Podcasts about Pharmacology

On this episode, we provide an overview of insulin. We discuss the various insulin products available, basal vs prandial insulin, and dosing strategies. We also review clinical concepts such as overbasalization.  Cole and I are happy to share that our listeners can claim ACPE-accredited continuing education for listening to this podcast episode! We have continued to partner with freeCE.com to provide listeners with the opportunity to claim 1-hour of continuing education credit for select episodes. For existing Unlimited (Gold) freeCE members, this CE option is included in your membership benefits at no additional cost! A password, which will be given at some point during this episode, is required to access the post-activity test. To earn credit for this episode, visit the following link below to go to freeCE's website: https://www.freece.com/ If you're not currently a freeCE member, we definitely suggest you explore all the benefits of their Unlimited Membership on their website and earn CE for listening to this podcast. Thanks for listening! If you want to support the podcast, check out our Patreon account. Subscribers will have access to all previous and new pharmacotherapy lectures as well as downloadable PowerPoint slides for each lecture. If you purchase an annual membership, you'll also get a free digital copy of High-Powered Medicine 3rd edition by Dr. Alex Poppen, PharmD. HPM is a book/website database of summaries for over 150 landmark clinical trials.You can visit our Patreon page at the website below:  www.patreon.com/corconsultrx We want to give a big thanks to Dr. Alex Poppen, PharmD and High-Powered Medicine for sponsoring the podcast..  You can get a copy of HPM at the links below:  Purchase a subscription or PDF copy - https://highpoweredmedicine.com/ Purchase the paperback and hardcover - Barnes and Noble website We want to say thank you to our sponsor, Pyrls. Try out their drug information app today. Visit the website below for a free trial: www.pyrls.com/corconsultrx We also want to thank our sponsor Freed AI. Freed is an AI scribe that listens, prepares your SOAP notes, and writes patient instructions. Charting is done before your patient walks out of the room. You can try 10 notes for free and after that it only costs $99/month. Visit the website below for more information: https://www.getfreed.ai/  If you have any questions for Cole or me, reach out to us via e-mail: Mike - mcorvino@corconsultrx.com Cole - cswanson@corconsultrx.com

In this episode of our pharmacology podcast, we take a deep dive into the pharmacology of levomilnacipran (Fetzima), a unique serotonin-norepinephrine reuptake inhibitor (SNRI) approved for the treatment of major depressive disorder (MDD) in adults. Designed for pharmacy students, clinicians, and anyone interested in psychopharmacology, this episode breaks down what makes levomilnacipran different from other antidepressants and how to use it effectively in clinical practice. We explore levomilnacipran's mechanism of action, which features a greater affinity for norepinephrine reuptake inhibition compared to serotonin—an uncommon trait among SNRIs. This pharmacologic profile gives it a distinctive effect on energy, motivation, and physical symptoms of depression. Listeners will also learn about its pharmacokinetics, including once-daily dosing, renal elimination, and metabolism via the CYP3A4 pathway—making drug interactions an important consideration. The episode also covers levomilnacipran side effects, including common adverse reactions like nausea, dry mouth, constipation, and increased heart rate or blood pressure. We'll also highlight rare but serious risks like serotonin syndrome and urinary hesitation. Because levomilnacipran drug interactions can impact safety and efficacy, we review important combinations to avoid, such as CYP3A4 inhibitors (e.g., ketoconazole), serotonergic drugs, and blood pressure-altering agents. For pharmacists and prescribers, this is a key segment to help guide safer medication use and monitoring. Finally, we wrap up with clinical pearls for starting, titrating, and monitoring levomilnacipran therapy—including renal dose adjustments and differences with duloxetine. Whether you're studying for boards or optimizing your patient's antidepressant regimen, this episode delivers a concise, evidence-based overview of levomilnacipran pharmacology in a digestible, podcast-friendly format.

Sébastien Gauvrit was only ten when his family let him have his first tank of guppies. Within weeks, he was hooked.   “I actually had to understand genetics directly by mixing these different fish together to get the colour or fin shape I was interested in,” said the vascular biologist and genetic modelling pioneer. From his home in France, to post-doctoral work pioneering new models for vascular disease in Germany, to his current position as an assistant professor of Anatomy, Physiology and Pharmacology at the University of Saskatchewan's College of Medicine —  tropical fish tanks remain a constant in Gauvrit's life.   This year, two grants from the National Sciences and Engineering Research Council of Canada (NSERC) totalling $340,000 mean Dr. Gauvrit will expand the University of Saskatchewan's zebrafish aquariums — and refine his laboratory's modelling work and research on vascular development.   Zebrafish are transparent in their first hours and days, which allows scientists to watch them forming vascular cells in real time.   “Most genes that trigger vascular disease in humans are present in zebrafish,” Gauvrit said, noting they share 70 per cent of of their genes with humans.   Using both fish and rodent models, Gauvrit will do a deeper analysis of the transcription factor HHEX [Hematopoietically Expressed Homeobox], because of its cascading effect on the cells that eventually determine lymphatic health.   “If you understand how this gene regulates others, we can identify new genes involved in lymphatic disease, and understand a bit more the process behind all these events,” Gauvrit said.   He's also looking at VEGF-A [vascular endothelial growth factor], a gene implicated in vascular diseases, including age-related macular degeneration [AMD]. Right now, patients with blurred vision and an overgrowth of blood vessels are treated with multiple injections to the eye, with the hope of limiting damage. “A high proportion of patients develop resistance against this therapy, which is a big issue,” Gauvrit said. “It's also very costly.”   Mice die quickly without VEGF-A, but zebrafish without it survive — even thrive. Gauvrit wants to know what processes help zebrafish compensate, and where mammalian cells diverge.   Gauvrit said the broader implications of vascular research will have ripple effects in treating lymphedema, strokes, and age-related macular degeneration. “We still discover new things,” Gauvrit said. “Just by serendipity and by randomness, sometimes you can find a bit greater science than when you have a very specific question.”

Welcome all to IS PHARMACOLOGY DIFFICULT Podcast! I am Dr Radhika VijayIt's the- "Fast Pharmacology-Drug in 5 minutes"Today Drug in this series is Dupixent (Dupilumab)In this episode, I will be breaking down name, mechanism, uses, side effects and clinical pearls of this new drug!Its for all- doctor, pharmacologist, med student, pharmacist and laymen interested in science of Pharmacology, drugs and medicinesMy podcast is featured in "BEST SCIENCE PODCASTS"- Check the link here:https://podcasts.feedspot.com/india_science_podcasts/My podcast is featured in "BEST INDIAN MEDICAL PODCASTS". Check the link here:https://podcasts.feedspot.com/india_medical_podcasts/?feedid=5503395For all the updates and latest episodes of my podcast, please visit www.ispharmacologydifficult.com where you can also sign up for a free monthly newsletter of mine."Pharmacology Further" E-Newsletter and Podcast:The links for these are at all my websites and specifically:Link for E-Newsletter: https://pharmacologyfurther.substack.com/Link for the E-Newsletter Podcast: https://www.pharmacologyfurther.comIt actually contains lot of updates about the medical sciences, drug information and my podcast updates also.You can follow me on different social media handles like twitter, insta, facebook and linkedin. They all are with same name "IS PHARMACOLOGY DIFFICULT". If you are listening for the first time, do follow me here, whatever platform you are consuming this episode, stay tuned, do rate and review on ITunes, Apple podcasts, stay safe, stay happy, stay enlightened, Thank you!!Please leave Review on Apple podcasts!My E-Newsletter sign up at Substack!Connect on Twitter & Instagram!My books on Amazon & Goodreads!

Episode Title: Social Connectedness & Health, with Dr. Cassidy Leibold, PhD!!! Cassidy's Bio: Is a graduate of the University of Dayton (2020) and University of Kentucky, with an MS and PhD in Experimental Psychology. Specifically, she studies Behavioral Neuroscience and Pharmacology. Her research focuses on the excitotoxic effects of alcohol on the hippocampus, and how prolonged alcohol exposure impairs neurogenesis and overall cell survival in this brain structure. She is now a lecturer in the Psychology department at the University of Kentucky, and loves getting to work with aspiring researchers and clinicians. Description: In this episode, Rob welcomes back Dr. Cassidy Leibold, PhD, a lecturer in the Psychology Department at the University of Kentucky. Cassidy shares the exciting developments since her last visit, including her new role teaching aspiring researchers and clinicians. She also reflects on her journey through her PhD, where she studied the effects of chronic binge alcohol use on neurogenesis in the hippocampus—a key brain region involved in memory formation. Cassidy discusses the importance of social connectedness and how our relationships play a significant role in our health. She explores the evolutionary significance of group membership, the brain's response to social pain, and how social media can both connect and amplify relationships. She also explains the delicate balance between the number and quality of social connections, highlighting why quality tends to matter more as we age. Cassidy wraps up the conversation with her personal insights on how she's grown since her PhD, including changes in how she views success, the impact of joining groups that support her, and the importance of personal well-being. Topics Covered: Cassidy's Journey and New Role at the University of Kentucky Cassidy shares her experiences during and after her PhD, discussing the challenges of conducting empirical research and the lessons she's learned along the way. What We Know About Social Connectedness Explore how social connectedness has shaped human survival and how it continues to impact our health today. Cassidy dives into the evolutionary psychology behind group membership and why being part of a group is so deeply ingrained in our brains. Quality vs. Quantity in Social Relationships Cassidy talks about the importance of both the number and quality of connections, explaining why the quality of relationships becomes more important with age and how our closest relationships influence our behaviors and beliefs. The Elevate Yourself Podcast is brought to you in partnership with Athletic Brewing. Use code ELEVATE30 for 30% OFF your first online order at checkout!

