nursing Considerations: Key assessments, patient safety tips, and education to empower your patients before discharge. ___________________ Full Transcript - Read the article and view references FREE CLASS - If all you've heard are nursing school horror stories, then you need this class! Join me in this on-demand session where I dispel all those nursing school myths and show you that YES...you can thrive in nursing school without it taking over your life! Pharmacology Success Pack - Want to get a head start on pharmacology? Download the FREE Pharmacology Success Pack. Fast Pharmacology - Learn pharmacology concepts in 5 minutes or less in this audio based program. Perfect for on-the-go review! Study Sesh - Change the way you study with this private podcast that includes dynamic audio formats that help you review and test your recall of important nursing concepts on-the-go. Free yourself from your desk with Study Sesh!
G.I. Joe Chronicles - Outpost: Episode 13 Title: G.I. Joe Toys: G.I. Joe Vehicles and Video Games of 1984 Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. On this Episode of the G.I.Joe Chronicle: Outpots, Join Jim the Joe Junkie and Jarrod Alberich, as they discuss the Glorious Vehicles of 1984. Which of these Vehicles do they have the best memories of? They also discuss some G.I.Joe Videos games. From Arcade Games, Console and Mobile Games. Take a listen and let them know what your Favorite Vehicle of 1984 was. Yo Joe! Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.com Let us know what you think! Leave a comment by sending an email to: contact@longboxcrusade.com This podcast is a member of the LONGBOX CRUSADE NETWORK: LINKTREE: https://linktr.ee/longboxcrusade Follow on TWITTER: https://twitter.com/LongboxCrusade Follow on INSTAGRAM: https://www.instagram.com/longboxcrusade Like the FACEBOOK page: https://www.facebook.com/LongboxCrusade Subscribe to the YouTube Channel: https://goo.gl/4Lkhov Subscribe on Apple Podcasts at: https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2 or https://anchor.fm/s/e9b9020/podcast/rss Thank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost! #gijoe #gijoearealamericanhero #gijoearah #gijoetoys #gijoecommunity #gijoenation #gijoe
G.I. Joe Chronicles - Outpost: Episode 13 Title: G.I. Joe Toys: G.I. Joe Vehicles and Video Games of 1984 Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. On this Episode of the G.I.Joe Chronicle: Outpots, Join Jim the Joe Junkie and Jarrod Alberich, as they discuss the Glorious Vehicles of 1984. Which of these Vehicles do they have the best memories of? They also discuss some G.I.Joe Videos games. From Arcade Games, Console and Mobile Games. Take a listen and let them know what your Favorite Vehicle of 1984 was. Yo Joe! Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.com Let us know what you think! Leave a comment by sending an email to: contact@longboxcrusade.com This podcast is a member of the LONGBOX CRUSADE NETWORK: LINKTREE: https://linktr.ee/longboxcrusade Follow on TWITTER: https://twitter.com/LongboxCrusade Follow on INSTAGRAM: https://www.instagram.com/longboxcrusade Like the FACEBOOK page: https://www.facebook.com/LongboxCrusade Subscribe to the YouTube Channel: https://goo.gl/4Lkhov Subscribe on Apple Podcasts at: https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2 or https://anchor.fm/s/e9b9020/podcast/rss Thank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost! #gijoe #gijoearealamericanhero #gijoearah #gijoetoys #gijoecommunity #gijoenation #gijoe
Presley and Andrew sit down with their friend Annie who is kind enough to get stats on every single second of tv that these two morons have watched. Enjoy this part one episode of our 50th episode spectacular.All our Links: https://linktr.ee/seasononepodTwo Years of Stats:Overview of Data• I got this data mostly from IMDb and Rotten Tomatoes• Disclaimer for stats nerds: There are limitations to the data that I'm not really going to gointo since this is just for fun— just know that this is more of an exploratory analysis ofgeneral trends, I didn't test for statistical significance or anything like that and it is asomewhat small sample size when it gets broken down by genre and network/streamingservice, for example• You watched 49 shows, spanning from 1999 (Freaks and Geeks) to 2024.• From 14 different networks or streaming services• They included eight major genres [of course every show is classified as multiple genres butthese were the major ones I landed on and consolidated a bit so they didn't get too niche](in order of most shows that fit the genre): Drama (19), comedy (12), crime (6), action (4),romance (2), fantasy (2), sci-fi (2), family (2)What are your favorite and least favorite genres?• Comedy favorite for both of you (but Presley rates them higher)• Worst one for Andrew is family, Presley's worst is a tie between family and romanceDo you have a network/streaming service that you associate withthe best shows?