Podcasts about Thickness

Talk Fishing with Music and ReportsBecome a supporter of this podcast: https://www.spreaker.com/podcast/angling-waters-outdoors--2728518/support.

Episode 133.1: Wine!, sommelier, Merlot, Pinot Noir, Skin Thickness, Turo, and Amici Cabernet Sauvignon

Episode 133.1: Wine!, sommelier, Merlot, Pinot Noir, Skin Thickness, Turo, and Amici Cabernet Sauvignon

Worktop Hub offers durable black granite worksurfaces in 20mm-25mm thicknesses, starting at just £100 per square metre. With square-edge designs, finance options, and UK delivery, it's the perfect choice for affordable kitchen upgrades! See the full granite range at: https://www.worktophub.co.uk/kitchen-worktops/solid-surface-worktops/granite-worktops & more options at https://www.worktophub.co.uk/kitchen-worktops Worktop Hub City: Doncaster Address: Unit 2 Tickhill Enterprise Park, Website: https://www.worktophub.co.uk/

How far should you extend composite resin? When does edge bonding become a composite veneer?  How do you decide where to finish the restoration?  And most importantly, how do you avoid that dreaded yellow-brown stain line that can form on anterior resins? These are just some of the burning questions tackled in this episode with my guest, Dr. Mahmoud Ibrahim. We dive deep into the artistry and engineering of  decision-making in anterior composites. https://youtu.be/_q2O57-Y-d4 Watch PDP211 on Youtube Protrusive Dental Pearl: use a zirconia primer which contains 10-MDP (e.g. Monobond, Z-Prime Plus) on the intaglio of crowns to enhance bond strength, even with conventional cements like GIC. This low-risk, high-reward tip improves retention, especially for teeth with limited height. Incorporating a zirconia primer can significantly improve outcomes without switching to resin cement. Interested in the Unchippable 2 Day Course? Click here to register your interest! Key Takeaways: Choosing between edge bonding or veneers is not a black-and-white decision. The height of contour is key in cosmetic dentistry. Seamless transitions between composite and tooth are pivotal. Aesthetic considerations vary based on individual cases. Material choice is influenced by patient risk factors. Layering techniques enhance the natural appearance of teeth. Patient previews are essential for managing expectations. Thickness of composite affects durability and aesthetics. Understanding angles is key to successful restorations. Not all patients require the same approach to bonding. Highlights of this Episode: 02:43  Protrusive Dental Pearl 04:49 Personal Anecdotes and Health Goals 09:37 Anterior Composites: Edge Bonding vs Veneering 16:00 Importance of Finishing Composite Correctly 17:09 Understanding the Height of Contour 18:36 Importance of Layering in Dental Procedures 21:35 Choosing the Right Materials for Layering 23:56 Importance of Layering in Dental Procedures 27:14 Challenges and Solutions in Composite Layering 32:31  The Marshall Hanson Method 36:29 Mockups and Wax-Ups: Planning for Success 43:03 Treatment Considerations This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance.  This episode meets GDC Outcome C - Maintenance and development of your knowledge and skills within your field(s) of practice. AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Direct restorations) Aim: To enhance clinicians' understanding and decision-making in anterior composite restorations, focusing on when edge bonding transitions to a veneer, optimizing aesthetics and functionality, and minimizing common challenges such as staining and occlusal complications. Dentists will be able to - Understand the key factors that influence the transition between edge bonding to full veneers. Apply guidelines for minimum composite thickness and bonding angles to enhance durability and aesthetic outcomes. Identify high-risk patients and tailor material choices, layering techniques, and bonding approaches to individual needs. If you loved this episode, make sure to watch Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075

What is a Ventilated Cavity?In simple terms, a ventilated cavity is an air space between the cladding of a building and its structure. This space allows the building to "breathe," circulating air and carrying moisture away. This is crucial to avoid issues like mould, rot, and other moisture-related problems. It's a technical topic which is why we're once again joined by Dr Cameron Munroe, who breaks down the nitty gritty of ventilated cavities. Cam explained that inheating-dependant climates like Melbourne or Canberra, building materials need to allow water vapour to escape. Unfortunately, traditional methods sometimes trap this vapour. A ventilated cavity helps in solving this by moving vapour out through a well-ventilated air space.We've noticed and discussed how modern weatherboards differ from older ones. The primary reason? Changes in building techniques and materials. Old hardwoods have been replaced with softwoods, which absorb more moisture and have less tolerance. With improved insulation, drying potential decreases, making material choice vital for moisture management.Different cladding types may require varied cavity depths for effective drainage and ventilation. It's essential to consider both ventilation (for air/moisture) and drainage (for liquid water). Thickness of battens used in cavities needs attention, as they play a role in air circulation and moisture drainage.Cameron suggests that while small gaps can handle drainage, air circulation requires larger cavities. Achieving the right balance between these is key in construction.So how do you choose the right cladding material for your climate? Well, buildings in colder regions require more consideration in cladding and batten selection to prevent moisture issues. We can model these factors to make informed decisions about batten thickness and design.1. Cavity Depths: Consider a standardised cavity size, like a 70mm, which can work across various applications and climates.2. Drainage vs Ventilation: Focus on creating effective drainage and ventilation solutions. Think about using metal mesh for venting and drainage to prevent clogging while allowing air to flow freely.3. Durability of Materials: Choose materials designed to withstand climate changes and prevent long-term degradation.It's also important to remember that your roof is essentially a wall at an angle. So, similar principles of ventilation and drainage apply. Make sure your roofing system is designed to handle moisture effectively. Avoid using products like Anticon under roof sheets as they can degrade over time and block airflow.So make sure you're considering the climate and how it'll impact moisture and heat within your building's interior. Ensure you have the right ventilation and drainage strategy to manage moisture efficiently!LINKS:Connect with us on Instagram: @themindfulbuilderpodConnect with Hamish:Instagram: @sanctumhomesWebsite: www.yoursanctum.com.au/Connect with Matt: Instagram: @carlandconstructionsWebsite: www.carlandconstructions.com/

Talk Fishing with Reports and MusicBecome a supporter of this podcast: https://www.spreaker.com/podcast/angling-waters-outdoors--2728518/support.

En el episodio de hoy, vamos a hablar de cómo hacer flexiones impacta positivamente en tu salud. No solo es un ejercicio excelente para fortalecer brazos y pecho, sino que también tiene increíbles beneficios para tu corazón, tus huesos y hasta tu metabolismo. Basándonos en estudios científicos reales, exploraremos cómo las flexiones pueden mejorar tu condición física atlética y tu salud cardiovascular. ¡Así que prepárate para descubrir por qué unos cuantos push-ups al día pueden marcar una gran diferencia en tu vida! Esto es Doctor Mau Informa ¡Vámonos! #drmauinforma #doctormauinforma Suscríbete a mi boletín informativo en: www.drmauriciogonzalez.com/ Redes sociales: ⁣ YouTube: /@doctormauinforma Instagram: www.instagram.com/dr.mauriciogonzalez TikTok: www.tiktok.com/@drmauriciogonzalez Twitter: www.twitter.com/DrMauricioGon CONTACTO ► booking@drmauriciogonzalez.com ¡Nos escuchamos pronto!⁣ Fuentes: Ebben WP, Wurm B, VanderZanden TL, et al. Kinetic analysis of several variations of push-ups. J Strength Cond Res. 2011;25(10):2891-2894. doi:10.1519/JSC.0b013e31820c8587 Yang J, Christophi CA, Farioli A, et al. Association Between Push-up Exercise Capacity and Future Cardiovascular Events Among Active Adult Men. JAMA Netw Open. 2019;2(2):e188341. Published 2019 Feb 1. doi:10.1001/jamanetworkopen.2018.8341 Kotarsky CJ, Christensen BK, Miller JS, Hackney KJ. Effect of Progressive Calisthenic Push-up Training on Muscle Strength and Thickness. J Strength Cond Res. 2018;32(3):651-659. doi:10.1519/JSC.0000000000002345 Ajisafe T. Association between 90o push-up and cardiorespiratory fitness: cross-sectional evidence of push-up as a tractable tool for physical fitness surveillance in youth. BMC Pediatr. 2019;19(1):458. Published 2019 Nov 25. doi:10.1186/s12887-019-1840-9 Learn more about your ad choices. Visit megaphone.fm/adchoices

Join hosts Ev, Sam, Sierra, and guest Liz Wade Stueckle as they discuss chapter 5 from Harry Potter and the Goblet of Fire: Weasleys Wizard Wheezes. Join the Discussion: https://threebroomstickspod.com/episode-48-gof-chapter-5-thickness-where-it-matters/  In this episode: Fred semantics, walking that thin line of Muggle baiting “No other word for it… cool” The true meaning of wheezes Justice for Veelas The worst thing Ginny has ever done The man, the myth, the legend: Barty Crouch Cauldron bottom themed songs It all comes back to the butt Dumbledore and Dobby sock exchange Pig adopted Ron Lupin is in Tibet handling his moon sickness Listen to the Pub's Jukebox here Contact: Website: https://threebroomstickspod.com/ Email: 3broomstickspod@gmail.com Patreon: https://www.patreon.com/3broomsticks Facebook: https://www.facebook.com/threebroomstickspod/ Instagram: https://www.instagram.com/threebroomstickspodcast/ Twitter: https://twitter.com/threebroompod YouTube: http://www.youtube.com/@ThreeBroomsticksPodcast 

2 sections- conclusion about how kerashim were placed on wagons so not "covered", debate regarding thickness of the kerashim

1 section- debate about the thickness of the kerashim

I might talk about Elevation next episode, I enjoyed it. --- Support this podcast: https://podcasters.spotify.com/pod/show/leroy-furious/support

4 years of doing this show. Me and Claire are still going strong and still churning out episodes (when we can). We play our favorite tracks we've played on this show from this past year. We also talk about AI, the PS5 Pro debacle, movies, sex ed in schools, and the new season of anime. 1. Fuyunohanashi- Shougo Yano 2. One Last Kiss- Utada Hikaru 3. Wish- Majiko 4. Roar- Olma Sound Junction 5. Data Atashi no- LiSA 6. Rough Diamonds- Screen Mode 7. Haru- Yorushika 8. Asterik War- Shiena Nishizawa 9. Work- Millenium Parade and Sheena Ringo 10. Slash- Yama Anime Suggestions Dan Da Dan Bonus Tracks Brave Shine- Aimer Without any words- SIX LOUNGE Bleach OP Otonoke- Creepy Nuts Dan Da Dan Op https://youtu.be/XRG4c-Pik8s?si=w7OEM5BUn2lh3_2e

This week the diapers are full and the milk bottles are empty. Feel the rage of these beautiful baby boys: Mark and Thickness. Enjoy!

This week the diapers are full and the milk bottles are empty. Feel the rage of these beautiful baby boys: Mark and Thickness. Enjoy!

