Podcasts about valsalva

For active women who've experienced that embarrassing leak during a heavy lift, this episode challenges everything you thought you knew about pelvic floor function. Diving deep into the science of bracing mechanics, Christina Previtt unravels the fascinating relationship between breath, core tension, and pelvic health that revolutionizes how we approach strength training.Forget the simplistic advice to "just do more Kegels." Research reveals a surprising truth: women who experience incontinence during lifting often have stronger pelvic floors than those who don't. Christina explains why coordination—not weakness—is frequently the real culprit, and how understanding the entire core canister system transforms both rehabilitation and performance.The Valsalva maneuver (that instinctive breath hold during heavy efforts) has been unnecessarily vilified, especially for pregnant and postpartum women. Christina presents compelling evidence that this natural bracing strategy isn't inherently problematic—it's a trainable skill that, when properly executed, can actually support pelvic health while enhancing performance.Whether you're an expecting mother concerned about safe lifting, a postpartum athlete working to rebuild your foundation, or simply someone who wants to lift without leaking, this episode provides actionable insights that bridge the all-too-common gap between rehabilitation and performance training. By understanding how proper bracing distributes pressure throughout your core system rather than directing it downward, you'll discover how to protect your pelvic floor while still challenging yourself in the gym.Ready to transform both how you think about and how you feel during your lifts? This episode might just be the missing piece in your training and recovery puzzle. Subscribe to Barbell Mamas for more evidence-based conversations at the intersection of motherhood, strength, and pelvic health—where we're redefining what's possible for athletic women through every stage of life.___________________________________________________________________________Don't miss out on any of the TEA coming out of the Barbell Mamas by subscribing to our newsletter You can also follow us on Instagram and YouTube for all the up-to-date information you need about pelvic health and female athletes. Interested in our programs? Check us out here!

Send us a text

Dans cet épisode, nous accueillons Sébastien Salingue pour aborder un sujet essentiel en plongée sous-marine : les oreilles et leur gestion sous l'eau.Que vous soyez débutant ou plongeur confirmé, vous avez sans doute déjà ressenti une gêne ou même une douleur en descendant en profondeur.Mais pourquoi cette douleur survient-elle ? Comment bien équilibrer ses oreilles pour plonger sans inconfort et éviter les blessures ?Sébastien nous explique de manière claire et détaillée les mécanismes de la pression en plongée, le rôle des trompes d'Eustache, et les différentes techniques pour équilibrer efficacement ses oreilles : Valsalva, Frenzel, et Béance Tubulaire Volontaire (BTV).Il revient également sur les erreurs courantes commises par les plongeurs débutants et les risques liés à une mauvaise gestion de l'équilibrage des oreilles.Nous abordons aussi les facteurs aggravants comme le stress, la fatigue ou encore un simple rhume qui peuvent rendre l'équilibrage difficile voire douloureux.Sébastien donne de précieux conseils pour mieux appréhender la descente, notamment en prenant son temps, en réalisant des manœuvres régulières et douces, et en se détendant au maximum.Enfin, nous discutons des bonnes pratiques à adopter pour éviter les complications, telles que ne pas plonger en étant malade, réaliser un rinçage des oreilles après la plongée ou encore consulter un ORL en cas de douleurs persistantes.Que vous soyez sujet aux douleurs d'oreilles en plongée ou que vous souhaitiez simplement améliorer votre technique d'équilibrage, cet épisode vous apportera des conseils précieux pour plonger en toute sécurité et avec plaisir.

This episode of the podcast is about breathing and bracing — the two foundational techniques that are essential for both movement quality and injury prevention. We discuss how your breath and core work together in every lift, why bracing is key for stability, and how techniques like diaphragmatic breathing and the Valsalva maneuver support heavy lifting. We also break down the difference between bracing and hollowing, when to use each one, and what the current research says about their role in core activation and spinal support. Plus, we touch on weight belts — when they're useful, when they're not, and how to use them intentionally as part of a smart strength training plan.Want More?Join our Newsletter Online Nutrition Coaching Join our Facebook Group1:1 Fitness Coaching Get 3 Weeks of Nutrition Support for FreeFree Knee Pain Training GuideGet Hundreds of Movement Demos on Our Youtube Channel

Hey Heart Buddies! A heart murmur, congenital aneurysm of sinus of Valsalva, ruptured sinus of Valsalva into right ventricle, bicuspid aortic valve, persistent left superior vena cava and pacemaker... all in one extraordinary heart...This week, I talk with my friend, Dawn Anderson, about her extraordinary heart health journey. Living in Adrian, Minnesota, Dawn shares her experience of discovering and surviving a rare aortic aneurysm and bicuspid aortic valve at age 41. Despite facing multiple challenges, including depression and the stress of losing her job, Dawn emphasizes the importance of self-advocacy and seeking support. Her story highlights the necessity of listening to your body and staying informed about heart health. Dawn and I met through WomenHeart which is a non-profit providing education and support to female heart disease patients. Don't forget to subscribe!Join the Newsletter for almost weekly content for this podcast and other heart related news.Join the Patreon Community! The Joyful Beat zoom group is where you'll find connection and hope that you aren't alone in your journey.If you just want to support the show as a one-time gift (thank you), go here.**I am not a doctor and this is not medical advice. Be sure to check in with your care team about all the next right steps for you and your heart.**How to connect with BootsEmail: Boots@theheartchamberpodcast.comInstagram: @openheartsurgerywithboots or @boots.knightonLinkedIn: linkedin.com/in/boots-knightonBoots KnightonIf you enjoyed this episode, take a minute and share it with someone you know who will find value in it as well.

Don't miss a beat as our guest Dr. Noble Maleque guides us through dominating narrow complex tachyarrhythmias (while keeping our own heart rates under control too). @Nobility75 (Emory University) Claim CME for this episode at curbsiders.vcuhealth.org! Patreon | Episodes | Subscribe | Spotify | YouTube | Newsletter | Contact | Swag! | CME Show Segments Intro Case 1, part 1: Unstable narrow tachyarrhythmias Case 1, part 2: Stable, narrow tachyarrhythmias – regular rhythm Vagal tone: Valsalva, Modified Valsalva, or Carotid Massage? Adenosine 2nd line AV nodal blockade: metoprolol, diltiazem Case 2: Stable, narrow tachyarrhythmias – irregular rhythm AV nodal blockade Amiodarone and diltiazem Rapid fire questions/Picks of the Week Outro Credits Please consolidate if performing multiple jobs (e.g. Written and Produced by: Cyrus Askin MD; cover art and infographic by Kate Grant) Producer, writer, Infographic, cover art, and show notes by: Caroline Coleman, MD Hosts: Meredith Trubitt, MD and Monee Amin, MD Reviewer: Rahul Ganatra, MD MPH Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP Technical Production: PodPaste Guest: Noble Maleque, MD Sponsor: Freed Start your free trial today, no credit card needed. Usecode: CURB50 to get $50 off your first month when you subscribe at Freed.ai  Sponsor: Grammarly Download Grammarly for FREE at grammarly.com/PODCAST Sponsor: Locumstory Visit free-to-use sponsor  at Locumstory.com

This week on The Beat, CTSNet Editor-in-Chief Joel Dunning spoke with Dr. Vinay Badhwar, the current vice president of the Society of Thoracic Surgeons (STS), about his groundbreaking achievement in combining robotic aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) through a single small incision. They discuss the background and premise of this technique, the process of taking this technique from an idea to performing it on a patient, differences between this approach and other cardiac approaches, and the future of cardiac surgery. They also explore the first operation performed using this technique in immense detail with visuals of the procedure.   Joel also highlights recent JANS articles on multisociety endorsement of the 2024 European guideline recommendations on coronary revascularization and bioprosthetic vs mechanical aortic valve replacement in patients 40-75 years. He also reviews short- and long-term outcomes of lung transplantation from brain death vs circulatory death donors and intracavitary cisplatin-fibrin followed by irradiation improved tumor control compared to the single treatments in a mesothelioma rat model.  In addition, Joel explores a Dacron graft double inversion for ascending aorta surgery, a redo mitral valve surgery with previous aortic valve replacement, and a right sinus of Valsalva aneurysm causing right ventricular tract obstruction. Before closing, he highlights upcoming events in CT surgery.   JANS Items Mentioned  1.) Multisociety Endorsement of the 2024 European Guideline Recommendations on Coronary Revascularization  2.) Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40-75 Years  3.) Short- and Long-Term Outcomes of Lung Transplantation From Brain Death vs. Circulatory Death Donors: A Meta-Analysis of Comparative Studies  4.) Intracavitary Cisplatin-Fibrin Followed by Irradiation Improved Tumor Control Compared to the Single Treatments in a Mesothelioma Rat Model  CTSNET Content Mentioned  1.) Dacron Graft Double Inversion for Ascending Aorta Surgery  2.) Redo Mitral Valve Surgery With Previous Aortic Valve Replacement  3.) Right Sinus of Valsalva Aneurysm Causing Right Ventricular Tract Obstruction  Other Items Mentioned  1.) CTSNet Career Center 2.) CTSNet Events Calendar  Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.

JHLT: The Podcast returns with a year-end recap of 2024. Each Digital Media Editor shares one of their favorite studies from JHLT in 2024 for a quick recap of last year's excellent science in advanced heart and lung disease. Studies featured: ·         Cardiac magnetic resonance assessment of acute rejection and cardiac allograft vasculopathy in pediatric heart transplant Kikano, Sandra et al. JHLT May 2024 5(43):745-754 ·         A modular simulation framework for organ allocation Rose, Johnie et al. JHLT Aug 2024 8(43):1326-1335. ·         HeartMate 3 Snoopy: Noninvasive cardiovascular diagnosis of patients with fully magnetically levitated blood pumps during echocardiographic speed ramp tests and Valsalva maneuvers Schlöglhofer, Thomas et al. JHLT Feb 2024 2(43):251-260. ·         Factors associated with acute limb ischemia in cardiogenic shock and downstream clinical outcomes: Insights from the Cardiogenic Shock Working Group Kochar, Ajar et al. JHLT Nov 2024 11(43):1846-1856.   For the latest studies from JHLT, visit www.jhltonline.org/current, or, if you're an ISHLT member, access your Journal membership at www.ishlt.org/jhlt. Don't already get the Journal and want to read along? Join the International Society of Heart and Lung Transplantation at www.ishlt.org for a free subscription, or subscribe today at www.jhltonline.org.

In the November 2024 episode of Critical Decisions in Emergency Medicine, Drs. Danya Khoujah and Wendy Chang discuss investigating lower GI bleeding in the emergency department and testicular torsion presentations. As always, you'll also hear about the hot topics covered in CDEM's regular features, including pediatric facial nerve palsy in Clinical Pediatrics, a distal triceps tendon tear in Orthopedics and Trauma, reverse Valsalva maneuver in The Critical Procedure, high-risk airway management in The LLSA Literature Review, and a patient with foot drop in The Critical Image.

Contributor: Taylor Lynch MD Supraventricular tachycardias (SVTs) arise above the bundle of His The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia  AVNRT is the most common form of SVT Paroxysmal Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease More common in women (3:1 women:men ratio) HR 160-240 Narrow complex with a normal QRS Unstable patients receive synchronized cardioversion at 0.5-1 J/kg Valsalva maneuver is attempted before pharmaceutical interventions Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction Traditionally, patients are asked to bear down, but this only works in 17% of patients REVERT trial assessed a modified valsalva that worked in 43% of patients Adenosine Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx Extremely uncomfortable for most patients Not commonly used anymore Nondihydropyridine calcium-channel blockers are preferred A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5% The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total References 1. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet. 2015;386(10005):1747-1753. doi:10.1016/S0140-6736(15)61485-4 Belz MK, Stambler BS, Wood MA, Pherson C, Ellenbogen KA. Effects of enhanced parasympathetic tone on atrioventricular nodal conduction during atrioventricular nodal reentrant tachycardia. Am J Cardiol. 1997;80(7):878-882. doi:10.1016/s0002-9149(97)00539-0 Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523-528. doi:10.1016/j.resuscitation.2009.01.017 Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e234-5. doi: 10.1161/CIR.0000000000000448]. Circulation. 2016;133(14):e506-e574. doi:10.1161/CIR.0000000000000311 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Discover the science and power of breath control in this insightful episode of Pac Talk with Emylee Vodden. Learn how to optimize your breath mechanics for enhanced strength, conditioning, and overall fitness. Emylee shares practical techniques such as box breathing, Valsalva maneuvers, and cadence breathing, designed to help you breathe more effectively during workouts, from endurance runs to heavy lifts. Whether you're a beginner or an athlete, this episode will teach you how to master your breath for peak performance and injury prevention. Tune in for tips, exercises, and expert advice on improving your breathwork today!Join the PAC and learn how to set yourself up for success, one habit at a time.Welcome to the Pac, please make sure you subscribe wherever you are listening to this show and if you loved this show please leave us a 5 star review in the iTunes store. It is the currency of podcasts and it really goes along in helping us grow our show.If you are in Southern California come train with us Echo ParkRedondo BeachIdyllwildPalm SpringsFollow Pharos, Piet and Emylee on Instagram for more fitness related content. Hosted on Acast. See acast.com/privacy for more information.

A manobra de Valsalva é mais complexa do que se divulga e suas consequências precisam ser analisadas com cuidado

Welcome back Rounds Table Listeners!We are back today with a solo episode with Dr. John Fralick!This week, he will discuss a paper exploring a modification of the Valsalva manoeuvre for the treatment of supraventricular tachycardias. Here we go!Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT) (0:00 – 7:00).And for the Good Stuff: Live Transcribe (7:00 – 8:16).Questions? Comments? Feedback? We'd love to hear from you! @roundstable