• You've watched the most from Netflix (9)• Best according to Presley's and Andrew's ratings combined: Tie between NBC and Netflix(2.75)• Best according to IMDb ratings: Prime (7.45)Do you have a network/streaming service that you associate withthe worst shows?• Worst according to Presley's and Andrew's ratings combined: Tie between Seven Networkand Showtime (only one show each, The New Tomorrow and American Gigolo,respectively, 0.5 each), next worst is Prime (1.25)• Worst according to IMDb ratings: Tie between ABC and Seven Network (6.2)What's the worst show you've watched?• Presley's bottom 5:1. Bionic Woman (0)2. American Gigolo (0)3. The Idol (0)4. The Peripheral (0)5. The Midnight Gospel (0.5)• Andrew's bottom 5:1. The New Tomorrow (0)2. The Idol (0)3. The Peripheral (0)4. My Lady Jane (0)5. Bionic Woman (0.5)• IMDb bottom 5:1. Resident Evil (4.1)2. The Acolyte (4.2)3. The Idol (5)4. Blockbuster (5.1)5. The Rookie: Feds (5.3)• Rotten Tomatoes critics bottom 5:1. The Idol (19%)2. Blockbuster (23%)3. Imaginary Mary (27%)4. Running Wilde (30%)5. Backstrom (36%)What's the best show you've watched?• Andrew's top 5:1. Freaks and Geeks (5) *tie2. The Brothers Sun (5) *tie3. Pan Am (4.5)4. Reboot (4) *four-way tie5. The Midnight Club (4) *four-way tie6. 1899 (4) *four-way tie7. Constellation (4) *four-way tie• Presley's top 5:1. Freaks and Geeks (5) *tie2. The Brothers Sun (5) *tie3. Reboot (4) *four-way tie4. Pan Am (4) four-way tie5. Constellation (4) four-way tie6. Scavengers Reign (4) *four-way tie• IMDb top 5:1. Freaks and Geeks (8.8)2. Scavengers Reign (8.6)3. The Midnight Gospel (8.2)4. The Muppets Mayhem (8) [this is what made me realize what slim pickings you guyshave)5. Almost Human (7.9)• Rotten Tomatoes critics top 5:1. Freaks and Geeks (100%) *four-way tie2. The Winchesters (100%) *four-way tie3. Riches (100%) *four-way tie4. Scavengers Reign (100%) *four-way tie5. A League of Their Own (95%) *tie6. My Lady Jane (95%) *tieHow long do you think you've spent watching shows?• 504 episodes, 22,023 minutes, 367.05 hours, 15.29 days• That's longer than the entire catalog of The Simpsons (about 285 hours)• That's like taking the longest nonstop flight in the world (19 hours New York toSingapore) 19 times• That's like watching the extended edition of The Lord of the Rings trilogy (11 hours 26minutes) 32 timesWho's the harsher critic?• Presley's average rating: 2.15• Andrew's average rating: 2.07Who is better overall at choosing shows?• Average rating of Andrew's choices: 2.08• Average rating of Presley's choices: 2.15• You each rate your own picks higher- When Presley chooses the show his average rating is 2.25 vs. Andrew's 2.04- When Andrew chooses the show his average rating is 2.1 vs. Presley's 2.06
Dr. Martin answers questions sent in by our listeners. Some of today's topics include: Pneumobilia Bile salts Macular degeneration Cortisol & hot flashes Licorice root tea on Reset Urine albumin Peripheral neuropathy Numbness in left arm & leg Endometrial ablation
In this episode of The Leadership Consultation, we had the pleasure to welcome Carlo Argiolas, Senior Business Director Peripheral Vascular Health, Western Europe at Medtronic for a compelling discussion on leadership, cultural adaptability, and career growth. Carlo shares his experiences leading multicultural teams, emphasizing the importance of adjusting leadership styles to different cultural dynamics. He highlights the role of trust, clear communication, and understanding diverse perspectives in fostering collaboration. Carlo reflects on his transition from marketing to business leadership, discussing the challenge of building credibility and balancing short-term sales goals with long-term strategy. He shares insights on effective team leadership, emphasizing personal relationships, psychological safety, and professional development. The conversation also explores Carlo's journey as an author and the motivation behind “The Medical Device Marketing Handbook”. He explains how the book fills a gap in industry knowledge, offering practical guidance for marketeers navigating the complexities of medical device marketing. On a personal note, Carlo talks about his approach to work-life balance, his passion for outdoor activities, and his love for cooking and reading. He recommends “The Culture Map: Breaking Through the Invisible Boundaries of Global Business” by Erin Meyer as must-read, providing many insights into how to deal with culturally diverse groups. As the episode wraps up, Carlo summarises his key lessons on cultural agility, continuous learning, and the importance of building trust as a leader. You can connect with Carlo on LinkedIn and explore his book for deeper insights into marketing and leadership in the medical device industry.Please do not hesitate to share your feedback with us on our LinkedIn or Instagram pages and to give us a rating on Apple Podcast. This is very important to help us grow The Leadership Consultation community...
