In this episode, Dr. Brian Joves shares a personal journey of confronting cancer and how it reshaped his perspective on nutrition. Despite the fact that most physicians receive only a few hours of formal training in nutrition, diet remains one of the most powerful—and underutilized—tools in medicine.We’ll discuss:Why nutrition education is lacking in medical training.The dangers of the Standard American Diet (SAD) and its role in chronic disease and pain.The science behind ketogenic diets, the Warburg effect, and what emerging research says about cancer and metabolism.How nutrition quality directly impacts chronic spinal pain and recovery.Practical, evidence-based ways patients can improve wellness and resilience—whether managing cancer, chronic pain, or simply aiming for better health.Key Takeaways:Nutrition is foundational—not optional—for long-term health, recovery, and resilience.Cancer and chronic pain share a common thread: both are influenced by inflammation, metabolic health, and lifestyle choices.Medical interventions—whether injections, medications, or surgery—are more effective when paired with better nutrition, movement, rest, and mindset.Patients don’t need to overhaul everything at once. Small, consistent changes—reducing processed foods, improving diet quality, and focusing on whole foods—can be transformative.Want to dive deeper into the link between nutrition and pain? Check out my prior episodes here:Nutrition and Chronic Pain (https://spotifycreators-web.app.link/e/eo3TZcNloWb?utm_source=chatgpt.com)Nutrition, Inflammation, and Pain Medicine (https://open.spotify.com/episode/18CCOiYVIN2yN4wOO2Xuwi?si=DQM3SJgwS5-Nj0Er_4P5Hg&utm_source=chatgpt.com)

In this episode, I take a step back from the usual discussions on interventional pain medicine to share something deeply personal. Recently, I was diagnosed with oral cancer—an unexpected and humbling moment that has given me a new lens through which to look at health, wellness, and the work we do every day in medicine.

This experience has reminded me of two important truths:

1. Health is never guaranteed. It requires intentional, daily choices.

2. True wellness goes beyond treating disease. It’s about prevention, proactive care, and balance—physical, emotional, and even spiritual.

We’ll explore how evidence-based medicine and wellness intersect, and why these conversations need to expand beyond procedures and medications. That means screening for silent diseases, prioritizing exercise and nutrition, managing stress, and building sustainable habits that allow us to live fully—not just avoid pain.

As a physician, as a patient, and as someone who has lived both sides of the exam room, I want to use this chapter of my life to expand the dialogue. My hope is that this conversation will not only resonate with those struggling with chronic pain, but also with anyone who needs the reminder that wellness is an ongoing journey—one that requires attention before the crisis, not just after it.

Takeaway: Wellness isn’t an abstract idea. It’s something we can integrate into pain medicine, into our personal lives, and into the daily decisions that shape our future health.

In this episode of the Spine & Nerve Podcast, Dr. Brian Joves and Dr. Jason Kung dive into the evolving world of peripheral nerve stimulation (PNS). As the field of pain medicine continues to progress, new studies are offering more insights into advanced therapies for challenging conditions like peripheral neuralgia and chronic pain. This discussion focused on the COMFORT study, which evaluates the efficacy of the Nalu PNS System, and discuss recent data presented at the American Society of Regional Anesthesia and Pain Medicine (ASRA) meeting concerning the SPRINT PNS System. Key Topics Covered: COMFORT Study Insights: The doctors analyze the one-year data from the COMFORT trial, a randomized controlled study assessing the Nalu PNS System combined with conventional treatments versus conventional treatments alone for chronic neuropathic pain. They highlight significant findings, including an 87% responder rate with an average pain reduction of 69% among responders at 12 months. SPRINT PNS System Data: Discussion extends to new data from the SPRINT PNS System, particularly the RESET Clinical Trial, which compares 60-day percutaneous PNS to standard interventional management for chronic low back pain. The trial's primary endpoint results indicate that PNS provided clinically meaningful and statistically superior reductions in pain, as well as improvements in function and quality of life. Clinical Implications and Future Directions: Dr. Joves and Dr. Kung explore the broader implications of these studies for clinical practice, emphasizing the importance of personalized treatment plans and the potential for PNS therapies to offer durable pain relief. They also discuss the evolving landscape of pain management and the need for ongoing research to refine and validate these therapeutic approaches. Resources and Links: https://nalumed.com/clinical-trials/comfort-trial/ https://www.sprtherapeutics.com/2024/11/21/new-sprint-pns-data-for-low-back-shoulder-knee-and-headache-at-23rd-annual-asra-pain-medicine-meeting/ Follow us on LinkedIn: ⁠Jason Kung, MD and Brian Joves, MD⁠ Subscribe to the Spine & Nerve Podcast everywhere podcasts are available Keep striving to provide the best care for your patients and stay informed on the evolving practices in pain management! This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