New daily persistent headache is a syndrome characterized by the acute onset of a continuous headache in the absence of any alternative cause. Triggers are commonly reported by patients at headache onset and include an infection or stressful life event. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Matthew Robbins, MD, FAAN, FAHS, author of the article “New Daily Persistent Headache,” in the Continuum® April 2024 Headache issue. Dr. Berkowitz is a Continuum® Audio interviewer and professor of neurology at the University of California San Francisco, Department of Neurology and a neurohospitalist, general neurologist, and a clinician educator at the San Francisco VA Medical Center and San Francisco General Hospital in San Francisco, California. Dr. Robbins is an associate professor of neurology and director of the Neurology Residency Program at New York-Presbyterian/Weill Cornell Medical Center in New York, New York. Additional Resources Read the article: New Daily Persistent Headache Subscribe to Continuum: continpub.com/Spring2024 Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @https://twitter.com/AaronLBerkowitz Guest: @ @mrobbinsmd Full Transcript Available: Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes. AAN members: stay tuned after the episode to hear how you can get CME for listening.   Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Matthew Robbins about his article on new daily persistent headache, from the April 2024 Continuum issue on headache. Dr Robbins is an Associate Professor of Neurology and Director of the Neurology Residency Program at New York-Presbyterian/Weill Cornell Medical Center, in New York. Welcome to the podcast. Dr Robbins: It's great to be with you, Dr Berkowitz. Dr Berkowitz: Well, thanks so much for joining us this morning. To start, what is new daily persistent headache? I think it's an entity maybe that might be new to some of our listeners. Dr Robbins: Yeah - it's an entity that also struck me when I was in training. I didn't hear much of it as a neurology trainee until I did a fellowship in headache, where, all of a sudden, we were seeing patients with this syndrome (and labeled as such) all the time. And that actually inspired me to begin a research project to better characterize it - a clinical project that ended up helping to broaden the diagnostic criteria. New daily persistent headache really is just defined by what it says - it's new; it's every day; it persists; it's a headache. It can't be from some other identifiable cause, which includes both secondary disorders (you know, something that, where headache is a symptom of) or a primary headache disorder; distinguishes itself from, say, migraine or tension-type headache because there's no real headache history and there's an abrupt onset of a daily and continuous headache that has to last for at least three months since onset. And the onset is typically remembered - it's usually acute or abrupt; there may or may not be some circumstances that surrounded the onset that might have some diagnostic or causal or associated implications that we can explore. Dr Berkowitz: Okay. So, I always find it challenging in headache medicine and some other areas where we don't have a biomarker, per se - an imaging finding, a lab finding; we have an eloquent and detailed clinical description - to know how comfortable to be making a diagnosis like this. In this case, particularly, right - you said it has to be going on for three months. What if I see a patient one month into something I think could be this, but I can't technically say, per the criteria, right (it's three months)? When do you start thinking about this diagnosis in patients, and what are some of the main considerations in confirming the diagnosis, and what needs to be ruled out or excluded for making the diagnosis?   Dr Robbins: I think traditionally, in headache, the term “chronic” has that three-month time period. The reasons are twofold: one is that, typically, if there's some secondary disorder that might have some distinguishing feature (something that really evokes the headache or some other neurological accompaniment that develops in addition to headache), it would pretty much be likely to declare itself by the three-month mark. Or if it was something that was very self-limited, it would probably go away before three months have elapsed. Or if it resolved after some days or weeks but then declared itself as a more episodic disorder, then we might say someone who begins with continuous headache that might, for example, resemble migraine (maybe it presented a status migrainosis but then it devolved into a more episodic disorder that might just be migraine overall). So, I think that's pretty much why the three-month mark has been so prevalent in the International Classification of Headache Disorders, including how new daily persistent headache is diagnosed. But at the same time, there's lots of disorders that might mimic (or might be misdiagnosed as) new daily persistent headache, and they really are a secondary disorder. Probably the most common one that we think about is a disorder of intracranial pressure or volume, mainly because routine MRI features could be normal or could be easily missed if they had subtle abnormalities. The defining symptom of those disorders are also continuous headache, often from onset, with an abrupt and remembered nature. So, that's often the main category of secondary headache that might be misdiagnosed as primary headache. I think, probably, idiopathic intracranial hypertension as the prototypical disorder of high pressure often declares itself with visual symptoms, pulsatile tinnitus, and other abnormalities. And nowadays, there's much more increasing recognition for MRI abnormalities or even MRV abnormalities with such patients. But spontaneous intracranial hypotension (despite increasing recognition of CSF leaks in the spine that lead to intracranial hypotension or hypovolemia) really remains an underdiagnosed entity. I think that's one disorder where - for example, if I'm seeing a patient with new daily persistent headache and there's no orthostatic or positional nature to their headache - I will still do an MRI, with and without contrast, to be sure. But that the chances of them having a spontaneous CSF leak are low if that scan is unremarkable. Dr Berkowitz: That's very helpful. Yeah. It's interesting; when you talked about the criteria for this condition - that it has an acute onset, which is a red flag, right, and it is persistent for months, which for a new headache would also be a red flag. So, this is a condition - correct me if I'm wrong – that, if you're considering it, there's no way that you're going to make this diagnosis without neuroimaging because there are two red flags, in a way, embedded in the criteria before we get to the other diagnoses being excluded. Is that right? So, this would only be a diagnosis made clinically but after neuroimaging is obtained, given that two red flags are part of the criteria – isn't that right? Dr Robbins That's absolutely right. So, I can't imagine there's anyone who has new daily persistent headache who hasn't had appropriate neuroimaging, and that typically should include an MRI, with and without contrast, unless there's some compelling reason to avoid that. There's some other workup that could be done that's not universal but - for example, in clinic-based studies of patients who have new daily persistent headache versus those who may have, say, chronic migraine or chronic tension-type headache, you may find more abnormalities. The biggest and more compelling example of that is hypothyroidism, which presumably would be somewhat subclinical if it hadn't been brought to someone's medical attention earlier. It doesn't mean that hypothyroidism is the cause of new daily persistent headache, but it could be some type of triggering or priming factor that leads to headache perpetuation in some patients. Sometimes, if that hasn't been done already, that would be a blood test I might think about sending. And, of course, the context of onset; if someone lived in a place where tick-borne illnesses are endemic, if there are other neurological symptoms, that might prompt looking for serological evidence of Lyme disease, as one example. Dr Berkowitz: We see a lot of headache. I'm a general neurologist; I know you're a headache specialist; we all see a lot of patients with headache. You and I both work closely with residents. Often, residents will come to present a headache patient to me and they'll say, “The patient seems to have a new daily persistent headache. They haven't been imaged yet. They have a completely normal exam. The history fits.” And I always ask them, “Okay, we have to get neuroimaging, right? There's at least one red flag of the chronicity, maybe the red flag of something beginning relatively abruptly. Even though you're looking at the patients - I'm pretty sure that imaging is going to be normal, but we've got to do it.” But I always encourage residents, “Try to predict - do you think the imaging is going to be normal (this is a rule out) or do you think you're going to see something (this is a rule in)? - just to sort of work on calibrating your clinical judgment.” I'd love to ask you - as a headache specialist, when you're looking at the patient and say, “I know I need to get neuroimaging here to fully make this diagnosis of exclusion,” or you've heard something that sounds like a red flag; you know you're obligated to image, but your clinical suspicion of finding anything more than something incidental is pretty low. How often are you surprised in practice in a sort of enriched tertiary headache population? Dr Robbins: That's a great way to frame such a presentation on how a resident would present to you the case and whether it's a rule in or rule out. I totally agree with your approach. I think much of it depends on the clinical story. I think if it was just a spontaneous onset of headache that kind of resembles migraine that just continued, then likely the MRI is being done to just be sure we're not missing anything else. However, if the headache started – really, say someone coughed vigorously or bent over and the headache started, and there was some clear change that you could perceive in - that was, say, the Valsalva or a transiently raised intracranial pressure, or some other maneuver; then you might really say, “Well, this really could be a spontaneous CSF leak,” for example. Even if the MRI of the brain, with and without contrast, is totally normal, I'm not really sure I'm convinced - that you might even take it further. For example, you might do an MRI of the total spine, with a CSF-leak-type protocol, to see if there's some sign of a spontaneous CSF leak or an extradural collection. So, I think in the cases where the preclinical suspicion is higher for a secondary headache, it might not stop at an MRI of the brain (with and without contrast) that's normal. Patients with spontaneous CSF leaks - about eighty percent of them have abnormal brain MRIs, but twenty percent don't. We found, from some observational studies, that a newer cause of intracranial hypotension, such as a CSF venous fistula in the spine, is more likely to present than other causes of CSF leak - with say, Valsalva-associated headache or cough-associated headache. That might prompt us to really take a workup more deeply into that territory, rather than someone where it really just sounds like chronic migraine that switched on. And maybe in those patients, when you dig around, they were carsick as a kid, or they were colicky babies, or they used to get stomachaches and missed school as a teenager here and there, and you think migraine biology is at play. Dr Berkowitz: So, if you're thinking of this diagnosis before you can make it, these patients are going to get an MRI, with and without contrast. And it sounds like the main things you're looking to make sure you're not missing are idiopathic intracranial hypertension or intracranial hypotension from some type of leak. Any other secondary headaches you worry about potentially missing in these patients or want to rule out with any particular testing? Dr Robbins: Yeah - I think sometimes we think of other vascular disorders, especially - when these patients come to medical attention, it's often a total change from what they're used to experiencing. They may present to the emergency room. So, it depends on the circumstance. You might need to rule out cerebral venous thrombosis. Or if there was a very abrupt onset or a relapsing nature of abrupt-onset headaches with sort of interictal persistent headache, we might think of other arteriopathies, such as reversible cerebral vasoconstriction syndrome. There's the more common things to rule out - or commonly identified conditions to rule out - like neoplasm and maybe a Chiari malformation in certain circumstances; those usually would declare themselves pretty easily and obviously on scan or even on clinical exam. Dr Berkowitz: Another question I'd love to ask you as a headache specialist, in your population - sometimes we see this type of new daily persistent headache presentation in older patients, and the teaching is always to rule out giant cell arteritis with an ESR and CRP, in the sense that older patients can present with just headache. Again, my clinical experience as a general neurologist - I wanted to ask you as a headache specialist – is, for the countless times I've done this (older patient has gotten their neuroimaging; we've gotten ESR and CRP), I've never made a diagnosis of giant cell arteritis based on a headache alone, without jaw claudication, scalp tenderness, visual symptoms or signs. Have you picked this up just based on a new headache, older person, ESR, CRP? I'm going to keep doing it either way, but just curious - your experience. Dr. Robbins: Yeah. We're taught in the textbooks (I'm sure we're taught by past Continuum issues and maybe even in this very issue) about that dictum that's classically in neurology teaching. But I agree - I've never really seen pure daily headache from onset, without any other accompaniments, to end up being giant cell arteritis. Then again, someone like that might walk in tomorrow, and the epidemiology of giant cell arteritis supports doing that in people over the age of fifty. But almost always, it's not the answer; I totally agree with you. Dr Berkowitz: Good to compare notes on that one. Okay - so let's say you're considering this diagnosis. You've gotten your neuroimaging, you've gotten (if the patient is over fifty) your ESR and CRP, and you ruled out any dangerous secondary causes here. You have a nice discussion in your article about the primary headache differential diagnosis here. So, now we're sort of really getting into pure clinical reasoning, right, where we're looking at descriptions (colleagues like yourself and your colleagues have come up with these descriptions in the International Classification of Headache Disorders). Here again, we're in a “biomarker-free zone,” right? We're really going on the history alone. What are some of the other primary headache disorders that would be management changing here, were you to make a diagnosis of a separate primary headache disorder, as compared to new daily persistent headache? Dr Robbins: I think the two main disorders really are chronic migraine and chronic tension-type headache. Now, what we're taught about chronic migraine and chronic tension-type headache is that they are disorders that begin in their episodic counterparts (episodic migraine, episodic tension-type headache) and then they evolve, over time, to reach or culminate in this daily and continuous headache pattern, typically in the presence of risk factors for that epidemiologic shift we know to exist but that may happen on the individual level, which does include things that we can't modify, like increasing age, women more than men, some social determinants of health (like low socioeconomic status), a head injury (even if it didn't cause a concussion or clear TBI), a stressful life event, medication overuse, having comorbid psychiatric or pain disorders in addition to the headache problem, having sleep apnea that's untreated, and so on. New daily persistent headache - by definition, it should really be kind of “switched on.” Many years ago, Dr Bill Young and Dr. Jerry Swanson wrote an editorial where they labeled new daily persistent headache as the “switched-on headache.” Then, we're taught in headache pathophysiology that this chronification process happens over time because of, perhaps, markers of central sensitization that might clinically express itself as allodynia in trigeminal or extratrigeminal distributions. So, we're not comfortable with this new daily persistent headache, where we think the biology is like chronic migraine that gets switched on abruptly, but in so many patients, it seems to be so - it behaves like chronic migraine otherwise; the comorbidities might be the same; the treatments might still work similarly for both disorders in parallel. So, I think those are the two that we think about. Obviously, if there's unilateral headache, we might think of a trigeminal autonomic cephalalgia that's continuous, even if it doesn't have associated autonomic signs like ptosis or rhinorrhea (which is hemicrania continua) - and in those patients, we would think about a trial of indomethacin. But otherwise, I think chronic migraine and chronic tension-type headache are the two that phenotypically can look like new daily persistent headache. In patients with new daily persistent headache, about half have migraine-type features and about half have tension-type features. When I was a fellow, the International Headache Society and the classification only allowed for those who have more tension-type features to be diagnosed as new daily persistent headache. But we (and many other groups) have found that migraine-type features are very common in people who fulfill rigorously the criteria for new daily persistent headache otherwise. And then the latest iteration of the classification has allowed for us to apply that diagnosis to those with migraine features. Dr Berkowitz: That's very helpful. So, we've ruled out secondary causes and now you're really trying to get into the nuances of the history to determine, did this truly have its abrupt onset or did it evolve from an episodic migraine or tension-type headache? But it could be described by the patient as migrainous, be described by the patient as having tension features The key characteristics (as you mentioned a few times) should be abrupt onset and a continuous nature. Let's say, now you (by history) zeroed in on this diagnosis of new daily persistent headache. You've ruled out potential secondary causes. You're pretty convinced, based on the history, that this is the appropriate primary headache designation. How do you treat these patients? Dr Robbins: Well, that's a great question, Dr Berkowitz, because there's this notoriety to the syndrome that suggests that patients just don't respond to treatments at all. In clinical practice, I can't dispute that to a degree. I think, in general, people who have this syndrome seem to not respond as well, to those who have clear established primary headache disorders. Part of that might be the biology of the disorder; maybe the disorder is turned on by mechanisms that are different to migraine (even though it resembles chronic migraine) and therefore, the medications we know to work for migraine may not be as effective. In some, it could be other factors. There's just a resistance to appreciating that you have this headache disorder that - one day you were normal, the next day you're afflicted by headache that's continuous. And there's almost this nihilism that, “Nothing will work for me, because it's not fair - there's this injustice that I have this continuous headache problem.” And often people with new daily persistent headache may be resistant to, say, behavioral therapies that often are really helpful for migraine or tension-type headache because of this sort of difficult with adjustment to it. But at least there's observational studies that suggest that most of the treatments that work for migraine work for new daily persistent headache. There's been studies that show that people can respond to triptans. In my clinical experience, CGRP antagonists that work for the acute treatment of migraine may work. There is evidence that many of the traditional, older medicines (like tricyclic antidepressants, topiramate, valproate, beta-blockers, probably candesartan) and others that we use for migraine may work. There's observational studies specifically for new daily persistent headache that show that anti-CGRP therapies in the form of monoclonal antibodies and botulinum toxin can work for the disorder. Are there anything specific for some of the new daily persistent headache that might work? Not that we really know. There's been some attempts to say, “Well, if you get these people in the hospital early and try to reduce the risk of headache persistence by giving them DHE, or dexamethasone, or lidocaine, or ketamine, will you reduce the chances of headache persistence at that three-month mark or longer?” We don't really know (there's some people who believe that, though). Maybe there's good reason to do some type of elective hospitalization for aggressive treatment because we know that, notoriously, the treatment response is very mixed. There's been specific treatments that people have looked at. There's been some anecdotes about doxycycline as a broad anti-inflammatory type of treatment that might be used in a variety of neurological disorders, but there's really nothing in the peer-reviewed literature that suggests that is effective or safe, necessarily. And I think a lot of people in new daily persistent headache do develop a profile that resembles chronic migraine (they can develop medication overuse very easily). Often, goal setting is really important in the counseling of such patients. You really have to suggest that the goal for them might be difficult to have them pain-free at zero and cured, but we want this to be treated so the peaks of severity flatten out a bit, and then the baseline level of pain diminishes so that it devolves into a much more episodic disorder over time that looks like regular migraine or regular tension-type headache. Dr Berkowitz: I see. So, in addition to starting a migraine-type prophylactic agent based on the patient's comorbidities and potential benefits of the medication (the same way we would choose a migraine prophylactic), do you do anything, typically, to try to, quote, “break the cycle” - a quick pulse of steroids as an outpatient or a triptan in the office - and see how they do, or do you typically start a prophylactic agent and go from there? Dr Robbins: I think, like all things, it kind of depends on the distress of the patient and how they are functioning. If it's someone who's just out of work, cannot function - and someone like that might be very amenable to an elective hospitalization or some parenteral therapy, or maybe an earlier threshold to use a preventative treatment than we would be doing otherwise in someone with migraine overall - I think that it really depends on that type of a disability that's apparent early. I think it's compelling that, with new daily persistent headache, about a third of people report some antecedent infection that was around at the time. When new daily persistent headache was first described by this Canadian neurologist, Dr Vanast, in the 1980s, it was described in the context of Epstein-Barr virus infection, or at least a higher rate of serologies that are positive for, perhaps, recent Epstein-Barr exposure. And we know that Epstein-Barr is obviously implicated in lots of neurological diseases, like multiple sclerosis. And I mean, I think about these things all the time, and especially with COVID now. So, it's compelling - as a postinfectious disorder, do we, as neurologists (who are so comfortable with using pulse-dose steroids, IVIG) - do we use these things for a new daily persistent headache? But there's no great evidence that enduring inflammation in the dura that would spill into CSF analyses is really present in such patients. There was one study that looked at markers, such as TNF-alpha, in the CSF, but the rates of seeing that were the same in new daily persistent headache and chronic migraine, so there isn't really a specificity to that. Many people we see with new persistent headaches since 2020 may have it as part of a long COVID syndrome (or postacute COVID syndrome), and in those cases, often it's more like “new daily persistent headache-plus.” They might have something that resembles POTS (postural orthostatic tachycardia syndrome); they might have something that resembles fibromyalgia, chronic fatigue. Often in those patients, it takes management of the whole collection of neurological syndromes to get them better, not just the headache alone. Dr Berkowitz: Well, this sounds like such a challenging condition to treat. How do you counsel patients when you've made this diagnosis - what to expect, what the goals are, what this condition is, and how you developed your certainty? It's often challenging (isn't it?) sometimes with patients with headache disorders, when we're not relying on an MRI or lab test to say, “This is the diagnosis”; telling them, it's just our opinion, based on their collection of symptoms and signs. So, how do you give the diagnosis and how do you counsel patients on what it means to them? Dr Robbins: Yeah, it's a great question because it's high stakes, because people will read online, or on social media, or on support groups that this is a dreadful condition - that no one gets better, that they're going to be afflicted with this forever, and the doctors don't know what they're doing, and, “Just don't bother seeing them.” And the truth is not that; there's so many people who can get substantially better. I tell people that it's common; in some epidemiologic studies, one in one thousand people in any given year develop new daily persistent headache, and most of those people get better (they don't seek medical care eventually, or they do, just in the beginning, and then they don't have follow-up because they got all better) - and I think that really happens. I think the people who we see in, say, a headache clinic (or even in general neurology practice) are typically the ones who are the worst of the worst. But even amongst those, we see so many stories of people who get better. So, I really try to reset expectations - like we mentioned before about assessing for treatment response and understanding that improvement will not just mean one day it switches off like it switched on (which seems unfair), but that the spikes will flatten out of pain (first), that the baseline level of intensity will then improve (second); that we turn it into a more manageable day-to-day disorder that really will have less of an impact on someone's quality of life. Sometimes people embrace that and sometimes people have a hard time. But it does require, like many conditions in neurology, incremental care to get people better. Dr Berkowitz: Fantastic. Well, Dr Robbins, thanks so much for taking the time to speak with us today. I've learned so much from your expertise in talking to you and getting to pick your brain about this and some broader concepts and challenges in headache medicine. And I encourage all our listeners to seek out your article on this condition that has even more clinical pearls on how to diagnose and treat patients with this disorder. Dr Robbins: Thanks Dr. Berkowitz - great to be with you. Dr Berkowitz: Again, for our listeners today, I've been interviewing Dr Matthew Robbins, whose article on new daily persistent headache appears in the most recent issue of Continuum, on headache. Be sure to check out other 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 practice. Right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024 or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