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Justin Dunaway takes a deep dive into a series of three studies tracking the same cohort of patients over 10 years and what they say about the importance of short term changes! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Persistent Pain Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JUSTIN DUNAWAYAll right, team, good morning. I am Justin Dunaway, lead faculty with the Institute of Clinical Excellence, coming at you live from Portland, Oregon. Welcome to another Clinical Tuesday. I am lead faculty for Total Spine Thrust and also our Persistent Pain Comprehensive Management course. 32nd cohort just began yesterday. So if you're thinking about jumping in that will the registration will remain open for another day or so So if you're thinking about it, go ahead and take a look But enough about that. Let's get into today's topic today we're gonna talk about full thickness a traumatic rotator cuff tears and looking at physical therapy or Surgery and what what kind of predicts that stuff? and it's really cool because it's a series of three studies over a decade that looked at the same same kind of cohort of humans and And while I'm going to talk a bunch about these three studies, realize that this really is more than a story about rehab for rotator cuff tears. This is really a story about the importance of our ability to demonstrate within session and between session change, early, often, and frequently. And at Ice, we often hear that we are obsessed with incessant change. We are obsessed with our ability to show short-term changes. And I couldn't agree with that sentence more. Like, totally. I am absolutely obsessed with that. The second half of that, though, which I don't agree with, is that short-term change, within-session change, those things don't matter. What we're really talking about is regression of mean or natural history. And short-term change doesn't predict long-term change. And I couldn't disagree with those sentences more on lots of different levels. But I think that the story I'm about to tell, the three studies that we're about to walk through, give some of the best evidence and support for the need for short-term and within-session change, for at least one of the many reasons why this stuff is so important. So let's dive in. First study, study number one, the effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears, multi-center prospective cohort study by Kuhn and Dunn, 2013. Mouthful. But basically what they did is they took a whole bunch of humans, 452 of them, that had full-thickness chronic degenerative rotator cuff tears, and all of them got six weeks of physical therapy. And then at the end of the six weeks, they were asked, you know, how are you doing? And they got one of three options. They could stay cured, in which case they were done, and we'll just check in at 12 weeks, and then at a couple time points over the next two years, or they're improved, in which case they would get another six weeks of physical therapy, or no better, and then they could opt for surgery. And then at the 12-week mark, the people that were left, that weren't cured in the first six, asked them the same question. If they were cured, awesome. If they were anything but cured, they were offered surgery, and then tracked over the next two years. The physical therapy protocol, I couldn't get my hands on the full version of Appendix A that went into detail about what they actually did, but in the study, in the methodology they just talked about doing the physical therapy was range of motion, was postural control, was scapular training, was mobilizations, was general strength training stuff. And I've got some thoughts on that and we'll dive into here in just a second. But the outcome here is what they found is that less than 25%, okay, full thickness chronic degenerative rotator cuff tears, less than 25% of the 452 people in the trial at the end of the 12 weeks needed surgery. At the six week mark, only 6% of people opted for surgery. At the 12 week mark, that number was up to 15. And then over the next two years, a few more trickled in and that went up to like 24%. So at gut shot, 75% of people with full thickness rotator cuff tears went on to have excellent results in pain, disability, range of motion, strength, functional stuff, and went totally back to life. That's awesome. That's huge, right? The second piece The thing I want to think about here, though, is I think that number could be a bit better, right? I'm going to make an assumption that once we dive into the exercise protocols there, were they really doing strength stuff? Were they really looking at multi-joint movements, overhead presses, rows, pushes, horizontal presses, things like that, and dosing them appropriately for strength? you know, thinking about low or high sets, low reps, two to three minute rest at roughly 80% of their calculated one rep max, or are they doing like three sets of 15 with a band? And call it strength. I have no idea. My assumption is that we probably could be a bit more aggressive with exercise, and I bet that number could get a bit better. But 75% is awesome. So let's run with that. And the conclusion of this first study, which is super important, That if I'm just gonna read the quote if a patient avoids surgery in the first 12 weeks He or she is unlikely to undergo surgery at a later time point up to 12 up to two years So this is the first point here if the patient doesn't opt for surgery in the first 12 weeks They're probably not going to get surgery so our ability to to show them functional improvements in the first six, in the first 12 weeks, is absolutely huge. Because if they don't feel like they need surgery at the end of the 12 weeks, they're not going to get it probably ever. And when we think about conservative management versus surgery, both these things can be effective. But there is massive risk to surgery, right? There's massive financial risk. It's super expensive. And then thinking about the risks of anesthesia, of something going wrong during the surgery, of infection, of interactions, adverse events with the medications, opioid addiction. All of these things are risks of surgery that don't exist in conservative management. Okay, so that's the first study. If you don't opt for surgery in the first 12 weeks, it's unlikely that you're going to. 75% of humans got totally back to life without needing surgery. Study number two, predictors of failure of non-operative treatment of chronic symptomatic full thickness rotator cuff tears. Same research team. This was published in 2016. Again, looking at the same cohort of 452 individuals, This time what they wanted to see is, okay, 25% of you failed conservative management, failed physical therapy. Why? Is there anything in there? Is there anything about you that predicts whether you will or won't do well with physical therapy? And this was really cool. So they looked at all the patient demographics. They looked at age, they looked at sex, they looked at pain, severity of the tear, disability, chronicity, activity levels. They looked at work status and education and handedness and really everything under the sun. And what they found, the first thing they found is that structural factors were not predictive at all. Tear didn't matter, pain didn't matter, disability didn't matter, what your MRI didn't look like. None of that stuff predicted whether you needed surgery or not. The number one most powerful and really only significant predictor of whether you went on to need surgery or not for your full thickness rotator cuff tear was belief that physical therapy wouldn't help you. That was it. If you believe physical therapy would help you, you succeeded, you didn't need surgery. If you didn't believe that, then you opted out and went for surgery. And then smoking status moved the needle just a little bit, which makes sense. If you're smoking, your body is widely inflamed. Things heal slower. Your pain systems are far more sensitive. And then the other thing that was a very small predictor was activity levels. If you had higher activity levels, you were slightly more likely to opt for surgery early. And that makes sense too, right? My shoulder hurts. I can't do all the things I want to do. I'm still trying to do them. Things aren't getting better quick enough. Give me the magic bullet. The important thing here, again, one, structure was not predictive. Two, the only real strong predictor was your belief in physical therapy. Now, this is where it gets interesting, right? If that is the thing that determines whether you get surgery in the first six to 12 weeks, or that's the thing that determines whether you get surgery, and most humans are gonna make that decision within the first six to 12 weeks, you cannot make the argument that within session change and short term changes don't matter and probably aren't the most important thing there is, right? Because I cannot, if the thing that determines whether you need surgery or not, whether you get into that MRI tube, whether you get in the OR suite, whether you're getting those injections, pills, things like that, is your belief that physical therapy can help you, I cannot think of a more powerful way to foster that relief than having some tools in my toolbox that when you walk in the door, very quickly, I can modulate your pain, I can change your pain, your pain pressure threshold, turn on painfully inhibited muscles, gain some access to proprioception, and then get out into the gym and do some things that actually build capacity in humans, and demonstrate that thing within session, and then session after session after session. Short-term change and within-session change are the things that get patients to believe in physical therapy. And belief in physical therapy is the thing that keeps the patient out of the OR. Simple as that. That is the most important tool we have to foster those beliefs. Okay, study number three. This one just came out like last month. The predictors of surgery for symptomatic, atraumatic, full thickness rotator cuff tears change over time. Same research team, again, looking at these same humans that were in this study. Now this is tracking them down 10 years later. The first thing that pops out is that at the 10 year mark, only 27% of these people went on to get surgery. So you think about that, at the two-year mark, it was around 24%. So just a few more people kicked into the surgery over the next two, between two years, year two and year 10. Most of them, over half, opted for surgery before the six-month mark, and then the rest of them slowly trickled in over the next 10 years, with it kind of being less and less each year down the road. At the six-month mark, And everything prior to that, the most predictive thing, again, whether you need surgery or not, was belief in physical therapy and nothing else, right? So those beliefs are gonna be powerful all the way up to the six month mark. Everything we can do in that window to convince patients. that this is the path they need is gonna be the thing that keeps them off the other path. Beyond six months, it doesn't switch to structure, it doesn't switch to pain and disability and any of that stuff. The only two predictors beyond six months were if you were on worker's comp, and again, if you reported high levels of activity. Now this is super important too, right? Because okay, we're six months, we're a year, we're two years, we're five years out. We've done physical therapy, it didn't work, we've kind of forgot about it, that's off the table. And now, the stuff that's really bugging us is the fact that, okay, we're still having trouble at work, we're on workers' comp, we're kind of in that system, we still have all these activities that we want to do that we can't do the way we want to do them, now it's time to do something else. It's important to realize that overall, at the 10-year mark, 70-ish percent of humans, again, didn't need the surgery. And this is an interesting bullet point, too, because one of the things that you'll frequently hear is that, great, people do well with conservative management for rotator cuff tears. But if you don't repair it anyway, you set the patient up for degenerative changes, arthritis, problems down the road. What this study showed us is that the 10-year mark, the 70% of humans that did well with conservative management 10 years ago in that six to 12-week PT window, All of them were successful. And the success that they gained 10 years ago didn't decline over time. They didn't have more disability. They didn't have increased pain or arthritis or things like that. Their gains stuck. And this is one of a few studies that look at conservative management for rotator cuff tears, track them out over long periods of time, and show that there is no negative mechanical effects from not repairing that thing. So, the important stuff here, the key clinical factors here, is that team, at the end of the day, beliefs and expectations are the foundation. They're everything. They're the thing that drive the decisions that patients make, right? And if we don't have the ability to demonstrate change to our patient, if we don't have the ability to show them, not just tell them, But show them time and time again, ruthlessly, within session and between sessions, slowly building up functional outcomes, session after session after session, they're not going to buy this. And if they don't believe in what they're doing, if they don't believe in physical therapy, if they don't think that this is the thing, that's the stuff that determines, OK, am I going to get shots? Am I going to be taking pain medications? Am I going to end up in the OR suite? We need, what this research tells me is that we really need to drill down on our ability to have tools in the toolbox that create quick, transient changes in pain, range of motion, muscle activation. And I get that that's transient, but what we're doing is we're open a window. And then once that window is open, we absolutely have to jump through it, get right into the gym and start doing the large functional movements that build capacity in humans. And then be ruthless about your comparable measures, your functional stuff between sessions and your objective stuff within sessions. and make sure that multiple times every session, you're showing patients change. In every session, when they walk in the door, you can show them change over time. This is where you started. This is where we were after the first week. This is where we were after the second week. The better we get at that, the better we get at demonstrating change in the moment and showing them incremental change over time in the short term, the better our odds of keeping these patients out of the surgical suite. If the only thing that separates these two groups, physical therapy or going under the knife, is their belief in the power of what we're doing in the clinic, then we have to invest everything we have in our ability to demonstrate those changes. All right, team, hope you're half as excited about these three studies as I am. I think it's a really cool thing to look at and then track these patients over the last 10 years. If you got any questions, throw them in the chat. Have an awesome day in the clinic, and I look forward to seeing you out there. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

In this episode of Ink Matters, we dive deep into the world of autograph pen thickness and its impact on your treasured collection. Whether you're a seasoned collector or just starting out, understanding the difference between extra fine, fine, and broad tip pens is crucial to preserving the value and appearance of your autographs. We'll explore the strengths and weaknesses of each tip size, discussing which works best for different types of memorabilia—from delicate paper to glossy photos and jerseys. Join us as we share expert tips on choosing the perfect pen thickness to ensure your autographs stand the test of time, look sharp, and maintain their integrity for years to come. https://powerssportsmemorabilia.com/

This week, Thickness sits down with some important men to discuss Roman horses, the history of arson, and contemplate the possibility of sending a big funny message to a sad boy with some shirts. Join us! FThatGuydotcom

Interview with Kemi M. Doll, MD, MSCR, author of Endometrial Thickness as Diagnostic Triage for Endometrial Cancer Among Black Individuals. Hosted by Vivek Subbiah, MD. Related Content: Endometrial Thickness as Diagnostic Triage for Endometrial Cancer Among Black Individuals

This week the boys discuss just how gross the air gets in a nerd tournament, Thickness takes a shot at sobriety and a special request to the listeners is made. Help Thickness choose his next video game! Send your suggestions to Jbthickness on Instagram today!