Visit NurseStudy.net for more FREE Nursing Diagnosis, Care Plans, Study Guides.Download my Audiobook Version for FREE If you love listening to audiobooks on-the-go, you can download the audiobook version of our NCLEX Prep book for FREE (Regularly $19.95) just by signing up for a FREE 30-day audible trial! Get this book for FREE when you sign up for a 30-day free-trial with Audible Audible US: https://bit.ly/42j6grx Audible UK: https://bit.ly/3Sp7SLN Audible FR : https://bit.ly/3UnJeOb Audible Canada : https://bit.ly/4bxh7T1 ___________________________________________See all of our FREE Nursing Exams onlineGet a FREE Copy of Pass The NCLEXVisit NurseStudy.Net we have over 800 Nursing care plans available.Nursing ResourcesRecommended NCLEX Nursing School Review ProgramNCLEX Review ProgramRecommended BooksLab Values for Nurses Over 160 Test QuestionsFundamentals of Nursing Review 110 Test QuestionsFluids and Electrolytes 100 Test QuestionsNursing Diagnosis HandbookNursing Care Plans HandbookMedical Surgical NursingComprehensive NCLEX Review*Social*Web: https://nursestudy.net/Shop: https://amzn.to/36jrZCNInstagramFacebookPinterestTikTokThe description contains affiliate links and I may be compensated a small amount if you make a purchase after clicking on my links.DisclaimerThis lesson is not intended to provide medical advice. The articles on this website are intended for entertainment or educational value only. While we strive to offer 100% accuracy, we cannot guarantee the validity or accuracy of any content. Medical procedures are rapidly changing, and laws vary greatly from location. #NCLEX #Nursing #NursingStudentSupport the show
In this episode of Footnotes, we delve into the fascinating world of the Peripheral Canon, often referred to as the Apocrypha. How were these texts viewed in the ancient world, and what role do they play in the New Testament? From Jesus' teachings to Paul's letters, echoes of these writings resonate throughout Scripture. Join us as we explore their theological significance, their historical context, and how they shape our understanding of the biblical narrative. Whether you're new to the Apocrypha or revisiting familiar territory, this episode offers fresh insights into the interconnectedness of Scripture. Some references made throughout this chapter are: John 8 / Jubilees 17 Forgiveness in Lord's Prayer / Sirach 28.2 Narrow Road / 4 Ezra 7.6-14 Hell as eternal worm & fire (e.g. Mark 9) / Judith 16 Mockers at cross Mt. 27.41-43 / WisSol 2.13-22 Golden Rule / Tobit 4.15 Armor of God Eph 6.13-17 / WisSol 5.17-20 Paul's disease theory of sin / 4 Ezra 3.21-26 Mt. 22.28-30 / Opening story of Tobit 1 Peter 1.12 / 1 Enoch 1.2 Angels chained 2 Peter 2.4, Jude 6, Revelation / 1 Enoch narrative Jude 14-15 / 1 Enoch 1
A guided contemplation for discerning the six sense bases as peripheral phenomena shaping your experience, revealing their anicca nature. If you wish to support the Hillside Hermitage Sangha and this channel you are very welcome to do so via: https://www.hillsidehermitage.org/support-us/
Here's another great podcast from early '24. This was a great conversation and finished the year at #9. In this podcast episode, Winston and I delve into the intricate world of pain and its pathways. They explore the nervous system's role in pain transmission, the different types of pain including nociceptive, neuropathic, and nociplastic pain, and the significance of sensitization in chronic pain conditions. The discussion also highlights practical approaches to pain management, including the use of multimodal therapies and the impact of neuroplasticity on pain perception, particularly in cases like phantom limb pain. In this conversation, Dennis discusses the complexities of pain management, emphasizing the importance of understanding the patient's history and the trajectory of their pain. He highlights the shift from opioid reliance to a multimodal approach that includes various analgesics such as acetaminophen, NSAIDs, lidocaine, capsaicin, cannabinoids, and ketamine. Dennis also covers the role of anticonvulsants and antidepressants in managing chronic pain, providing practical recommendations for healthcare practitioners. Takeaways Understanding pain pathways can enhance treatment effectiveness. Pain transmission involves complex processes in the nervous system. There are three main types of pain: nociceptive, neuropathic, and nociplastic. Peripheral and central sensitization play crucial roles in chronic pain. Ketamine is effective in reducing central sensitization. The placebo effect can significantly influence pain management. Recognizing nociplastic pain is essential for proper treatment. Mirror therapy can help alleviate phantom limb pain. Neuroplasticity affects how pain is perceived and treated. A multimodal approach is necessary for effective pain management. History taking is crucial in understanding pain types. The goal of pain management is to improve function and quality of life. Acetaminophen can be as effective as opioids in certain cases. Lidocaine should be used with caution due to potential side effects. Capsaicin is a natural option for neuropathic pain relief. Opioids have significant side effects and should be used carefully. Cannabinoids are gaining popularity but require more research. Ketamine offers a new avenue for pain management. Anticonvulsants can help with neuropathic pain but take time to work. Amitriptyline is a cost-effective option for chronic pain management. Thank you to Delta Development Team for in part, sponsoring this podcast. deltadevteam.com For more content go to www.prolongedfieldcare.org Consider supporting us: patreon.com/ProlongedFieldCareCollective or www.lobocoffeeco.com/product-page/prolonged-field-care
In this episode of the Spine & Nerve Podcast, Dr. Brian Joves and Dr. Jason Kung dive into the evolving world of peripheral nerve stimulation (PNS). As the field of pain medicine continues to progress, new studies are offering more insights into advanced therapies for challenging conditions like peripheral neuralgia and chronic pain. This discussion focused on the COMFORT study, which evaluates the efficacy of the Nalu PNS System, and discuss recent data presented at the American Society of Regional Anesthesia and Pain Medicine (ASRA) meeting concerning the SPRINT PNS System. Key Topics Covered: COMFORT Study Insights: The doctors analyze the one-year data from the COMFORT trial, a randomized controlled study assessing the Nalu PNS System combined with conventional treatments versus conventional treatments alone for chronic neuropathic pain. They highlight significant findings, including an 87% responder rate with an average pain reduction of 69% among responders at 12 months. SPRINT PNS System Data: Discussion extends to new data from the SPRINT PNS System, particularly the RESET Clinical Trial, which compares 60-day percutaneous PNS to standard interventional management for chronic low back pain. The trial's primary endpoint results indicate that PNS provided clinically meaningful and statistically superior reductions in pain, as well as improvements in function and quality of life. Clinical Implications and Future Directions: Dr. Joves and Dr. Kung explore the broader implications of these studies for clinical practice, emphasizing the importance of personalized treatment plans and the potential for PNS therapies to offer durable pain relief. They also discuss the evolving landscape of pain management and the need for ongoing research to refine and validate these therapeutic approaches. Resources and Links: https://nalumed.com/clinical-trials/comfort-trial/ https://www.sprtherapeutics.com/2024/11/21/new-sprint-pns-data-for-low-back-shoulder-knee-and-headache-at-23rd-annual-asra-pain-medicine-meeting/ Follow us on LinkedIn: Jason Kung, MD and Brian Joves, MD Subscribe to the Spine & Nerve Podcast everywhere podcasts are available Keep striving to provide the best care for your patients and stay informed on the evolving practices in pain management! This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.