Episode Overview: In this episode, Dr. Brian Joves sits down with Dr. Scott Pritzlaff, an esteemed pain management specialist and the residency program director at UC Davis, to tackle some big questions on the current state and future of pain medicine. They dive into Dr. Pritzlaff's recent thought-provoking editorial, "From Pain Medicine to Pain Surgery: How Our Specialty Lost Its Way," which critiques the field’s shifting focus toward procedures at the expense of comprehensive patient care. Together, Dr. Joves and Dr. Pritzlaff discuss challenges in pain medicine, including recruitment issues, the evolving landscape of interventional procedures, and the complexities of training the next generation of pain specialists.

Key Topics Discussed:

• The Evolution of Pain Medicine:

  • Dr. Pritzlaff explains the rapid technological advancements in pain medicine, especially in peripheral nerve stimulation, spinal cord stimulation, and minimally invasive spine procedures.
  • While these advancements offer more options for patients, he warns that they can overshadow the core values of patient-centered care and non-procedural management.

• Pain Medicine’s “Identity Crisis”:

  • In his editorial, Dr. Pritzlaff questions the growing emphasis on procedures and the trend of “pain surgery” within the specialty.
  • He emphasizes that pain management is about more than just interventions—it’s about the art of diagnosis, multidisciplinary treatment plans, and knowing when not to perform procedures.
  • This emphasis on procedure-heavy training, he argues, risks alienating future specialists who are passionate about comprehensive patient care.

• The Challenge of Training in a One-Year Fellowship:

  • With the increasing complexity of pain medicine, a one-year fellowship may no longer suffice.
  • Dr. Pritzlaff advocates for an expanded training period to cover essential skills, such as advanced imaging interpretation, opioid and multimodal pharmacology, and honing the “soft skills” crucial for patient communication and holistic care.

• Recruitment Issues in Pain Medicine:

  • Pain medicine residency applications have dropped, especially from anesthesiology—a trend driven largely by competitive anesthesiology salaries and demand.
  • Dr. Pritzlaff and Dr. Joves discuss how pain medicine needs to rebrand itself to attract applicants who are passionate about improving patients’ quality of life through comprehensive care, not just procedures.

• Future Training Models and Vision for Pain Medicine:

  • A 2 year fellowship model or a dedicated residency program are presented as potential solutions to better prepare trainees.
  • Dr. Pritzlaff imagines a program where the first year focuses on foundational knowledge and multi-disciplinary skills, and a second year sharpens advanced interventional skills.

Takeaways for Listeners:

• Pain medicine is at a pivotal point, balancing advancements in interventional procedures with the traditional values of comprehensive patient care.
• The field must prioritize holistic training and mentorship to foster well-rounded pain physicians who can deliver thoughtful, personalized care.

Links & Resources:

• Dr. Scott Pritzlaff’s Editorial: "From Pain Medicine to Pain Surgery: How Our Specialty Lost Its Way" in the Journal of Pain Research
• Connect with Dr. Pritzlaff and Dr. Joves on Linkedin or Twitter

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In this episode of the Spine & Nerve podcast, Dr. Brian Joves sits down with Dr. Richard Winters, an emergency physician, leadership coach, and author, to discuss leadership, coaching, and the unique challenges physicians face as they transition into leadership roles. Whether you're early in your career or a seasoned physician looking to expand your leadership skills, this episode offers practical advice on how to build a successful career in medicine while growing as a leader.