Interview with Kemi M. Doll, MD, MSCR, author of Endometrial Thickness as Diagnostic Triage for Endometrial Cancer Among Black Individuals. Hosted by Vivek Subbiah, MD. Related Content: Endometrial Thickness as Diagnostic Triage for Endometrial Cancer Among Black Individuals

This week the boys return with some hard opinions on movies, Thickness lays out his most prestigious dumps, and somebody gets poisoned by their neighbor! Enjoy!

In today's episode, we've got some compelling new research from the European Spine Journal focusing on thoracolumbar fascia, chronic low back pain, and idiopathic lumbar scoliosis. We'll dive into how ultrasound technology is used to uncover critical findings that could impact chiropractic practices worldwide.Episode Notes: Thoracolumbar fascia and chronic low back pain in idiopathic lumbar scoliosis: an ultrasonographic studyThe Best Objective Assessment of the Cervical Spine- Provide reliable assessments and exercises for Neuromuscular Control, Proprioception, Range of Motion, and Sensorimotor-Integration. Learn more at NeckCare.comInterested in ShockWave technology? I built a practice using StemWave and can't recommend it enough. Learn more at- https://gostemwave.com/theevidencebasedchiropractor Patient Pilot by The Smart Chiropractor is the fastest, easiest to generate weekly patient reactivations on autopilot…without spending any money on advertising. Click here to schedule a call with our team.Our members use research to GROW their practice. Are you interested in increasing your referrals? Discover the best chiropractic marketing you aren't currently using right here!

Drew has some social anxiety. Paul is going to teach Drew how to play Diablo 4. Paul likes his new iPad. Drew and Paul discuss some shows they've gotten into recently. Recorded 5/30/2024 Show Links Smart Casual Semi Formal Tailscale VNC The Newsroom X-Men 97 Modern X-Men Comics Reading Order Thread

Join us this week as the bois discuss Ghosts of Tsushima and Thickness's skepticism of the Samurai honor code before dipping into the cozy conversation of prison reform through the viewpoint of a documentary. Enjoy!

Guess what! Fundiferous Rex (aka Zach Cranor) is here with us and he's spilling all his beans about ghost, among other things. I Love This Business is also making an appearance, so check it out, why don't ya?! www.coolparents.co --- Send in a voice message: https://podcasters.spotify.com/pod/show/cool-parents/message Support this podcast: https://podcasters.spotify.com/pod/show/cool-parents/support

This week Thickness buys a PS5 and the boys deep dive into the new experience. Later, we talk about how data transfer really works and how the new remake of the year might be the flop of the century.

Gary Linden is well-known for his big wave surfing and shaping prowess. He's also the foremost expert on Agave surfboards. In this episode of the Boardroom Podcast Gary talks Agave, Balsa and the always interesting Volume vs. Thickness debate, and much more. Learn more about your ad choices. Visit podcastchoices.com/adchoices

In this episode of DIY Guitar Making, I answer YOUR questions!Questions/Topics:– What do you do with your scrap wood?– Buying pre-bent sides– Best heating blanket for side bending – radial rosettes – thicknessing backs as a resonator or a reflector – Thicknessing tops– Plate gluing jig– laminated sides– inlaying Opal for fret marker dots– What is the purpose of a shooting board– modifying an existing guitar to increase the bass response– inlaying mother of pearl without teflon strips All episodes available at diyguitarmaking.com Register for an 9 day Hands-On Guitar Building Workshop in Bernville, Pennsylvania: https://www.ericschaeferguitars.com/learn-to-build-your-own-guitar/ Check out the online course “Building an OM Acoustic”: https://www.ericschaeferguitars.com/course/building-an-om-acoustic/ To commission an instrument from Eric: https://www.ericschaeferguitars.com/instruments-ordering/  Check out the Radial Rosette Maker Jig: https://www.ericschaeferguitars.com/the-radial-rosette-maker-kit/To find the "DIY Guitar Making" podcasts AND videos all in one place visit:www.diyguitarmaking.comFor information on the Hands-on Guitar Building Workshops and online guitar building courses visit:www.ericschaeferguitars.com

TIME STAMPS: 02:12 FAITH & FITNESS: The foundation of SUPERSETYOURLIFE.COM! 03:03 “My story, His glory!” 08:55 Is SWEARING & foul language SINFUL? 14:11 The POWER behind the the name “YAHWEH” and other names for God in the Bible. 16:53 Mark 10:23-31 “It is easier for a CAMEL to go through the EYE OF A NEEDLE than for a RICH MAN to enter the Kingdom of God.” What is meant by the EYE OF THE NEEDLE?! 20:20 John 10:11 “I am the good shepherd. The good shepherd lays down his life for the sheep.” 24:21 GRACE is not a license to sin freely!!! 27:45 “Psalm 23 introduces one of the best-known names of God in the Bible. David calls the Lord “Jehovah Rohi,” indicating that he relies on God as a sheep depends on his shepherd. He paints a beautiful word picture describing how the Lord leads him beside quiet waters, refreshes his soul, and guides him along the right paths. He recounts how God's rod and staff comfort and guide him through the valleys of life. Because of God's presence, he knows he has no reason to fear evil.” (article from Abundant Life) / STR7462 “ROH-ee” is translated “shepherd” / reading of Psalm 23 CSB. 36:20 Going KETO as a VEGAN—is this possible?! 40:05 Somebody was STUPID enough to write this in a 1911 publication of Encyclopedia Britannica: “The possibility that we can ever again recover the correct pronunciation of ancient Hebrew is as remote as the possibility that a Jewish empire will ever again be established in Middle East.” They should have read EZEKIEL 37:11-3. 47:09 The importance of training your back from DIFFERENT ANGLES. 49:57 The difference between a THICK BACK and a WIDE BACK and how to build THICKNESS without deadlifts using safer exercises. 53:11 DANGEROUS BACK EXERCISES to avoid!! 54:29 REAR DELTOIDS: back muscle or a shoulder muscle? Methods to train this often neglected muscle group. 56:56 The BEST BACK EXERCISE TO DO if you had to pick only one. 01:04:52 Back training tips to improve your BENCH PRESS (yes you read that correctly). 01:09:08 The value of UNILATERAL TRAINING to optimize range of motion and fix muscle imbalances. 01:15:17 Advanced move you probably haven't tried: SINGLE ARM DUMBBELL PULLOVERS. 01:23:11 Safer, smarter variations of conventional deadlifts. 01:26:06 Macros & game plan for Jimmy's Carnivore Contest Prep. 01:32:02 Crazy CARBOHYDRATE LOADING & REFEEDING stories and how they differ from FAT LOADING. Do you like RIBEYES? Search Carnivore Coaches Corner (the #1 bodybuilding podcast in England) on any platform for our NUTRITION PODCAST co-hosted with Coach Mark Ennis! 30-minute consultation with Coach Colt: https://calendly.com/ssyl/1-on-1-consultation-30-min Shop Natural Sea Salts: https://supersetyourlife.com/products/baja-gold-sea-salt All of the supplements we take: https://supersetyourlife.com/collections/supplements

Rip answers questions from Starting Strength Network subscribers and fans. 02:13 Comments from the Haters! 10:41 Deadlifting without shoes 14:00 Importance of your vertical jump 26:48 Rip's thoughts on dips 28:44 Do good GPs exist? 33:44 Fingerprints of the Gods 40:39 Rack pulls and haltings 55:37 Bouncing the bar during bench press 56:41 Master and Commander 1:02:05 Long-legged lifters 1:05:45 Bar thickness

This week the boys dive into the success of the new Final Fantasy game, discuss the inevitable Hogwarts Legacy 2 release and Thickness watches Wonka! Nude?

Join Hugh Ross and Jeff Zweerink as they discuss new discoveries taking place at the frontiers of science that have theological and philosophical implications, including the reality of God's existence. Crust Thickness and Life A team of five geophysicists demonstrated that the level of oxides in basalt primary melts are a good proxy for the thickness of Earth's crust. They then supervised a machine-learning algorithm to analyze global geodatabases (e.g., EarthChem and GEOROC) of basalts to determine the variation of the thickness of Earth's crust spanning the past 3.8 billion years. Their analysis revealed five features of Earth's crust that led to supercontinent cycles and plate tectonics that are highly fine-tuned for complex life on Earth. Antimatter Feels Gravity When Einstein first published his general theory of relativity, scientists did not even know about antimatter—which was discovered almost 15 years later. Since then, scientists have speculated about how antimatter behaves in gravitational fields. Most think that it behaves just like normal matter. However, gravity's weakness compared to electromagnetic forces has prevented any direct test to see if antimatter falls like normal matter. Recently, the ALPHA collaboration was able to isolate enough atoms of antihydrogen (antimatter counterpart of hydrogen) to demonstrate that the atoms behave like normal hydrogen atoms in a gravitational field. This result demonstrates two things. First, it provides even more evidence for the constancy of the laws of physics. Second, it shows that scientists are willing, able, and driven to test fundamental parts of theories rather than simply accept them without data. LINKS & RESOURCES - PLAYLIST – https://youtube.com/playlist?list=PLUwTeBAi_JFG-J6mqU3em0LV7pFUiq9wp&si=uiWkZdNWit1syzgn Crust Thickness and Life Zhen-Jie Zhang et al., “Lithospheric Thickness Records Tectonic Evolution by Controlling Metamorphic Conditions,” https://www.science.org/doi/10.1126/sciadv.adi2134 Meng Guo and Jun Korenaga, “Argon Constraints on the Early Growth of Felsic Continental Crust,” https://www.science.org/doi/10.1126/sciadv.aaz6234 Antimatter Feels Gravity E. K. Anderson et al., “Observation of the Effect of Gravity on the Motion of Antimatter,” https://www.nature.com/articles/s41586-023-06527-1

Follow the hosts on Instagram @robnudds, @alonbenjoseph, and @davaucher.Thanks to @skillymusic for the theme tune.

