Advertise on podcast: BackTable MSK

How is genicular artery embolization reshaping our clinical approach to patients with chronic knee pain? Dr. Rachel Piechowiak and Dr. Faraz Khan, interventional radiologists at IR Centers join Dr. Don Garbett in a deep dive into the current state of Genicular Artery Embolization (GAE). --- SYNPOSIS Dr. Piechowiak and Dr. Khan provide a deep dive on the technical nuances of GAE, covering patient selection, access strategies, and key procedural techniques. The conversation also details complex case scenarios and how to tailor catheters and embolics to navigate challenging anatomy. The doctors then share their structured approach to post-procedure follow-up, underscoring the importance of setting realistic treatment expectations with patients. The episode closes with their perspective on the future of genicular artery embolization, emphasizing the need for robust long-term outcomes data to better define the role of GAE in chronic knee pain management. --- TIMESTAMPS 00:00 - Introduction05:54 - Patient Workup for GAE10:42 - Setting Patient Expectations for GAE16:24 - Procedure Approaches and Techniques30:41 - Understanding Artery Targeting Strategies34:56 - Approaches to Microcatheter Selection38:18 - Choosing the Right Embolic Agents47:43 - Managing Complications and Follow-Ups51:23 - Challenges with Post-TKA Patients54:16 - Future Directions

Frozen shoulder is characterized by progressive motion loss, distinct disease stages, and new treatment opportunities; raising important questions about timing, patient selection, and new interventional strategies. In this episode of the BackTable MSK Podcast, guest host Osman Ahmed welcomes orthopedic surgeon and upper extremity specialist Dr. Sameer Nagda to discuss the intricacies of adhesive capsulitis of the shoulder (“frozen shoulder”). --- SYNPOSIS Dr. Nagda shares his expertise on diagnosing and treating frozen shoulder, including the evaluation process, treatment options, and the role of early intervention. He emphasizes the importance of recognizing the stages of frozen shoulder and the potential benefits of embolization, particularly in the inflammatory stage. Dr. Nagda also shares his journey into shoulder specialization and his collaborative efforts with IR specialists to improve patient outcomes. --- TIMESTAMPS 00:00 - Introduction 04:29 - The Run Down: What is Frozen Shoulder?08:37 - Approaching the Diagnosis of Frozen Shoulder13:51 - Treatment Paradigms 22:48 - Comparing Traditional Treatments vs. Embolization26:39 - An Orthopedic Surgeon’s Perspective on Embolization for Frozen Shoulder35:36 - Surgical Options and When to Consider Them 37:55 - Final Thoughts --- RESOURCES Dr. Sameer Nagda, MDhttps://www.sameernagdamd.com/sameer-nagda-md-sports-medicine-specialist-arlington-va.html Adhesive Capsulitis of the Shoulderhttps://journals.lww.com/jaaos/abstract/2011/09000/adhesive_capsulitis_of_the_shoulder.4.aspx Treatment of Adhesive Capsulitis of the Shoulderhttps://journals.lww.com/jaaos/abstract/2019/06150/treatment_of_adhesive_capsulitis_of_the_shoulder.3.aspx