“Next-generation sequencing, or NGS, can be used to help us determine if the patient has specific biomarkers we can identify and use to target for treatment. Certain findings can tell us if a particular treatment might work for that patient, and we can see if there are any genetic variants we might have a biomarker targeted agent to use to treat them with,” ONS member Jackie Peterson, MSN, RN, OCN®, NE-BC, MBA, ambulatory nurse manager at the University of Chicago Medical Center in Illinois, told Lenise Taylor, MN, RN, AOCNS®, BMTCN®, oncology clinical specialist at ONS, during a conversation about prostate cancer and biomarker testing.  This podcast is sponsored by AstraZeneca and is not eligible for NCPD contact hours. ONS is solely responsible for the criteria, objectives, content, quality, and scientific integrity of its programs and publications.   Music Credit: “Fireflies and Stardust” by Kevin MacLeod    Licensed under Creative Commons by Attribution 3.0   Episode Notes This episode is not eligible for NCPD. ONS Podcast™ episodes: Episode 324: Pharmacology 101: LHRH Antagonists and Agonists Episode 321: Pharmacology 101: CYP17 Inhibitors Episode 180: Learn How Nurse Practitioners Use Biomarker Testing in Cancer Care ONS Voice articles: An Oncology Nurse's Guide to Cascade Testing Genetic Disorder Reference Sheet: BRCA1 and BRCA2 Hereditary Disorders Genetic Disorder Reference Sheet: Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer) Germline and Somatic Variants: What Is the Difference? Help Patients Understand Genomic Variants of Unknown Significance Prostate Cancer Clinical Trials Don't Reflect Racial Diversity—And It's Getting Worse Over Time Prostate Cancer Disparities Disappear With Equal Access to Care Prostate Cancer Prevention, Screening, Treatment, and Survivorship Recommendations The Case of the Genomics-Guided Care for Prostate Cancer ONS book: Understanding Genomic and Hereditary Cancer Risk: A Handbook for Oncology Nurses ONS course: Genomic Foundations for Precision Oncology Clinical Journal of Oncology Nursing articles: Metastatic Prostate Cancer: An Update on Treatments and a Review of Patient Symptom Management Prostate Cancer: How Nurse Practicioners Can Aid in Disease Diagnosis and Management Oncology Nursing Forum article: Identification of Symptom Profiles in Prostate Cancer Survivors Other ONS Resources: Biomarker Database (refine by prostate cancer or specific biomarkers) Clinical tool/case study: Biomarker Testing in Prostate Cancer: The Role of the Oncology Nurse Genomics and Precision Oncology Learning Library Huddle Card: Genomic Biomarkers Infographic: Talking to Your Patient About a Germline Variant of Uncertain Significance (VUS) American Cancer Society - Genetic Testing and Counseling for Prostate Cancer Risk American Cancer Society - Prostate Cancer Clinicaltrials.gov National Cancer Institute - Prostate Cancer National Comprehensive Cancer Network ZERO Prostate Cancer To discuss the information in this episode with other oncology nurses, visit the ONS Communities.   To find resources for creating an ONS Podcast club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org.  Highlights From This Episode “Some of the risk factors for developing prostate cancer include age, race, family history, and certain genetic changes or variants. Prostate cancer has some hereditary components, but most prostate cancer occurs in men without any significant family history of it.” TS 1:31 “Key biomarkers include PSA and prostate cancer gene 3, which is PCA3, and prostate-specific membrane antigen, or PSMA. Other biomarkers that are important for us to test include BRCA1, BRCA2, and Lynch syndrome–associated genes, which are MLH1, MSH2, MSH6, PMS2, and EPCAM. Biomarkers can be collected via your blood, urine, saliva, or tissue samples, so these are different ways that we can test and look for biomarkers in our patients.” TS 3:24 “It does matter how advanced the disease is. Usually, for our castrate-sensitive patients, they respond better to androgen deprivation therapy because that really is slowing down the growth of the cancer by reducing the available testosterone that the cancer needs to grow. Whereas our patients that are more advanced and have castrate-resistant prostate cancer, that cancer will continue to grow despite having the lowered testosterone levels, so they might need additional layers of treatment to really get their cancer under control.” TS 7:50 “When I talk to [patients] about biomarker testing, I tell them it's another tool in our toolbox that we can use to help us determine if they might benefit from other therapy options now or in the future. I tell them that sometimes we'll get a report back with a variant of unknown significance, and basically that means that we don't really know whether or not this has an impact on their health or risk factors for the disease. That can sometimes be a little bit of a concern for these patients, so we just have to reassure them that we're continually doing research around biomarker testing. The science is always advancing, so if there's something that [researchers] find in the future, we'll make them aware of that.” TS 9:08 “One of the biggest topics I think about is the inequity that exists in biomarker testing and research, especially surrounding the African American population. When these tests were developed, that population really wasn't studied as much, so there's not a lot of good data yet to make a decision or impact on those patients and that population.” TS: 12:30

Asenapine is an atypical antipsychotic that acts as an antagonist at multiple receptors, including dopamine D2 and serotonin 5-HT2A, contributing to its antipsychotic and mood-stabilizing effects. Adverse effects of asenapine include somnolence, dizziness, and extrapyramidal symptoms. Because asenapine is significantly metabolized by CYP1A2, inhibitors or inducers of these enzymes can affect its plasma concentrations. Co-administration with other CNS depressants may increase the risk of sedation and impaired cognitive or motor function. Asenapine can prolong the QT interval, so caution is advised when used with other medications that affect cardiac conduction.

Lee Gayle is an entheogenic researcher and educator passionate about the science and sacred use of psychoactive plants, animals, and fungi. She's the creator of the Psychedelic Society's course on Naturally Occurring Psychotropics, where she shares accessible, research-based knowledge on mind-altering medicines and their ritual use. Her work blends deep curiosity, cultural respect, and a grounded approach to self-love and transformation.The next NATURALLY OCCURRING PSYCHOTROPICS course begins 16th September 2025.In this 9 week online course:- Gain essential knowledge for facilitators, space-holders and any curious mind caleld to the psychedelic path- Deepen your foundational understanding, depth and integrity in this exciting and expanding fieldThe course includes weekly modules that unlock as you progress, with written content, reading materials, and self-assessment tests to help you engage with the material. We also meet live every Wednesday from 6–8pm (SA time) on Zoom for interactive webinars where we explore the week's topic in more depth and open the space for questions and discussion.Topics we cover include: • The chemistry, history, and cultural use of psychoactive plants, fungi, and animals • Indigenous knowledge systems and ceremonial use • Pharmacology, safety, and harm reduction • Addiction, integration, and ethical considerations • Case studies, legal context, and emerging researchTo receive your certificate, you'll need to complete all the modules and pass the final exam. The certificate reflects 120 hours of training and is recognised within psychedelic education and harm reduction circles, especially through the Psychedelic Society of South Africa.Register for this incredible course by visiting www.psychedelicsociety.co.za

“The proteasome itself, it really helps us unfold or get rid of misfolded proteins or degradations of different cells. We used to have garbage disposals in our sinks, and we used to put food product in there. If your garbage disposal is clogged, then everything backs up. So that's kind of what's really going on in the cell itself, is that I'm building up these unnecessary proteins that we should be getting rid of, and it actually causes apoptosis or cell death,” ONS member Daniel Verina, DNP, RN, ACNP-BC, nurse practitioner for the multiple myeloma program at Mount Sinai Medical Center in New York, NY, told Lenise Taylor, MN, RN, AOCNS®, BMTCN®, oncology clinical specialist at ONS, during a conversation about the proteasome inhibitor drug class. Music Credit: “Fireflies and Stardust” by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0  Earn 0.75 contact hours (including 40 minutes of pharmacotherapeutic content) of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by July 18, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: Learner will report an increase in knowledge related to the use of proteasome inhibitors in the treatment of cancer. Episode Notes  Complete this evaluation for free NCPD.  ONS Podcast™ Pharmacology 101 series ONS Voice article: AI Multiple Myeloma Model Predicts Individual Risk, Outcomes, and Genomic Implications ONS books: Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (second edition) Clinical Guide to Antineoplastic Therapy: A Chemotherapy Handbook (fourth edition) Guide to Cancer Immunotherapy (second edition) Multiple Myeloma: A Textbook for Nurses (third edition) Clinical Journal of Oncology Nursing article: Optimizing Transitions of Care in Multiple Myeloma Immunotherapy: Nurse Roles Oncology Nursing Forum articles: Changes in Health-Related Quality of Life During Multiple Myeloma Treatment: A Qualitative Interview Study Facilitators of Multiple Myeloma Treatment: A Qualitative Study ONS Guidelines™ and Symptom Interventions Adherence to Oral Anticancer Medication Peripheral neuropathy ONS Hematology, Cellular Therapy, and Stem Cell Transplantation Learning Library American Society of Hematology International Myeloma Foundation Leukemia and Lymphoma Society Multiple Myeloma Research Foundation To discuss the information in this episode with other oncology nurses, visit the ONS Communities. To find resources for creating an ONS Podcast club in your chapter or nursing community, visit the ONS Podcast Library. To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org. Highlights From This Episode “When we look at the administration, we also want to make sure that we're looking at the blood counts, right? Because proteasome inhibitors are well known for causing thrombocytopenia and neutropenia. So making sure that the patients do meet eligibility for the treatment for that day, and do they have anemia or lower red blood cell counts. You want to make sure that, because of these therapies, that the patient has no symptoms or infections going into each therapy for that day.” TS 10:19 “[Bortezomib], interesting enough, it can cause hypotension, cardiac failure, and sometimes pulmonary edema. Switching that up a little bit, what makes it slightly different, carfilzomib … a lot of times we saw, even in the clinical trial, that there was a lot of hypertension or cardiomyopathies, or arrythmias that we saw with carfilzomib and different dosages that they have indicated from the FDA. So again, monitoring the hypertension … or heart failure.” TS 15:16 “We also want to keep in mind another adverse effect, and especially in myeloma—our patients come in the door already immunocompromised just by the disease state alone. But now I'm giving them therapies that can drop their neutrophil count, so neutropenia and thrombocytopenia, so they are at a higher risk of having serious infections, even including like pneumonia or having outbreaks of herpes zoster or shingles.” TS 16:50 “If the patient has shortness of breath or symptoms, hold the therapy. I think that's one of my biggest messages when it comes to cancer treatments and educating other healthcare providers, or even educating our patients and their caregivers or the care partners with them, is that we need to sometimes hold the therapy for safety.” TS 22:02 “I say keep a log, keep a book. Let me know when the symptoms happen. Are they happening the day of treatment? Are they happening two days later from the treatment? Are they happening a week later from the treatment? And being able to kind of guide which therapy is causing some of these adverse events or side effects alone. So, making them have calendars. When did you take the drug, when did you get your last infusion or your last [subcutaneous] injection? Always talk to your care team, whether it's in the academic center or next to your house in the community.” TS 26:17 “It's us learning how to listen to the patient going forward. We have tasks to do—we all have tasks to do in our lives—but we have to take a breath, be mindful who's in front of us, listen to them first, and then be able to talk to them and care for them upfront and see what the symptoms are. I think that's what we need to do. We have to take a breath in cancer.” TS 39:35

Pharmacology can be a bit confusing when you are first learning about how drugs enter and are processed by the body. It is a very important concept to know well as we move forward with the administration of local anesthesia.In this episode, we will review Potency, efficacy, and the therapeutic index. I will go over ways to remember each in a way that creates learning and understanding. You can do this! Other Resources:Tutoring with Me: ⁠⁠⁠https://calendly.com/d/cszb-s4r-hy4/tutoring-with-billie⁠⁠⁠Leave me a message or send a question I can share on the Podcast⁠⁠⁠⁠ Here⁠⁠⁠⁠Time Management Prioritization Quiz - Find out how you rate ⁠⁠⁠⁠⁠HERE ⁠⁠⁠⁠Study Sheets: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://thehappyflosserrdh.etsy.com/ ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Specialized Course: How to be successful in Dental Hygiene School⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://billie-lunt-s-school.teachable.com/p/how-to-be-successful-in-dental-hygiene-school⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Other Podcasts: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠blog.feedspot.com/dental_hygiene_podcasts/⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠  Email Me: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠HappyflosserRDH@gmail.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Leave me a message or ask a question I can share on the Podcast ⁠Here ⁠Time Management Prioritization Quiz - Find out how you rate ⁠⁠HERE ⁠Check out my free scorecard for students - you can rank yourself on how you are doing to take action on the steps toward being a successful college student. Sign up on the Google doc ⁠⁠⁠⁠HERE⁠⁠⁠⁠ - I will send along your scorecard to use the entire time you are enrolled in school. Study Sheets: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://thehappyflosserrdh.etsy.com/ ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Specialized Course: How to be successful in Dental Hygiene School⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://billie-lunt-s-school.teachable.com/p/how-to-be-successful-in-dental-hygiene-school⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Other Podcasts: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠blog.feedspot.com/dental_hygiene_podcasts/⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ Tooth fairy escape room ⁠⁠⁠Here ⁠⁠⁠Email Me: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠HappyflosserRDH@gmail.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Billie Lunt Media Kit: ⁠https://www.canva.com/design/DAGaiUvmKTI/R8NEtEIUAwS9pptthWb6QQ/view?utm_content=DAGaiUvmKTI&utm_campaign=designshare&utm_medium=link2&utm_source=uniquelinks&utlId=hb5fb9186b2⁠