In this episode of the Award-winning PRS Journal Club Podcast, 2024 Resident Ambassadors to the PRS Editorial Board – Rami Kantar, Yoshi Toyoda, and Amanda Sergesketter- and special guest, Harvey Chim, MD, discuss the following articles from the December 2024 issue: “Polyethylene Glycol–Mediated Axonal Fusion Promotes Early Sensory Recovery after Digital Nerve Injury: A Randomized Clinical Trial” by Nemani, Chaker, Ismail, et al. Read the article for FREE: https://bit.ly/PNIRecovery Special guest, Harvey Chim, MD. Dr. Chim began his education in Singapore, then completed his plastic surgery residency at Case Western Reserve University, followed by hand fellowship at the Mayo Clinic. He is currently a full professor at the University of Florida and will soon be the Chief of Plastic Surgery at Louisiana State University. He is a world-renown expert in a variety of fields including peripheral nerve and brachial plexus surgery, thin perforator flaps, vascularized bone grafts and replantation, and has authored more than 160 publications. He received the Gelberman Scholar Award from the American Society of Surgery of the Hand in 2018. READ the articles discussed in this podcast as well as free related content: https://bit.ly/JCDec24Collection
BONUS POD: Keep It Peripheral—Eszter Horanyi of iRunFar. Nolan's 14, The Tour Divide, And A Life Of Possibilities. Kia ora e te whānau! Sometimes it happens. You speak with someone cool and interesting then you come away with a nagging stem of a question that you should have asked. When I spoke to Eszter Horanyi this was some variation of the following. “What does Coddiwompling even mean??” Well if you must know, to Coddiwomple means to travel purposefully to an unknown destination. And goodness me if that isn't a raison d'etre for Colorado-based Horanyi. Growing up in the mountains as a free-range kid, and then racing bikes for a decade, including a 19-day Tour Divide FKT, transitioning to two feet to focus on the shiny things in the periphery and not “big goals”. Splitting her time between Colorado and Te Waiponamu Eszter embodies the true spirit of adventure and freedom that our sport can (sometimes) only touch on. Please Enjoy this bonus podcast while we are away in the Snowy Mountains. Dirt Church Radio - Best Enjoyed Running. Sign up to the DCR AidStation Episode links:Eszter Horanyi Instagram iRunFarDirt Church Merch!SQUADRUNCurranzJulbo Eyewear UltrAspireDirt Church Radio on InstagramDirt Church Radio on Twitter Dirt Church Radio on Facebook CieleFurther Faster New ZealandEnjoy!Music by Andrew McDowall, Digicake100% Natural Manuka oil Anti Chafe Gel from Aotearoa. Thatsit.nz
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode976. In this episode, I'll discuss peripheral IV administration of 3% sodium chloride solution. The post 976: Can 3% (hypertonic) sodium chloride ever be given via a peripheral IV? appeared first on Pharmacy Joe.
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.
In the October 2024 episode of Critical Decisions in Emergency Medicine, Drs. Danya Khoujah and Wendy Chang discuss emergency management of hanging and strangulation injuries and peripheral neuropathies. As always, you'll also hear about the hot topics covered in CDEM's regular features, including undifferentiated hypoxia following a home birth in Clinical Pediatrics, a vanishing hip in Orthopedics and Trauma, string yank technique for fishhook removal in The Critical Procedure, acute atrial fibrillation and atrial flutter best practices in The LLSA Literature Review, and a knee injury in The Critical Image.
Dyspnea After Pulmonary Embolism: Optimal Medical Therapy in Peripheral Vascular Disease Guest: Stan Henkin, M.D. Host: Malcolm R. Bell, M.D. Historically, majority of clinical and research focus has been on acute management of pulmonary embolism (PE). However, long-standing functional impairment after PE is common, occurring in up to 50% of individuals with history of PE. This is termed post-PE syndrome – an underrecognized, underdiagnosed, and undertreated entity. In this podcast, experts discuss epidemiology, pathophysiology, diagnosis, and treatment of post-PE syndrome. Topics Discussed: What is Post-PE syndrome? How common is it? What is your suggested work-up of patient who presents with dyspnea after PE? When should a patient be referred to a tertiary/expert center? Connect with Mayo Clinic's Cardiovascular Continuing Medical Education online at https://cveducation.mayo.edu or on Twitter @MayoClinicCV and @MayoCVservices. LinkedIn: Mayo Clinic Cardiovascular Services Cardiovascular Education App: The Mayo Clinic Cardiovascular CME App is an innovative educational platform that features cardiology-focused continuing medical education wherever and whenever you need it. Use this app to access other free content and browse upcoming courses. Download it for free in Apple or Google stores today! No CME credit offered for this episode. Podcast episode transcript found here.