In this episode, we dove deep into the complexities of neural processes with the renowned professor Barry Komisaruk. Today, we unraveled the mysteries of pain, pleasure, and consciousness, explored the Morse code of neurons, and discussed Barry's groundbreaking research on non-genital orgasms. We reflected on the power of love, the influence of human connection, and the transformative role of pain in personal growth. Barry shared profoundly personal stories, highlighting the importance of emotional awareness and the pursuit of passion, regardless of life's challenges. This episode was rich with scientific exploration and heartfelt advice, a true journey through the mind and soul. Become a Member to Receive Exclusive Content: renamalik.supercast.com Schedule an appointment with me: https://www.renamalikmd.com/appointments ▶️Chapters: 00:00 Introduction 02:23 Activation of brain regions during pain and pleasure. 08:04 Genital touch and orgasms show brain interaction. 15:57 Stimulation of different body parts for orgasm. 17:22 Neurosurgeon specializes in epilepsy treatment at University. 24:17 Push swing rhythmically to increase its height. 27:51 Orgasm can be experienced from various stimulations. 37:24 Release mechanism for prolactin: dopamine depletion. Orgasm involves dopamine pathway activation. 40:59 Brain extension enabling high excitation and stress adaptation. 46:48 Unknown substances can stimulate fluid accumulation in rats. 49:27 Explanation of Valsalva maneuver and effects. 58:55 Vaginal and cervical sensation, bypasses spinal cord. 01:04:46 How do neurons produce consciousness? 01:06:27 Mapping brain activity; neurophrenology and neuron capabilities. 01:13:03 Spouse urges change in goal-oriented husband. 01:16:50 Following my heart has guided my life. 01:26:44 Support the podcast by subscribing and reviewing. Let's Connect!: WEBSITE: http://www.renamalikmd.com YOUTUBE: https://www.youtube.com/@RenaMalikMD INSTAGRAM: http://www.instagram.com/RenaMalikMD TWITTER: http://twitter.com/RenaMalikMD FACEBOOK: https://www.facebook.com/RenaMalikMD/ LINKEDIN: https://www.linkedin.com/in/renadmalik PINTEREST: https://www.pinterest.com/renamalikmd/ TIKTOK: https://www.tiktok.com/RenaMalikMD ------------------------------------------------------ DISCLAIMER: This podcast is purely educational and does not constitute medical advice. The content of this podcast is my personal opinion, and not that of my employer(s). Use of this information is at your own risk. Rena Malik, M.D. will not assume any liability for any direct or indirect losses or damages that may result from the use of information contained in this podcast including but not limited to economic loss, injury, illness or death. Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the ins and outs of bracing and how to engage in conversations with fitness professionals to make sure we are all speaking the same language. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL MOORE Good morning, PT on ICE Daily Show. What is up? It is Monday morning. My name is Dr. Rachel Moore. I am here representing our pelvic division, hanging out today to chat with you guys about bracing. So really breaking down the brace, understanding this concept a little bit more, understanding maybe where some pitfalls are in our communication with our fitness professionals that we are working with. So diving into that, let's just get started. IS ALL BRACING INSTRUCTION THE SAME?The brace as a term is kind of like poorly defined. There's really an understanding maybe in the PT world of what the brace is and then maybe in the strength world of what the brace is. And oftentimes what we're seeing or what we're getting feedback from is maybe there's a disconnect between what we're teaching as PTs or being taught as PTs and what the fitness professionals in our communities are being taught. And we wanted to kind of break down where this comes from. So for one, a lot of times fitness professionals aren't necessarily ever truly like taught how to do a brace. The most common cue we hear in like the fitness professional space is brace like somebody is going to punch you in the belly or like somebody is going to hit you in the stomach. And a lot of times that kind of brings about, or people think that this means this push out and this push out. on the PT side of things is actually what we're trying to avoid. And so we get some feedback from students in our courses and that's actually kind of what inspired the topic today is we got an email from one of the students who had taken our courses who said that she was kind of hearing from fitness professionals in her community that the way she was teaching the brace wasn't correct. So what do we do with that conversation? How do we navigate that conversation with those fitness professionals? And how do we kind of get across that we're probably saying the same thing, but it's not coming across the same way. WHAT DOES IT MEAN TO BRACE? So first thing I want to do is really define what the brace is. And in order to define what the brace is, we have to define the component pieces of the core canister, which is what's involved in the brace. So when we're talking about our core canister, we're talking about a 360 degree canister that has a top and a bottom. The top of that is going to be our diaphragm. The bottom of that is going to be our pelvic floor. The front insides are our anterior abdominal wall. A lot of times people just say, oh, that's the transverse abdominal muscles. But in reality, we have to understand that that is more than just the transverse abs. That's actually all of the layers of the abdominal wall. and then the back is the spine and the muscles of the spine. When we talk about this brace, we want the canister to have equal pressure distributed around it and dissipate forces in an equalized manner, rather than maybe one side of the canister getting too much force, which then causes a leakage of pressure into a different direction. So when we're explaining the brace, or we're teaching the brace, We oftentimes teach it as tense your abs, or think about pulling your pelvic bones together. A cue that we use a ton over in the pelvic division with our pregnant athletes is if you have a baby, hug your baby, or if you can remember what it felt like to recently be pregnant, hug baby, that pull together of the abs. We are never queuing a push out because if we think about this canister, a push outwards is going to cause a mismatch of pressure within the inside of that canister. That's then going to come downwards through the pelvic floor. And oftentimes in the pelvic space can elicit pelvic floor symptoms like leakage, heaviness, or farting in the bottom of a squat or when we're lifting. so we expect that the pelvic floor is going to match the degree of abdominal brace we don't necessarily cue an intentional pelvic floor contraction when we're saying brace we might in our populations that are having issues with symptoms cue almost like an over correction because especially if there's somebody that's actually bearing down or pushing when they're bracing and not understanding that they're lengthening their pelvic floor rather than either staying at the same level or allowing their pelvic floor to match the demand of everything that's on top of it. So when we're cuing our brace, it is tense your abs, pelvic floor either stays the same or we slightly lift pelvic floor to match that pressure. That's how we teach that brace. THE CONFUSING NATURE OF THE WEIGHTLIFTING BELT The confusion I think comes in especially when we start talking about layering in a belt. So oftentimes in the strength training world, we see athletes busting out a belt and maybe they're using it all the time for every However, whatever the weight is on the bar, it's not necessarily just that they're heavier lifts or maybe they're reserving it for their heavier lifts. The key thing with the belt is that when we layer in the belt, the brace doesn't change. And that's something that I think we need to make sure our athletes and our coaches are understanding is that the belt is there to give us this extra support and really proprioceptive input to allow that increase in spinal stiffness to happen, but it is not a mechanism to push into. and I have my husband's belt. I left mine at the gym, so this isn't gonna fit me exactly right, but I wanna walk through the fit of the belt and where I think this confusion maybe comes from when we start talking about fitness professionals queuing a push-out. So with the belt, when we're talking about using a weightlifting belt, we want to think about, if you have YouTube or Instagram live up, I've got the belt here, and I'm just gonna kinda walk through the fit of the belt and what we're looking for. So when we are putting a weightlifting belt on, we're looking to fill that space in between our pelvis and our ribcage. If there's a little bit of overlap, that's totally fine, but we're kind of going like the top of the pelvis and that's my marker for where this belt is going to go. When I put my belt on, I'm going to put my belt on and as I tighten it, I want to fully exhale. I'm not like sucking in and shrinking and shriveling up as tiny as I can. I'm just doing a comfortable exhale. And then from there, I'm tightening. And in this tightening, I can breathe. I can talk. I can put a finger in between me and my belt, and I'm not uncomfortable. It's not squeezing me. If we have the fit of the belt correct, then that approximation that comes from inhaling i think is maybe what the confusion is coming from so if i have my belt on right i tightened it on my exhale as i do an inhale and i think about inhaling into my belly and into my spine that good solid 360 breath i feel my tissues push into that belt that is different than me intentionally pushing into the belt, that push your belly out sensation. If you're watching this live or listening to this later, put your hands on your belly and feel what happens when you push your stomach out. What do you feel at your pelvic floor? More than likely, it's a dropdown. If we think about tensing our core, Usually we don't feel much there. Maybe we feel a slight lift. And if we do feel a drop down, then we over correct and think about going up towards the basement to mitigate that. But the key here is the fit of the belt and understanding how to do that brace. So where does the confusion come in? When we're talking about our fitness professionals or maybe people who have never been trained in how to use a belt, the thought is to push out into the belt to create that contact with the belt. But if we have the belt fitting correctly, we don't need to do that push up. That's the biggest thing that I want you guys to understand and take away is it all comes back to the fit and making sure that we're using that belt correctly. Even without the belt, our brace stays the same, right? We're thinking inhale into belly, tense abs. It's never push out as if we're pushing our abdominal wall away. WORKING ALONGSIDE FITNESS PROFESSIONALS So when we're having these conversations with Fitness professionals or other coaches in our community who are maybe pushing back and saying like that's not how we teach our brace Really breaking this down and explaining to them where we're coming from and why. I think a lot of the time like we assume that everybody is just saying the opposite just for the sake of saying the opposite or maybe like they're just digging their heels in and there's no sense in educating them. But in reality like we have a lot of opportunity here to create bridges with these fitness professionals and create positive relationships. And we're not gonna do that by saying, well, you're wrong, or telling the athletes, well, your coach is wrong, just do it how I teach you. So using this as an opportunity to get in front of those coaches and those fitness professionals, and as a way to kind of bridge this relationship of, hey, you guys are coaching, I'm teaching your athletes, I would love to get on the same page, this is how I teach a brace, this is why. The goal here is to create equalized pressure across this core canister, If we push out in one direction or another, we put ourselves at risk of potentially having pressure leakage, quote unquote, out through that wall. It's also just not as strong. And at the end of the day, all of us are here to help people get stronger and move better. So if we think about this and conceptualize all of these walls of this castle being strong rather than one being broken or pushed out, then we can kind of understand that that applies into better, more efficient bracing mechanic, which then leads into better lifting and higher strength with our sets that we're working on, increasing our strength and capacity there. If this is confusing to you, I've got another podcast episode, episode 1577 of PT on Ice Daily Show that's all about the Valsalva, kind of breaks down a little bit more of the specifics of the Valsalva, which is that breath hold with the brace. The Valsalva can also have the belt, so we can have this spectrum of breathing. SUMMARY We really break down the spectrum of breathing in our live courses. Our live course is coming up in March. There are so many opportunities to catch the live course out on the road in March, y'all. March 2nd and 3rd in California, 9th and 10th in North Dakota, 23rd and 24th in South Carolina. So holy cow, so many opportunities to come hang out with us. Be on the lookout. Christina Prevett and I also did a clinical commentary that will be coming out in the spring 2024 edition. of the Journal of Pelvic Obstetric and Gynecologic Physiotherapy, so that should be coming out here pretty soon. We'll be blasting that all over the place when it does come out, but be on the lookout. Sign up for our pelvic newsletter, because that's gonna be one of the first places that drops, as well as on our hump day hustling. Thanks for joining me this morning, guys. I hope that cleared up some confusion. If you have any questions about bracing, or you're not sure how to explain it, or anything along those lines, please reach out, shoot me a message. I'm happy to chat with you more. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

In this Q&A episode of the podcast, Greg and Lyndsey answer questions about how to research a new subject, the effect of diabetes or insulin resistance on hypertrophy, how a pump might affect moment arms in movements, how much is too much isolation work, and more. They also give an update on the future of the podcast and announce that Dr Pak and Dr Milo Wolf are teaming up with Stronger By Science. TIME STAMPS00:00:00 – Podcast Updateshttps://www.strongerbyscience.com/future/00:21:29 – Q&A Intro and "How do you go about researching a whole new subject?" (Q1 from Teo)00:39:29 – "Does T2DM make hypertrophy impossible?" (Q2 from Jon) https://www.strongerbyscience.com/p-ratios/https://www.strongerbyscience.com/p-ratios-rebuttal/https://www.strongerbyscience.com/p-ratios-rebuttal-2/For more direct data on diabetic populations: Beyond general resistance training. Hypertrophy versus muscular endurance training as therapeutic interventions in adults with type 2 diabetes mellitus: A systematic review and meta-analysis. Acosta-Manzano et al. (2020)Another 2020 systematic review: A Systematic Review with Meta-Analysis of the Effect of Resistance Training on Whole-Body Muscle Growth in Healthy Adult Males. Benito et al. Average increase of about 1.51kg.Metformin: optimism that it would help with hypertrophy: Metformin to Augment Strength Training Effective Response in Seniors (MASTERS): study protocol for a randomized controlled trialBut, that didn't pan out. Didn't stop hypertrophy altogether, but did seem to reduce it: Metformin blunts muscle hypertrophy in response to progressive resistance exercise training in older adults: A randomized, double-blind, placebo-controlled, multicenter trial: The MASTERS trial00:55:18 – "Does getting a pump increase strength?" (Q3 from Alexander) https://www.strongerbyscience.com/size-vs-strength/https://peerj.com/articles/1462/01:05:20 –  Stimulant metabolism (Q4 from Connor Smith)01:17:40 – "How much can BMR vary between individuals?" (Q5 from Jon) Do People Really Have “Fast Metabolisms” or “Slow Metabolisms”?01:29:35 – "Is it possible to taper down activity levels (steps) without reducing calories?" (Q6 from Angela) Constrained energy expenditure01:41:10 – "How do you incorporate plyometrics and explosive training for jump height" (Q8 from trugor) 01:54:29 – "Is there any research showing damage to the blood vessels or whatnot in the longer term due to the blood pressure increase, because of bracing/Valsalva maneuver?" (Q9 from No_Performer_8133)https://pubmed.ncbi.nlm.nih.gov/23231790/https://pubmed.ncbi.nlm.nih.gov/33737330/https://pubmed.ncbi.nlm.nih.gov/38142405/  02:00:51 – "How much isolation work is too much?" (Q10 from tompa01) 02:10:05 – "Favorite and least favorite things I've cooked" (Q11 from Ali Shah)  MORE FROM THE SBS TEAMWork with a Stronger By Science coach: Get personalized training and nutrition plans and ongoing support from one of our expert coaches.Join the Research Spotlight newsletter: Get a two-minute breakdown of one recent study every Wednesday. Our newsletter is the easiest way to stay up to date with the latest exercise and nutrition science.Join the SBS Facebook group and Subreddit.RECOMMENDED PRODUCTSTry MacroFactor for free: Use code SBS to get a 14-day free trial of our nutrition app MacroFactor. MacroFactor has the fastest food logger on the market and its smart nutrition coach adapts to your metabolism to keep you on track with your goals. Download it today on the App Store or Google Play.BulkSupplements: Next time you stock up on supplements, be sure to use the promo code “SBSPOD” (all caps) to get 5% off your entire order.MASS Research Review: Subscribe to the MASS Research Review to get concise and applicable breakdowns of the latest strength, physique, and nutrition research – delivered monthly.

In this podcast Adam talks you through a key skill that will benefit you in the gym especially with your heavier compound exercises. This is the Valsalva manoeuvre. It is essentially holding a breath and forcing pressure against your body so that you back stays straight and technique is good.

