Podcasts about clinical endocrinologists

Deb (00:03.606)Within the next seven months, up to 1.5 million Americans could lose access to a medication that they’ve relied on for decades. Not because it’s dangerous, but because a pharmaceutical giant may have lobbied the FDA to eliminate their competition. And if you’re one of them, your doctor may already have told you about this issue and stopped prescribing it.This isn’t a conspiracy theory. This is documented in federal court filings. This is happening right now. And the company that stands to profit, well, they’re the same ones manufacturing the only product that might survive.Today on Let’s Talk Wellness Now, we’re exposing the desiccated thyroid extract crisis, the corporate manipulation behind it, and what you need to do right now to protect your health. Stay with me because I’m about to share what could save your access to the medication keeping you alive.Welcome back to Let’s Talk Wellness Now, the show where we uncover the root causes of chronic illness, expose regulatory capture in healthcare, and empower you with the tools to advocate for yourself. I’m Dr. Deb, naturopathic doctor, your medical detective, and today we’re diving into one of the most consequential and corrupt healthcare decisions affecting patients right now. If you or someone you love takes Armour thyroid, NP thyroid, or any desiccated thyroid extract,for hypothyroidism or if you’ve struggled to find a thyroid medication that actually works for your body, this episode is absolutely critical. And if you have celiac disease, gluten sensitivity or corn allergies, what I’m about to reveal will make your blood boil. Now grab your cup of coffee, don’t forget your notebook and settle in because what’s happening to this medication right now is a masterclass in how pharmaceutical companies use regular Deb (02:06.544)agencies to eliminate competition, control markets, and price gouge patients. And I have all the receipts. Deb (02:20.982)Let me start with what might surprise you. Desiccated thyroid extract, or DTE as we call it, is actually one of the most oldest thyroid medications in the world. And I mean old. From the 1890s through 1970, this was the standard treatment for hypothyroidism.Now let’s really dive into that. From the 1890s to the 1970s, this was standard hypothyroidism treatment.In 1965 alone, and this is documented in peer-reviewed literature published in the Journal of Clinical Endocrinology and Metabolism, approximately four out of every five prescriptions for thyroid hormone in the United States were of natural desiccated thyroid preparations.The Journal of Clinical Endocrinology and Metabolism is a very high-end journal. Now think about that. This wasn’t some fringe therapy. This was mainstream medicine. Armour Thyroid, the most recognizable brand name, has been manufactured since the early 1900s, well over a century ago.and this is cited again in NIH bookshelf. When the FDA was officially established in 1938, Arbor thyroid was already on the market. And this is important and I want you to understand why. Under the federal Food, Drug and Cosmetic Act, any drug that was already being marketed before 1938 was automatically grandfathered into the system. That means it didn’t have to Deb (04:08.112)go through the formal FDA approval process. And this again is cited under the Federal Food, Drug and Cosmetic Act, grandfathered drugs and exemptions. And this is crucial to understanding what happens next. By the 1970s, synthetic levothyroxine, brand name Synthroid and generics became the preferred treatment. Hmm, wonder why?It was easier to standardize, came into consistent doses, and worked well for most patients, and could be mass manufactured. By the 1980s, levothyroxine had largely replaced desiccated thyroid in clinical practice, according to the American Thyroid Association 2014 guidelines for the treatment of hypothyroidism. But here’s what matters. Some patients…a very significant minority of them, never felt right on levothyroxine alone. Despite their lab work looking normal, they still had fatigue, brain fog, weight gain, cold intolerance, and depression.These patients often found relief when they switched back to their desiccated thyroid, which contains both T4 and T3 hormones, the way human thyroid naturally produces them. And this is not anecdotal. This is documented in randomized double-blind crossover studies published in Endocrine Practice.For decades, that was fine. Their doctors prescribed it, insurance sometimes covered it, patients were getting better, and the system worked really well. Until August 6th of 2025, just a short time ago, everything changed. On that date, the FDA sent letters to manufacturers, importers, and distributors of desiccated thyroid extract products stating that these medications would need an approval. Deb (06:04.654)a biologics licensed application, a BLA, to remain legally on the market. And this is cited in the FDA’s official statement, FDA’s actions to address unapproved thyroid medications. understand it says unapproved thyroid medications. However, desiccated thyroid, specifically Armour, has been approved since 1938. And this was dated August 6th through 7th, 2025.This wasn’t a guideline. This wasn’t a suggestion. It was an endorsement of action. And the timeline they gave them? Well, just 12 months to transition patients to another medication before enforcement action could begin.This was also cited by an FDA notice to the industry, animal derived thyroid products notice to industry, August 6th, 2025. Now do the math, that means August 2026, seven months from now, 1.5 million Americans currently taking this medication. And this number comes from the FDA official statement, citing that it’s an estimation of 1.5 million patients receiving prescriptions for these medications.could potentially lose their thyroid access. Now, here’s where it gets interesting. The FDA didn’t wake up in August of 2025 and decide to regulate desiccated thyroid after a century. This decision has a much longer backstory. And understanding that backstory is critical to understanding what’s really happening in this industry.The shift started in 2022. Back in September of 2022, over three years ago, an FDA branch chief sent a letter to the National Associations of Boards of Pharmacy noting that the agency had decided to designate DTE as a biological product, which would affect its eligibility for compounding. Deb (08:13.972)This also is cited in an FDA letter to the National Association of Boards of Pharmacy September 2022.Then two months later, in November of 2022, the FDA’s Office of Compounding Quality and Compliance sent a softer letter acknowledging that many Americans take medication to treat hypothyroidism and some choose to take DTE products. The letter stated that the FDA would focus enforcement on cases that pose the greatest public health risks, such as serious adverse offense or serious product quality or adulteration.also is cited by an FDA letter from Francis G. Bromel, the director, Office of Compounding Quality and Compliance, November of 2022. Now, let me just think about this for a second. If this drug has been on the market since the 1800s, been FDA approved since 1938, would we not have seen a health crisis long before 2022?I honestly don’t know of any other drug that’s been around this long that’s used by this many people. Now granted, I haven’t done the research on it either, which I can do for you guys, but I’m just thinking if a drug is on the market today and it causes harm, it doesn’t make it three years, five years before you see lawsuits everywhere. Why are there no lawsuits on this drug? Why are there no major reactions that people are seen having?Hmm, just thought. But here’s the pattern. The FDA was already laying the groundwork back in 2022, testing the waters, signaling where this was headed. The August 2025 action. Then this came down. Deb (10:09.806)August 6, 2025, the FDA announced its position publicly and sent formal letters to all DTE manufacturers, importers, and distributors. This was cited by the FDA Enforcement Action August 6, 2025, letters to manufacturers, importers, distributions of DTE products. The agency stated several concerns. First, DTE products have experienced quality and dosing issues.The FDA cited, and I’m quoting directly from their statement, over 500 adverse events reported associated with DTE products from 1968 to 2025. From 1968 to 2025, we had 500 adverse reactions? What is that math equate to?A couple a year? Come on guys, this is insane! With a substantial increase, you, between 2019 and 2020 that the agency suggested was related to voluntary recalls of sub-potent or super-potent products.This was cited in the FDA statement, over 500 adverse events reported associated with ADT products from 1968 through 2025.Second, the agency expressed concern about batch inconsistency. According to the FDA’s official statements, tablets made from the same manufacturing batches may not always provide the same thyroid hormone levels. Okay, this was cited in the FDA statement, tablets made from the same manufacturing batches may not always provide the same thyroid hormone levels. Thirdly, and I want to actually let’s back up. I want you to remember I said that Deb (12:11.216)because further down in this podcast, we’re going to talk about this. This is an important point to remember. Thirdly, the agency raised concerns about potential impurities from animal source material, including potential for viral contamination due to the animal source and supraphysiological levels of T3.the FDA statement on impurities, viral contamination and super physiological T3 levels. Now I will tell you, I’ve been prescribing armarithograde for 20 years. I’ve rarely seen a super physiological dose given of T3 in lab results, unless the patient takes their medication like four or five hours before you do the blood test, then you’ll see a false rise because you’re actually seeing the medication. You’re not seeing people walking aroundsuperphysiological T3 levels. Nobody would like that feeling. So anyway, I digress. Now let me pause here because this is where I need to give you some context that the FDA hasn’t quite emphasized yet. Of course, we have another connection and it is the China connection.So the FDA’s concerns about contaminated drugs and quality issues don’t exist in a vacuum. In 2024, the U.S. over 828,000 metric tons of pharmaceuticals, seven times the level from 2000. And here’s the kicker. China and India supply the majority of active pharmaceutical ingredients. APIs for U.S. generics accounting for 70 to 80 % of the total genericdrug supply. According to Reuters industry report in 2024, they state that China supplies 82 % of the APIs for critical drugs. Deb (14:08.204)Got to question that, right? Why are we giving all of our drug formulas to China and allowing them to import them into our country? In fact, roughly 20 % of the critical drugs have APIs exclusively sourced from China. And China controls 80 to 90 % of the global production for antibiotics and other key compounds. This was also cited by Reuters industry data thatcontrols 80 to 90 percent of the global production for antibiotics and other key compounds. Now just think about this. They control 80 to 90 percent of our medication. They control 20 percent of our critical drugs and we just put what kind of tariff on them? Hmm.In 2025 alone, the FDA issued multiple warning letters to foreign manufacturers for contamination issues and failure to follow good manufacturing practices. This is also cited by the FDA warning letters 2024 through 2025 and multiple citations to foreign manufacturing facilities. This is a systematic problem affecting the entire US drug supply, not just desiccated thyroid.So when the FDA suddenly became concerned about DTE quality and contamination, part of that concern was legitimate. But this is crucial. The same inconsistencies and contamination issues exist across the entire generic drug supply. And the FDA has not taken the same enforcement action against them. Let that sink in.They have not taken the same enforcement action against the other drug companies. So what’s behind all of this? Where is this all coming from? Hmm. Let’s address something directly, because you deserve to know it. And I’m going to cite my sources precisely so that when the medical boards have something to say about this, and they might, I have a documentation for every single word that I am about to speak. Deb (16:24.878)According to the court documents filed in October 2025, in the case ofa urine, a urine. I’m going to say that wrong. Pharmaceuticals versus Dr. George Tidmarsh from ABBV, the multinational pharmaceutical company that manufactures armor thyroid, reportedly petitioned the FDA in 2024, asking the agency to reclassify DTE as a biologic and to prohibit other manufacturers from selling unlicensed DTE products unless they havehad an investigational new drug application, we call this an IND, and a clinical development program aimed at eventual approval. This is cited in the court filing a Urena pharmaceuticals lawsuit versus Dr. George Tidmarsh, October 2025, reported by Fierce Pharma. Now let me explain why this matters and why this is one of the most brazen examples of regulatory capture I’ve ever seen in my career.AbbeVee is one of the world’s largest pharmaceutical companies. In 2024, they reported over $54 billion in revenue. Drop the mic on that one.They have the resources, the regulatory expertise, the legal teams, and the financial capacity to navigate a biologics license application process that costs between $500 million and $1 billion. Let that sink in. Deb (18:07.882)A drug that’s been on the market since the 1800s that was grandfathered in 1938 that’s making plenty of money right now. They’re going to spend 500 million to $1 billion to get a biologics license application. Why would they do that? Well, we’re about to find out. Most otherDTE manufacturers, smaller companies like Acela Pharmaceuticals, which makes NP-thyroid, and RLC Labs, which made WP-thyroid, do not have those same resources. And this is cited in Pharma Voice in 2025. Why a treatment older than the FDA is getting new regulatory scrutiny. So when you petition the FDA to reclassify a drug in a way that requires this type of expensivetime-consuming biological approval, you’re not just asking for safety. You’re asking to eliminate your competitors from the marketplace. Now, I want to be very precise here. These allegations are documented in federal court filings, and it hasn’t been approved in court. It’s also been reported by multiple industry sources, including Fierce Pharma. But I’m telling you,what has been reported in legal proceedings, not stating it as an absolute fact because you deserve to know the difference and because I have to protect my license. Now, what do we know for certain?AbbeVee is working on a biologics license application for Armour thyroid through clinical trials called Avantia. This is cited by the AbbeVee corporate statement 2025 Avantia clinical trial for Armour thyroid. A cell of pharmaceuticals has been pursuing BLA approval for NP thyroid for seven years since 2017 and it completed its phase two trials successfully in 2025. They’re now moving Deb (20:15.448)into Phase 3 trials. This is also cited by the Acela Pharmaceuticals CEO statement 2025 seven-year pursuit for BLA approval completed Phase 2 trials moving to Phase 3.RLC Labs, which manufactured WP thyroid, has made no public announcement about pursuing BLA approval and really probably don’t have a plan to do this since they’ve been off the market for some time now. About five years, I think maybe a little longer. Here’s the market manipulation.If only ABBV is successful and obtains a BLA approval for Armour thyroid, that company would effectively have a monopoly on the DDT market. And in pharmaceutical markets, monopolies historically lead to price increases.We’ve seen this pattern over and over again when turning pharmaceuticals acquired Daraprim and raised their price from $13.50 to $750 per tablet overnight. When Myelin raised EpiPen increased prices by 400 % when insulin manufacturers colluded to raise prices in lockstep. This is the playbook.use regulatory barriers to eliminate your competition and then exploit pricing power. For a drug that’s been on the market since the 1800s, guess corporate greed is everywhere. They’re not making enough money on this product already and they’re taking advantage of the rules that they can manipulate their competition by. And here’s what really makes me furious. The American Thyroid Association, the professional organization Deb (22:06.672)representing endocrinologists sent letters to the FDA commissioner on October 8th of 2025 and September 18th of 2025.advocating for continued patient access to DTEs. This is cited in the American Thyroid Association statement and letter to the FDA commissioner dated October 8th, 2025 and September 18th, 2025. The American Association of Clinical Endocrinologists issued a statement on September 9th of 2025 supporting equitable access and personalized medicine for DTE. This was also cited in the American AssociationAssociation of Clinical Endocrinologists, AACE, statement dated September 9th, 2025. Even the medical establishment, which has historically favored levothyroxine, is saying, wait, this is going too far. Patients need access to this medication. But the FDA is moving forward anyway. Why? Well, where does it always lead us? Follow the money trail.Okay, so I need to explain what a biologics license application actually is because this is where the rubber meets the road for what’s going to happen to pricing and availability. What is a BLA?A BLA is a biologics license application. It’s a formal request submitted to the FDA to market a biologic product in the United States. A biologic is defined under the Public Health Service Act section 351 as a product derived from or made using living material, in this case, animal thyroid glands. And this is cited in the FDA definition for biologic products. So they’re putting armor thyroid right Deb (23:57.377)right up with stem cells and exosomes. Think about that. Stem cells and exosomes cost thousands of dollars per application because of how they have to be harvested, stored, freezed, all of that. But we’re talking about a thyroid gland. Good Lord, people.Unlike regular drug applications for synthetic medications which follow a simpler pathway, the BLA process is designed for complex biological products like monoclonal antibodies, vaccines, and gene therapy products. It’s a much more expensive, much more time-consuming process. The BLA processis what manufacturers have to do. And we’re going to talk about that. So according to Reprocell and Forge Biologics analysis of the FDA’s BLA process, here’s what companies need to submit. First, they need to complete a clinical trial data, phase one, two, and three trials, proving safety and efficacy for desiccated thyroid. Haven’t we done that since it’s been on the market since the 1800s? Just saying.This means they have to conduct large randomized controlled trials comparing it to levothyroxine, measuring safety outcomes, efficacy outcomes, and quality of life metrics. Second,Chemistry, Manufacturing and Controls, CMC’s data. Detailed information about how the product is manufactured, quality control measures, stability testing and specifications that must be met for every batch. Third, preclinical and animal safety data. Fourth, labeling and product information. Now, I think we have labeling and product information. Deb (25:53.717)since the 1800s? But just saying. Fifth, they need Pharma Covigilance Plan, a detailed plan for monitoring safety after the product is on the market. Haven’t they had to do that since the 1800s? And they have to have a timeline. And this is the critical part. The FDA’s standard review time for a BLA is 10 months.That’s after the application is deemed complete and accepted for filing. So this is cited by the FDA standard review timeline, BLA submission, and FDA review.Now, before you even get to filing, you need to conduct the clinical trials and compile all the data that’s typically several years of work. How are you going to prove safety and effectiveness in a large clinical trial long term? What do they consider? What do they deem long term? Three months, six months, a year, two years. These companies had 10 months.Well, maybe 12. They did it a year in advance. But unless you knew this was coming, how are you going to put together a trial, enroll the people, have all the trial components set up and ready to go in less than 12 months unless you knew it was coming beforehand? Even ifhad started all their clinical trials in 2024, completing them, compiling the data, and getting a complete application ready for submission, this would likely take you through mid-2026, then add another 10 months