Podcasts about vas

Ryan Chaw shares his bedroom real estate rental property strategy. As a pharmacist-turned-real estate investor Ryan shares how he built a successful portfolio of 14 rental properties generating $50,000/month in income by renting out homes by the bedroom to students and professionals near college campuses. Now financially free, he spends his time coaching others and maintaining a disciplined approach to growth while avoiding low-quality competition and preserving strong tenant relationships. Today we discuss...  Ryan Chaw transitioned from a pharmacist to a real estate investor inspired by his grandfather's success in Bay Area real estate. He began investing in 2016 with a $262,000 property in Stockton, California, renting it by the bedroom to maximize cash flow. His strategy involves converting 3-bedroom homes into 5- or 6-bedroom rentals and leasing them to students and professionals. Ryan now owns 14 rental properties generating $50,000 per month in income and has fully replaced his pharmacist salary. Most of his tenants come from word-of-mouth referrals, especially from student communities at nearby colleges. Properties that would rent for $1,500–$2,200 annually generate $4,000+ per month when rented by the room. Competition in his niche is limited and often low quality, with few landlords offering the same level of service. Ryan sees consistent long-term demand with students signing multi-year leases and bringing in future tenants. Ryan targets neighborhoods favored by graduate students and healthcare professionals by researching Reddit forums for off-campus housing recommendations. He rents to both students and healthcare workers, often securing two-year leases from medical residents and fellows. He continues to acquire at least one new property per year and currently owns 14 rentals. He recommends keeping $7,000 to $10,000 per property in reserves to cover unexpected maintenance like HVAC or roof issues. He clusters tenants by category (e.g., pharmacy students, dental students, healthcare workers) to foster a sense of community. His four key success factors for student rentals are proximity to campus, neighborhood safety, affordability, and tenant community. Ryan uses VAs to triage maintenance requests and relies on a vetted contractor network to address issues within 24 to 48 hours. Today's Panelists: Kirk Chisholm | Innovative Wealth Barbara Friedberg | Barbara Friedberg Personal Finance Douglas Heagren | Pro College Planners Follow on Facebook: https://www.facebook.com/moneytreepodcast Follow LinkedIn: https://www.linkedin.com/showcase/money-tree-investing-podcast Follow on Twitter/X: https://x.com/MTIPodcast For more information, visit the show notes at https://moneytreepodcast.com/bedroom-real-estate-ryan-chaw-726 

Do you ever feel buried in marketing, admin, and editing tasks—and wonder what you should be doing instead? In this episode, Marc Scott breaks down how to identify which voice over tasks to outsource, why some of the best candidates are the ones you do well but don't need to do yourself, and where to find help within or outside the VO industry.

In this empowering episode of The Visibility Impact Show, Crissy interviews hiring and delegation expert Kate Lenihan, founder of Rise Hire Consulting. Kate has supported over 400 small business owners, including names like Amy Porterfield and Sue B. Zimmerman, and matched 200+ VAs with overwhelmed solopreneurs ready to rise into their CEO role. If you've ever said “I don't have time to get visible” this episode is your wake-up call.This episode is for: women entrepreneurs, coaches, and content creators ready to grow, delegate, and finally stop doing it all alone.Kate's Instagram: https://www.instagram.com/risehireconsulting/Kate's Email: kate@risehireconsulting.comKate's Freebie:  The Rise Audit (AI Prompt + 15-min Call)    https://risehireconsulting.com/the-rise-audit/Drop us a message...This isn't just a mid-year mindset shift. It's a full reset of how you lead, what you commit to, and how you move, so your second half is built on aligned action, not survival mode. https://thevisibleceo.com/midyearreset OMNI is my full visibility system built for CEOs who want to grow online without living on their phone. If you're ready to be truly seen, more strategic, and unmistakably in demand, head to check out OMNI at www.omniqueens.com Take the FREE Quiz to find out how visible you really are at www.thevisibleceo.com/quiz Review, share with a friend and tag me! IG: itscrissyconner FB: crissyconner LI: crissyconner

In this empowering episode of The Visibility Impact Show, Crissy interviews hiring and delegation expert Kate Lenihan, founder of Rise Hire Consulting. Kate has supported over 400 small business owners, including names like Amy Porterfield and Sue B. Zimmerman, and matched 200+ VAs with overwhelmed solopreneurs ready to rise into their CEO role. If you've ever said “I don't have time to get visible” this episode is your wake-up call.This episode is for: women entrepreneurs, coaches, and content creators ready to grow, delegate, and finally stop doing it all alone.Kate's Instagram: https://www.instagram.com/risehireconsulting/Kate's Email: kate@risehireconsulting.comKate's Freebie:  The Rise Audit (AI Prompt + 15-min Call)    https://risehireconsulting.com/the-rise-audit/Drop us a message...This isn't just a mid-year mindset shift. It's a full reset of how you lead, what you commit to, and how you move, so your second half is built on aligned action, not survival mode. https://thevisibleceo.com/midyearreset OMNI is my full visibility system built for CEOs who want to grow online without living on their phone. If you're ready to be truly seen, more strategic, and unmistakably in demand, head to check out OMNI at www.omniqueens.com Take the FREE Quiz to find out how visible you really are at www.thevisibleceo.com/quiz Review, share with a friend and tag me! IG: itscrissyconner FB: crissyconner LI: crissyconner

