Podcasts about TIA

Tia Levings is the New York Times bestselling author of A Well-Trained Wife and her newest book, I Belong to Me. She survived a Christian patriarchy cult, escaped a near murder-suicide, was excommunicated for telling her own story, and spent 15 years in intensive trauma therapy doing the work to put herself back together. Now she's handing you the map to healing from religious trauma.In this episode, Tia and I dig into the real mechanics of religious trauma recovery: why your body refuses to believe you're safe even when your brain knows it, what "aftermath" actually means (it's an agricultural word, and it will change how you see your own devastation), why grief work is not optional, and what agency has to do with the entire trajectory of your healing.Key Takeaways:What does it actually mean to "belong to yourself" after religious trauma has dismantled your sense of identity from the inside out?Why trauma survivors often write, speak, and even think about themselves in the passive voice, and what that reveals about the agency that was quietly stolen from themWhat the agricultural origin of the word "aftermath" tells us about why the most painful, raw season of your healing is also the most generativeWhy anger and bitterness after religious trauma aren't signs that something is wrong with you, and what they're actually trying to show youHow complex PTSD can keep a survivor locked in survival mode for years, making life-altering decisions in a state of ongoing shock without ever realizing itGet Tia's books:A Well Trained WifeI Belong to MeFollow Tia everywhere on social media! Her handle is @tialevingswriter Get Today's Free Resource:

Today Dr. Mays brings back Miss Gainesville Tia Unsell. Join them as they discuss life in the Miss Florida Organization, life after the Miss Florida Organization, and of course, their favorite topic, their walk with Jesus Christ.How can Agape Leaders serve you?  Please find us at:         Website:  http://www.agapeleaders.org/    LinkedIn:  https://www.linkedin.com/in/gregg-mays/      Facebook:  https://www.facebook.com/agapeleaders.org     Instagram:  https://www.instagram.com/agapeleaders10/    Bible Break With Agape Leaders: http://www.agapeleaders.org/daily-devotionTik Tok: https://www.tiktok.com/@greggmaysYouTube: https://youtube.com/channel/UCmM7ETR652mLtDSKSjda-pwGet Your Copy of the A Word Wednesday Devotion: https://www.amazon.com/s?k=A+Word+Wednesday+Devotion&ref=nav_bb_sbRead Dr. Mays' book Practical Leadership: https://www.amazon.com/s?k=practical+leadership+lessons+from+an+average+leader&crid=259U5RNS5J5W5&sprefix=Practical+Leadership%2Caps%2C102&ref=nb_sb_ss_ts-doa-p_4_20 Give to ALCFM: http://www.agapeleaders.org/store/p15/Agape_Leaders_Christian_Fellowship_Ministry_Support.htmlPlease contact Tia at:Instagram: ⁠https://instagram.com/tiaunsell?igshi...Facebook: ⁠https://www.facebook.com/tia.unsell?m...

Joined by Candice, Tia and Kim Cares (or Hates). GH celebrates 16,000 episodes! Will Victor leave his issues for Jack aside for Nikki? Bill life at balance yet again. Days continues to Days. Jason has returned. Will and Electra forced apart like teens...

Political and economic power is increasingly moving toward the South as corporations relocate, populations grow and Southern leaders gain more influence in Washington. On today's episode of The Atlanta Journal-Constitution's Politically Georgia podcast, Tia Mitchell and Patricia Murphy speak with Democratic strategist Howard Franklin about his new report, Accelerating South: Risks, Rewards and the Road Ahead. Franklin explains how migration, business investment and a new generation of governors could reshape the region and Georgia's place within it. The conversation also examines the debate over data center growth, Atlanta Mayor Andre Dickens' second-term priorities and the possibility that Georgia could elect a Democratic governor while Republicans retain control of the General Assembly. Tia and Patricia then assess how Keisha Lance Bottoms and Rick Jackson are repositioning themselves for the general election, and what Democrats still want to see from the Bottoms campaign. Have a question or comment for the show? Call or text the 24-hour Politically Georgia Podcast Hotline at 770-810-5297. We'll play back your question and answer it during our next Monday Mailbag segment. You can also email your questions at PoliticallyGeorgia@ajc.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

Joined by Candice, Kerry, Tia, Daphne and Jay. We react to the nominees of the 53rd annual Daytime Emmy noms. Who are the subs and who are the ones who deserved it?

Art Dielhenn joined me to discuss watching Roy Rogers; having celiac disease and dyslexia; a drama coach turns him onto acting; realizing in college he is not an actor; moving Oppenheimer's possessions as a moving man; spending 7 years directing at KRMA Denver; moving to KQED San Francisco and directing Pauline Kael; Peter Bonerz is a guest and invites Art to L.A.; Norman Lear hires him as an AD on Apple Pie and Hello Larry; does Sanford and says Redd and Jamie Foxx are two funniest people he's ever worked with; working with Jack Shea on Silver Spoons; Insight; getting the job on Punky Brewster; "Perils of Punky" episode; censor problems; 15 minute episodes; going to Webster; everyone hates Susan Clark; being friends with Soleil Moon Frye's mom and they both protect Soleil; going to Head of the Class; Howard Hesseman being miserable; working with Brian Robbins, Dan Schneider, and Elaine Stritch; getting hired to direct Free Spirit, wanting Amy Yasbeck as star, but getting Corrine Bohrer; wanting and getting Allison Hannigan as co-star; directing a Cosby Show and having to give Cosby notes; directing Pacific Station and dealing with a depressed Robert Guillaume; having fun with Ron Liebman; Sister, Sister with Tia & Tamera Mowry; directing Lifetime show Maggie; going into life coaching; getting clients; going to AA; writing Get Out of Your Head and Addiction is a Family Disease; how alcoholism is a progressive disease even if you're not actively drinking

In this heartwarming episode of Reading With Your Kids, Jed welcomes two middle grade authors whose stories are perfect for sparking big family conversations. First, singer-songwriter and author Tia McGraff joins us from the shores of Lake Erie to celebrate her new novel In Your Dreams, Jake, part of the Jake the Road Dog series. Tia shares how her rescue dog Jake, once just a day away from being euthanized, became a beloved "road dog" traveling to festivals, bookstores, and schools—and eventually inspired a middle grade story told through his eyes. She and Jed talk about the joy of live family events, the sacred honor of performing for kids, and how music, books, and creativity help families cope with grief, change, and challenging times. Tia also reflects on her journey from country music stages and Johnny Cash appearances to writing children's novels and kid-friendly songs like her "Caterpillar Song." Then, Jed chats with Austin Kairnes, author of The Blind Boy Who Saw the Invisible King. Austin explains how a title that came to him on a COVID-era walk grew into a rich quest story about Joe, a blind boy searching for answers from a mysterious king. They explore themes of bullying, empathy, faith, and seeing the world through non-visual senses. Austin shares how his Catholic faith quietly shapes the story, how reading aloud shaped his own family life, and why he believes nightly reading is one of the best ways to pass on values and build lifelong connections.

“I got the best of both worlds, country and as well as Detroit.” Tia Graham, co-host of WDET 101.9 FM's 'The Metro,' brings that layered truth into this Detroit is Different conversation, tracing her family's journey from Alabama and Arkansas to Detroit, where factory work, survival, and community shaped generations. From her grandfather “fleeing the Klan” to her Joy Rd upbringing near Exit 9, Tia opens up about the past that built her and the neighborhood that raised her. She remembers block parties, kids playing football in the street, the Boys and Girls Club, the Belle Isle strip with her Big Sister, and the everyday beauty often hidden from national & traditional media's Detroit narrative. “It was just our neighborhood McDonald's,” she says, challenging the way people talk about Joy Rd. This interview matters because it connects migration, memory, media, and Black Detroit's future. Tia's story shows how community survives through elders, siblings, culture, laughter, and people who choose to tell the truth with care. Listen to hear how a Detroit voice behind the microphone became a witness to the city's resilience, rhythm, and responsibility. Detroit is Different is a podcast hosted by Khary Frazier covering people adding to the culture of an American Classic city. Visit www.detroitisdifferent.com to hear, see and experience more of what makes Detroit different. Follow, like, share, and subscribe to the Podcast on iTunes, Google Play, and Sticher. Comment, suggest and connect with the podcast by emailing info@detroitisdifferent.com Find out more at https://detroit-is-different.pinecast.co

Tia Mitchell looks at the unusual race to succeed the late U.S. Rep. David Scott in Georgia's 13th Congressional District. She speaks with state Rep. Jasmine Clark, who won the Democratic primary for the next full term, about why she did not enter the special election and how she is preparing for Congress. Tia also talks with Dr. Everton Blair and Marcye Scott, who are running in the special election to finish David Scott's current term, about what they believe can be done in a short window before January. Have a question or comment for the show? Call or text the 24-hour Politically Georgia Podcast Hotline at 770-810-5297. We'll play back your question and answer it during our next Monday Mailbag segment. You can also email your questions at PoliticallyGeorgia@ajc.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

Do your loved ones in spirit hear your prayers? Can they guide you through life's most difficult seasons? In this heartfelt episode of Radio Medium, internationally known psychic medium Laura Lee connects with Tia from Michigan for an evidential psychic reading filled with powerful spirit messages, emotional validation, and hope. During this moving mediumship session, Laura connects with Tia's father, Russ, in spirit, who lovingly confirms he remains close, watching over the family as they navigate caregiving responsibilities after her mother's serious health crisis. Through unmistakable validations, spirit acknowledges Tia's unwavering strength, encourages her to trust an upcoming career opportunity, and reminds her that divine timing is unfolding—even when life feels uncertain. This touching reading explores grief healing, faith, resilience, caregiving, and the enduring connection between loved ones on Earth and in the afterlife. Whether you're caring for aging parents, grieving someone you love, seeking spiritual guidance, or wondering whether your loved ones still walk beside you, this episode offers comfort, reassurance, and an inspiring reminder that love never ends. Tune in for a powerful intuitive reading that will strengthen your faith and renew your hope.

What does it take to build a successful career in film while staying true to your creative vision?In this episode of A Conversation With Floyd Marshall Jr., co-hosted by Okema T. Moore, award-winning director, executive producer, and creative visionary Tia A. Smith shares her remarkable journey from an internship at BET to leading award-winning projects in film, television, documentaries, and branded entertainment. Tia discusses her transition from producer to director, the inspiration behind her acclaimed short film The Heir, and why she believes the best storytellers refuse to be boxed into a single role. She also shares valuable lessons on leadership, networking, mentorship, career pivots, authentic storytelling, and creating work that leaves a lasting impact.

Tia steps into the trivia ring to challenge Victoria in another hilarious round of You vs. Victoria—and things go off the rails almost immediately!

Lynn Gravley, Founder of NTG and TIA's incoming Chairman, on why brokers who cut shipments instead of chasing them win the freight game, and more.This week's episode is sponsored by  Epay Manager, Highway, Goodship, BitfreighterInterested in sponsoring our podcast? Send us an email at pbj@freightcaviar.com.

Across Christian traditions, there are many ideas about Satan and demons, but today we will explore this topic to think theologically about Spiritual Warfare.For the study resources and manuscript go to messiahbible.org

Dr. Terry Dubrow — board-certified plastic surgeon, star of Botched, and self-described "preservation longevity" obsessive — joins Dr. Will Cole for one of the most wide-ranging and genuinely entertaining conversations the podcast has had. They cover the accidental origin of Real Housewives of Orange County (Terry signed Heather's name to the contract without asking her), the peptide landscape including Terry's take on retatrutide and the importance of compounding pharmacies being legal again, high-dose creatine and memory testing, AI erasing the price of intelligence, the TIA he had at The Ivy restaurant and the 3-minute PFO repair that followed, why deep plane facelifts are overhyped and overpriced, and what he actually takes every day to preserve what he calls his "meat body." For all links mentioned in this episode, visit http://www.drwillcole.com/podcastPlease note that this episode may contain paid endorsements and advertisements for products and services. Individuals on the show may have a direct or indirect financial interest in products or services referred to in this episode.Sponsors:Visit fromourplace.com/WILLCOLE and use code WILLCOLE for 10% off sitewide.Head to MANUKORA.com/WILLCOLE to save up to 31% plus $25 worth of free gifts with the Starter Kit, which comes with an MGO 850+ Manuka Honey jar, 5 honey travel sticks, a wooden spoon, and a guidebook.Text ABW to 64000 to get 20% off all IQBAR products, plus FREE shipping. Message and data rates may apply.Go to CLEARSTEM.com/WILLCOLE and use code WILLCOLE at checkout for 15% off your entire order. Produced by Dear Media.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Greg Bluestein and Tia Mitchell answer listener questions about the prospect of another special session if Democrats win key statewide offices in November. They also break down Mike Collins' continued embrace of Trump's false 2020 election claims, the fight over Fulton County election board nominees and the stalled effort to replace Georgia's QR code voting system. Greg and Tia close with a look at split-ticket voters and why they could again decide statewide races in Georgia. Have a question or comment for the show? Call or text the 24-hour Politically Georgia Podcast Hotline at 770-810-5297. We'll play back your question and answer it during our next Monday Mailbag segment. You can also email your questions at PoliticallyGeorgia@ajc.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

In "The Broken Safety System Threatening Shippers and Brokers," Joe Lynch and Chris Burroughs, President and CEO of the Transportation Intermediaries Association (TIA), discuss the fallout from a landmark Supreme Court ruling and rising freight fraud are reshaping the logistics liability landscape.  About Chris Burroughs Chris Burroughs is the President and CEO of the Transportation Intermediaries Association (TIA), a position he assumed in November 2024. With over 14 years at TIA, he previously served as Vice President of Government Affairs, overseeing legislative and regulatory efforts before Congress and federal agencies. Before joining TIA, Burroughs gained valuable experience on Capitol Hill, working for the House Transportation & Infrastructure Committee and the House Natural Resources Committee. He also served as Director of Government Affairs at the Twenty-First Century Group, advocating for clients in transportation, telecommunications, health care, and defense. Burroughs holds a Bachelor of Science degree in Political Science from Shepherd University in Shepherdstown, West Virginia. About TIA The Transportation Intermediaries Association (TIA) is the professional organization of the $343 billion third-party logistics industry. TIA is the only organization exclusively representing transportation intermediaries of all disciplines doing business in domestic and international commerce. TIA is the voice of transportation intermediaries to shippers, carriers, government officials, and international organizations. Learn more about TIA at www.tianet.org Key Takeaways: The Broken Safety System Threatening Shippers and Brokers In "The Broken Safety System Threatening Shippers and Brokers," Joe Lynch and Chris Burroughs, President and CEO of the Transportation Intermediaries Association (TIA), discuss ow the fallout from a landmark Supreme Court ruling and rising freight fraud are reshaping the logistics liability landscape.  The Montgomery Decision Resets the Liability Landscape: The Supreme Court's recent 9-0 ruling in the Montgomery case (involving C.H. Robinson) eliminated the long-standing F4A federal preemption defense for brokers regarding carrier safety selection. While 31 states had already rejected this defense prior to the ruling, the decision officially shifts safety and negligent selection liability standards back to a patchwork of differing state regulations. TIA Petitions the FMCSA for a National Carrier Selection Standard: In response to the confusion caused by the Montgomery decision, the Transportation Intermediaries Association (TIA) filed a petition for rulemaking with the Federal Motor Carrier Safety Administration (FMCSA). TIA is pushing for a clear, national federal standard to dictate exactly what checks a shipper or broker must perform when vetting and selecting a trucking company, eliminating state-by-state confusion. The Core Elements of TIA's Proposed Vetting Standard: TIA outlines three baseline data points that the federal government should mandate for a secure carrier selection process: operating authority (ensuring full compliance with the FMCSA), valid insurance (confirming active, legitimate coverage to combat marketplace fraud), and safety status (verifying the carrier has not been placed out of service for safety violations or paperwork compliance issues). A Broken Data System Leaves 94% of Carriers Unrated: A major hurdle in carrier vetting is that 94% of trucking companies remain "unrated" by the federal government. Because the FMCSA relies on strenuous, physical audits and suffers from limited inspector resources (drastically worsened during the pandemic), they only audit carriers that trigger red flags. TIA strongly advocates shifting from this outdated physical audit system to an absolute, data-driven safety rating algorithm. TIA Demands the Release of the "High-Risk Carrier List": The FMCSA maintains an internal database of approximately 3,000 to 4,000 trucking companies categorized as "high-risk," based on their Safety Measurement System data. As a key part of their petition, TIA is demanding that the government publicize this list so brokers and shippers have the transparency needed to actively avoid dangerous carriers. The Sophistication and Rise of Strategic Freight Fraud: Freight fraud and cargo theft have evolved past opportunistic crimes into highly organized, international cyber syndicates. Strategic theft has skyrocketed by 1,500% since 2020. Bad actors are shifting tactics—moving away from registering new fraudulent entities to buying up clean, legitimate, 2-year-old authorities on online marketplaces, executing massive "heists," and then vanishing. Industry Consolidation and the Value of Trusted Associations: The compounding costs of increased insurance premiums, tighter vetting processes, and necessary technology stacks are expected to drive significant market consolidation, forcing smaller players out. Because of this complex environment, shippers are increasingly looking to work with brokers tied to professional organizations like TIA, which enforces a strict code of ethics, offers ongoing education, and acts as the exclusive advocacy voice for the $343 billion 3PL industry on Capitol Hill. Learn More About The Broken Safety System Threatening Shippers and Brokers Chris Burroughs | Linkedin TIA | Linkedin TIA TIA Technovations TIA Technovations with Tom Curee Trucking Through Trouble with TIA & Anne Reinke TIA Unpacks Freight: Tariffs, Trust, and the Fight Against Fraud with Chris Burroughs FMCSA Petitions for Rulemaking (Open Petitions) The Logistics of Logistics Podcast If you enjoy the podcast, please leave a positive review, subscribe, and share it with your friends and colleagues. The Logistics of Logistics Podcast: Google, Apple, Castbox, Spotify, Stitcher, PlayerFM, Tunein, Podbean, Owltail, Libsyn, Overcast Check out The Logistics of Logistics on Youtube