for FDA review. We’re looking at 2027 at the earliest for most of these companies to receive a BLA application. Deb (27:54.319)But the FDA gave the manufacturers until August of 2026. That’s approximately 19 months from when the August 2025 letters were sent. Most companies cannot reasonably complete the BLA approval in that timeframe. And when I’m talking about the 19 months, I’m talking about the information they would have had earlier. Now the cost.This gets me even more frustrated. Why are we spending this kind of money? The BLL process is extraordinarily expensive. The current FDA user fee for a BLA submission is approximately $483,560 just for the filing fee. And this is cited at the FDA user fees prescription drug user fee rates for 2025.The full cost of conducting clinical trials, CMC studies, and all the supporting documentation typically ranges from $500 million to over $1 billion, depending on the scope of the trials and the complexity. And this is cited in JAMA’s network, Open2023. A cell of pharmaceuticals has been pursuing the BLA approval since 2017. That’s eight years. And it’s just now.moving into phase three trials with a planned enrollment of approximately 300 patients. This is cited by the Acela Pharmacies CEO statement of 2025. Now that’s unusual. That’s typical for this process. This is not unusual. This is typical for this process to take seven, 10 years to get approval for this. So if Abby’s the one that requested this,Abby V. And Acela started this in 2017. Was Abby V threatened by Acela that Acela might get this approval and it would be quietly done without anybody seeing it? And maybe Abby V would be left out of the market after a century? Who knows? It’s possible. Deb (30:13.112)But for smaller manufacturers without billions in revenue, this cost is completely prohibitive. And this is why this matters. When you push an old established medication through an extraordinary, expensive approval process with a compromised timeline, one of three things happen. First, only the largest companies can afford it, creating a monopoly. And when that happens, the company that holds the only approved product can set pricing withminimal competitive pressures. Two, smaller manufacturers can’t afford it and their products disappear and the market shrinks and access decreases. Three, we see a combination of both and who pays the price? Literally, patients do. Now here’s whereThere’s something I want you to really think about because this is where the regulatory argument falls apart when you look at it carefully. The FDA’s concern about DTE is that, and I’m quoting their official statement, tablets from the same manufacturing batches may not always provide the same thyroid hormone levels. This is from their FDA statement.And that’s a legitimate quality concern, right? It is. Thyroid medications have a narrow therapeutic window like any other hormone, meaning the difference between an effective dose and the dose that causes problems can be quite small. But here’s what the FDA doesn’t emphasize. Generic drugs have the exact same dosing inconsistency issue, and it’s considered acceptable and has been since we allowed generics on the market.So how does a generic drug dose work anyway? Well, for generic drugs to be approved as bioequivalent to a brand name medication, the FDA requires that the generic drugs bioavailability fall within 80 to 125 % of the brand name product. Isn’t that a dose inconsistency? Deb (32:22.894)from the brand name medication? 800 or sorry, 80 to 125%. According to the pharmacy times analysis of the FDA’s bioequivalent standards, the 80 to 125 % bioequivalence rule means that a generic drug can have 20 to 45 % variability compared to the original brand product.Now, most generics are much closer than that. The FDA study data shows that the mean difference for an AUC value between generic and reference products is about three and a half percent in the two year post-Waxman hatch period, and 80 % of the generics fall within a five percent range. But the FDA’s regulations allow for that much higher variability. And this is cited in an FDA study data mean difference for AUC.Now, let me put this in plain language. A patient could take a generic levothyroxine tablet where one batch provides, say, 75 micrograms of an active thyroid hormone. And the next batch from a different manufacturer, a different generic manufacturer, could provide up to 93.75 micrograms, 125 % of that 75. That’s an 18 microgram difference.in the same prescribed dose. Now, this is considered acceptable and patients tolerate it and this system works.Yet the FDA’s argument against DTE is that batch-to-batch inconsistency is unacceptable and requires this expensive biologic approval? That’s a double standard. So why is batch inconsistency acceptable for generic levothyroxine, but supposedly unacceptable for desiccated thyroid? I’ll give you the regulatory answer. Deb (34:29.366)because DDT is a biological product derived from an animal tissue and the FDA considers biological products to require more rigorous control. That’s the regulatory answer, but I’ll give you the real answer.because there’s no billion dollar pharmaceutical company with a patent pending on generic levothyroxine who petitioned the FDA to regulate their competitors more strictly. The inconsistency argument is legitimate, but it’s selectively applied. And that matters when you’re trying to understand whether this is really about patient safety or whether it’s about market control.Now I want to talk about something that hasn’t gotten nearly enough attention in this discussion and it’s something that makes me absolutely furious. What is Armour Thyroid? According to the official prescribing information published by AbbeV and available through rxabbev.com and the FDA’s daily med database, Armour Thyroid contains the following inactive ingredients. Calcium steroid,dextrose derived from corn, mycocrystalline cellulose,sodium starch glycolate and a opadri white coating. Now let’s talk about dextrose. Dextrose is a sugar derived from corn and while manufacturers claim that the corn derived dextrose in armor thyroid is gluten free, here’s the problem. Cross contamination during corn processing can introduce gluten proteins especially if the corn is processed in facilities that also handle Deb (36:18.808)wheat, barley, or rye. Corn sensitivity is extremely common in patients with celiac disease and non-celiac gluten sensitivity, and studies show that up to 50 % of the celiac patients react to corn proteins due to molecular mimicry, and the corn proteins look similar enough to gluten that the immune system attacks them. And this is cited by RestartMD.com.And here’s what’s documented in peer-reviewed medical literature in a 2023 case report published in Case Reports in Endocrinology. These researchers documented five patients with gluten intolerance or celiac who were taking natural desiccated thyroid. Three of those patients also reported lactose intolerance. Now these patients had to switch from DTE to liquid levothyroxine formulations to avoid the inactiveSo here’s my question. If AbbeV becomes the only manufacturer with an approved DTE product and their formulations contain corn-derived dextrose that triggers reactions in celiac patients, what are those patients supposed to do? They can’t take armor because of the corn. They can’t take compounded DTE because the FDA is banning compounding of these biologics. They can’t take NPKsor WP thyroid because those companies may not survive the BLA process. So they’re left with a synthetic version of levothyroxine which may not work for them.Now the NP thyroid and WP thyroid difference. Now here’s what’s interesting according to drugs.com comparison of inactive ingredients and P thyroid and P thyroid has calcium steroid dextrose also derived from corn, mineral oil, multi-crystalline cellulose. Deb (38:19.31)cross carmelicin sodium and a opadri to white. So NP thyroid also has corn-derived dextrose. WP thyroid on the other hand was specifically formulated to be hypoallergenic according to ROC labs, but it’s no longer available and its ingredients were inulin from chicory root and medium chain triglycerides. No corn, no gluten, no common allergies. So todayWe do not have a glandular thyroid, a DTE, that is not potentially contaminated with gluten. Yet, patients with autoimmune thyroid disease are supposed to avoid gluten.Now, some of these people can handle a DTE and many cannot, so that argument could be a mute point. But at the end of the day, the one product that we had that was designated for patients with multiple chemical sensitivities, celiac disease and coron allergies, has been off the market for a long time already.We have a monopoly problem. So if ABBV becomes the only approved manufacturer, patients with these celiac diseases and corn allergies will either be forced to take a medicine that makes them sick and triggers their immune reaction or switch to a synthetic that doesn’t adequately treat their hypothyroidism or choose to go without treatment. This is not hypothetical. This is real patients with real medical needs who are about to lose accessto the only formulation that works for their body. And the FDA’s response is silence. Deb (40:07.69)Now I want to highlight something that hasn’t gotten nearly enough attention in this discussion. Compounding pharmacies. What is a compounding pharmacy? Compounded medications are custom made by licensed pharmacists to meet a patient’s specific needs. Maybe you need a different strength that was commercially available, but you have an allergy to a filler or a dye in the commercial product. Maybe you need a liquid formulation or instead of a tablet or you need a capsule. That’s when compoundingin. And the FDA’s, this is the FDA’s definition of compounding. And for decades, compounding pharmacies have been making desiccated thyroid extract for patients who needed customization. Some patients couldn’t take the commercial products because of the dyes and the fillers, and some needed strengths that were not available. And these compounding pharmacies filled the gap.But reclassification changes everything. When the FDA reclassified DTE as a biologic in 2022 and reinforced that decision in August of 2025, explicitly stated, and I’m quoting directly from the FDA’s official statement, these unapproved animal-derived thyroid medications are not eligible for compounding because these products are regulated as biologic products under the Public Health Service Act.How can that be? These products have been approved since 1938 and the Biologics Act didn’t go into effect or doesn’t go into effect until August of 2026.So how in 2022 were they able to say that the compounding pharmacies could not make these products? Anyway, what this means is after August 2026, compounding pharmacies will no longer be permitted to compound a desiccated thyroid extract, even for patients with specific medical needs. Now, compounding pharmacies can still compound T4 and T3 separately, synthetic versions of levothyroxine and liothyronine, according to Deb (42:12.728)healing dose compounding pharmacy. These pharmacists can create custom ratios of these two synthetic hormones to approximate what a patient was receiving from a DTE. But that’s not the same thing. Some patients respond better to the whole DTE preparation than to a compounded synthetic combination. And for patients with specific allergies to standard fillers like your celiac patients that I just talked about, losing the ability to get a compounded DTE alternative isreal hardship. This is going to be a ripple effect. For a subset of patients, maybe 5 to 10 percent of those on DTE compounding was their lifeline and it was their way to get a medication formulation that worked for their unique body. When compounding goes away, these patients lose that option as well and for some it will be a significant problem. Now let’s talk about what this likely means for your wallet.The current pricing right now, according to SingleCare and GoodRx, Armour Thyroid costs approximately $150 to $157 for a 90-day supply of 60-milligram tablets, about $1.67 per tablet. With discount cards, some patients can get it down to $101 to $152 for a 90-day supply.Generic levon thyroxine costs about $70 for a 90 day supply, less than half that price. And p-thyroid costs approximately $133 for a 90 day supply of 60 milligrams with a discount card about $83 to $101.What happens after we get BLA approval? Well, here’s the pharmaceuticals pricing model. When a company spends 500 million to $1 billion to bring a product to market, including conducting massive clinical trials, the cost tens of millions of dollars they recoup in that investment through pricing power. And this is cited in the pharmaceutical pricing models. If ABBIEV is the only company with an approved BLA of DTE, Deb (44:18.248)They have pricing power. They don’t have competitors. They can set their price, whatever they want. And historically, when drugs transition from grandfather status, which is basically unregulated to formal formally approved status, prices often increase significantly, not always, but often. And typically they have to get re-approval for insurance. SoTouring Pharmaceuticals acquired DARPM and raised the price again from $1,350 to $750 overnight, a 5,000 % increase. This is the playbook.Let’s talk about insurance coverage. This is the other consideration. Insurance companies sometimes have different coverage policies for approved versions versus unapproved drugs. And right now, many insurance plans cover armor thyroid or NP thyroid, even though they’re technically unapproved because they’ve been on the market for decades and patients are on them. Once a drug becomes formally approved, insurance companies may have new contractual relationships, prior authorization requirements, or preferred drugs.list that could affect your coverage. If 1.5 million people have to get a prior auth for their insurance to cover this new medication, this is going to drive the doctor’s offices crazy. We do not have the staff to man this. We do not have the manpower. We do not have the time. This is going to interrupt people’s ability to get their medications. This is going to create chaos within the system. And some patients might see better coverage, but manymost likely are going to see worse coverage and some might find themselves in a situation where they need to try to get the drug approved first or get an approval for something else like levothyroxine and they’re going to have to document that it didn’t work and the documentation that they had from 20 years ago is probably not going to be enough because it’s not documented anywhere. It’s lost in the system after 10 years. So for patients the practical takeaway is expect Deb (46:25.774)a price increase. I would say possible, but I don’t think that’s true. think you’re going to see a price increase if they get approved. Expect possible insurance complexities, budget accordingly, talk to your insurance company now about what your coverage is going to look like in 2027 if they even know. And if you want my honest assessment of what is likely to happen,I’ll give you a scenario, 30 % likelihood. The FDA enforces the August 26 deadline and DTE products not approved by then are pulled from the market. Patients will have 30 to 90 days to transition to other medications. Some patients suffer significant symptom relapse. Compounding for DTE becomes illegal and this disruptiveness of the system creates a real hardship. Scenario two.which is 50 % likely. This is actually what the FDA commissioner, Marty McCreary suggested on August 13th of 2025 when he posted on social media. The FDA is committed to pursuing the first ever approval of desiccated thyroid access pending results of the ongoing clinical trials. In the meantime, we’ll ensure access for all Americans. Hopefully that continues. What this likely means is the FDA uses enforcement discretion to allow continuedsales while approvals are being pursued and the deadline gets extended. Maybe patients get access for another two to three years while companies work on a BLA approval. This would be the least disruptive scenario, but it’s also legally uncertain because the enforcement letters have been formally rescinded. And scenario three, which is 20 % likelihood, one or two companies get BLA approval. Those products stay on the market at higher product prices and companies, products, other companiescompanies, products are pulled, the market shrinks, availability is limited, prices are higher, but patients can still get something. This is likely if a seller successfully completes phase three trials for NP-thyroid. And my assessment is based on the regulatory language and the enforcement letters that have not been rescinded yet, that the pattern of FDA enforcement, I believe scenario two enforcement discretion with an extended time frame is most likely what we’re going to see. Deb (48:49.488)doesn’t mean patients should sit back and do nothing. It means you should be prepared for change while advocating for access. If you want to keep Arm or Thigh Right on the market, 1.5 million people need to start talking about this publicly and flooding our Congress people, Bobby Kennedy, the FDA, with what you want to see happen. We have the ability to shape this and to change this with our voice. But if we sit back on our laurels and we do absolutelynothing. What is going to happen is what the FDA wants to have happen and ABV wants to have happen because they’re going to simply think people don’t give a shit. And if the American people are going to be lazy and not want to step forward and actually start using their voice for some good and instead of just going to social media and bitching and hoping something is going to happen, well, then we’re going to get what we deserve. But if you start taking someaction and you start advocating for the things that you want. Contacting your representatives, contacting your U.S. tell them the FDA has done this. Many of them may not know this, may not be on their radar. Tell them what you want. Start going after this. Start writing to the FDA Commissioner’s Office. They have a website. They have a Commissioner’s Office at fda.hhs.gov. Be responsible.respectful, but be firm. Explain your scenario. How long you’ve been on DTE. Why levothyroxine doesn’t work. What symptoms you experience when not adequately treated. How this decision will affect your quality of life and your pocketbook. Let’s do something proactive. So let’s consider this. Moving forward, work with your provider who understands the regulatory landscape around DTE. You can discuss the evidence for and against combination therapy.You can monitor for thyroid function with free T3 and free T4 testing, not just TSH. If you’re willing to try individualized approaches, you can do that. If you need help finding a functional medicine provider who understands this issue, come to serenityhealthcarecenter.com or explorethevanari.com. It’s a self-directed functional medicine support group. And right now what is happening is going to shape how history Deb (51:19.024)is made with not just armor thyroid, but many drugs to come. And it is important for you to take action. So I want to thank you for joining me today on Let’s Talk Wellness Now. This episode is about far more than thyroid medication. It’s about your right to personalized medical treatment. It’s about your regulatory capture and corporate influence. And it’s about what happens when billion dollar companies shape healthcare policy in ways that reduce patient choice and increase their profits.this episode resonates with you or you know somebody who’s going to be affected by desiccated thyroid, please share it. Post it on social media, send it to your doctor, email it to your representatives, tag AbbeVee, tag FDA. Make noise because the only way we stop this is if we make it too politically costly for them to continue. Your voice truly matters. Your health truly matters and you deserve access to treatments that work best for your unique body.If you’re ready to explore comprehensive personalized health care that puts you in control, visit us at SerenityHealthCareCenter.com. Learn more about functional medicine approaches to thyroid and beyond and explore my new platform, Venari.com, which is a self-directed functional medicine tool. Thank you for joining me today. Until next time, I’m Dr. Deb reminding you, your health is your responsibility, your choice, and your right. Be well, stay informed, fight back.and I’ll see you in the next episode. And if you’re looking for a full citation list of this episode, you can head over to letstalkwellnessnow.com and I will post all the citations for you so you have them in your arsenal as well. Thank you again.The post Episode 259 – The Desiccated Thyroid Crisis: FDA's Unseen Impact & Corporate Manipulation first appeared on Let's Talk Wellness Now.