This week's episode with Ariel Smith was such a fun conversation! Ariel is the face behind Stay At The Coastline vacation rentals in San Diego, CA, and in just 8 months she's grown her cohosting business from zero to 40+ properties. Ariel walks us through exactly how she's finding her clients, how she's grown so fast, and the details behind her unique partnership structure with her brokerage that has sped up her growth process. Most importantly, she tells us exactly how she's managing over 40 listings without using any VAs for guest messaging?! It seems like every guest we've had on the podcast in the last 2 years is sharing how essential VAs have been to their operations, so I was dying to hear how Ariel is successfully scaling while still personally responding to every single guest message. If you've been hesitant to hire VAs, you'll find this conversation so encouraging that you might not need to! Maybe what you're already doing is exactly your secret sauce that's helping your business thrive. Connect with Ariel here, and check our her listings here. Thank you to my sponsors! Lodgify - ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Link⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ Receive 20% off Lodgify's most powerful plans with code NoVacancy20 at checkout Proper - ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Link⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ Visit the link to claim your free risk assessment with Proper. Learn more about your ad choices. Visit megaphone.fm/adchoices

#Bésameenlanoche Primera consulta con un psiquiatra: qué esperar, qué preguntar, qué no temer ¿Vas al psiquiatra por primera vez? ¿Te da miedo no saber qué va a pasar? ¿Sentís vergüenza?Nos acompaña el Dr. Mauricio Campos, psiquiatra, para desmitificar este primer paso y ayudarte a vivirlo con claridad, calma y seguridad. Un cierre de semana para hablar de salud mental sin miedo, sin estigma, sin mitos. Bésame de Noche, en el 89.9 FM, a las 20:00 horas Costa Rica Escuchanos en www.mmradio.com Conducido por el Dr. Rafael Ramos

Are you hiring help… or accidentally setting yourself up for burnout? In this video, I'm breaking down the biggest mistakes business owners make when hiring Virtual Assistants (VAs)—and why it often leads to more stress, not less. If you've ever hired someone and felt like it's just easier to do it yourself, this is for you. With over 20 years of experience and multiple 7-figure companies, I've built teams of employees, contractors, overseas VAs, and executive assistants. I'm sharing what works, what doesn't, and how to make the right hire based on what your business really needs—not just what you think you can afford. ✅ You'll learn: The #1 myth about hiring VAs (and why it's costing you time) What kind of support you actually need (VA, freelancer, EA, OBM?) Why hiring for tasks isn't the same as hiring for ownership How to match compensation with the role's responsibility The real cost of under-hiring (it's not just money)  

We've curated a special 10-minute version of the podcast for those in a hurry. Here you can listen to the full episode: https://podcasts.apple.com/no/podcast/novartis-ceo-medical-innovation-tech-partnerships-and/id1614211565?i=1000714438745&l=nb Can AI help us find cures for diseases we've never been able to treat? Nicolai Tangen speaks with Vasant 'Vas' Narasimhan, CEO of Novartis, about pioneering pharmaceutical innovation. They explore breakthrough cell and gene therapies, AI partnerships with leading tech companies, and how Novartis transformed from a sprawling conglomerate into a streamlined drug discovery company. Vas shares his unique perspective as a physician-scientist turned CEO, his concerns about Europe's declining pharma competitiveness, and his leadership philosophy of being the 'chief energy officer.' With €235 billion in market cap and groundbreaking treatments reaching patients worldwide, Novartis continues unlocking medical breakthroughs. Tune in!In Good Company is hosted by Nicolai Tangen, CEO of Norges Bank Investment Management. New full episodes every Wednesday, and don't miss our Highlight episodes every Friday.The production team for this episode includes Isabelle Karlsson and PLAN-B's Niklas Figenschau Johansen, Sebastian Langvik-Hansen and Pål Huuse. Background research was conducted by Isabelle Karlsson.Watch the episode on YouTube: Norges Bank Investment Management - YouTubeWant to learn more about the fund? The fund | Norges Bank Investment Management (nbim.no)Follow Nicolai Tangen on LinkedIn: Nicolai Tangen | LinkedInFollow NBIM on LinkedIn: Norges Bank Investment Management: Administrator for bedriftsside | LinkedInFollow NBIM on Instagram: Explore Norges Bank Investment Management on Instagram Hosted on Acast. See acast.com/privacy for more information.

Vas zanima aktualno dogajanje? V Dogodkih in odmevih, osrednji popoldanski informativni oddaji, vam ponujamo poročila, analize in komentarje ključnih aktualnih dogodkov tekočega dne – tako s področja politike kot gospodarstva, zdravstva, šolstva, kulture in športa. Vsak dan ob 15.30 na Radiu Slovenija.

¿Vas a viajar a España y no quieres que te timen al sentarte a comer? En este episodio te doy 7 consejos clave para no ser tomado por tonto en bares y restaurantes. Aprende a identificar una trampa para turistas, descubre qué no pedir y cómo detectar un sitio auténtico donde se come bien en España. ¡Evita errores típicos y disfruta como un local! Descarga el PDF del podcast desde tu área de estudiante: http://bit.ly/3bNABDT (solo para estudiantes de la Academia de Español) ‍ ACADEMIA DE ESPAÑOL ONLINE ‍ ➡ https://bit.ly/2P7L2JA ‍ ‍ ⭐ Club de Conversación https://bit.ly/4auVa5O Próximo viaje a España https://bit.ly/3tqCnZg Tapas de español (Newsletter): https://bit.ly/4gPD1T2

A review of all things Royal Ascot 2025, including the weather, the winners and losers, and Vas' unique communication style. In the NFL, Aaron Rodgers has announced that this will be his last season, but what inspiration can Tyrese Haliburton draw from the Steelers quarterback when it comes to recovering from an Achilles injury? The Oklahoma City Thunder won the NBA title, but the big sports news of the week is Lyon being relegated from Ligue 1 after going into administration. What does this mean for the future of French football, and is this a sign of things to come?  Plus, Frank's bluff gets called by Delta as he finds himself downgraded, the Netflix documentary on the Oceangate disaster, and Eddie gets an inside-the-park home run on a bunt in his softball league. 