Walking After Stroke: What Your PT Knows That Your Doctor Doesn’t A doctor walked in, ran a reflex test, and told the patient they would never walk again. That same day, a physical therapist from Dr. Kory Langwell’s team arrived. The patient was in tears. And then they walked 70 feet. “I hope you go back and tell that doctor,” Kory said, “that they missed that.” Dr. Kory Langwell is a Doctor of Physical Therapy with over 15 years of experience. He runs a mobile home therapy practice across Southern California, and now coaches stroke survivors worldwide through his virtual program at Unlimited Potential Physical Therapy. In episode 410 of the Recovery After Stroke podcast, Kory broke down the realities of walking after stroke what’s actually possible, where the system fails survivors, and what a good physical therapist knows that most doctors don’t. The Moment the System Stops For most stroke survivors in the United States, recovery starts with intensity. In the hospital, you might receive three hours of therapy a day. Then you go home. Within weeks, that drops to thirty minutes, once or twice a week. “Insurance doesn’t know when your brain stops recovering,” Kory says. “Therapy ending doesn’t mean progress ends.” The problem is that for many survivors, the message lands the other way around. When the funding stops, the belief follows: that recovery is over, that this is where they plateau, that there’s nothing left to do. That belief, more than the stroke itself, can stall everything that comes next. The Plateau Is Not a Full Stop One of the most damaging phrases in stroke recovery is “you’ve plateaued.” It implies that the brain has reached its ceiling, that whatever function you have now is what you’ll have forever. Kory pushes back hard on this. “I’ve seen progress years, decades, 10 to 20 years after a stroke. Arms, hands, legs, walking ability. People just get fed up and stop looking for resources.” What a plateau usually means is that the current approach has stopped working, not that progress itself is impossible. The clinical response isn’t to discharge the patient. It’s to audit what they’re doing and change something. Different exercises, different load, different feedback. Reassess in six weeks. See what moves. Walking After Stroke: Why More Isn’t Always Better Walking after stroke is where survivors often get their first taste of both independence and confusion. The instinct, and it’s a good one, is to walk more. Further, longer, more often. But Kory draws an important distinction between the acute stage and everything that comes after. In the early weeks post-stroke, more isn’t always better. If someone can walk five steps, pushing them to twenty-five on back-to-back days may overtax the neurological system rather than rebuild it. Fatigue compounds quickly. Quality collapses. And when quality collapses, the brain reinforces the wrong patterns. “I’d rather have somebody walk 50 feet really well than 150 feet terribly,” Kory says. Visual feedback changes this completely. When survivors watch themselves walk in a mirror, or on a phone recording, they often see something very different from what they feel. Bill Gasiamis described exactly this: convinced his running gait was dangerous, he watched the footage and found it was far better than he’d thought. The problem wasn’t the movement. It was the feedback. Once a survivor moves into the chronic stage months or years post-stroke, the calculus shifts. Walking remains one of the best exercises available. Kory also recommends walking backwards in a safe environment like a hallway or near a kitchen sink: it challenges balance, engages the brain differently, and creates new neurological input. Why Falls Happen – And What Actually Prevents Them Falls after stroke aren’t random. They follow a pattern. The clinical term is proprioception: the brain’s sense of where the body’s joints and limbs are in space. After a stroke, this system is often disrupted. Survivors may not feel their foot on the ground, or may not register that a leg isn’t bearing weight the way it needs to. Add a divided attention task carrying a plate, thinking about turning off the television, reaching for something, and the risk multiplies immediately. Bill described this directly: he’d made a sandwich, sat down, finished eating, and went to stand up. His attention was on getting the plate to the sink without dropping it. His left leg wasn’t registered as being on the floor. He fell before he’d taken a step. The countermeasure is simple: stop, feel the floor, confirm the leg is active before moving, then carry the plate. Step by step, not simultaneously. Foot Drop, AFOs, and Electrical Stimulation Foot drop, where the muscles that lift the front of the foot are weakened or uncoordinated, is one of the most common walking challenges after stroke. Many survivors are placed in an AFO (ankle foot orthosis) to manage it. Kory’s view on AFOs is measured: they’re a tool, not a sentence. Whether to wear one, when, and whether to eventually stop using one depends entirely on the individual. “Take it off every once in a while if you’re in a safe environment,” Kory advises. “That gives new input to the brain a chance for things to improve.” Electrical stimulation is another tool worth exploring. Kory recommends starting with an affordable unit available on Amazon for around $40 to test whether the technique produces results before investing in higher-end systems. You can find Kory’s recommended unit at linktr.ee/unlimitedpotentialpt. The “Life Athlete” Mindset Kory calls his stroke survivor clients “life athletes.” Not because they run marathons or lift heavy, but because athlete thinking produces athlete results. Athletes track. They audit their approach. They celebrate small gains. They adjust when progress slows. And they don’t let one bad assessment from one clinician define what they believe is possible. “If somebody told you you’d never walk again, you can take that feedback and use it as motivation,” Kory says. “Or you can let it get you down. That’s up to you.” What to Do With a Limiting Prognosis When a doctor says “you’ll never walk again,” it’s rarely cruelty; it’s usually outdated thinking. General practitioners have limited training in neurological rehabilitation. Some are still working from research that concluded recovery stops at six months or a year. That conclusion was drawn from patients who stopped therapy and stopped trying, not from the brain’s actual ceiling. “I just want to leave the door open,” Kory says. The research on neuroplasticity is clear: the brain continues to adapt when given the right challenge, the right environment, and enough time. A prognosis isn’t a prophecy. It’s a snapshot of what one clinician observed on one day. Walking after stroke real, functional, independent walking is possible far longer and far later than most doctors suggest. And sometimes, it happens the same day they said it never would. If this episode has helped you, Bill’s book The Unexpected Way That A Stroke Became The Best Thing That Happened shares the tools and mindset that made the difference across his own recovery. If the Recovery After Stroke podcast has been valuable to you, you can support it financially at patreon.com/recoveryafterstroke. This blog is for informational purposes only and does not constitute medical advice. Please consult your doctor before making any changes to your health or recovery plan. She Was Told She’d Never Walk Again – Her PT Proved Them Wrong | Dr. Kory Langwell (Interview) Dr. Kory Langwell on the therapy gap, foot drop, and why the plateau after stroke is a label not a limit. Highlights: 00:00 Introduction – Walking After Stroke 07:24 Insurance and Therapy Limitations 11:22 Supporting Survivors and Caregivers 16:45 Community and Support in Recovery 26:57 The Impact of Electrical Stimulation in Rehabilitation 29:17 Walking: Quality Over Quantity in Recovery 30:25 Understanding the Stages of Recovery 36:39 Navigating the Challenges of Falling Post-Stroke 42:05 Setting Realistic Goals for Recovery 44:46 The Role of Medical Professionals in Rehabilitation Transcript: Introduction – Walking After Stroke Kory Langwell (00:00) So we had a client recently there. Doctor told them they were never gonna walk again. And literally, like they our therapist showed up, the patient was in tears, and then they walked 70 feet with our therapist. And it was all because it was a doctor that didn’t know them. They did like some reflex testing and said, you’re hyporeflexic, you’re never gonna walk again. And then literally that same day walked 70 feet. I was like, I hope you go back and tell them, BIll Gasiamis video 25, image (00:23) Before we get into today’s conversation, I want to extend a genuine thank you to everyone who supports this show. Whether you’ve joined as a YouTube member, contributed through Patreon, left a review, shared an episode, commented, or picked up a copy of my book, You Are the Reason This Podcast Keeps Going. Today’s guest is Dr. Corey Langwell. A doctor of physical therapy with over 15 years of clinical experience. Corey runs a mobile therapy practice across Southern California and now coaches stroke survivors worldwide through unlimited potential physical therapy, a virtual program built for people who can’t access the in-person care they need. In this conversation, we get into the gap that opens up the moment you leave hospital. While the word plateau might be the most dangerous word in stroke recovery, What physical therapists know about walking after stroke that most doctors do not, and what it actually takes to keep making progress, years or even decades post-stroke. If you’ve ever been told there’s a ceiling on your recovery, this episode is going to challenge that. Here’s my conversation with Dr. Corey. BIll Gasiamis (01:39) Kory Langwell, welcome to the podcast. Kory Langwell (01:42) Thanks for having me. BIll Gasiamis (01:43) Tell me a little bit about your background. Kory Langwell (01:47) Yeah, I’ve been a doctor of physical therapy for over 15 years and I’ve had my own mobile therapy practice for a little over five years. So helping people in their homes throughout Southern California with my staff of PTs, OTs, and speech therapists. And now we’re expanding to worldwide really with our virtual coaching program for people that have had strokes. So BIll Gasiamis (02:12) Worldwide. That’s awesome, right? So that’s where I found you on the TikTok app. And it’s a pretty decent channel to follow. Tell me just while we’re here and I remembered to ask, what is the TikTok handle? Kory Langwell (02:14) Yeah. Yeah. Yeah, yeah. It’s Dr. Kory Stroke Recovery PT and I can I can send you the link later on. But yeah, so I started two months ago and it’s been growing ever since. So BIll Gasiamis (02:38) Yeah, it’s really good because I think your information comes from the clinical background, something that I can’t do. I can put a lot of information out about my personal experience with stroke, what other people tell me about their experience, but your specific instructions around how to improve or how to do something differently or how to achieve an outcome with regards to whatever physical deficit people have after stroke. Is really helpful. So for people who are watching and listening, go to TikTok and probably the other social media channels, yeah, Kory? Kory Langwell (03:12) Yeah, yeah, I started a YouTube recently, unlimited potential physical therapy. And yeah, I’m also on Facebook, Unlimited Potential Rehab. So yeah. BIll Gasiamis (03:22) Yeah. You’re one of those people. I often get asked where can I find somebody that’s going to help me with my stroke recovery? I can’t get there or whatever. And I’m I’m often the middleman. People think that I know everything about everyone, especially from Australia to the United States, right? But what’s weird is I do know a lot of people and I can connect people. So it’s great that we connected and I found you. And I think it’s really important that. Kory Langwell (03:39) Yeah. Yeah. BIll Gasiamis (03:50) It’s your perspective and the way you think about recovery that’s different. And that’s why I reckon people A, should follow you and B, listen to this podcast episode. So don’t leave yet. F listen to the episode and then go and follow Kory on TikTok and all the socials. We’ll have all the links in the show notes. My first question is about the gap. Okay. So we’re often Kory Langwell (04:01) I appreciate that. BIll Gasiamis (04:17) Find ourselves as stroke survivors get sent home from hospital. Everyone does amazing things before we leave hospital. The care is amazing. They try and rehabilitate us as much as they can. They keep us alive. They send us home. But then the gap at home is we’re kind of left alone. Nobody to check in with us to make sure that things are kind of on track, that we’ve settled in. And it feels for a lot of people like recovery ends after therapy ends. But Can you give us a bit of a your your thoughts on that? Kory Langwell (04:54) Yeah, usually at least here in the States, people go from getting three hours of therapy a day in the hospital to literally dropping down to thirty minutes once or twice a week. So there is this huge gap where they just feel like they’re not getting enough and then that it really slows down their progress, or so they feel. and that’s where we’ve come in with our in-home care. But what I’ve seen is people just they need that accountability, whether it’s virtually or in person. And so that’s one thing that we really strive to do is just provide that that one-on-one support virtually. And also, you know, what I see with a lot of people is they think that, stroke recovery. Stops at you know, three months, six months, a year. We’ll probably talk about this more later on. But you just got to keep challenging yourself, doing new things. And I find a lot of times people get stuck on just finding random things on the internet, and then they just they don’t reach out or have the support that they need to move forward and make progress. So grant you just don’t want insurance to tell you when therapy ends or when progress ends. So that doesn’t mean your brain just immediately is yeah. Yeah, therapy’s done because insurance says it is and the brain just shuts off. I mean, I’ve seen progress years, decades, you know, 10 to 20 years after a stroke. I’ve seen progress with arms, hands, legs, general walking ability, you know, stuff like that. So it’s a lot of times they just people get fed up, they get frustrated, and then they stop doing or looking for resources. So BIll Gasiamis (06:26) Y the thing that you said is very interesting about insurance telling you when therapy ends. Now what they’re doing, what are they doing? Are they like I know what they’re doing fundamentally, right? They can’t forever pay somebody to have rehabilitation. And maybe they’re encouraged to pay them for as little as possible as well, because it costs money, right? So they they Kory Langwell (06:49) Yeah. Yeah. BIll Gasiamis (06:53) come up with some kind of a conclusion or whatever, and then they say to people, Well, y that’s about it. You’re not going to really improve any more than that. And we need you to we we’re going to stop funding it. So how does that conversation go from what you understand? And can anyone intervene in that moment and continue the therapy? Is there a way to kind of argue your case to get more therapy? Insurance and Therapy Limitations Kory Langwell (07:24) Yeah, it’s a tough one. So having worked in hospitals in acute rehab units, having worked in outpatient clinics, and then now as my own mobile practice in people’s homes, I’ve seen the whole spectrum of therapy and the issues that come along along each step of the way. in the hospital, you know, it used to be therapy they would get six to eight weeks in the hospital a lot of times here in the States. And now it it used it dropped down to like three weeks for a lot of acute rehabs, and now they’re pushing it down to like 10 to 14 days. which is not a lot of time. And, you know, we used to be able to get people to near independence with a lot of their their skills, you know, the activities or ADLs, activities of daily living. But what I see now is a lot of times hospitals when I left the hospital world in November of 2021, at that point, it was like, let’s just get people to like minimum assistance, meaning they need about 25% or less, and let’s we gotta ship them out of here because it’s like it’s like a churn. It cause hospitals, to be honest. They’re big business. They they are, you know, it’s unfortunate. and they have some of the most highly trained therapists, but the therapists are kind of hamstrung from upper management, middle management, you know, being told probably from people above them that they can only do so much. in the states we have private equity buying out a lot of hospitals and stuff like that. So there are things are changing in the length of stay that clients get. Once somebody goes to home health, they usually only get like two to three weeks, once or twice a week, because the goal of home health is usually get them to outpatient, get them to a clinic. and when they go to a clinic, most of the time somebody will reach like a maintenance level where like they’re not really making a ton of progress and the therapists know they’re not gonna be getting reimbursed as well for that. So that gets really challenging and they have to write really good goals to help. you know, progress things or continue with therapy. So if your therapist is telling you in the outpatient clinic, that’s the one area where you can oftentimes have the best chance of extending therapy. They might be able to, you know, wiggle their way around writing new goals, higher level goals that you can work towards and progressing. And then other times they want to stop therapy for one to two months, three months and then reassess, you know, down the road, which is where a lot of times people seek us out for private therapies on the side. So It’s unfortunate, but yeah, the insurance game does have a their hand in it a lot of times, telling people when they can discharge or not. So yeah. BIll Gasiamis (09:50) How hard is it for a therapist to know that the stroke survivor patient is not ready to go home, but you have to wind it up for them. Kory Langwell (09:59) Yeah. Whew, it’s really challenging. And usually, I mean, in out most outpatient clinics, you might get somebody two or three days a week if you’re lucky. Usually 30 minute sessions in in the clinic. Sometimes you have one-on-one places for an hour, which are great, or 45 minutes, but you’re it’s a volume game in the clinics because the reimbursements have shrunk in the outpatient world too. So they’re like, We need more volume here. And it’s unfortunate. It’s not on the therapist. It’s more on the, you know, just the the whole game that they have to do in order to survive, or else they would have to close up shop. But as far as like extending somebody, it it it can be a challenge. It’s it’s really you see it coming as a therapist, you know, and you’re in the outpatient insurance-based game. you’re like, ooh, you know, I I in about two to four weeks I can tell this is gonna be an issue with your insurance or whatnot. And most therapists, if you can get somebody to like 90% better. You know, that’s pretty darn good, especially after a stroke. there’s a lot of factors that go into that, a lot of variables. But yeah, so it’s it’s tough and getting somebody back to a hundred percent is can be challenging with the insurance game. BIll Gasiamis (11:07) Yeah, getting back to a hundred percent is Kory Langwell (11:12) It’s hard. It’s like the new one hundred percent or yeah, it’s another topic for yeah. BIll Gasiamis (11:13) my gosh. Yeah. The new hundred percent I pref yeah, that I love that. That’s a great statement actually, because a hundred percent, I mean Supporting Survivors and Caregivers BIll Gasiamis video 25, image (11:22) If this podcast has helped you in any way, here’s how you can help it reach more people. Share this episode with a survivor, a carer, or anyone who needs to hear that recovery doesn’t have an expiry date. Leave a review. It makes a massive difference. And if you’d like to support the show financially, you can do that through Patreon at patreon.com/recoveryafterstroke or by becoming a YouTube member. Now it’s back to the show. BIll Gasiamis (11:50) I I have that challenge with a lot of stroke survivors who are early on in their recovery. They reach out and they say, you know, how long is this going to take for me to get better? And like, dude, like it might never get better. in that what they want is they want to go back to where they were before the stroke. And there’s n nobody’s going back there. Nobody at all. Kory Langwell (11:59) We don’t know. Yeah. Yeah. BIll Gasiamis (12:11) Not a single person. And if there’s damage in the brain and the damage is permanent, which damage is in some instances, then you cannot reverse that damage. You have to accept that damage and then adjust and recover and overcome the challenges that you’ve been left with. And it’s such a difficult thing. But the new 100%, I love that, Kory, because I kind of am there. And if people ask me how do you feel, which nobody nobody understands to ask how do I feel after my stroke, my left side is completely numb. You know, I get spasticity. It doesn’t look visibly like other people experience spasticity. So I got away with that part of it. I don’t look like I’ve had a stroke, but I have the fatigue, I have the balance issues when I get tired, I have all these challenges that are always there and they’ve been there since two thousand and fourteen. Like it’s not going away. Kory Langwell (13:07) Yeah. There’s There are those silent problems too that like you said, like you’re doing so well in general that a lot of people just can’t see the fatigue or the how tight your arm feels or different things, which is oftentimes really challenging. But if you put it even, you know, towards like an orthopedic injury where somebody has like a shoulder surgery or a knee surgery, typically they also have like that new one hundred percent where it’s you know, it’s never gonna it’s hard to have it feel a hundred percent like it was before. There are certain instances where somebody might make this miraculous recovery. It does happen. Maybe they’ve had a TIA, a mini stroke, or you know, just made this miraculous recovery. Those those people do exist and it does happen. But what I find in the stroke community that happens a lot is there’s this everyone wants to compare themselves to other people, or they’re they’re wanting to get the answers from things, but there is no crystal ball on these recoveries, you know, for for neuro issues. It’s more like let’s see how it progresses in one month, three months, six months, a year, and then just continue to track because it is a lifelong issue that you have. have to manage and and continue to, you know, have things come up over over time. So yeah. BIll Gasiamis (14:14) Yeah, I agree with that. So this next question I thought about how I’m gonna ask it a lot. So I’m gonna ask it just the way my gut’s telling me to ask it, which is how much bullshit is that you’ve reached the plateau? Kory Langwell (14:31) yeah, that’s a that’s a fun one. I I love the I love the the BS part of that. yeah, it’s tough. I mean, you can see a lot of times what you’ll see is like there’s almost, you know, you think of plateau as like a flat line. And a lot of times what we do see is you’re there’s still room for progress. Like maybe somebody’s feeling like they’re 60% back to their normal self. Well, if we can get you to 65%, would you take that? Like most people would say. You know, it’s either sixty or sixty five percent. Like, yeah, let’s do that. But a lot of times what I see is Progress has just slowed down, they get upset, you know, the doctor’s like, whoop, this is as good as it’s gonna get. This is where you’re at. You’ve plateaued and you’ve entered a maintenance stage. And what I often see with that is it’s that’s the time to shift something up, mix something up, do something different. so what we like to do is take into account what kind of audit what somebody’s doing when their exercises, their daily routine and all that, and then shift things in some certain way and reassess in six weeks to see if we can progress that or make any other changes. So just like with any other training, like if somebody was a bodybuilder going for a competition or a professional athlete, we take that kind of same approach to our stroke recovery. We call athletes in general. Like they’re life athletes, you know. So we wanna help people feel as independent and as strong as they can. So yeah. BIll Gasiamis (15:50) That’s a great mindset shift, right? So if you consider yourself somebody who’s injured, somebody who’s never gonna be the same, all that kind of stuff, well, it might be accurate, but it may not be helpful in the way you approach your recovery. But an athlete, that’s very cool. Now I know some people say what an athlete runs on a track and field you know, facility. An athlete does this, an athlete does that. Well, Maybe, maybe they don’t, you know, maybe you can be your own version of an athlete that allows you to think about that constant and never ending pursuit of getting better and improving. And whether you’re getting better and improving your physical side or your mental attitude or your emotional side or your or your nutrition, you know. Community and Support in Recovery Athletes have all these things that they always constantly forever focus on and their gains come from, you know, that really last part, which is almost unattainable, but it’s about going for it. It’s about going for the last one percent. And then reflecting back, like you said, maybe twelve months later and going, Look how far I’ve come, rather than look what I can’t do or look what I haven’t achieved yet. It’s like, look what I have been able to achieve. That’s Kory Langwell (17:03) Yeah. Yeah. Yeah. And that’s where and that’s where tracking comes into it. Are there, you know, your what what are your BIll Gasiamis (17:15) Such a different mindset. Kory Langwell (17:21) you know, your KPIs, your key performance indicators that you’re looking into as far as, hey, I was only lifting one pound with my arm and now I’m do lifting three pounds. Like that’s huge improvement in a, you know, what however long it’s been. So those whatever you’re tracking, it helps to you know, it could be your diet. Am I making good choices eighty percent of the time? Am I so making sure in like all of your life assets assets and that or facets of life, that’s what we try to do as well. And like you said, mindset, movement, muscle, all that. all those things together. we we you know, tie all those things into our our program. And I think everyone needs to do that as far as, you know, their strengthen those the mental muscle, the physical muscle, you know, they’re just as important. And having that support, whether it’s with a coach or whether it’s with family, friends, outsiders, you know, other stroke survivors, it’s really important. So BIll Gasiamis (18:14) Yeah, community is the I think biggest thing for me. because then with the right community, the one that I’ve created for myself, at least I get to talk about the things that bug me about what happened to me with people who one hundred percent understand it. And then that way, even if we’re different in our attitude in the way we go about things, at least we understand. Kory Langwell (18:35) Yeah. BIll Gasiamis (18:45) And you’re totally being heard. Do know what mean? Like it takes one minute to listen to the story of a stroke survivor and to fully understand where they’re coming from because they’ve been through a a similar, a very similar experience to to myself. Kory Langwell (18:52) Yeah. Yeah, yeah, absolutely. for sure. It’s so true. I mean, as a therapist, I I never really I mean, I knew there was a mental toll to it, but having worked with people for, you know, they come on and they’re with us for several years, you really see the mental aspects, like the ups and downs that occur with that. And it’s so huge to you know, important to to focus on that as well. So and not lose sight of it. So those silent symptoms of the stroke, you know, like we were talking about as far as the the emotional aspect or other things of that. So yeah. BIll Gasiamis (19:26) Yeah. Yeah, one of the biggest complaints that I get from stroke survivors, not about their spouse, but about people about people who haven’t had a stroke, right? So often it’s the spouse that gets the raw end of the stick. But it’s that they just don’t understand me. And it’s so true, right? There’s no way that that person can understand you unless they’ve had a stroke, and we do not want that for them. That’s better that they don’t understand you and that you have to learn how to explain yourself in a way Kory Langwell (19:53) Yeah. Yeah. BIll Gasiamis (20:04) that gets the message across even if they don’t get it. Like it’s okay because they’re never gonna get it. We don’t want them to really ever get it. What we wanna do is accept that they can’t understand something that they have never experienced, which we don’t want them to experience. Kory Langwell (20:20) Yeah, that’s so true. I mean, the it a lot of times it comes from a good place. They’re like, just get up and move. Why are you so tired? or you know, things of that nature. And it y you’re right. They just they don’t understand it. It’s it’s tough. There really should be more caregiver support and education. I’ve tr I’ve strived to do that on my page or on my different resources that I’ve included on my bio. But yeah, it’s it’s in sh it’s a challenge for people to to see the whole picture and the recoveries process that’s going on with that. So yeah. BIll Gasiamis (20:51) Yeah. How common is foot drop? Kory Langwell (20:56) yeah. Strokes you you do see it a fair amount. it’s what I see a lot of times with that. You know, when in the hospital, a lot of times I don’t like to immediately put somebody in like an AFO. Everyone knows ankle foot orthosis and stuff like that. but it’s something that I like to see how the body reacts initially to to the the weaker ankle or whatnot, and how is somebody compensating? So you’ll see somebody, you know, try to march their leg up to clear their foot through the gate cycle, or they’ll kick their their leg out to the side so that they don’t drag their foot or their toe. so I like to see. See what’s going on for the first week or so before we start trying to, you know, put a bunch of equipment on somebody. But honestly, it it’s it’s