Send us a message with this link, we would love to hear from you. Standard message rates may apply.We break down osteopenia and osteoporosis with clear steps to protect independence: how bones weaken, how DEXA scoring works, and which daily habits reduce fracture risk. We share nutrition, exercise, lifestyle changes, and home safety that make a measurable difference.• key stats on fracture risk in women and men over 50• definitions of osteopenia and osteoporosis using T-scores• hip, spine and wrist as common fracture sites• why bone loss accelerates after menopause• risk factors including family history, smoking and low weight• DEXA scan basics and when to ask for screening• calcium and vitamin D targets and food sources• Mediterranean diet, protein and supportive micronutrients• weight-bearing, resistance and balance training essentials• Tai Chi and fall risk reduction• home safety changes that prevent falls• when medications like bisphosphonates or denosumab help• practical questions to ask your clinicianReferences1. Osteoporosis: Common Questions and Answers. Harris K, Zagar CA, Lawrence KV. American Family Physician. 2023;107(3):238-246.2. Postmenopausal Osteoporosis. Walker MD, Shane E. The New England Journal of Medicine. 2023;389(21):1979-1991. doi:10.1056/NEJMcp2307353.3. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis-2020 Update. Camacho PM, Petak SM, Binkley N, et al. Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2020;26(Suppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL.4. Global, Regional Prevalence, and Risk Factors of Osteoporosis According to the World Health Organization Diagnostic Criteria: A Systematic Review and Meta-Analysis. Xiao PL, Cui AY, Hsu CJ, et al. Osteoporosis International : A Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2022;33(10):2137-2153. doi:10.1007/s00198-022-06454-3.5. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. Curry SJ, Krist AH, Owens DK, et al. JAMA. 2018;319(24):2521-2531. doi:10.1001/jama.2018.7498.6. The Cost of Osteoporosis, Osteopenia, and Associated Fractures in Australia in 2017. Tatangelo G, Watts J, Lim K, et al. Journal of Bone and Mineral Research : The Official Journal of the American Society for Bone and Mineral Research. 2019;34(4):616-625. doi:10.1002/jbmr.3640.7. The Prevalence and Treatment Rate Trends of Osteoporosis in Postmenopausal Women. Zhang X, Wang Z, Zhang D, et al. PloS One. 2023;18(9):e0290289. doi:10.1371/journal.pone.0290289.8. Osteopenia: A Key Target for Fracture Prevention. Reid IR, McClung MR. The Lancet. Diabetes & Endocrinology. 2024;12(11):856-864. doi:10.1016/S2213-8587(24)00225-0.9. Effectiveness and Safety of Treatments to Prevent Fractures in People With Low Bone Mass or Primary Osteoporosis: A Living Systematic Review and Network Meta-Analysis for the American College of Physicians. Ayers C, Kansagara D, Lazur B, et al. Annals of Internal Medicine. 2023;176(2):182-195. doi:10.7326/M22-0684.Support the showSubscribe to Our Newsletter! Production and Content: Edward Delesky, MD & Nicole Aruffo, RNArtwork: Olivia Pawlowski