Your bony fixation technique can make (or break) a complex fracture case. In this episode of the BackTable MSK Podcast, host Kavi Krishnasamy welcomes Dr. Brandon Key, interventional radiologist at Medical College of Wisconsin (MCW) in Milwaukee, to discuss bone stabilization techniques in treating pathologic and non-pathologic fractures. --- SYNPOSIS Dr. Key shares insights into his practice, highlighting the importance of multidisciplinary collaboration with orthopedic surgery, the challenges of training in bony fixation, and the evolving technology that aids in these procedures, including the use of IlluminOss Photodynamic nails in complex bone interventions. Several detailed case studies illustrate the practical application and benefits of these advanced techniques, emphasizing their impact on patient outcomes and functionality. --- TIMESTAMPS 00:00 - Introduction02:06 - A Run Down of Bone Stabilization in the IR Space12:54 - What’s in the Toolbox?17:51 - Patient Preparation and Procedure Setup29:47 - Combining Fixation with Thermal Ablation34:12 - Introducing the Photodynamic Nail by IlluminOss40:22 - “The Learning Curve” of the Photodynamic Nail47:48 - Dr. Key’s Guidance for Practice Building 52:01 - Literature Highlights on IlluminOss 55:01 - Case 1: Anterior Column Disease 01:01:27 - Case 2: Isolated Posterior Column Disease 01:05:37 - Case 3: Non-healing Pathologic Fracture of Pubic Ramus01:09:37 - Case 4: Iliac Wing Fixation with Orthopedic Surgery01:15:40 - Case 5: Sacral Defects01:19:45 - Case 6: Reconstruction of Posterior Iliac Wing 01:23:50 - Post-Procedure Outcomes and Reflections01:29:02 - Final Thoughts: Encouragement for Collaboration and Innovation --- RESOURCES Dr. Brandon Key, MDhttps://www.linkedin.com/in/brandon-key-md-367a01310/ A Prospective Study of the IlluminOss Photodynamic Nail System for Pelvic Stabilization: Treatment of Impending and Actual Fractures from Metastatic Bone Disease, Multiple Myeloma, and Primary Bone Lymphomahttps://pubmed.ncbi.nlm.nih.gov/39281295/ Minimally Invasive Stabilization Using Screws and Cement for Pelvic Metastases: Technical Considerations for the Pelvic "Screw and Glue" Techniquehttps://pubmed.ncbi.nlm.nih.gov/31435131/ IlluminOsshttps://illuminoss.com/us Flow-FXhttps://flow-fx.net/products/

How to stay cool when a thermal ablation case gets complicated? Your toolbox can make all the difference. In this episode of the BackTable MSK Podcast, Dr. Alan Sag returns with host Dr. Jacob Fleming to continue the discussion on thermal protection in musculoskeletal ablation procedures. Part 2 focuses on real-world cases to provide practical insights and illustrate decision-making in complex thermal ablation cases. --- SYNPOSIS Dr. Sag and Dr. Fleming discuss thermoprotection strategies in real-world cases, such as radiofrequency ablation (RFA) of inoperable rectal cancer and sacral metastases near nerve roots. They also discuss the importance of interdisciplinary collaboration, emerging technologies in the field, and the role of intraoperative neuromonitoring. --- TIMESTAMPS 00:00 - Introduction00:55 - Ganglion Impar and Pelvic Pain Strategies09:08 - The Active Thaw Phenomenon18:20 - Nerve Protection During Ablations23:16 - Motor and Sensory Neuromonitoring34:06 - Temperature Management in Ablative Procedures40:28 - Dosing Strategies for Gabapentin and Lyrica in Nerve Injuries42:33 - Future Directions --- RESOURCES Dr. Alan Alper Sag, M.D., FSIRhttps://med.miami.edu/faculty/alan-alper-sag-md-fsir Thermal Protection: Heightened Safety for Minimally Invasive Percutaneous Ablation of Musculoskeletal Tumorshttps://pubs.rsna.org/doi/10.1148/rg.240238 Intraoperative Neuromonitoring for Peripheral Nerve Surgeryhttps://mayoclinic.elsevierpure.com/en/publications/intraoperative-neuromonitoring-for-peripheral-nerve-surgery/

Burns = big consequences. Let’s talk thermoprotection. In this episode of the BackTable MSK Podcast, host Jacob Fleming welcomes longtime friend and colleague Dr. Alan Sag to discuss thermoprotection in musculoskeletal ablation procedures over this two-part episode series. Part 1 focuses on established strategies and new techniques for protecting critical structures during ablation. --- SYNPOSIS Dr. Sag shares how he approaches thermoprotection in complex MSK ablation cases. The discussion covers hydro-dissection techniques, hydro convection needle strategies, pump and tubing set up, troubleshooting, and visualization of the protective layer. --- TIMESTAMPS 00:00 - Introduction02:49 - Thermoprotection 10112:37 - Skin Injury and Mitigation Strategies18:57 - Avoiding Bottlenecks with Hydrodissection23:49 - Practical Recommendations for Cold Skin Protection 29:36 - Managing Complications and Wound Care38:12 - Heating up with RFA and Microwave Ablations --- RESOURCES Dr. Alan Alper Sag, M.D., FSIRhttps://med.miami.edu/faculty/alan-alper-sag-md-fsir Thermal Protection: Heightened Safety for Minimally Invasive Percutaneous Ablation of Musculoskeletal Tumorshttps://pubs.rsna.org/doi/10.1148/rg.240238 Intraoperative Neuromonitoring for Peripheral Nerve Surgeryhttps://mayoclinic.elsevierpure.com/en/publications/intraoperative-neuromonitoring-for-peripheral-nerve-surgery/