Peripheral or Integral Participant ?
Peripheral or Integral Participant ?
Listen to Victor Davis Hanson's weekend episode with cohost Sami Winc. VDH talks about the peripheral wars in WWII, the shake up at the LA Times, the Left clinging to "mass" rhetoric on deportations, Gen. Austin on "lawful" orders, the Daniel Penny trial, and Melania Trump coming into her own.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.
On this episode of The Story & Craft Podcast, we sit down with actor, Jack Reynor from the Netflix show “The Perfect Couple”, as well as Amazon Prime Video's, “Peripheral!” Jack discusses his early passion for acting, the trajectory of his career, and personal anecdotes. We also discuss his unique experiences in both indie films and major Hollywood productions, his life growing up in Ireland, and even delve into his creative pursuits outside of acting…including his project of building a pub in a horse trailer. Jack discusses philosophy on life, his future projects, and the importance of balancing personal and professional life…and a perfectly pulled pint.SHOW HIGHLIGHTS03:49 Current Projects and Career Highlights04:51 Jack's Background and Early Career11:31 The Actor's Studio Experience16:06 Breaking into Hollywood28:13 The Peripheral and Working with Chloe Moretz33:05 Gaming and Alternate Realities33:42 Acting Challenges and Collaboration34:57 Balancing Humor in Dark Themes37:35 Improvisation on Set41:17 Personal Projects and Hobbies46:25 The Seven QuestionsListen and subscribe on your favorite podcast app. Also, check out the show and sign up for the newsletter at www.storyandcraftpod.com...#podcast #JackReynor #Acting #Netflix #Actor #ThePeripheral #PrimeVideo #IrishActor #Ireland #storyandcraft
Peripheral neuropathic pain is primarily influenced by the biology and pathophysiology of the underlying structures, peripheral sensory nerves, and their central pathways. In this episode, Kait Nevel, MD speaks with Miroslav Bačkonja, MD, an author of the article “Peripheral Neuropathic Pain,” in the Continuum October 2024 Pain Management in Neurology issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Bačkonja is the clinical director in the Division of Intramural Research at the National Institutes of Health in Bethesda, Maryland. Additional Resources Read the article: Peripheral Neuropathic Pain Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor in Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Nevel: Hello, this is Dr Kait Nevel. Today I'm interviewing Dr Miroslav Backonja about his article on peripheral neuropathic pain, which appears in the October 2024 Continuum issue on pain management and neurology. Welcome to the podcast. Dr Backonja: Thank you. Dr Nevel: Misha, can you please introduce yourself to the audience? Dr Backonja: Yes, I'm Miroslav Backonja, but everybody calls me Misha. So everybody knows me by that. I'm a training neurologist, and I also have training as well as certification in pain management. And most of my practice has been where neurology meets the pain, which is neuropathic pain. I spend some time basic science lab and then transition into clinical research. And I was in academia for a couple of decades and was most recently recruited by NCCIH National Center for Complementary and Integrated Health and have been there for two and a half years now. Dr Nevel: That's wonderful. I would love to hear more about your career at the NCCIH, a little bit and what you do in your role now, and how that came to be. Dr Backonja: Yeah, I was recruited to help and provide clinical support to efforts at NCCIH in the phenotyping of pain and neurologists who've done research in quantitative sensory assessment and other quantitative means of assessment of pain. Coming to NIH was very rewarding and quite of a learning experience. After six months being there, I've discovered that NIH is the biggest secret in plain sight. They say in the plain sight because it's public institution and everything is open to public and it's a secret because we don't think about it. This is in particular in reference to biomedical research training, including clinical trainings. So, I would encourage everybody to think of NIH as a place to spend some time and learn. There are wonderful research opportunities as well as educational opportunities. Vast library of presentations, green rounds and different other types of courses - some of them open to public, and some of them are up to FAS, which is a foundation of advances in science education by discovering. I feel like being back in school and having fun. Dr Nevel: That's wonderful. Can you share with us a little bit about how you became interested in peripheral neuropathy and pain management of peripheral neuropathic pain? Dr Backonja: It actually goes back to my residency and fellowship. And actually, you know, I had the luck of being exposed to a couple of clinicians who actually became my mentors. First was Jose Ochoa, who was one of the first people to quote from a small fiber, C fiber specifically, and he also was pioneered in quantitative sensory testing. And the other one was Charles Cleland, who was a psychologist and who pioneered assessment of patient symptoms, developing the Brief Pain Inventory is one of the tools. That actually peaked my interest in the topic of pain and once when I started learning about pain, what is the kind of mysterious experience of humans' pain, turns out that we have learned a lot of science about the pain and can make the pain very accessible. And I hope some of this will come to the chapter that we've provided. Dr Nevel: Thank you for sharing that. I think of peripheral neuropathy and I think most neurologists think of peripheral neuropathy as one of the bread-and-butter diagnosis within our field. For the practicing neurologist out there who might be listening, what do you think is the most important takeaway from your article that maybe they don't already know about peripheral neuropathic pain? Dr Backonja: When it comes to peripheral neuropathy and peripheral neuropathic pain, it goes back to my early experience and still holds the truth. Neuropathies don't kill people, they just maim them. They create- cause lots of disability and if you add a pain to it, it can be quite disabling. In some regards, it has been neglected the area of development in neurology in terms of scientific discoveries, although things are changing quite rapidly as of recently. Main take home messages, and especially when it comes to a sensory neuropathies and painful neuropathies, is that it's one of the skills that has not been well researched and then not well communicated to the vaccine neurologist in terms of what to do with it. But most neurologist sensory symptoms are just like a noise because, especially when it comes to pain and prosthesias and allodynia and hyperalgesias, like, what is that like? It's just not knowing what to make of it. Frequently associated also with emotional components in terms of the people are either depressed because of persistence of pain or anxious, not knowing what's going on. And that really can create quite a bit