Tune into our weekly LIVE Mastermind Q+A Podcast for expert advice, peer collaboration, and actionable insights on success in the Probate, Divorce, Late Mortgage/Pre-Foreclosure and Aged Expired niches!In today's episode of the All The Leads Mastermind podcast, the conversation focused on creating long-term success in probate real estate by building systems, setting realistic expectations, and leveraging multi-channel outreach. The panel explored how to shift your mindset from short-term wins to building a predictable business model—emphasizing that probate is a long game that often converts after 6 to 12 months. Bill shared his strategy of weekly mailing campaigns and personalized follow-ups that continue producing deals months later, while Bruce broke down how to turn common objections like “we have an attorney” into deeper conversations and future opportunities. New agent Melinda received tactical advice on overcoming DNC roadblocks, refining her call scripts, and segmenting lead lists for smarter follow-up. Patty and Michelle sparked a lively discussion on when to use virtual assistants versus handling calls personally, especially when building rapport with families in distress. The team also highlighted the opportunity with late mortgage leads, with tips on approaching these homeowners with empathy, avoiding “trigger words,” and connecting them to investors and creative solutions before foreclosure strikes. The episode wrapped with a discussion on mailing cadence, long-term drip campaigns, and why combining phone, print, and digital touches is key to winning trust and staying top-of-mind in any market.

Vas zanima aktualno dogajanje? V Dogodkih in odmevih, osrednji popoldanski informativni oddaji, vam ponujamo poročila, analize in komentarje ključnih aktualnih dogodkov tekočega dne – tako s področja politike kot gospodarstva, zdravstva, šolstva, kulture in športa. Vsak dan ob 15.30 na Radiu Slovenija.

¡Calienta motores, pisa el acelerador y compite por un vasto mundo en el que todo está conectado! Copia cedida por Nintendo España ¿Vas a comprar en Wakkap? Usa el código UNCAFECONINTENDO y ahórrate un 5% en tu próxima compra (máximo 3€ de descuento) Visita nuestra TIENDA ONLINE en cafeconnintendo.redbubble.com APÓYANOS por lo que cuesta un café en https://uncafeconnintendo.wordpress.com/ Para estar informado del programa síguenos en nuestra cuenta de X @cafeconnintendo o Bluesky uncafeconnintendo.bsky.social Únete también a nuestra comunidad de Telegram solicitando un enlace de invitación en los comentarios del programa

Can AI help us find cures for diseases we've never been able to treat? Nicolai Tangen speaks with Vasant 'Vas' Narasimhan, CEO of Novartis, about pioneering pharmaceutical innovation. They explore breakthrough cell and gene therapies, AI partnerships with leading tech companies, and how Novartis transformed from a sprawling conglomerate into a streamlined drug discovery company. Vas shares his unique perspective as a physician-scientist turned CEO, his concerns about Europe's declining pharma competitiveness, and his leadership philosophy of being the 'chief energy officer.' With €235 billion in market cap and groundbreaking treatments reaching patients worldwide, Novartis continues unlocking medical breakthroughs. Tune in! In Good Company is hosted by Nicolai Tangen, CEO of Norges Bank Investment Management. New full episodes every Wednesday, and don't miss our Highlight episodes every Friday. The production team for this episode includes Isabelle Karlsson and PLAN-B's Niklas Figenschau Johansen, Sebastian Langvik-Hansen and Pål Huuse. Background research was conducted by Isabelle Karlsson. Watch the episode on YouTube: Norges Bank Investment Management - YouTubeWant to learn more about the fund? The fund | Norges Bank Investment Management (nbim.no)Follow Nicolai Tangen on LinkedIn: Nicolai Tangen | LinkedInFollow NBIM on LinkedIn: Norges Bank Investment Management: Administrator for bedriftsside | LinkedInFollow NBIM on Instagram: Explore Norges Bank Investment Management on Instagram Hosted on Acast. See acast.com/privacy for more information.

Mindset isn't just some fluffy concept reserved for self-help books and vision boards. It's the foundation of your business. Your beliefs, your self-talk, your expectations. These are the things that shape your actions every single day. And in turn, those actions determine the results you get. In this episode, I want to talk about the one mindset shift that I believe every VA needs to make in order to grow a truly successful business. Not just a side hustle. Not just a bit of extra income. But a sustainable, fulfilling, well-paying VA business that you're proud to run. Most of the VAs I work with already have the knowledge. They've taken the courses, they've learned the tech, and they've even started putting themselves out there. But they still find themselves playing small. They second-guess everything. I help VAs just like you shift into that confident business owner mindset, and combine that with practical strategies to attract clients, price your services, and grow sustainably. If that's something you know you need, reach out to me. I'd love to support you. I'm here to help – you know that's the only reason I'm here at all – to help you become a ridiculously good VA. Remember, you don't have to wait until you feel confident to act like a business owner. Confidence comes from taking action. From showing up. From deciding that you're done playing small. The shift starts with a choice. And you get to make that choice today. If I can help, let me know. In the meantime, be sure to connect with me on your favourite social media platform. Find my links at YourVAMentor.com/links. That's all I've got for you this time. I'm Tracey D'Aviero, The Confidence Coach for VAs and I'll see you next time!