Ablate before you radiate. Success with bone tumor ablation may have as much to do with your procedure technique as it does with your ability to collaborate. In this episode of BackTable MSK, interventional oncologist Dr. Damian Dupuy shares his approach to bone tumor ablation with host Dr. Kavi Krishnasamy, and offers practical advice on how to partner with your cancer care team to make ablation a viable treatment option. --- This podcast is supported by: Medtronic Osteocool https://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-2-0-bone-tumor-ablation-system.html --- SYNPOSIS The doctors review the history of bone ablation techniques, including radiofrequency and cryoablation modalities. They discuss the significance of targeting the bone-tumor interface for pain palliation and highlight several case studies to illustrate various techniques and successful outcomes. The conversation also touches upon the synergistic benefits of combining ablation with radiation therapy and emphasizes the importance of multidisciplinary collaboration in treating cancer patients. --- TIMESTAMPS 00:00 - Introduction02:07 - Dr. Dupuy’s Start in Bone Ablation06:29 - Cryo vs. Microwave Therapies08:25 - Dr. Dupuy’s Clinical Trial and Research Involvement 12:49 - Patient Selection and Treatment Strategies25:54 - Sedation and Anesthesia Practices in Bone Ablation28:46 - Treatment Approach: Oligometastases vs. Progressive Disease36:22 - Microwave Ablation in Bone: Future Prospects37:30 - Techniques for Treating Sclerotic and Lytic Lesions40:01 - Skin Protection Methods in Superficial Lesion Treatments41:49 - Reviewing Recent Clinical Trials: MOTION, OPuS One, and More52:35 - Case Studies: Achieving Effective Ablation Techniques01:08:08 - Final Thoughts and Recommendations --- RESOURCES Dr. Damian E. Dupuy, MD, FACRhttps://www.linkedin.com/in/damian-e-dupuy-md-facr-6b080b1b/ Solitary painful osseous metastases: correlation of imaging features with pain palliation after radiofrequency ablation--a multicenter american college of radiology imaging network studyhttps://pubmed.ncbi.nlm.nih.gov/23657892/ Radiofrequency Ablation Provides Rapid and Durable Pain Relief for the Palliative Treatment of Lytic Bone Metastases Independent of Radiation Therapy: Final Results from the OsteoCool Tumor Ablation Post-Market Studyhttps://pmc.ncbi.nlm.nih.gov/articles/PMC10156864/ Cryoablation for Palliation of Painful Bone Metastases: The MOTION Multicenter Studyhttps://pmc.ncbi.nlm.nih.gov/articles/PMC8011449/ A Multi-Center Observational Trial of Symptomatic, High-Risk Bone Metastases Treated with Percutaneous Ablation and Palliative Radiation Therapy (TRIBUTE)https://clinicaltrials.gov/study/NCT06859801