Update on Missing kids in Nova Scotia Guest: Lindsay Jones, reporter for the Globe and Mail Iranian immigration into Canada Guest: Ram Joubin, Immigration Lawyer,  Iranian-Canadian who specializes in refugee and human-rights law Do we need to regulate the amount of THC in cannabis products? Guest: Ruth A. Ross, Ph.D.  Professor, Department of Pharmacology & Toxicology, University of Toronto Weekly Cecchini Check-In Guest: Reggie Cecchini, Washington Correspondent for Global News Police charge a man who's been impersonating a police officer Guest: Corporal Mansoor Sahak, North Van RCMP Learn more about your ad choices. Visit megaphone.fm/adchoices

Do we need to regulate the amount of THC in cannabis products? Guest: Ruth A. Ross, Ph.D.  Professor, Department of Pharmacology & Toxicology, University of Toronto Learn more about your ad choices. Visit megaphone.fm/adchoices

Loxapine is a first-generation (typical) antipsychotic with dopamine D2 receptor antagonism as its primary mechanism, though it also has affinity for serotonin 5-HT2A receptors, making its pharmacology somewhat atypical. Loxapine is available in multiple formulations, including oral capsules and an inhalation powder, the latter approved specifically for acute agitation in patients with schizophrenia or bipolar I disorder. Sedation and extrapyramidal symptoms (EPS), including dystonia, akathisia, and parkinsonism, are common adverse effects due to its potent dopamine blockade in the nigrostriatal pathway. Orthostatic hypotension can occur with loxapine due to its alpha-1 adrenergic blockade, requiring monitoring in elderly patients or those on antihypertensives.

Are you preparing to start dental hygiene school soon? If so, this is the perfect episode for you! Marie Richey, a current dental hygiene educator, joins me on this episode to give insider tips and tricks for incoming and current students. Listen to her perspective as a professor to have a clear understanding of what dental hygiene school will look like and be ready to go on your first day!Timestamps: (00:00) Marie's RDH Origin Story (04:03) Working as a Travel Dental Hygienist (11:51) Marie's Tips and Tricks for Dental Hygiene Students (21:16) Struggling in Pharmacology (30:08) Don't Stop Learning Dental Hygiene

What if everything you thought about trauma and healing was missing one simple truth—that you are not broken?In this deeply inspiring episode, we sit down with Academy Award-winning Hollywood veteran turned trauma recovery expert, Chana Studley, to explore a radically different approach to healing. After surviving three brutal muggings, battling severe PTSD, and struggling with chronic pain for years, Chana discovered something life-changing: true healing doesn't come from doing more—it comes from understanding more.Chana shares her remarkable journey of transformation, from years of physical and emotional suffering to a thriving life of purpose, peace, and creativity.She introduces us to a powerful new paradigm rooted in the understanding that we are not our thoughts, and that well-being isn't something to chase—it's something we already have within us.We talk about:The moment that sparked Chana's healingWhy trying to “fix” ourselves can keep us stuckThe truth about anxiety, chronic pain, and the stories we carryWhat it really means to “settle” the mindHow insight, not effort, opens the door to lasting peaceWhether you're navigating trauma, anxiety, chronic pain, or simply feeling overwhelmed by the constant pressure to improve, this conversation is your invitation to breathe, let go, and remember who you truly are.Because healing isn't hard when you realise—you were never broken to begin with.Chana Studley is a coach, counselor, international speaker, and author with over 35 years of experience in the field of mental health.After surviving three violent muggings in the 1980s and living with severe PTSD, Chana went on to build an award-winning career in Hollywood, including receiving an Academy Award for her work in special effects.Her personal journey from trauma to healing eventually led her to train as a counselor with the Manchester Women in Crisis Center and later become a certified Life Coach and Three Principles Practitioner.In 2018, Chana graduated from The One Thought Institute and has since become a leading voice in the field of mind-body health, particularly through her pioneering work with the Three Principles and the connection between psychological and physical well-being.She is also a World Health Organization Psychological First Responder and holds diplomas in both Psychology and Pharmacology.Chana is the founder of the Beyond Chronic Pain Masterclass, an accessible six-hour online course designed to empower individuals suffering from chronic pain through a new understanding of healing.Chana is the author of four books, including Beyond Diagnosis: A Paradigm Shift from Pathology to Innate Health, and three Amazon #1 bestselling novels—The Myth of Low Self-Esteem, Painless, and Very Well—which blend storytelling with insights on trauma, chronic pain, and hormonal health.Her work has been praised for offering fresh hope and clarity to those overwhelmed by pain and psychological distress. She is also a proud member of United Hatzalah and continues to support individuals and communities around the world through her coaching and writing.Find out more and connect with Chana online:Book website: beyond-diagnosis.comWebsite: chanastudley.comLinkedIn: https://www.linkedin.com/in/chanastudley/Facebook: https://www.facebook.com/groups/understandinganxietystressandtrauma

On this episode, we evaluate current guidelines and evidence-based treatment strategies for managing insomnia, including both pharmacological and non-pharmacological approaches. We compare and contrast the efficacy, safety profiles, and appropriate use of pharmacologic agents, behavioral therapies, and lifestyle interventions for treating insomnia.  Cole and I are happy to share that our listeners can claim ACPE-accredited continuing education for listening to this podcast episode! We have continued to partner with freeCE.com to provide listeners with the opportunity to claim 1-hour of continuing education credit for select episodes. For existing Unlimited (Gold) freeCE members, this CE option is included in your membership benefits at no additional cost! A password, which will be given at some point during this episode, is required to access the post-activity test. To earn credit for this episode, visit the following link below to go to freeCE's website: https://www.freece.com/ If you're not currently a freeCE member, we definitely suggest you explore all the benefits of their Unlimited Membership on their website and earn CE for listening to this podcast. Thanks for listening! If you want to support the podcast, check out our Patreon account. Subscribers will have access to all previous and new pharmacotherapy lectures as well as downloadable PowerPoint slides for each lecture. If you purchase an annual membership, you'll also get a free digital copy of High-Powered Medicine 3rd edition by Dr. Alex Poppen, PharmD. HPM is a book/website database of summaries for over 150 landmark clinical trials.You can visit our Patreon page at the website below:  www.patreon.com/corconsultrx We want to give a big thanks to Dr. Alex Poppen, PharmD and High-Powered Medicine for sponsoring the podcast..  You can get a copy of HPM at the links below:  Purchase a subscription or PDF copy - https://highpoweredmedicine.com/ Purchase the paperback and hardcover - Barnes and Noble website We want to say thank you to our sponsor, Pyrls. Try out their drug information app today. Visit the website below for a free trial: www.pyrls.com/corconsultrx We also want to thank our sponsor Freed AI. Freed is an AI scribe that listens, prepares your SOAP notes, and writes patient instructions. Charting is done before your patient walks out of the room. You can try 10 notes for free and after that it only costs $99/month. Visit the website below for more information: https://www.getfreed.ai/  If you have any questions for Cole or me, reach out to us via e-mail: Mike - mcorvino@corconsultrx.com Cole - cswanson@corconsultrx.com

The Bodybuilding-friendly HRT Clinic - Get professional medical guidance on peptides AND optimizing your health as a man or bodybuilder: [ Pharma Test, IGF1, Tesamorelin, Glutathione, BPC, Semaglutide, Var troche, etc]https://transcendcompany.com/patient-intake-form/?ls=Nyle+NaygaWatch it: https://www.youtube.com/watch?v=6Ihq4tIzyS8&t=5618sRP Hypertrophy Training App: rpstrength.com/nylePlease share this episode if you liked it. To support the podcast, the best cost-free way is to subscribe and please rate the podcast 5* wherever you find your podcasts. Thanks for watching.To be part of any Q&A, follow trensparentpodcast or nylenayga on instagram and watch for Q&A prompts on the story  https://www.instagram.com/trensparentpodcast/Huge Supplements (Protein, Pre, Defend Cycle Support, Utilize GDA, Vital, Astragalus, Citrus Bergamot): https://www.hugesupplements.com/discount/NYLESupport code 'NYLE' 10% off - proceeds go towards upgrading content productionYoungLA Clothes: https://www.youngla.com/discount/nyleCode ‘NYLE' to support the podcastLet's chat about the Podcast:Instagram: https://www.instagram.com/trensparentpodcast/TikTok: https://www.tiktok.com/@transparentpodcastPersonalized Bodybuilding Program:  https://www.nylenaygafitness.comTimestamps:00:00:00 Intro  00:02:40 Personal Life Updates  00:04:51 Pregnancy and Lifestyle Changes  00:10:57 Early Steroid Use and Coaching  00:18:43 Sleep Schedules and Productivity  00:26:45 Bodybuilding Industry Evolution  00:27:52 Modern Bodybuilding Aesthetics  00:37:31 GLP-1 Agonists and Nutrition  00:41:37 Classic Physique and Weight Caps  00:46:51 Coaching and Knowledge Evolution  00:53:07 Family Genetics and Hard Work  00:56:55 Diminishing Returns With Protein  01:08:23 Growth Hormone Dosing Insights  01:16:41 Insulin and GH Combinations  01:22:54 Elite Coaching and Drug Testing  01:27:17 Insulin Resistance Myths  01:32:30 Social Media Arguments01:34:38 Trenbolone and Kidney Concerns  01:39:30 Smart Drug Choices in Bodybuilding  01:49:55 Living In Thailand01:56:35 HGH Timing 02:06:30 Tirzepatide vs. Retatrutide  02:12:00 Prescriptions and Traveling02:16:58 Reversing LVH Growth  02:22:42 Estradiol Levels on Cycle  02:27:04 Anabolic Synonymous Shutdown02:30:45 Classic Physique Drug Use 02:33:40 Life Updates and Fatherhood

The Daily Quiz - Science and Nature Today's Questions: Question 1: In Computing, What Does The Abbreviation USB Stand for Question 2: Which organ stores urine? Question 3: What is Dermatopathology the study of? Question 4: What is Pharmacology the study of? Question 5: Who Invented The Telephone? Question 6: What are the two different values of the square root of 144? Question 7: What is Astacology the study of? Question 8: What would you call a female bird? Question 9: What is a female pig known as? This podcast is produced by Klassic Studios Learn more about your ad choices. Visit megaphone.fm/adchoices

Ketoconazole is an imidazole antifungal that works by inhibiting fungal cytochrome P450 14α-demethylase, an enzyme essential for ergosterol synthesis, which disrupts fungal cell membrane integrity. Common adverse effects of ketoconazole include nausea, vomiting, abdominal pain, and elevated liver enzymes, with hepatotoxicity being a notable concern. Ketoconazole carries a boxed warning for severe hepatotoxicity, including cases of liver failure and death, and should not be used as a first-line treatment for fungal infections when other safer antifungals are available. Another boxed warning highlights ketoconazole's potential to prolong the QT interval, increasing the risk for life-threatening ventricular arrhythmias such as torsades de pointes. Ketoconazole is a strong inhibitor of CYP3A4 and can cause significant drug interactions by increasing serum concentrations of medications metabolized by this pathway, including statins, certain benzodiazepines, and some antiarrhythmic.