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore takes a deep dive into the Valsalva Maneuver from 3 different lenses: the scholarly research, the pregnancy & postpartum patient, and the strength & conditioning world. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION00:00 - RACHEL MOORE Good morning PT on ice daily show. My name is dr. Rachel Moore. I am here with Representing the ice pelvic division. I'm on faculty with ice pelvic division. Whoo. Sorry. I need to drink my coffee um i just got back in last night super late night flying from a course this weekend our pelvic live course in um wisconsin it was so much fun we got to see some leaves change which is exciting for me because in houston we don't really have that happen um so really awesome super great weekend awesome and engaged group that we had. If you are looking to join us on the road to catch our live course, our live pelvic course, there are still so many opportunities this year. In that course, we are doing so many things. We are talking about pelvic floor considerations. We're talking about the internal assessment and actually going over and practicing it on your back and in standing. We're talking about pelvic girdle pain which is such a huge topic in the pregnancy and postpartum and just pelvic world in general and then day two we're diving into the actual fitness side of things where we're doing squats and we're learning how to brace and we're using weightlifting belts and we're getting up on the rig and doing gymnastics moves it is a blast every time I come home from a course I'm hyped and there are four more chances of in 2023 to catch this course on the road. So October 21st, we've got a course in Corvallis, Oregon. November 4th, we've got one coming up in Bozeman, Montana. November 18th, we've got one coming up in Bear, Delaware. And then December 2nd, we've got one in Nova Scotia, Canada. So tons of opportunities to catch this course live on the road. Our online course will pick up again in January. So if you're interested in joining us in the ice pelvic division, that's what we got coming up. 02:08 - THE HISTORY OF VALSALVA This morning we are here to talk about Valsalva. So the word Valsalva is kind of a term that nobody really knows what it means or everybody thinks they know what it means and they all have their own separate camps of what it could mean because it's described so many different ways in the literature. So what we're going to do this morning is clarify what the different definitions of this one word are, talk about the history of it a little bit more, where this term really even came from in the first place. So this topic is really near and dear to my heart. Recently, Christina Prevett and I recently just wrote a clinical commentary on Valsalva and on the nuances of Valsalva. and how as clinicians we can take this term and how we need to take this term and understand the lens, especially when we're looking at research, but when we're talking to patients about what this term even means and what we're actually looking for in our strength training fitness world when we say the word Valsalva. So let's kick it off with the history of Valsalva. The term Valsalva is actually named after a physician from the 18th century. So he was an otolaryngologist. Anyway, he worked in ears and throat, ear, nose and throat doctor. And he created this maneuver essentially as a way to push infection out of the ears. So, the maneuver that Dr. Valsalva described actually doesn't even look like the Valsalva that a lot of people talk about today. His maneuver was plugging your nose and blowing out, but not against a closed glottis. And when he created this maneuver, the purpose of it was to flush infection out of the ear by having that tympanic membrane push outwards to, in theory, push pus out of the ear. That is where this term was created. So when we look at Valsalva in the research lens, when we talk about diving into the specifics of research on this topic, if we're looking in the ENT world, autolaryngological world, we're thinking about this maneuver as a plugged nose, closed glottis, now push out in order to push that tympanic membrane out. When we're looking at this word in the urogynecologic world, it has a very different emphasis or purpose. So when we think about pelvic organ prolapse and the diagnosis of pelvic organ prolapse, that's where we see the Valsalva, quote unquote, being useful, I would say. So the Valsalva in a urogynecologic world is an intentional bear down and strain with a closed glottis. in order to measure the descent of the pelvic organs, particularly during that POPQ or that assessment for pelvic organ prolapse. So on the ENT side, we have the focus of plugging nose, blowing out, pushing tympanic membranes out. In the urogynecologic world, we've got this strain down through the pelvic floor in order to descend the pelvic organs and measure what that descent is. 06:04 - VALSALVA IN STRENGTH TRAINING In the strength and conditioning world, the term Valsalva means something completely different. In the strength and conditioning world, the Valsalva is a maneuver that is advantageous, particularly if you're a competing athlete in the strength training world, where we need a little bit extra spinal stiffness in order to hit a lift to PR. so in the strength training world this is an inhale into the belly and then a brace of those core muscles that anterior abdominal wall and all of those muscles within the core in general in order to increase that intra-abdominal pressure and spinal stiffness to be able to lift heavier. So when we do the Valsalva, we have a 10% increase in that spinal stiffness and that carries over or translates into pounds on the barbell. So when we're again thinking about our competitive athletes who are maybe trying to like edge somebody out, the Valsalva is an incredibly useful and productive maneuver. Even if we're not a competing athlete, if we're talking about just getting stronger and we're pushing ourselves to the capacity that we want to push ourselves to in order to make those strength gains, the Valsalva is likely utilized in order to increase that capacity to lift heavier. The confusion here comes from that one word having many different definitions. And when we look at the urogynecologic world versus the strength training world, they really are truly opposite. When we're thinking about straining and bearing down, we're pushing down with our abdominal wall muscles, we're pushing down with our pelvic floor, and we expect to see that descent. I 100% agree that we shouldn't put a heavy barbell on our back and then strain and push down through our pelvic floor. That is not beneficial and it is going to put a lot of strain through the pelvic floor. Absolutely. However, when we talk about Valsalva in a strength training capacity, that's not what the Valsalva is. The Valsalva in a strength and conditioning world is that intentional inhale into the belly and brace of that anterior abdominal wall muscles. When we do that brace of those anterior abdominal wall muscles, we don't want to see a descent of the pelvic floor. That would be an improper brace that would need training to improve that coordination. What we expect to see with a valsalva in the pelvic floor world is a matched degree of contraction for the demand that's placed on that system. So if we're thinking about somebody who's lifting a heavy lift, a one rep max, We expect that pelvic floor to kick on, but we're not necessarily volitionally thinking about lifting pelvic floor and doing that pelvic floor contraction. As that core canister is engaged and we engage that proper brace, the entire core canister should kick on to a relatively equal degree. So in the strength and conditioning world, that Valsalva is advantageous. In the urogynecologic world, if we're taking that concept and applying it to lifting, it is the opposite of advantageous. So when we're looking at recommendations for our strength training athletes and our patients, we need to understand the language that is being used and what the definition of that language is. So from the standpoint of our OBs who are telling our patients, don't ever do a Valsalva, in their mind, they're saying, don't ever strain and push your pelvic floor down when you're lifting. Totally. We agree. 100%. Don't do that. It's not going to be great. But the disconnect is that this one word has so many different definitions. So we really have to dive in and break down what was that recommendation specifically. So when we're with our patients, that looks like breaking down the definition for them. 09:01 - VALSALVA MANUVEUR IN THE LITERATURE But if we're looking in the research world and we're trying to read literature, read the newest evidence about what recommendations are for our pregnant and postpartum athletes, we need to go into the article itself and look at how they define Valsalva. Because we can easily read the abstract and the conclusion of an article that says Valsalva is not recommended, but if we're, looking at this article and it's actually meaning the bearing down, then we're not getting, we're not able to extrapolate that to the strength and conditioning side. So really with this term, it's one word named after a man who the original maneuver isn't even what we're talking about anymore anyway. Across the board, we have to either figure out different words or different ways to describe this, or it really falls on us as providers to break down what it is we're talking about. So rather than just telling your patients, do a Valsalva, maybe we don't use that language at all, and we just talk about bracing. When we do a brace, we can manipulate breath. If we're gonna take that intentional inhale and then brace, that is a Valsalva, But in order to eliminate the confusion across the board, we can just call it a brace. This makes a lot more sense to patients than being told by one person to never valsalva and then by another person to valsalva. And when we lay it all out and explain what all of these differences are and how it's all one term, but it has different meanings, and none of these meanings necessarily are the same. And in fact, in the urogynecologic world, in the strength and conditioning world, they're literally the opposite. It starts to click with patients, why it's okay that my physician told me not to do this Valsalva, but you're telling me that I can, because I understand that these are two very different physiologic mechanisms. Our clinical commentary over this that dives into all of this and so much more comes out in the spring. So keep an eye out. We'll be sending it out in the ice pelvic newsletter. So if you are not signed up for that newsletter, head to PT on ice.com, go to the resources tab, sign up for that newsletter, not only for our clinical commentary in the spring, but for all kinds of resources. in the pelvic floor world. Stay up to date on the newest evidence and also just check out some cool stuff that we find along the way. I hope you guys have an awesome Monday and I hope we see you on the road soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Christina Prevett breaks down two recent studies, one that is VERY new to challenge beliefs on prolapse, the pelvic floor and strength training. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show. 01:22 CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the team within our pelvic health division. If you are interested in learning more about our pelvic health division, we have a online newsletter that goes out every two weeks that focuses on the research, which I'm going to talk about today, in pelvic health. One of the things that is so exciting, but maybe a little bit overwhelming about being in public health and being in this area of exercise and rehab in the pelvic health space is that it is constantly changing. The research is coming out at a very fast pace, fast being relative because research is very slow, but we try and focus in on getting that research to your inboxes every two weeks. You can go to PTonICE.com slash resources and sign up for that newsletter. I am writing it this week and it goes out on Thursday. Also all of our online content, our next online cohort, and all of our upcoming live courses, our two-day live course is in that email newsletter. I hope that you all sign up to get all that research straight to your inbox. 02:48 ACUTE EFFECTS OF RESISTANCE TRAINING Today I'm going to be talking about a new study that came out of Carrie Bowes' lab, talking about the acute effects of resistance training on the pelvic floor. And so before I do that, I kind of want to set the stage for you all around some of the thoughts in pelvic health around heavy strength training. Where we have started this journey was that one of the risk factors for pelvic organ prolapse or descent of one or more of the vaginal walls towards the vaginal opening is that occupational heavy lifting. So individuals who lift heavy weights for their job, consistently lifting heavy weights, were shown to be at risk for more objective descent of one or more of those walls compared to those that didn't. And that because we didn't have any research on resistance training was extrapolated and said, well, maybe we shouldn't do any strenuous heavy lifting as females in order to mitigate or prevent the risk of pelvic organ prolapse from occurring. That was kind of the thought. Since then, we have really pushed back against that narrative and said, well, that doesn't really make a lot of sense because it's very different to go in for eight hours a day doing lifting versus, you know, the 30 to 90 minutes that individuals are doing. In your job, you can't control if you're feeling bad or feeling weak and just take a rest day or modify the way that you're doing your exercise. So again, there isn't really that comparison. 04:24 ACUTE CHANGES TO THE PELVIC FLOOR And now we're starting to get more and more research come out that's talking about kind of this acute change to the pelvic floor that we're seeing with different amounts of strength training or different types of strength training. So Carrie Bo came out with a study and what she was doing was she was taking individuals who were resistance trained. So on average, these were individuals who had never had kids. They were Nellie Parris. And so I never had a delivery and were trained resistance trained athletes. So they had on average about two years of experience. They were then put into a crossover design. So what that means was they took half the individuals and got them to strength train first and then took half the individuals and got them to rest first and then kind of compared. So what they were trying to look at was after a high load resistance training session, what was the impact on the pelvic floor? The thoughts were one of two camps. There's two camps in this space. One is that individuals who strenuously lift are going to have bigger pelvic floor muscles, stronger pelvic floor muscles. And the other is that it may actually create damage over time that they're going to see a big change in symptoms or change in vaginal descent. So you kind of have individuals in both of these camps and we're trying to figure out which hypothesis is correct. And so they took, they did a one rep max or a perceived or rate of perceived exertion that was very high in the squat and the deadlift on one day. And then they got them to come back the next day. So after that one rep max test, they kind of flushed out, let the body recover, came back in. Half the group started with a rest window. So took pelvic floor muscle strength measures at the beginning pre, then half of them rested and did a post and then half of them did a four by four strength training session between 75 and 85% of their one rep max on the squat and the deadlift with reps in reserve between one and three and then did a post assessment and then they flipped, they flipped them. So what they saw was that there was no big differences, no statistically significant differences between the rest pre post, but then also the resistance training pre post. And I think that's really interesting because one of the things that we kind of explain around our, our thoughts around heaviness or prolapse are things like that it's a fatigue issue or so maybe it isn't fatigue or maybe it is, but doing a supine assessment, which is our traditional way of conceptualizing pelvic floor muscle strengthening, isn't sufficient to look at this type of, of fatigue, like to really evaluate this type of fatigue in individuals who are experiencing these symptoms. So that was really interesting. The other thing was that, you know, they did see some individuals who complained of urinary incontinence in this sample around 28%, I believe. And so those individuals, the study wasn't powered enough to be able to subgroup those that experienced incontinence versus those that didn't, but there, what it was not just on individuals who were symptom free. I think that's a pro to this study because we can say, well, of course there isn't any fatigue or any downstream effects of individuals who've never experienced pelvic floor dysfunction, but that's not the case in this study. There was a significant cohort of these individuals who did experience leaking with lifting and the study just wasn't powered enough to subgroup this out. So the first step was to kind of take a full circle approach and say, was there any differences? And then the next step is going to say, is there any differences for individuals who do experience pelvic floor dysfunction versus those that don't? And then the next step is those that are multiparous or multiparous, like multiparous, we kind of, tomato, tomato, those who have had vaginal deliveries before or have given birth before vaginally versus those that haven't. And so this is kind of setting up this conversation around the way that we message things. So another study was done in 2016 and I just found it because it was in the discussion section of this paper around vaginal descent. So Carrie said the Bowe study was looking at pelvic floor muscle strengthening, pelvic floor muscle strength and assessment. 09:23 VAGINAL DESCENT AND EXERCISE The next question is around vaginal descent and are you more likely to experience symptoms of prolapse or heaviness post resistance training? And so this study was done in 2016, I believe it was published out of Janet Shaw and Ingrid lab that was looking at CrossFit athletes, those who experience, sorry, those who participate in strenuous exercise. So they got CrossFitters and they got them to do pre-post on the pop cue versus those that participate in non-strenuous exercise. So let's kind of break this study down too, because I think it's important. So in this second, this, I guess it was the first study, what the group from Nygaard and Shaw's lab did was they took individuals who were CrossFitters, got to check their pelvic floor muscle strength and the pop cues. The pop cue is an objective assessment of prolapse that has good reliability that looks at the different segments of the different walls of the vagina. And then as they do a strain maneuver, they see what the range of motion or the amount of each segment of each component of the wall are, and then create a grade based on the most amount of movement in whichever section of the vaginal wall that may be. So they took individuals who were CrossFitters and then they took individuals who participated in non-strenuous, non-high impact exercise and got them to come into the lab. And then the strenuous group was, they did a pelvic floor muscle strength exam and then the pop cue and then in the non-strenuous group, they did the same thing. And then they got the CrossFit group, the strenuous group to do a 20 minute AMRAP of sit-ups, heavy deadlifts. There was an impact movement in there and kind of went for 20 minutes. And then they got the non-strenuous group to do 20 minutes of an exercise of their choice at a self-selected pace. And then they did the pop cue again. Here's something that's really interesting. So the strenuous group was participating in CrossFit for over two years. They had an extensive history of strenuous exercise versus the non-strenuous group. And they kind of conceptualized this based on looking at what they did for exercise and the amount of loading in their bones to try and get some sort of measure of impact, which I thought was kind of brilliant. And they compared them. Strenuous group had done a lot more loading of their bones and musculature and therefore loading of their pelvic floor compared to the other group. And what they saw was that before their pre-exercise, descent in pelvic floor muscle strength was not different. Was not different. So this created preliminary research that the strength, individuals who are participating in strength training for several years, so it was like on average 22 months plus or minus, and they had to have at least, I think, a year of doing CrossFit regularly, three to four times per week to be able to get into the study in the first place, that there was no difference in vaginal descent. They had, there was no differences between the two. So that kind of goes against this argument that resistance training is going to cause a prolapse, resistance training in general for individuals who haven't had a vaginal birth yet. So I think that's interesting. And then post-partum, or post-exercise rather, they did see differences in descent in both groups. So both groups saw a difference in descent immediately post-exercise, which again, I think is really interesting because this does not support that resistance training and high impact is going to lead to prolapse down the line. Now again, we have a lot of work to do within this space. This was one study. I'm not going to just start shouting from the rooftops that all of a sudden, you know, we know all of the things that we need to know. I'm not saying that, but the fear focused language that is coming into this space around resistance training and avoiding Valsalva and all these types of things isn't founded objectively. So the other interesting thing was that there was only one individual, even though there was a change in descent, right? There was some changes pre-post-exercise and they didn't re, they didn't kind of follow them further and further forward. I would have loved to see them do multiple time points to see how long it took before that changed or kind of returned to baseline. There wasn't anything that, that was looking at what, what that change of symptoms were. 12:57 RESISTANCE TRAINING & PROLAPSE And there was only one person with subjective symptoms of prolapse. So again, we're, we're seeing this disconnect between objective signs and subjective experiences, which I think again is really interesting because we are focusing a lot on the grade, like what grade do you have? What grade do you have? And the evidence isn't really supporting that we, that should be our focus. If you are thinking surgical routes, if it is coming past the level of the Hymen, absolutely, because then we're going to say, is this impacting your quality of life? Is there sufficient imaging data to see that a surgery, for example, would be warranted? For individuals in the conservative space, again, we're, we're, we're questioning, does the objective signs matter? And, you know, we can't answer that question, but it is an interesting thought experiment and we're starting to have more evidence accumulate that, you know, there is a big disconnect. And yes, our body is going to change and show signs of fatigue with things like impact, but what's the cost benefit? What is the risk of telling people that they shouldn't be getting strong for their 60-year-old self, for their 70-year-old self, for their 85-year-old self, when we know that strength is such a huge, huge component of independence in later life? So it is so exciting, kind of going through Carrie Bowes where she didn't see any change in pelvic floor muscle strength to some of the research coming out of the Nygaard and Shaw lab that are talking about changes in pelvic organ support with heavy lifting and long-term heavy lifting. I think we're starting to get more and more data that the fear-focused messages aren't warranted, that we're going to start treating the symptoms and that we can expect changes to the pelvic floor when the pelvic floor gets a workout. Again, I don't think for anybody in the ice fitness forward community that that is necessarily a surprising finding, but it is definitely pushing some of the narratives in pelvic health and I think pushing them in a really necessary direction to try and change this narrative around the fear-focused language of resistance training in the pelvic floor. If you are interested in those studies, I'll post their DOIs below in the comment section. I am so excited to be talking about this research. Again, if you are a research nerd like me and you want to see the new studies that are coming out in this space, which these two studies are going to be in our newsletter this next week, I encourage you to go to ptonice.com slash resources to look for the pelvic newsletter. I am really excited to see some of the changes happening within our course and I just can't wait to continue connecting with you all about research in the pelvic health space. All right. Have a great day, everyone, and I will talk to you soon.  16:40 OUTRO Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

The following question refers to Section 4.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Rochester General Hospital cardiology fellow and Director of CardioNerds Journal Club Dr. Devesh Rai, and then by expert faculty Dr. Eldrin Lewis.Dr. Lewis is an Advanced Heart Failure and Transplant Cardiologist, Professor of Medicine and Chief of the Division of Cardiovascular Medicine at Stanford University. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #26 A 45-year-old man presents to cardiology clinic to establish care. He has had several months of progressive dyspnea on exertion while playing basketball. He also reports intermittent palpitations for the last month. Two weeks ago, he passed out while playing and attributed this to exertion and dehydration. He denies smoking and alcohol intake.   Family history is significant for sudden cardiac death in his father at the age of 50 years. Autopsy has shown a thick heart, but he is unaware of the exact diagnosis. He has two children, ages 12 and 15 years old, who are healthy.   Vitals signs are blood pressure of 124/84 mmHg, heart rate of 70 bpm, and normal respiratory rate. On auscultation, a systolic murmur is present at the left lower sternal border. A 12-lead ECG showed normal sinus rhythm with signs of LVH and associated repolarization abnormalities. Echocardiography reveals normal LV chamber volume, preserved LVEF, asymmetric septal hypertrophy with wall thickness up to 16mm, systolic anterior motion of the anterior mitral valve leaflet with 2+ eccentric posteriorly directed MR, and resting LVOT gradient of 30mmHg which increases to 60mmHg on Valsalva.   You discuss your concern for an inherited cardiomyopathy, namely hypertrophic cardiomyopathy. In addition to medical management of his symptoms and referral to electrophysiology for ICD evaluation, which of the following is appropriate at this time? A  Order blood work for genetic testing B  Referral for genetic counseling C  Cardiac MRI D  Coronary angiogram E  All of the above Answer #26 Explanation   The correct answer is B – referral for genetic counseling.  Several factors on clinical evaluation may indicate a possible underlying genetic cardiomyopathy. Clues may be found in: ·       Cardiac morphology – marked LV hypertrophy, LV noncompaction, RV thinning or fatty replacement on imaging or biopsy ·       12-lead ECG – abnormal high or low voltage or conduction, and repolarization, altered RV forces ·       Presence of arrhythmias – frequent NSVT or very frequent PVCs, sustained VT or VF, early onset AF, early onset conduction disease ·       Extracardiac features – skeletal myopathy, neuropathy, cutaneous stigmata, and other possible manifestations of specific syndromes In select patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members (Class 2a, LOE B-NR). In first-degree relatives of selected patients with genetic or inherited cardiomyopathies, genetic screening and counseling are recommended to ...