“We learn traditionally that bone metastasis is terminal.” 一 Or is it? In this episode of the BackTable MSK podcast, host Dr. Jacob Fleming welcomes Dr. Francis Lee, a leading figure in orthopedic oncology, to discuss advancements in treating skeletal metastasis. Dr. Lee, the Wayne O. Southwick Professor from Yale and President-elect of the Musculoskeletal Tumor Society, shares his innovative AORIF (Ablation, Osteoplasty, Reinforcement and Internal Fixation) technique, which emphasizes collaboration between orthopedic oncologists and interventional radiologists. --- This podcast is supported by an educational grant from Medtronic. --- SYNPOSIS The conversation covers the complexities of bone metastasis, the biomechanics of skeletal ablation, and the importance of understanding bone-cancer interactions. Dr. Lee also shares insights from his translational research on cancer and bone dynamics, and emphasizes the need for continued interdisciplinary collaboration to drive forward minimally invasive treatments. --- TIMESTAMPS 00:00 - Introduction 01:39 - Crash Course: Orthopedic Oncology 10113:24 - The Important Role of Biomechanics20:10 - Dr Lee’s Training and Interdisciplinary Collaboration28:13 - Intraoperative Imaging and Techniques in AORIF40:15 - Cannulated Screws for Access and Fixation 42:24 - Case Study: Sacral Insufficiency Fracture and Cement Injection44:17 - Understanding Cement Properties and Application46:45 - Case Study Series: Approach to Reconstruction57:58 - Decision Making in Complex Procedures01:08:40 - The Power of Bone Regeneration01:12:31 - Final Thoughts --- RESOURCES Dr. Francis Lee, MD, PhD, FAAOS, MBAhttps://medicine.yale.edu/profile/francis-lee/ Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Boneshttps://pubmed.ncbi.nlm.nih.gov/32139256/

Living in the best of both worlds: balancing pain management and quality of life. In this BackTable MSK Brief, Dr. Mark Amsbaugh and Dr. Ran Lador discuss multidisciplinary approaches to treating spinal tumors with a particular focus on pain management. They explore the complexities of defining and treating pain related to spinal tumors, differentiating between mechanical instability, tumor burden, and neuropathic pain.  The conversation delves into the roles of various treatments including opioids, radiation, nerve blocks, cryoablation, and surgical interventions. They highlight the evolving landscape of spine oncology, emphasizing the need for holistic approaches and the promising future of integrating advanced technologies for better patient outcomes. Episode Outline 00:00 - Introduction  00:53 - Approach to Pain Management in Spine Oncology 02:54 - Multimodal Analgesia 04:25 - What is a Safe Radiation Dose that Spares Spinal Nerves? 07:59 - The Balance Between Quality of Life and Pain Management  09:58 - Final Remarks Resources Dr. Mark Amsbaugh, MD https://med.uth.edu/neurosciences/dr-mark-j-amsbaugh-md/  Dr. Ran Lador, MD https://med.uth.edu/ortho/2022/11/02/ran-lador-md/  Dr. Alexa Levey, MD https://medicine.yale.edu/profile/alexa-levey/

As our understanding of pain physiology evolves, neuromodulation continues to offer new treatment possibilities in MSK pain management. In this episode of the BackTable MSK, host Jacob Fleming discusses the evolving world of neuromodulation with Dr. Timothy Deer, a leading expert in the field. Dr. Deer shares insights from his extensive career and his innovative contributions in neuromodulation.---This podcast is supported by:Medtronic Osteocoolhttps://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-2-0-bone-tumor-ablation-system.html---SYNPOSISThe conversation covers the development of spinal cord and dorsal root ganglion (DRG) stimulation, the significance of patient selection and challenges facing neuromodulation therapies, and exciting developments in the field, including AI. Dr. Deer and Dr. Fleming also discuss the importance of advanced training and the pioneering work by the American Society of Pain and Neuroscience (ASPN) to improve procedural education through its innovative MIS Certification Program.---TIMESTAMPS00:00 - Introduction02:52 - What is Neuromodulation?06:03 - Evolution of Neuromodulation08:49 - Use of Closed Loop and AI 13:58 - DRG Stimulation Explained19:58 - Progression of Peripheral Nerve Stimulation26:26 - Handheld Navigation and Reducing Radiation Exposure 30:18 - The Umbrella of Specialties within ASPN35:15 - Obtaining MIS Certification and Fellowship Program Outlook44:07 - Future Directions of Neuromodulation48:09 - Concluding Thoughts---RESOURCESDr. Timothy Deer, MDhttps://centerforpainrelief.com/doctor-timothy-deer/ American Society of Pain and Neuroscience (ASPN)https://aspnpain.com/