The Science Behind Chemical Sensitivity with Haylie Pomroy and Dr. Theoharis Theoharides Support the Institute today. https://www.nova.edu/give/index.html?area=Institute%20for%20Neuro-Immune%20Medicine&designation=INIM%20Grateful%20Patient%20Fund  In this episode, Dr. Theoharis Theoharides breaks down the science behind Multiple Chemical Sensitivity (MCS), offering a clear and research-informed perspective on this often misunderstood condition.  He defines what MCS is, how individuals can be triggered by even minimal chemical exposures, and the wide range of symptoms that may follow. He also addresses the serious immunological effects of chemical exposure and emphasizes the importance of creating chemically safe environments. The discussion also covers the role of mast cell activation in MCS, the ways stress can intensify symptoms, and the diagnostic codes currently used for clinical management and treatment.  Tune in to the Hope and Help for Fatigue and Chronic Illness Podcast – The Science Behind Chemical Sensitivity Learn more about INIM's Research Studies: https://www.nova.edu/nim/research-studies/index.html  Sign up for the COVID-UPP Study: https://redcap.nova.edu/redcap/surveys/?s=RMEDJ7LKCX&_gl=1*1h830h7*_gcl_au*MTM2NDA0MTQyOS4xNzE1MDA0ODAy If you are interested in joining a Gulf War Illness (GWI) trial, please complete the Recruitment Registry Form. https://redcap.nova.edu/redcap/surveys/?s=Y9YF8JJWJRK8HEKL%20&_gl=1*1fipp18*_gcl_aw*R0NMLjE3MDc5MTgwMzIuRUFJYUlRb2JDaE1JeWNyUXVfcXFoQU1WU1pCYUJSM3AyQWRBRUFBWUFTQUFFZ0s1NWZEX0J3RQ..*_gcl_au*MTg2NjgwMDQ4Ni4xNzA3MTQwNzgx   Dr. Theoharis Theoharides is a Professor, Vice Chair of Clinical Immunology, and Director at the Institute for Neuro-Immune Medicine-Clearwater, an Adjunct Professor of Immunology at Tufts School of Medicine, where he was a Professor of Pharmacology and Internal Medicine, and also the  Director of Molecular Immunopharmacology & Drug Discovery, and Clinical Pharmacologist at the Massachusetts Drug Formulary Commission (1983-2022). He received his BA, MS, MPhil, PhD, and MD degrees and the Winternitz Price in Pathology from Yale University and received a Certificate in Global Leadership from Tufts Fletcher School of Law and Diplomacy and a Fellowship at Harvard Kennedy  School of Government. He trained in internal medicine at New England Medical Center, which awarded him the Oliver Smith Award, “recognizing excellence, compassion, and service.” Dr. Theoharides has 485 publications (46,491 citations; h-index 106), placing him in the world's top 2% of most cited authors, and he was rated the worldwide expert on mast cells by Expertscape. He was inducted into the Alpha Omega Alpha National Medical Honor Society, the Rare Diseases Hall of Fame, and the World Academy of Sciences.  Website: https://www.drtheoharides.com  LinkedIn: linkedin.com/in/theoharis-theoharides-ms-phd-md-faaaai-67123735   Instagram: https://www.instagram.com/dr.theoharides/   Haylie Pomroy, Founder and CEO of The Haylie Pomroy Group, is a leading health strategist specializing in metabolism, weight loss, and integrative wellness. With over 25 years of experience, she has worked with top medical institutions and high-profile clients, developing targeted programs and supplements rooted in the "Food is Medicine" philosophy. Inspired by her own autoimmune journey, she combines expertise in nutrition, biochemistry, and patient advocacy to help others reclaim their health. She is a New York Times bestselling author of The Fast Metabolism Diet. Learn more about Haylie Pomroy's approach to wellness through her website: https://hayliepomroy.com Instagram: https://www.instagram.com/hayliepomroy  Facebook: https://www.facebook.com/hayliepomroy  YouTube: https://www.youtube.com/@hayliepomroy/videos  LinkedIn: https://www.linkedin.com/in/hayliepomroy/  X: https://x.com/hayliepomroy  Enjoy our show? Please leave us a 5-star review so we can bring hope and help to others. You can also find this show on our YouTube channel. Sign up today for our newsletter. https://nova.us4.list-manage.com/subscribe?u=419072c88a85f355f15ab1257&id=5e03a4de7d Learn more about the Institute for Neuro-Immune Medicine. Website: https://www.nova.edu/nim/ Facebook: https://www.facebook.com/InstituteForNeuroImmuneMedicine Instagram: https://www.instagram.com/NSU_INIM/ Twitter: https://www.twitter.com/NSU_INIM

Watch the video version of this podcast episode.https://www.ecosystem.drgpcr.com/dr-gpcr-podcast/ep-169-with-dr-sokhom-pin---------------------------------Become a #DrGPCR Ecosystem Member---------------------------------Imagine a world in which the vast majority of us are healthy.The #DrGPCR Ecosystem is all about dynamic interactions between us working towards exploiting the druggability of #GPCRs. We aspire to provide opportunities to connect, share, form trusting partnerships, grow, and thrive together.---------------------------------To build our #GPCR Ecosystem, we created various enabling outlets.Premium YearlyPremium Yearly for TeamsDeveloping CountriesAre you a #GPCR professional?Subscribe to the Classified GPCR Weekly NewsListen and subscribe to #DrGPCRPodcast⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠

This week on Dr. Greg we continue to take an in-depth look at what and how today's medical students are learning. We usually expect our physicians to know just about everything about us and to give us advice on just about every topic. One area that has traditionally been lacking in medical education is nutritional aspects of patient care. A new gift account has been established in the UK College of Medicine Department of Pharmacology and Nutritional Sciences to expand nutrition education for health care professionals in training across the College of Medicine. The initiative, led by Sara Police, PhD, associate professor of pharmacology and nutritional sciences, aims to integrate more comprehensive, evidence-based nutrition content into medical education to better equip future physicians with the tools to address nutrition-related aspects of patient care. Sara talks about the project with Dr. Greg.

Episode 07 - Ben Malcom: The Spirit Pharmacist This all new episode of the Psychedelics Then and Now Podcast features an all new interview with the ever wise and important Ben Malcom, The Spirit Pharmacist. Ben's knowledge of psychedelic compounds, drug interactions, safe use and pharmacological histories holds a unique place in today's psychedelic culture. His welcoming approach to very complicated topics really sets him apart from other scientific luminaries. Our conversation illuminated so many nooks and crannies within this ever expanding knowledge base. Also, the intro brings classic 1977 Ram Dass's take on cognitive liberty and consciousness exploration. (Thank you to the Love Serve Remember Foundation) About Ben Malcom I envision a society in which access to psychedelic drugs in a variety of safe settings is available for purposes of psychospiritual well-being, personal development, ceremonial sacraments, and treatment of mental illness. I strive to let my loves and passions guide my activity and provide the canvas my life is painted on. I hope this site can be of service to my vision as well as you. Professionally, I was trained as a clinical psychiatric pharmacist and worked in academia for almost five years before dedicating myself to Spirit Pharmacist. Today I provide psychopharmacology consulting, courses in psychedelic pharmacy, and a Member Resource and Support Program. On a more personal note, I'm a lover of nature, exercise, music, and consciousness as well as being a father. I'm passionate about cognitive liberty, self-realization, and psychedelic drugs.

Bailey presents with a history of osteoarthritis and hypertension and is referred to physical therapy for knee pain management. She reports taking over-the-counter medication daily for pain relief. During the session, she mentions experiencing mild stomach discomfort and occasional dizziness. Her blood pressure is 138/86 mmHg. Which medication is MOST likely contributing to the patient's symptoms?A) AcetaminophenB) IbuprofenC) Calcium-channel blockerD) Glucosamine supplementDOWNLOAD THIS EPISODE'S CHEATSHEET:www.nptecheatsheet.com/common-med

Michael Barry, Adjunct Associate Professor, Pharmacology & Therapeutics and Clinical Director National Centre for Pharmacoeconomics, outlines how much pharmaceutical companies are paying out to healthcare professionals and organisations.

SAT's getting shorter to match diminished attention spans of college applicants; Comprehensive review finds most of the studies on which we base our most accepted drugs and medical therapies are flawed; A heart drug approved in 2011 and used by millions comes under renewed scrutiny due to research irregularities; Best supplements for preventing osteoporosis; Tremors after Covid shot; Researchers discover how exercise lowers Alzheimer's risk; Two new studies show exercise curbs cancer recurrence.

Send us a textWrapping up Season 11, Cara and Missi dig deep into their fan mail bag to answer questions from listeners spanning clinical practice, education, and professional development. With their characteristic warmth and wisdom, they tackle everything from postpartum mental health screening to specialized pharmacology knowledge that you won't find in textbooks.The conversation flows through practical clinical topics, starting with the importance of comprehensive mental health screening for postpartum patients.  They share touching feedback from colleagues about creating supportive collaborative practices with physicians, highlighting how direct, respectful communication builds successful interprofessional relationships.For students and new midwives, the hosts offer a treasure trove of specialized resources. They offer insights to suturing resources, discuss scope of practice questions, and answer questions galore. Pharmacology pearls abound as they discuss innovative approaches to breakthrough bleeding, the exact formulation for All-Purpose Nipple Ointment for treating breast yeast infections, and compounded antiemetic gels for pregnancy nausea.Before previewing exciting topics for Season 12—including ovarian masses, cancer screening, osteoporosis, fertility treatments, and AI in midwifery—Cara and Missi remind listeners of the best ways to reach them with questions. Their generosity in sharing expertise and resources demonstrates why this podcast has become such a valuable companion for midwives at every career stage.Email your questions directly to missi@deliveredexamprep.com or cara@deliveredexamprep.com to become part of future episodes, and visit deliveredexamprep.com to access the resources mentioned throughout this knowledge-packed finale.

Lotrisone is a topical cream that contains a combination of clotrimazole, an antifungal, and betamethasone dipropionate, a corticosteroid. It is used to treat fungal skin infections such as athlete's foot, jock itch, and ringworm that also involve inflammation or itching. Clotrimazole works by disrupting the fungal cell membrane, while betamethasone reduces redness, swelling, and itching. Lotrisone should not be used on the face, groin, or underarms for extended periods due to the risk of skin thinning and other steroid-related side effects.