This week the boys discuss a horrible thing happening at the thunder dome, Thickness explains why corporate life is not for him while Thomas babbles away on his experience, and we go over the timeline of Rooster Teeth falling all the way out of the internet.

TTO-181 New Mixing Board, Downs with the Thickness, Workout Chicks, Girls, School Board Suing, 10 Dollar Lawsuit, Disabilities Discrimination, Waterworld Piss Machine, Super Bowl Prop Bets, Usher Halftime Show, Chiefs Win Mahomes Gloat, Krispy Crème Donuts, Cops thought Meth Iced Glazing, Tattoo Proposal, Tesla Recall, Cyber Truck, Silverado, Truck Talk, Instagram Gay Hashtag, Robot Sandwich Sex, Monster Voice Fun,  

How and Why to do Immediate Dentine Sealing: In this first episode, Zahid and Jaz not only explored the fundamental principles of IDS but also offered a practical guide for its smooth implementation in clinical settings. Every single step of IDS is broken down and made tangible. https://youtu.be/UrrnSNWouf8 Watch PDP173 on Youtube Protrusive Dental Pearl: When dental work fails after a long time service, remind the patient that 'it does not owe us anything' and 'What could they buy today that would last X years?' Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 00:00 Introduction07:13 Zahid Shaikh Introduction11:39 Immediate Dentin Sealing (IDS)14:54 History of Immediate Dentin Sealing18:47 Onlay vs Overlay?21:33 Occlusal Reduction for Ceramic Onlays23:28 Caries Removal and Isolation24:58 Air Abrasion in Adhesive Dentistry27:36 Clinical Steps in Immediate Dentine Sealing35:48 Thickness of IDS Layer40:12 Enamel Refinement42:02 Preventing Temps from Sticking to Your IDS51:11 Liquid Dam to Temporise Onlays52:47 Removing Temporary Onlays In part 2 of this episode we will explain how to reactivate your IDS layer. Check out Dr Zahid Sheikh on Instagram! We're thrilled to announce the upcoming arrival of our Protrusive Guidance App, not only just a great source of CPD but a community of the nicest and geekiest Dentists in the world. Keep an eye out!

Live IVIRMA Journal Club from January 18th. Dr. Haley Genovese presents an article by Baris Ata et al. recently published in Fertility & Sterility. Drs. Jason Franasiak and Emre Seli comment on the effect of the endometrial thickness on the live birth rate after a euploid frozen embryo transfer, followed by Q&A from the audience including Antonio Pellicer, Thomas Molinaro, Kassie Bollig, and Filippo Ubaldi. Podcast website: https://www.ivi-rmainnovation.com/fertilipod/

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: The Good Balsamic Vinegar, published by jenn on January 27, 2024 on LessWrong. For a long time I only went to one specialty gourmet store for balsamic vinegar. Their house brand was thick and sweet and amazing on everything, from bread to salad to chicken. The gourmet store only stocked their house brand, and it had an entire dedicated shelf. As far as I knew, the house brand was not available anywhere else in town. The gourmet store was slightly out of the way, and eventually there were times when I wished I could grab balsamic vinegar at the normal grocery stores that I did most of my grocery shopping in. The first time I attempted it, I was rushed for time and it was a disaster. I knew the approximate price range that I should be looking at (around $25 CAD for a ~200ml bottle), but there were a dozen vinegars that fit the bill, and they all had pretty fancy looking packaging, and I was AP'd AF. I basically picked randomly based on vibes, and I picked wrong. The vinegar was the consistency of water, sour, and not fragrant at all. The second time, I was ready. Recall that the balsamic vinegar I wanted was thick and sweet. It turns out that you can use your literacy skills and senses to ensure that the vinegar you buy are both of those things! Again, first I culled all the vinegars that seemed to be priced way too cheaply - like under $10 for a sizeable bottle. Then I started systemically picking up the remaining bottles, and tipping them sideways. Most of the bottles were tinted but not opaque, so you can see the vinegar inside. Anything that moved like water I put back - those were a sizeable portion. A few bottles were truly opaque, those also went back on the shelf. For the vinegars that flowed a bit more slowly, I turned the bottle around to look at the nutrition facts. Sweet vinegars are going to have sugar in them - no one has been brave and visionary enough to make fancy vinegars with aspartame yet. Thickness and sweetness turned out to be traits that were 100% correlated, at least in one direction: all the thick vinegars had sugar content of around 8-12g per tablespoon. I picked the cheapest bottle that met the two criteria to try. It was $2 more than the bottle I get at the gourmet store for the same volume, and slightly better tasting IMO. I am now incrementally more powerful at grocery shopping. Bonus: In fancy restaurants they sometimes give you bread and a bowl of nice vinegar and olive oil to dip it in. This is delicious, but we can do better. When the vinegar and oil are in the same bowl, the bread must travel through the layer of oil (hydrophobic) to get to the vinegar (water-based), and then back out through the oil. This results in bread pieces that have very little vinegar and too much oil on them. If you instead put the vinegar and oil in separate bowls, you can dip the bread lightly into the vinegar first and then dunk it in the oil. This results in a much better ratio of vinegar and oil on your bread. Having fresh baguette slices and bowls of nice olive oil and vinegar out at a party has never been a bad choice in my experience. It's not actually that expensive, and it's vegan by default :) Thanks for listening. To help us out with The Nonlinear Library or to learn more, please visit nonlinear.org

We are your struggle specialist! Our podcast consist of topics based on trending topics, comedy, pop culture, nerd/geek culture, music, etc! Please like comment & subscribe so you can be apart of our journey while the channel grows! Today's topics are: -Detroit Lions -Brittney Spears allegedly banned from 4 season -Mental illness -Jackson Mississippi & More!

Join me for a summary looking at gingival recession in orthodontics, and whether it is detrimental or beneficial. This lecture was given by James Andrews, he explored the effect of orthodontics on the periodontium, an area under increasing interest within aesthetics to achieve the ideal ‘pink aesthetics' with the increasing adult population receiving orthodontic treatment. His lecture was based on, is orthodontics good or bad for the gingiva? What is the starting point ? Increase in adult orthodontics from 1970 by 800% 50% of adults have some element of periodontal disease Untreated adult population 51% dehiscence 37% areas of fenestration Evangelista 2010 Facial type and bone morphology Tunis 2021 Dolichocephalic = narrow alveolus and elongated to compensate for vertical growth Brachycephalic = larger alveolus Dolichocephalic - Red flag patients Tooth movement:  What happens when teeth move buccally? facial tooth movement Wennström 1996 Reduced bucco lingual width Therefore, reduced free gingiva Increased risk only if tooth is moved out of the alveolar housing What type of movement Tipping (uncontrolled) increase likelihood of recession Condo 2017 Proclination causes recession, but inconclusive  Thickness more relevant than final inclination Yared 2006 How to decide what to do? WALA line – Will Andrews Larry Andrews ridge Andrews 2000 Limit of labial bone – shape is coincident with the mucogingival junction, coincident with centre of resistance Upper incisors – located anterior 1/3 of alveolus Mandibular incisors – cantered within the alveolus  Gingival recession did not increase in treatment orthodontic population with segmental mechanics Melsen 2005 Aligners any different? Association between non-extraction clear aligner therapy and alveolar bone deficiency and fenestration Presence of both fenestration and dehiscence What do we do to correct extra-alveolar teeth? If teeth pushed outside of cortical plate then retracted, what happens Monkey – moved teeth outside of bone for 8 months, then reposition within bone with appliances =  repair bony dehiscence and fenestration Morten  Laursen and Melsen 12 consecutive patients 2020 Teeth moved towards the centre of the cortical plate = improvement in gingival height of depth decrease of 23%, the width with 38% Intrusion Use of intrusion arch increases the thickness of the periodontal fibres 0.7 to 2.3 mm  Melsen 1988 Gingival graft when to move teeth Free gingival graft – 6 weeks Connective tissue graft – 12 weeks “Diagnose and treat each tooth no miracles shortcuts for good orthodontics” Peck 2017 

We love a thick bodied babe and it probably doesn't take a genius to figure out that our man Rubens did too! And though we are all finally recovering from the mindfuck in media we grew up with, we're here to remind that FAT has always been P.H.A.T. in this  episode! Join us as Chelsea unearths all the TEA surrounding this painter's life. There will be AFFAIRS, there will be MURDER, and there will be... really not-okay age differences within marriages... again! I know, I know, EWWWW. I'm sorry it's not our fault all these artists are just SOOOOO gross. We still make it fun though, promise!Thanks for listening and as always, we love you!Xoxo,The Baroque Bitches#arthistorypodcast #artpodcast #arthistory