pretty common. it just depends on the nature or severity of the stroke. Most muscle recovery starts proximally, meaning like at the hip and then works its way down, or in the shoulder and then works its way down to the hand. so the ankle and the hand are usually the last to recover. but yeah, so it’s obviously it’s very noticeable on somebody’s walk gate or whatnot if they have it, or you know, as you just see their AFO and you’re like, that guy’s got foot drop, most likely, or whatnot. So yeah, just trying to figure out where’s is there are there other weak links up the chain and the knee, the quad, you know, your your your glutes, your hip, what other areas could use some help to help you get that leg through and help you be more independent? So BIll Gasiamis (22:28) Mm. Kory Langwell (22:29) really treating the whole ankle or the whole walking pattern, not just the ankle or the foot. Cause we a lot of times we get laser focused into one area after a stroke like my hand or my foot, but we gotta look at the whole body. So yeah. BIll Gasiamis (22:41) So there is a conversation that happens again in the community about whether I should be wearing AFO or I shouldn’t. And you often hear people saying, I got rid of my AFO. it was causing me to walk badly or incorrectly and it was decreasing the muscle activity in the correct way. Kory Langwell (22:51) Yeah. Yeah. BIll Gasiamis (23:08) And then you hear the exact opposite. Well, you know, you should definitely have an AFO so you don’t trip over, you don’t do this, you don’t do that. Like, how do you determine that whole should I or should I not have an AFO? And do some people definitely need an AFO? And then also are there some people who can transition out of an AFO? Kory Langwell (23:20) Yeah. Yeah, it it really is with a lot of neurotype issues, it it really does depend. You’ll hear the answer, it depends a lot of times in the neuro world, neurological issue or you know, in the stroke world. But on a case by case basis, it’s really how does somebody look? How independent are they with and without it? How much strength do they have in their the muscles on your shin and on the outside of your leg that help lift your ankle up? is it something that maybe you just wear it when you’re outside? And then when you’re inside the house, you’re getting that input. with your shoes off. I I really liked the shoes off, you know, kind of full input on how your foot’s moving. You can really see it visually, get some feedback there on what’s going on. So it it and it can change over time. Maybe somebody ditches it after a while or maybe they w they know like, hey, I’m gonna be going on this longer walk. I’m gonna use my AFO so I don’t get as tired because it can be more taxing and energy draining to have to, you know, lift your leg up more, kick it out to the side or whatnot. So we’re really trying to figure out what’s the best quality over quantity for for most folks so that they’re not overdoing it, but they still are getting you know, the appropriate amount of feedback and and to help them live their life, be as independent as possible. So I’m not against or for it. It’s just wanna it depends on the person. So yeah. BIll Gasiamis (24:45) Sounds like it’s a tool to be probably continuously assessed and determine its usability and then also for some people determine whether or not it’s short term, long term thing. And then also keep looking at it. What I seem to also see is people get told something, they do it, and then they do it for a long, long time and nobody kind of ever intervenes a year later to say, where are we at with that? Kory Langwell (24:51) Yeah. Yeah. It you know, it it’s it’s good to take it off every once in a while if you’re especially if you’re in safe environment and just reassess things, you know, on your own or with a therapist or whatnot. That again gives new input and sensory, you know, feedback to your brain of like, what’s going on here? And that that’s a chance for that neuroplasticity to occur, which you know, is a is a is a big buzzword in the in the neuro world. But yeah, so we’re just trying to create those environments and those chances for, you know, things to improve and and reassess. assess things as as you’re going along. So yeah. BIll Gasiamis (25:49) Can you explain to me briefly if you can, like what happens with foot drop, why does it occur? and why don’t I hear about the opposite of foot drop, which is the foot changing and going in the other direction? The Impact of Electrical Stimulation in Rehabilitation Kory Langwell (26:06) Yeah. so your your muscles on your shin, you know, like those those are the ones that people get shin splints on from working out or whatnot, your anterior tibialis muscle, those are a prime mover of lifting your foot up. And oftentimes the feedback and the timing, the coordination down to those muscles is just weakened or impaired. So you’ll see a lot of issues with that. You also have muscles on the outside of your shin. They’re called everters. So they evert or turn the foot out. So the combination of those everters and then the dorsiflexors that lift the foot up, those muscles are the two prime movers of that motion. They’re oftentimes affected with different strokes. And then so a lot of times what we end up using is like things. like electrical stimulation. I have a really good video on my YouTube, about eight to ten minutes long on how to set that up. but you can You c I I see a lot of good impact with the with the E stem, whether somebody’s laying down or sitting, or then there’s other things like the bioness for the leg and the arm, but the one for the leg to help with the timing and coordination, all that, all those things that go into it. So it’s just not just weakness, it’s that timing, coordination, balance, all those things combined. So yeah. BIll Gasiamis (27:19) Got it, got it. So you’ve seen some positive, helpful, supportive kind of outcomes from those electrical stimulators at like Bioness and other other types. Kory Langwell (27:33) Yeah, yeah. I’ve even like I’ve I have one that I use with clients that I I bought on Amazon for like forty bucks because the the range is anywhere from thirty to forty bucks up to like hundreds of dollars. Or, you know, the Bioness is you I think they can get that covered with insurance, at least a partial bit of it, but those are a lot more expensive. like thousands of dollars from to my knowledge. But I what I’ve seen is I don’t see a huge difference between some of those cheaper versions and then the larger ones. some of the bigger ones, like the Bioness, you do get a little more feedback or like that since like it will come on at a certain point of your gait cycle. So it’s like, lifts the toes at a certain point. helps you go through whereas versus you know a standard ESTEM unit, you’re usually it’s on for like 10 seconds, it’s off for 10 to 30 seconds depending on the settings. So but as an exercise tool in the general, in general, if somebody’s having issues and they have good sensation to that area. So you don’t want to put it on somebody that like can’t feel their leg or whatever. But it can be very beneficial at like getting that sensory and then the motor or muscle input back to that area. So not saying it’s going to get to that 100%. But it’s gonna help you. it oftentimes does help people, even, you know, if it’s ten to fifty percent better, great. You know, that’s a huge difference with somebody getting around. So yeah. BIll Gasiamis (28:53) Okay. So worth people considering the possibility of getting a forty dollar version just to sort of try it out and see whether or not it might be supportive. And then if it is and they want to get something more expensive, then go f go from there. your homework after this conversation is going to be to send us the links to every single thing you mentioned. So we can put it in the show notes and everyone can have a look at it. Now, with walking, Kory Langwell (29:12) Yeah. Yeah, absolutely. Walking: Quality Over Quantity in Recovery BIll Gasiamis (29:23) I’m of the I’m I I’m I’m in the camp of do more in the from the perspective of if you’re only walking for a minute, try and get to two. If you’re walking for two, try and get to four and so on. And then if you can get to thirty minutes or an hour at some stage, doesn’t matter when, then that’s even better. but when we started that conversation about Kory Langwell (29:39) Yeah. BIll Gasiamis (29:53) you joining me on the podcast and we share ideas about what we’re gonna talk about. You came back with me with regards to something about walking that people miss that could mean that walking further, longer, and more could actually be causing a problem. Tell me about about walking and the things that we can run into that make well, not things worse necessarily, but Not from an exercise perspective, but from a rehabilitation’s pers perspective. Understanding the Stages of Recovery Kory Langwell (30:20) Yeah. Yeah, I think it there’s a little differentiator in there. It’s like where what stage are you at in the recovery? So if somebody’s in that really acute stage, it’s you know, pretty fresh on the stroke, maybe it’s like somebody less than a month post stroke. We don’t want to get to the point where they’re just like you know, nearly exhausting themselves every single walk, you know, so there’s a time and a place for that. So you know, if somebody can only walk like five steps, we don’t want to go try to, you know, you’re gonna walk 25. And like you can do that every now and then, but don’t do it on like back to back days. Don’t do it on like back to back therapy sessions or whatever. So there’s a there’s a combination of like early on we want to make sure things are good quality. And then as we get moving forward, we want to progress in a fashion that’s comfortable and not over Taxing the neurological system, because a lot of times, as you know, fatigue plays a huge role in that. And how is that affecting you? Are you like you went for a super long walk, but now you’re down for the count for two days or you know, at least a day. So you know, walking a hundred feet can feel like a marathon early on. So it’s just making sure that you’re getting the right feedback, that accountability, support, where you’re it’s quality. in not just overdoing it. So I find that a lot where people want to do a ton of reps or like they’re doing an exercise, like they’re trying to lift their arm up, but they’re doing this the whole time, you know, and I’m like, you’re just you’re not lifting your arm, they’re just like tiring out their trap muscle as opposed to like some of the the delt or bicep or different areas. So like you’re just gonna get really bulky but traps up here, but you’re not really necessarily helping yourself versus if you did good quality and like keep that shoulder down. I’m just using that as an example. But for walking, you know, same thing. Like are you using a mirror for feedback? To see, like, I’m actually, I’m every step, I’m kind of falling off to the side. Why is that? I’d rather like have somebody walk 50 feet really well than like 150 feet terribly, you know. So it’s and that that again goes into more of the acute stage. Now, if somebody’s sub-acute, more of a chronic, it’s been 10, 15 years, go for it. Like, if you want, if you feel good about it, you’re not overtact taxing yourself, getting overtired or anything, you know, do what you can. Walking is one of the best exercises for you. I also like I I’m a big fan of walking backwards. So in a safe area like by the kitchen sink or a hallway or something, it just challenges your mind and it’s a really good balance exercise for somebody post stroke or with any neurological issue because it just told you you see somebody try it the first time, they’re like, What do you want me to do? Walk backwards. And then there’s tons of ways you can adjust the the intensity on that as well. So yeah. BIll Gasiamis (33:01) So also I remember being in outpatient rehab and feeling like I actually wasn’t able to walk well. And then the therapist saying, Well, why don’t we just record it and have a look at how you’re walking? And it was also about running because I I wanted to run, but I didn’t want to run marathons. I just wanted to be able to run across the road if a car’s coming or something. And I said, Well, I’m a bit concerned about how that Kory Langwell (33:15) Yeah. BIll Gasiamis (33:30) goes ’cause I don’t want to injure myself running, et cetera. And well he said, Well, why don’t we do a run, I’ll record you and I’ll then we’ll break it down and I’ll show you what you’re doing or what you’re not doing. And it turns out that my running style was fine. What wasn’t fine was the feedback that I was getting because it was completely different to the previous thirty seven years of my life. And I and because it felt different and my brain registered it differently, it It was scary. Like it was like, well, this doesn’t I’m gonna probably injure myself is how I I thought it. But when I saw the video, it was completely different. And sure, there was some instructions still about how to do it correctly, what I might be able to improve, especially with my left leg, but the but the overall picture was more positive than I t made it out to be. And that’s the challenging part. Sometimes we think we’re less capable than we are. Kory Langwell (34:06) Yeah, yeah. Yeah, and that’s why the visual feedback is so important, whether you record it with your cell phone or you know, just getting the real time feedback on with a mirror or something like that. It’s you know, you see that used in therapy a lot because you may not notice that you’re doing something and just having somebody tell you that isn’t gonna help as much as if you’re somebody’s telling you plus they’re showing you what you’re doing. Yeah, that that can be a huge, you know, help of like, you know, that I can feel that now. It’s good biofeedback. I can, you know, move on from there. So yeah. BIll Gasiamis (35:01) Yeah. And so it sounds like there’s two parts to that conversation. Is sometimes we think we’re doing it better than we are, and sometimes we think we’re doing it worse than we are. So it’s really important to have somebody assess you or at least give you feedback and give you the opportunity to check your assumptions about yourself and then also to check via perhaps a recording to check, you know, how you are actually doing things. So you can see it from Kory Langwell (35:10) Yeah. BIll Gasiamis (35:31) their perspective and then you can adjust as you’re going forward. Kory Langwell (35:35) Yeah, absolutely. BIll Gasiamis (35:37) So what about falling? That’s a huge issue after stroke. I fell quite a few times after surgery. The first time I fell, Kory, was about I don’t know, less than twenty-four hours after I woke up after brain surgery. And the nurse said to me, Have you been to the bathroom to movie bowels? And I was like, No, I haven’t been anywhere. And she said, Well, great, get up, I’ll let I’ll help you. get there and now she was a lot smaller than me and a lot thinner framed and she said just put your arm around me and I’ll help you get to the bathroom. Okay, cool. I did that and when I stepped out onto my left leg, from the left side of the bed, as soon as I put weight on it, without her having any idea, I completely fell straight to the ground, in the ward, screaming Kory Langwell (36:32) no. Yeah. Yeah. BIll Gasiamis (36:36) I’ve got a fresh h scar and patch on my head from brain surgery literally twenty-four hours ago. so it became quite a concern after that because it was the first time I realized that my left side doesn’t work. And it was the first time I realized that th falling after a stroke with a cr a fresh craniotomy and all that kind of stuff is also very dangerous, right? So when I came home Navigating the Challenges of Falling Post-Stroke Kory Langwell (36:37) Yeah. BIll Gasiamis (37:04) I was pretty independent and I felt really good about the fact that I was able to walk on my own. but when I got up from the couch one time and many other times when I’ve fallen, when I got up from the couch on time, I forgot to connect my new leg to my my standing up, my getting up from the couch. I had just eaten a sandwich. It was in a plate. I was the one that went and made the sandwich, sat down and started eating it. And then as soon as I finished it, I went to get up to take the plate to the sink. And my left leg wasn’t aware that it was on the ground. And I fell immediately. And I dropped the plate, I broke the plate, I smashed my ribs on the arm of the couch. I thankfully didn’t injure myself terribly, but it was a close call. And I always after that, I always made a point and still do in the morning when I wake up to get out of bed. Kory Langwell (37:41) Yeah. Wow. Yeah. BIll Gasiamis (38:01) make sure my foot is on the ground before I stand up so that I don’t lose balance and fall. So that’s my that’s my story about falling, but also it’s very common in stroke survivors. I hear that a lot. Tell me about why falls happen after stroke. Kory Langwell (38:05) Yeah. Yeah. Yeah. You know, first off it Kinda hurts my therapist heart to hear that what you know, the nurse and you will fall in there. That’s where I’m like, he needed a PT evaluation to see how strong his legs are, where his, you know, sensation is and all that. Usually when we get somebody up, we want to make sure they’re safe at the edge of the bed. And then maybe we’re transferring just to like a a bedside commode in the the first time. And then you’re you you check that box then. We start moving towards walking once we make sure it’s safe. But sometimes the nurses get a little gung ho with things and get a little excited. we try to stay in our lane and, you know, just do the That PTS needed. but as far as like, you know, making sure somebody’s safe, it’s creating the right environment for them that, you know, like I mentioned, making sure they’re strong enough with their legs to, you know, and the most people will know as they started physical therapy what level they’re at, how much help they need, all those things. So, and then not over challenging somebody where we’re doing like very advanced balance exercises or doing very, you know, doing three tasks at once or like you carrying that dish, you know, and that’s a more your brain is like thinking, we’re good and I’m just gonna carry this dish and I’m gonna go turn off the TV while I’m getting up or whatever. And your brain’s like, nope, no you’re not, and you just fall over. So it’s like creating, you know, those too many environmental stimuli probably and then just where it kind of I don’t tricked your brain into to not focusing on where your your leg is at. We call that the proprioception or just realizing where your joints are, your limbs are in space. And sometimes that can be very affected after strokes. So we just wanna, you know, see how that looks, see how you’re moving, and and you know, go from there. So yeah. BIll Gasiamis (40:08) You probably describe that better than anybody, actually. Proprioception is my is a challenge that I have, but nobody ever connected that to what you just said, too many things happening at once. And it was exactly that. I had a plate, I just finished a meal, and my goal was to get the plate back to the sink safely without dropping it. And it was my my attention was Kory Langwell (40:33) Yeah. BIll Gasiamis (40:36) diverted away from making sure my leg was in the right position for me to stand up and was the muscles were activated, which I had been doing every day before that, right? I’d been making sure. But right now I had a plate in my hand and it was get up without dropping the plate. Kory Langwell (40:37) Yeah, Yeah. Yeah, yeah. Yep. Yeah. Pun pun intended, step by step, right? Just looking into like, okay, my feet are on the ground. I am able to push myself up to stand. Now we’re gonna take a step slowly, you know, go through that. So yeah, it’s it’s making sure everything looks appropriate and is, you know, safe for that specific client. So yeah. BIll Gasiamis (41:12) In my case I think now reflecting back on it, it would have been better if I’d gotten up and then reached over to pick up the plate and then moved to towards the the kitchen sink. And I think I was at home alone that day. And again, I screamed because before I knew it all was on the ground. Kory Langwell (41:27) Yeah. It happens. Yeah. Yeah. Setting Realistic Goals for Recovery BIll Gasiamis (41:35) It’s a very interesting thing to reflect back on it. under these sort of conditions where you and I are talking about things that seem they’re very glossed over. They’re not often spoken about in detail and people miss the the point. And sometimes people think I can’t do something properly, therefore I’m not gonna do it at all. But with regards to walking, what’s the best thing to do? about a walk that you haven’t been able to get back to the normal sort of style and and feel uncomfortable about doing. Some people will go, well, I’m opting out, I’m not gonna do that anymore because I can’t do it properly. It’s too difficult or it’s uncomfortable. Kory Langwell (42:21) Yeah. Yeah. I think it’s making goals that are you know, you hear about those specific, measurable, attainable, realistic time frame, the smart goals. So making sure that applies here. So It you gotta be able to walk before you can run, like with anything in life. So and that’s just you know, symbolic quote or whatnot, but you just wanna be able to do stuff that you can be working towards, but it’s also not so far out there that it’s like really hard. And then I see a lot of times people move those goalposts on themselves too much where they’re like, I got here. Now it’s like I wanna, you know, it’s you got to celebrate those small wins and then go from there as like far as you know, moving forward. So we had a client recently there. Doctor told them they were never gonna walk again. And literally, like they our therapist showed up, the patient was in tears, and then they walked 70 feet with our therapist. And it was all because it was a doctor that didn’t know them. They did like some reflex testing and said, you’re hyporeflexic, you’re never gonna walk again. And then literally that same day walked 70 feet. I was like, I hope you go back and tell them, you know, that that you missed that. So it’s BIll Gasiamis (43:15) Mm. Kory Langwell (43:36) really just making sure that you’re creating these sustainable goals that You know, and not letting people like that doctor that may not know you, a family member, you know, get in your ear and and cause these things that are detrimental to your your progress and take it in the right way. So yeah. BIll Gasiamis (43:55) You can’t actually answer this and I’m putting you on the spot, but I’m gonna ask it anyway. Like I assume that doctors, therapists, everybody is about rehabilitating, supporting, helping people and all that kind of stuff. I I not assume they definitely are, right? But what do you think is behind a questi a statement like you’re never going to X again? Like I hear that so, so much and I thought that by the time we get to twenty twenty six that that won’t be a thing that I hear about so often. Like, but I I don’t think it comes from being nasty or trying to give people setbacks or whatever. But do you have a sense of what that might be? Is it training? Is it a lack of training? Kory Langwell (44:30) Yeah. The Role of Medical Professionals in Rehabilitation I think yeah, you see a lot of like GPs, general practitioners, they don’t really have great training in like neurological rehab. So if it’s a PM and R doc, like a physical medicine and rehab doc, I find usually they’re a little more open-minded or or willing to s you know see the the progress or or whatnot over time. If you go into a doctor’s appointment, you show up in a wheelchair and it’s been, you know, six months, the doctor’s probably your general practitioner is probably gonna be like, well, this is what it is. It’s been six months. And I think some of that is from old research that came out that you can’t make progress after six months to a year, which was more because they just stopped therapy, they stopped doing things and you know, didn’t see progress because of that. So it’s, you know, yeah, if you don’t do anything and you just sit on your butt, all day you’re you’re not gonna see progress or you’re not gonna change. So but yeah as far as from a doctor’s standpoint it it can also be case by case with the doctors as far as their own experience and whatnot. And I don’t think necessarily they ever mean like harm or anything. Maybe they are trying to be realistic with clients as far as like this is what I’m seeing. I don’t think you know, the chances of this are slim, but they they it’s probably just a way of wording it better versus saying you’re never gonna do something again because there’s so many different things that are coming out, like research wise, treatment, you know, like things change drastically now. so it’s I I just like to to leave a at least leave the door open for people to see that improvement. So yeah. BIll Gasiamis (46:16) And walking doesn’t have to be the way you walked before. It could be a different version. It looked differently, feel differently, but it can still be walking. also I think it’s from ignorance, right? And again, ignorance, I don’t throw that out as a way to attack somebody, but it’s like literally that person hasn’t been in the space where Kory might work. They haven’t been in a space where they have seen people overcome some difficult challenges. Kory Langwell (46:23) Yeah. BIll Gasiamis (46:41) So they just make a assumption based on old thinking or something they heard in the past or old research that just stuck. And they’re just telling you, your job, your responsibility is to find new research to overcome that challenge because that research, it’s so bad if there was some and if they disseminated it to all the population in the medical community, and that has been continued to be passed on. I mean, that is so crazy that it persists and now. I just want to encourage people, do not believe anyone that tells you, A, you’ve hit hit a plateau, B, that you’re never going to do something again. And even though that might be true, just don’t believe it because there might be a technology around the corner that happens to solve that problem for you. You just don’t know about it yet. And always work towards the solution rather than focusing on the problem is kind of how I see it. And that’s generally what you guys tend to do. You guys tend to help people focus on. Kory Langwell (47:27) Yeah. Yeah. BIll Gasiamis (47:41) How do we overcome a problem? What’s the solution to this? Kory Langwell (47:46) Yeah, I think using it as motivation is is huge. So like you can take anything somebody tells you, you can take it one of two ways. And if you let it get you down, that’s up to you. Or if you’re like, Okay, I take that feedback, I appreciate it, but I’m not gonna accept it and use it as motivation to to strive to do better and move better. Like that that’s up to you. and who somebody is in their own, you know, life. So I always tell people it’s like, Well, what do you want to work on? You know, if some people are like, I don’t wanna do this anymore, I don’t wanna exercise, it’s like that’s up to you. So And other people they’re like, I want to push as hard as I can, I want to do what I can do. And so it’s really, you know, up to the what that somebody wants to do with their life and their progress, their recovery. BIll Gasiamis (48:28) Kory, it’s been an awesome conversation. Thanks so much for joining me on the podcast and saying yes when I reached out to have you on here and share your wisdom. Can you tell me where can people go and find th information about you? Kory Langwell (48:44) Yeah, so our our main website is unlimitedpotential.biz and you we have a health coaching page on there where people could message me on there if they want. I’ve had some people reach out. I’m pretty active in TikTok on on like DMs if people in my private messages of people reach out there as well. Dr. Kory, K-O-R-Y, stroke recovery PT. and then I’ll we’ll try to get you the handle there, the links on all that stuff. Those are probably the two best ways to reach me. I will say it’s really hard to give specific advice over a text or an email or whatnot. So I and there obviously I understand like there’s a lot of people that have financial issues or they they want the free advice or whatnot, but it’s just it’s really hard as a therapist to give a lot of that. I try my best and I can’t reach everyone doing that, but we really are able to to make a difference when we do work with people one on one. So yeah. BIll Gasiamis (49:36) Yeah. There might be programs that people can look into that you are offering either in house or somewhere else. That’s probably why I would encourage people to reach out to get an answer about your specific issue. Dr. Corey’s not going to do that. just like many people can’t answer a specific question about a problem that you may or may not have un unless they have information about your data or you know, they’re your physician or they have your scans and all that kind of stuff, that’s not gonna happen. But that’s okay. people can still follow you because your tips on TikTok are really cool. They’re on the mark and that’s where I love listening and learning from you. Kory Langwell (50:16) Thank you, I appreciate it. I’ll keep coming. BIll Gasiamis (50:19) Yeah, definitely keep them coming, man. it’s been a great thing, this social media thing because it brings information to people that otherwise wouldn’t be able to access it. Some people might be stuck with the doctor who said, You’re never gonna do this again. And that would be the most terrible place to be stuck and have nobody else to kind of throw a spanner in the works in that type of thinking and then suggest something more, more hopeful, more positive. Kory Langwell (50:34) Yeah. Yep. Yeah, absolutely. And it’s always good. I mean, I learn from stroke survivors all the time on what they’re going through. And it’s just, you know, it’s everyone working together around the world now. So I’m in I’m in California and we have, you know, like we’re talking you’re in Australia. I’ve talked to people all over the world now and it’s it’s just been great to to open those doors to a lot of people and you know, at least have conversations with them. So BIll Gasiamis (51:09) Doctor Kory, thank you so much for joining me on the podcast. Kory Langwell (51:11) Yeah. Thanks. Thanks for having me. BIll Gasiamis video 25, image (51:13) Well, that was Dr. Corey Langwell, Doctor of Physi