On this episode, we evaluate current guidelines and evidence-based strategies for managing chronic pain, including both pharmacologic and non-pharmacologic options. We compare and contrast the efficacy, safety profiles, and appropriate use of various analgesic classes and adjuvant therapies in chronic pain management. Cole and I are happy to share that our listeners can claim ACPE-accredited continuing education for listening to this podcast episode! We have continued to partner with freeCE.com to provide listeners with the opportunity to claim 1-hour of continuing education credit for select episodes. For existing Unlimited (Gold) freeCE members, this CE option is included in your membership benefits at no additional cost! A password, which will be given at some point during this episode, is required to access the post-activity test. To earn credit for this episode, visit the following link below to go to freeCE's website: https://www.freece.com/ If you're not currently a freeCE member, we definitely suggest you explore all the benefits of their Unlimited Membership on their website and earn CE for listening to this podcast. Thanks for listening! If you want to support the podcast, check out our Patreon account. Subscribers will have access to all previous and new pharmacotherapy lectures as well as downloadable PowerPoint slides for each lecture. If you purchase an annual membership, you'll also get a free digital copy of High-Powered Medicine 3rd edition by Dr. Alex Poppen, PharmD. HPM is a book/website database of summaries for over 150 landmark clinical trials.You can visit our Patreon page at the website below:  www.patreon.com/corconsultrx We want to give a big thanks to Dr. Alex Poppen, PharmD and High-Powered Medicine for sponsoring the podcast..  You can get a copy of HPM at the links below:  Purchase a subscription or PDF copy - https://highpoweredmedicine.com/ Purchase the paperback and hardcover - Barnes and Noble website We want to say thank you to our sponsor, Pyrls. Try out their drug information app today. Visit the website below for a free trial: www.pyrls.com/corconsultrx We also want to thank our sponsor Freed AI. Freed is an AI scribe that listens, prepares your SOAP notes, and writes patient instructions. Charting is done before your patient walks out of the room. You can try 10 notes for free and after that it only costs $99/month. Visit the website below for more information: https://www.getfreed.ai/  If you have any questions for Cole or me, reach out to us via e-mail: Mike - mcorvino@corconsultrx.com Cole - cswanson@corconsultrx.com

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

AABP Executive Director Dr. Fred Gingrich is joined by Dr. Sarah Wager, Professor of Pharmacology and Assistant Dean at Texas Tech University College of Veterinary Medicine. Wagner is the principal investigator for a survey of bovine veterinarians and the results of this research were published in the AABP peer-reviewed journal The Bovine Practitioner.  This episode of Have You Herd? is sponsored by Boehringer Ingelheim. Bacteria can strike udders from any angle. The dairy health portfolio that rises to the challenge is Mastitis 360 by Boehringer Ingelheim. It offers powerful solutions for lactation through dry-off. So, manage udder health with the ultimate tools at your disposal. Because you're more than a veterinarian. You're... a hero of the herd. For more information, visit this link. The objectives of this study were to find out what bovine veterinarians earn, what factors affect incomes, and what factors affect job satisfaction. Out of 900 respondents, 600 were private practitioners and this paper provides the results from the private practitioner responses working 40 or more hours per week. The overall mean income reported was $150,000 per year and the median income was $120,000 per year with a range of $40,000 to $1,000,000. Sixty-two percent of respondents were compensated via salary only, 25% were a mix of salary and production, and 6% were production only. Factors that are positively associated with increased income include years since graduation, prac­tice ownership, type-exclusive practice (beef or dairy only), and a production-based compensation structure. Wagner discusses the gender disparity in salary with women reporting lower earnings than men for all graduation year decades. We also discuss the interaction between practice ownership, gender and pay structure. The only situation where women earned the same as men were when they were compensated on a production basis vs. straight salary basis.  Wagner also reports drivers of job satisfaction. Income transparency is positively associated with job satisfaction, while being on call and working increased hours are nega­tively associated with job satisfaction.  It has been reported that only 17% of private sector jobs (vs. 80% of public sector) have income transparency. In this study, 55% of respondents were aware of how much other veterinarians at their workplace were paid. Only 10% of respondents reported leaving a job primarily due to income.  To find out more information about the AABP Veterinary Practice Sustainability Committee, visit this page. AABP members can view the presentation from Dr. Wagner at the 2023 AABP Conference in Milwaukee by going to the online CE portal found here.  Incomes and satisfaction among bovine focused veterinary practitioners in the United States and Canada. (2025). The Bovine Practitioner, 59(2), 17-25. https://doi.org/10.21423/bpj20259256

⚡Gatekeepers of Strength: Allopurinol, Calcium & the RyR Revolution”!   Did you know that an old gout drug might hold the key to reversing age-related muscle weakness and heart failure? Using cryo-EM, researchers found that allopurinol and xanthine derivatives directly activate ryanodine receptors—calcium channels essential for muscle contraction.  

Fluphenazine is a high-potency typical antipsychotic that primarily acts as a dopamine D2 receptor antagonist in the mesolimbic pathway, reducing positive symptoms of schizophrenia. Extrapyramidal symptoms (EPS), such as dystonia, akathisia, and parkinsonism, are common due to potent D2 blockade in the nigrostriatal pathway. Neuroleptic malignant syndrome (NMS), though rare, is a life-threatening adverse effect characterized by rigidity, hyperthermia, altered mental status, and autonomic instability. CYP2D6 inhibitors (e.g., fluoxetine, paroxetine) can increase fluphenazine plasma concentrations, potentially raising the risk of toxicity and side effects. Concomitant use of fluphenazine with CNS depressants (e.g., alcohol, benzodiazepines) can enhance sedation and respiratory depression.