Key Takeaways:

🩺 Leadership at All Levels: Dr. Winters explains that leadership doesn't just come from holding formal titles—it's about how we lead in our everyday roles as physicians, working with our teams, and even interacting with patients and their families.

🔍 Understanding the Difference Between Mentorship and Coaching: Dr. Winters breaks down the critical distinction between mentorship and coaching, emphasizing how mentors provide guidance based on their experiences, while coaches help you unlock your potential by asking the right questions and facilitating growth.

💡 Overplaying Expertise: One common pitfall physicians face, especially early in their careers, is overplaying their expertise. Dr. Winters highlights the importance of knowing when to lead as an expert and when to step back and facilitate collaboration, especially in complex, uncertain environments.

🤝 Leading Teams & Self: As a physician leader, it’s essential to learn how to lead small teams, larger organizations, and, most importantly, yourself. Dr. Winters discusses the value of self-awareness and continuous personal development.

💬 Quotes from the Episode:

• "Expertise is valuable, but knowing when to step back and allow others to contribute can be even more powerful."
• "Physician leadership isn’t just about running committees or managing departments—it’s about how we interact, communicate, and support the people around us every day."
• "Coaching is about helping people find their own answers. It’s not about telling them what to do."

📈 Practical Applications:

• For New Leaders: If you're stepping into a leadership role for the first time, this episode will help you understand the dynamics of leading teams and how to balance your role as an expert with that of a coach.
• For Mentors and Coaches: Learn how to support younger physicians by balancing mentorship and coaching, helping them grow without imposing your own path on them.

Resources:

• Dr. Winters' Book: You're the Leader, Now What?
• Richard Winters Website
• Connect with Dr. Winters on LinkedIn and Twitter

🎧 Don’t forget to subscribe to the Spine & Nerve Podcast for more conversations with leading experts on pain management, leadership, and healthcare!

#LeadershipInMedicine #PhysicianCoach #BrianJovesMD #RichardWinters #HealthcareLeadership #CoachingInMedicine #SpineAndNerve #Podcast

The Pros and Cons of Ambulatory Surgery Centers (ASCs) vs. Office-Based Procedure SuitesWelcome back to another insightful episode! Today, we’re diving deep into a topic that’s been on the minds of many healthcare providers: the differences between Ambulatory Surgery Centers (ASCs) and office-based procedure suites. Joining us is Teri Yates, an expert in helping physicians navigate the complexities of practice management and facility development. Whether you're a solo practitioner or part of a growing group, understanding the pros and cons of these options is crucial for optimizing your practice.

In This Episode, We Cover:

- The Key Differences Between ASCs and Office-Based Procedure Suites:Learn what sets these two options apart, from regulatory requirements to billing practices, and why the choice matters for your practice.

- The Benefits and Challenges of Setting Up an ASC: Discover why ASCs require a significant investment but can offer unparalleled control over your operations, leading to increased efficiency and patient satisfaction.

- The Hybrid Model Explained:Some physicians are choosing to combine both ASCs and office-based suites in one facility. Find out how this approach can provide flexibility and maximize reimbursement.

- Why a Feasibility Study is Essential:Before jumping into ASC development, a feasibility study is crucial. We discuss the key factors that should influence your decision, including case volume and state regulations.

- Long-term Strategic Considerations:Thinking about the future? We explore how owning an ASC can be a valuable asset, offering opportunities for future sale, real estate investment, and even a retirement plan.

Why You Should Listen:

If you’re considering expanding your practice or simply want to understand the best operational setup for your needs, this episode is packed with actionable insights. Teri Yates shares expert advice that could help you make informed decisions about the future of your practice.

Connect with Terri Yates:

- Website: Doc Centric Surgery Centers www.doccentricasc.com-

Contact: Teri Yates - Accountable Physician Advisors teri@accountableconsultants.com

Don’t miss this episode if you’re looking to enhance your practice’s efficiency, revenue, and future potential!