Patrick answers listener questions about switching to Charity Mobile, selecting worthwhile pro-life charities, and gives practical advice on keeping phone numbers during transitions. He responds to messages about celebrating big family news, grapples with immigration’s legal and compassionate sides, and offers book recommendations to young Catholics interested in learning about their faith. Everyday tools like ChatGPT, the meaning behind apology and forgiveness, and personal encouragement thread through the conversation as Patrick moves from the serious to the lighthearted, always circling back to faith’s presence through ordinary moments. David (email) – I’m pro-life and will be switching to Charity Mobile (00:42) Tia – Pregnancy Announcement (05:48) Jamille (email) - I am looking for an apologetics book for my 15-year-old daughter who would like to learn more about why we believe what we do as Catholics. (12:46) Email – What is your personal favorite book that you wrote? (15:20) Sharon (email) - Is it ok for Catholics to recite the “Ho'o pono pono” prayer. (23:00) Frank (email) – How can I find a Catholic wife? (25:18) Lea (email) – ChatGPT (35:34) Lawrence - The US Bishops have called for immigrants to be treated with compassion. Is our support for them really out of compassion or are we trying to take advantage? (38:59)

Tread Perilously's pilot season wraps up with Beyond Witch Mountain, an attempt to extend the Witch Mountain film duology into a weekly series. When extraterrestrials Tia and Tony leave their community atop Witch Mountain in search of their Uncle Bené, they learn his missing son has been located. But when Bené passes in a very Jedi-like way, they take on the rescue mission themselves and recruit the aid of helpful curmudgeon Jason O'Day -- the man who drove them to Witch Mountain in the first place. And, as it turns out, rich industrialist Aristotle Bolt is not over losing them before and continues his search for the kids. Will he finally abduct O'Day and use him as leverage?  Erik and Justin get lost talking about Disney in the 1970s and renegade animator Ralph Bakshi. Eddie Albert makes his Tread Perilously debut as O'Day while Erik reveals where Justin might recognize Witch Mountain film stars Kim Richards and Ike Eisenmann. Justin puts the pilot to the Cinema Test. He also fails to recognize the voice of the opening sequence's narrator. Geography Corner gets a workout as the Southern California mountains and Highland Park seem to play the Pacific Northwest. Tracy Gold makes an earlier appearance replacing Richards as Tia. Justin disagrees with the naming of Uncle Bené and Erik recalls the Long Distance Rate Wars of the 1980s.