What Can a VA Do for Your Personal Lines Team? Discover the Benefits

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

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

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

Vasárnap hajnalban megvolt az eszkaláció, két nappal később a kapituláció is – nem így képzelnénk két atomhatalom háborúját. Irán megrogyott, de ennek a háborúnak valójában aligha van vége. Keresztes Imrével, a HVG Világ rovatának újságírójával Kacskovics Mihály Béla beszélgetett Iratkozz fel a Fülke csatornájára! Spotify: tiny.cc/FulkeSpotify Apple Podcasts: tiny.cc/FulkeApple Hallgasd meg a HVG többi podcastját: Spotify: tiny.cc/HVGpodcastokSpotify Apple Podcasts: tiny.cc/HVGpodcastokApple SoundCloud: tiny.cc/HVGpodcastokSC 0:00 Intro 01:12 Lehet hinni Trumpnak? 12:27 Komolyan lehet még venni Iránt? 22:12 Amikor kiderül, hogy kamu az „America first” 35:29 Az orosz érdekszféra összeomlása

Most entrepreneurs aren't drowning in work because they lack ambition. They're stuck doing too much of the wrong kind of work.   Sarah Lockwood talks with Julie Johnston, the founder of Rhino Squad, about what it looks like to operate from your zone of genius. They unpack the mindset traps that keep founders stuck in the weeds and walk through how small shifts in delegation can lead to major changes in time management and business growth.   Julie shares what she's learned helping leaders hire and work with virtual assistants, especially from the Philippines, and how a global workforce can unlock more freedom, better output, and stronger team culture. Are your top people doing high-value work? What could your business look like if they were?     Julie encourages founders to think big and recognize where VAs can support every part of your organization from revenue driving activities to business operations - VAs can do much more than confirm appointments, reschedule meetings or manage your inbox (although that ‘s a great place to start if you haven't yet)! If you've been hesitant to delegate or unsure where to start, Sarah and Julie's conversation will help you rethink how you're spending your time and what it's really costing you.   Episode Breakdown: 00:00 Meet Julie Johnston and Rhino Squad 02:03 Mindset Shifts for Effective Delegation 06:53 Maximizing Time with Virtual Assistants 10:50 Building a Supportive Team Culture 14:01 10X Thinking and Global Workforce Strategy 24:17 Julie's Conscious Entrepreneurial Journey 29:49 Core Values Behind Rhino Squad   Links Connect with The Conscious Entrepreneur: Website: http://www.consciousentrepreneur.us  LinkedIn: https://www.linkedin.com/company/conscious-entrepreneur/  Instagram: https://www.instagram.com/conscious_entrepreneur_summit/   Connect with Julie Johnston: Website: www.rhinosquad.org  Instagram: https://www.instagram.com/rhinosquad_virtualassistants/  LinkedIn: https://www.linkedin.com/in/rhinojulie/   Connect with Sarah Lockwood: LinkedIn: https://www.linkedin.com/in/lockwoodsarah/ Website: https://hivecast.fm HiveCast.fm is a proud sponsor of The Conscious Entrepreneur Podcast. Podcast production and show notes provided by HiveCast.fm

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No necesitas que llegue un momento perfecto para comenzar de nuevo. Hoy te acompañamos con un recordatorio amoroso: puedes ir a tu ritmo, soltar la prisa y abrazar cada paso que das.–A lo largo de estos 3 años de Durmiendo Podcast, hemos compartido episodios que les han ayudado muchísimo. Por eso, hoy traemos de vuelta las herramientas que más han resonado con ustedes y que les han acompañado a cerrar su día con calma

¡Hola, cafeteros! En el programa de hoy comentamos los siguientes temas: 1️⃣ Todas las novedades del Donkey Kong Bananza Direct 2️⃣ Las bajas ventas de las third en el lanzamiento de Switch 2 3️⃣ Impresiones express de Cyberpunk 2077 ... ¡y mucho más! ¿Vas a comprar en Wakkap? Usa el código UNCAFECONINTENDO y ahórrate un 5% en tu próxima compra (máximo 3€ de descuento) Visita nuestra TIENDA ONLINE en cafeconnintendo.redbubble.com APÓYANOS por lo que cuesta un café en https://uncafeconnintendo.wordpress.com/ Para estar informado del programa síguenos en nuestra cuenta de X @cafeconnintendo o Bluesky uncafeconnintendo.bsky.social Únete también a nuestra comunidad de Telegram solicitando un enlace de invitación en los comentarios del programa

Some investors go big to win big — but Hunter built a thriving land business by doing the opposite.In this episode, Jessey sits down with Hunter to break down how he flips smaller, rural parcels at scale for outsized returns. You'll hear how a college side hustle turned into a full-time business, why he avoids blind offers, and how he's built passive income by offering seller financing to buyers who weren't even looking.With just two VAs and a tight system, Hunter is moving 100+ deals a year — using creative direct mail, a smooth checkout experience, and 27 marketing channels to keep his pipeline full.In this episode:How flipping low-cost rural parcels led to 100+ deals a yearCreative seller financing that converts casual browsers into buyersDirect mail strategies that stand out — without using blind offers