SERGE A. JABBOUR, MD, FACP, FACE is a Professor of Medicine and the Director of the Division of Endocrinology, Diabetes, and Metabolic Diseases at Jefferson. He is also the Director of the Jefferson Diabetes Center. Dr Jabbour completed his training in Endocrinology, Diabetes, and Metabolic Diseases at Thomas Jefferson University in Philadelphia.Dr Jabbour has been recognized with many honors and he is holder of many teaching awards. Dr Jabbour was named Top Doc in Philadelphia area every year since 2011 by Philadelphia Magazine and one of the best endocrinologists in the nation by Castle Connolly every year since 2012. Dr Jabbour is a member of numerous professional organizations, including The Endocrine Society, American Diabetes Association and American Association of Clinical Endocrinologists.Dr Jabbour has published many articles and chapters on diabetes, metabolic syndrome, various endocrine topics; he serves on the Editorial Board of many journals and he just finished in September 2021 his 5-year tenure as the Chair of the Endocrine Board Review Committee for The Endocrine Society.Dr Jabbour's main research interest is in the field of diabetes. He is involved in many clinical research trials related to new diabetes drugs. He also gives many lectures all over the world on different endocrine topics, mainly diabetes, either in the setting of grand rounds, symposia or other CME presentations. I am truly honored to have such an inspiring and world-class endocrinologist with me today. Welcome Dr. Jabbour, let's see how many people we can convince to do endocrinology.Jefferson Endocrinology:https://www.jeffersonhealth.org/clinical-specialties/endocrinology-diabetes-metabolic-diseases?gclid=CjwKCAjwiOCgBhAgEiwAjv5whBW4FTPRCa_lVxnQI577rjIie4qMEkxca7tNsBwTxndwYCamtYfiMBoCknsQAvD_BwEJefferson Diabetes Center:https://www.jeffersonhealth.org/clinical-specialties/diabetes-center___0:00 - Intro1:49 - Statistics About Endocrinology3:10 - What Is Endocrinology?5:22 - Journey Into Medicine and Endocrinology13:07 - Keeping the Team Happy15:42 - An Average Day/Week of an Endocrinologist19:40 - Advice for People Looking Into Leveling up Ranks22:50 - If I Give You $100 Million, What Would You Do?25:25 - Best Thing About Being an Endocrinologist27:35 - Making a Rare Diagnosis32:16 - Passion for Studying Diabetes34:21 - Things We Should Know About Type 2 & 1 Diabetes53:06 - What Do You Think About Ozempic and Glp-1?59:44 - Dietary Tips1:06:21 - Hemoglobin a1c Levels1:20:10 - SGLT2 Inhibitors1:16:48 - Future of Endocrinology1:19:34 - Changes Over the Years1:20:17 - Myths About Diabetes1:24:29 - High Number of Diabetic Patients in the U.S.1:30:39 - Advice to People Looking Into Endocrinology1:32:36 - Maximizing Competitiveness Going Into Endocrinology1:39:00 - What Makes the Best-Med Students/Residents/Fellows?1:42:28 - Advice to People Entering a Career in Medicine1:45:17 - What Advice Would You Give Your 18-Year-Old Self?1:48:20 - Adapting to the U.S.1:49:43 - Closing Message1:51:57 - Outro__ResourcesWho Moved My Cheese? by Dr Spencer Johnson: https://amzn.eu/d/dZHrYY8 ___View the Show Notes Page for This Episode for transcript and more information: zhighley.com/podcast___Connect With ZachMain YouTube: @ZachHighley Newsletter: https://zhighley.com/newsletter/Instagram: https://www.instagram.com/zachhighley/?hl=enWebsite: https://zhighley.comTwitter: https://twitter.com/zachhighleyLinkedln: https://www.linkedin.com/in/zach-highley-gergel-44763766/Business Inquiries: zachhighley@nebula.tv___Listen for FreeSpotify: https://open.spotify.com/show/23TvJdEBAJuW5WY1QHEc6A?si=cf65ae0abbaf46a4Apple Podcast: https://podcasts.apple.com/us/podcast/the-zach-highley-show/id1666374777___Welcome to the Zach Highley Show, where we discuss personal growth and medicine to figure out how to improve our lives. My name is Zach a Resident Physician in Boston. Throughout these episodes I'll interview top performers from around the world in business, life, and medicine in hopes of extracting the resources and techniques they use to get to the top.The best way to help the show is share episodes on any platform. If you think a friend or family member will like a certain episode, send it to them!See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

In this first ever CE episode, we discuss the A-Zs of continuous glucose monitors (CGMs). In specific, our learning objective for the CE are: Describe commonly available types of continuous glucose monitors (CGMs) in the US market and the features and capabilities of these devices. Summarize the evidence and guideline recommendations for use of CGMs in the management of diabetes. Identify the role of the pharmacist in the selection of CGMs and provision of education to patients and providers. Interpret the ambulatory glucose profile (CGM data output) and recommend changes in antihyperglycemic regimen for a patient. ACPE-Accredited Pharmacist CE (1.0 hrs) To obtain CE credit for a $5 fee, visit the following link: https://rfums.wufoo.com/forms/z1qzh5vf0ggr832/. Once payment is successful, you will be redirected to our CE partner (CE Impact) to complete an evaluation and to earn 1.0 hour of CE credit. CE is available for 12 months after episode publication. Key Concepts There are two main types of stand-alone personal CGMs available in the US market – real-time (rtCGM) and intermittently scanning (isCGM). [1] These CGMs vary in their features such as sensor wear time, sensor warm up time, sensor application site, reader availability, approved age for use, fingerstick calibration, non-adjunctive FDA labeling, interconnectability with other technology such as insulin pumps, and drug interactions – these variabilities can be used in decision-making when selecting an appropriate CGM for a patient. [2-7] Based on the evidence for use, both types of CGMs (real-time and intermittently scanning) are recommended in patients with Type 1 and Type 2 diabetes who are on multiple-daily insulin or continuous insulin infusion (pump), patients with Type 2 diabetes on basal insulin therapy, and as adjunct use in patients with diabetes who are pregnant. The strength of recommendations in general is stronger for real-time CGMs than for intermittently scanning CGMs. [1,11] These recommendations are supported by the evidence that CGMs can help improve glucose control, reduce risk of hypoglycemia, diabetes-related hospitalizations, and patient/caregiver satisfaction. Pharmacists play an integral role in education, on-going support, data interpretation, and resulting disease management in patients who qualify for CGM use and providers who care for patients with diabetes. [14] The ambulatory glucose profile is a standardized data output that informs understanding of glucose trends. [15] The recommended goal for most patients is to maintain a glucose range between 70-180 mg/dL with at least 70% of time spent in this range with variability coefficient of no more than 36%. [1,11,15] Supplemental Content Comparison of rtCGM and isCGM devices "Mary's" Example AGP Report (adapted from Battelino et al.) References ElSayed NA, Aleppo G, Aroda VR, et al. American Diabetes Association. Chapter 7. Diabetes technology: Standards of medical care in diabetes - 2023. Diabetes Care. 2023;46(suppl 1):S111-S127. Dexcom G6 User Guide. Dexcom, Inc. 2020. Accessed February 20, 2023. https://s3-us-west-2.amazonaws.com/dexcompdf/G6-CGM-Users-Guide.pdf. Dexcom G7 User Guide. Dexcom, Inc. 2022. Accessed February 20, 2023. https://dexcompdf.s3.us-west-2.amazonaws.com/en-us/G7-CGM-Users-Guide.pdf#page=12 Guardian Connect System User Guide. Medtronic MiniMed. 2020. Accessed February 20, 2023. https://www.medtronicdiabetes.com/sites/default/files/library/download-library/user-guides/Guardian-Connect-System-User-Guide.pdf. Eversense E3 User Guide. Sensionics, Inc. 2022. Accessed February 20, 2023. https://www.eversensediabetes.com/wp-content/uploads/LBL-4002-01-001-Rev-F_Eversense-E3-User-Guide_mgdL_R1_web.pdf FreeStyle Libre 3 User's Manual. Abbott Diabetes Care Inc. 2022. Accessed February 20, 2023. https://freestyleserver.com/Payloads/IFU/2022/q2/ART44140-002_rev-A.pdf FreeStyle Libre 2 User's Manual. Abbott Diabetes Care Inc. 2020. Accessed February 20, 2023. https://freestyleserver.com/Payloads/IFU/2020/q2/ART40703-001_rev-D-Web.pdf. Products. American Diabetes Association. Accessed February 20, 2023. https://consumerguide.diabetes.org/ Wood A, O'Neal D, Furler J, Ekinci EI. Continuous glucose monitoring: a review of the evidence, opportunities for future use and ongoing challenges. Intern Med J. 2018 May;48(5):499-508. Edelman SV, Argento NB, Petty SJ, Hirsch IB. Clinical implications of real-time and intermittently scanned continuous glucose monitoring. Diabetes Care. 2018;41:2265-2274. Fonseca VA, Grunberger G, Anhalt H, et al. Continuous glucose monitoring: A consensus conference of the American Association of Clinical Endocrinologists and American College of Endocrinology. Endocr Pract. 2016;22(8):1008-21. Reiterer F, Polterauer P, Schoemaker M, Schmelzeisen-Redecker G, Freckmann G, Heinemann L, Del Re L. Significance and Reliability of MARD for the Accuracy of CGM Systems. J Diabetes Sci Technol. 2017 Jan;11(1):59-67. doi: 10.1177/1932296816662047. Epub 2016 Sep 25. PMID: 27566735; PMCID: PMC5375072. Food and Drug Administration. Premarket Notification 510(k). 2022. Accessed February 25, 2023. https://www.fda.gov/medical-devices/premarket-submissions-selecting-and-preparing-correct-submission/premarket-notification-510k. Isaacs, Diana. The pharmacist's role in continuous glucose monitoring. Pharmacy Today. 2020;26:37-54. Battelino T, Danne T, Bergenstal RM, et al. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations from the International Consensus on Time in Range. Diabetes Care. 2019;42(8):1593-1603.

I am interviewing Dr. Rachel Kilpatrick for Diabetes Awareness Month!Dr. Kilpatrick is a full time practicing endocrinologist who spends most of her time managing patients with diabetes, and other hormone disorders including insulin resistance, polycystic ovarian syndrome, thyroid disorders, adrenal disease, pituitary disease, and other complicated endocrine disease.  She has a special interest in Lifestyle medicine and is pursuing a certification in lifestyle medicine.  She believes that most diseases can be modified positively with lifestyle intervention. Dr. Kilpatrick is board certified in both internal medicine as well as endocrinology, diabetes, and metabolism.  She did her medical school training at the University of Texas Southwestern Medical School, and did her internal medicine residency and endocrinology fellowship at Washington University in St Louis. Dr. Kilpatrick is a member of the American Diabetes Association, the Endocrine Society, the American College of Physicians, and the American Association of Clinical Endocrinologists.  She is also a Fellow of the American Association of Clinical Endocrinologists.You can find Dr. Kilpatrick on Instagram and Facebook :Facebook: @rachelkilpatrickmd Instagram: @rachelkilpatrickmd Twitter: @rachelkilpatrickmdTikTok: @rachelkilpatrickmdDuring the Podcast, we discuss:What are the different types of Diabetes?What Causes Diabetes ?What are the symptoms of diabetes?If I have Diabetes, what should I be the most worried about?What are three things you would ask every diabetic to start doing today?What three things would you like all diabetics to stop doing right now?How does stress affect diabetes?Mindfulness has been shown to improve diseases related to stress, such as anxiety, depression, and chronic pain.As a gift to my listeners, I am giving away access to my course Mindfulness Meditation Mastery.  All it takes is to signup to receive your free access.Sign UpWelcome to the Art of Healing Podcast.Let's explore your mind, body and spirit through Integrative Medicine, Meditation and Reiki.Don't miss the latest episodes. Sign up to get the weekly newsletters and get the Art of Healing Podcast in your inbox:Healing Arts Weekly Newsletter Thank you for listening to the Art of Healing Podcast.Ready to start your journey into Meditation, Mindfulness or Reiki?Learn about the Programs at Healing Arts here.Want to make sure you catch every episode of the Art of Healing? Click here for my weekly newsletter.Never miss an episode of Art of Healing Podcast...the podcast devoted to helping you heal your mind, body and spirit.Sign up for my weekly newsletter, and never miss an episode along with other great content:Art of Healing PodcastStay in touch socially here:Healing Arts Link in BioLearn more about me and my offerings here:Healing Arts Health and Wellness

Deepak is founder of The Chopra Foundation and Chopra Global, as well as Professor of Family Medicine and Public Health at UCSD and senior scientist with Gallup Organization. He is author of over 90 books translated into 43 languages, including New York Times bestsellers. Chopra has been at the forefront of the meditation and personal transformation revolution. TIME magazine has described him as “one of the top 100 heroes and icons of the century.” Larry King has described his work as “some of the most important of the decade.” The Wall Street Journal has declared his books “must reads for your career”.His books have been awarded the prestigious Nautilus Award and Quill Award. Two of his books have been recognized on “The Books of The Century Bestsellers List”. He is a columnist for the San Francisco Chronicle and contributes to Oprah.com, Intent.com, and Huffington Post. He has been recognized as one of “The 100 Most Influential People in Health and Fitness “, the #17 “most influential thinker in the world” and #1 in Medicine. As background, Dr. Chopra is Board Certified in Internal Medicine, Endocrinology, and Metabolism.  He is a Fellow of the American College of Physicians and a member of the American Association of Clinical Endocrinologists.