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

Männerabend Special – 11 Jahre Beyond Beer! Dennis ist heute extra früh aufgestanden und hat Kuchen gebacken: Beyond Beer in der Weidenallee 55 in Hamburg feiert nämlich seinen 11. Geburtstag! Rino und Tia geben Einblicke in das Mi. – Sa. stattfindende Geburtstagsprogramm, wir probieren das von Fuerst Wiacek gebraute Geburtstagsbier und dann gibt es auch noch ein Quiz zu 11 Jahren Beyond Beer. Kommt vorbei und stoßt mit den beiden und dem ganzen Team auf 11 Jahre geile Biere, legendäre Veranstaltungen und unvergessliche Momente an. Das kann man natürlich auch noch nachträglich machen, falls ihr es in dieser Woche nicht schafft. ;-) Viel Spaß beim Hören! Beyond Beer Öffnungszeiten 22. – 27.06.26: Mo. – Mi.: 13 – 20 Uhr Do. – Sa.: 12 – 22 Uhr Programm: Mi. 24. Juni 2026: „Old School“ Tap Takeover: 1. Riegele – Feines Urhell 2. Cantillon – Sang Bleau 3. Schönramer – Dunkel Lager 4. Sierra Nevada – Pale Ale 5. Mikkeller – Burst 6. La Trappe – Dubbel Do. 25. Juni 2026: Stichfass Specials: 1. Hofbräu Oberle Hofbier 2. Hofbräu Oberle Sommersprossen 3. Hofbräu Oberle Fränkisches Pils  Fr.26. Juni: Premiere Jubiläumsbier ab 17 Uhr mit Georg von Fuerst Wiacek Sa. 27. Juni: Slushy Fassbier & Slushys Für alle Infos und Updates schaut bei Instagram (@beyondbeer) vorbei! [Stream] Männerabend – Der Craft Beer Podcast: Spotify – iTunes – Deezer [Social Media] Männerabend – Der Craft Beer Podcast: Instagram – Facebook – Twitter Download: (Rechtsklick -> „Ziel speichern unter“) Männerabend Special – 11 Jahre Beyond Beer // (adsbygoogle = window.adsbygoogle || []).push({}); // ]] // ]]>

Lynn Gravley, the newly appointed chairman of the Transportation Intermediaries Association (TIA) and founder of NT Logistics, joins us to break down the real side of the freight industry! Lynn shares his journey from being a broke, freshly minted college graduate to building a thriving managed transportation business. He dives into how managing full networks differs from traditional freight brokerage, the massive role of data analytics and Power BI dashboards, and why aligning with the TIA is a game-changer for building authority. If you are ready to stop fighting fires and start optimizing your logistics network, tune in now!   Connect with Lynn Website: https://www.ntlogistics.com/ / https://www.tianet.org/  LinkedIn: https://www.linkedin.com/in/lynn-gravley/  

We used to say OG's or Old Head...today it's called "Unc." Are you in your Unc or Tia era? We talk about how we're dealing with it and be accepting of it.

Ever looked around your house and thought, "How did it get like this? I used to have it all together"? You are not alone, and according to this week's guest, that mess is not a character flaw. It is a sign your life has outgrown your system. And that is fixable. Angie sits down with Tia Toso, founder of Room for Serenity, a home organizing service in the Twin Cities. Tia isn't the kind of organizer who swoops in, makes everything pretty, and leaves you with a bin system you will never maintain. As a mom herself, she coaches families through the decisions so the change actually sticks. In this episode you will learn why there is no quick hack to organizing when you have kids, how to organize for function instead of for the perfect Instagram shelf, how to get your spouse and kids genuinely on board, and a low-pressure way to declutter a little at a time. Most of all, Tia reframes the guilt and shame so many of us carry, reminding us we were built to live in community, not to handle it all alone. If you have a counter that hasn't seen daylight in weeks, press play. Follow Mom Essentials, leave a review, and visit theparenttoolbox.info for more. Connect with Tia: https://www.roomforserenity.com/book-free-consult http://instagram.com/room_for_serenity  http://www.linkedin.com/company/roomforserenity Essential Minute: https://link.doterra.com/aHuOcj Family Planner: https://www.theparenttoolbox.info/the-calm-family-planner  

We're back with a deep dive on one of our favorite recent romances, Seven Days in June by Tia Williams! We talk about yearning in contemporaries, about books that have a powerful sense of place, about dual timelines, about secondary characters, about lines that stick with us years later, and about how fated mates works as a trope in a contemporary romance.Tia also has a new book out this month, The Missed Connection. Get it wherever you get your books.Listen to our Season 3 episode with Tia Williams about writers in romance and head over to talk about Seven Days in June or any of her other books on the Fated Mates Discord, accessible to our Patreon subscribers. By joining the Patreon, you meet other Fated Mates listeners and get an extra monthly episode from us. Support us and learn more at fatedmates.net/patreon.Read Seven Days in June at Amazon, Barnes & Noble, Kobo, Apple Books, wherever you get your books, or with your monthly subscription to Kindle Unlimited.NotesSorry, we're a Knicks podcast now, everyone. Sarah because of New York and Jen because of Villanova. Sarah did look up that Knickerbocker thing, but we never got back to it. Learn more about how those trousers became a symbol of NYC here. Sports curses are bad, just ask Red Sox fans! Spike Lee has really been through it, Jalen Brunson's interview after the game just shows you a man trying to deal with his feelings.The World Cup, we just don't know anything about that yet, but we're gonna get up to speed on that, just like all the people of the world getting up to speed on America. Also, feels important to romance that we bring you the news that the Tartan Army cleared Boston out of beer.We had Tia Williams on the podcast back in season 3 when Seven Days in June was released. Although there is not a sequel to Seven Days, Shane and Eva are secondary characters in the YA romance with Audre that came out in 2025. Find out more about Tia, and see all her books at her website.Come see Sophia Benoit in conversation with us in NYC (June 23) and Chicago (June 24) to celebrate the release of her first historical romance, The Very Definition of Love.SponsorsFrederick Smith, author of Love is a Contact Sport, available in print, ebook, audiobook from Amazon, Barnes & Noble, Kobo, or wherever you get your books.Little Brown & Company, publishers of Lu Chekowsky's Don't Buy What I'm Selling: On Breaking Up with Advertising and Finally Learning to Love My Whole, Fat Self, available in print, ebook, audiobook from Amazon, Apple Books, Barnes & Noble, Kobo or wherever you get your books.The What in the Smut? Podcast, available wherever you get your podcasts.W by Wattpad Books, publishers of Nicole Alfrine's Brain Games. Available in print and ebook from Amazon, Apple Books, Barnes & Noble, Kobo, or wherever you get your books.The RestFor even more info about this episode, and to explore everything Fated Mates has to offer, visit: https://fatedmates.net/2026/6/16/s0838-seven-days-in-june-by-tia-williams If you wish you had six more days in a week of people talking about romance, may we suggest joining our Patreon? Aside from an additional episode every month you get access to our Discord, where other romance readers are talking about books they love (and many other things!) all the time. It's so fun! Learn more about the Patreon and go join those cool people who love romance as much as you do at patreon.com/fatedmates. Beyond your favorite podcast app, you can find us on Instagram, Threads, Blue Sky, Tumblr, and probably some other places, too, if you look hard enough. If you've never listened to our Stop Book Banning episode, there's no better time than now.

Greg Bluestein hosts a special edition of The Atlanta Journal-Constitution's Politically Georgia podcast with Tia Mitchell and Patricia Murphy after Georgia's primary runoff elections delivered two major Republican verdicts. Rick Jackson defeated Lt. Gov. Burt Jones in the GOP race for governor despite late support from Donald Trump and Brian Kemp, while Mike Collins beat Derek Dooley in the Senate runoff after Trump backed Collins and Kemp helped build Dooley's campaign. The episode looks at what the results say about Kemp's political machine, Trump's uneven influence, Republican unity and the general election fights ahead against Keisha Lance Bottoms and Jon Ossoff. Greg, Tia and Patricia also break down key down-ballot races and the uncertain future of redistricting in a special legislative session. Have a question or comment for the show? Call or text the 24-hour Politically Georgia Podcast Hotline at 770-810-5297. We'll play back your question and answer it during our next Monday Mailbag segment. You can also email your questions at PoliticallyGeorgia@ajc.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