En Argentina, decenas de miles de personas se manifestaron a favor de Cristina Fernández de Kirchner, que vio ratificada su condena a 6 años de prisión domiciliaria y inhabilitación de por vida, por el caso de corrupción conocido como Causa Vialidad.  Los simpatizantes de la expresidenta se concentraron en la Plaza de Mayo y las calles aledañas de Buenos Aires, con tambores y banderas nacionales.  A pesar de una condena de seis años por corrupción y su actual arresto domiciliario, la influencia de la expresidenta argentina Cristina Fernández de Kirchner recibe el apoyo de una parte de los argentinos. Una masiva manifestación en la emblemática Plaza de Mayo de Buenos Aires ha dejado claro que su capital político no se ha extinguido, abriendo un intenso debate sobre el futuro del Kirchnerismo y quién podría tomar las riendas del movimiento. "¡Te amamos, Cristina!", "¡Vas a volver, Cristina!", gritaban la víspera simpatizantes de Cristina Fernández de Kirchner al pie de su balcón. El martes, la ex presidenta de Argentina comenzó a cumplir una condena de seis años de prisión domiciliaria por corrupción.  Leer tambiénCristina Fernández cumplirá su condena por corrupción en prisión domiciliaria Para sus partidarios, la causa judicial no es más que una excusa. Como explica la abogada y periodista Lourdes Marchesse, la propia expresidenta enmarcó su situación ante la multitud como un intento de proscripción. "Ella misma planteó que no la quieren en las elecciones y que por eso la sacan de la cancha con esta condena", señala Marchesse, quien recuerda que, más allá de las percepciones políticas, el caso judicial fue un proceso extenso que duró 17 años. La gran pregunta que surge es si, a pesar del arresto domiciliario, Cristina Kirchner podrá seguir ejerciendo su liderazgo. La respuesta parece ser un rotundo sí, aunque de una manera diferente. "Primero y principal, Cristina ya no puede ejercer ningún cargo público", aclara Marchesse. "Ella puede ejercer un liderazgo desde atrás". Este poder intangible se fundamenta en una carrera política que la consolidó como una figura central en la historia reciente de Argentina. "Cristina te puede gustar o no como política, pero nadie puede negar que ella es una líder", afirma Marchesse. "Fue dos veces presidenta de la nación, antes había sido senadora, fue diputada. Entonces, tiene un gran liderazgo". ¿Quién Tomará las Riendas del Kirchnerismo? Con la líder principal legalmente inhabilitada para ocupar cargos, la mirada se dirige a sus posibles herederos políticos. El periodista y analista argentino Eduardo Aulicino destaca dos nombres que suenan con fuerza para tomar el control del movimiento: su hijo, Máximo Kirchner, y el exministro de Economía y actual gobernador de Buenos Aires, Axel Kicillof. Sin embargo, para Aulicino, las balanzas se inclinan claramente hacia uno de ellos. "Yo creo que, por lo menos en esta primera etapa, Axel Kicillof por ahora asoma como el único integrante del Kirchnerismo con vocación de tener un proyecto presidencial dentro de dos años", analiza. En contraste, el rol de Máximo Kirchner parece estar más limitado al círculo interno del poder. "Máximo puede aparecer como principal operador, incluso ahora como voz autorizada de Cristina detenida, pero no tiene ascendentes fuera de la estructura kirchnerista", explica Aulicino. Agrega un dato contundente: "Es más, todos los estudios de opinión dicen que tiene una imagen muy, muy mala". En el caso Vialidad, Cristina Fernández fue declarada culpable por conceder de manera irregular medio centenar de obras públicas a un empresario amigo durante su presidencia.

Explora, interactúa y experimenta todas las funciones y la tecnología de Nintendo Switch 2 en esta exposición interactiva de la consola y sus accesorios. Copia cedida por Nintendo España ¿Vas a comprar en Wakkap? Usa el código UNCAFECONINTENDO y ahórrate un 5% en tu próxima compra (máximo 3€ de descuento) Visita nuestra TIENDA ONLINE en cafeconnintendo.redbubble.com APÓYANOS por lo que cuesta un café en https://uncafeconnintendo.wordpress.com/ Para estar informado del programa síguenos en nuestra cuenta de X @cafeconnintendo o Bluesky uncafeconnintendo.bsky.social Únete también a nuestra comunidad de Telegram solicitando un enlace de invitación en los comentarios del programa

Ad Astra Travelers! Welcome back to Tales of Teyvat: A Genshin Lore Podcast. This week, we're at Angel's Share with the one and only Corina Boettger! Corina is best known in Teyvat for previously playing the best travel guide, our emergency food, and Traveler's best friend: Paimon! Our talkative companion shares the same lively energy with their former English voice actor who has been acting since they were eight. Our hosts sat down with Corina to ask them about their experience recording Genshin Impact, where they pulled their inspiration for Paimon, and if Paimon has the capability to be evil or not. After learning about the ins and outs of recording for Genshin Impact, our hosts make their questions more personal: the importance of advocating for those with chronic illness, if their birds like to mimic their voices, and what type of support you need to make it in the industry. Make sure to bring a drink, or juice, to Angel's Share and listen to everything Corina has to say, especially before Six-Fingered Jose starts his shift!Please note: This episode was recorded in June of 2024 and was set to release on July 26, 2024 - the same date the Video Game Voice Actor Strike began. Our hosts decided to hold the episode and stand in solidarity with the VAs. Though we are excited to finally be releasing this episode, we were saddened to hear with the release of 5.7 that Corina will no longer be voicing Paimon. We think this episode encapsulates everything that they brought to the character and we're excited to share it with the community. Thank you Corina! We wish you the best in your future projects.Visit https://bit.ly/tot-corinaboettger to find a comprehensive lore sheet that provides visual aids and links to videos and important Genshin Impact resources.Tales of Teyvat has partnered with the Shade Chamber Podcast to create a Genshin Community on Discord for our listeners! We are so excited to chat Genshin Lore, Honkai Star Rail, and so much more with you! You can join our server at https://bit.ly/shadesofteyvat.Follow us on Twitter: @talesofteyvat or Instagram: @talesofteyvatpodThis podcast episode initially aired on June 18, 2025, on Spotify, Anchor, and Apple Podcasts. All our opinions are our own. This podcast is not at all associated with Hoyoverse/Genshin Impact.