“There is always constant review and constant learning”. In this BackTable MSK Brief, Dr. Mark Amsbaugh and Dr. Ran Lador discuss comprehensive treatment strategies for spinal tumors, highlighting the critical interplay between surgical and radiation oncology.  The doctors explain the complex planning required based on tumor characteristics, including surgical options like en bloc resection and minimally invasive techniques, as well as the advancements in radiation therapy. The conversation emphasizes the importance of collaboration across disciplines to optimize patient outcomes, improve quality of life, and adapt to new medical advancements. Episode Outline 00:00 - Introduction 00:21 - Collaboration Between Surgeons and Interventionalists 05:42 - Intertwined Approach of Radiation and Surgical Treatment 07:37 - Advancements in Radiation Techniques 14:15 - Advancements in Surgical Approach  16:20 - Final Thoughts Resources Dr. Mark Amsbaugh, MD https://med.uth.edu/neurosciences/dr-mark-j-amsbaugh-md/  Dr. Ran Lador, MD https://med.uth.edu/ortho/2022/11/02/ran-lador-md/  Dr. Alexa Levey, MD https://medicine.yale.edu/profile/alexa-levey/

Check your ego at the door! In this BackTable MSK Brief, Dr. Mark Amsbaugh and Dr. Ran Lador share their multidisciplinary approach to the treatment of spinal tumors at the University of Texas and Memorial Hermann in Houston. They highlight the distinctive aspects of their practice, including their extensive collaboration and support system for patients, the intricate process of managing spinal tumors, and the unique challenges and solutions they encounter. The doctors emphasize the importance of teamwork, minimally invasive techniques, and comprehensive patient-centered care to improve treatment outcomes for patients with spinal tumors. Episode Outline 00:00 - Introduction  03:18 - Addressing Potential Barriers in Receiving Spinal Tumor Treatment 04:32 - The Multidisciplinary Approach in Action 07:46 - Minimally Invasive Techniques and Their Impact 09:49 - Navigating Patient Care and Referrals 14:29 - Final Thoughts  Resources Dr. Mark Amsbaugh, MD https://med.uth.edu/neurosciences/dr-mark-j-amsbaugh-md/  Dr. Ran Lador, MD https://med.uth.edu/ortho/2022/11/02/ran-lador-md/  Dr. Alexa Levey, MD https://medicine.yale.edu/profile/alexa-levey/

Are you considering expanding your IR practice into pain management services? Get the download from someone who’s done it already. In this episode of BackTable MSK, Dr. Sean Maratto from Philadelphia's Jefferson Health Network is joined by guest Dr. Junjian Huang from Emory University School of Medicine to discuss the intricacies of building a pain management practice within the interventional radiology space. ---This podcast is supported by an educational grant from Medtronic.---SYNPOSISDr. Huang shares his career journey, highlighting his shift towards pain palliation. The conversation covers a range of topics including procedural insights, patient management strategies, navigating institutional politics, and future trends in orthopedic IR. Dr. Huang emphasizes the importance of balancing patient care with building robust referral networks, and shares valuable advice for budding interventional radiologists.---TIMESTAMPS00:00 - Introduction02:20 - What’s Your Why? Why Pain Intervention? 12:52 - Building a Complex Pain Management Practice24:47 - Marketing a Service Line30:57 - Patient Impact from Pain Management Services39:53 - Recommendations and Indications for Cryoneurolysis and BVNA 45:36 - Post-Procedure Follow-up and Psychosomatic Pain Guidance52:35 - Insight to the Future of Interventional Pain and Final Thoughts---RESOURCESDr. Junjian Huang, MDhttps://med.emory.edu/directory/profile/?u=JHUAN22 Dr. Sean Maratto, MDhttps://www.jeffersonhealth.org/find-a-doctor/m/maratto-sean-a