In this episode of The Spine & Nerve Podcast, Dr. Jason Kung and Dr. Brian Joves break down the new California opioid guidelines with insights that every healthcare provider and pain management specialist should know.

Our doctors explore the latest guidelines from the California Medical Board, published in July 2023 and designed to navigate the complexities of prescribing opioids in chronic pain management. Whether you're in California or beyond, this episode is a must-listen to understand the evolving landscape of pain treatment.

1. Understanding the New Guidelines

   • Published in July 2023, these guidelines are a response to the opioid crisis and aim to balance effective pain management with reducing opioid-related risks.

2. Patient-Centered Approach

   • Discover how the new guidelines emphasize a patient-focused approach. From initial evaluations to risk assessments- the guidelines highlight the importance of treating each patient as an individual, tailoring treatments to their specific needs and conditions.

3. The Role of Documentation

   thorough documentation in pain management is critical. Proper documentation not only supports clinical decisions but also safeguards both the provider and the patient throughout the treatment process.

4. Managing High-Risk Patients

   • Explore strategies for managing patients at high risk of opioid misuse. The guidelines provide tools for assessing and mitigating risks, ensuring that opioid therapy is reserved for those who will benefit most and are least likely to experience adverse outcomes.

5. Opioid Tapering and Legacy Patients

   • The team discusses the sensitive topic of tapering long-term opioid therapy, particularly for legacy patients who have been on high-dose opioids for extended periods. Learn how to approach tapering with caution to minimize patient distress and maximize safety.

6. Telehealth and Pain Management

   • Understand the role of telehealth in pain management as outlined in the new guidelines. While a valuable tool, telehealth requires careful use to ensure that patients receive appropriate examinations and care.

• Social Media Spotlight: Dr. Kung shares his experience rejoining social media through LinkedIn, offering a glimpse into how pain management professionals stay connected and informed.

• Breaking Down the Guidelines: A detailed exploration of the California Medical Board’s opioid guidelines, including patient evaluation, risk assessment, and non-opioid treatments.

• Explore the California Opioid Guidelines: Access the document directly from the show notes to understand the specifics and apply them in your practice.
• Engage with Us: Subscribe to the Spine & Nerve podcast, share this episode with your colleagues, and join the discussion on LinkedIn and other social media platforms.

"Pain relief is important, but it is difficult to measure objectively. Our goal is to maintain or improve function while managing pain effectively." - Dr. Brian Joves

Dive into this episode and equip yourself with the knowledge and tools to navigate the complex world of pain management with confidence and compassion.

• California Opioid Guidelines: Access the full guidelines here
• Follow us on LinkedIn: Jason Kung, MD and Brian Joves, MD
• Subscribe to the Spine & Nerve Podcast everywhere podcasts are available

Keep striving to provide the best care for your patients and stay informed on the evolving practices in pain management!

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In this episode of The Spine & Nerve Podcast, Dr. Dr. Jason Kung and Dr. Brian Joves have a reflective and forward-looking discussion as we transition from 2023 into 2024, sharing our podcast's journey, personal insights, biggest happenings in pain medicine, and anticipations for the new year. 1. Podcast Journey and Global Reach: Transitioning through 2023: The evolution of our podcast through the year. Spotify Wrapped Insights: A deep dive into our audience demographics, celebrating a significant international listenership with a special shoutout to our friends in New Zealand, India, Spain, Brazil, and Hungary. 2. Engaging Medical Discussions: Spotlight Episode - Spinal Stenosis: Discussion on why our spinal stenosis episode resonated with so many listeners and the importance of addressing prevalent health issues. Medical Innovations and Literature: A look back at the year's significant advancements in radiofrequency ablation and the evolving landscape of pain management. 3. Personal Reflections and Resolutions: Embracing Challenges: The team's participation in a Spartan Race, symbolizing our dedication to personal growth and community engagement. 4. Community Impact and Listener Engagement: Top 10 Recognition: Celebrating being in the top 10 of listeners' favorite podcasts and what it means to us. Listener Interaction: Encouraging feedback, stories, and engagement from our global audience. 5. Looking Forward to 2024: Medical Community and Conferences: Anticipation for upcoming medical conferences, new technologies, and the continuing battle against the opioid crisis. Optimism for the Future: Our commitment to staying informed, optimistic, and ready to tackle the challenges and opportunities the new year brings. Closing Thoughts: A heartfelt thank you to all our listeners for their continued support and engagement. We look forward to another year of learning, growth, and community. Contact Information: We Encourage listeners to stay connected through our social media channels (LinkedIn, YouTube, Twitter (X), and Facebook are the easiest), website, and Spotify Podcast page for feedback, questions, and community stories. Disclaimer: Reminder that the information provided is for educational purposes and is not intended as medical advice. Always consult with a healthcare professional.