VAs in the Philippines love tools. And there are tons of tools out there—but which ones actually work?I've been working with Filipino VAs for almost 20 years. Over that time, I've tested just about every tool available—some stuck, most didn't. The ones that stuck? They've made my VAs way more productive and made my life easier. And today, I'm breaking down exactly what we use—and why.If you're wondering where to start—and which tools will actually make your VAs more productive without overwhelming them—here's what I cover:

I want to get back to basics a bit today and talk about your virtual assistant website. Whether you have just started your business, are just getting your website together, or have been around a while and want to update yours, in this episode we talk about what you need to focus on to make yours work best for you. It can feel overwhelming at any stage but that's the important thing – is that it actually does what it's supposed to do. So many VAs either avoid building a website entirely, or they slap one together just to say they have one. But here's the truth: your website isn't just a business card. It's a trust builder, a lead qualifier, and, when done right, a quiet salesperson that works 24/7. Today, I want to walk you through what your VA business website should actually include. No fluff, no filler, just the essentials that will help your visitors feel confident enough to take the next step with you. And of course, if you're not sure what your next step should be, you can always work with me on this. Helping VAs build strong, simple websites that speak directly to their ideal clients is something I do often—and it doesn't have to be complicated. If you're in a place where you're updating or building your website and you're not sure if it's doing what it should, I can help. It's the only reason I'm here at all is to help you become a ridiculously good virtual assistant! If you want to work with me or learn more about my coaching, courses, or membership programs, just visit YourVAMentor.com/links. You can start by connecting with me on your favourite social platform. You don't have to do it all at once. You just have to make sure that your site is working for you. It's a marketing tool, not a burden. When you get really clear on what you do, who you help, and why it's important for them to get your help, the website part is actually pretty easy. It's just there to tell them.   That's all I've got for you this week. I'm Tracey D'Aviero, The Confidence Coach for VAs and I'll see you next time!

Join Nick Lamagna on The A Game Podcast with our guest Ricardo Rosales, a full-time real estate investor, entrepreneur, educator and podcast host from Venezuela who is now investing out of Texas!  After being a bit lost in his early years, he found some purpose in the military as a diesel mechanic in the US Navy.  The oil and gas industry brought him to Texas and after seeing a real estate investor make money flipping homes it gave him the confidence to jump into real estate investing He borrowed money from his mother-in-law and learned some lessons through the school of hard knocks as he earned his stripes as a contractor and after getting laid off from his job, he became a  full-time investor and became an accident landlord and was bit by the cash flow bug owning up to 100 rentals at one time. Over the years he scaled his business to doing 40-50 deals a month after overcoming adversity in business a hurricane threw some unexpected winds into his sails and caused him to once again pivot his business into wholesaling to pay make his private lenders whole and fell into hiring and training virtual assistants to manage his day to day and scale his business.  Today that has become his bread and butter helping business owners and investors through his company Top Of The Line VA.  He holds exciting live real estate events for investors throughout the year known as Attend Growth and has one coming up June 27 and 28th in Tampa you won't want to miss! Topics for this episode include: ✅ Why having a high quality VA is important ✅ Top things VAs can help you with today ✅ How to stop being your own enemy in business ✅ How to rebuild and pivot your business after a setback ✅ Inspiring story of rags to riches you wont want to miss + more!   Connect with Ricardo: Ricardo Rosales on Facebook Ricardo Rosales on Instagram Ricardo Rosales on Youtube Ricardo Rosales on TikTok Real Estate Entrepreneurs Podcast   Connect with Top Of The Line VA: www.topofthelineva.com Top Of The Line VA on Facebook Top Of The Line VA on Instagram Top Of The Line VA on LinkedIn   Connect with Attend Growth Event: www.attendgrowth.com Attend Growth Conference on Instagram --- Connect with Nick Lamagna www.nicknicknick.com Text Nick (516)540-5733 Connect on ALL Social Media and Podcast Platforms Here FREE Checklist on how to bring more value to your buyers

Vas a por una cosa y te encuentras con otra, a veces para bien y a veces para mal. Y de ello hablamos en este nuevo ratito podcastero con el mejor equipo radiofónico del mercado de segunda mano. ¿Será casualidad o será serendipia? ✅ Y además, es un gusto contar con el patrocinio en este podcast de Airbnb... ¡Y es que algunos viajes son mejores con Airbnb! ... ya lo deberíais saber:¡PÍLLATE UN AIRBNB! 😎 Escucha el episodio completo en la app de iVoox, o descubre todo el catálogo de iVoox Originals