To ablate or not to ablate? That is the question. Learn how to tackle complex and unique cases of kyphoplasty and spinal ablation in part two of our discussion with Dr. Asad Baig and host Dr. Michael Barrazza.---This podcast is supported by an educational grant from Medtronic.---SYNPOSISThis episode looks at the ins and outs of real-world kyphoplasty and spinal ablation cases, including detailed patient histories, diagnostic techniques like the Oswestry Disability Index and Roland-Morris Disability Questionnaire, and the challenges of treating patients with extensive spinal hardware, osteoporosis, and other complicating factors.---TIMESTAMPS00:00 - Introduction01:38 - Hx of Osteoporosis and Previous Kyphoplasty04:06 - Challenges in Identifying Fractures05:29 - Tool Selection and Technique10:35 - Post-Kyphoplasty Follow-Up and Patient Outcomes13:29 - Importance of Timely Treatment18:13 - Weight Loss and Cancer Concerns28:26 - Final Thoughts and Takeaway---RESOURCESDr. Asad Baig, MDhttps://doctors.columbia.edu/us/ny/new-york/asad-baig-md-51-west-51st-street OsteoCool RF Ablation System by Medtronichttps://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-radiofrequency-ablation-system.html

From patient selection to procedure technique–learn the key insights that shape a successful kyphoplasty and spine ablation practice. In this episode of the BackTable MSK Podcast, host Dr. Michael Barraza welcomes back Dr. Asad Baig, an Interventional Radiologist and director of the Interventional Spine Center at Columbia University. They discuss the latest developments at Columbia, focusing on exciting expansions in the interventional radiology and spine realms. The primary focus of their conversation is on advanced techniques in spine ablation and kyphoplasty, and the ideal patient profile for these treatments.---This podcast is supported by:Medtronic OsteoCoolhttps://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-2-0-bone-tumor-ablation-system.html---SYNPOSISDr. Baig begins the episode by explaining the importance of collaborating with radiation oncologists and spine surgeons to optimize patient outcomes and emphasizes considerations, such as bone quality, prior to a spinal ablation. The episode also features Dr. Baig’s approach to treating sclerotic versus lytic lesions with his insights on navigating complex cases involving post-radiation fractures and internal fixation complications. This first episode of a two-part series emphasizes a multi-disciplinary approach and the need for precise imaging and patient communication when treating patients with spinal ablation.---TIMESTAMPS00:00 - Introduction 01:31 - Evaluating Patients Prior to Spine Ablation 09:02 - Who is the Ideal Candidate for Ablation Kyphoplasty?14:24 - Approaching Lesions Within the Vertebral Body21:26 - When is it Appropriate to Use Balloons After an OsteoCool Ablation?27:58 - Approach to Patients with Significant Vertebral Height Loss35:33 - Challenging Cases with Kyphoplasty39:02 - Sclerotic versus Lytic Lesions---RESOURCESDr. Asad Baig, MDhttps://doctors.columbia.edu/us/ny/new-york/asad-baig-md-51-west-51st-street OsteoCool RF Ablation System by Medtronic https://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-radiofrequency-ablation-system.html

Resorbable embolics are gaining traction in musculoskeletal interventions, but what are the key technical considerations? Dr. Keerthi Prasad, interventional radiologist at the Centers for Pain Control and Vein Care joins host Dr. Ally Baheti to share practical insights when using resorbable embolics in MSK interventions.---This podcast is supported by:Medtronic OsteoCoolhttps://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-2-0-bone-tumor-ablation-system.html---SYNPOSISDr. Prasad opens the conversation with an overview of embolic agents used in MSK interventions—including Imipenem, Lipiodol, and Nexsphere-F—and shares practical insights into technique selection. He explores the nuances of working with various resorbable embolics, highlighting clinical cases from his personal experience. The discussion also highlights Dr. Prasad’s innovative approach to establishing an outpatient-based lab (OBL) focused on musculoskeletal interventions. Additionally, Dr. Prasad also offers insight into the expanding role of resorbable embolics in treating conditions such as knee arthritis, plantar fasciitis, and adhesive capsulitis. The episode ends with a call to broaden access to this evolving treatment.---TIMESTAMPS00:00 - Introduction01:55 - Outpatient Embolization and MSK Procedures04:20 - Resorbable Embolics in Joint Embolization04:52 - Available Resorbable Embolics in the US07:57 - Technical Insights on Using Resorbable Embolics15:18 - Patient Outcomes and Long-Term Durability22:24 - Future of MSK Embolization Techniques24:05 - Exploring New Applications for Resorbable Embolics27:30 - Innovative Procedures and Techniques37:00 - Final Thoughts and Advice for Practitioners