JCO PO author Dr. Philip Philip at Henry Ford Cancer Institute and Wayne State University shares insights into his JCO PO article, “Incorporating Circulating Tumor DNA Testing Into Clinical Trials: A Position Paper by the National Cancer Institute GI Oncology Circulating Tumor DNA Working Group.” Host Dr. Rafeh Naqash and Dr. Philip discuss how prospective trials are required to clarify the role of ctDNA as a valid surrogate end point for progression-free or overall survival in GI cancers. Transcript Dr. Rafeh Naqash: Hello and welcome to JCO Precision Oncology Conversations, where we bring you engaging conversations with authors of clinically relevant and highly significant JCO PO articles. I'm your host, Dr. Rafeh Naqash, Podcast Editor for JCO Precision Oncology and Assistant Professor at the OU Health Stephenson Cancer Center at the University of Oklahoma. Today, we are excited to be joined by Dr. Philip Philip, Chair of Hematology and Oncology, as well as leader of GI and Neuroendocrine Oncology. He's also the Professor of Oncology and Pharmacology, as well as Co-Leader of the Pancreatic Cancer Program and Medical Director of the Cancer Clinical Trial and Translational Research Office at the Henry Ford Cancer Institute at Wayne State University. Dr. Philip is also the Senior Corresponding Author of the JCO Precision Oncology article entitled, "Incorporating Circulating Tumor DNA Testing into Clinical Trials: A Position Paper by the National Cancer Institute GI Oncology Circulating Tumor DNA Working Group." At the time of this recording, our guest's disclosures will be linked in the transcript. Dr. Philip, welcome to our podcast, and thank you so much for joining us today. Dr. Philip Philip: Thank you so much, Dr. Naqash, for providing me this opportunity to be discussing this with you. Dr. Rafeh Naqash: This is a very timely and interesting topic. We've done a couple of podcasts on ctDNA before, but none that is an opinion piece or a guidance piece based on what you guys have done. Could you tell us what led to this perspective piece or guidance manuscript being published? There is some background to this. Could you tell us, for the sake of our listeners, what was the initial thought process of why you all wanted to do this? Dr. Philip Philip: The major reason for this was the fact that investigators were considering using ctDNA as a primary endpoint in clinical trials. Obviously, you hear my focus will be on gastrointestinal cancers. So, the idea was, can we use ctDNA instead of using the traditional endpoints such as disease-free survival, progression-free survival, or overall survival? And the question was, do we have enough data to support that in patients with gastrointestinal cancers? Now, the article obviously goes over some review of the data available, but the core of the article was not to do a comprehensive review of ctDNA use and the evidence so far, although we used that in really putting our recommendations. So, we really had to evaluate available data. But the focus was, what are the gaps? What do we need to do? And are we ready to use ctDNA as a primary endpoint in clinical trials? Dr. Rafeh Naqash: Thank you for giving us that background. Obviously, a very broad, complicated topic with a bunch of emerging data that you've highlighted. But most importantly, for the sake of, again, trainees and listeners, could you help us understand the difference between tumor-informed and non-tumor-based ctDNA assessments? Dr. Philip Philip: Sure. So, the tumor-informed is simply meaning that you're taking the genomic makeup or the DNA fingerprint of the cancer in a given patient, and you create a profile, and then use that profile to see whether that DNA is present in the blood. So, it's very simple. It's like barcoding DNA and then going and looking for it in the blood, which means that you have to have the primary tumor. When I say primary tumor, you need to have the tumor to start off with. It doesn't really apply, maybe easily, if you just have a fine-needle aspirate and things like that. So, you really have to have a good amount of the tumor for you to be able to do that. So, that's a tumor-informed, and from the name, you can easily understand how it's done, compared to the other one, which is uninformed, whereby off-the-shelf probes are used to look for tumor DNA. And again, they're based on prior experience and prior identification of the key DNA changes that will be seen in tumors. So, that's the difference between the two in terms of the principle of the test. The uninformed will not require you to send the original tumor that you're trying to test. However, the informed, you do. The turnaround time is, again, a bit different because, as you would expect, it's shorter in the uninformed. And the reason for that, again, is the initial preparation of the profile that is going to be used in the future when you do serial testing. The sensitivity has been a bit of a discussion. Initially, people have thought that tumor-informed assays are more sensitive, more specific, more sensitive, et cetera. But in our review, we come to the conclusion saying that we don't think that's going to be a major difference. And there are obviously improvements happening in both types of assays. The sensitivities have been improving. So, at this point in time, we do feel that you have two types of assays, and we didn't feel strongly about recommending one over the other. Dr. Rafeh Naqash: Thank you for that description. You mentioned something about sensitivity, specificity. Obviously, many of us who have ordered both tumor-informed and tumor-uninformed, we understand the differences with respect to the timing. The tumor-informed one can take more time. The uninformed one, being a sort of a liquid biopsy, may not necessarily have as much of a turnaround time. Could you briefly speak to those limitations or advantages in the context of the two versions? Dr. Philip Philip: I just really want to also highlight that when we say turnaround time, so for the tumor-informed assays, the first assay that we do will be requiring a turnaround time. But once the pattern has been set and the profile has been documented, the subsequent testing doesn't require much in the way of waiting. However, when you're using this for the minimal residual disease, then you have a window of opportunity to work at. That's number one. So, it means that in patients who have resected cancer, you may end up having to wait longer than the tumor-uninformed assay, especially if you don't have easy access to your material for the baseline material to send. And also, what we'd like to do is not do the test immediately after the operation or soon after the operation. Give it some time. There's a window where you can work at, and starting minimally two weeks after the surgery. But in my experience, I'd like to wait at least four weeks just to make sure that we got an accurate reading. Sometimes when you do it very early after surgery, because of the effect of the surgery and the release of the normal DNA is also, it may dilute the tumor DNA, and then you may get a false negative. So, basically, it depends on the clinical situation. And your question is, is one better to be used than the other? I think ultimately, it ends up with the turnaround time not being as much of an issue. It might be in certain situations, depending on when you see the patients after the operation or any definitive treatment you've done and you want to look for minimal residual disease. But in general, I don't think that's going to be a real major issue. Dr. Rafeh Naqash: I remember discussing this with one of the tumor-informed platforms with regards to this barcode you mentioned. They generate a fingerprint of sorts for the tumor on the tissue, then they map it out in the blood and try to assess it longitudinally. And one of the questions and discussions we had was around the fact that most of the time, these barcoded genes are not the driver genes. If you have a KRAS mutant tumor, it's not going to be the KRAS gene that they map out. It's something that is specific. So, is there a possibility that when you are mapping out, let's say, a metastatic tumor where there is truncal and subclonal mutations at different sites, that you capture something that is not necessarily truncal, and that does not necessarily reflect some other metastatic site having a recurrence? So basically, over time, you don't see a specific mutational pattern or the signature on the tumor-informed, and then you see something on the scan which makes you think, "Well, it was not the right test," but actually it could be a different subclone or a clone mutation at a different site. Is there a concept that could help us understand that better? Dr. Philip Philip: I think you raise a very important point. Although, I have to say from my practical experience, that is not a common thing to see. In fact, for some reason, we don't see it that often in any frequency that should, at this point in time, make us concerned about the serial testing. But what you were mentioning is a real challenge which can happen. Now, the question is, how often does the clonal evolution or the divergence happen to the point that it's going to be like a false negative, is what you're saying. At this point in time, we don't really have good information on that, or any good information, practical information. And when we went through the literature and we were looking for the evidence, that wasn't something which was there clearly telling us. Although, this is something that has to be studied further prospectively. And I don't know of a study, but I might be missing it, I don't know of a study which is systematically looking at this. Although it's a very valid hypothesis and theoretical basis for it, but in real life, we still have to see how much does it really interfere with the validity of this kind of testing. Dr. Rafeh Naqash: Which brings us to the more important discussion around your manuscript. And I think that the overarching theme here is the consensus panel that you guys had recommended that ctDNA-based metrics be used as a co-primary endpoint. Could you tell us, for early-phase trials, maybe phase two studies for that matter, could you tell us what were some of the aspects that led to this consensus being formed from your working group? Dr. Philip Philip: Well, there were a number of reasons, in any order of priority, but one of them is we don't have a good sense of dynamics of the ctDNA. And again, remember this article was about gastrointestinal cancers. Maybe we know more about colon cancer, but, or colorectal cancer, but we don't know that well about the upper GI, like gastroesophageal, pancreatic, et cetera. So, we don't know what is the false negative percentages. And in fact, we know that there are certain sites of the disease, metastases, that do not lead to enough shedding of the DNA into the circulation. So, that was something else. I mean, false negativity, not knowing exactly what the dynamics are, especially in different disease types. So, that was another reason, which we felt that it may not be at this time primetime to really have those ctDNA tests as a primary endpoint. We wanted to make sure that, on the other hand, we wanted to make sure that people consider including ctDNA more like a secondary endpoint so that we can gain the information that we're lacking, at least the ones I mentioned to you. So, that was an important point of our discussions and deliberations when we were writing the article. Dr. Rafeh Naqash: And I myself have been on both sides of the aisle where - I treat people with lung cancer, you mentioned appropriately that most of the data that we have for ctDNA is generated from GI cancers, especially colorectal - on the lung cancer side, I myself had a patient with an early-stage cancer, had treatment, surgery, immunotherapy, and then had ctDNA that was tumor-informed, was positive four to five months before the imaging actually showed up. And on the other side, I've also had an individual where early-stage lung cancer, surgery, immunotherapy, and then had PET scans that showed a positive finding, but the ctDNA, tumor-informed ctDNA, was negative multiple times. So, I've seen both aspects of it, and your paper tries to address some of these questions on how to approach a negative, radiologically negative imaging but positive ctDNA potentially, and vice versa. Could you elaborate upon that a little bit? Dr. Philip Philip: Well, obviously, we do see this in practice. Again, I do GI oncology. I have patients who, you do ctDNA. I mean, my advice to anyone, when you order a test, you have to make sure that you know what you're going to do with the test, because that's the most important thing. You get a positive test, you do something. You get a negative test, you do something. But most importantly, our patients who you're following up, they are very anxious for a diagnosis they have that is not- I mean, it's cancer. If you're doing these tests, if we get continuous, repeatedly negative testing, then you really have to also tell the patient that there's a false negativity. And I mentioned to you earlier, there are certain sites of disease, like peritoneal, they may not be producing enough, or there are some tumors, their biology is such that they don't release as much to be detected in the blood. Now, one day we will get maybe a more sensitive test, but I'm talking about the tests we have now. On the other hand, if you get a positive testing, you have to make a distinction for ctDNA in the minimal residual disease situation. If you get a positive test, there is enough evidence that the patient has a worse prognosis. There's evidence for that. No one can dispute that. Again, I'm talking about colorectal cancer where there are a lot of data for that. So, in that situation, there are studies that are looking, if you get a positive test in someone who you're not intending to give any adjuvant treatment, there are studies looking into that, both in terms of intensifying, like chemotherapy, in certain patients. And also, there's work being done, if you have a negative test in someone who has stage III disease, for example, or definitely stage II disease, they may not need to give them chemo. Those things are happening. But in metastatic disease, it's a different situation. Or even in someone who has received surgery, adjuvant chemotherapy, in those patients where they, whether they're now under, in the surveillance mode, those patients, if you have a positive, it may be positive. I had a recent patient like those, eight months before we saw anything on the scans. So, the question is, if you have a positive test, is there any advantage in giving them treatment, systemic treatment? Of course, we're assuming that the PET scan is negative. So, is there really any advantage in giving someone treatment ahead of time, before you see the imaging changes? That kind of data, in my opinion, is not really available or strong. You can always think of it in different ways, explain it in different ways. It's minimal disease, maybe you get a better response. But I don't know if we really can justify at this time. Therefore, in my practice, my own practice, I do not treat just a positive ctDNA. Again, that's different than after surgery when you're thinking of whether to give adjuvant treatment, no adjuvant treatment. But someone who's finished treatments and then you're just serially monitoring the disease, those patients, I do not treat them with chemotherapy. And that was something which, based on the literature we reviewed, there was nothing out there to definitely- I mean, if you see something positive, you will do a scan earlier, you will talk to the patient, examine the patient, whatever. But if there's nothing there, starting a treatment, that's not justified at this point in time. Now, you need to do a study like that. Definitely, you need to do a study. But I can tell you that from my experience, having been involved with study design and all that, it's not an easy trial to do. It's going to be a trial- at a minimum, it will take many patients, it will take longer time to complete, and there are a number of variables there. If someone is willing to put a lot of money into it, it can be done. But I can tell you that that kind of intention to do a study like that has been very much a challenge at this time. Dr. Rafeh Naqash: Of course, as you mentioned, the follow-up time that you need for a study like that is going to be very long to get to meaningful outcomes. Dr. Philip Philip: You need to be very patient to do such a study. But the problem with a very long study is that things change, standard of care changes with time, and the assays will change. So, that's why we don't have that kind of data. I'm not sure if there are people in the community or in the academic centers who do treat based on only positive ctDNA. The other thing is that you really have to always consider the psychological impact of these tests on patients and caregivers. Sometimes it can be really very stressful, burdensome to people to sit there just waiting for the disease to show up on a scan. And therefore, in my opinion, I'm not saying definitely don't use it in that situation, I'm just saying that you have to personalize it also, to see the patient who you would like to do it and then other patients who may not do it, or you think that it's not good for them to do it. And the patient also has to understand the outcome of the test and how you're going to be interpreting it. Dr. Rafeh Naqash: That's a lot of great insights, Dr. Philip, and I know you've been involved in trial designs. I'm sure NCT and cooperative groups are actively thinking and incorporating ctDNA-based metrics as one of the endpoints in their trial. I know of a GU study that's, I think it's an Alliance study, trying to de-escalate treatment based on ctDNA. I have one of my colleagues who's also a GU investigator at OU, he's doing a ctDNA-based, tumor-informed-based de-escalation. So, obviously, more and more data, hopefully, that'll be generated in the next couple of years. Dr. Philip Philip: But remember, these studies are not using it as an endpoint. They're using it as a means of optimizing treatment, which is a bit different. So, as an endpoint, can you do a phase III trial of, let's say, a thousand patients, and your primary endpoint is not survival, but you're saying, "Can I reduce the ctDNA, clear it earlier, or whatever?" That's the sort of thing this article was about. We can't do that at this time. Dr. Rafeh Naqash: I totally understand. Thank you for explaining the difference, and hopefully more to come in this space in the next couple of years. I briefly wanted to touch upon your personal career and journey based on all that you've done and accomplished. Could you tell us about how you started, what your journey has been like, and how that connects with what you're doing right now, including mentoring other trainees and junior faculty? Dr. Philip Philip: Well, when I was in high school, I wanted to be an engineer, but I grew up in Baghdad, and all my friends wanted to do medicine, so I went with the tide, so I did medicine. I don't regret that. I would do it again if I had the opportunity. The reason why I did oncology was, I left the country and did a PhD in clinical pharmacology at the University of London. And that really got me, it was a topic which included, which was on cancer. So, I really got interested in a disease that is really a lot of science, and things are new, or were new at the time. And if I want to look back what I was doing, the beginning of my training in the 80s, second half of the 80s, and now, it's unbelievable how things have changed. But one of the things which I really have to say is that almost all my life I've been in what we call academic institutions. But I firmly believe that for people, whether academic or not, you have to be a very good, astute clinician, because many of the things we do, really, we're trying to put the patients in the center. It's not only doing fancy science, it's to do things that help the patients. And you can bring in bits and pieces of fancy science or less fancy science, but that's something which is really extremely important for us to think about, being a very good clinician, very good doctor, because medicine is a science, whether you're practicing as a solo practitioner or you're part of a large academic center. It's the way you think, the way you interrogate things that you're not sure of, the way you collaborate, the way you learn every day. I mean, at my age, I still don't like to miss any tumor board, because in each tumor board, there's something you learn, even if you think that you know everything. So, that's really the whole thing of it, is that be a very good clinician, be open-minded. Always, you have to think of things that, they look interesting, they look somehow unexplained. Always try to help find the solutions and do that. One of the major things that I feel that people should do is being also very focused on things. I mean, you have to also know what you want to do in the next 5, 10, 15 years. Because although everyone is in it in the same way when we start, but there are different things that drive people, people who want to do more of the formal research, like being an academic-like institution. But there are also a lot of people who are very successful outside of a- what we call an academic setting. In the United States, most people are not working in an academic kind of setting. Although, for me, the distinction between academic and community is getting less and less, because if you think that you do phase I trials in academia only, that's not true, because there are, in fact, in the state of Michigan, the most active phase I doctor is not even in academia, he's in private practice. So, you can do all these things. It's a matter of what you like to do, and you really have to make sure you know what you want to do. Because sometimes people are, especially early on, they get a bit confused, “What I want to do.” There's an issue of doing general oncology versus subspecialist. If you're a subspecialist doing only GI, you have to make sure that you really also have some kind of recognition that you're only a GI oncologist, recognition regional, national, international, but some degree of recognition that you feel that people are coming to you for advice as a second opinion or whatever it is. But again, you have to decide what you think you want to be, how you want to be, because there's a lot of options here between community practice, academic practice, industry, and of course, there's always the administrative thing. Some people tend to be more like going into the line of being an administrator. So, there's a lot of options for you. Dr. Rafeh Naqash: Well, thank you again, Dr. Philip, for those pearls of wisdom. I think that was very insightful. I'm sure all the trainees and early-career investigators will find all that advice very helpful. Thank you again for joining us today. Thank you for listening to JCO Precision Oncology Conversations. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all ASCO shows at asco.org/podcast. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Dr. Philip Philip Disclosures Honoraria: Bayer, Ipsen, incyte, Taiho Pharmaceutical, Astellas Pharma, BioNTech SE, Novocure, TriSalus Life Sciences, SERVIER, Seagen Consulting or Advisory Role: Celgene, Ipsen, Merck, TriSalus Life Sciences, Daiichi Sankyo, SynCoreBio, Taiho Pharmaceutical Speakers' Bureau: Incyte Research Funding: Bayer (Inst), incyte (Inst), Merck (Inst), Taiho Pharmaceutical (Inst), novartis (Inst), Regeneron (Inst), Genentech (Inst), halozyme (Inst), Lilly (Inst), Taiho Pharmaceutical (Inst), merus (Inst), BioNTech SE (Inst) Uncompensated Relationships: Rafael Pharmaceuticals, Caris MPI  