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses how virtual pelvic floor care can prove beneficial for physical therapists in both virtual and in-person settings. Alexis shares that engaging in virtual pelvic floor care has significantly improved her overall abilities as a physical therapist, particularly in asking questions and gathering necessary information. She also notes that virtual care seamlessly integrates into both virtual and in-person worlds. Alexis highly recommends physical therapists to explore virtual pelvic floor care as it can be incredibly helpful. Furthermore, she mentions that a future podcast episode will delve into objective exams for pelvic floor virtual PT, indicating the importance of further exploring virtual care. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show 01:27 ALEXIS MORGANGood morning, Instagram. Good morning, PT on ICE Daily Show. My name is Dr. Alexis Morgan. I am one of the faculty with the Ice Pelvic Division. Really happy to have you all here joining me this Monday morning. My voice is a little raw from the weekend. We were just in Denver, Colorado, right outside of Denver at Onward Denver in Parker. This whole weekend, April and I spent with an awesome, awesome group of individuals and we were going through all of our material in our live course. We did our internal exams, supine and standing, and dove into all issues of pelvic floor dysfunction. We of course didn't stop there. We progressed through everything that our athletes are doing at the gym. So talking about how pelvic floor dysfunction fits into weightlifting and Valsalva and using a weightlifting belt and jumping and running and doing gymnastics. We had an absolute blast with this last weekend and we hope that you all will join us in the future for not only our live course but also our online course. I want to talk with you all today about virtual pelvic floor PT. We get a lot of questions asked over Instagram and on our Ice Students Facebook page. Sometimes we answer you all directly with some help. A lot of times we like to use your questions to teach everyone else about the topic that you asked. 03:10 VIRTUAL PELVIC FLOOR PT This particular topic actually came from an Ice student who was wanting to know some more information about how to really apply what we talk about in our live and online courses into the virtual setting. And so that's exactly what I want to dive into today. Kind of similar to what we talk about really in all of our courses is that our subjective exam should be very detailed. It should be specific and we should be taking a while to do our subjective exams. I will say that when it comes to doing an assessment virtually, the subjective becomes huge. Not everything but a vast majority of especially that initial assessment. I'll talk through some ways that we do some objective exams but I want to before we even get there really emphasize to you all the importance of that subjective exam particularly in the virtual setting. So when I say be specific, there's a couple of things I mean with this. Depending on the issue that they may be coming to you for, whether that's leaking urine, whether that's pelvic organ prolapse or feelings of heaviness or vaginal bulge, that might be leaking bowels, whether that's anal incontinence with stool or potentially with flatulence. Maybe it's constipation. Whatever that may be, we want to get very specific on their problem. Again, this is true in person and in virtual but it really does become extremely important in this setting because all you've got to track changes are your words. By you having conversations and by asking questions, that's how you track the person's change. So it's not in session, which sometimes we can gather on that first virtual, but definitely between sessions. It's really, really important. So maybe you use the patient specific functional scale where they fill this out ahead of time or maybe you help them out and ask them further questions when they tell you they leak with double unders. 06:26 LEAKING WITH DOUBLE UNDERS When I hear I'm leaking with double unders, that is not enough information for me to help you just yet. I've got a lot more questions and you should too because depending on how they answer, it could really change how you're going to treat them for that leaking. Not all leaking with jump rope is treated in the same way. And we've talked about this so much yesterday in our live course as we were going through jumping rope. But what we need to do is ask questions. So when does the leaking occur? When in that workout? And tell me what jumping rope looks like to you. Is it single unders? Is it double unders? If it's double unders, is it always doubles? Did you just gain that skill or is that an old skill for you? At what point during the workout? If it's early on, that's going to be different than if it's later on, right? I'm starting to think fatigue plays a role in their leaking. If it's later on in a workout, does it matter about which exact workout it is? What is the volume with that? That's going to be different, right? If it's 50 double unders versus 500 double unders, that's going to be different. And so we need to figure that out and we need to ask those questions. So you can use the patient specific functional scale and make that work for you. You can also use the PFDI, a specific to pelvic floor questionnaire. Now that is not an open box. That is marking, marking symptoms on a questionnaire. But what we've got to do is we've got to get information about their specific number one problem that they have. And moving forward, we need to understand what is their entire pelvic floor environment like. So we're going to ask questions and see if they have issues in other pelvic floor realms. Realizing we understand the number one reason why you came to me and I promise you I'm going to help you with that. But sometimes some of these other issues kind of play into your main leaking problem. Or as we're addressing your leaking, we can also address these other issues and together everything within your pelvic floor is going to function better. So a couple of those questions, again, depending on what they're coming in for, whether that's vaginal or bowel issues, you're going to ask, are you experiencing any leaking with maybe coughing or laughing, sneezing? And even with that, sometimes people are like, no, I don't leak with sneezing, but I do have to cross my legs together aggressively in order not to pee. OK, that's a problem, right? We're going to add that to our list. Do you feel like you can fully void? How frequently are you peeing? This one's a hard question for people to answer, but I generally want to know like, is it every 5, 10, 15 minutes or is it more like every hour or two? If it's very frequent, like every 15 minutes, that's going to be something that we note down and address early on. If it's every hour or two, we're going to lower that on our list. We may get to that if it's every hour and bothersome, we may not get to that. If there is high frequency, we're going to send them with a bladder diary and that's going to be one of our first trial treatments that we do with them. 12:00 STRAINING TO POOP We want to actually pull up the Bristol stool chart. I always laugh when I pull this up. I'm like, OK, listen, I'm going to ask you a weird question. I promise it's relevant. And then I pull up the Bristol stool chart and I say, give me a range like where do your poops normally fall within this Bristol stool chart? Looking at that to see, we want to see around that three or four that are relatively normal. But if it's above or below that, we're thinking, what does diet and hydration look like? And that may lead us into more questions. How frequently are we having a bowel movement? Is it every one to three days? Because that's normal. Or is it six times a day or every six days? Those are not normal. And so we can dive into that. Do you feel like you have to strain really hard in order to have your bowel movement? We have evidence and plenty of it on straining to poop. And we need to be teaching people not to do that for their pelvic floor health. It's a very simple and effective intervention. Do you use a squatty potty or do you use something under your feet to bring your knees up higher than your hips? For most cases, that's going to dramatically improve the ability to go have a bowel movement. And that's really, really helpful. And again, is there any leaking, any anal incontinence that is, again, flatulence or potentially stool? All of these, again, are good questions to ask, even if they're not coming in with bowel problems for you to resolve. We want to go through this with them. And then vaginally, we're going to ask some questions as well. Do you have any pain with insertion? So that insertion could be anything from a tampon to a penis, sex toy, or speculum exams. Do you have any pain with that insertion? And asking, do you have any loss of air, especially with our active individuals who might be going upside down, whether that's in yoga, Pilates, CrossFit? Sometimes people can have loss of air or queefing. And we want to know about that because all of these things really paint a picture for us. Now, usually, this takes up quite a bit of time. I mean, I've been talking about what questions to ask for the last 10 minutes with absolutely no answers behind them. So this typically is a really good starting point and often is the vast majority of my first virtual pelvic floor assessment. However, I like to leave time for a few more questions and then getting into education as my trial treatment. So the few other questions that we always want to know is what is exercise or movement look like, how is sleep, and what do you do for stress management? Some of these questions you can ask in your intake paperwork. You may want to go over that with them as well. But looking at them as a whole person and looking at their pelvic floor issues as a whole. And then from here, we do trial treatments as education. So depending on how they answer any of these questions, typically, and it's beyond the scope of this podcast to really talk about various education pieces for each of those questions, but I'm going to educate and I'm going to intervene. So maybe that is let's start hydrating. Get yourself a favorite water bottle and I actually want you to hydrate. Or potentially it's the opposite if they're over hydrating. Maybe it's can we decrease that intake throughout the day or right before bed? Maybe it's get a squatty potty or get your toddler's stool that's right in front of the sink and slide that under your feet for when you need to have bowel movement. Going back to our initial example of the leaking with double unders, perhaps it is I want you to video yourself doing double unders from the side view and the front view and send it back to me. But between now and then, I want you to make sure that we are videoing it at the end of you're having that leaking. And after we get that, I'm going to have you take more rest breaks if that's what they need. Or maybe it's go into your single unders since double unders are always causing leaking and throughout our plan of care, we are going to dive into that. I try to find some piece of education and something that we know will help them resolve a little bit of their issue and get us rolling with this. We talk about it in our live course, but we have good evidence for education actually improving pelvic floor symptoms. And I think there's no better place to really feel that as a practitioner to feel the difference in the amount of education that you can provide and the amount of change that can occur. There's no better place than in this virtual care where truly we are guides. I can do nothing with my hands. I can do nothing with my body to change how that individual is functioning. I purely have to use my voice and teach and ask questions. If you have not done virtual pelvic floor care, I would highly recommend it. It has made me a much better physical therapist altogether, much better at asking these questions and getting the information that I need. And it blends into both worlds, both virtual and in person. So if you haven't done it, I highly recommend getting some patients in that virtual care because it can be really helpful. That needs to be all for today. I have a lot more that I could say, especially if we dive into the objective exam and how to do that. But I think that's going to need to be a podcast part two for virtual care. So I will do that the next time I hop on to the daily show and talk with you all about how we do objective exams for pelvic floor virtual PT. Thank you all so much for joining me and listening in this Monday morning. Or if you're listening later on the podcast, thank you for listening. One quick note, it is CrossFit Games Week and we are so, so excited to be cheering on our very own Kelly Bimpy at the Games with her team this year. So tune in to the Games. If you're going to be there, let us know. There's several of us ICE faculty that are going to be at the Games. We would love to see you and say hello. And I don't know, maybe we can snag a workout in or something. But we are so excited. It is Games Week. Have an awesome week. Hopefully we'll see you up north. If not, catch you later. Have a good one. 19:26 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.    

GREAT question from one of my clients on ShonaStrong Mums. What is the best way to breath during heavy lifts? Advice from her Coach and her Pelvic Floor Physio seemed conflicted, so what's the answer? @shonastrong www.shonastrong.com

TBM EPI 2: When a woman gets pregnant, there's a lot of well-meaning advice. They can be told to not lift over 20 lbs, to not lift on their back or exercise on their back, to not hold their breath while lifting. Christina has published (with her research team) the ONLY study that has looked at women that did heavy strength training during their pregnancies on outcomes. In this episode, Christina talks about common myths, where these myths come from and what the research ACTUALLY says. She then goes on to help you talk to your midwife or obstetrician if they are giving you some of these recommendations. Strength training is unbelievably beneficial for pregnant mamas and we want to be ENCOURAGING getting stronger ___________________________________________________________________________Don't miss out on any of the TEA coming out of the Barbell Mamas by subscribing to our newsletter You can also follow us on Instagram and YouTube for all the up-to-date information you need about pelvic health and female athletes. Interested in our programs? Check us out here!

Kathe Wallace and I talk about:How intra abdominal pressure occurs functionally and translates over into meaningful tasks. What's the difference between the Valsalva maneuver and the bear down maneuver. Kathe mentions, "airdown as you bear down."The Pelvic Floor excursion --- contract, lift and releaseWhere Kathe puts her hands and then asks her clients to put their hands for enhanced interoception?Telling clients how to learn vs giving them a functional taskPosture as a reflection of our beliefs and our moodHow Kathe uses a flexible ruler The foot and the pelvic floor relationship -- what??!!!How Kathe explains the concept of a 360 approach of breathing to clientsKathe shares about the future of pelvic healthHow to find Kathe:Her Website- (KatheWallace.com)InstagramHer Pressure, Posture, Pulls and Performance courseOT Pioneers: Intro to Pelvic Floor Therapy for Occupational Therapists opens April 24-28, 2023. I would love to be support you!   

In this episode, I sit down with fellow physiotherapist, Brittany Klingmann to discuss: Various messages that people hear regarding weight lifting and the pelvic floor:“Weightlifting causes too much pressure on the pelvic floor”“Weightlifting causes prolapse”“Valsalva should be avoided and you should always exhale when you lift”“Weight lifting is too hard on the pelvic floor and that is why you leak”Brittany's personal journey with CrossFit and weightliftingThe use of weightlifting beltsTips for people who want to progress to liftingA recent study published by Christina Prevett et al ‘Impact of Heavy Resistance Training on Pregnancy and Postpartum Health Outcomes' Brittany is an Orthopaedic and Pelvic Health Physiotherapist who has now been practicing for 12 years.  She currently lives in Halifax, NS and works at Young Kempt Physiotherapy. Although her caseload remains very diverse, a growing percentage is dedicated to Pelvic Health and an athletic population participating in CrossFit and Olympic Weightlifting.   As a mother of 2 beautiful babies who came into the world by c-sections she has experienced her unique journey and challenges with regards to returning to fitness and heavy lifting postpartum, and with that lived experience a passion for helping individuals navigating  their desire to participated in the sports or activities they love evolved. Brittany has the wonderful opportunity to blend the worlds of orthopedics and pelvic health by working with clients through our satellite clinic at Ironstone Strength and Conditioning. Outside of the clinic, I love to spend time with my husband and two children. We are always up for an outdoor adventure. She also has developed a love and passion for Olympic Weightlifting and in the fall of 2022 she met the qualifying standard for the World Masters Weightlifting Championships. She plans to make her international competition debut this Summer in Krakow, Poland, representing Canada at the World Masters Weightlifting Championships. Links to contact Brittany: Website: www.youngkemptphysiotherapy.com Instagram Mentioned in the episode: Prevett et al: Impact of Heavy Resistance Training On Pregnancy and Postpartum Health Outcomes - https://pubmed.ncbi.nlm.nih.gov/36331580/13. CrossFit and weightlifting during pregnancy and postpartum with Brittany Klingmann Thanks for joining me! Here is where you can find out how to work with me:  mommyberries.comSupport the show