In this episode of the Spine & Nerve podcast, Dr. Jason Kung and Dr. Brian Joves delve into a comprehensive discussion surrounding anticoagulation guidelines and their implications in interventional pain procedures.

With over a hundred thousand downloads and over 1,000 YouTube subscribers, we would like to express our sincere gratitude to all the listeners for your engagement and support. Please continue to share and subscribe to help more people discover the podcast.

Today's episode focuses on the safety of epidural steroid injections and the critical role of anticoagulation management.Understanding the rationale behind a patient's anticoagulation therapy is vital for interventional pain physicians. This approach empowers clinicians to make informed decisions about whether to continue or withhold anticoagulation medications prior to procedures. There is a delicate balance between patient-specific risks and the benefits of these interventions.

One of the things that must be known and emphasized is the remarkable safety profile of epidural steroid injections. Approximately nine million epidural steroid injections are administered annually, resulting in an adverse event rate of about one in 780,000. This reassuring statistic is attributed to the collaborative efforts of medical societies and the implementation of strict anticoagulation guidelines. The hosts emphasize the role of fluoroscopic guidance, non-particulate steroids, and avoidance of deep sedation in enhancing the safety of these procedures.

The episode further delves into the nuances of assessing bleeding risks in patients undergoing interventional pain procedures. As always, we must underscore the importance of a comprehensive physical examination, with a specific focus on identifying signs of easy bruising and mucosal bleeding. The hosts discuss the relevance of specific medications, including aspirin and NSAIDs, and their implications for procedural safety.

The hosts engage in an insightful exploration of the guidelines for managing anticoagulation medications pre- and post-procedure. They stress the need for pain physicians to consider the anatomical location of the intervention and evaluate the potential risks versus benefits.

The doctors conclude the episode by highlighting the crucial role of shared decision-making and patient education. By fostering collaboration between patients and physicians, the hosts emphasize the creation of a safe and informed healthcare environment.In this thought-provoking episode, the doctors try to help you navigate the complexities of anticoagulation management in interventional pain procedures, and offer some insights for practitioners seeking to provide the highest level of care to their patients.

References:

Anesthesia Quality Institute Closed Claims Database Review 2011 through 2021 for Epidural Steroid Complications. Naeem Haider. Pain Physician 26 (3), E251, 2023

Stephen Endres, MD and others, The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures, Pain Medicine, Volume 18, Issue 3, March 2017, Pages 403–409, https://doi.org/10.1093/pm/pnw108

Narouze S, Benzon HT, Provenzano D, et alInterventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of PainRegional Anesthesia & Pain Medicine 2018; 43:225-262.