In this episode of Soulpreneur Scaling Stories, I sit down with Teresa Cavalla, a Leadership and High Performance Consultant, Certified Online Business Manager, ClickUp Vetted Consultant, and Systems Pro. Teresa shares her unique perspective on what it truly means to be an entrepreneur in the online space versus simply working online.During our conversation, Teresa reveals how she built a successful business without traditional social media marketing, instead focusing on authentic relationships and referrals. She explores the critical leadership components that entrepreneurs often overlook and explains why understanding your team members' motivations is essential for business growth.Teresa opens up about her own business evolution, from VA to OBM to leadership consultant, and shares the mindset shifts that helped her create alignment between her natural strengths and her business model. We also discuss the importance of building an emergency fund as a business owner and the power of making space for your intuition.If you're a service provider feeling pressured to market yourself in ways that feel inauthentic or struggling with team dynamics, this episode offers refreshing perspectives on building a business that honors your unique leadership style.Key Points Covered:✨ The critical difference between working online and being an entrepreneur✨ How to identify what types of clients and team members align with your business vision✨ Building a successful business without traditional social media marketing✨ The importance of authenticity and understanding your unique strengths✨ Why making silence and connecting with your intuition is essential for business clarity✨ Creating financial stability through proper planning and emergency fundsConnect with Teresa:Learn more about Teresa and her leadership consulting services at www.leadershipfirstobm.comSubscribe HERE  to get tips on leadership, neuroscience, and conscious business practices.Ready to streamline your business systems? Visit www.systemsfirstobm.com for expert support.Subscribe HERE for actionable tips on SOPs, workflows, and special offers on system setup services. InstagramSend us a text Thank you for being a part of the Soulpreneur Scaling Stories community!FREE RESOURCES

Welcome back to the Empower Her Business Accelerator podcast! I'm your host, Philippa Channer, and this month we've been diving into the key activities that drive business success. In the last two episodes, we explored how to identify and prioritize the core tasks that truly matter. Today, we're taking it a step further by focusing on how to streamline your operations so your business runs smoother, smarter, and with a whole lot less stress. If you've ever felt buried under repetitive tasks, struggled with inefficiencies, or wished there were more hours in the day, this episode is your permission slip to simplify. You'll walk away with tangible strategies to systematize, automate, delegate, and batch your way to a more efficient business.

In this episode of Management Unfiltered, host Zach Shelley chats with Cory Pinegar about the changing world of dental office management and the role of virtual assistants (VAs). They dive into the perks and challenges of using VAs, stressing the importance of communication and empathy in patient care. The discussion also covers how to set clear expectations when hiring VAs to boost efficiency and enhance patient satisfaction.

Drawing from her own experiences of burnout and overwhelm, Kris Ward illustrates the importance of recognizing when the demands of entrepreneurship become unsustainable. Ward advocates for the strategic use of virtual assistants (VAs) as a means to reclaim valuable time and energy. By delegating tasks that do not require a business owner's direct involvement, entrepreneurs can focus on high-impact activities that drive growth and innovation. This shift not only alleviates stress but also fosters a healthier work-life balance, allowing individuals to pursue their passions without being weighed down by the minutiae of daily operations. Ward's approach to delegation is rooted in collaboration and empowerment. She emphasizes the necessity of onboarding and training VAs effectively, ensuring they are aligned with the business's vision and values. By encouraging entrepreneurs to trust their teams and embrace a mindset of collaboration, she illustrates how effective delegation can lead to enhanced productivity and creativity. Her insights serve as a powerful reminder that success in business is not solely about individual effort but rather about building a supportive network that drives collective achievement. To delve deeper into Kris Ward's transformative strategies and resources, visit her website and find a wealth of tools and insights designed to help you enhance your business efficiency through effective delegation and the strategic use of virtual assistants. Take actionable steps to reclaim your time, streamline your operations, and create a more fulfilling entrepreneurial journey. Embrace the opportunity to transform your approach to business and personal well-being with the guidance and support that Kris provides. For the accessible version of the podcast, go to our Ziotag gallery.We're happy you're here! Like the pod?Support the podcast and receive discounts from our sponsors: https://yourbrandamplified.codeadx.me/Leave a rating and review on your favorite platformFollow @yourbrandamplified on the socialsTalk to my digital avatar

In this episode of The Wealthy & Well Podcast, I'm joined by Anne Whitney business transformation mentor, health tech exec, and mom of two. Annie helps ambitious women break free from the “good girl” mold and step fully into their boldest, most aligned vision of success. We talk about balancing a demanding corporate role with a thriving online business, how Anne makes it all look effortless (hint: it wasn't always this way), and the daily strategies that keep her grounded, magnetic, and in motion. Inside This Episode: • The powerful overlap between executive leadership and online coaching • Moving from hustle to harmony without losing your edge • Anne's take on “making it look easy” and what it really took to get there • The mindset shift from “I have to” → “I get to” • Her non-negotiables for health, business flow, and family time • Time-blocking, content strategy, and choosing aligned action • Why support systems (husbands, VAs, mentors, and rooms) matter • The 3 most important tasks to focus on daily Whether you're in your corporate era, coaching era, or doing both this conversation will expand what you believe is possible for women who want it all and want it to feel good. Connect with Annie: Instagram: @annewhitney_ Connect with Kat: Instagram: @katcynewski Website: www.katcynewski.com