Deepak Chopra is the author of Life After Death: The Burden of Proof. He is also founder of The Chopra Foundation, a non-profit entity for research on well-being and humanitarianism, and Chopra Global, a modern-day health company at the intersection of science and spirituality, is a world-renowned pioneer in integrative medicine and personal transformation. Dr. Chopra is Board Certified in Internal Medicine, Endocrinology and Metabolism, a Fellow of the American College of Physicians, and a member of the American Association of Clinical Endocrinologists. He serves as a Clinical Professor of Medicine at the University of California, San Diego, and hosts the podcast Daily Breath.The World Post and The Huffington Post global internet survey ranked “Chopra #17 influential thinker in the world and #1 in Medicine.” He is the author of over 90 books translated into over forty-three languages, including numerous New York Times bestsellers. For the last thirty years, Chopra has been at the forefront of the meditation revolution and his book, Total Meditation (Harmony Book, September 22, 2020) will help to achieve new dimensions of stress-free living and joyful living. TIME magazine has described Dr. Chopra as “one of the top 100 heroes and icons of the century.” More information about the guest can be found at https://www.deepakchopra.com/

According to the American Association of Clinical Endocrinologists, an estimated 27 million Americans have thyroid disease, and more than half of those individuals are undiagnosed and unaware that they have a thyroid condition.However, it's important to understand that if more comprehensive thyroid testing was used by doctors and functional reference ranges were used to interpret that testing instead of the overly lax lab reference ranges, a much larger number of people would be classified as having some type of thyroid dysfunction.Most doctors rely almost exclusively on the thyroid stimulating hormone or TSH test to detect thyroid dysfunction, yet TSH is not even technically a marker of thyroid function, it's actually a marker of pituitary function. Even worse, the medical community can't even agree on what the normal reference range is for the TSH test.My other issue with conventional medicine is its refusal to actually look at underlying causes of thyroid dysfunction including but not limited to gut inflammation, chronic stress, adrenal issues, nutrient deficiencies, toxins in our food, air, and water, and chronic infections such as periodontal disease and h. Pylori.The thyroid's primary function is to control the body's metabolism – the rate at which cells perform duties essential to living. It manages how we turn our food into energy by facilitating the processes of energy production in the mitochondria. I want you to think of your thyroid as your body's “engine,” which sets the pace at which the body operates. Too little thyroid hormone can cause the body's systems to slow down, and too much thyroid hormone can cause the body's systems to speed up.In today's episode, I've brought back my friend and pharmacist Jim Paoletti to talk about this amazing gland that does so much for us. In fact, there's not a single cell in the body that doesn't depend on thyroid hormone in some way.Jim Paoletti, B.S. Pharmacy, FAARFM, FIACP is an independent clinical consultant on hormones, nutrition, and wellness. Jim has 40 years of experience with bio-identical hormone therapies in clinical practice, both in retail pharmacy and as a consultant and educator. Jim served previously as Director of Provider Education for ZRT Laboratory, Beaverton, Oregon, and as consultant and Education Director for Professional Compounding Centers of America of Houston, TX.He is a graduate and former faculty member of the Fellowship of Anti-Aging and Functional Medicine. Jim has lectured extensively and internationally on all aspects of compounding and BHRT to medical practitioners and consumers, and has several articles published on BHRT and compounding pharmacy issues. Jim has published the book A Practitioner's Guide to Physiologic Bioidentical Hormone Balance.Listen to the full episode to hear:Why your doctor may be relying on testing that provides an incomplete picture of thyroid functionHow laboratory reference ranges don't reflect optimal functional ranges that end up leaving patients frustrated and without resolutionWhy assessing adrenal function is key to evaluating and treating thyroid issuesWhy synthetic vs natural thyroid hormone replacement is misleadingLearn more about Jim Paoletti, BS Pharmacy, FAARFM, FIACP:A Practitioner's Guide to Physiologic Bioidentical Hormone BalanceLearn more about Sami:Eatfor.lifeBook Your Complimentary ConsultationEat For Life cookbooks for each unique biotypeResources:Overcoming Thyroid Disorders 3rd EditionWhy Do I Still Have Thyroid Symptoms? when My Lab Tests Are Normal: a Revolutionary Breakthrough in Understanding Hashimoto's Disease and Hypothyroidism, Dr. Datis Kharrazian

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-241   Overview: Seven percent of the US population has an active levothyroxine prescription, which is significantly greater than the number of people diagnosed with overt hypothyroidism. Many of these prescriptions appear to be for the treatment of subclinical hypothyroidism and other conditions in euthyroid individuals. Join us to uncover the latest findings on the use of levothyroxine and what the evidence tells us about appropriate use and misuse of this drug.   Episode resource links: Brito, J., Ross, J., El Kawkgi, O., Maraka, S., Deng, Y., Shah, N., Lipska, K. & (9000). Levothyroxine Use in the United States, 2008-2018. JAMA Internal Medicine, Publish Ahead of Print, doi: 10.1001/jamainternmed.2021.2686. Johansen, M., Marcinek, J., Yun, J. & (2020). Thyroid Hormone Use in the United States, 1997–2016. Journal of the American Board of Family Medicine, 33 (2), 284-288. doi: 10.3122/jabfm.2020.02.190159. Jeffrey R. Garber, Rhoda H. Cobin,Hossein Gharib,James V. Hennessey, Irwin Klein, Jeffrey I. Mechanick, Rachel Pessah-Pollack, Peter A. Singer,Kenneth A. Woeber. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association; November–December 2012. https://www.endocrinepractice.org/article/S1530-891X(20)43030-7/fulltext; https://www.endocrinepractice.org/action/showPdf?pii=S1530-891X%2820%2943030-7   Guest: Susan Feeney, DNP, FNP-BC, NP-C   Music Credit: Richard Onorato

Deepak is founder of The Chopra Foundation and Chopra Global, as well as Professor of Family Medicine and Public Health at UCSD and senior scientist with Gallup Organization. He is author of over 90 books translated into 43 languages, including New York Times bestsellers. Chopra has been at the forefront of the meditation and personal transformation revolution. TIME magazine has described him as “one of the top 100 heroes and icons of the century.” Larry King has described his work as “some of the most important of the decade.” The Wall Street Journal has declared his books “must reads for your career”.His books have been awarded the prestigious Nautilus Award and Quill Award. Two of his books have been recognized on “The Books of The Century Bestsellers List”. He is a columnist for the San Francisco Chronicle and contributes to Oprah.com, Intent.com, and Huffington Post. He has been recognized as one of “The 100 Most Influential People in Health and Fitness “, the #17 “most influential thinker in the world” and #1 in Medicine. As background, Dr. Chopra is Board Certified in Internal Medicine, Endocrinology, and Metabolism.  He is a Fellow of the American College of Physicians and a member of the American Association of Clinical Endocrinologists.

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-241   Overview: Seven percent of the US population has an active levothyroxine prescription, which is significantly greater than the number of people diagnosed with overt hypothyroidism. Many of these prescriptions appear to be for the treatment of subclinical hypothyroidism and other conditions in euthyroid individuals. Join us to uncover the latest findings on the use of levothyroxine and what the evidence tells us about appropriate use and misuse of this drug.   Episode resource links: Brito, J., Ross, J., El Kawkgi, O., Maraka, S., Deng, Y., Shah, N., Lipska, K. & (9000). Levothyroxine Use in the United States, 2008-2018. JAMA Internal Medicine, Publish Ahead of Print, doi: 10.1001/jamainternmed.2021.2686. Johansen, M., Marcinek, J., Yun, J. & (2020). Thyroid Hormone Use in the United States, 1997–2016. Journal of the American Board of Family Medicine, 33 (2), 284-288. doi: 10.3122/jabfm.2020.02.190159. Jeffrey R. Garber, Rhoda H. Cobin,Hossein Gharib,James V. Hennessey, Irwin Klein, Jeffrey I. Mechanick, Rachel Pessah-Pollack, Peter A. Singer,Kenneth A. Woeber. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association; November–December 2012. https://www.endocrinepractice.org/article/S1530-891X(20)43030-7/fulltext; https://www.endocrinepractice.org/action/showPdf?pii=S1530-891X%2820%2943030-7   Guest: Susan Feeney, DNP, FNP-BC, NP-C   Music Credit: Richard Onorato

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-241   Overview: Seven percent of the US population has an active levothyroxine prescription, which is significantly greater than the number of people diagnosed with overt hypothyroidism. Many of these prescriptions appear to be for the treatment of subclinical hypothyroidism and other conditions in euthyroid individuals. Join us to uncover the latest findings on the use of levothyroxine and what the evidence tells us about appropriate use and misuse of this drug.   Episode resource links: Brito, J., Ross, J., El Kawkgi, O., Maraka, S., Deng, Y., Shah, N., Lipska, K. & (9000). Levothyroxine Use in the United States, 2008-2018. JAMA Internal Medicine, Publish Ahead of Print, doi: 10.1001/jamainternmed.2021.2686. Johansen, M., Marcinek, J., Yun, J. & (2020). Thyroid Hormone Use in the United States, 1997–2016. Journal of the American Board of Family Medicine, 33 (2), 284-288. doi: 10.3122/jabfm.2020.02.190159. Jeffrey R. Garber, Rhoda H. Cobin,Hossein Gharib,James V. Hennessey, Irwin Klein, Jeffrey I. Mechanick, Rachel Pessah-Pollack, Peter A. Singer,Kenneth A. Woeber. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association; November–December 2012. https://www.endocrinepractice.org/article/S1530-891X(20)43030-7/fulltext; https://www.endocrinepractice.org/action/showPdf?pii=S1530-891X%2820%2943030-7 Guest: Susan Feeney, DNP, FNP-BC, NP-C   Music Credit: Richard Onorato

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-241   Overview: Seven percent of the US population has an active levothyroxine prescription, which is significantly greater than the number of people diagnosed with overt hypothyroidism. Many of these prescriptions appear to be for the treatment of subclinical hypothyroidism and other conditions in euthyroid individuals. Join us to uncover the latest findings on the use of levothyroxine and what the evidence tells us about appropriate use and misuse of this drug.   Episode resource links: Brito, J., Ross, J., El Kawkgi, O., Maraka, S., Deng, Y., Shah, N., Lipska, K. & (9000). Levothyroxine Use in the United States, 2008-2018. JAMA Internal Medicine, Publish Ahead of Print, doi: 10.1001/jamainternmed.2021.2686. Johansen, M., Marcinek, J., Yun, J. & (2020). Thyroid Hormone Use in the United States, 1997–2016. Journal of the American Board of Family Medicine, 33 (2), 284-288. doi: 10.3122/jabfm.2020.02.190159. Jeffrey R. Garber, Rhoda H. Cobin,Hossein Gharib,James V. Hennessey, Irwin Klein, Jeffrey I. Mechanick, Rachel Pessah-Pollack, Peter A. Singer,Kenneth A. Woeber. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association; November–December 2012. https://www.endocrinepractice.org/article/S1530-891X(20)43030-7/fulltext; https://www.endocrinepractice.org/action/showPdf?pii=S1530-891X%2820%2943030-7   Guest: Susan Feeney, DNP, FNP-BC, NP-C   Music Credit: Richard Onorato

Our guest endocrinologist, Dr. Akshay Jain, will be answering your questions about T1D technology, devices, and the latest scientific research. Dr. Jain is the first Canadian physician to be triple board-certified by the American Boards in Endocrinology, Internal Medicine and Obesity Medicine. He is also the past president of the Canadian Chapter of the American Association of Clinical Endocrinologists. In 2020, he became the only non-American physician to feature on Medscape's list of 25 Top Rising Stars of Medicine. Dr. Jain is a renowned educator and has spoken at over 700 medical conferences/events across the world to date! His clinical interests include diabetes, obesity, thyroid disorders and osteoporosis. He is also fluent in 6 languages including English, Hindi, Gujarati, Marathi, Marwari and Urdu. Join us for this Huddle to hear from Dr. Jain on topics around T1D teach such as T1D device coverage, CGM usage, and looping techniques. Over 18 and interested in sharing your experiences living with type 1? Register to attend a live huddle at www.t1dhuddle.com