Dr. Nathan Fox is a practicing OB/GYN and Maternal Fetal Medicine provider in New York City. Two of his children were also VBAC babies! He joins Meagan on the podcast today where they discuss topics in depth to help listeners make more informed decisions about their VBACs. Topics today include where to find evidence-based information, how to interpret it, the risks of uterine rupture, VBAC and COVID-19, induction, scar thickness, due dates, and third-trimester ultrasounds. Additional LinksHealthful Woman WebsiteMFM, High-Risk Pregnancy New York City WebsiteNeeded WebsiteHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode Details Meagan: Hello, hello. You guys, it's November. How are we at the end of 2023? It is crazy how fast this year has gone. We have a special guest today. It's Dr. Nathan S. Fox. He is so amazing to come on today to talk to us about a couple of topics that I don't know if we've actually ever talked about on the podcast. We're going to be talking about scar thickness. We're going to talk about third-trimester ultrasounds. We're going to be talking a little bit about COVID and is it really best to induce at 39 weeks? We've had COVID. What does it mean with our placenta? We know we've been hearing it out there where our placentas are not doing well. So you guys, get ready. Buckle up. It's going to be great. I want to tell you a little bit about Nathan Fox first. He is a board-certified OB/GYN and he is also certified in MFM which is Maternal Fetal Medicine. In his clinic, he sees a lot of higher risk and unique situations. He did his residency at Mount Sinai. He has an amazing podcast that really dials in on helping people know the evidence and then also understanding the evidence in English because if you are like me, you'll know that it is kind of hard to break down some of these studies sometimes and it's hard to understand what the evidence is even saying and then how to apply it. He has this podcast and it is Healthful Woman. We are going to make sure that it is linked. You guys, he has so many incredible guests on there talking about a wide range of things. It's not VBAC-specific, but it definitely has a wide range of topics and things that you're probably going to love. Definitely check that out. We'll have it in the show notes. Dr. Fox, seriously, we are so grateful for you today. We can't wait to have you on. We'll be right back. Dr. Nathan FoxMeagan: All right, I need to pull up those questions really fast. There are a lot. Literally, we do not have to get to all of them. Dr. Fox: I'll come back if you want. Don't worry about it. Meagan: Yeah, we'll have to do a part two. You are so sweet to take the time out of your busy life, I'm sure. Dr. Fox: We are mission-aligned as they say in the fancy world. It's about getting good education, and good information out to people so they don't have to hear crazy stuff on the World Wide Web and get terrified. Meagan: Right. That's why we started this podcast even just to share stories of people who are having VBACs so people can hear and learn through those VBACs and also know it is an option and it is possible. I have a question. You said before we started recording that you have two VBAC babies. Dr. Fox: Yeah. Meagan: How was that journey as an OB and MFM? Was your wife getting information that you were like, “Wait, that's not true,” or were you like, “Actually, we need to think about this”? How was that journey as someone in the field?Dr. Fox: Full disclosure, I was getting into the field. I have four kids. My first two are twins and they were born when I was a medical student so I knew very little. I guess more than nothing, but closer to nothing than where I am now. They were born by C-section. Both of them were breech. Thank God, both of them did great. All was well. With the next one, my wife was pregnant when I was a second to third-year resident in OB/GYN. For most of her pregnancy, I was a second-year, then she was born a month after I became– not even. She was born July 17th so 16 days after starting my third year. Meagan: Right after, yeah. Dr. Fox: I knew a little bit more then. That was our first VBAC. Then my fourth was born when I was an MFM fellow. I like to say that I had kids in all of my points in training. Honestly, we didn't think much about VBAC in terms of being this grand decision and conversation. I would say mostly because the OB my wife was seeing was on board with it and didn't make it into a big deal and she was delivering at a hospital at Mount Sinai where I trained and where I now practice where VBAC is commonly done. There was a conversation about it. It wasn't like we were blind to it, but it was part of the normal culture in that hospital on the labor floor so we didn't think much about it. My wife said, “Why would I want a repeat C-section if I can try and do it vaginally?” It worked out fine, thank God for both of them. The third was also actually a forceps. We're like a textbook of obstetrics, my wife. But yeah. It wasn't dramatic. Let's put it that way, the VBAC process.Meagan: Wow. Yeah. I love hearing about it that it was just a thing. It didn't have to be a big deal. She was just going in and wanted to have a baby. She didn't want to have a C-section.Dr. Fox: Yeah, again, I think it is something that should be discussed. People should understand and not even everyone understands that it is a thing meaning people don't even realize why you wouldn't. Meagan: Why you would not, yeah. Dr. Fox: There is risk, but ultimately, if it is an option, the risk of a VBAC– again, in the right person– is not markedly higher than the risk of a C-section. So it's a conversation. Which risk would you prefer or which risk would you least prefer? So that conversation was very straightforward. “Would you want a repeat C-section? Would you want a VBAC?” She was like, “I want a VBAC.” Fine, so that was done. It wasn't like she had to meet with an attorney to go over everything and sign a waiver or anything like that which sometimes happens. Meagan: Yeah. I love hearing that. Well, I am so excited that you are here with us today. I know that we have so many questions to dive into. They're kind of all over the place. With the first one, I think a lot of our community members– we have a Facebook community, a forum, and one of the most common posts in there is looking for a provider that is supportive because they were with a provider and then they found out that the provider that was seemingly supportive is not supportive anymore. It all seems to focus around things with evidence-based information and they're getting all of the different things. One of the questions is why is it so hard to find evidence-based information on VBAC, VBAMC, and uterine rupture– because we have some providers that are saying you have a 60% chance of uterine rupture and then some saying you have a 0.4-1% chance. Those are very dramatic numbers. The range of answers is just so wide. I'm just wondering why do you think it's so hard and where can we find this information. Where would you suggest our listeners go? Let's talk about your podcast being one of those places. It's not just VBAC-specific. Your podcast isn't VBAC-specific but it's very, very good at a whole, wide range. But yeah, can we talk about where to find evidence-based information about birth in general but especially about VBAC? Dr. Fox: I mean, yeah. That's really the million-dollar question. I think that both the problem and solution are essentially that we have access to all of the information that's ever been available ever. There was a great Simpson's thing where Homer Simpson said, “Beer. The cause of and the solution to all of my problems.” Information is the same way. On the one hand, it is unbelievable how much information we have access to and that's a great thing. It's not hidden. It's not only amongst the elite that have the information. Everyone can have the same information so that's the good part. The bad part is it's very difficult to sift through all of that information and find a) what's correct or b) what's applicable to me. So for example, let's say I'm someone who has a prior C-section and I have a friend who is also someone who has a prior C-section, but one of us has a prior low transverse C-section and one of us has a prior classical C-section. How do we know that we have different percent risks? It's a high level in a certain sense. So sometimes the websites or the podcasts or whatever will spell it out for you and explain it very clearly, but other times, you just get a list like, “Okay, the risk is this, this, this, and this.” You can't really apply it appropriately. One of the things we try to do in our podcasts is to be much more user-friendly and to really explain it and what would apply to you, what wouldn't in certain situations, and what questions to ask, but I would say for people trying to find information, usually it's a shotgun approach. You Google something and find a website then find a list. You have to be very cautious and make sure that this applies to me and my unique circumstances. Hopefully, you have a doctor or a midwife who can help you with that. You might not. It's possible that you may not. The other part is sometimes, it's hard to interpret data. Understanding medical literature is a science. It's something that we train to do. We practice it. I do a weekly journal club with the OB/GYN residents. This is the top of the food chain. These are the smartest of the smart. They got into a great undergraduate. They got into medical school. They got into residency. These are really, really smart people. It's not always intuitive when you read a study or several studies on how to interpret it and apply what is and isn't applicable. It's very difficult stuff. I would say don't be dismayed if you are not understanding the information out there or seeing such variation because you are in the same boat as all of us. It's hard. It's hard to get the right information out there. Meagan: It is. Yeah. Even when I'm reading through studies or things, it's even hard for me to just understand what it's saying and what the relevance is of it and all of it, so yeah. It's really hard. I think what you said, “Don't be dismayed,” it can be really frustrating when we're out there and we're like, “Okay, I have a special scar or not a normal low, transverse incision. What does this mean for me? What does this mean for my future? What does this mean for right now?” It's really hard.I think you nailed it where one friend can have this and one friend can have this. You can both have similarities in your risks, but they also don't apply because there are other things going on in addition. Dr. Fox: There are facts like what is the truth? What is the true fact? There are always some brackets around those numbers because different studies will find different things. Let's say one study finds 1% and one study finds 4%. Is it 1? Is it 4? Is it the average of the two? Is it a range from 1-4? There are some nuances in that. But then there is also trying to sift through the interpretation of the fact. A lot of that is why sometimes you'll see different doctors feel differently about something. For example, let's say the risk of uterine rupture is– let's just do very rounded, broad numbers. Don't hold me to it. Let's say the risk of uterine rupture is 1% and if you've had two C-sections, let's say it's 2%. Let's say those are the true numbers and you can argue about those. Those are the numbers. I could describe those very differently. I could say to somebody, “All right, you've had one C-section. Your risk of rupture is 1%. You've had two. It's a little bit higher. You need to know that it's now 2%. Maybe your chance of a successful VBAC is a little bit lower.” Okay. I could say it that way or I could say, “Whoa, your risk of uterine rupture where the baby could die is doubled.” Right? Meagan: Yeah. That just gave me the chills. Dr. Fox: That's the same number. I've said the same thing in two very different ways. One person hears it and says, “It doesn't sound like a big deal. My doctor said it's fine.” Another person said, “My doctor said that my baby is going to die.” Meagan: Doubled and die, yeah. Dr. Fox: It's understandable because the doctors and midwives, people who are pregnant are all humans. Humans are complicated beings. We have emotions. We have fears. We have experiences. We have anxieties. We have all of these things that come into our heads and it colors how we view risk and how we describe it to other people. So I would say that another lesson is when you are getting information, try to differentiate the numbers and the hard facts from the interpretation of the number or the feeling about the number. That's why you always have to be very cautious when someone says increased, higher, or doubled. That's a relative risk, right? The risk of something is increased. Well, by how much? Is it increased a lot or a little? If the number was very, very low, is it still very, very low but a little bit higher?I always give people an example. If I walk across the street, there's a certain chance that someone moving a piano is going to fall on my head. If I look up every time I cross the street, I'm going to lower that risk but it doesn't matter. The risk is so low to begin with that it doesn't have any practical application to me. It's sort of the same thing. You can talk about something increasing or decreasing your risk, but if the risk is still very, very low anyway, it may not matter to the person practically. Trying to get that from a provider is sometimes difficult because they may not know themselves the actual numbers. They may just know increased or doubled or this. They may be so colored by it that they have a hard time talking about it just as numbers or vice versa. They might just give you hard numbers and you want to know how they feel about it and they're not giving it to you. It is hard, but that's one thing to try to think about or differentiate. Meagan: I love that. I love that. Okay, this can be a very political topic. Dr. Fox: Oh, all right. You're not going to mention Trump. Are we going to talk about Trump?Meagan: We are not talking about Trump. Dr. Fox: Everyone in New York talks about Trump. We like him. We hate him. We hate him. We like him. It's all we talk about. Meagan: I bet. I bet in New York, it's really hot. Maybe in New York, this is even a hot topic but we're going to talk a little bit about COVID-19. Dr. Fox: Oh okay. Meagan: We have a lot of moms who had babies during COVID-19. It was a really hard time for everyone involved. Giving birth as a provider, as a nurse, and everybody in life. This whole world of ours. Dr. Fox: It was unpleasant. Meagan: It was and that's putting it nicely, I think, in a lot of ways. Dr. Fox: I still have scars on my face from wearing my N-95 for six straight months. Meagan: I bet. I bet. It is. It was a very traumatic time. Dr. Fox: Yeah. Meagan: We're interested to see if you felt like COVID-19 had an impact on the C-section rate and if you saw more inductions happening and things like that. But right now, we have a lot of our moms being told even today, that if they had COVID-19 during their pregnancy from the time of conception to the end, they have to give birth by 39 weeks. Dr. Fox: By 39 weeks or after? Meagan: By 39 weeks. What they're being told is that their placentas will just crap out. They're just done. So it can be really hard in the VBAC community when they're being told this and then we may have a provider who doesn't want to induce. Dr. Fox: Yeah, yeah. For sure. Meagan: We have providers all over the world who are not comfortable inducing. We have VBAC moms who are like, “I want to have a VBAC. I had COVID when I was 20 weeks. I'm fine. All is well, but now I have to have a baby at 39 weeks. Here I am and my body's not doing it.” Dr. Fox: Yeah. There is a lot there to unpack. No, it's okay. You're throwing fastballs at me. I like it. You're throwing heat. I'm ready. I knew it was coming. Whether COVID increases the risk of things like the placenta crapping out so to speak is itself a controversial question. The data on that is mixed. It seems that there are some people who COVID has a negative impact on their placenta that manifests as the baby is not growing well. It can manifest as the baby getting preeclampsia. The worst-case scenario is that it can manifest as a stillbirth. However, you wouldn't expect the stillbirth to come out of nowhere. You would expect there to be multiple things leading up to it