of a challenge in terms of what to do with it. But once anybody who's interested learns the fact that sensory neuropathies and fever neuropathies as well could be as well and is easily diagnosed by a neurologist who pays a little bit of attention and gains some skills in assessing not only negative sensory phenomena, because that's what he as a neurologist get trained to detect and quantify sensory deficits as well as motor deficits and loss reflexes. Also, if you pay attention to positive sensory phenomena, which is part of the repertoire of symptoms that patients with neuropathic pain experience, it's not whether patients would have either positive sensory phenomena like prosthesia and pain or negative sensory phenomena. Actually, they have all of them. And that's kind of puzzling for many patients. And lots of times, very patients say, like, how can I hurt when I don't feel like, let's say, like most commonly it's lower extremities. Like I don't feel my feet, but it hurts. I mean, how come? Oh, that's a cardinal feature of neuropathic pain, neuropathic painful neuropathy. Dr Nevel: Yeah, thanks for that. You know, I really thought that your Table 3-1 was really nice. It kind of lists through the common causes of peripheral neuropathic pain and just demonstrates the diversity of the different etiologies or other conditions that can cause neuropathic pain. And so, I encourage the listeners to review that table. But, on that topic, can you share with us what you think are the most important components of evaluating patients with neuropathic pain to maybe come to a diagnosis, to find what the underlying etiology or driver is? Dr Backonja: When it comes to painful neuropathies, there are actually two problems you have to solve. So, don't forget that part. The first one is finding a pathological theology. Why a person has a neuropathy, what kind of neuropathy. And then second is, what's the nature of the sensory problems? What's the nature of the sensory symptoms, specifically pain, levodenia and hypogesia. So, figuring out the theology of the B12 deficiency or diabetic painful neuropathy, you can relatively quickly or hopefully one would relatively quickly come to that at theological diagnosis. But then the second part is the diagnosis of symptoms. What's the underlying metaphysiology of that. And again, just reminding colleagues that the specific sensory phenomena such as thermal hyperalgesia is now well established to be due to what's called peripheral sensitization of C fibers, which are the small unmyelinated fibers, expressed TP 1 receptors. So, patients who will report that taking a hot shower is very painful. An example of that or when conducting sensory exam and applying if you come to the point of examining the perception of warm and hot and patient affords the pain. That's just the hallmark of the C hurtful sensitizations to C fibrous sensitization. On the other hand, if somebody has mechanical ordinia like putting the shirt on hurts, putting the socks hurts. Well, that's evident to central sensitization. These are the simple, relatively simple but symptoms or signs that could have implication if those patients with central sensitization are more than likely to benefit from medications that restore descending inhibition, such as tricyclic antidepressants or SNRI's. And so just paying attention to that, it gives a clinician being a clinician or a neurologist, like, let me consider prescribing medication that have central A acting properties. Or if it's purpose sensitization, something we have like a sodium channel blocking property, things of that sort. Actually, there are some other strategies such as antagonist TRPV1receptors, the capsaicin base. Those are the kind of things that can help a neurologist kind of take the evaluation of painful neuropathies to the next level. Dr Nevel: Yeah, the- by getting a careful history and exam, that can influence what treatment you prescribe to patients. Understanding whether it's central or peripheral. On the topic of treating patients and talking with patients and evaluating them, what do you think is most important to counsel our patients about who we are treating for neuropathic pain? Dr Backonja: Number one: by getting good history and exam. Well, really in the coming to specific diagnosis is huge relief to the patients who thinks many themselves that they're just going nuts are crazy because nobody else understands these symptoms. So, validation in terms they have a real problem. Second important step is that for the most patients, there is probably reasonable degree of therapeutic interventions that can lead to relief of pain. And also, with applying the integrative approaches with complementary medicine is that patients are given tools to deal with what is otherwise underlying problem. Those two steps make a huge difference. Dr Nevel: Absolutely. What's the most challenging aspect about managing patients with peripheral neuropathic pain? Dr Backonja: Actually, there are a couple. Number one thus far: we do not have a cure for any other neuropathies or painful neuropathies. So that's one of the big disappointing things one would need to communicate to the patient. The second challenge is actually the therapies that actually for neuropathic pain. There's a half a dozen- yeah, half a dozen FDA approved treatment. One thing that's interesting characteristic that all of them prove proven efficacy in clinical trials. If you scratch the surface, you find out that only 40% of patients obtain 30% pain relief. So, it's a rare patient that gets 100% pain relief, and even those, too, get what we call clinically significant, and then in studies, basically significant benefit. It's only partial penalty. But for the most those who do get the benefit, pain goes down probably enough for them to get some a semblance of normality in terms of having some control over the symptoms and their function. It's then the third challenge is really working through those available therapies to find what works for individual patients because we're not at the point yet where for example, other fields like oncology, you can quickly through the means of biomedical and other evaluation come to the patient specific therapy. So, at this point in time you're far from that. What we end up doing with when it comes to management for painful neuropathies is a trial. Sometimes patients say, well, trial and error. I would say, well, it's a treatment trials. We try one thing at a time, assess the risks and benefits and then there was many treatments that carry the benefit. If you carry it on when once, when they don't or if there's adverse events, side effects, we discontinue them. And then most of the patients end up with a combination of pharmacological and now pharmacological treatments and most of them can get some semblance of symptoms control. Dr Nevel: I really appreciate your point on preparing our patients and you know, expectations and things like that and working with them and looking for things that may help. But also having an understanding that the likelihood of complete pain relief is maybe not a super