Episode 448 Deepak Chopra is a First Class Father and a world renowned pioneer in integrative medicine and personal transformation. TIME magazine included Deepak Chopra in their list of the top 100 heroes and icons of the Twentieth Century. In conjunction with his medical achievements, he is recognized as a prolific author of over 90 books translated into over forty-three languages, including numerous New York Times bestsellers. For the last thirty years, Chopra has been at the forefront of the meditation revolution. He is the founder of The Chopra Foundation, a non-profit entity for research on well-being and humanitarianism. Dr. Chopra is Board Certified in Internal Medicine, Endocrinology and Metabolism, a Fellow of the American College of Physicians, and a member of the American Association of Clinical Endocrinologists. In this Episode, Deepak shares his Fatherhood journey which includes two children. He discusses the pandemic from the physical and spiritual point of view. He describes the benefits of meditation, how to introduce kids to meditation and what age to start. He talks about his AI twin Digital Deepak and how it can help parents through seven different aspects of their lives. He offers some great advice for new or about to be Dads and more! DEEPAK CHOPRA - https://www.deepakchopra.com Belcampo Meat - https://belcampo.com/?utm_source=FATHERHOOD&utm_medium=INFL&utm_campaign=FATHERHOOD MY PILLOW - https://www.mypillow.com Promo Code: Fatherhood Save Up To 66% Off 1-800-875-0219 More Ways To Listen - https://linktr.ee/alec_lace First Class Fatherhood Merch - https://shop.spreadshirt.com/first-class-fatherhood-/we+are+not+babysitters-A5d09ea872051763ad613ec8e?productType=812&sellable=3017x1aBoNI8jJe83pw5-812-7&appearance=1 Follow me on instagram - https://instagram.com/alec_lace?igshid=ebfecg0yvbap For information about becoming a Sponsor of First Class Fatherhood please hit me with an email: FirstClassFatherhood@gmail.com --- Support this podcast: https://anchor.fm/alec-lace/support

In this episode, Dr. Rakesh Jain and Dr. Andrew Cutler review the pathophysiology and comorbidities in patients with schizophrenia and explore how serious mental illnesses (SMIs) may affect the whole patient. They also discuss the potential dysfunction that may be present across multiple symptoms in patients with schizophrenia based on evidence from antipsychotic-naïve patients. TAKE HOME POINTS – When considering physical comorbidities—including infectious, respiratory, metabolic, and cardiovascular diseases—in patients with SMI, including schizophrenia and bipolar disorder, multiple studies have reported an increased prevalence compared with the general population. There may be dysfunction across cardiometabolic, immune, and endocrine systems in patients with schizophrenia—whether we see elevation of certain blood cytokines or an imbalance between adiponectin and pro-inflammatory cytokines, this may contribute to a persistent cycle of obesity and inflammation. There are opportunities to improve whole patient care through comprehensive management of comorbidities and behavioral risk factors that may be present in patients living with SMIs like schizophrenia. For example, efforts to enhance tobacco smoking cessation, given over half of people with schizophrenia smoke and smoking is a known risk factor for cardiovascular disease, may involve behavioral interventions and cognitive behavioral therapy that have shown promise for smokers with SMIs. References ADA, APA, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Diabetes Care. 2004;27:596-601. APA. Practice Guideline for the Treatment of Patients with Schizophrenia (September 2020). https://doi.org/10.1176/appi.books.9780890424841. Accessed September 17, 2020. Cohn TA et al. Can J Psychiatry. 2006;51(6):382-386. Bahorik AL et al. J Psychosom Res. 2017;100:35-45. Balu DT. Adv Pharmacol. 2016;76:351-382. Brisch R et al. Front Psychiatry. 2014;5:47. De Hert M et al. Eur Psychiatry. 2009;24(6):412-424. De Hert M et al. World Psychiatry. 2011;10(1):52-77. Di Chiara T et al. J Nutr Metab. 2012;2012:175245. Diez JJ et al. Eur J Endocrinol. 2003;148(3):293-300. Fernandes BS et al. Mol Psychiatry. 2016;21(4):554-564. Freyberg Z et al. Front Neurosci. 2017;11:432. Gonzalez-Blanco L et al. Schizophr Res. 2016;174(1-3):156-160. Grimm O et al. Neurosci Biobehav Rev. 2017;75:91-103. Hayes JF et al. Br J Psychiatry. 2017;211(3):175-181. Helleberg M et al. Lancet HIV. 2015;2(8):e344-350. Huckans MS et al. Psychiatr Serv. 2006;57(3):403-406. Khokha JY et al. Schizophr Res. 2018;194:78-85. Leonard BE et al. J Psychopharmacol. 2012;26(5 Suppl):33-41. Lucatch AM et al. Front Psychiatry. 2018;9:672. Mangurian C et al. J Gen Intern Med. 2016;31(9):1083-1091. Menzaghi C. Diabetes. 2007 May;56(5):1198-1209. Myles N et al. J Clin Psychiatry. 2012;73(4):468-475. Nakamizo S et al. Trends in Immunotherapy. 2017;1(2):67-74. NIMH. Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788. Accessed May 8, 2019. NIMH. Schizophrenia. https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml. Accessed August 26, 2020. Pillinger T et al. Mol Psychiatry. 2018;24(6):776-794. Ringen PA et al. Front Psychiatry. 2014;5:137. Sokal J et al. J Nerv Ment Dis. 2004;192(6):421-427. Stahl SM. Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press; 2013. Toda M et al. Curr Psychiatry Rep. 2007;9(4):329-336 Yang AC et al. Int J Mol Sci. 2017;18(8). © 2020 Alkermes, Inc. All rights reserved. UNB-003069

For over a century, the treatments and technologies used to treat diabetes have evolved. New tools are now available to aid in diabetes management and to help patients further manage and better control their glucose levels. 1,2 Through their recently announced collaboration, Dexcom and Lilly are at the forefront of enhancing diabetes care. 3 In this episode Dr. Chad Worz and guest speakers Deirdre Ibsen and Dr. Thomas Blevins discuss these important technological and therapeutic achievements over time, as well as 2 products available from Dexcom and Lilly and how they may benefit patients with diabetes. References:  Dexcom G6 Pro User Guide. https://dexcompdf.s3-us-west-2.amazonaws.com/Dexcom-G6-Pro-User-Guide.pdf. Accessed October 12, 2020. Lyumjev [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC. Eli Lilly and Company. Lilly and Dexcom team up on new program to help improve diabetes management. https://provider.dexcom.com/products/dexcom-g6-pro/training-resources. Accessed October 12, 2020. Centers for Disease Control. National Diabetes Statistics Report 2020 Estimates of Diabetes and Its Burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed October 1, 2020. American Diabetes Association. Diabetes and Quality of Life. http://journal.diabetes.org/diabetesspectrum/00v13n1/pg48.htm. Accessed October 1, 2020. American Diabetes Association. Caring for the Caregiver. https://spectrum.diabetesjournals.org/content/17/1/37.full-text.pdf. Accessed October 15, 2020. Ali MK, Bullard KM, Gregg EW. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med. 2013;369(3):287-288. Foster NC, Beck RW, Miller KM, et al. State of type 1 diabetes management and outcomes from the T1D Exchange in 2016-2018. Diabetes Technol Ther. 2019;21(2):66-72. American Diabetes Association. 7. Diabetes Technology: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(suppl 1):S77-S88. Hirsch IB. History of Glucose Monitoring. https://professional.diabetes.org/sites/professional.diabetes.org/files/media/db201811.pdf. Accessed October 1, 2020. White JR. A brief history of the development of diabetes medications. Diabetes Spectr. 2014;27(2):82-86. Science History Institute. Frederick Banting, Charles Best, James Collip, and John Macleod. https://www.sciencehistory.org/historical-profile/frederick-banting-charles-best-james-collip-and-john-macleod. Accessed October 1, 2020. American Diabetes Association. Timeline. https://www.diabetes.org/resources/timeline. Accessed October 9, 2020. Humalog [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC. Selam J-L. Evolution of diabetes insulin delivery devices. J Diabetes Sci Technol. 2010;4(3):505-513. American Association of Diabetes Educators. Insulin Injection Know-How. https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Insulin_Injection_How_To_AADE.pdf. Accessed October 1, 2020. Hyllested-Winge J, Jensen KH, Rex J. A review of 25 years' experience with the NovoPen® family of insulin pens in the management of diabetes mellitus. Clin Drug Investig. 2010;30(10):643-674. Eli Lilly and Company. Lilly Launches KwikPen(TM) for Humalog(R) and Humalog Mixtures [press release]. https://investor.lilly.com/news-releases/news-release-details/lilly-launches-kwikpentm-humalogr-and-humalog-mixtures. Accessed October 12, 2020. American Diabetes Association. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(suppl 1):S66-S76. Garber AJ, Handelsman Y, Grunberger G, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2020 executive summary. Endocr Pract. 2020;26(1):107-139. Fonseca VA, Grunberger G, Anhalt H, et al. Continuous glucose monitoring: a consensus conference of the American Association of Clinical Endocrinologists and American College of Endocrinology. Endocr Pract. 2016;22(8):1008-1021. Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care. 2019;42(8):1593-1603. Dexcom G6 Pro Unblinded Patient Guide. https://dexcompdf.s3-us-west-2.amazonaws.com/Dexcom-G6-Pro-Unblinded-Patient-Guide.pdf. Accessed October 12, 2020. Dexcom Announces FDA Clearance of New Dexcom G6 Pro CGM. https://provider.dexcom.com/industry-news/fda-authorizes-dexcom-g6-pro. Accessed October 2, 2020. Beck RW, Riddlesworth T, Ruedy K, et al. Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial. 2017;317(4):371-378. Beck RW, Riddlesworth TD, Ruedy K, et al. Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: a randomized trial. Ann Intern Med. 2017;167(6):365-374. Polonsky WH, Hessler D, Ruedy KJ, Beck RW. The impact of continuous glucose monitoring on markers of quality of life in adults with type 1 diabetes: further findings from the DIAMOND randomized clinical trial. Diabetes Care. 2017;40(6):736-741. Pratley RE, Kanapka LG, Rickels MR, et al. Effect of continuous glucose monitoring on hypoglycemia in older adults with type 1 diabetes: a randomized clinical trial. 2020;323(23):2397-2406. Ruedy KJ, Parkin CG, Riddlesworth TD, Graham C. Continuous glucose monitoring in older adults with type 1 and type 2 diabetes using multiple daily injections of insulin: results from the DIAMOND trial. J Diabetes Sci Technol. 2017;11(6):1138-1146. Lind M, Polonsky W, Hirsch IB, et al. Continuous glucose monitoring vs conventional therapy for glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections: the GOLD randomized clinical trial. 2017;317(4):379-387. Frequently Asked Questions. https://provider.dexcom.com/products/dexcom-g6-pro/faqs. Accessed October 15, 2020. Dexcom Products: Dexcom G6 Pro. https://provider.dexcom.com/products/professional-cgm. Accessed October 15, 2020. How to Customize Alarm and Alerts. https://www.dexcom.com/faqs/how-to-customize-alarm-and-alerts. Accessed October 15, 2020. Trend Arrows and Treatment Decisions. https://s3-us-west-2.amazonaws.com/dexcompdf/HCP_Website/LBL015804+G6+Trend+Arrows+and+Treatment+Decisions.pdf. Accessed October 15, 2020. Why CGM? https://provider.dexcom.com/why-cgm. Accessed October 12, 2020. Pharmacy Coverage. https://provider.dexcom.com/pharmacy-coverage. Accessed October 12, 2020. Is There Reimbursement for Using Dexcom G6 Pro? https://provider.dexcom.com/faqs/there-reimbursement-using-dexcom-g6-pro. Accessed October 12, 2020. Hypoglycemia Unawareness. https://provider.dexcom.com/education-research/clinical-evidence/clinical-studies/real-time-continuous-glucose-monitoring-cgm. Accessed October 15, 2020. Garg SK, Wernicke-Panten K, Wardecki M, et al. Safety, immunogenicity, and glycemic control of insulin aspart biosimilar SAR341402 versus originator insulin aspart in people with diabetes also using insulin glargine: 12-month results from the GEMELLI 1 trial. Diabetes Technol Ther. 2020;22(7):516-526. Dexcom G6 Pro Blinded Patient Guide. https://dexcompdf.s3-us-west-2.amazonaws.com/HCP_Website/Dexcom+G6+Pro+Resources/LBL017177+Rev+004+Artwork%2C+Dexcom+G6+Pro+Blinded+Patient+Guide+US_r5_WEB.pdf. Accessed November 24, 2020. Dexcom CLARITY Diabetes Management Software. https://www.dexcom.com/clarity. Accessed May 15, 2020. Blevins T, Zhang Q, Frias JP, Jinnouchi H, Chang AM. Randomized double-blind clinical trial comparing ultra rapid lispro with lispro in a basal-bolus regimen in patients with type 2 diabetes: PRONTO-T2D. Diabetes Care. Published online July 2, 2020. doi: 10.2337/dc19-2550. Klaff L, Cao D, Dellva MA, et al. Ultra rapid lispro improves postprandial glucose control compared with lispro in patients with type 1 diabetes: results from the 26-week PRONTO-T1D study. Diabetes Obes Metab. 2020;22(10):1799-1807. See omnystudio.com/listener for privacy information. Learn more about your ad choices. Visit megaphone.fm/adchoices