This week, please join author Milind Desai and Associate Editor Mark Link as they discuss the article "Dose-Blinded Myosin Inhibition in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy: Outcomes Through 32 Weeks." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr Greg Hundley, Associate Editor, Director of the Poly Heart Center at VCU Health in Richmond, Virginia.  Dr. Carolyn Lam: Oh, Greg. Today's feature paper is just so, so important. It's the long-term follow up or the longer term follow up of the VALOR-HCM trial. And this, if I can remind you, examined the effect of mavacampten on the need for septal reduction therapy in patients with intractable symptoms from obstructive hypertrophic cardiomyopathy. So we're going to hear the results through 32 weeks, but not until we discuss the other papers in today's issue. And I'd like to go first. I'd like to tell you about a paper that really provides the foundation for deciphering chamber selective gene transcription. So in this study from Dr. William Pu of Boston Children's Hospital and colleagues, authors mapped the chromatin features of atrial and ventricular cardiomyocytes and nominated candidate chamber selective enhancers based on differential features. The candidate enhancers were tested in vivo using adeno associated virus delivered massively parallel reporter assay leading to identification of 229 chamber selective enhancers. They then characterized chromatin features of these chamber selective enhancers and used dense mutagenesis to identify their essential features. Altogether the study suggested that estrogen-related receptor promoted ventricular chamber selective enhancer activity. They validated this prediction by showing that estrogen-related receptor inactivation led to loss of ventricular cardiomyocyte identity. So in aggregate, the studies yielded a rich resource of chamber selective chromatin features and chamber selective enhancers, and began to unravel the molecular basis for chamber selective transcriptional programs. Dr. Greg Hundley: Wow. So Carolyn, estrogen-related receptor promotion and then inactivation and finding really very interested preclinical results. So tell us now what are the clinical implications of this very nice study.  Dr. Carolyn Lam: Wow. I mean, there are just so many implications. It can facilitate functional interpretation of genetic associations between variants and cardiac disease. Of course, it opens the doors to potential gene therapies and regenerative medicine and finally, identification of transcription regulators of the chamber identity really yield important mechanistic insights into the pathogenesis of important diseases like atrial fibrillation and cardiomyopathy. Dr. Greg Hundley: Wow, Carolyn, beautifully summarized. Well, my next paper pertains to COVID vaccines. So Carolyn, as we have seen SARS-CoV-2 targeted mRNA vaccines are a life-saving medical advancement developed to combat, of course, the COVID-19 pandemic. But in rare cases, some individuals can develop myocarditis following these mRNA vaccinations. Cases of adolescents and young adults developing post vaccine myocarditis have been reported globally, although the underlying immuno profiles of these individuals, they really haven't been described in detail. So these authors led by Dr. Lael Yonker from Massachusetts General Hospital, performed extensive system serology SARS-CoV-2 specific T-cell analysis and cytokine and SARS-CoV-2 antigen profiling on blood samples collected from adolescents and young adults either developed myocarditis or were asymptomatic following SARS-CoV-2 targeted mRNA vaccination.  Dr. Carolyn Lam: Wow. Wow. Important question. Everyone's interested in the results. So what did they find? Dr. Greg Hundley: Right, Carolyn. So 16 cases with post vaccine myocarditis and 45 asymptomatic vaccinated controls were enrolled with extensive antibodies profiling, including assessment for autoantibodies or antibodies against the human relevant virome. And Carolyn, they found that T-cell responses were essentially indistinguishable from controls despite a modest increase in cytokine production. Notably, markedly elevated levels of full length spike protein unbound by antibodies were detected in the plasma of individuals with post vaccine myocarditis, a finding that was absent. It was absent in the asymptomatic vaccinated controls. So Carolyn, in conclusion, immunoprofiling of vaccinated adolescents and young adults revealed that the mRNA vaccine-induced immune responses did not differ between individuals that developed myocarditis versus individuals that did not. However, free spike antigen was detected in the blood of adolescents and young adults who developed post mRNA vaccine myocarditis. Now while this finding does not alter the risk benefit ratio favoring vaccination against COVID-19 to prevent severe clinical outcomes, it may provide some insight into the potential underlying etiology associated with post mRNA vaccine-induced myocarditis. Carolyn, this is accompanied by a wonderful editorial by Dr. Biykem Bozkurt indicating that these results raise a question as to why the circulating spike protein levels remain elevated despite adequate levels and functionality of the anti-spike antibodies. Well, Carolyn, we do have some other articles in the issue and from the mailbag we have a research letter from Professor Cho entitled PERM1 Protects the Heart From Pressure Overload Induced Dysfunction by Promoting Oxidative Metabolism. Also, there's a new drugs and devices piece from Professor Kabatano entitled Pharmacology and Clinical Development of Factor XI inhibitors. And then Tracy Hansen has a wonderful cardiology news summary regarding articles entitled The Study Reveals Rapid Intestinal Adaptations after Switching to High Fat Diet From Cell Research. Another article entitled New Insights into Immunotherapy Related Myocarditis from Nature. And finally, an article entitled Scientist Identified Genetic Variants Linked to Longevity published in the Journal of Science.  Dr. Carolyn Lam: Wow. Interesting. There's also an exchange of letters between Drs. Monzo and Shah regarding the article, “Metabolomic Profiling of Effects of Dapagliflozin in Heart Failure with Reduced Ejection Fraction.” That is a Perspective piece by Dr. Davenport on contrast induced acute kidney injury and cardiovascular imaging, danger or distraction? Wow. What a beautiful issue. Thank you so much, Greg. Let's go to our feature discussion, shall we? Dr. Greg Hundley: Absolutely. Welcome, listeners, to this feature discussion on March 14th. And we have with us today Dr. Milind Desai from Cleveland Clinic in Cleveland, Ohio, and our own associate editor, Dr. Mark Link from University of Texas Southwestern Medical Center in Dallas, Texas. Welcome, gentlemen, Milind, we'll begin with you and bringing to us this study of mavacampten. Can you describe for us some of the background information that went into the preparation of this study, and what was the hypothesis that you wanted to address? Dr. Milind Desai: Thank you to the editorial staff, Dr. Hundley and the editorial staff at Circulation. So yes, mavacampten, as we know, is a novel first in class cardiac myocin inhibitor that was developed in the context of managing patients with hypertrophic obstructive cardiomyopathy. So the preliminary early stage studies have shown that it helped significantly in reducing outflow tract gradients as well as improved symptoms. But we wanted to take the conversation a bit further. In highly symptomatic patients, the current standard of care treatment is septal reduction therapy, which requires an experienced center and an experienced set of providers. So what we wanted to see was in such patients that are referred for septal reduction therapy, what does mavacampten do versus placebo? So does it reduce the need for septal reduction therapy? We divided the study into three parts. The first part was the placebo controlled 16 week study. The second part was we wanted to see what happens when the placebo arm crossed over to mavacampten and the mavacampten arm continued long-term. And that was the genesis of the study that we are discussing today. Dr. Greg Hundley: Very nice. So we've got a planned study, patients with hypertrophic cardiomyopathy, they ordinarily, because of guideline related therapeutic recommendations would undergo septal reduction therapy, but before that you're going to randomize patients to mavacampten versus a placebo. So we've sort of described a little bit the study design, and let's clarify specifically perhaps the study population and how many patients did you enroll? Dr. Milind Desai: Yes. In the original study, we enrolled 112 patients, 56 to mavacampten and 56 to placebo. After week 16, four patients, two of which underwent SRT and two withdrew consent. So essentially for the 32 week analysis, we had 108 patients, 56 in the mavacampten group and 52 in the placebo group that crossed over to mavacampten. So 108 patients. Dr. Greg Hundley: Very nice. So Milind, what were your study results? Dr. Milind Desai: Yes. What we found was at week 16, we have previously demonstrated that the group that got randomized mavacampten had a significant reduction in outflow tract radius, both resting and Valsalva, as well as biomarkers. And at week 16, what we found was 82% patients from the original group did not meet criteria for septal reduction therapy. So a hundred percent to begin with, 82%, that was at week 16. What we wanted to see, is the effect continued longer lasting and what happens to the placebo group that crossed over? So essentially what we found was at week 32, 89% of the total population no longer met criteria for septal reduction therapy. In addition to that, the mavacampten group continued to have reduced outflow tract gradients, continued improvement in Kansas City Score as well as biomarkers. But more importantly, the similar findings were demonstrated in the placebo arm that cross over to the mavacampten where, again, a significant proportion continued to show improvement in outflow tract gradient, Kansas City Score, as well as biomarker. The important point here in this study was at week 32, 95% patients chose to remain on medical therapy as opposed to going for SRT. Remember, a hundred percent patients were referred at the outset to undergo SRT. Dr. Greg Hundley: And Milind, did you notice any differences in your study results based on the age of the patients or based on their sex? Dr. Milind Desai: No, actually, we did not. This had a beneficial effect across gender, age, all the other variables. In fact, this is one of the strengths of the study because almost 50% patients that were randomized were women. So this was well represented across different genders. Dr. Greg Hundley: And then you mentioned a marked reduction in the gradient across the left ventricular outflow tract. What about the patient's symptomatology? Did you notice differences there? Dr. Milind Desai: There were significant improvement in patient symptomatology. More than 70% patients had a improvement in one NYHA class, 30% or thereabouts had a significant improvement in two NYHA class compared to placebo. So yes, there was a significant improvement in their functional capacity. Dr. Greg Hundley: And then last question, hypertrophic cardiomyopathy. Were most of these patients, was this concentric? Was this asymmetric septal hypertrophy? What was the breakdown, if you will, of the morphology of the left ventricles? Dr. Milind Desai: The vast majority of the patients had asymmetric septal hypertrophy, the characteristic with dynamic outflow tract gradient. There were some patients, but the vast majority of them were asymmetric septal hypertrophy. Dr. Greg Hundley: Very nice. Well, listeners, we're going to turn to our associate editor, Dr. Mark Link. Mark, this really sounds striking, randomized clinical trial, patients needing septal reduction therapy. They're randomized. The group randomized to mavacampten has marked reductions in left ventricular outflow tract gradient, symptomatology, and so much so that they no longer met the criteria for septal reduction therapy. I know you have a lot of papers come across your desk. Can you help us put what seemingly are exciting results into the context of other studies pertaining to mavacampten as well as treatment for patients with symptomatic hypertrophic cardiomyopathy? Dr. Mark Link: Yeah. There are very few randomized studies in patients with hypertrophic cardiomyopathy, probably only two that I know of. And mavacampten is a very exciting new drug that's a novel drug, a novel mechanism and has the potential to really improve life for our patients with hypertrophic cardiomyopathy. So this is a longer term study of mavacampten that's ever been published. So yeah, it was very exciting for us to look at this data to see how the patients did and we were very, very pleased to publish this paper. Dr. Greg Hundley: Very nice. So maybe, Milind, turn this back to you. What do you think are some of the next studies that'll be performed really in this arena of research? Dr. Milind Desai: Yes. Obviously, as Mark pointed out, this was one of the longest term studies, but we need to do a lot longer. So long term extension studies are ongoing. We should be evaluating one year outcomes in this specific population as well as longer, number one. Number two, I think in the grand scheme of things, this is a brand new class. So overall it is obviously now FDA approved and post-marketing survey and analysis should help us see a signal in terms of outcomes, mortality, et cetera. In your sister journal Circulation Imaging, we have simultaneously also published that mavacampten is causing a significant improvement in the structural changes like diastolic dysfunction, like LV mass, LA volume index. So we need to see how that plays out. Another important piece is about 30% patients have non-obstructive hypertrophic cardiomyopathy and there's no real treatment for this group and there's no outflow tract obstruction to cure in this. So we have just recently launched and started to randomize ODYSSEY HCM trial, which is checking the role of mavacampten versus placebo in non-obstructive HCM group. And I am fortunate. So it's a multi-centered trial that is being led out of Cleveland Clinic. So more data in that exciting field. But overall, this entire field of hypertrophic cardiomyopathies is exploding with multiple randomized controlled trials. There's another drug that is being tested in phase three trials, cardiac myocin inhibition. So that story also remains to see how that plays out. So a lot of stuff that is happening in this space. And then now there's gene therapy emerging. Dr. Greg Hundley: Right. And Milind, since you have quite extensive experience here, for our listeners, what side effect profiles have you observed in some of these patients? And if someone is considering working with placing a patient on this therapy, what are some of the considerations that they should be thinking about? Dr. Milind Desai: So that's a very important question. So the drug, as you are aware, was approved by the FDA under the REMS or Risk Evaluation Mitigation Strategy program. So the fundamental thing is both the patient and the physician have to sign up for the REMS program. The biggest issue that FDA wants us to be careful about is this is a cardiac myosin inhibitor. So it means we have to be very careful about over inhibition of the cardiac myosin and a drop in ejection fraction and its downstream ramifications including heart failure. The other aspect is drug-drug interaction because of its pathway of metabolism. So these are the two key things we have to be on the careful about. Now you asked my clinical experience. So we have been prescribing this for almost six, seven months, and we have dozens of patients on this using the REMS strategy, careful echocardiographic monitoring and clinical decision making. So far, we have been very successfully able to navigate these patients without any major adverse events. And the vast majority of the patients, true to form as we have shown in the clinical trial, are doing very, very well in terms of their symptoms, their need for SRT, as well as their markers, including outflow tract gradient. Dr. Greg Hundley: Very nice. And Mark, turning to you from the perspective of an electrophysiologist, what potential future studies do you see forming in this space? Dr. Mark Link: Yeah, very similar to Milind. And I think the long term efficacy and safety really has to be looked at. There's a signal for potential harm in that the EF can drop, and Milind mentioned that too, that we have to learn how to deal with that. The way to prescribe it now, you have to be in a special program. You have to be trained, you have to agree to get echoes every three months, I believe it is, essentially for the rest of their life. So we need to see what happens long term with these drugs and we need to know how to dose them and how to do it safely. Dr. Greg Hundley: Very nice. So for our listeners, really a class of drugs that is emerging and at this time only under really strictly supervise protocols. Well, from the perspective of our listeners, we want to thank Dr. Milind Desai and our own associate editor, Dr. Mark Link, for bringing us this informative new early randomized trial study results indicating that in severely symptomatic patients with obstructive hypertrophic cardiomyopathy, 32 weeks of mavacampten treatment showed sustained reduction in the proportion proceeding to septal reduction therapy. Well, on behalf of Petter, Carolyn and myself, we want to wish you a great week and we will catch you next week on The Run. This program is copyright of the American Heart Association, 2023. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

Hoy hablo con Domingo Sánchez, licenciado en Ciencias de la Actividad Física y con una amplia experiencia en el diseño de programas de entrenamiento. Algunos de los temas que tocamos: - ¿Qué es realmente el core? - Anatomía y función del core y los abdominales. - Ejercicios básicos para entrenar el core. - Hipopresivos, maniobra de Valsalva y otras técnicas. - Mejores equipamientos para entrenar los abdominales. - Cómo incluir el core en nuestros entrenamientos. - Cómo lograr abdominales visibles (six-pack). - Y mucho más. Para conocer más el trabajo de Domingo visita su web e Instagram. Como siempre, puedes escuchar también el episodio en iVoox, Spotify  y Apple Podcast. Apúntate a la segunda edición del curso de Nutrición Deportiva de Perform Institute aquí: https://www.fitnessrevolucionario.com/perform

Contributor: Jared Scott, MD Educational Pearls: Two conventional ways to aid in external jugular vein (EJ) catheter placement are Trendelenburg's position and Valsalva's maneuver by patient  One study compared ultrasound visualization of cross sections of EJ and common femoral vein at baseline and with patients in Trendelenburg's position, Valsalva's maneuver, and while humming The study found all three conditions distended the veins from baseline, but there was no significant difference in diameter between the conditions   Humming may be a viable technique in distended EJ for catheter placement, and may be easier for patients to comprehend than Valsalva    References Lewin MR, Stein J, Wang R, et al. Humming is as effective as Valsalva's maneuver and Trendelenburg's position for ultrasonographic visualization of the jugular venous system and common femoral veins. Ann Emerg Med. 2007;50(1):73-77. doi:10.1016/j.annemergmed.2007.01.024   Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD   In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Do you even lift?Yeah, & I can help you too!I had the pleasure of catching up with the dynamic duo of PT's @alexismorganpt & @christina_prevettBoth are physios who work with postpartum women & female athletes. Both women are barbell athletes themselves. Christina helps female athletes maximize fitness potential with online programming for pregnant & postpartum CrossFitters & weightlifters via @thebarbellmamas & Alexis practices within @onwardtnptThese postpartum education rockstars also teach other rehab pros to do the same via @icephysio courses. Christina & Alexis are leading the charge to teach and inform moms & pros alike, that women can come back to the barbell postpartum & be even stronger! We talk about using the research to inform our practice instead of letting the research limit what we do, and why the line is so fine. We dispel common myths and set the record straight on the what is really possible for female athletes postpartum!We talk about: 

There's a lot of fear around Valsalva, especially in the geriatric space. In todays episode, Christina goes over

Christina Prevett // #GeriOnICE // www.ptonice.com 

Welcome to the newest Discover Strength Podcast Mini-Series where we will focus on 12 things we think are essential to getting better results from your workouts in less time. Join us as we go deeper on each topic in a format that's perfect for sharing and broadening your own knowledge. Thanks for joining us, and please enjoy this week's episode on the Valsalva maneuver.Picture this: you're working out, the exercise is getting harder, so you get ready to push and hold your breath. That, right there, is the Valsalva maneuver. When you perform the Valsalva maneuver, a couple of things are happening, mainly involving internal pressure build-up. When you hold your breath while exerting force in an exercise, you build pressure in your lungs (intrathoracic pressure) and head (intracranial pressure), as well as a spike in blood pressure. You are, in fact, able to produce slightly more effort and force while performing the Valsalva maneuver. However, the problems associated with that extra force (increased lung, head, and blood pressure) lead us to recommend avoiding holding your breath during a workout.Throughout a workout, your respiratory needs will change. At the beginning of a set, you may not need to breathe very hard or frequently. As you continue through the workout, you will most likely feel the urge to hold your breath, to perform a Valsalva maneuver. This is precisely when you should incorporate short, frequent breaths (instead of holding your breath). This will avoid all of the pressure increases that come from the Valsalva maneuver, and will leave you performing and feeling better.Hear Logan and David go deep on this topic by listening to this week's podcast mini-series episode today.If you or someone you know is interested in trying out a FREE Discover Strength Introductory workout, please send them our way!Send any inquiries HERE to get scheduled for a FREE Introductory Session today to take the first step towards getting your life back.