like the baby not growing well, the blood pressure going up, the fluid dropping, and a lot of things instead of a sudden stillbirth. Meagan: Right, warning signs. Dr. Fox: Now, that is different from someone with COVID who is in the midst of a very severe COVID infection. That is very dangerous to the mother and potentially the baby but we're talking about someone who got COVID and recovered or someone who just found out they had COVID and are fine, that type of thing. A) the data is questionable and B) what to do about it is also questionable. Let's say you're over the age of 35. You also have a slightly increased risk of all of those things if you had IVF. There is a whole list of things that put you at increased risk of your placenta crapping out so to speak and what to do about it is also more of a philosophical question than a hard-data question. Whether someone has to be delivered– I wouldn't say before but usually at 39 weeks– because they had COVID, I'm not doing that personally in my practice. We do follow up and do an ultrasound to make sure the baby is growing well, but if someone had COVID at 20 weeks and is otherwise doing well later in pregnancy, we don't say they need to be induced at a certain point. That's not something I'm doing. I'm not aware of anybody in professional societies like ACOG, American College of OB/GYN, or the Society for Maternal Medicine who actually recommended that or advocated that, but again, some individual doctors are very uncomfortable with any risk. I think the other part of this that is really coloring a lot of these discussions nowadays is there was a study called the ARRIVE trial that got published a few years ago. It's a very, very good study. The study was essentially designed to test if inducing everybody– these are low-risk, first-time pregnant moms. The lowest, lowest risk whether inducing everybody at 39 weeks improved outcomes or worsened outcomes. The outcome they really looked at was the death of the baby. It did not have any impact on that in either direction. What they also learned was that the rate of C-sections did not go up by getting induced. That was the biggest, I don't want to say surprised because medically, we actually thought that would happen, but in the community, that was a surprise because everyone was always told that if you get induced, you have an increased risk of C-section so the study did not show that. It showed a slightly lower risk of getting higher blood pressure which makes sense because the longer you are pregnant, the more it goes. The way I look at that study is if I want to induce someone or if a patient wants to be induced at 39 weeks, there's an upside. There's a downside, but the downside does not include an increased risk of C-section. The downside could be longer labor. It takes more time. It's not as pleasant. Okay, fine. That's how I look at the study. Some people took the study and interpreted it to say, “Since there's no risk of C-section, you should induce everyone at 39 weeks. That's the optimal thing to do.” Meagan: And it's happening a lot.Dr. Fox: Yes. There are definitely people interpreting it. I don't think it's an unreasonable interpretation because you could say, “Listen, if I'm delivering you, there's no chance for a stillbirth in the next two weeks,” I get it. But I don't think it's the only interpretation and it's also a very impractical interpretation because if you induce someone, the amount of time they are in the labor room is on average 18 hours. 12-24 hours they are in a labor room. A common labor on their own, the average is let's say 6-12 hours or something like that. So if you induce everyone, you need twice as many labor rooms. I don't think every hospital in the country plans to double their labor floor so now, you just can't do it practically. This is a very, very long answer to your question. I think what's happened is that you have a new risk factor which is COVID which is very prevalent. Everybody got COVID basically at some point and you have a new fact that inducing at 39 weeks does not seem to increase the risk of C-section so there are some people concluding, “Well, I have a risk factor, and inducing at 39 weeks isn't ‘bad' so I'm going to affirmatively recommend it on everybody.” That's tough. I don't usually recommend it. If they want it, I think it's an option but I think that that's again, hard to know when you sign up with somebody who has provided prenatal care what their philosophy is. These are questions you probably want to ask very, very early on in prenatal care. Again, the things that really matter. So for example, if it very much matters to you not to have an episiotomy, you should ask very early, “Do you perform routine episiotomies?” Most OBs these days will say no, but if your OB says, “Yeah. I do them on everybody,” and you don't want that, get the hell out. Switch. Meagan: Yeah. It's probably not your provider. Dr. Fox: Yeah, and again, if it doesn't matter to you, then don't ask that question. Or for example, let's talk specifically about VBAC. Very early on, just ask, “What are your thoughts on VBAC?” They're not going to lie to you. They're going to tell you. If they don't tell you, you're going to be able to tell right away. If they say, “VBAC is awesome. I love it. I love it when I can help someone with a VBAC. It's so satisfying. It's rewarding. There are some risks and we can talk about that. I think it's great.” Versus they could tell you, “I don't do them.” Or they say, “Yeah, I'm okay with that but I don't know.” They're telling you. They're telling you that it's okay, but they're clearly not a fan of it. Meagan: They're not gungho about it. Dr. Fox: Or the question is if they're gung-ho, you can say, “What's the culture in your hospital like?” So if they say, “I'm gung-ho, but the labor nurses think it's a stupid thing to do and the hospital is trying to get us to stop doing it because they have a lawsuit and this,” you may have a great doctor or midwife but they may be practicing in a place that isn't supportive. That's also an issue. Again, I guess there are some people who would lie to you because they “want your business”, but most OBs aren't like that because if they don't want to do it, it's because a) they think it's wrong, b) they sort of thing it's okay, but they don't want to get into a lawsuit, or c) they're just afraid. So why would they want to hide that from you? It's the opposite. They would want to tell you upfront. I think if you ask very blunt questions very early, they will tell you. If you have a provider who is uncomfortable, you don't want to be with them for your VBAC. It's not a good match. Meagan: We talk to our community members about that a lot. Don't just say, “Do you support VBAC, yes or no?” It's, “How do you feel about VBAC?” I love the question of, “What is the culture in your labor and delivery unit?” I love, love that. Dr. Fox: Usually, this is a good time when open-ended questions are best.Meagan: Yep, yeah. Dr. Fox: Let them talk. Let them cook. They will tell you their thoughts and you can read it very quickly. Meagan: Their body language, yeah. So circling back to this whole induction thing by 39 weeks, you're saying that there's not really any organization that is hard-core supporting this evidence for someone who has had COVID has to have a baby by 39 weeks. Dr. Fox: I have not heard that of anybody. Usually, if someone said that, it usually wouldn't be by 39 weeks. It's a big thing not to induce people before 39 weeks unless there is a very good reason. Meagan: Yeah, and that's what they're doing. They're inducing at 39 weeks or as soon as possible after but I don't know that anyone is recommending that specifically because of COVID. Again, I'm sure there's someone who might but I don't know. Personally, what I would do is if they had COVID, again, I would just check that everything is okay with the placenta. Usually, in later pregnancy, it's just with an ultrasound and then if everything is fine, I wouldn't. If there is a concern, then it would be based on the concern. There are people who I recommend to get induced at 39 weeks but there is a reason and COVID has not been one of them. Meagan: Okay, that's so good to know. We kind of dabbled into the ARRIVE trial. Can we talk about the 40-week mark? We have seen ever since ARRIVE came out that things have moved up. It's like 40 weeks is really 39 weeks. 41 weeks is 40. Dr. Fox: 39 is the new 40? Meagan: 39 is the new 40, yes. It seems to be happening, not everywhere, but it's happening. We talk about uterine rupture after 40 weeks. Our original 40-week, here we are, we know ACOG suggests or supports going past it, but can we talk about the risk of uterine rupture the further into pregnancy that we go?Dr. Fox: So there are two risks. Part of the reason for the shift going earlier is not because of the risk of uterine rupture. It's more of the risk of stillbirth. As you get more pregnant, if you look at just for the baby- I don't want to say this and be recorded but forget about the mom. Meagan: Let's not think about the mom. Dr. Fox: For this question, we're going to forget about the mom. Mother first, baby second but for this question, you're just looking at the health of the baby and you look at the timing of delivery. Generally, things get better and better for the baby as you get closer to 39 weeks meaning your baby born at 37 does better than at 36 weeks. A baby born at 38 does better than 37 and at 39 does generally better than 38. Once you hit 39, it plateaus and then it starts to diminish meaning that the optimal time for a baby is sometime between 39-41 weeks. As you get past that, it goes down. Part of that is because of stuff after birth like meconium or this and some of it is because some of these babies unfortunately will have stillbirths inside. That's very, very rare and I'm not saying this to scare anybody, but it happens. As you go past your due date further and further, the risk seems to go up. With that said, is it worth inducing because of that? Generally, for a typical, low-risk, healthy person, the difference between 39-41 weeks is very minuscule in terms of the baby. So I don't typically tell people that if you are low risk, then you need to be induced at 39 or 40. I tell people that 39-41 seems to be very similar for the baby or have very, very slight differences and I leave it to people's preferences. If there's someone who wants to get the hell out of pregnancy as soon as possible because they are uncomfortable and they have family coming in town or whatever it might be or they are worried about stillbirth, fine. We can go closer to 39 weeks versus if there's someone who really wants to go into labor on their own, then you wait towards 41 weeks. After 41 weeks, the risk really starts going up so there are people who– I don't really let them– I am okay with them staying past 41 weeks, but generally when we get to 42, pretty much everyone recommends inducing at 42 weeks and pretty much at 41. That's all because of the baby. Now, in that conversation for someone with VBAC, there is a second risk on top of that which is okay, that's for the baby, but what about for uterine rupture? So there doesn't seem to be a huge difference between 39, 40, or 41 weeks for uterine rupture. It's slightly higher if the baby is bigger and it's slightly higher if you induce. So you're sort of balancing, is it better to induce and have a slightly smaller baby or is it better to wait and go into labor on your own and have a slightly bigger baby also knowing that if you don't go into labor on your own, now I'm inducing with a slightly bigger baby? That's part of the risk that you may end up in a situation that is worse. And that again, there isn't a right or a wrong answer. It's a conversation. For people whose doctors or midwives won't induce them, out of principle, the hospital won't allow it, they won't allow it, then yeah. You wait as long as they will let you until it's unsafe for the baby and hope to go into labor on your own. In our practice, we do induce people with a prior C-section. It's a conversation. There are risks that are discussed. They decide, “Is it better to do it earlier? Is it better to do it later?” That's again, a conversation based on taking on all of the risks. The risk of inducing, probably ballpark adds another 1% so if your risk was 1%, it probably makes it 2%. Again, I could tell you that makes it doubled or I could tell you it makes it 2%. But you know, it increases a little bit. Not so much if they've had prior vaginal deliveries. That's more so if they've never had a vaginal delivery. The risk of waiting an extra two weeks is also probably less than 1%. These are very small numbers and I don't want to say pick your poison because neither is really poison, but whichever is sort of more palatable, that's the one you'll do. But again, you have to have someone where both options are on the table and for some people, the option to induce is not on the table. Meagan: So for someone who is really worried about uterine rupture, going to 41 weeks and maybe not getting induced or trying to go into spontaneous labor at 41 weeks, we shouldn't be feeling that we have passed that 41 weeks so our chance of uterine rupture just skyrocketed. Dr. Fox: No. The chance of uterine rupture doesn't really go up markedly the more pregnant you get. If you get induced, it goes up a little bit. You have a risk to the baby of waiting.Meagan: Or a bigger baby. Dr. Fox: But the rupture risk is not markedly changed by your gestational age of delivery. Maybe there are slight differences, but nothing crazy. Meagan: Okay, that's good to know for the audience because they ask that a lot. Dr. Fox: Right. But a lot of people or some of the doctors want a “controlled setting”. It also depends on what the situation is. Again, I practice in an area where people can usually get to the hospital very quickly if they go into labor. But if you are practicing somewhere where someone has– I actually just had someone. She actually was 2 hours away. She comes to our practice because we are a high-risk practice and she doesn't want to go somewhere local, fine. She is someone who has two prior C-sections and this. That does play into this because she's not someone who when she goes into labor is going to be monitored right away. She's 2-3 hours. Meagan: She's far away. Dr. Fox: Yeah, so that is sometimes a factor in these discussions. What you do about it depends but that may be a reason that someone might prefer to have you induced rather than going into labor on your own if they are worried about time to get to the hospital or something like that. Again, usually not relevant for me but sometimes. Meagan: More of a controlled setting.Dr. Fox: Yeah. Meagan: You have a lot of knowledge in imaging and testing and all of these things. We're going to take a little bit of a turn from due dates and all of those things and talk about tests that happen during pregnancy. This is kind of something that comes up a lot. We've got early, middle, and late tests that are happening. A couple that is happening in the early stages is genetic testing. It's becoming a lot more popular and a lot of people are wondering, does this impact my chance of VBAC at all? Does this increase my chance of Cesarean? Can genetic testing impact the mode of birth? Is there anything that you feel that our community should know about that early-on test ritual? Dr. Fox: It shouldn't. It really shouldn't impact anything about the mode of birth. For genetic testing, fortunately, if you get to the point where you are 10, 11, 12, 13 weeks when this is done whether it's a blood test or an ultrasound, if it's a screening test or an invasive test like an amnio, again, fortunately, high 90% of people have a baby with no genetic issues whatsoever, thank God. We are very fortunate. For the few people who unfortunately have a baby with one of those genetic conditions, genetic screening and testing is information. It's just to find out before birth. Now obviously, some people get results and choose to terminate pregnancies. Other people get results and choose not to terminate pregnancies. It's just information they want before birth. That's also another political discussion, obviously. But ultimately, at the end of the day, none of that really impacts the mode of delivery. Occasionally, it impacts the timing of delivery. Sometimes with certain genetic things if there are associated anomalies, then occasionally. So I don't think it really impacts. It would