For over a century, the treatments and technologies used to treat diabetes have evolved. New tools are now available to aid in diabetes management and to help patients further manage and better control their glucose levels. 1,2 Through their recently announced collaboration, Dexcom and Lilly are at the forefront of enhancing diabetes care. 3 In this episode Dr. Chad Worz and guest speakers Deirdre Ibsen and Dr. Thomas Blevins discuss these important technological and therapeutic achievements over time, as well as 2 products available from Dexcom and Lilly and how they may benefit patients with diabetes. References:  Dexcom G6 Pro User Guide. https://dexcompdf.s3-us-west-2.amazonaws.com/Dexcom-G6-Pro-User-Guide.pdf. Accessed October 12, 2020. Lyumjev [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC. Eli Lilly and Company. Lilly and Dexcom team up on new program to help improve diabetes management. https://provider.dexcom.com/products/dexcom-g6-pro/training-resources. Accessed October 12, 2020. Centers for Disease Control. National Diabetes Statistics Report 2020 Estimates of Diabetes and Its Burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed October 1, 2020. American Diabetes Association. Diabetes and Quality of Life. http://journal.diabetes.org/diabetesspectrum/00v13n1/pg48.htm. Accessed October 1, 2020. American Diabetes Association. Caring for the Caregiver. https://spectrum.diabetesjournals.org/content/17/1/37.full-text.pdf. Accessed October 15, 2020. Ali MK, Bullard KM, Gregg EW. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med. 2013;369(3):287-288. Foster NC, Beck RW, Miller KM, et al. State of type 1 diabetes management and outcomes from the T1D Exchange in 2016-2018. Diabetes Technol Ther. 2019;21(2):66-72. American Diabetes Association. 7. Diabetes Technology: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(suppl 1):S77-S88. Hirsch IB. History of Glucose Monitoring. https://professional.diabetes.org/sites/professional.diabetes.org/files/media/db201811.pdf. Accessed October 1, 2020. White JR. A brief history of the development of diabetes medications. Diabetes Spectr. 2014;27(2):82-86. Science History Institute. Frederick Banting, Charles Best, James Collip, and John Macleod. https://www.sciencehistory.org/historical-profile/frederick-banting-charles-best-james-collip-and-john-macleod. Accessed October 1, 2020. American Diabetes Association. Timeline. https://www.diabetes.org/resources/timeline. Accessed October 9, 2020. Humalog [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC. Selam J-L. Evolution of diabetes insulin delivery devices. J Diabetes Sci Technol. 2010;4(3):505-513. American Association of Diabetes Educators. Insulin Injection Know-How. https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Insulin_Injection_How_To_AADE.pdf. Accessed October 1, 2020. Hyllested-Winge J, Jensen KH, Rex J. A review of 25 years’ experience with the NovoPen® family of insulin pens in the management of diabetes mellitus. Clin Drug Investig. 2010;30(10):643-674. Eli Lilly and Company. Lilly Launches KwikPen(TM) for Humalog(R) and Humalog Mixtures [press release]. https://investor.lilly.com/news-releases/news-release-details/lilly-launches-kwikpentm-humalogr-and-humalog-mixtures. Accessed October 12, 2020. American Diabetes Association. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(suppl 1):S66-S76. Garber AJ, Handelsman Y, Grunberger G, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2020 executive summary. Endocr Pract. 2020;26(1):107-139. Fonseca VA, Grunberger G, Anhalt H, et al. Continuous glucose monitoring: a consensus conference of the American Association of Clinical Endocrinologists and American College of Endocrinology. Endocr Pract. 2016;22(8):1008-1021. Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care. 2019;42(8):1593-1603. Dexcom G6 Pro Unblinded Patient Guide. https://dexcompdf.s3-us-west-2.amazonaws.com/Dexcom-G6-Pro-Unblinded-Patient-Guide.pdf. Accessed October 12, 2020. Dexcom Announces FDA Clearance of New Dexcom G6 Pro CGM. https://provider.dexcom.com/industry-news/fda-authorizes-dexcom-g6-pro. Accessed October 2, 2020. Beck RW, Riddlesworth T, Ruedy K, et al. Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial. 2017;317(4):371-378. Beck RW, Riddlesworth TD, Ruedy K, et al. Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: a randomized trial. Ann Intern Med. 2017;167(6):365-374. Polonsky WH, Hessler D, Ruedy KJ, Beck RW. The impact of continuous glucose monitoring on markers of quality of life in adults with type 1 diabetes: further findings from the DIAMOND randomized clinical trial. Diabetes Care. 2017;40(6):736-741. Pratley RE, Kanapka LG, Rickels MR, et al. Effect of continuous glucose monitoring on hypoglycemia in older adults with type 1 diabetes: a randomized clinical trial. 2020;323(23):2397-2406. Ruedy KJ, Parkin CG, Riddlesworth TD, Graham C. Continuous glucose monitoring in older adults with type 1 and type 2 diabetes using multiple daily injections of insulin: results from the DIAMOND trial. J Diabetes Sci Technol. 2017;11(6):1138-1146. Lind M, Polonsky W, Hirsch IB, et al. Continuous glucose monitoring vs conventional therapy for glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections: the GOLD randomized clinical trial. 2017;317(4):379-387. Frequently Asked Questions. https://provider.dexcom.com/products/dexcom-g6-pro/faqs. Accessed October 15, 2020. Dexcom Products: Dexcom G6 Pro. https://provider.dexcom.com/products/professional-cgm. Accessed October 15, 2020. How to Customize Alarm and Alerts. https://www.dexcom.com/faqs/how-to-customize-alarm-and-alerts. Accessed October 15, 2020. Trend Arrows and Treatment Decisions. https://s3-us-west-2.amazonaws.com/dexcompdf/HCP_Website/LBL015804+G6+Trend+Arrows+and+Treatment+Decisions.pdf. Accessed October 15, 2020. Why CGM? https://provider.dexcom.com/why-cgm. Accessed October 12, 2020. Pharmacy Coverage. https://provider.dexcom.com/pharmacy-coverage. Accessed October 12, 2020. Is There Reimbursement for Using Dexcom G6 Pro? https://provider.dexcom.com/faqs/there-reimbursement-using-dexcom-g6-pro. Accessed October 12, 2020. Hypoglycemia Unawareness. https://provider.dexcom.com/education-research/clinical-evidence/clinical-studies/real-time-continuous-glucose-monitoring-cgm. Accessed October 15, 2020. Garg SK, Wernicke-Panten K, Wardecki M, et al. Safety, immunogenicity, and glycemic control of insulin aspart biosimilar SAR341402 versus originator insulin aspart in people with diabetes also using insulin glargine: 12-month results from the GEMELLI 1 trial. Diabetes Technol Ther. 2020;22(7):516-526. Dexcom G6 Pro Blinded Patient Guide. https://dexcompdf.s3-us-west-2.amazonaws.com/HCP_Website/Dexcom+G6+Pro+Resources/LBL017177+Rev+004+Artwork%2C+Dexcom+G6+Pro+Blinded+Patient+Guide+US_r5_WEB.pdf. Accessed November 24, 2020. Dexcom CLARITY Diabetes Management Software. https://www.dexcom.com/clarity. Accessed May 15, 2020. Blevins T, Zhang Q, Frias JP, Jinnouchi H, Chang AM. Randomized double-blind clinical trial comparing ultra rapid lispro with lispro in a basal-bolus regimen in patients with type 2 diabetes: PRONTO-T2D. Diabetes Care. Published online July 2, 2020. doi: 10.2337/dc19-2550. Klaff L, Cao D, Dellva MA, et al. Ultra rapid lispro improves postprandial glucose control compared with lispro in patients with type 1 diabetes: results from the 26-week PRONTO-T1D study. Diabetes Obes Metab. 2020;22(10):1799-1807. See omnystudio.com/listener for privacy information.

Las hormonas son sustancias químicas especiales fabricadas por partes del cuerpo llamadas glándulas. Son mensajeros que le dicen a otras partes del cuerpo cómo y cuándo trabajar. Las hormonas controlan casi todas las tareas del cuerpo. Estos incluyen la función sexual y cerebral, el crecimiento y la descomposición de los alimentos. Cuando las hormonas están desequilibradas, pueden aparecer síntomas. Las hormonas bioidénticas se definen como hormonas artificiales que son muy similares a las hormonas producidas por el cuerpo humano. Las hormonas comunes que se combinan son el estrógeno, la progesterona y la testosterona. Estos se utilizan luego como tratamiento para hombres y mujeres cuyas propias hormonas están bajas o fuera de equilibrio. Algunas formas recetadas de hormonas bioidénticas están prefabricadas por una compañía farmacéutica. Otros formularios son hechos a medida por un farmacéutico según la orden de un médico. A esto se le llama capitalización. La Administración de Drogas y Alimentos de los Estados Unidos (FDA) ha aprobado una serie de preparaciones de estradiol y progesterona bioidénticos, que son molecularmente idénticas a la estructura de las hormonas generadas por el cuerpo humano. Han pasado por pruebas de seguridad y pureza y para asegurarse de que cada dosis tenga la misma cantidad de hormonas. Las formas compuestas no han sido probadas ni aprobadas por la FDA. Escucha el podcast en tu plataforma favorita: Spotify, iVoox, Apple Podcast, Google Podcast, Anchor.Fm, Breaker.Audio, Pocketcast y Radio Public. Si deseas contactarte conmigo para tomar sesiones de coaching hormonal, puedes mandarme un mensaje a cualquiera de estas direcciones: hola@alquimiahormonal.com, https://edusantibanez.com/, o puedes simplemente mandarme un DM en mis redes sociales. Quieres adquirir la Guía Menopausia Integral Lo puedes hacer a través de este enlace. https://edusantibanez.com/ebook/ Enlances y/o referecias de los estudios y artículos relacionados con el tema de hoy: Stuenkel, CA. and Manson, JE: Compounded Bioidentical Hormone Therapy: Does the Regulatory Double Standard Harm Women? JAMA Internal Medicine. Published online October 9, 2017. Available at: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2656887 Accessed October 10, 2017. Cohen PA. Assessing supplement safety—the FDA’s controversial proposal. N Engl J Med. 2012;366:389-391. US Food and Drug Administration. Estrogen and estrogen with progestin therapies for postmenopausal women. Available at: www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm135318.htm. Accessed October 13, 2017. Goodman NF, Cobin RH, Ginzburg SB, Katz IA, Woode DE. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and treatment of menopause. Endocrine Practice. 2011;17(Suppl6):1-25. Cobin RH, Goodman NF. American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on Menopause—2017 update. Endocrine Practice. 2017;23(7):869-880. Manson, JE et al. Menopausal Hormone Therapy and Long-Term All-Cause and Cause-Specific Mortality. JAMA. September 12, 2017. https://jamanetwork.com/journals/jama/article-abstract/2653735 Accessed October 12, 2017. ¡Aprende a entender a tus hormonas para que ellas trabajen para ti y no en tu contra! --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

References: American Academy of Clinical Endocrinologists' Guidelines: https://www.aace.com/pdfs/diabetes/algorithm-exec-summary.pdf https://www.aace.com/pdfs/diabetes/AACE_2019_Diabetes_Algorithm_FINAL_ES.pdf https://journals.aace.com/doi/pdf/10.4158/EP15672.GLSUPPL History of Diabetes https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749019/ Hypoglycemia https://ihsgonline.com/wp-content/uploads/2017/05/Jan_2017-Diabetes_Care-Glucose_Concentrations.pdf Sleep Podcast: https://podcasts.apple.com/us/podcast/episode-93-sleep/id1199780143 For more of our stuff: Podcasts: goo.gl/X4H4z8 Website: www.barbellmedicine.com Instagram: @austin_barbellmedicine @jordan_barbellmedicine @leah_barbellmedicine @vaness_barbellmedicine @untamedstrength @michael_barbellmedicine @derek_barbellmedicine @hassan_barbellmedicine @michael_amato_barbellmedicine @charlie_barbellmedicine @alex_barbellmedicine @tomcampitelli Email: info@barbellmedicine.com Supplements/Templates/Seminars: www.barbellmedicine.com/shop/ Forum: forum.barbellmedicine.com/

Singer/songwriter Crystal Bowersox, who has diabetes, and Dr. Gregory Dodell, member of the American Association of Clinical Endocrinologists, discuss the new initiative "Know Before the Low" to help those living with diabetes be prepared for low blood sugar, which includes having a “rescue plan” in place for very low blood sugar emergencies and telling their support network about it in advance.