high chance of complete pain relief. Dr Backonja: But if you're going back to the kind of preparing patients, it's a good to acknowledge or give a chance to express themselves because many times they patients are confused because they have symptoms that are confusing to them. And so just to have them express it. And for example, my alma mater, we developed the color paint drawing where the different sensory qualities are presented by different colors. And then on the body diagram, patients draw where they have symptoms. And this is probably one of the rare examples where you can literally see a pain because these neurologists can recognize the patterns. You can see the pattern of the motor, right, is multiplex or radiculopathy or the list goes on and on. So, this is one of the kind of tools that's very simple, but gives the patients another way to communicate because lots of times they really have difficulties expressing themselves. Dr Nevel: Right. So, the opposite of the most challenging, can you share with the listeners what you find the most rewarding about taking care of patients with peripheral neuropathic pain? Dr Backonja: What is rewarding is that with some work- and again, it's not easy work because it does require multiple visits and multiple assessments and the reassessments, most patients can get control over their symptoms to the point of coming to beginning some of the functional improvement and aspects of quality of life like sleep and work, they are definitely rewarding and most of the time it's fairly obvious. And again, pain management is definitely a team sport where really, it's important to gauge colleagues. Most of the places don't have what I have had when I was in academic institutions, easy access to health psychologist or physical therapist. Most communities do have those specialties. And many patients actually benefit from things that are what's considered a complementary medicine, such as Tai chi or yoga. And actually, in my practice, Tai chi was probably most common prescription for my patients because, as I tell them, there are multiple benefits. Number one: one of the risks of patients, especially prophyl neuropathies and lower extremities, is a loss of proprioception. Again, even those who have a reasonable preserved proprioception over welding, noise of pain actually makes the problem walking the at risk of falling. Actually, Tai chi one gets improvement in balance. There's also medicating component to it. So, mindfulness medication is kind of built in it and that all kind of gives the patients a better control of symptoms. So, some of those interventions are easily accessible in community. So, it's, again, it's a patient education that really takes important part. Dr Nevel: Yeah. And that Tai chi is maybe one of the answers to the next question that I have for you. But as the clinical director of the Division of Intramural Research at the National Center for Complementary and Integrative Health, I have to ask you, Misha, what sort of integrative and complementary type interventions do you counsel your patients about, maybe beyond Tai chi, and which ones do you think are the most helpful? Dr Backonja: To clarify, the NIH patients I see are all admitted per protocol. Actually, NIH has the largest research hospitals called clinical NIH Clinical Centre, which has a hospital and clinics. All the patients that come to our program, they come per protocol for the most part. They come for specific investigations. At the moment, we do not have intramural treatment protocols, although in near future one of my goals is to establish that. The NIH funds- 90% of funding from NIH goes extramurally to academic institutions and other healthcare organizations and so on, and only 10% goes for intermural research. So, what we do is much smaller in scope, much more focused. So, what do we support NCCIH actually support extramurally full range of anything from probiotics, research in microbiome related to health and pain all the way to interventions such as mindfulness meditation? Intramurally, once when patients come for protocol, we evaluated and it's unavoidable to be a question. So, what do we do now? What recommendations do we make? Again, we don't- with the present time, we have treatment protocols and then, most of the time, what I can do is provide recommendations to the patients when they go back to the treating community, to the treating providers. It's usually a fairly comprehensive list including pharmacological and non-pharmacological accommodations for those who have had experience with pharmacology. Sometimes I can just say yes, continue or change or whatever. But then when it comes to additional complementary accommodations, they always provide information. For example, why do I recommend Tai chi? Or, what's the benefit of yoga and why would one want to try to learn trying to behavioral therapy or mindfulness meditation? What's the benefit of turmeric and some other components of what's called anti-inflammatory diet and what's the rationale behind all of that? So rather than just giving a list of recommendations and leaving it that, I try to engage patients in terms of having to understand why something is recommended, whether the fits with their expectations and what fits with their lifestyle and so on. Dr Nevel: Yeah. So, what's coming up, what's next in painful peripheral neuropathy? What do you think is exciting? Where do you foresee some breakthroughs in this field? Dr Backonja: Probably what will make the most difference is application of some of the really molecular biology tools that are being applied to peripheral neuropathy. So hopefully one of these days you'll have a cure for neuropathy and pain and anything would come to that will be probably interaction between a nervous system and an immune system, in particular neuroinflammation. That's kind of my bias. They're probably that's- well, the answer will be, but many painful neuropathies - actually every painful neuropathy, because they come from, as a result, specific pathologies - are different in a sense of trajectory natural course that will have to be first addressed. And again, depending on the underlying disease and molecular biology of that and genetics of it will determine that. But on the other hand, there are some common denominators, as we talked, when it comes to painful neuropathies, which is drivers of peripheral and central sensitization. And maybe one of these days, we'll find what are those drivers and how to change the system so it does not produce pain and other associated symptoms. Dr Nevel: So once again, today I've been interviewing Dr Miroslav Misha Backonja, whose article on peripheral neuropathic pain appears in the most recent issue of Continuum on pain management in neurology. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining us today. And thank you, Misha, so much for talking with me today about your article. I encourage all of the listeners to read it. It was very comprehensive and just really wonderful to read. Dr Backonja: Thank you. Enjoyed it. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.