In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Seilesh Babu discuss Eustachian tube dysfunction and balloon dilation as a therapeutic option. --- CHECK OUT OUR SPONSOR Acclarent https://www.jnjmedtech.com/en-US/companies/acclarent --- SHOW NOTES First, Dr. Babu provides background on Eustachian tube dysfunction. In kids and adults, Eustachian tube dysfunction can present as a sensation of “ear fullness”, recurrent fluid in the ear, or discomfort with pressure challenges, such as flying or scuba diving. Medical management involves nasal steroids, allergy medications, anti-reflux medications, avoidance of allergens, and doing a modified Valsalva maneuver at home. Additionally, ear tubes and balloon dilation are procedural options. Next, Dr. Babu explains his workup for Eustachian tube dysfunction patients. He takes a thorough patient history and examines the patient's tympanic membrane, nasopharynx, and serous outflow using a flexible scope. He orders an audiogram for all of his patients but notes that tympanograms are not as critical. For patients with discomfort during pressure challenges, he will consider doing a balloon dilation or placing an ear tube. For patients presenting with “ear fullness”, a more in-depth examination must be done through a trial tympanostomy tube or a myringotomy. He also looks for red flags, which indicate Eustachian tube dysfunction may not be the correct etiology for their ear symptoms. These red flags include: aggravation of symptoms upon tube insertion, symptoms of dizziness and vertigo, autophony, and pulsatile tinnitus. Although it is rare, a diagnosis of Patulous Eustachian tube dysfunction must be considered. If the patient does not have these red flags and has had multiple ear tubes without symptom relief, they may be a good candidate for balloon dilation. Dr. Babu then delineates his procedure for a Eustachian tube balloon dilation. He performs this procedure in the OR using the Acclarent AERA Eustachian tube dilation system. He inflates the balloon to achieve a pressure of 12 atm, keeps it dilated for 2 minutes, then removes the instrument. Some procedural pearls he shares are: putting the scope and balloon in at the same time to minimize bleeding in the nasopharynx and guiding the instruments in a lateral direction towards the external ear canal. He usually waits 2-3 weeks before reassessing the patient for recurrent symptoms. Upon discharge, he encourages patients to avoid nose blowing and Valsalva maneuvers, as these actions can cause a pneumothorax or pneumomediastinum. Common postoperative symptoms include minor nose bleeds and the sensation of a sore throat. Dr. Babu usually performs the balloon dilation in conjunction with other OR procedures, such as myringotomies and tympanoplasties, for efficacy. Finally, the doctors discuss the specifics of billing for the Eustachian tube dilation procedure. In recent years, a specific billing code has been assigned for balloon dilation, and insurance companies are beginning to authorize this procedure for a variety of patients. Devices discussed in this podcast are currently available in the US only. Acclarent, Inc. 223616-220810 --- RESOURCES Acclarent: https://www.jnjmedtech.com/en-US/companies/acclarent AERA® Esutachian Tube Balloon Dilation System: https://www.jnjmedtech.com/en-US/product/Acclarent-aera-eustachian-tube-balloon-dilation-system Howard, A., Babu, S., Haupert, M., & Thottam, P. J. (2021). Balloon Eustachian Tuboplasty in Pediatric Patients: Is it Safe?. The Laryngoscope, 131(7), 1657–1662. https://doi.org/10.1002/lary.29241

Have you ever focused on how you breathe during exercise? For some people, it's the last thing that comes to mind, especially when lifting weights. But is there a best practice for breathing while resistance training? There are many strategies out there, some that even involve not breathing (Valsalva maneuver). The goal of breathing (or not breathing) is to increase intra-thoracic pressure (pressure around the spine) to best maintain posture & technique during the movement. With that, pressure around your heart & throughout the cardiovascular system will be affected. You may have even noticed feeling light-headed or left with a headache post workout. I bet your breathing may be the culprit. So, tune in for some of my best breathing strategies for resistance training, as well as a way to improve your breathing in general.

Guest Panelist: Dr. Jan Fritz, Musculoskeletal Imaging specialist, NYU Langone, New York City, NY.This week, the topic of discussion was: Ultrasound CT Scan MRI MR neurography Nerve Block Nerve Imaging Chronic Pain Scar Tissue Nerve Entrapment Cryoablation Imaging SafetyIV Contrast Oral Contrast Valsalva Imaging of Mesh Adhesions Neuroma Image Guided Injections Pudendal NeuralgiaHerniaTalk LIVE is a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.If you find this content informative, please LIKE, SHARE, and SUBSCRIBE to the HerniaTalk Live channel and visit us on www.HerniaTalk.com.Follow Dr. Towfigh on the following platforms:Youtube | Facebook | Instagram | Twitter

Episode 83: Solitary Rectal Ulcer. Dr Singh explains how we can diagnose and treat solitary rectal ulcer syndrome (SURS) and Brandy gave an introduction regarding Elvis Presley's death.  Introduction: Did Elvis Die Pooping?By Brandy Truong, MS4, Ross University School of Medicine. A pop culture trivia fact I always found interesting was that Elvis Presley may have died from trying to have a bowel movement. There are different statements on the cause of death ranging from cardiac arrest, drug overdose, anaphylactic shock, and straining to have a bowel movement. But we're not here to figure out which one is accurate or debate all that. Elvis was found in the bathroom on the floor and many people described it as if he was on the toilet and then fell forward. If he died from pooping, how does that even happen? We're going to explore that a little.When we strain to have a bowel movement, it's called the Valsalva maneuver. This maneuver is divided into 4 stages. Phase 1 is when one first starts straining or bears down. This causes an increase in chest pressure and blood being forced out from the large veins. This is reflected in a rise in blood pressure and a decrease in heart rate. In phase 2, there is reduced venous return to the heart because the blood was forced out of the large veins. Because there is less return to the heart, the heart doesn't pump out as much as it normally would which leads to a fall in blood pressure. The body senses this fall in blood pressure and will compensate by increasing the heart rate significantly. Phase 3 is when one stops bearing down which results in a release of chest pressure. This causes a fall in blood pressure which causes the heart rate to increase as a reflex. In phase 4, the decreased venous return seen in phase 2 is now restored, which causes an increase in blood pressure. The heart rate then decreases as a reflex response. Both blood pressure and heart rate will return to normal. This entire process occurs over a span of a little over 10 seconds.Elvis was known to have a drug addiction and later some doctors found that he had hypertrophic cardiomyopathy which is a condition in which the heart is unable to pump blood well. He abused a variety of pain medications including opioids. Opioids often cause constipation; therefore, if Elvis was constipated and straining, the Valsalva maneuver compounded by heart disease and other unhealthy lifestyles he had would have caused his cardiac arrest. Intense straining during the process of defecation can result in subarachnoid hemorrhage in people with congenital berry aneurysms, for example. If you end up googling to find out how Elvis died, let us know what you think and if you think he died from pooping. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.   Solitary Rectal Ulcer Syndrome.  By Parneeta Singh, MD, Ross University School of Medicine. Discussed with Hector Arreaza, MD.Solitary Rectal Ulcer Syndrome (SRUS) is a benign, rare, underdiagnosed disorder that can mimic and be incorrectly diagnosed as inflammatory bowel disease (IBD) or rectal cancer. The exact prevalence is unknown but in general, it is reported as an annual prevalence of one in 100,000 people. It mostly occurs in the third decade in men and fourth decade in women, with men and women being equally affected. However, cases have been identified in the pediatric and geriatric populations as well. SRUS is a misnomer because although some patients may present with a solitary ulcer, many present with multiple ulcers that may also involve the sigmoid colon. Presentation. Rectal bleeding (with the amount varying from a little fresh blood to severe hemorrhage that may require blood transfusions), mucus discharge, excessive straining, abdominal and perineal pain, constipation, or diarrhea, feeling of incomplete defecation, tenesmus, and rarely rectal prolapse are clinical symptoms associated with SRUS. Presentation may resemble intestinal parasites such as Entamoeba histolytica (amebiasis) and Enterobius vermicularis (pinworm).The underlying etiology is unknown, but a number of mechanisms have been suggested including ischemic injury from the pressure of impacted fecal matter and local trauma due to repetitive self-digitation, although the latter remains unproven. Ulcers usually occur in the mid-rectum which cannot be reached by self-digitation. Additionally, it has been proposed that the perineum's descent along with the abnormal contraction of the puborectalis muscle during defecation results in trauma or a prolapsed rectum with mucosal prolapse being the most common underlying pathogenesis in SRUS. Diagnosis. The diagnosis of SRUS is based on clinical features and proctosigmoidoscopy findings, with histological examination and biopsies being the key to the diagnosis. Imaging studies including defecating proctography, dynamic MRI and anorectal functional studies also aid in the diagnosis with the latter showing that 25% to 82% of SRUS patients have dyssynergia with paradoxical anal contraction. A thorough evaluation is important in ruling out IBD, ischemic colitis, and malignancy.Histology evaluation of biopsy establishes the diagnosis of solitary rectal ulcer syndrome. Findings include fibromuscular obliteration of the lamina propria. This obliteration causes hypertrophy and disorganization of the muscularis mucosa and regenerative changes. There is an abnormal crypt organization. In cases were polypoid lesions are prevalent, the mucosa has a villiform configuration, and in some cases, the glands may be trapped in the submucosa, which is called colitis cystica profunda.Treatments.Various treatment options are available for SRUS with the treatment choice depending on symptom severity and the presence of rectal prolapse. The initial steps, especially in asymptomatic patients, include patient education and behavioral modifications which include a high-fiber diet, straining discontinuation, and a discussion of psychosocial factors. Biofeedback is the next step in those who fail to respond to conservative measures. Biofeedback seems to help by altering efferent autonomic pathways to the gut that reduces straining with defecation by correcting abnormal pelvic-floor behavior. Topical treatments used include corticosteroids, salicylate, sulfasalazine, mesalazine, sucralfate suppositories and topical fibrin sealant. Unfortunately, surgery is necessary in almost one-third of adults with associated rectal prolapse who do not respond to the above treatment options. Surgical treatments include ulcer excision, treatment of internal or overt rectal prolapse, and de-functioning colostomy. Open rectopexy and mucosal resection have shown a success rate of 42% to 100%. In conclusion, SRUS is an uncommon disease that can mimic IBD and rectal cancer. Thus, a thorough and complete patient history and work-up is required to accurately diagnose SRUS, following which patient education, reassurance that the lesion is benign and a conservative, stepwise individualized approach is important in the management of this syndrome.Conclusion: Now we conclude our episode number 83 “Solitary Rectal Ulcer.” Rectal bleeding, constipation, diarrhea, abdominal pain… yes, it sounds like Chron's syndrome, but your list of differentials may be very long. You may want to add to that list Single Rectal Ulcer Syndrome. The treatment goes beyond medications for inflammation and includes pelvic floor training. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Brandy Truong, and Parneeta Singh. Audio edition: Suraj Amrutia. See you next week! _____________________References:“Elvis Presley.” Wikipedia, Wikimedia Foundation, 21 Jan. 2022, https://en.wikipedia.org/wiki/Elvis_Presley#Cause_of_death.  Markel, Dr. Howard. “Elvis' Addiction Was The Perfect Prescription for an Early Death.” PBS, Public Broadcasting Service, 16 Aug. 2018, https://www.pbs.org/newshour/health/elvis-addiction-was-the-perfect-prescription-for-an-early-death.   Srivastav, Shival. “Valsalva Maneuver.” StatPearls [Internet]., U.S. National Library of Medicine, 28 July 2021, www.ncbi.nlm.nih.gov/books/NBK537248/.  Zipes, Douglas. “Valsalva Maneuver.” Valsalva Maneuver - an Overview, ScienceDirect Topics, www.sciencedirect.com/topics/neuroscience/valsalva-maneuver . Qing-Chao Zhu, Rong-Rong Shen, Huan-Long, Yu Wang. Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis, and treatment strategies. World J Gastroenterology. 2014 Jan 21; 20(3): 738–744. doi: 10.3748/wjg.v20.i3.738. PMID: 24574747; PMCID: PMC3921483. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921483/ Young Min Choi, Hyun Joo Song, Min Jung Kim, Weon Young Chang, Bong Soo Kim, Chang Lim Hyun. Solitary Rectal Ulcer Syndrome Mimicking Rectal Cancer. The Ewha Medical Journal. 2016 Jan 29; 39(1): 28-31. doi: https://doi.org/10.12771/emj.2016.39.1.28. Department of Internal Medicine, Surgery, Radiology and Pathology, Jeju National University School of Medicine, Jeju, Korea. https://synapse.koreamed.org/articles/1058669 Sachin B Ingle, Yogesh G Patle, Hemant G Murdeshwar, Chitra R Hinge Ingle. An unusual case of solitary rectal ulcer syndrome mimicking inflammatory bowel disease and malignancy. Arab J Gastroenterol. 2012 Jun 13(2):102. doi: 10.1016/j.ajg.2012.02.004. Epub 2012 Apr 11. Department of Pathology. PMID: 22980604. https://pubmed.ncbi.nlm.nih.gov/22980604/     

Commentary by Dr. Julia Grapsa

It's January and the snow is piling up in Saint John, NB, so what better time to share a few winter tips? Amy and Jeff are representing Canadians for this one, so have a listen and a few laughs. Stay safe and warm, friends!

Gościem dzisiejszego odcinka jest Tomek Nitka, który napisał książkę „Wyrównywanie ciśnienia we freedivingu i nurkowaniu sprzętowym". To zagadnienie jest o wiele ciekawsze i ma o wiele więcej niuansów, niż mógłbym się tego spodziewać - sprawdźcie, czym zaskoczył mnie Tomek! Poznajcie metody takie jak próba Vaslava, Frenzla i Mouthfill. Wysłuchaj odcinka!Poczytaj na: https://spodwody.pl/wyrownywanie-cisnienia-tomasz-nitka/

Dr. Ashley Agan sits down with the eustachian tube expert Dr. Dennis Poe to discuss his approach to management and treatment of eustachian tube dysfunction. --- CHECK OUT OUR SPONSOR Stryker ENT https://ent.stryker.com --- SHOW NOTES In this episode of BackTable ENT, Dr. Agan discusses eustachian tube disorders with Dr. Dennis Poe, professor of otolaryngology at Harvard Medical School. First, the doctors discuss the difference between the two main types of Eustachian tube disorders: obstructive dysfunctions and Patulous dysfunctions. Obstructive dysfunctions are a result of pathologies that cause inflamed or clogged Eustachian tubes, while Patulous dysfunctions are a result of the Eustachian tube remaining perpetually open. Obstructive and Patulous dysfunctions can be clinically differentiated. Patulous dysfunctions commonly experience extraordinary loud noises, variable pressure sensation, aural fullness, habitual sniffing, relief upon using the Valsalva maneuver, and autophony. Although autophony is not pathognomonic for Patulous dysfunction, it can give otolaryngologists a clue for a potential Patulous dysfunction diagnosis. Obstructive dysfunction patients commonly experience negative pressure in tympanic membrane, fluid in middle ear, scarring, and fixed retraction pockets. Otolaryngologists can also insert an endoscope through the nose to perform a physical examination on Eustachian tube disorder patients. Dr. Poe recommends that otolaryngologists obtain a longitudinal view of the Eustachian tube lumen to observe the cartilaginous and membranous walls and the quality of the valve. He recommends using the MEELO assessment (mucus production, erythema, edema, lymphoid hyperplasia, and opening quality) to grade Eustachian tube disorder patients on a scale of 1-4, with 4 being the most severe dysfunction. He cautions against using tympanograms for diagnoses because of their inaccuracy. Eustachian tube disorders can be treated with medication. Because the most common etiology of obstructive Eustachian tube disorder is allergic rhinitis, Dr. Poe starts with allergy testing to identify possible allergens. He notes that topical nasal steroids and nasal drops are effective, but may be difficult for patients to self-administer. For this reason, patient education is very important. If medications do not work after 6 weeks, Dr. Poe recommends performing a balloon dilation of the Eustachian tube. The length of balloon dilation depends on the MEELO grading scale. If obstructive Eustachian tube dysfunction patients are a grade 3 or 4 with moderate to severe inflammatory disease and a significantly compromised valve, he dilates for the full two minutes. If they are a grade 2 or low grade 3 with a lesser disease, he only dilates for one and a half minutes or even one minute. Because pediatric patients are very sensitive to balloons, he never goes above one and a half minutes in pediatric patients. Finally, he notes that Patulous Eustachian tube dysfunction patients can be surgically treated via a transtympanic tripod-shaped angiocatheter procedure. --- RESOURCES Eustachian Tube Disorder Questionnaire: https://earandsinusinstitute.com/online-questionnaires/etdq-7-questionnaire/ ​​ Xhance Nasal Spray: https://www.xhancehcp.com/