Primary stroke prevention is a critical opportunity for neurologists, with most stroke risk driven by modifiable factors such as hypertension and lifestyle behaviors. This episode highlights practical tools and strategies, including Life's Essential 8 and contemporary risk calculators, while also exploring evolving approaches to shared decision making and secondary prevention. In this episode, Katie Grouse, MD, FAAN, speaks with Mitchell S. Elkind, MD, MS, FAAN, author of the article "Stroke Prevention" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California, San Francisco in San Francisco, California. Dr. Elkind is the Chief Science Officer for Brain Health and Stroke at the American Heart Association in Dallas, Texas, and a professor of neurology and epidemiology at Columbia University in New York, New York. Additional Resources Read the article: Stroke Prevention Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Guest: @MitchElkind Full episode transcript available here Dr Grouse: Neurologists have generally been more involved in secondary stroke prevention, but primary stroke prevention is increasingly recognized as an important topic of discussion for neurologists. Today, I have the opportunity to interview Dr. Mitchell Elkind, who wrote the article on stroke prevention in the newest Continuum issue on cerebrovascular disease.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Grouse: This is Dr. Katie Grouse. Today, I'm interviewing Dr. Mitchell Elkind about his article on stroke prevention. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, and please introduce yourself to the audience.  Dr Elkind: Thank you so much, Katie. So, my name is Mitch Elkind, and I'm the Chief Science Officer for Brain Health and Stroke at the American Heart Association and a stroke neurologist by background.  Dr Grouse: Well, I just want to start by saying that I really enjoyed reading this article. I think this is just a really wonderful article I recommend strongly. Such a high yield, an important topic for a lot of us who see patients who are interested in learning about their stroke risks or need help with, uh, stroke prevention after having a stroke. So, I wanted to start. What's changed in the last couple of years? You know, what are some big highlights that you really want to stress that are different from maybe the last time we reviewed this topic?  Dr Elkind: Sure. Well, there's been a lot of development in the field of secondary stroke prevention, for one thing. But even beyond that, I think we increasingly appreciate how important it is to control what we call the social drivers of health on the earlier side, primordial or primary prevention. And that has been a big advance, I'd say. And I would also say, I think it's really important for neurologists to understand some of those questions about primordial and primary prevention. You know, we tend to get involved with patients after they've had a stroke or maybe a TIA, some kind of event. But sometimes we find people who are following for, you know, non-stroke related conditions who have risk factors also. And we can really play an important role in identifying those risk factors and helping to prevent a first stroke or vascular event as well. So, I think it's real important for us to be doctors even before we're neurologists. So, you know, Katie, about ninety percent of stroke risk is modifiable, so we can do a great job as neurologists in preventing stroke. And one of the most important things that we can do is to identify and treat high blood pressure. And recently, actually, the American Heart Association, American College of Cardiology guidelines on the management of hypertension have said that treatment of high blood pressure not only prevents stroke, but it can also help to prevent cognitive decline and dementia. And this is the first time that we've had a class of recommendation one and level of evidence A, the highest level of recommendation we give for the use of blood pressure treatment to prevent dementia. And that's largely based on the results of some large trials that have come out recently showing that you can prevent dementia with blood pressure control. So that's a really exciting link, I think, between cardiovascular risk factor control and subsequent brain health. It just illustrates the role that neurologists can play in, so many conditions outside of stroke as well.  Dr Grouse: That's a really great point, and I want to get a little more into the idea of primordial stroke prevention. Can you tell us a little bit more about what that might be?  Dr Elkind: So primordial prevention refers to addressing how we can prevent risk factors from occurring in the first place, and how can we improve the environments in which people live. You know, we know that only about twenty percent of health outcomes is dependent on what happens between the patient and their doctor in the office. About eighty percent of it is due to what happens in the environments in which we live, work, pray, and play. And so that's what we mean when we refer to the social drivers of health. What is the neighborhood like where somebody lives? Do they have access to healthy food? Do they have places where they can go to exercise? Is there air pollution in the area that may affect their health? You know, one really interesting fact that's become apparent in the last few years is that air pollution is a major risk factor for stroke. Something like a sixth of all strokes can be attributed to the quality of air. And so, what are the things we can do at the broader public policy, community level to reduce the risk of risk factors like high blood pressure and diabetes even before somebody has an event that brings them to the attention of the doctor? So that's what we're thinking about with regard to primordial prevention. It's the earliest stage in prevention.  Dr Grouse: And that's really fascinating. You know, I think an area that we haven't, as neurologists, really put a lot of our time thinking about, but clearly a very important thing. I really appreciated reading your article about how you incorporated the fact that, you know, a lot of these risk factors overlap very, very closely with all the risk factors for various types of cardiovascular events. And I would imagine that the work you've done as the Chief Clinical Science Officer for the American Heart Association has informed a lot of the way you've thought about-Trying to bring all these risks together and think a little bit more holistically about the whole thing. Could you tell us a little bit more about that and the work that you've done on the American Heart Association's Life's Essential 8 score?  Dr Elkind: Sure. I can't take credit for it. It's really work that was done by others at the Heart Association, particularly a cardiologist and epidemiologist named Don Lloyd-Jones. But many other volunteers participated. Life's Essential 8 is our approach to primary stroke prevention and cardiovascular prevention more broadly. We say Life's Essential 8 because it includes four health behaviors and four health factors that people can observe to reduce their risk of cardiovascular disease. The four factors are kind of things like know your numbers, your blood pressure, your blood sugar, your body mass index, right, which is a combination of weight and height, and your cholesterol level. So, know those numbers and keep them within the recommended ranges, and talk to your doctor if they're not. And then four lifestyle behaviors. So, one of them is to eat a healthy diet, and typically that means the Mediterranean diet. It means getting regular exercise, and we recommend 150 minutes a week of moderate to vigorous physical activity. Of course, it means abstinence from smoking or other tobacco products. And the last one, the eighth one, which I was so excited about when we added this, is sleep, recommending at least seven hours of sleep a night. So, I was really excited about this because we used to talk about Life's Simple 7, and then the last iteration of our recommendations included this recommendation for adequate sleep because of the mounting evidence of the importance of sleep to cardiovascular health. But sleep is really a brain function, right? And so, it was really the first, in a way, specific brain function that was added to our recommendations. So that's Life's Essential 8. People can read about it online at heart.org and recommend it to your patients as a simple way for people to understand the best approach to reducing their risk of cardiovascular disease, including stroke.  Dr Grouse: I checked it out myself after reading the article. It's very accessible to patients. It's a great education tool. And they can, you know, see their own score and use that in their own way to, to think about what their risks are and how they can help mitigate and then rescore themselves down the line. There's also, though, on the kind of more the clinician side, the PREVENT calculator as well. Could you tell us a little bit more about how we could use that in approaching this patient population?  Dr Elkind: Yeah. So, I think of Life's Essential 8 as being a patient-focused tool that people can use. PREVENT is really more for clinicians. Anybody can look it up online and enter your data into it. There's a risk calculator online. But the basic idea behind PREVENT and other similar risk calculators is that it's a way to estimate somebody's risk of having a cardiovascular event like stroke or a heart attack or even heart failure by entering information about your health. And we used to think, we used to use something called the ASCVD, atherosclerotic cardiovascular disease risk calculator, or the Framingham score. Framingham Heart Score, for example, was another one. PREVENT is the latest version, and it has several advantages over those earlier types of risk predictors. For one thing, it predicts risk at younger ages as well. It goes down to age 30. It predicts risk over a longer duration of time, so over 30, 10 or 30 years. It eliminates the use of race as an item to put into the calculator and substitutes for that socioeconomic status, so it's not a race base, but a measure of social disadvantage. And it also includes kidney elements, kidney measures. It includes renal function, for example, that weren't included in prior measures, and it can also be used to predict heart failure, which was not part of the original calculators. Another major advantage of the PREVENT study is that it was based on real-world data from about three million patients, many, many more than the 50,000 or so that the earlier risk calculators were based on. So, it has a much more robust data set and therefore allows a bit more precision in the ability to predict future risk of events. And typically, primary care doctors would enter their patient's data, calculate a risk, and then based on the results of the risk calculator, they can make recommendations about what type of medications a person should take or what other strategies they could use to reduce their risk. And so that's the role that PREVENT plays, is really being focused more for the clinician than the patient.  Dr Grouse: Really great tool for us to be aware of. You earlier alluded to the fact that neurologists are in the situation where we sometimes are helping patients with this primary prevention. But you also make a case for why it's in the patient's best interest for us to be involved in, in these conversations when we can, when we have the opportunity. Can you tell us more about that?  Dr Elkind: Shared decision-making is really important because we know that people aren't going to lead the healthiest possible lives if they're not invested in their care. And so, a doctor telling somebody what to do if the patient doesn't want to do it is gonna have limited benefit.So we emphasize the importance of shared decision-making as much as possible. And I think that where this comes up a lot is actually in the situation of, for example, atrial fibrillation, where patients will often be put on a blood thinner. And many people are fearful of blood thinners. They worry about the risk of bleeding. Maybe they know a relative who's had a bleeding complication from a blood thinner, and so they may be disinclined to try it. And so, it's really important to have these discussions about the risks and the benefits of medication and engage the patient in thinking about this. And there are even tools and visual aids that people can look to to help explain some of these complicated concepts to patients. So, these are the kinds of things that reflect implementation science as a way to improve adherence. We know what works in a clinical trial setting often, but the challenge is translating that into the real world and getting our patients to use the medications that we believe scientifically have been shown to be of benefit. I've actually been surprised sometimes at conversations I've had with people, in some cases, healthcare professionals who resist going on blood thinners because of their fear of the complications. And I feel like the evidence is there. Why don't they believe me? And that's why it's really important to have the conversation. Even our peers and colleagues can sometimes question the evidence, and it's important for us to be aware of that.  Dr Grouse: Absolutely. I think that sounds very reasonable to me, and hopefully these tools will help us with making some of these decisions with our patients. Now, turning our attention a little bit to secondary prevention. So, you know, someone's already had a stroke or a TIA, sort of thinking about what we can do to optimize their risk factors for further strokes. You know, I think there has been some changes that have happened, I think, in the last few years that might be affecting some of the decisions we're making and some of the advice we're giving our patients. I wanted to talk a little bit about GLP-1 receptor agonist medications. Is the data there to support use of this either in secondary prevention or even in primary prevention in the case of stroke?  Dr Elkind: There is evidence that supports the use of GLP-1s for stroke prevention. We need more data, though. We need trials that focus only on patients with stroke, for example, there have been studies in patients with cardiovascular disease broadly that include stroke patients. But if you look at the subcategory just of stroke patients alone, the data in that subgroup alone don't always show a benefit. And so, we need more data that's focused on stroke patients alone. So, I think the data are continuing to emerge, but we need more still.  Dr Grouse: Is there any development in the thought about whether we should be putting patients on antiplatelet therapies for incidental, incidentally identified strokes? For instance, if you got an MRI for migraine or for other reasons and you found one, no history of any stroke-like symptoms. Should we be putting these patients on aspirin or any other types of therapies?  Dr Elkind: That's a really great question. And again, it's an area where there's some controversy and really, there's really no definitive data that would support using antiplatelet therapy in people with incidentally discovered infarcts or what we call, you know, whispering strokes or silent strokes. Many stroke neurologists will use antiplatelet agents. This is one of those areas where it's so important to identify the risk factors. As we were saying before, patients who have other neurological disorders like migraine or epilepsy may turn out to have cardiovascular risk factors like diabetes and high blood pressure. That's why it's so important for neurologists to be able to treat those patients or refer them to specialists who can. Patients who have incidentally discovered lesions similarly are a group where we should be looking for risk factors. So, I don't think of it only in terms of do we put them on an antiplatelet or not, but really more holistically, can we identify their other risk factors and address those? Should the patient's information be entered into a risk calculator like PREVENT, for example, so that we can come up with a more global or holistic measure of their cardiovascular risk and address that as appropriate? Because if they are at risk for stroke, they're also at risk for cardiac events, including heart attack, heart failure, sudden cardiac arrest, and so forth. So, I think of it as a, as a great kind of teachable moment or an opportunity to catch somebody and bring them into the healthcare system more broadly and address those other potential risk factors.  Dr Grouse: Speaking of, of risk factors that we often like to think about and work up when possible, in cases where it seems certainly possible the patient had an embolic stroke, but perhaps we've done a few weeks or four weeks of cardiac monitoring, have not found any evidence of atrial fibrillation. What's new and what's the current recommendations for doing further monitoring when there's high suspicion for cardioembolic stroke?  Dr Elkind: This is a really active area of investigation, and guidelines suggest that we should do some cardiac monitoring for atrial fibrillation after an unexplained stroke, but it's not clear how much we should do. Studies generally show that the longer you follow somebody on a cardiac monitor after stroke, the more likely you are to detect atrial fibrillation. It could be as high as thirty percent after a few years. And that's great. And if you detect atrial fibrillation, people usually end up being recommended for a blood thinner. But how extensively we should monitor remains unknown. And I think a lot of the investigation recently has been around the question of, are there other ways to get that information rather than waiting six months or a year for the person to develop atrial fibrillation?It's a little bit funny logically to think a person has a stroke today, a year later you discover atrial fibrillation on the monitor, and you say, "Oh, now I know what caused your stroke a year ago." Right? The temporality, the causality perhaps is off in that case. And so, wouldn't it be better if we could tell what somebody's risk of having another cardioembolic stroke is, or the likelihood that they have atrial fibrillation is at the time that you first see them for the stroke, you know, in the hospital, for example. And so, there's some really new technologies that have evolved like AI or artificial intelligence interpretation of EKGs that can give a really good indication of which people are gonna go on to develop atrial fibrillation. And so, I think we need some more trials in that area to demonstrate that we can detect the risk of AFib and treat that even before it appears on one of those delayed monitors. That's an area that I think is very exciting right now. There's also a further question with regard to how to treat these patients, which is that sometimes atrial fibrillation is a consequence of the stroke itself. So, we can think about what people call known AF, meaning atrial fibrillation that's known about before the stroke even occurs, versus AF that's detected after a stroke, or AF-DAS, people will say. Those may have very different implications for the risk of recurrence and what the person's cardiovascular status is. So, I think what we've learned over the last few years is that atrial fibrillation, it used to be like the slam dunk for a stroke neurologist. It was the easy thing. You know, you had a stroke, you have AFib, you should be on a blood thinner. Now we know that there's lots of different kinds of AFib. There's AFib before stroke, there's AFib after stroke, there's burden of atrial fibrillation. So, some people may have 30 seconds of AFib, some people may have several hours, some people may be in it continuously. It comes and goes, and that can make it challenging to manage. So, we have a lot more work to do to understand this problem better.  Dr Grouse: That also gets me into some other interesting areas that I think there's still some question, you know, how aggressive should you be? How often is it a case of is this correlated or is this causative? For instance, when a patent foramen ovale is, is discovered in patients with cryptogenic stroke. Are there any tools or new developments to help us understand whether these PFOs should be closed in these cases?  Dr Elkind: PFO and stroke is a great story that's been going on for decades. And again, we've made tremendous progress in the last several years. So, it's true that about 20% or so of people have a PFO, and because of that, it can be really hard to say with any certainty whether an individual patient sitting in front of you, that the PFO was the cause of their stroke. Rarely we can have a really high degree of certainty. You know, if somebody has, uh, a DVT, for example, and shortly after that maybe they have pulmonary embolism and then a stroke, and we can say, "Oh, clearly this was a paradoxical embolism," went to the lungs and then some crossed over and went to the brain. That happens really infrequently. Most of the time you're faced with a patient who has a PFO and a stroke, and they may have some other risk factors. There are some tools that we can use to help figure out the likelihood that a PFO is related to a stroke. One of those is called the ROPE score or the risk of paradoxical embolism score that was developed by David Thaler and, uh, David Kent from Tufts and a group of other investigators as well. That score allows one to say what the likelihood is that the PFO was causative of the stroke, and it's based on a person's risk factors such that the younger you are, the more likely it is the PFO caused the stroke. And the absence of risk factors make it more likely that the PFO caused the stroke. So, the higher your ROPE score indicating the fewer other reasons you have a stroke, the more likely the PFO is to be causative. So that can be helpful in identifying patients who may have had a stroke due to their PFO. There are other features that are identified in something called the PASCAL score, which is a way of assessing the degree of shunting and whether or not there's an atrial septal aneurysm that can be used as additional factors that lead to the likelihood that a PFO was causative rather than just incidental. So, by putting this kind of information together, we can kind of do precision neurology or precision prevention by identifying which patients with a PFO are really the ones we need to worry about and do procedures like closure.  Dr Grouse: I look forward to hearing more and learning more as more advances are made in these areas. Dr Elkind: Thank you.   Dr Grouse: And thank you so much for joining us today to talk about your article.   Dr Elkind: Oh, I appreciate it. Thank you for giving me the opportunity. I really enjoyed it.  Dr Grouse: Again, today I've been interviewing Dr. Mitchell Elkind about his article on stroke prevention. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today.  Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Is social media morally neutral? Is digital discipleship possible in our over-digitized world? We explore doomscrolling, guardrails, and sharing the gospel online.For the study resources and manuscript go to messiahbible.org

Bob Kerr returns to break down his Tax Notes article on the IRS's Centralized Authorization File, the decades-old system that processes Forms 2848 and 8821 almost entirely by hand, now buried under 7 million forms a year at roughly 500 staff years and $50 million to run. He, Roger, and Annie get into why the backlog keeps growing, how practitioners can get ahead of it by putting 8821s on file early, and why transcripts belong in your current-year filing, not just your representation work.SponsorsPadgett -  Contact Padgett or Email Jeff PhillipsGet NASBA Approved CPE or IRS Approved CELaunch the course on EarmarkCPE to get free CPE/CE for listening to this episode.Read Bob's Article https://www.taxnotes.com/tax-notes-federal/practice-and-procedure/high-costs-irss-centralized-authorization-file-system/2026/04/06/7vjccChapters(00:00) - Welcome and Setup (02:36) - Why CAF Matters Now (06:54) - CAF Explained POA vs TIA (10:42) - Choosing 8821 vs 2848 (13:46) - Backlogs and Real Impacts (15:45) - Manual Processing Volume Surge (18:54) - Million Hours and 50M Cost (21:23) - Deadlines Snowball Effect (24:01) - CAF Volume Spiral (24:59) - Early Transcripts Benefits (28:33) - Client Use Cases (30:27) - Why IRS Can't Keep Up (39:13) - Train Clients and Set Expectations (43:33) - Transcripts Beyond Representation (44:32) - VITA Volunteering Insights (48:56) - Wrap Up and Thanks Follow the Federal Tax Updates Podcast on Social Mediatwitter.com/FedTaxPodfacebook.com/FedTaxPodlinkedin.com/showcase/fedtaxpodConnect with the Hosts on LinkedInRoger HarrisAnnie SchwabReviewLeave a review on Apple Podcasts or PodchaserSubscribeSubscribe to the Federal Tax Updates podcast in your favorite podcast app!This podcast is a production of Earmark MediaThe full transcript for this episode is available by clicking on the Transcript tab at the top of this pageAll content from this podcast by SmallBizPros, Inc. DBA PADGETT BUSINESS SERVICES is intended for informational purposes only.

"What if the way we pick politicians is the real problem? Here's a bold idea that flips the script on politics.Tom Joseph's American Main Street Party is creating a new way to choose leaders — without the money, power, or insider deals. It's a tech-driven, transparent process designed to give every voter a real voice.Imagine a political system where your vote actually shapes the candidate — not just the most funded or connected. And what if we could fix gerrymandering that keeps corrupt districts in place?This isn't just talk. It's a movement rooted in the founders' original ideals — equality, fairness, and democracy for all: The future of politics is in your hands. Are you ready to be part of the change?Link in bio to learn more and get involved.Become a supporter of this podcast: https://www.spreaker.com/podcast/this-is-america-podcast--4182415/support.A Pod by the People for the People.