Episode 367: Pharmacology 101: PARP Inhibitors “We know that in cells that are proliferating very quickly, including cancer cells, single-strand DNA breaks are very common. When that happens, these breaks are often repaired by the PARP enzyme, and the cells can continue their replication process. If we block PARP, that repair cannot happen. So in blocking that, these single-strand breaks then lead to double-strand breaks, which ultimately is leading to cell apoptosis,” Danielle Roman, PharmD, BCOP, manager of clinical pharmacy services at the Allegheny Health Network Cancer Institute in Pittsburgh, PA, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a conversation about the PARP inhibitor drug class. Music Credit: “Fireflies and Stardust” by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0  Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by June 13, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: Learners will report an increase in knowledge related to the use of PARP inhibitors in cancer care. Episode Notes  Complete this evaluation for free NCPD.  ONS Podcast™ episodes: Pharmacology 101 series Episode 330: Stay Up to Date on Safe Handling of Hazardous Drugs Episode 232: Managing Fatigue During PARP Inhibitor Maintenance Therapy Episode 227: Biomarker Testing, PARP Inhibitors, and Oral Adherence During Ovarian Cancer Maintenance Therapy ONS Voice articles: PARP Inhibitors and Ovarian Cancer Genomics May Trick PARP Inhibitors to Treat More Cancers Oncology Drug Reference Sheet: Niraparib ONS books: Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (second edition) Clinical Guide to Antineoplastic Therapy: A Chemotherapy Handbook (fourth edition) Safe Handling of Hazardous Drugs (fourth edition) ONS courses: Safe Handling Basics Clinical Journal of Oncology Nursing articles: PARP Inhibition: Genomics-Informed Care for Patients With Malignancies Driven by BRCA1/BRCA2 Pathogenic Variants Talazoparib Plus Enzalutamide in Patients With HRR-Deficient mCRPC: Practical Implementation Steps for Oncology Nurses and Advanced Practice Providers Oncology Nursing Forum article: Familiarity and Perceptions of Ovarian Cancer Biomarker Testing and Targeted Therapy: A Survey of Oncology Nurses in the United States Oral Anticancer Medication Care Compass: Resources for Interprofessional Navigation ONS Biomarker Database ONS Oral Anticancer Medication Learning Library ONS Oral Anticancer Medication Toolkit Oral Chemotherapy Education Sheets To discuss the information in this episode with other oncology nurses, visit the ONS Communities. To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library. To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org. Highlights From This Episode “The big toxicities here to watch for are primarily hematologic toxicities. It is one of those targeted therapies that does affect blood cell counts. So I'd say the blood cell count that is most commonly affected here is the hemoglobin. So, anemia very frequent complication that we see, probably a little bit more with olaparib compared with other drugs, but we see it as a class side effect. And we can also see neutropenia and thrombocytopenia with these agents, probably a little bit more with niraparib versus the others, but again, you can see it across all of these drugs.” TS 8:16 “We mentioned that rare risk of MDS and AML. This isn't a particularly scary thing if you talk to patients about it. Because of the rarity that we see this, it isn't something that we need to overemphasize, but I think careful monitoring of blood counts in is stressing the importance of that and early intervention here is very important.” TS 16:55 “This is a collaborative effort. And because of the home administration here, these patients do need to be followed very closely. So we are not laying eyes on them usually with the frequency that we do when we have patients actually coming into our infusion centers for treatments—so making sure that there is a plan for regular follow-up with these patients to ensure that they're getting that lab work done, that that's being looked at closely, that we're adjusting the dose if we need to based on that lab work, that we are managing the patient's fatigue. Again, that potentially dose reductions may be needed if patients are having that extreme fatigue.” TS 19:34 “I think one of those [misconceptions] could be that they're only effective in patients that have that BRCA1/2 mutation. And again, remember here that there is some data in particular disease states that we can use them and that they work in the absence of those mutations.” TS 25:12

Every other week I'm republishing one of my most popular or impactful episodes and adding an update, new insight, or context that will help you benefit from it even more. This week I'm highlighting Episode 116, which is all about pediatric pharmacology. When you understand these key foundation concepts, the whole subject of pharm gets a whole lot easier. Enjoy! As cute and adorable as they are, kids are not just tiny adults. Especially when it comes to pharmacology. The way kids absorb, distribute, metabolize and excrete drugs varies greatly, making pediatric pharmacology a truly unique subject.  If you're heading into your pediatric rotation or starting out as a new pediatric RN, then pop in those earbuds. I'll talk you through the key things you need to know to utilize medications safely in this very special and vulnerable population.  ___________________ ⁠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! ⁠Dosage Calculations Guide⁠ - Kick math anxiety to the curb and learn the basics of how to set up and perform dosage calculations using dimensional analysis with this FREE guide. Includes 10 free practice questions! ⁠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! ⁠Straight A Nursing App⁠ - Study on-the-go with the Straight A Nursing app! Review more than 5,000 flashcards covering a wide range of subjects including Fundamentals, Pediatrics, Med Surg, Mental Health, Maternal Newborn, and more! Available for free in the Apple App Store and Google Play Store.

On this podcast episode, I discuss quinapril pharmacology, adverse effects, drug interactions, pharmacokinetics, and much more. Quinapril is a prodrug that is converted in the liver to its active metabolite, quinaprilat, which inhibits ACE, leading to decreased formation of angiotensin II and reduced aldosterone secretion. Hyperkalemia can occur with quinapril use due to decreased aldosterone, leading to potassium retention—especially in patients with renal impairment. Concomitant use of potassium-sparing diuretics or potassium supplements with quinapril increases the risk of hyperkalemia. NSAIDs may reduce the antihypertensive effect of quinapril and increase the risk of nephrotoxicity, especially in patients with preexisting renal dysfunction.

GLP-1 receptor agonists have changed the landscape of obesity treatment, offering levels of weight loss once thought unattainable without surgery. But what happens after the weight is lost? And can we really talk about success without talking about maintenance? While much of the public discourse fixates on dramatic weight loss numbers, the harder question is what comes next. Can lifestyle interventions alone sustain weight loss after GLP-1 cessation? How do metabolic adaptations and behavioral relapse factor in? And what does the data actually show about relapse rates, nutritional adequacy, and lean mass preservation when using these medications? In this episode, Danny sits down with Tara Schmidt, dietitian at the Mayo Clinic, to examine the intersection of pharmacology and behavior in long-term weight management. Tara Schmidt is a registered dietitian and an instructor of nutrition at Mayo Clinic. As the lead dietitian for the Mayo Clinic Diet, she provides guidance rooted in evidence-based principles. She hosts the Mayo Clinic On Nutrition podcast and co-authored The Mayo Clinic Diet: Weight Loss Medications Edition. Timestamps [05:17] Understanding weight loss maintenance [08:44] Defining success in weight loss maintenance [11:54] Predictors of maintenance: self-monitoring and behavioral strategies [23:37] Pharmacological interventions: GLP-1 receptor agonists [31:06] Dietary considerations for those taking GLP-1 RAs [37:07] Addressing misconceptions about weight loss drugs [42:48] Final thoughts and takeaways [48:49] Key ideas (Premium-only) Links/Resources Subscribe to Sigma Nutrition Premium Go to episode page Join the Sigma email newsletter for free Enroll in the next cohort of our Applied Nutrition Literacy course Visit sigmanutrition.com

Behavioral Health Integration in Pediatric Care with Dr. Nelson BrancoIn this episode of The Pediatric Lounge, hosts George and Herb are joined by Dr. Nelson Branco, a general pediatrician with a strong commitment to behavioral health and community care, to discuss the future of healthcare and the integration of behavioral health into pediatric medical homes. Dr. Branco shares his journey in pediatrics, his experience working with underserved populations, and the steps his practice took to integrate behavioral health services. The conversation covers the challenges and benefits of behavioral health integration, the importance of collaboration with therapists and psychiatrists, and strategies for managing financial sustainability. The episode also delves into the impact of mental health on pediatricians' burnout and the evolving role of pediatric care in addressing behavioral health concerns.00:00 Introduction to The Pediatric Lounge00:36 Meet Dr. Nelson Branco01:16 Dr. Bronco's Journey to Pediatrics03:00 Behavioral Health Integration in Pediatrics03:54 Building a Behavioral Health Team05:32 Challenges and Realities of Behavioral Health07:26 Innovative Solutions and Collaborations10:17 The Evolution of Pediatric Care25:24 Pharmacology and Changing Practices28:56 Training and Preparedness for Physicians29:39 Virginia Mental Access Program and Project Echo30:34 Challenges in Child Psychiatry31:21 Primary Care Mental Health Experience36:49 Operations and Management in Pediatric Practices42:16 Behavioral Health Integration and Financial Sustainability45:11 Burnout and Mental Health in Pediatricians52:51 Historical Perspective on Pediatric Practice55:18 Preventative Behavioral Health and ConclusionDr. Branco has kindly shared his folder on Mental Health in Pediatrics, which is an incredible resource: https://bit.ly/BHIshared.Support the show

Nifedipine is a dihydropyridine calcium channel blocker that selectively inhibits L-type calcium channels in vascular smooth muscle, leading to vasodilation and reduced peripheral vascular resistance. The extended-release formulation of nifedipine provides more stable plasma concentrations and is preferred for chronic management of hypertension and angina. Common adverse effects include headache, flushing, peripheral edema, and dizziness, all related to its vasodilatory action. Nifedipine undergoes extensive first-pass metabolism in the liver, primarily via CYP3A4 enzymes, which significantly influences its bioavailability and potential drug interactions. CYP3A4 inhibitors (e.g., ketoconazole, erythromycin, grapefruit juice) can increase plasma levels of nifedipine, raising the risk of hypotension and adverse effects.