have to be a very rare case where genetic testing would then somehow preclude someone from a VBAC. Meagan: That they would have to have a C-section. Dr. Fox: Again, if it precludes someone from having a VBAC, it would also preclude someone from having a vaginal delivery with their first delivery. There are some abnormalities in babies where they are better off being born by C-section but then it has nothing to do with VBAC. That's just the case. But they are also pretty unusual. Even babies with certain abnormalities can usually be born vaginally safely. But occasionally, there are some that they shouldn't. But again, not specific to VBAC. That's just anybody. So yeah. I think if they want to know more about their baby's genetics, they should do it. They should feel comfortable and if for some reason, they don't want to know, fine. That's okay, too but it should not impact VBAC. Genetics is the most complicated part of all of prenatal care for patients, for doctors, for everybody. We have 6 hours of podcasting on this and it's just scratching the surface because it's complex. It is growing. It's expanding. So definitely try to get educated on that, but the short answer, it should not affect VBAC. Meagan: Yeah, it's seeming like it's growing. Dr. Fox: Huge, huge. Meagan: It's a popular topic. Dr. Fox: We know nothing more about labor than we did 100 years ago, but we know a bajillion times more about genetic testing than we did 100 years ago.Meagan: Well, and if anyone wants to find out more about genetic testing, then we will make sure to link your podcast or one of the episodes and they can filter through. Dr. Fox: Definitely, they're free. Meagan: Okay, so another one, and this is usually done through ultrasound, is the scar thickness. Dr. Fox: Mmm, yeah. Meagan: What is the evidence? What do you have to say about the scar thickness? We have some providers that are like, “Ope, it's too thin. You cannot, will not, absolutely will rupture.” They are making very big comments like that. Dr. Fox: I just did a consultation for someone on this two days ago. Well, today is Tuesday. Friday, three days ago, whatever it was. Here's the issue. When you have a C-section, you're essentially cutting open the uterus, taking out the baby, taking out the placenta, and sewing it back together. If the uterus healed perfectly, exactly the same as before you cut it open, then fine. You don't have a risk of uterine rupture any more than anyone else in the world who is having a baby. But when you cut things open and sew them back together, we know that the integrity of that tissue is always diminished compared to before. That's true in every part of the body. So when you're laboring, you are contracting and squeezing and all of that stuff, there is a chance that it would open up. Fortunately, we've learned that for people who have this low transverse type of incision, while that is true, the risk of it is pretty low– 1% or less. There are times when it is higher like if you make a different type of incision on them. So the question is are there ways to further quantify this risk or to find who is that 1%? Can we predict who that 1% is or is it just pure luck? So someone came up with an idea that, “All right. If I look at the area of the scar where I made the incision and sewed it together either before pregnancy or during pregnancy and I measure it, I can measure the thickness of the muscle.” You're taking a muscle and sewing it back together. If it's very thick, the implication is that it's stronger whereas if it is very thin, the implication is that it's weaker. I would say that is probably true that the thicker it is, the stronger it is and the thinner it is, the weaker it is, but the question is how do you use that practically? Right? Is there a cutoff where I could say, “Okay, if it's this thickness or greater, the risk of rupture is less than 1% whereas if it's this thickness and thinner, the risk is more than 1%. It's 2%. It's 5%. It's 10%. It's 50%.” The problem is that we've never been able to identify a good cutoff meaning let's say a lot of people use 2 or 3 millimeters. Under that number, it is a higher risk. If it's over that number, it's a lower risk. The problem with that is that there are enough people whose uteruses rupture despite being over 3 millimeters and there are enough people who don't rupture despite being under 3 millimeters that it doesn't seem to be any practical or useful cutoff. Most of the studies that have looked at– for example, there is a study where they said, “All right, I'm going to take 1000 women or whatever the number was who have had a prior C-section, and in half of them, I'm going to measure the thickness and do this exercise where if it's this thick, I will have them VBAC or if it's this thick, I won't have them VBAC. And then the other 500, I'm not going to even measure. I'm not going to look.” If you look at those two groups, neither one did better. It sort of indicates that this exercise of measuring the thickness of the incision doesn't seem to be fruitful. I'm sure there is somebody on Earth who you measure the thickness, you see it's then, you don't have them VBAC, and you save them a bad outcome, but there are also probably a lot of people who you then said couldn't VBAC when they would have a perfectly fine VBAC. So the short answer is that nobody knows. There isn't one standard and that is something that some people use in their practice and some people don't. In our practice, we don't formally measure the thickness and make decisions about it. If we see something that looks remarkably unusual, then we have a discussion about it. It depends on your circumstances, but we don't do that ourselves. There are those that do it. Whether they are helping the world or harming the world, I have no idea. Nobody knows. That's the problem. Now, there's a different situation where you measure the thickness before pregnancy. Meagan: That's what I was just going to ask. Is there a situation where, “Okay. We're done. We're not even pregnant and we measure.” Dr. Fox: That is something that is an emerging field of research. We do that on certain people who have had multiple C-sections. It's not often because I want to know if they should VBAC or not. It's usually if I'm worried about something called a Cesarean scar pregnancy where their pregnancy implants there or if they're at risk of uterine rupture during pregnancy. There are different cutoffs used. You have to have a very specific test called a saline sonohysterogram where we squirt water into your uterus and measure the thickness of the scar. What to do about it, you need surgery to repair that and then what do those people do in pregnancy? This is definitely not standardized and different people do it differently ranging from not doing it at all to doing it very religiously. You still don't know what is the optimal method for this. Again, we don't do this test on everybody who has had a C-section between pregnancies. We do it on certain people, but a lot of it is about planning for the pregnancy more than deciding about VBAC or not is what I would say. Meagan: If they can or cannot. Okay, that is good to know. And then in the same area, we have some people talking about adhesions. We get adhesions after we have C-sections. If we have really dense adhesions and we're having issues, does our risk– and we're seeing this on these ultrasounds– of rupture go up with adhesions? Dr. Fox: Adhesions are generally scar tissue in your belly. That's either between the uterus and other parts of your belly or between layers of your abdominal wall. Number one, we don't think that they have any impact on the risk of rupture. They make a C-section harder on your surgeon but we don't usually see them on ultrasound. That's actually not correct. Meagan: People are saying that they are told that. Dr. Fox: Adhesion just means that two things are stuck together. Meagan: It's just scar tissue, right? Dr. Fox: Yeah. It's hard to tell if two things are stuck together versus just sitting next to each other on ultrasound. If I showed you a picture of my hands together, you would have no way of knowing if they are superglued together or not unless I tried to pull them apart. So it's the same thing. On ultrasound, we rarely– sometimes, you'll see that the uterus is tilted in a really weird way and you know it must be scarred or this or that. That's also prepregnancy. During pregnancy, your uterus grows very, very large and you can't typically tell who is and who is not going to have scar tissue. It does not usually impact VBAC. Also, you rarely have a lot of scar tissue after only one or two C-sections. Usually, it's if you've had three or four or five and we're not doing VBACs on people who have had three, four, or five C-sections and no vaginal births and so it doesn't really come into play practically. Meagan: Okay, yeah. That's good to know because people are being told that in these scar thickness visits that, “Oh, and you have a lot of adhesions so your chance of rupture is increased.” Dr. Fox: Listen, I don't have the skill myself to recognize adhesions on ultrasound. I'm not sure if anyone does. I'm not sure if they're telling people that because maybe– I guess the only way you would know is say someone has had two prior C-sections and they want a VBAC and the person who did their second C-section saw a lot of scar tissue from their first C-section, then they would say, “Listen, I did your second C-section. It's a mess in there. You're not a good candidate for VBAC because if you needed an emergency C-section in labor, it would take a long time to do it.” That is a very reasonable discussion to say, “Listen, part of doing your VBAC is having the capability of doing an emergency C-section if it goes wrong or if something bad happens or there is a concern over that.” If you know in advance, I can't do a C-section easily, then it makes it more difficult. For example, that happened to someone who we know has scar tissue, or let's say someone who had multiple surgeries. Let's say someone had a tummy tuck which has a lot of scar tissue or they have Crohn's disease and they had three other surgeries. Let's say because of the size of the person themselves if they are much larger, then it is harder to do a C-section quickly, then that is a very reasonable concern over VBAC. Listen, if the VBAC goes well, great. But if I have to do a C-section in labor and I have to do it quickly, I can't do it quickly. That's sort of the reason why hospitals don't have VBACs because they're like, “Listen, we don't have an anesthesiologist 24/7. If you need a C-section, I need 30-60 minutes to get a team in place. That may not be safe.” That's one of the reasons why smaller community hospitals don't allow VBACs. It's not because they're mean. It's because they don't have the proper staffing to address an emergency. Now, anybody can have emergency labor, so it's a problem for everyone, but it's more common that if you have a prior C-section, then you may have to do something emergently. Meagan: Okay, and one of the last and most famous ultrasounds in our community is the third-trimester ultrasound to check baby's size. In our community, we have a lot of people doubting their body's ability to give birth because they are told that their babies are too large or their pelvis is too small. La dee dah, we could go on for a long time about that, or that their fluid is too low. We're getting these third-trimester ultrasounds. One, the question is, is it absolutely necessary? Can someone turn it down? Is it a bad idea to turn it down? And two, if they're told, “You're baby is too large. Your fluid is too low,” is it possible to increase their fluid somehow? Is it really possible to know exactly how big that baby is? Dr: Fox: To answer that question fully, we need more than the 5 minutes that we have left. I can come back, but the short answer is whether it's a good idea or not to have that ultrasound is debatable. In our practice, we do it but we have a higher-risk population typically. And I am pretty confident that we interpret the results appropriately. The issue isn't so much the ultrasound. It's the interpretation of it. Low fluid is a legitimate concern and that's a concern for the health of the baby because low fluid could indicate a non-functioning placenta or as we said earlier, that your placenta is crapping out. That could be a sign of that. That's real. That's legit. If the baby is measuring too small, most of them are fine, but the concern is maybe it means that your placenta is crapping out. The baby being too big, there are two issues with that. One is that, especially with big babies, they are less accurate. With smaller babies, we tend to be more accurate. Bigger babies, we tend to be more inaccurate. We may be right that the baby is big, but how big, we're not that precise. And what to do about that. Like you said, most people having a baby can deliver a big baby and everyone's going to be fine. But yes, there are risks that go up as the baby gets bigger. There is a risk of injury to the baby. There is a risk of injury to the mother and there is a risk of uterine rupture because a) the baby is bigger and b) the labor is likely going to be longer and more difficult which increases the risk. Now, whether that should be used as a criterion to prohibit VBAC, again, is debatable. There isn't a perfect answer to this. I would be less comfortable managing a VBAC if the estimated weight of the baby is 10 pounds over 8 pounds. Do I have to be so uncomfortable that I wouldn't allow it? It depends on the circumstances, obviously. It is a legitimate concern that the baby is measuring big, but again, how confident are we? Those are difficult details. Our ability to assess the size of the pelvis is even worse because the pelvis changes in labor. It's part of our assessment, but we have the humility to know that we are frequently wrong about that. It's tough. Listen, if someone had a prior C-section and their story is, “I pushed for 4 hours and this 6-pound baby didn't come out and they did a C-section,” then in the next pregnancy, I'm estimating a 10-pound baby and the pelvis does not feel so great and the baby is very high, I'm certainly a lot less gungho about it than if they said the opposite. “I pushed for 4 hours for a 10-pound baby,” in the next pregnancy, the pelvis feels really roomy and great and the baby is measuring 6 pounds. That's legitimate. I could be wrong, but that's information that might be helpful to me. But again, this has to be individualized. There isn't a perfect answer to this. I wish we could be more scientific. People have tried a lot of different things. There used to be routine X-rays and to see the size of the pelvis and the size of the baby's head. It didn't help. The baby's head changes shape in labor and the pelvis changes shape in labor so we are not precise with this, unfortunately. Meagan: No, I love that you said it's all unique. We're all individuals. We're all different and even from one baby to another, we need to remember that it's always different. Dr. Fox: Yeah. Yeah. Meagan: Well, I know that we could dive into so much more. There are so many topics, but I really wanted to just thank you so much for taking the time today. I know you've got quite the schedule and spent this hour with us answering these questions. Dr. Fox: My pleasure. Thank you for inviting me. Thanks for doing what you're doing. I think it's great and hopefully, we can continue getting people better information and making good choices. Meagan: Yes. We will make sure to link everything to your podcast and your website so people can read more about you. In New York, people can find you. Sometimes, it can be that VBAC people are looking for doctors all of the time. Dr. Fox: If you are in New York City, at our practice, we do VBACs so come on over. If we don't think it's a good idea, we'll tell you but if it's a good idea, we're on board. Meagan: And you do VBAC after two C-sections, you said? Dr. Fox: We do. It depends on the exact circumstances, but we don't prohibit it because of two C-sections. Obviously, there are some people in that category who think it is a better idea than others, but it's not a hard rule or anything like that. Meagan: Okay, good to know. Okay, well thank you so much. Have a wonderful day. Dr. Fox: You too. Thank you very much, I appreciate it.Meagan: Okay, bye. ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan's bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands

It's pretty standard of an evaluation… TVUS for postmenopausal bleeding. It's well accepted that an endometrial thickness of 4 mm (5 mm in some studies) should trigger further endometrial tissue analysis in women with postmenopausal bleeding. But is there a cut-off endometrial thickness at which endometrial tissue should be evaluated in a postmenopausal patient WITHOUT bleeding, where this was found incidentally? There is definitely an evidence-based recommendation, and we will cover that in this episode.(With a special guest host

Nic Rummel is an applied mathematician and expert boulderer. Ethan Pringle joins as co-host for another fun episode from Rocklands. We talked about embracing his nickname “Thick Nic”, lessons from working with Matt Fultz, sending V13 crimp boulders at 185 lbs, epic math projects, taking ballet to practice movement, the keys to a good spray wall, go-to hangboard protocols for epic finger strength, how lifting weights led to his best trip ever, finding mentorship in an 80-year-old climbing legend, and much more!Check out Crimpd!crimpd.comOr download the Crimpd app!Check out AG1!drinkAG1.com/NUGGETUse this link to get a free year's supply of vitamin D + 5 travel packs!Check out Wonderful Pistachios!WonderfulPistachios.com to learn more!Check out Rocky Talkie!RockyTalkie.com/NuggetUse this link to get 10% off your first order of backcountry radios!Check out Rumpl!rumpl.com/nuggetUse code "NUGGET" at checkout for 10% off your first order!We are supported by these amazing BIG GIVERS:Leo Franchi, Michael Roy, David Lahaie, Robert Freehill, Jeremiah Johnson, Scott Donahue, Eli Conlee, Skyler Maxwell, Craig Lee, Mark and Julie Calhoun, Yinan Liu, Renzollama, Zach Emery, and Brandt MickolasBecome a Patron:patreon.com/thenuggetclimbingShow Notes:  thenuggetclimbing.com/episodes/nic-rummelNuggets:0:06:39 – Test, test, testing…0:08:24 – How Thique Nic got his nickname, and embracing the body you're given0:15:02 – Viking-built, trucks vs. Mazdas0:17:43 – Working with Matt & Hailey (Franklin) Fultz, and the confidence that comes with hitting strength benchmarks0:20:39 – Everyone wants to be like someone else, and being proud of the climber you've become0:23:29 – I'm on one, training for his local project in Fort Collins CO, and why he had such a successful trip to Rocklands0:30:08 – Deloading, Nic's job in missile tracking and detection, and going back to school for a graduate degree0:35:23 – Needing more rest now that he is in school0:36:14 – Nic's longest boulder project vs. his math problem0:41:29 – Applied math vs. pure math0:46:00 – The math problem that took Nic the longest to solve0:49:01 – Finding better beta on the JABE problem0:54:06 – Mathing vs. bouldering, comparison, and balancing multiple passions0:58:49 – Having a physical goal, an artistic goal, and an intellectual goal1:00:04 – Artistic outlets, and making an art film1:02:13 – Ballet1:11:32 – Nic's crimping journey1:16:29 – Beating Matt Fultz to the 200 lb OTG, doing 58 pullups in a minute, and getting confidence from metrics1:21:19 – Nic's crimping journey continued, and long-term hangboard training1:24:32 – Nic's key takeaways from reading Ned Feehally's book Beastmaking1:26:07 – Doing a hangboarding workout before trying your project, and adapting over time1:27:53 – Nic's go-to hangboard protocols1:32:09 – Nic's top hangboard recommendation that he got from Will Anglin1:34:15 – Nic's thoughts on training micros1:35:53 – When to do the Will Anglin workout, and doing long-duration hangs as part of his warmup1:37:34 – Being warmup kings, and training less than usual1:41:05 – Ethan's feelings1:42:41 – Nic's secret crimp project, and doing the stand to Andramada1:44:41 – Working on climbing movement, and how he set up his home wall to work on his weaknesses1:47:56 – How the home wall facilitated community, and buying his house in Fort Collins1:51:54 – The evolution of Nic's home wall, and why he doesn't like big holds on boards1:56:04 – Ethan tries to convince Nic to try Scorsese 5.14c in the Poudre1:57:45 – Setting as a creative outlet, and what he wishes he could change about his home wall2:00:07 – Why Nic doesn't recommend using T-nuts on a home wall2:02:15 – Using electric scooters to get to Lincoln Lake2:09:06 – Ethan hates on CO alpine bouldering, and the boys compare it to Eldo and the Flatirons2:13:59 – How Nic ended up in Boulder, living on Paul's land, and renovating his trailer2:23:22 – Showering, splitting time between the trailer and his house, and having Paul as a mentor2:28:54 – Wanting to feel like a badass, and finding balance2:32:30 – Feeling content with his trip, getting sick, and sending Sky V132:35:59 – Lifting weights to keep up with his sister2:38:02 – Taking measurements of his body, and how he's changed over the years2:39:04 – Nic's brother, his siblings' climbing, and a lesson from powerlifting2:43:54 – Dream climbs, plans to try more V14s, and why he got hurt on his project2:47:58 – Music City Hot Chicken2:48:34 – Go-to breakfast2:49:37 – Go-to climbing shoes2:52:17 – Climbing in Red Feather2:53:07 – Trap music2:54:31 – Obtaining big goals2:56:55 – Ethan talks about Nic's send of Airstar V132:58:41 – Wrap up

David and Tamler return to the work of old favorite William James and argue about the 6th lecture (inspired by the French philosopher Henri Bergson) of his 1909 book “A Pluralistic Universe.” James attacks the philosophical habit of elevating unchanging concepts over the continuous ever-changing flux that characterizes raw experience. Concepts, James argues, carves joints where there are none. But why does James trust pure perception (unmediated by concepts) as a true window into reality? Does he want us to return to the blooming buzzing confusion of our infancy? Is his mystical side superseding his pragmatism? Plus, a new study on generosity after receiving a $10,000 windfall leads to a discussion of what we can interpret from null results, and lots more. Dwyer, R. J., Brady, W. J., Anderson, C., & Dunn, E. W. (2023). Are People Generous When the Financial Stakes Are High?. Psychological Science, 09567976231184887. A Pluralistic Universe by William James (Lecture VI)   Sponsored by: BetterHelp: You deserve to be happy. BetterHelp online counseling is there for you. Connect with your professional counselor in a safe and private online environment. Our listeners get 10% off the first month by visiting BetterHelp.com/vbw. Promo Code: VBW Rocket Money: Stop throwing your money away. Cancel unwanted subscriptions, and manage your expenses the easy way, by going to RocketMoney.com/vbw. Promo Code: VBW