In this episode, we kick things off with a massive milestone for autonomous trucking as ⁠Volvo Autonomous Solutions plans to remove safety drivers from its trucks in early 2027⁠ and begin fully driverless operations on U.S. highways. The company currently runs commercial freight daily in Texas with safety drivers aboard, but projects it will have over three hundred autonomous trucks operating by the end of 2027, with industrial scaling beginning in 2028 and revenue approaching three billion dollars within five years. Over on the rails, ⁠agricultural retailers are raising serious alarm bells about the proposed Union Pacific-Norfolk Southern mega-merger⁠ and its impact on the agribusiness sector. The Agricultural Retailers Association, which represents more than five thousand retail locations nationwide, warns that freight rail rates have risen over forty percent in the past twenty years—seventy percent faster than truck rates—and that further consolidation among the four Class I carriers controlling ninety percent of rail traffic directly threatens supply chain reliability for moving fertilizer, chemicals, and fuel to America's farms. Finally, we explore how ⁠the Transportation Intermediaries Association is pushing FMCSA for federal clarity on approved carrier selection standards⁠ following the landmark Montgomery versus Caribe Transport II Supreme Court decision. With more than ninety percent of authorized motor carriers currently operating without an FMCSA safety rating, the TIA is requesting a federal rulemaking that would establish objective criteria to help brokers and shippers determine whether the use of a given carrier is reasonable based on demonstrable safety performance. ⁠Follow the FreightWaves NOW Podcast⁠ ⁠Other FreightWaves Shows⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome back to a Friday edition of What The Truck?!Malcolm Harris and Michael Vincent kick off the show with their signature banter before diving into some of the biggest stories shaping freight, transportation, and supply chain today.In this episode:* Amazon's latest move into the LTL market and what it could mean for established carriers* Craig Fuller's analysis of Amazon's freight strategy and whether acquisitions like Forward Air make sense* The Transportation Intermediaries Association's (TIA) push for FMCSA guidance following the Montgomery case* How rising liability concerns and insurance costs could impact brokers, carriers, and the future of the industry* The growing role of technology, compliance, and risk management in modern truckingPlus, Chief Business Development Officer Adam Kahn of Netradyne joins the show to discuss:* How safety technology is transforming fleet operations* Netradyne's partnership with one of the nation's largest Domino's franchise operators* The impressive 66% reduction in at-fault crashes following implementation* Driver coaching, AI-powered safety insights, and building a stronger safety cultureThe crew also talks freight fraud, cargo theft, supply chain AI, LNG export developments, entrepreneurship, and plenty of Friday fun along the way. Watch on YouTube Visit our sponsor - KOONER FLEET MANAGEMENT SOLUTIONS Subscribe to the WTT newsletter Apple Podcasts Spotify More FreightWaves Podcasts #WHATTHETRUCK #FreightNews #supplychain Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome back to a Friday edition of What The Truck?!Malcolm Harris and Michael Vincent kick off the show with their signature banter before diving into some of the biggest stories shaping freight, transportation, and supply chain today.In this episode:* Amazon's latest move into the LTL market and what it could mean for established carriers* Craig Fuller's analysis of Amazon's freight strategy and whether acquisitions like Forward Air make sense* The Transportation Intermediaries Association's (TIA) push for FMCSA guidance following the Montgomery case* How rising liability concerns and insurance costs could impact brokers, carriers, and the future of the industry* The growing role of technology, compliance, and risk management in modern truckingPlus, Chief Business Development Officer Adam Kahn of Netradyne joins the show to discuss:* How safety technology is transforming fleet operations* Netradyne's partnership with one of the nation's largest Domino's franchise operators* The impressive 66% reduction in at-fault crashes following implementation* Driver coaching, AI-powered safety insights, and building a stronger safety cultureThe crew also talks freight fraud, cargo theft, supply chain AI, LNG export developments, entrepreneurship, and plenty of Friday fun along the way. Watch on YouTube Visit our sponsor - KOONER FLEET MANAGEMENT SOLUTIONS Subscribe to the WTT newsletter Apple Podcasts Spotify More FreightWaves Podcasts #WHATTHETRUCK #FreightNews #supplychain Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode, we kick things off with a massive milestone for autonomous trucking as Volvo Autonomous Solutions plans to remove safety drivers from its trucks in early 2027 and begin fully driverless operations on U.S. highways. The company currently runs commercial freight daily in Texas with safety drivers aboard, but projects it will have over three hundred autonomous trucks operating by the end of 2027, with industrial scaling beginning in 2028 and revenue approaching three billion dollars within five years. Over on the rails, agricultural retailers are raising serious alarm bells about the proposed Union Pacific-Norfolk Southern mega-merger and its impact on the agribusiness sector. The Agricultural Retailers Association, which represents more than five thousand retail locations nationwide, warns that freight rail rates have risen over forty percent in the past twenty years—seventy percent faster than truck rates—and that further consolidation among the four Class I carriers controlling ninety percent of rail traffic directly threatens supply chain reliability for moving fertilizer, chemicals, and fuel to America's farms. Finally, we explore how the Transportation Intermediaries Association is pushing FMCSA for federal clarity on approved carrier selection standards following the landmark Montgomery versus Caribe Transport II Supreme Court decision. With more than ninety percent of authorized motor carriers currently operating without an FMCSA safety rating, the TIA is requesting a federal rulemaking that would establish objective criteria to help brokers and shippers determine whether the use of a given carrier is reasonable based on demonstrable safety performance. Follow the FreightWaves NOW Podcast Other FreightWaves Shows Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello, Audio Visitors!This week, it's all about solo trips with our friend Tia!Episode 228:What We Love About Solo Trips with Our Friend Tia Listen here:https://linktr.ee/ofmiceandmainstreetmenCheck out links to the shop and travel agency:OfMiceAndMainStreetMen.comShare this episode with your friends and help us spread the gospel of Of Mice & Main Street Men! Thank you for listening! Cheers!Sean & Tristan #disneypodcast #waltdisneyworld  #waltdisney #disneyfans #ofmiceandmainstreetmen 

Click to Text Thoughts on Today's EpisodeWhen a friend described drooping eyes, slurred words, and fuzzy thinking at brunch — and then brushed it off as anxiety — I knew something wasn't right. That conversation sparked this important Common Sense episode on recognizing the warning signs of stroke, TIA, and heart attacks, and why acting fast can make all the difference. I hope this episode gives you a little more confidence and a little less hesitation if you ever need it. Share it with someone you love. It might matter more than you know.In This Episode:Why women are more likely to dismiss their symptoms — and the cost of waitingThe FAST acronym for stroke and TIA: F — Face droopingA — Arm weaknessS — Speech difficultyT — Time to call 911What a TIA (transient ischemic attack) is and why feeling better doesn't mean you're in the clearAdditional stroke warning signs beyond FASTHow heart attacks present differently in women — including jaw pain, back pain, nausea, fatigue, and shortness of breath with no chest pain at allWhy you should call 911 instead of driving yourselfA personal reflection on loss and the what-ifs we carryEpisodes Discussed:500th Episode: ​5 Uncomfortable Lessons from 500 Episodes​For more information on heart attacks and stroke visit:American Heart Association — heart.org — covers both heart attack and stroke, very thorough, well-organized for general audiencesAmerican Stroke Association — stroke.org — technically a division of AHA but has its own dedicated stroke content including FAST informationMy latest recommended ways to nourish and move your body, mind and spirit: Nourished Notes Bi-Weekly Newsletter30+ Non-Gym Ways to Improve Your Health (free download)Connect with Amy: GracedHealth.com Instagram: @GracedHealthYouTube: @AmyConnell

Pinch me! I got to welcome back one of my absolute favorites, Tia Williams! We reunited to celebrate her latest novel, The Missed Connection, a steamy summer romance guaranteed to turn up the heat.Filled with chance encounters, heart, chemistry, and just the right touch of mystery, this novel delivers all the signature elements readers have come to love from Tia. We caught up about her writing process, book-to-screen adaptations, beauty products, and so much more.And if you haven't explored Tia's backlist yet, consider this your sign. Her catalog is a beach reader's dream and the perfect summer spritz - light, refreshing, and impossible to stop sipping before diving into The Missed Connection.

Greg Bluestein and Tia Mitchell take on listener questions ahead of Georgia's upcoming runoffs and a special legislative session. They dig into the Rick Jackson ad that leans on Brian Kemp's words without an actual endorsement, and size up how both Republican governor's race candidates are racing to claim the MAGA lane while also courting Kemp's political brand. Greg and Tia also weigh in on Keisha Lance Bottoms and Jon Ossoff's early joint campaigning, what the black women's vote actually delivered for Stacey Abrams in 2018, and how Georgia's leadership committee fundraising law created a money advantage that's still generating legal fights this cycle. Have a question or comment for the show? Call or text the 24-hour Politically Georgia Podcast Hotline at 770-810-5297. We'll play back your question and answer it during our next Monday Mailbag segment. You can also email your questions at PoliticallyGeorgia@ajc.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

This week on the Lin. Woods Gospel Entertainment Podcast, Lin. sits down with award-winning filmmaker Tia A. Smith, a visionary storyteller whose remarkable career journey has taken her from radio broadcasting to producing content for BET, TV One, VH1, and now the big screen.Tia opens up about the path that led her to become a respected filmmaker, the challenges she's faced as a woman navigating the entertainment industry, and the determination that has fueled her success. She also discusses her latest film, The Heir, which recently earned international recognition with an award at the prestigious Cannes Film Festival in France.In this inspiring conversation, Tia shares valuable lessons learned throughout her career, the importance of perseverance, and practical advice for aspiring filmmakers looking to break into the industry. Whether you're a film lover, creative entrepreneur, or someone pursuing a dream, this episode is packed with wisdom, encouragement, and behind-the-scenes insights from one of today's rising filmmaking talents.Connect with Lin. Woods on Social Media:Instagram & Tik Tok: @Lin Woods.Facebook & LinkedIn: @Lin. WoodsX/Twitter: @linwoods#LinWoodsGospelEntertainmentPodcast #Podcasts #blackfilmmakers #WomenInFilm #faith #inspiration 

We're premiering the video for ‘Abiotic Factors' – Patricia Wolf's opening dispatch from Gothic, Colorado and the invisible forces that determine whether anything grows at all… Tia and Wil's Music To Watch Seeds Grow By series – the ambient/new-age/planty cassette label has in nine editions, tried to make a compelling case that the best way to understand ambient is to get your hands in some soil and think about it properly. Each artist chooses a plant that inspires their music and can be sown in the month of the release. Simple. Seasonal. You may have noticed it already. For the ninth edition – the third of Season Two – they've brought in Portland, Oregon-based musician and field recordist Patricia Wolf, whose album Yarrow takes its name from Achillea millefolium, a flowering plant whose broad geographic range spans North America and Eurasia, which also happens to make it the perfect conceptual thread to connect Portland (where the music was written and recorded) to London (where the cassette was pressed and will land through your letterbox alongside a packet of yarrow seeds and a fact card about the plant). A transatlantic weed of the most beautiful kind. Wolf is one of the most interesting people quietly operating at the edges of sound art. Her recent arc has taken her from grief (I'll Look For You In Others, 2022) to a kind of luminous rebirth (See-Through, 2022), then to birds – literal birds, in Iceland, for a documentary score (Hrafnamynd, 2025) – and now, with this album, to plants. Specifically, to the invisible forces that determine whether plants live or die at all. Yarrow was created in response to Wolf's artist residency at the Rocky Mountain Biological Laboratory in Gothic, Colorado, as part of the Art-Science Exchange Project in the summer of 2024. She worked closely with ecologists Dr Paul CaraDonna, Dr Amy Iler, Dr Jane Ogilvie, Dr Nickolas Waser, Dr Mary Price, and Dr Will Petry, spending weeks embedded in long-term research on plants, pollinators, and their interactions as the climate changes. This is not, in other words, an ambient album about plants in the vague, pastoral sense. It's an album about plants in the way a botanist might describe them: as dynamic organisms in constant, often invisible negotiation with their environment. Which brings us to ‘Abiotic Factors', the album's opening track and the subject of today's premiere. Abiotic factors – for those of us who skipped that particular biology lesson – are the non-living environmental conditions that determine whether an organism can exist at all: light availability, temperature, rainfall, wind, soil composition. They are the infrastructure beneath the visible world, the silent set of forces that a plant cannot choose but must simply work with, adapt to, or perish. As a concept for an opening track, it's contemplative and a perfect orientation into the album… which you'll all hear in its entirety soon little seedlings. The video was shot closer to home – in Wolf's Portland neighbourhood - through the lens of Edward Pack Davee, the filmmaker behind the Hrafnamynd documentary Wolf scored last year. Watch here: https://www.theransomnote.com/art-culture/video-premiere-patricia-wolf-abiotic-factors/

Get out your physical media collections, fire up the record player, and get ready to unlock some serious childhood magic. This week, we are taking a trip past the stars and straight to the movies that defined a generation of Disney fans. We are thrilled to welcome Hollywood legend, voiceover maestro, and a true cornerstone of the Magical World of Disney, IKE EISENMANN (Escape to Witch Mountain, Return to Witch Mountain, Wrath of Khan, Magical World of Disney, Author), to the show! From floating coat hangers to navigating the cosmos, Ike has done it all. He sits down with DizRadio to look back at an incredible multi-decade career and celebrate the release of his brand-new autobiography, You'll Never be a Star. Ike chats, Getting into the Business, The Magic of Witch Mountain, Star Trek Secrets, Meeting The Rock, The Art of Looping and his All-New Autobiography and a heartwarming look at what it was really like to grow up on the Disney lot and survive the entertainment industry with your soul intact. Jonathan from the D-Team steps up to the microphone to geeks out over some classic Witch Mountain trivia. Growing up with Tony and Tia's adventures, these films weren't just Saturday night entertainment; they were a blueprint for imagination. He reflects on what these movies meant to a generation of kids who preferred practical movie magic over modern CGI, and he shares a deeply personal story about fulfilling a lifelong goal fueled by the inspiration of those very films. So enjoy the Nostalgia, the Magic, the Wonder, and the Memories with The DizRadio Show "A Pop Culture Celebrity Guest Show"!