On this episode, we evaluate current guidelines and evidence-based treatment strategies for managing GAD. We define generalized anxiety disorder (GAD) and describe its clinical presentations, diagnostic criteria, and underlying pathophysiology. We also compare and contrast the efficacy, safety profiles, and appropriate use of anxiolytic medications, cognitive behavioral therapy, and lifestyle modifications in treating GAD. Dr. David Osser's Website: https://psychopharm.mobi/algo_live/ Cole and I are happy to share that our listeners can claim ACPE-accredited continuing education for listening to this podcast episode! We have continued to partner with freeCE.com to provide listeners with the opportunity to claim 1-hour of continuing education credit for select episodes. For existing Unlimited (Gold) freeCE members, this CE option is included in your membership benefits at no additional cost! A password, which will be given at some point during this episode, is required to access the post-activity test. To earn credit for this episode, visit the following link below to go to freeCE's website: https://www.freece.com/ If you're not currently a freeCE member, we definitely suggest you explore all the benefits of their Unlimited Membership on their website and earn CE for listening to this podcast. Thanks for listening! If you want to support the podcast, check out our Patreon account. Subscribers will have access to all previous and new pharmacotherapy lectures as well as downloadable PowerPoint slides for each lecture. If you purchase an annual membership, you'll also get a free digital copy of High-Powered Medicine 3rd edition by Dr. Alex Poppen, PharmD. HPM is a book/website database of summaries for over 150 landmark clinical trials.You can visit our Patreon page at the website below:  www.patreon.com/corconsultrx We want to give a big thanks to Dr. Alex Poppen, PharmD and High-Powered Medicine for sponsoring the podcast..  You can get a copy of HPM at the links below:  Purchase a subscription or PDF copy - https://highpoweredmedicine.com/ Purchase the paperback and hardcover - Barnes and Noble website We want to say thank you to our sponsor, Pyrls. Try out their drug information app today. Visit the website below for a free trial: www.pyrls.com/corconsultrx We also want to thank our sponsor Freed AI. Freed is an AI scribe that listens, prepares your SOAP notes, and writes patient instructions. Charting is done before your patient walks out of the room. You can try 10 notes for free and after that it only costs $99/month. Visit the website below for more information: https://www.getfreed.ai/  If you have any questions for Cole or me, reach out to us via e-mail: Mike - mcorvino@corconsultrx.com Cole - cswanson@corconsultrx.com

On this podcast episode, I discuss Clotrimazole pharmacology, adverse effects, indications, administration, and much more. Clotrimazole is an imidazole antifungal that exerts its pharmacological effect by inhibiting the synthesis of ergosterol, an essential component of fungal cell membranes. This inhibition compromises membrane integrity, leading to leakage of cellular contents and ultimately fungal cell death. Clotrimazole is primarily used topically due to poor systemic absorption when administered via the skin or mucous membranes, which limits systemic side effects. When clotrimazole is used intravaginally or orally in lozenge form, localized concentrations are sufficient to treat mucocutaneous infections without significant systemic exposure. Pay attention when clotrimazole is used frequently to treat Candida infections as corticosteroids, immunosuppression, and antibiotics may increase the risk of this type of infection.

Donate for chronic fatigue and long COVID research today. https://givenow.nova.edu/donations-for-chronic-fatigue-and-long-covid-research/?a=4951638  In this episode, Haylie Pomroy speaks with Dr. Theoharis Theoharides about the physiological consequences of stress on the body. They discuss how stress impacts the immune system, including its role in both anti-inflammatory and pro-inflammatory responses. Dr. Theoharides explains how mast cells are involved in the body's stress response, the symptoms of mast cell activation, and how to recognize if someone may be experiencing chronic issues. He also shares practical steps to identify when stress is not being managed well and highlights the importance of nutrition and lifestyle in recovery. Tune in to the Hope and Help for Fatigue and Chronic Illness Podcast – The Physiological Consequences of Chronic Stress Sign up for the COVID-UPP Study: https://redcap.nova.edu/redcap/surveys/?s=RMEDJ7LKCX&_gl=1*1h830h7*_gcl_au*MTM2NDA0MTQyOS4xNzE1MDA0ODAy If you are interested in joining a Gulf War Illness (GWI) trial, please complete the Recruitment Registry Form. https://redcap.nova.edu/redcap/surveys/?s=Y9YF8JJWJRK8HEKL%20&_gl=1*1fipp18*_gcl_aw*R0NMLjE3MDc5MTgwMzIuRUFJYUlRb2JDaE1JeWNyUXVfcXFoQU1WU1pCYUJSM3AyQWRBRUFBWUFTQUFFZ0s1NWZEX0J3RQ..*_gcl_au*MTg2NjgwMDQ4Ni4xNzA3MTQwNzgx  Learn more about INIM's Research Studies: https://www.nova.edu/nim/research-studies/index.html Read INIM's latest publication. https://pubmed.ncbi.nlm.nih.gov/40332133/ Dr. Theoharis Theoharides is Professor and Vice Chair of Clinical Immunology and Director at the Institute for Neuro-Immune Medicine–Clearwater. He is also Adjunct Professor of Immunology at Tufts School of Medicine, where he previously served as Professor of Pharmacology and Internal Medicine, and Director of Molecular Immunopharmacology & Drug Discovery. He earned multiple advanced degrees (BA, MS, MPhil, PhD, MD) from Yale University, received a Certificate in Global Leadership from Tufts Fletcher School, and completed a fellowship at Harvard Kennedy School. With over 485 publications and an h-index of 106, he ranks among the top 2% of most-cited researchers and was named the leading global expert on mast cells by Expertscape. His honors include induction into Alpha Omega Alpha, the Rare Diseases Hall of Fame, and the World Academy of Sciences. Website: https://www.drtheoharides.com  LinkedIn: linkedin.com/in/theoharis-theoharides-ms-phd-md-faaaai-67123735   Instagram: https://www.instagram.com/dr.theoharides Haylie Pomroy, Founder and CEO of The Haylie Pomroy Group, is a leading health strategist specializing in metabolism, weight loss, and integrative wellness. With over 25 years of experience, she has worked with top medical institutions and high-profile clients, developing targeted programs and supplements rooted in the "Food is Medicine" philosophy. Inspired by her own autoimmune journey, she combines expertise in nutrition, biochemistry, and patient advocacy to help others reclaim their health. She is a New York Times bestselling author of The Fast Metabolism Diet. Website: https://hayliepomroy.com/podcast Instagram: https://www.instagram.com/hayliepomroy  Facebook: https://www.facebook.com/hayliepomroy  LinkedIn: https://www.linkedin.com/in/hayliepomroy/  X: https://x.com/hayliepomroy  TikTok: https://tiktok.com/@hayliepomroy Enjoy our show? Please leave us a 5-star review so we can bring hope and help to others. Sign up today for our newsletter. https://nova.us4.list-manage.com/subscribe?u=419072c88a85f355f15ab1257&id=5e03a4de7d Learn more about the Institute here. Website: https://www.nova.edu/nim/ Facebook: https://www.facebook.com/InstituteForNeuroImmuneMedicine Instagram: https://www.instagram.com/NSU_INIM/ Twitter: https://www.twitter.com/NSU_INIM

Irbesartan is an angiotensin II receptor blocker (ARB) used primarily for the management of hypertension and diabetic nephropathy in type 2 diabetes. It selectively inhibits the binding of angiotensin II to the AT1 receptor found in vascular smooth muscle and the adrenal gland. This blockade results in vasodilation, reduced aldosterone secretion, decreased sodium and water retention, and ultimately lower blood pressure. Irbesartan is administered orally, with a typical starting dose of 150 mg once daily, which may be increased to 300 mg depending on the patient's clinical response and tolerability. Adverse effects of irbesartan are generally mild but can include hyperkalemia and dizziness. Hypotension may occur, especially in volume-depleted individuals or those on diuretics. Routine monitoring of renal function and serum potassium is recommended, especially in patients with underlying kidney disease or those taking potassium-sparing agents or supplements. Irbesartan is contraindicated in pregnancy due to the risk of fetal toxicity and should be discontinued as soon as pregnancy is detected.

On this episode, I discuss benzonatate pharmacology, adverse reactions, and much more. Tessalon Pearls (benzonatate) are a non-narcotic antitussive commonly prescribed to relieve dry, non-productive coughs. Benzonatate acts by numbing stretch receptors in the respiratory tract, lungs, and pleura, which helps suppress the cough reflex at its source. Unlike opioid-based cough suppressants, it doesn't work in the brain's cough center. The usual adult dose is 100 to 200 mg taken orally three times a day as needed, with a maximum daily dose of 600 mg. One of the most critical points is that the capsules must be swallowed whole. Chewing, sucking, or crushing them can cause numbness in the mouth and throat, leading to a risk of choking or aspiration. There are no major drug interactions associated with benzonatate.

What's in our medicines? There are active ingredients, and there are excipients, which is everything else. From colorants to emulsifiers to adjuvants, excipients hide many horrors, and it's not even possible to know which ones are in your meds (or foods). Dairy that has been fortified with vitamins A & D also has seed oils and emulsifiers, but those things aren't on the label. The government database that should have all the information is full of errors. Polysorbate 80, a common emulsifier in food and drugs, is so complex that it hasn't been fully characterized, and is known to be cytotoxic generally, including being hemolytic—it breaks apart red blood cells. Meanwhile, Moderna's Covid “vax” has even more contaminants than previously recognized.*****Our sponsors:Masa Chips: Delicious chips made with corn, salt, and beef tallow—nothing else—in loads of great flavors. Go to http://masachips.com/DarkHorse, use code DarkHorse, for 20% off.Dose for your Liver: Tasty drink with milk thistle, ginger, dandelion & turmeric to support liver health. Save 30% of your first month at http://dosedaily.co/DarkHorse.Jolie: Beautiful showerheads that filter out the garbage without reducing water pressure. Go to http://jolieskinco.com/DarkHorse to get free shipping; free returns within 60 days.*****Join us on Locals! Get access to our Discord server, exclusive live streams, live chats for all streams, and early access to many podcasts: https://darkhorse.locals.comHeather's newsletter, Natural Selections (subscribe to get free weekly essays in your inbox): https://naturalselections.substack.comOur book, A Hunter-Gatherer's Guide to the 21st Century, is available everywhere books are sold, including from Amazon: https://amzn.to/3AGANGg (commission earned)Check out our store! Epic tabby, digital book burning, saddle up the dire wolves, and more: https://darkhorsestore.org*****Mentioned in this episode:FDA to ban petroleum-based dyes: https://www.fda.gov/news-events/press-announcements/hhs-fda-phase-out-petroleum-based-synthetic-dyes-nations-food-supplyMilk fortified with seed oils and Polysorbate 80: https://x.com/strong_sistas/status/1906085634357236222Abrantes et al 2016. An overview of pharmaceutical excipients: safe or not safe? Journal of pharmaceutical sciences, 105(7): 2019-2026: https://www.sciencedirect.com/science/article/abs/pii/S0022354916004470Betty Pezzimenti on DarkHorse, Nov 26, 2021: https://www.youtube.com/watch?v=-qA0wZD0iPwKinsella et al 2024. Inconsistent excipient listings in DailyMed: implications for drug safety. Naunyn-Schmiedeberg's Archives of Pharmacology, 397(9): 6851-6854: https://link.springer.com/article/10.1007/s00210-024-03067-xRFK on Dr. Phil: https://www.youtube.com/watch?v=ZofNzZ8UoPkOn Food and Cooking by Harold McGee: https://amzn.to/3EFZBAj (commission earned)Sun et al 2017. Component-based biocompatibility and safety evaluation of polysorbate 80. RSC advances, 7(25): 15127-15138: https://pubs.rsc.org/en/content/articlepdf/2017/ra/c6ra27242hMore contaminants in the Moderna vaccine: https://x.com/kevin_mckernan/status/1917252562442506303Support the show