Featuring an interview with Dr Steven Horwitz, including the following topics: Overview of peripheral T-cell lymphomas (PTCLs) (0:00) Efficacy and safety of brentuximab vedotin in the management of treatment-naïve and relapsed PTCLs (9:57) Emerging therapeutic strategies for PTCLs (19:48) Case: A man in his early 50s with CD30-positive anaplastic large cell lymphoma who experienced complete response (CR) to BV-CHP and continued remission after consolidation with autologous stem cell transplant (ASCT) (25:53) Management of ALK-positive anaplastic large cell lymphoma (32:14) Case: A man in his late 50s with CD8-positive PTCL not otherwise specified who achieved CR with CHOEP and experienced relapse after ASCT (34:33) Case: A woman in her early 70s with chemorefractory CD30-positive angioimmunoblastic T-cell lymphoma (38:26) Ongoing first-line studies for T-cell lymphomas; association of CAR T-cell therapy with T-cell malignancies (42:18) CME information and select publications
Featuring a slide presentation and related discussion from Dr Steven Horwitz, including the following topics: Front-line management of peripheral T-cell lymphomas (PCTLs) (0:00) Dose-intensified chemotherapy in combination with brentuximab vedotin for PTCL (9:59) Role of CD30 for PTCLs (14:36) Management of relapsed PTCL (20:40) CME information and select publications
Dr Stephen Horwitz from Memorial Sloan Kettering Cancer Center in New York, New York, discusses management strategies for previously untreated and relapsed peripheral T-cell lymphomas.
Dr Stephen Horwitz from Memorial Sloan Kettering Cancer Center in New York, New York, discusses management strategies for previously untreated and relapsed peripheral T-cell lymphomas, moderated by Dr Neil Love. Produced by Research To Practice. CME information and select publications here (https://www.researchtopractice.com/OncologyTodayPTCL24).
G.I. Joe Chronicles - Outpost: Episode 12 Title: G.I. Joe A Real American Hero - Sunbow G.I. Joe Cartoon: S1.E20 - E24 Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. Join Jim the Joe Junkie and his Brother George the Quartermaster of the Outpost as they Discuss Some G.I.Joe Sunbow Cartoons. How will Cobra attempt to take over the World in these 5 Episodes? They burn money, use Individuals with Extraordinary Powers, Soundwaves and aTrain of Gold. And what did they think about the Lunchboxes from 1988 to 1992? Find out in this Episode of G.I.Joe Chronicles Outpost and YO JOE! Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.com Let us know what you think! Leave a comment by sending an email to: contact@longboxcrusade.com This podcast is a member of the LONGBOX CRUSADE NETWORK: LINKTREE: https://linktr.ee/longboxcrusade Follow on TWITTER: https://twitter.com/LongboxCrusade Follow on INSTAGRAM: https://www.instagram.com/longboxcrusade Like the FACEBOOK page: https://www.facebook.com/LongboxCrusade Subscribe to the YouTube Channel: https://goo.gl/4Lkhov Subscribe on Apple Podcasts at: https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2 or https://anchor.fm/s/e9b9020/podcast/rss Thank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost!
G.I. Joe Chronicles - Outpost: Episode 11 Title: G.I. Joe A Real American Hero Marvel Comics - Issues: 20-23 (1983-1984) Fall-in Troops and Welcome to G.I.Joe Outpost. Join Jim the Joe Junkie and his rotating cast of co-hosts. Beginning in 1982 they will explore many aspects of the World(s) of G.I.Joe. They will Discuss the Toys, Comics, Cartoons and other Peripheral items from each year to current day. Join Jim “the Joe Junkie” and Pat "DJ" Kristatos Sampson as they discuss Clutch's "Vacation", Snake-eyes and Scarlett's "Romantic" night in a Castle, Duke and Roadblock Crashing, General Flaggs Funeral and Baroness's new Face. All of this and more from G.I.Joe Marvel Comics Issues 20-23. And they also discuss some G.I.Joe School Supplies, where you one of the Cool Kids that went to school with some G.I.Joe Supplies? Be sure to check out all the other Longbox Crusade shows at: www.LongboxCrusade.com Let us know what you think! Leave a comment by sending an email to: contact@longboxcrusade.com This podcast is a member of the LONGBOX CRUSADE NETWORK: LINKTREE: https://linktr.ee/longboxcrusade Follow on TWITTER: https://twitter.com/LongboxCrusade Follow on INSTAGRAM: https://www.instagram.com/longboxcrusade Like the FACEBOOK page: https://www.facebook.com/LongboxCrusade Subscribe to the YouTube Channel: https://goo.gl/4Lkhov Subscribe on Apple Podcasts at: https://itunes.apple.com/us/podcast/the-longboxcrusade/id1118783510?mt=2 or https://anchor.fm/s/e9b9020/podcast/rss Thank you for listening and we hope you have enjoyed this episode of G.I. Joe Chronicles: Outpost!
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