In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Cheryl Bushnell, MD, MHS, who served as the guest editor of the June 2026 Cerebrovascular Disease issue. They provide a preview of the issue, which publishes on June 3, 2026. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Bushnell is a Professor of Neurology and Director of the Center for Transformative Stroke Care at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Additional Resources Read the issue: continuum.aan.com Subscribe to Continuum®: shop.lww.com/Continuum Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @CBushnellMD  Full episode transcript available here Dr Jones: One of the core tenets of our field is that we learn neurology one stroke at a time. But what do we have to learn about preventing them altogether? The science of stroke prevention, acute treatment, and recovery are evolving rapidly, and it's hard to keep up. Today, we're speaking with Dr. Cheryl Bushnell, guest editor of our latest Continuum issue on Cerebrovascular Disease, to discuss these topics and much more.  Dr Jones: This is Dr. Lyell Jones, editor-in-chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about subscribing to the journal, listening to verbatim recordings of the articles, and exclusive access to interviews not featured on the podcast.  Dr Jones: This is Dr. Lyell Jones, editor-in-chief of Continuum: Lifelong Learning in Neurology. Today, I'm interviewing Dr. Cheryl Bushnell, who is Continuum's guest editor for our latest issue on Cerebrovascular Disease. Dr. Bushnell is a professor of neurology and the director of the Center for Transformative Stroke Care at the Wake Forest University School of Medicine in Winston-Salem, North Carolina, where she specializes in the care of stroke patients and their social and functional determinants of recovery and health, and is an internationally recognized expert on those topics. Dr. Bushnell, welcome. Thank you for joining us today. Why don't you introduce yourself to our listeners?  Dr Bushnell: Absolutely. Thank you for the invitation. It's really an honor to be here. So, as you mentioned, I am the director of the Center for Transformative Stroke Care at Wake Forest. It's a really fun transition for me to be involved with different care models for stroke, and I think a lot of the Continuum topics are directly relevant to some of the things that I'm doing now as an administrator and sort of a facilitator of new research. So, thanks again for having me.  Dr Jones: Yeah, and, and you have a wonderful perspective, and we're gonna pull that out today in our interview questions, and I'm looking forward to sharing that with our listeners. But before we get to the questions, we're gonna start off today's podcast with another Continuum Audio trivia question for our listeners. Anticoagulation has played a critical role in secondary ischemic stroke prevention for a long time now. While direct oral anticoagulants have taken on a greater role in the treatment of prevention of stroke, there are still some use cases for vitamin K antagonists like warfarin. The trivia question for our listeners is this: How was warfarin discovered, and how did it get its name? Stick around and we'll share the answer to that question toward the end of our interview today. So, Dr. Bushnell, let's get right to it. You alluded to your various roles, and your leadership in the field has been exemplary. The interventions for acute ischemic stroke have really exploded over the last decade or so, and they get a lot of attention and discussion, but prevention and recovery are just as important in the care of these patients. Tell us a little more about how you approached this issue, about the article topics you chose, etc.  Dr Bushnell: Well, once I was chosen to lead the guest editorship, I wanted to come up with a group of topics that were maybe a little bit different from previous issues. So, I kind of looked at the previous issues and saw, as you said, an emphasis on acute stroke, and that's really important because it has been evolving. But my thought was, how about what happens to patients after they get the intervention and they're discharged home? And because a lot of trainees may not get to see these patients ever again, or it's months before they might see them, or if they're readmitted, which is what we don't want to see, but that certainly is a lot of the exposure is in the inpatient setting. So, I thought I would kind of transport the education into the outpatient and transitional setting, as well as prevention, not only secondary, but primary prevention, with an emphasis on brain health. Some of the populations that may not get as much attention. So, sex differences, stroke in women, pregnancy, the transitions of care, and also the emphasis on holistic view of patients and their challenges, which includes the non-medical factors that drive health, otherwise known as social determinants of health.  Dr Jones: I appreciate that perspective, and obviously th-this is an area of your deep expertise, and it's great to have an issue that really digs into some of those topics a little more deeply. As an educator, I'm really glad you mentioned that about the trainee's perspective. You know, especially junior neurology trainees that are in the hospital all the time. They're seeing patients in the middle of a cerebrovascular catastrophe. But there's a long tail of recovery, right? And they'll get to see that in continuity clinic, but it's a good message to share from an evidence and, um, experiential perspective in the issue. So, appreciate that perspective. You've just read all these articles and edited them. Was there anything that you ran across that was a surprise to you?  Dr Bushnell: Well, I personally chose a lot of the authors based on my knowledge of their work. So, I wouldn't say that it was completely surprising, but I do think that I was just genuinely impressed with the quality of the writing and the synthesis of information. I just was incredibly proud of the work that these co-authors have put together. I'd say that that was-- it wasn't surprising so much as just a sense of pride that I had with the product that's coming out. But of course, there have been some new trials that had to be incorporated at the last minute, some of which were presented at the International Stroke Conference just a few weeks ago.  Dr Jones: Yeah. We try to be as up-to-date as we can, and I will completely agree with you. We have some really good writers in our field, and it's really just a pleasure when you read an article that's by an expert, and it's a joy to read. I can tell you it's one of the best parts of this job, and you get to learn a lot. I think one of the more challenging scenarios that I hear about from colleagues in recent years has been optimal management of patients with asymptomatic extracranial atherosclerosis. The pivotal trials that inform how we manage those patients were from a long time ago, decades ago, predating a lot of the more intensive medical management tools that we have today. In that scenario, Dr. Bushnell, what's the latest on that, and what should our listeners know?  Dr Bushnell: Well, obviously, the CREST 2 trial has been long awaited. It's been going on for over ten years, I believe. Of course, it's, uh, two different trials all in one, the carotid stenting and angioplasty versus intensive medical management. And of course, each of the carotid vascularization arms of the trial also had intensive medical management. And then the other trial is the carotid endarterectomy as the form of revascularization. And it interestingly did not show any benefit of carotid endarterectomy compared to intensive medical management. But of course, the somewhat surprising result was that carotid angioplasty and stenting truly was superior, although it was a small number of events in the trial overall. But that stenting plus intensive medical management was somewhat better than intensive medical management alone. And I think stenting has come a long way in terms of safety, and so I think that's been part of the evolution of the field. I do wanna say that I'm a huge fan of the intensive medical management, and I think that what the protocol does in terms of blood pressure management, cholesterol management is very much above and beyond what's done in private practice even. And the health coaching for all the other things related to diabetes and weight loss and smoking cessation and physical activity, that is what we need to be doing to actually decrease the risk of stroke, and I think that it's very effective. I can't say enough about the design of the study for that reason, that everyone gets the intensive medical management, and then you just layer on the type of revascularization on top of it. So, I wouldn't have been surprised if this was a completely negative trial overall. They just happened to have some better outcomes in the stenting arm.  Dr Jones: I recall a few years ago when the series of endovascular therapy trials for acute stroke came out, and I think there was a, a period of time where the field had to adapt to that. I wonder what you think about with the CREST 2 findings on stenting. I mean, is that gonna be a big change? Because obviously atherosclerosis is highly prevalent. Is that gonna be a big change? Is the field ready for that? How much adjustment do we have in store?  Dr Bushnell: I'm not sure it's gonna be a really big change. If you read the editorial that accompanied the trial in the New England Journal, just a few patients in either direction would have changed the outcome. I kind of look at it as an absolute difference that's relatively small. So, I'm not sure that it will have a huge impact on the field. I do think that the specialists who insert the stents may have some differences of opinion of who should be stented and who shouldn't. Because I think, you know, all of the specialists who do procedures were involved with the trial. But I would say there's a larger percentage of vascular surgeons who were involved, and so I'd say they may have a change of their practice. And neurologists may not even get involved at all.  Dr Jones: Right.  Dr Bushnell: That was one of the challenges for getting patients in the trial is that, you know, not all of us see the asymptomatic carotid stenosis, that they tend to get referred to vascular surgery. So, I think maybe in a corner of the practices of vascular surgeons is where you might see the differences.  Dr Jones: Your point about the way the trial was designed or the trials were designed, that intensive medical management is really important, and we have huge gaps in that. In our specialty, it's, you know, we have probably an opportunity in primary care even to address that. And that leads me to my next question. You know, given your perspective and your expertise, what do you think is the biggest practice gap in the care of patients with stroke or with cerebrovascular disease of any kind?  Dr Bushnell: I think by far the biggest gap is transitions of care and access to follow-up in a specialty clinic after discharge and continuous secondary prevention. We only call it secondary prevention because it happened to come after a stroke, but I really feel like we should just focus on prevention and call it that. There are a lot of people who are trying to kind of, get us away from primary versus secondary prevention. And, and Mitch Elkind is phenomenal and had a beautiful chapter weaving in prevention and brain health. So, I highly recommend that people, if they don't read any other chapters of the Continuum to read his, because I think that it's getting to your point about where the gaps are, and I think prevention is the biggest one. I think we could do so much more in models of care to ensure that there is a pathway once patients are discharged. We have no quality metrics. We have no measurement of how well people are doing after they're discharged. We have all of these fancy things and sophisticated acute treatments, but all of those are for naught if somebody goes home and they fall and they have a severe head injury or hip fracture because they weren't properly supervised or they didn't have the help that they needed at home. So, you got me on my soapbox here for a second, but that is definitely what I see as the gap.  Dr Jones: That's an important soapbox, an important gap, and obviously, if it was a simple problem, we could solve it. But it's obviously something that education is a valuable tool for that, and that's part of why we are including so much content in this issue of Continuum. So, if we put that aside as a gap that we would love to close, when you look into the near future or distant future, Dr. Bushnell, and what's the next big thing on the horizon? New interventions, new prevention tools, or something else entirely? What do you think?  Dr Bushnell: There are two things that I would mention. One is sort of the new category of anticoagulants, antithrombotics, the factor XIa inhibitors. We had an amazing presentation of the oceanic stroke trial at the International Stroke Conference, and this is probably going to be a game changer for the arsenal of antithrombotic therapies that we can offer to patients that do not have a reason for anticoagulation. So, they, they don't have atrial fibrillation, for example, or something else that requires anticoagulation. And so, the factor XI, asundexian, is the drug that they used in that trial. The safety profile is pretty amazing. There was very little bleeding complications and a great benefit in those patients with some degree of atherosclerosis, but, you know, of course, not enough to require carotid revascularization, but then also, um, small vessel disease and cryptogenic stroke. I think those are the three categories of patients, and that's a lot of the strokes that we see all benefited from this new drug. So, I think that's gonna be exciting. There, of course, it has to go through the FDA approval process, and so it might take a little bit of time before that's on the market, and we don't know how much it's gonna cost, but I think it is a, a major breakthrough. And of course, there are other similar medications in that category that are coming. And then I think the other thing is the emphasis on brain health and lifestyle factors and the things that we can do to prevent stroke and dementia because they are the same, essentially. Those are really important. And when we have someone in the hospital with a stroke or a TIA in particular, it's a great teaching opportunity for those patients to say, "Hey, here's what you can do to protect your brain." These are things that we always tell people to prevent a stroke, but just think about it as protecting your brain and keeping your brain as healthy as possible.  Dr Jones: That's a great message, and one that you get to share with patients directly. You're joining us today for this interview. You're on stroke service, so you're actively involved in caring for patients with stroke. What in your practice is the most rewarding aspect of caring for these patients? What is it that you find most rewarding?  Dr Bushnell: I've been involved in a clinical trial that has focused on managing blood pressure and also coaching and other aspects of stroke recovery. I think that has probably been the most rewarding aspect of my career. Until I was involved with this trial, I didn't necessarily do intensive blood pressure monitoring, but I'm seeing the benefits of having data from home, what those blood pressures are over a span of time. I see the immediate or intermediate effects of the blood pressure medication changes that I've made, and I see how the patients respond. So, I have to say that this is not part of usual practice, but I think it should be. And I think it's been incredible from the perspective of a neurologist who is really intensively trying to make the patients' lives better. And it's not just what I do, it's what the health coaches do as part of this intervention. And again, very similar to intensive medical management. So, I, I feel like I've been living it in a slightly different setting than in the CREST 2 trials. But there are other trials that have used the intensive medical management as approach as well. But I would say that's the most rewarding. I've seen people who've lost weight, who are physically fit, who are able to get off of blood pressure medications practically by the end of six months, and that's amazing. And then they continue doing it because they see the benefits.  Dr Jones: You've had a front row seat to a lot of that. That's really got to feel rewarding.  Dr Bushnell: It is, absolutely.  Dr Jones: You know, when you put it that way, it makes me want to go home and check my blood pressure, which I haven't done in a while. But I think that's a message to all of our listeners that we do have plenty of opportunity for risk factor optimization and following the evidence that has been generated and is being generated. Huge opportunity, not only at the population level, but I think the, um, individual patient level too. Okay, so now we're back to our Continuum Audio trivia question, and I'll repeat it for our listeners. How was warfarin discovered, and how did it get its name? Dr. Bushnell and I were talking about this earlier, so I'll just go ahead and share the answer. So, in the early 20th century in the U.S. Midwest, there were epidemics of a hemorrhagic disease in cattle, of all places, and this was eventually traced to moldy cattle feed that was made from sweet clover. And in 1940, researchers at the University of Wisconsin discovered that the anticoagulant in the sweet clover was a compound that was later synthesized for therapeutic use in 1954 as warfarin. And the name came from, uh, the support for the research. The research support came from the Wisconsin Alumni Research Foundation, or WARF, and the end of the word came from the underlying compound, which was coumarin. So that was a little bit of trivia that I had never heard. It's not in the issue, everyone, so you're getting something extra here on the podcast. But been using the drug forever. It still has its uses, even though it's become less advantageous than some of the newer agents. But-- And of course, Dr. Bushnell already knew that when I brought it up, but I just thought that was an interesting bit of history. Well, Dr. Bushnell, thank you for joining us. Thank you for such a great conversation about the latest in cerebrovascular disease. I learned a lot today. I learned a lot in reading these wonderful articles. I hope our listeners learned a lot today as well. I'm really grateful for your hard work on the issue, which I think will come in handy for junior readers and subscribers, as well as our more experienced neurologists as well. Sometimes it's hard to keep up with a rapidly changing subspecialty of our field. So, thank you for joining us today.  Dr Bushnell: Thank you for having me. It's been my pleasure.  Dr Jones: Again, today we've been speaking with Dr. Cheryl Bushnell, guest editor of Continuum's most recent issue on cerebrovascular disease. Please check it out, and thank you to our listeners for joining today.  Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. Thank you for listening to Continuum Audio.

What does it take to crack down on cargo theft, chameleon carriers, and unregulated dispatch services? In this episode, Chris Burroughs from the Transportation Intermediaries Association (TIA) is back to discuss the real cost of silence on Capitol Hill and why your voice matters now more than ever! We're diving straight into the Build America 250 Act, what the Supreme Court's Montgomery v. Caribe ruling actually means for broker liability, and how the FMCSA's new MOTUS registration system is set to purge fraudulent entities from the marketplace. If you want to protect your freight business, stay ahead of tightening carrier vetting standards, and learn how to manage risk in a shifting legal landscape proactively, you can't afford to miss this conversation on why the brokerage community must band together and control the narrative   About Chris Burroughs Chris Burroughs is the President and CEO for the Transportation Intermediaries Association (TIA). He brings over 18 years of Congressional affairs experience to TIA. As the former Vice President of Government Affairs for TIA, he led the Government Relations department including the legislative, regulatory, PAC, and internal policy committee functions. Chris served as the staff liaison for the Highway Logistics Conference, the Intermodal Logistics Conference, and several other policy committees within TIA. Chris additionally served on the Board of Directors for the Unified Carrier Registration (UCR) as the Subcommittee Chairman of Industry Advisory Subcommittee and sole representative of the 3PL industry. During his time on Capitol Hill, Chris gained invaluable knowledge of the legislative process. He began his career working on the House Transportation & Infrastructure Committee in 2006 and then later the House Natural Resources Committee. In 2009, Chris joined the Twenty-First Century Group, a bipartisan government affairs firm, as their Director of Government Affairs. In this position, Chris advocated on behalf of multiple clients involved in the transportation, telecommunications, health care, tax, and defense arenas. Additionally, he represented TIA on their issues of interest on Capitol Hill. Chris lives in Gainesville, Virginia with his wife Stacey and children Kelly, Christopher, and Connor. Chris earned a BS degree in Political Science from Shepherd University located in Shepherdstown, West Virginia.  

Stroke is often thought of as something that happens later in life — but more young adults are experiencing strokes, and many don't recognize the warning signs until it's too late.In this episode of Baptist Health Talk, host Sandra Peebles speaks with Dr. Felipe De Los Rios La Rosa, cerebrovascular neurologist and director of the stroke program at Baptist Health Miami Neuroscience Institute, about why stroke risk is rising among younger adults and what people can do to protect themselves.You'll learn:• Why strokes are becoming more common in adults under 55 • How recreational drug use, alcohol, vaping and marijuana may affect stroke risk • Why being young, active or healthy does not make you immune • The FAST warning signs everyone should know • What a TIA or “mini stroke” really means • Why calling 911 quickly can make a major difference • Practical steps that may help lower your stroke riskDr. De Los Rios also explains why stroke symptoms can be missed in younger people, how sudden changes in speech, vision, balance or strength should never be ignored, and why prevention should start earlier than many people think.

Greg Bluestein and Tia Mitchell answer listener questions about Georgia's post-primary landscape, including Keisha Lance Bottoms' sweeping Democratic win, the money gap between Republican and Democratic candidates, and legal questions around newly passed legislation. They also examine how self-funded candidates use personal loans and what those numbers signal in the governor's race. In segment two, Greg and Tia feature Q&A recorded live at the Politically Georgia happy hour at Manuel's Tavern with Patricia Murphy, including questions about judicial elections, political power and the AJC's coverage of Georgia's changing suburbs. Have a question or comment for the show? Call or text the 24-hour Politically Georgia Podcast Hotline at 770-810-5297. We'll play back your question and answer it during our next Monday Mailbag segment. You can also email your questions at PoliticallyGeorgia@ajc.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

Tia from the Alien Effect podcast joins The Order this episode to discuss a sequel: Ghost Rider Spirit Of Vengeance! For more from The Alien Effect, click HERE!

Joe and Taylor are back together to break down RuPaul's Drag Race All Stars 11 Episode 3, “Shop Till You Drop.” Before diving into the competition, Taylor opens up about the frightening family emergency that caused his absence last week and shares an update on his mother's health following a TIA. Then it's time to unpack the final Orange Bracket showdown. The queens tackle a spooky home shopping acting challenge, the MVQ point strategy reaches a boiling point, and Morgan McMichaels continues to quietly produce some of the best television of the season. Joe and Taylor debate whether the right queens won the challenge, whether Dawn actually won the lip sync, and whether RuPaul made the correct final call sending A'Keria and Dawn into the semifinals. Plus: Mystique Summers Madison's increasingly tense behavior Why Morgan McMichaels came out looking like the consummate professional Morphine's stunning Phantom of the Opera runway The problem with Lucky Starzzz's performance style The hidden strategy behind the MVQ points Why A'Keria may be the most well-rounded queen in the bracket And Joe compares Drag Race Philippines craftsmanship to the Louvre runway looks Learn more about your ad choices. Visit podcastchoices.com/adchoices

Presenting Sponsor Thirdzy!  https://thirdzy.com/JAZZYPromotion Code for 15% off: JAZZYSupport Carolyne with the purchase of your CrossFit Games Tickets, Use Code cfgprevost10 at checkoutEveryday we take a break from the busy work day to catch our breath, hang out with friends and talk about the world of Sports, Entertainment and specifically CrossFit. Today we talk about the sickness, wellness, fitness continuum, Tia ready for the Games now after giving birth? French Throwdown recap.

Biomechanist Katy Bowman speaks with physical therapist Dr Anietie (Tia) Ukpe-Wallace about pelvic health, movement, and self-care.They discuss Tia's recent book, Tending To Your Womb, a guide to caring for the uterus and pelvic tissues through awareness, movement, and practical self-care strategies. In this episode, Katy and Tia focus on movement-based approaches for uterine retroversion, a pelvic misalignment that can contribute to sacral pain, sciatic symptoms, and constipation.They also explore clitoral atrophy — a reduction in tissue size, tone, and flexibility that can occur during menopause — and share movement and self-care practices to help maintain mobility and function.Tune in and join in for a guided pelvic clock movement sequence taught by Tia.Enhanced Show Notes and Full Transcript0:00 Intro & New Dynamic Collective6:56 Meet Dr. Tia Ukpe-Wallace9:49 Misalignments of the uterus15:30 Symptoms of a retroverted uterus: constipation, sacral pain & sciatica19:55 The pelvic clock: join in with a guided practice!27:43 Clitoral atrophy in menopause & movement-based approaches35:24 Self-care: not indulgence, but simple body maintenance42:25 Where to find Tia Ukpe-Wallace46:34 Listener question on prolapse, sponsored by Earth RunnersBooks, Links and Resources:Tending to your Womb: Self-Care for Every Stage of Your Reproductive Journey, No Matter the Outcome by Anietie Ukpe-Wallace About Tia Ukpe-WallaceTia on Instagram @selfcarephysio Connect, Move & Learn:Join Our Newsletter: Movement Colored GlassesFollow Katy on SubstackTry Katy's Virtual Studio Free for 7 days!Made Possible By Our Wonderful Sponsors:Freet Barefoot: creators of comfortable barefoot shoes built for natural movement, flexibility, and durability— use code DNA10 for 10% off. Earth Runners:  makers of minimalist earthing sandals designed for natural foot movement and connection to the ground— use code DNA10 for 10% off.ScreenFit™: a complete online vision training program —take $200% off with code NUTRITIOUSMOVEMENTMy Happy Feet: Toe-spacing socks that gently realign toes for comfortable shoe recovery—take 20% off with code MYDNAIkaria Design: The Soul Seat® offers height-adjustable, multi-position sitting—get 10% off new chairs and desks with code DNA10Movemate: Active standing boards with smoothly articulating wooden slats. Designed to keep you moving without interrupting your focus.Venn Design: Beautifully upholstered ball-shaped Air Chairs and floor cushions that encourage dynamic sittingThoughts/questions email us at podcast@nutritiousmovement.comYour Voice on the Podcast: Read The Credits