To watch this episode and other past episodes, please visit Rachel's YouTube channel. Listeners can find Dr. Zachary Long at his website thebarbellphysio.com and http://performanceplusprogramming.com, and on Instagram @thebarbellphysio and @performanceplusprogram Dr. Zachary Long is a physical therapist in Charlotte, North Carolina, and runs an industry-leading fitness website “The Barbell Physio” where he is a trusted resource to thousands of athletes, coaches, and health care professionals across the United States and beyond.  Additionally, Dr. Zach teaches with the Institute of Clinical Excellence in their “Fitness Athlete” division where he helps medical professionals better understand the needs of CrossFitters, powerlifters, and weightlifters. Zach is a Board Certified Sports Specialist, Level One CrossFit Trainer, NASM Performance Enhancement Specialist, and certified SFMA practitioner. In this episode, Dr. Zachary Long and I chat about some of the most common mistakes people make when it comes to injury rehab, misinformation surrounding squat depth and why squatting with your knees over your toes isn't an inherently “bad” thing, why (and how) CrossFit training can lead to muscle or hypertrophy gains, and much more! “Our goal should always be ‘how close can we be to our intended stimulus in the workout without slowing down the healing process.' And when we do that, we're going to be significantly better off in the long term.” Dr. Zachary Long Top Takeaways: Why resting is often the worst thing you can do when injured and what you should do instead. How CrossFit training can lead to muscle gains Benefits of using modalities such as lifting shoes or heel elevation, wrist straps, and weight belts. Squatting misconceptions & misinformation How to know if you should be stretching something vs. strengthening something Show Notes: [0:00] Intro to episode trailer  [0:30] Rachel gives a brief introduction of guest Dr. Zachary Long     [1:30] Welcome back to MetFlex and Chill! Rachel welcomes guest, Dr. Zachary Long, @thebarbellphysio to the listeners [2:00] Dr. Long gives an intro to himself and how he got into sports and physical therapy [3:30] Question: If it is not resting, what should we be focusing on instead when we get an injury? [7:00] Question: What other modifications aside from rest would you focus on? [8:30] “Our goal should always be - how close can we be to our intended stimulus in the workout without slowing down the healing process - And when we do that, we're going to be significantly better off in the long term.” Dr. Zachary Long [9:00] Question: Is there any validity to R.I.C.E? (Rest Ice Compression Elevation)  [11:00] Question: What are your thoughts on NSAIDs? [12:30] Question: How do you know if you should be stretching something versus strengthening something? [15:00] Question: Do you use foam rolling and massage therapy in your practice? [20:30] Question: Limiting factors in training - should we try to “fix” them or is it okay to use external ‘help' depending on the goal? [24:00] Question: In terms of squatting, is it okay if your knees travel over your toes? [32:30] Question: Can you chat about how lots of CrossFit athletes get super jacked?  [35:00] Question: Is there anything specific that you personally do with your clients to help with accessory movements that they might not be getting in a typical CrossFit workout? [39:30] Question: When is it beneficial to use a lifting belt?  [43:30] Valsalva maneuver  [44:30] Using external lifting tools depending on your goals  [46:30] Question: Is there anything you've changed your mind about in the past year, and why? [49:00] To check out more from Dr. Zachary Long at his website thebarbellphysio.com and http://performanceplusprogramming.com, and on Instagram @thebarbellphysio and @performanceplusprogram   [50:00] Thanks for listening to another episode! If you're loving MetFlex and Chill and want to help grow the show, please head over to Itunes and leave a rating and review! How to Leave an Apple Podcast Review: First, Open the podcast app on your iPhone, Mac, or iPad. Then, hit the “Search” tab at the bottom right-hand corner of the page and search for MetFlex and Chill. Select the podcast, scroll down to find the subheading “Ratings & Reviews”. and select “Write a Review.” Next, select the number of stars you'd like to leave. Please choose 5 stars! Using the text box which says “Title,” write a title for your review. Then in the text box, write the review itself. The review can be up to 300 words long, but doesn't need to be much more than: “Love the show! Thanks!” or “Rachel provides wonderful content from a multitude of expert guests!” Once you're done select “Send” in the upper right-hand corner.   --- Join the FREE MetFLex Life Course: www.metflexandchill.com  Rachel Gregory is a Board-Certified Nutritionist, Strength and Conditioning Specialist, Podcaster, and founder of MetFlex Life. She is also the author of the international best-selling book, "21-Day Ketogenic Diet Weight Loss Challenge." Rachel received her Master's Degree in Nutrition & Exercise Physiology from James Madison University and Bachelor's Degree in Sports Medicine from the University of Miami. Rachel completed the first-ever human clinical trial looking at the effects of the Ketogenic Diet in non-elite CrossFit athletes, which is published in the International Journal of Sports and Exercise Medicine. Currently, in her day-to-day coaching business, Rachel guides her clients to becoming the best, most confident version of themselves. She has a passion for educating those dedicated to optimizing their physical and mental well-being while improving long-term health and fitness goals. Her most popular course, Keto for Women, has helped women all across the world learn how to ditch the restrictive, all-or-nothing mindset associated with keto and instead thrive through the power of metabolic flexibility. You can connect and learn more about Rachel's work by visiting her website www.metflexlife.com  Social Links: Youtube: @rachelgregory Instagram: @rachelgregory.cns TikTok: @metflexlife Facebook: @metflexlife  Primary Programs: Keto For Women Muscle Science For Women

CardioNerds Rounds Co-Chair, Dr. Karan Desai, joins Dr. Michelle Kittleson (Director of Postgraduate Education in Heart Failure and Transplantation, Director of Heart Failure Research, and Professor of Medicine at the Smidt Heart Institute at Cedars-Sinai) to discuss challenging cases of hypertrophic cardiomyopathy. As a guideline author on the 2020 ACC/AHA Hypertrophic Cardiomyopathy Guidelines, Dr. Kittleson shows us how the latest evidence informs our management of HCM patients, while sharing many #Kittlesonrules and pearls on clinical care. Come round with us today by listening to the episodes now and joining future sessions of #CardsRounds! This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  Speaker disclosures: None Cases discussed and Show Notes • References • Production Team CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Hypertrophic Cardiomyopaty Cases Case #1 Synopsis: Two non-white brothers in their early 20s come to clinic to establish care. They have no cardiopulmonary symptoms, normal EKGs and normal echos, but there was a possible family history of HCM. Their mother had LV hypertrophy and underwent septal myectomy, but she could not afford genetic testing and was no longer in the patients' lives. The path report suggested “myocyte hypertrophy without disarray or bundles of myocytes.” How would you advise these patients regarding screening and surveillance? Listen to #CardsRounds for the full details!  Quotes from Case #1: “Let's take a walk down memory lane and let's get to our evolution of understanding hypertrophic cardiomyopathy… [our understanding] follows the parable of the six blind men and the elephant. Each of the six blind man approached it from different angles, its tusk, its ear, its tail, and they all try to convince each other what an elephant is … because none of them can see the big picture.” Dr. Kittleson on the history of HCM and coming to a unifying diagnosis  “The next time you are sitting there mashing your teeth because you have to memorize what the HCM murmur does squat to stand, Valsalva, or handgrip … remember you are standing on the shoulder of Giants. They [Drs. Braunwald and Morrow] pioneered surgical myectomy based on physical exam and cath lab findings” Dr. Kittleson on the physical exam guiding HCM management Takeaways from Case #1 Before we round, we think it is important to get on the same page regarding the nomenclature around HCM. Since the original characterization of hypertrophic cardiomyopathy (HCM) more than 60 years ago (see the Braunwald Chronicles for the origin stories!), different terms have been used to describe the disease. These include idiopathic hypertrophic subaortic stenosis, hypertrophic obstructive cardiomyopathy (HoCM), and “burnt out HCM” when heart failure develops.The 2020 guideline committee recommended a common language to avoid confusion: since left ventricular (LV) outflow tract obstruction (LVOTO) occurs in >60% of patients over time, but one-third remain non-obstructive, the recommendation is t0 call the disease state HCM with or without outflow tract obstruction.Dr. Kittleson added that when heart failure develops we should characterize the pathology as HCM with heart failure rather than “burnt out HCM.”  Do we use HCM to describe any LV that has thick walls? Some clinicians will use HCM to describe all disease states that can...

Dica de prova: Manobra de Valsalva Modificada. by Cardiopapers

Interviews from The Eastern Voyager Today's episode is a special one! It features interviews done while out on the Adreno Capricorn Bunker Trip, a 1 week spearfishing charter on the Great Barrier Reef aboard the Eastern Voyager! Join some of the legends from Adreno like Wayne Judge and Taylor Slattery along with the familiar voice of Trevor Ketchion and some actual Noob Spearos as they discuss plans, expectations and goals for the trip. This is a great opportunity and one of the easiest spearfishing charters you can get - hot showers, great food and priceless advice and guidance from legendary spearos, we highly recommend doing this trip! As always, a massive thanks to for making this trip so memorable! 00:13 Intro 02:56 PADI Level 1 Course 09:45 Welcome to the Eastern Voyager! Introducing Adreno legend Wayne Judge and Noob Spearos Ryan, Jack and Jordy 13:31 Wayne, what is the plan for this trip? 14:00 We are going spearfishing, not freediving 17:03 How is everyone feeling about the trip? 18:22 Great advice from Wayne 21:28 Hunting: find the fish's weakness 23:20 We have some great conditions here 24:08 What goals do you have for this trip? 26:10 Frenzel or Valsalva? 32:55 Questions for Wayne: How do I prepare for that first dive? 34:17 How much weight should I use? 35:50 Sharks: When do we get out of the water? 40:58 How do you stop the urge to breathe? 44:24 How long should I be recovering for? 48:21 Diving with more experienced spearos 50:40 Part 2 51:53 Day 3: Taylor, How has it been so far? 52:54 Trevor is hitting his prime! 53:26 Fish of the trip? 55:03 Luke 56:44 Ryan shooting his first fish ever! 59:00 My first Blackspot Tuskfish and Spangled Emperors 01:01:52 How has the boat been? Good meals and hot showers are excellent 01:03:04 The Queen of Content: Amy! 01:07:57 Trevor Ketchion vs Daniel Mann: Most underrated fish 01:11:08 What struggles have you had? 01:13:00 What are your goals for the rest of the trip? Shoot a trout! How are you going to do it? 01:16:51 Being a good boaty 01:21:14 Trevor's advice 01:23:20 Safe buddy diving 01:26:16 Taylor's boaty advice 01:31:14 What goals do you all want to achieve on the last few days? 01:33:24 Coronation trout 01:36:46 Trevor, what are you hoping to achieve? 01:38:02 Outro Listen in and subscribe on iOS or Android Important Links Noob Spearo Partners and Discount Codes . Use the code NOOBSPEARO save $20 on every purchase over $200 at checkout – Flat shipping rate, especially in AUS! – Use the code NOOB10 to save 10% off anything store-wide. Free Shipping on USA orders over $99 + Free Shipping with promo code NOOBSPEARO at ! #ad #manscapedpod | Simple, Effective, Dependable Wooden Spearguns. Use the Code NOOB to save $30 on any speargun:) use the code SPEARO to get 20% off any course and the code NOOBSPEARO to get 40% off any and all courses! Use the code NOOBSPEARO to save $25 on the full Penetrator Spearfishing Fin Range . 28-day Freediving Transformation (CODE: NOOB28 for 15% off) | Equalization Masterclass – Roadmap to Frenzel | Free Courses | Freediving Safety Course | How to Take a 25-30% Bigger Breath! | The 5 minute Freediver | Break the 10 Meter Barrier – Use the code NOOBSPEARO to save $ | Wickedly tough and well thought out gear! Check out their | ‘Spearo Dad' | ‘Girls with Gills' | ‘Jobfish Tribute' | Fishing Trips () Subscribe to the best spearfishing magazine in the world. International subscription available! . Listen to 99 Tips to Get Better at Spearfishing

After the last group function where a juicy bit of dry socket has been tackled, I was again surprised by Dr. Chris Waith that managing OACs was such a simple matter of using your existing tools - there is some super real-world GDP-friendly advice in this episode. https://youtu.be/aHV15R0SNaw Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! "If the OAC is bigger than 5mm, you really get into the point where I don't necessarily think we should be expecting GDPs to do something super courageous at that point." - Dr. Chris Waith In this group function we talked about: The Classic OAC regimen  1:31Oro-Antral Communication Management 6:37Medications for an OAC 8:55 If you loved this episode, be sure to check out the first part! Dry Sockets – How to Prevent and Manage Them? Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome back to another group function again, Oral Surgery, we're doing a three part for surgery with Chris Waith, we already covered dry sockets. And his answer was very surprising to me. This one OACs was a bit more of what I expected to hear. And so we're gonna jump straight in, right? You are now very familiar with these group functions. So how do you prevent and manage an OAC? Shall we move on to now?... Main Interview: [Jaz]OACs. Okay, so, OACs, I was taught at dental school that a lot of times when we take tooth out, we probably make an OAC without even realizing. And it's a very common thing. And actually the probably heals up, especially when it's less than x millimeters, maybe that's four millimeters or whatever it might be. I was also taught and here's why I've been a little bit naughty. So let's play Zak's stuff 'Am I naughty, I get my, if I'm really not sure if there's an OAC and then I want to start them on the regimen, which we'll talk about shortly and see if our regimens are the same. But if I'm really not sure, then am I naughty if I get them to pinch their nose and try and blow out the nose aka the Valsalva maneuver, because I was taught not to but a few times, I'm really not sure whether I'm about to start this patient on the regimen. I have done it. What do you think? [Chris]I'd say yes, you are naughty. I mean, my logic is that I think we must close OACs all the time. But 99% plus they just heal. Some of the time will be because the membranes completely intact. And the whole, the communication is actually it's just a bony break. Sometimes the hole in the membrane will be so small that your body can heal it. If you've got a small hole, and you squeeze your nose and blow. Essentially, what we've just got them to do is what we're about to instruct them not to do for the next two weeks, because we know it might open up the OAC. So I would say if you got, if you're going to check and grab your suction off of your Nurse (so that she's not tempted to put it down to the bottom of the socket), just get your suction over the top of the socket, either get the light from your loupes or your chair light in a decent position. And just look. And I think if you can't see anything obvious, it's not to say it's not there. But if you can't see it, that's good. Because I usually teach five millimeters, I say less than five millimeters, I think you can kind of sit on that. Give them the instructions. And I try and make myself feel better - I put some collagen cubes in the coronal portion of the socket. [Jaz] So do I [Chris] If it's bigger than five millimeters, you really get into the point where I don't necessarily think we should be expecting GDPs to do something super courageous at that point. If you were thinking that that actually needs some kind of physical closure. I think if you're the GDP, the quickest, simplest thing you could do is just take an alginate, take an alginate send it to the lab, just say to the lab this needs to be kind of processed now.

Our fearlessly absurd friends find themselves in the land of musicals until Simon reveals that he did his long overdue Suspiria watching homework.Get in touch with Lee and Simon at info@midlifing.net.Related links (and necessary corrections):Sweet Caroline (don't watch it, you'll never get it out of your head): https://www.youtube.com/watch?v=ty1dwBCR6D0Michael Jackson Black or White: https://youtu.be/pTFE8cirkdQStevie Wonder and Paul McCartney Ebony and Ivory: https://youtu.be/fXAlfh6QKQscolons and titles: https://www.psychnewsdaily.com/psychology-article-titles-do-better-with-colons-and-questions/The Ladies Who Lunch (Sondheim): https://en.wikipedia.org/wiki/The_Ladies_Who_Lunch_(song)Valsalva maneuver: https://en.wikipedia.org/wiki/Valsalva_maneuverHeathers (musical): https://en.wikipedia.org/wiki/Heathers:_The_MusicalWaitress (musical): https://en.wikipedia.org/wiki/Waitress_(musical)Todaytix: https://www.todaytix.comSuspiria (2018): https://en.wikipedia.org/wiki/Suspiria_(2018_film)Dario Argento original Suspiria (1977): https://en.wikipedia.org/wiki/SuspiriaItalian giallo (Lee was right, the original novels had yellow covers): https://en.wikipedia.org/wiki/GialloDashiell Hammett: https://en.wikipedia.org/wiki/Dashiell_HammettLuca Guadagnino: https://en.wikipedia.org/wiki/Luca_GuadagninoTilda Swinton: https://en.wikipedia.org/wiki/Tilda_SwintonGoblin's main theme of Suspiria (1977) - note that Simon tried to watch and listen to this but became terrified and couldn't finish it: https://youtu.be/9-IEUz3KqpwGoblin: https://en.wikipedia.org/wiki/Goblin_(band)Pina Bausch: https://en.wikipedia.org/wiki/Pina_BauschAusdruckstanz: https://en.wikipedia.org/wiki/Expressionist_danceAnne Teresa De Keersmaeker Rosa Danst Rosa: https://www.youtube.com/watch?v=oQCTbCcSxisDamien Jalet: http://www.damienjalet.comSuspiria (2018) final dance costumes: https://dazedimg-dazedgroup.netdna-ssl.com/1041/336-0-1041-694/azure/dazed-prod/1250/4/1254980.jpgDaria Nicolodi (co-writer Suspiria, 1977): Get in touch with Lee and Simon at info@midlifing.net. ---The Midlifing logo is adapted from an original image by H.L.I.T: https://www.flickr.com/photos/29311691@N05/8571921679 (CC BY 2.0)

Test your breathing this week, take a very deep breath and see if your shoulders rise and you fill your chest or whether you fill your belly and ribs. #cubreath #cupod @aj.afterbabyfit - afterbabyfit.com / @sweatandshineon - sweatandshineon.com A lot can change from just a breath. Fun fact: when babies take their first breath it closes a hole in their heart. Breathing is fundamental, natural, something we generally take for granted. Breathing is always the first session in our postpartum programs, resetting is and pushing it down into the belly and the ribs instead of allowing the breath to live in our neck and shoulders. When you are pregnant, your organs shift and the baby takes up space in your belly and ribs that you would normally use to breathe. It's a huge mental challenge to shift your breath and start to use your core muscles to breathe again. Breathing into your shoulders and chest is a stressful breath. Breathing into your belly and ribs is a full breathe, calming or meditative breathe that fills your body with oxygen. In order to correctly engage muscles we first need to work on the breathe and posture and then work from there. An entire niche of physical therapy is actually dedicated to the mechanics of breathing, to help with dysfunction in breathing. Breathing is really efficiency of gas exchange, and supporting the function of your organs. The chest breath or stress breath doesn't promote that exchange. You need big breaths to sleep to function throughout your day. Are you someone that takes short breaths and has high anxiety? If you aren't breathing well at night while you sleep you will wake up feeling tired and not rested. This applies to everyone not just postpartum. Breathing can relax your parasympathetic nervous system and calm you. The ribs can actually become really tight and rib mobility is important, actually putting your fingers in between the rib bones and breathing in to that space to release the tension. Set a timer for 5 minutes and see how wonderful your big breath feels after. Adding focused breathing to your exercises makes them more challenging and intense. For example, using a balloon can add intensity to an exercise. Holding our breath during movements is called the Valsalva maneuver. This increases your blood pressure very quickly. And many people do movements without realizing they are holding their breathe. Many times people hold their breathe during a plank, trying to brace their core. You need to be able to brace your core and still breathe through it. Practicing the inhale and exhale. Teaching a child to breathe when they are feeling stress or anxiety can help calm them. And holding them tight to feel the breath and mimic the breath can be such a powerful tool to reach calm. One breathe at a time. --- Send in a voice message: https://podcasters.spotify.com/pod/show/comfortablyuncomfortable/message Support this podcast: https://podcasters.spotify.com/pod/show/comfortablyuncomfortable/support

This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_102_0-AVNRT_Final_Cut.m4a Download Leave a Comment Tags: Adenosine, AVNRT, Cardiology, SVT, Tachydysrhythmia Show Notes Read More Rebel EM: The REVERT Trial – A Modified Valsalva Maneuver to Convert SVT SGEM: This is a SVT and I'm Gonna Revert It Using a Modified Valsalva Manoeuvre Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. PMID: 26314489 Read More