The ASRA App: https://www.asra.com/the-asra-family/asra-app

In this episode, we have a special guest, Dr. Nikhil Verma, who shares his inspiring journey from undergrad to establishing his own medical practice. Dr. Verma opens up about the challenges he faced, the pivotal moments that shaped his career, and the lessons he learned along the way. Join us as we delve into his story of perseverance, passion, and the pursuit of personalized medicine. Episode Highlights: Dr. Verma recounts his early struggles and the uncertainties he faced during his pursuit of medical school. Despite not getting accepted initially, he used the time to reflect and explore different options, eventually finding his way to St. George's University. The importance of resilience and perseverance shines through as he shares how he overcame setbacks and stayed motivated. Dr. Verma's interest in rehabilitation medicine and sports medicine grew during his residency. He shares how his personal experience with a sports-related injury shaped his perspective and ignited his passion for helping others through physical therapy and non-surgical interventions. Dr. Verma discusses the decision to open his own medical practice, highlighting the challenges and rewards of being an independent practitioner. From finding the ideal location to setting up the practice and acquiring necessary equipment, he shares the steps involved in laying the groundwork for his venture. Dr. Verma emphasizes the importance of tailoring treatments to individual patients, providing temporary relief while considering long-term solutions. He highlights advanced procedures and technologies that enable more targeted and effective interventions, showcasing the potential impact of personalized medicine.

Dr. Verma encourages med students and early residents to stay open-minded and embrace change. He shares the significance of finding passion and purpose in one's work, reminding listeners that it's okay to evolve and pursue new interests within the medical field.

Dr. Nikhil Verma's story is a testament to the power of determination, adaptability, and following one's true calling. His journey from facing initial rejections to establishing a successful practice showcases the importance of resilience and finding personal fulfillment in the medical profession. Join us in thanking Dr. Verma for sharing his insights and experiences. Tune in to the full episode to hear his story in his own words.

You can find Dr. Verma on all your favorite social platforms, as well as our hosts.

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In this week's episode of the Spine & Nerve podcast, we have a return guest! Dr. Hunter Vincent returns to the show to chat with Dr. Brian Joves about health coaches and how they can help your patients to be more successful in their journey with and through chronic pain.

In this episode we'll discuss:

What is a health coach?

Where does this fit into the treatment and provider paradigm?

How can ancillary team members like health coaches help your patients and your team to be more successful?

Dr. Vincent is the CEO of Pogo Health. He is a double board certified physician who received his residency training from UC Davis in Physical Medicine & Rehabilitation (PM&R) with a subspecialty certification in Pain Medicine from UCLA. Prior to starting his medical training, he received a Bachelor's of Science in Exercise Biology. He has spent the last decade actively involved in healthcare initiatives focused on maximizing patient engagement in their own health journey. He has worked with various healthcare teams in the fields of clinical obesity, chronic pain, and neurological disorders. 

Pogo Health is a virtual platform Virtual that utilizes a team approach to treating chronic pain. Their interdisciplinary opioid-free approach integrates the pain physician, pain therapist and specialized health coach to create a completely virtual and customized treatment program. The Pogo Health multi-modal approach utilizes evidence based techniques to provide long term physical and mental health benefits to combat chronic pain.

Learn more at https://pogo-health.com/

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In this week's episode of the Spine & Nerve Podcast we would like to introduce you all to the newest member of the Spine & Nerve family... Dr. Jason Kung.  Jason Kung, MD, is a board-eligible anesthesiologist and interventional pain physician who joined Spine & Nerve last year. Listen in as Brian Joves, MD gets to know Dr. Kung better and explore his journey into medicine and to discovering his passion for pain medicine.

He  graduated from the University of San Francisco in California with a  bachelor's degree in biology. He then went to Boston University School  of Medicine in Massachusetts for his medical degree.

Dr. Kung  completed his residency in Anesthesiology and fellowship in  Interventional Pain at Harvard Medical School, Massachusetts General  Hospital in 2020.

Dr. Kung specializes in several interventional  procedures, including spinal cord stimulation, epidural injections,  radiofrequency ablations, implantable devices, and ultrasound-guided  nerve/joint injections. He strives to provide  compassionate evidence-based care to all his patients.

He is certified as an instructor in  medical simulation. Dr. Kung has completed research and published in the  areas of bone healing and the effects of natural sources of vitamin D.

During  his free time, he enjoys playing guitar, surfing/snowboarding, and  exploring California with his wife and dog. 

This podcast is for information and educational purposes only, it is not  meant to be medical or career advice. If anything discussed may pertain  to you, please seek council with your healthcare provider. The views  expressed are those of the individuals expressing them, they may not  represent the views of Spine & Nerve.