Hay una gran diferencia entre “agradar” y VENDER.En este episodio te doy todas mis estrategias para dejar de solo buscar aprobación y empezar a liderar con tu comunicación. Vas a aprender por qué agradar no es lo mismo que influir, y 7 estrategias para Comandar Admiración Intelectual. Hacemos un análisis de como Christian Dior supo Vender Sin Vender y te enseño porque tienes que dejar de sonar como un eco de tu industria. Es hora de aprender como DETONAR ventas sin rogar ni convencer. Para conseguir las notas del episodio y desbloquear el cupón de $77 USD para VENDER SIN VENDER, entra a mi instagram ⁠⁠⁠@isagarcia ⁠⁠⁠y mándame un mensaje por interno que diga 183CUPON.Para crear tu estrategia de ventas más influyente y persuasiva-⁠ Click aquí

In this episode, we explore how virtual assistants can transform your business by streamlining operations, increasing efficiency, and freeing you up to focus on growth. We share practical tips on hiring, training, and integrating VAs into your team, along with common pitfalls to avoid. Whether you're just considering your first VA or looking to scale your virtual team, this episode offers the insights you need to build smart and scale faster.

La Venganza Será Terrible: todo el año festejando los 40 años Estudios AM 750 Alejandro Dolina, Patricio Barton Introducción • Entrada0:01:29 Segmento Inicial • ¿Cómo saber cuándo reemplazar un electrodoméstico?0:08:14 • Oyentes Segmento Dispositivo • Un asunto chino1:00:00 • "Tu Nombre Me Sabe a Yerba" ♫ (Joan Manuel Serrat) Segmento Humorístico • ¿Vas a viajar a las islas Galápagos?: conoce sus costumbres Sordo Gancé / Manuel Moreira (segmento musical grabado, emitido el 25/4) • Presentación • "Lloro Como Una Mujer" ♫ (Celedonio Flores/José María Aguilar) • "Imagine" ♫ (John Lennon) • "El Tercer Hombre (The Third Man Theme)" ♫ (Anton Karas) • "Hey Hey" ♫ (Big Bill Broonzy) • "El Deschave" ♫ (José Tiscornia/Edmundo Rivero) • "Al Ritmo Del Pan Dulce De Rolón" ♫ (Ritmo de Maracas y Bongo, Los Lamas)

¿Qué pasa cuando te sentís triste… Pero no te lo permitís?Hablamos de una emoción que muchas veces evitamos: la tristeza. Vas a descubrir por qué nos cuesta tanto conectarnos con ella, qué mecanismos usamos para escapar, y por qué aprender a sentirla puede ser una puerta a la sanación.Reflexionamos sobre la importancia de dejar de exigirnos estar bien todo el tiempo, y de darle espacio a lo que duele. Porque no todo lo que incomoda está mal. A veces, simplemente necesita ser escuchado.Sentir tristeza no te hace débil. Te hace humano.

In this episode, Adrianne Agulla, CEO of Hamilton Heights Child Development Centers in Nebraska and the true definition of an education entrepreneur, joins Kris. Adrianne shares how she went from working in the corporate world to owning six successful daycares and a catering business called Milton's Amazing Kitchen. Together, she and Kris talk about growing from three to six locations, empowering a leadership team, using VAs to streamline operations, creating a strong scorecard, and what it really takes to scale with excellence. Adrianne goes through the very real ups and downs of growing with intention and building a company that inspires.   Key Takeaways: [6:19] Adrianne owns and operates Hamilton Heights Child Development Centers, with six centers across Nebraska. She originally purchased three as a package in 2017 and has grown from there. She also owns Milton's Amazing Kitchen, a catering company focused on child nutrition. [8:27] Hamilton Heights believes that it's their professional responsibility to protect childhood from all of the external threats in today's world, and they have a focus on play. [9:31] Adrianne's earlier career included leadership roles at Coca-Cola and ConAgra, before pivoting into child care. [11:30] She juggles the business while raising three busy teenagers. [13:46] Adrianne shares reflections plus a funny story about upgrading her wardrobe from a trip to Vietnam. [15:19] What benefits Adrianne has found being part of the highest-level membership of the Child Care Success Academy: the Empire level. [22:15] She explains her leadership structure, including a director of ops, finance lead, and a high-tenure team. [24:15] The leadership team meets weekly to review scorecards and KPIs. Accountability plus support equals success. [28:55] Adrianne shares how she works with three virtual assistants (VAs), including one for marketing, one for data and reports, and one for administrative support. [31:05] She talks about the industry-wide challenge of attracting and retaining staff and how her company stays focused on its leadership vision. [38:37] Her 2025 goals: simplify, streamline, and build an even stronger team. [40:55] Why she acquired a catering business and how it's improved their food program and opened new business channels.   Quotes: “We say that we're very serious about play. And we believe that it's our professional responsibility to protect childhood from all of the external threats in today's world.” — Adrianne [8:27] “That combination of loyalty and commitment and tenure and then new energy and new ideas and fresh faces, has created a really, I think, a unique and just a sustainable culture.” — Adrianne [9:12] “We are working to create an Early Learning Company that inspires because of the opportunity it creates for staff, families, and children, and so we are just trying to be single-mindedly focused on what it means to create abundant opportunities for our staff from a professional development standpoint, from a wage standpoint, and from a benefit standpoint.” — Adrianne [34:40]   Sponsored By: ChildCare Education Institute (CCEI) Use code CCSC5 to claim a free course!   Mentioned in This Episode: Kris Murray @iamkrismurray The Child Care Success Company The Child Care Success Academy The Child Care Success Summit Grow Your Center Childcare Education Institute: use code CDARenewal22 to get $100 off your renewal Hamilton Heights Child Development Center Milton's Amazing Kitchen