  Dr. Kelly N. Wood, MD is an internal medicine physician, board certified in Endocrinology, Diabetes and Metabolism. She earned her medical degree from The University of the West Indies in Barbados before relocating to the United States in 2006. Licensed in three states, Dr. Kelly is currently in clinical practice in Atlanta, Georgia. Beyond the stethoscope, Dr. Kelly is recognized as “The Bounce Back Coach,” helping high-performing women to bounce back from failed relationships, rebuild their self-esteem, and reclaim their identity. Her debut book, “Bounce Back to Better: Recovering from the Disappointment of a Failed Relationship,” walks readers through her personal journey of reconstructing her life after her engagement ended.   Through a multi-dimensional platform that addresses the mind, body, and spirit, Dr. Kelly lives out her passion to help others achieve total wellness and lead a balanced life. She makes expert health and wellness advice accessible to all through speaking engagements, media appearances, her Facebook show, and personal blog. Dr. Kelly maintains connection with professional organizations such as the Endocrine Society and the American Association of Clinical Endocrinologists. She also holds a Master’s degree in Business Administration from West Connecticut State University.   In this episode, Dr. Kelly joins the podcast to share her knowledge and experience as a well traveled medical professional.  How she survived a tough program to become the professional she is today. How marriage and relationships impacted her career. Strategies used to invest in herself and growth as a business woman.   Dr. Kelly got a chance to give us some insight on her journey as the The Bounce Back Coach. Today’s episode will even cover infertility and religious views on the issues that women are facing. You’re going to live this episode because Dr. Kelly six vulnerable and honest about her current state and the failures she’s experienced.   More about Dr. Kelly Get the book Bounce Back to Better: Recovering from the Disappointment of a Failed Relationship     

Deepak Chopra, M.D., F.A.C.P., is the co-founder of the Chopra Center for Wellbeing, the founder of the Chopra Foundation, and a world-renowned pioneer in integrative medicine and personal transformation. He is board certified in internal medicine, endocrinology, and metabolism. He is a Fellow of the American College of Physicians, a member of the American Association of Clinical Endocrinologists, and a clinical professor in the Family Medicine and Public Health Department at the University of California, San Diego. He is the author of some 90 books translated into over 43 languages, including numerous New York Times bestsellers. His most recent book is Metahuman: Unleashing Your Infinite Potential.  His resume itself reflects the infinite potential itself that Deepak speaks of and will discuss with Mitchell in this week's interview.  Interesting bonus gifts available when purchasing Metahuman at https://www.deepakchopra.com/metahuman  Learn more at www.deepakchopra.com. Mitchell Rabin is the Founder, President and CEO of A Better World Foundation & Media, with a background in psychology  stress management, acupuncture and social entrepreneurship.   www.abetterworld.tv   www.mitchellrabin.com --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/abwmitchellrabin/support

As a progressive disease diabetes presents an ongoing challenge for physicians to provide adequate control of patients’ diabetes, and new agents with novel mechanisms of action help reduce the burden in the management of diabetes. In a recent Peer Exchange discussion, Dr Peter Salgo, of Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, led a discussion on novel agents and their role in treating patients with and with cardiovascular disease. On the panel was Dr. Om Ganda of Joslin Diabetes Center; Jim Kenney of JTKenney, a managed care consulting practice; and Dr Helena Rodbard, past president of the American College of Endocrinology and past president of the American Association of Clinical Endocrinologists. Listen to the full discussion: https://www.ajmc.com/peer-exchange/new-classes-for-treatment-of-type-2-diabetes/

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine's Emergency Medicine Practice. I'm Jeff Nusbaum and I'm back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month's author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month's evidence-based article. Nachi: And don't forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let's dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that's kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That's almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80's to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it's not exactly core EM, we're going to briefly discuss indications for bariatric surgery, as this is something we don't often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures.

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine's Emergency Medicine Practice. I'm Jeff Nusbaum and I'm back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month's author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month's evidence-based article. Nachi: And don't forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let's dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that's kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That's almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80's to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it's not exactly core EM, we're going to briefly discuss indications for bariatric surgery, as this is something we don't often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time. Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications. Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%. Jeff: Before we get into the ED specific treatment guidelines, I think it's worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier. Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective. Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals. Nachi: That's certainly an important point for the candidate patient. Let's start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications. Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously. Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption. Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50. Nachi: Now that you have a sense of the procedures, let's talk complications, both general and specific. Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications. Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period. Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery. Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later… Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress. Nachi: All of that being said, each specific procedure has it's own unique set of complications that we should discuss. Let's start with the sleeve gastrectomy. Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%. Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake. Jeff: Hemorrhag...

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article. Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that’s kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time. Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications. Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%. Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier. Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective. Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals. Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications. Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously. Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption. Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50. Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific. Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications. Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period. Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery. Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later… Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress. Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy. Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%. Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake. Jeff: Hemorrhage occurs due to erosions at the staple line, resulting in peritonitis, hematemesis, or melena. Nachi: Late complications of sleeve gastrectomies include reflux, which occurs in up to 25% of patients, and strictures, which lead to epigastric discomfort, nausea, and dysphagia. Jeff: I’m getting reflux and massive heartburn just thinking about all of these complications, or the tacos i just ate…. Next we have the Roux-en-Y bypass. Nachi: Early complications of the Roux-en-Y Gastric Bypass include anastomotic or staple line leaks, hemorrhage, early postoperative obstruction, and dumping syndrome. Jeff: Leak incidence ranges from 1-6%, usually occurring at the gastro-jejunostomy site. Patients typically present within the first 10 days with abdominal pain, nausea, vomiting, and the feeling of impending doom. Some may present with isolated tachycardia while others may present with profound sepsis – tachycardia, hypotension, and fever. Nachi: Similar to the sleeve, hemorrhage can occur both intraperitoneally or intraluminally. This may lead to hematemesis or melena depending on the location of bleeding. Jeff: Early obstructions usually occur at either the gastro-jejunal or jejuno-jejunal junction. Depending on the location, patients typically present either within 2 days or in the first few weeks in the case of the gastro-jejunal site. Nachi: If the obstruction occurs in the jejuno-jejunostomy site, this can cause subsequent dilatation of the excluded stomach and lead to perforation, which portends a very poor prognosis. Jeff: Next, we have dumping syndrome. This has been seen in up to 50% of Roux-en-Y patients. Nachi: Early dumping occurs within 10-30 minutes after ingestion. As food rapidly empties from the stomach, this leads to distention and increased contractility, leading to nausea, abdominal pain, bloating, and diarrhea. This usually resolves within 7-12 weeks. Jeff: Moving on to late complications of the roux-en y - first we have marginal ulcers. Peptic ulcer disease and diabetes are risk factors and tobacco use and NSAIDs appear to increase your risk. In the worse case, they present with hematemesis or melena. Nachi: Internal hernias, intussusception, and SBOs are also seen after Roux-en-y gastric bypass. Patients with internal hernias usually present late in the postoperative period following significant weight loss. Jeff: Most studies cite a rate of 1-3% for internal hernias, with mortality up to 50% if there is strangulation. Nachi: And unfortunately for us on the front lines, diagnosis can be challenging. Presenting symptoms may be vague and CT imaging may be negative when patients are pain free, thus laparoscopy may be needed to definitively exclude an internal hernia. Jeff: Strictures may occur both during the early and late period. Most are minor, but significant strictures may result in obstruction. Nachi: Trocar site hernias and ventral hernias are also late complications, usually found after significant weight loss. Jeff: Cholelithiasis is another very common complication of bypass surgery, occurring in up to one third of patients, usually occurring during a peak incidence period between 6-18 months. Nachi: For this reason, the current recommendation is that patients undergoing bypass be placed on ursodeoxycholic acid for 6 months preventatively. Jeff: Some even go as far as to recommend prophylactic cholecystectomy to prevent complications, but as of 2013, the recommendation was only ‘to consider’ it. Nachi: Nutritional deficiencies are also common complications. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. Jeff: And next we have late dumping syndrome, which is far more rare than the last two complications. In late dumping syndrome, 1-3 hours after a meal, patients suffer hypoglycemia from excessive insulin release following the food bolus entering the GI tract. Symptoms are those typical of hypoglycemia. Nachi: Lastly, let’s talk about complications of lap adjustable gastric band surgery. In the early post op period, you can have esophageal and gastric perforations, which typically occur during balloon placement. Patients present with abd pain, n/v, and peritonitis. These patients often require emergent operative intervention. Jeff: The band can also be overtightened resulting in distention of the proximal gastric pouch. Presenting symptoms include abd pain with food and liquid intolerance and vomiting. Symptoms resolves once the balloon is deflated. The band can also slip, allowing the stomach to move upward and within the band. This occurs in up to 22% of patients and can cause strangulation. Presentation is similar to bowel ischemia. Nachi: Later complications include port site infections due to repeated port access. The infection can spread into connector tubing and the peritoneal cavity causing systemic symptoms. Definitely start antibiotics and touch base with the bariatric surgeon. Jeff: The connector can also dislodge or rupture with time. This can present as an arrest in weight loss. It’s diagnosed by contrast injection into the port. Of note, this complication is less common due to changes in the technique used. Nachi: Much like early band slippage and prolapse, patients can also experience late band slippage and prolapse after weeks or months. In extreme cases, the patients can again have strangulation and symptoms of bowel ischemia. More mild cases will present with arrest in weight loss, reflux, and n/v. Jeff: The band can also erode and migrate into the stomach cavity. If this occurs, it usually happens within 2 years of the initial procedure with an incidence of 4-11%. Presenting symptoms here include epigastric pain, bleeding, and infections. You’ll want to obtain emergent imaging if you are concerned. Nachi: And lastly there are two rare complications worth mentioning from any gastric bypass surgery. These are nephrolithiasis, possibly due to increased urinary oxalate excretion or hypocitraturia, and rhabdomyloysis. Jeff: That was a ton of information but certainly valuable as most EM clinicians, even ones in practice for decades, are unlikely to have that depth of knowledge on bariatric surgery. Nachi: And truthfully these patients are complicated. Aside from the pathologies we just discussed, you also have to still bear in mind other abdominal conditions unrelated to their surgery like appendicitis, diverticulitis, pyelo, colitis, hepatitis, pancreatitis, mesenteric ischemia, and GI bleeds. Jeff: Moving on to my favorite - prehospital care - as always, ABCs first. Consider IV access and early IV fluids in those at risk for dehydration and intra-abdominal infections. In terms of destination, if it’s feasible and the patient is stable consider transport directly to the nearest bariatric center - early efforts up front will really expedite patient care. Nachi: Once in the ED, you will want to continue initial stabilization. Special considerations for the airway include a concern for a difficult airway due to body habitus. Make sure to position appropriately and preoxygenate the patients if time allows. Keep the patient upright for as long as possible as they may desaturate quickly when flat. Jeff: We both routinely raise the head of the bed for all of our intubations. This is ever more important for your obese patients to help maximize your chance of first pass success without significant desaturation. Nachi: And though I’m sure we all remember this from residency, it’s worth repeating: tidal volume settings on the ventilator should be based on ideal body weight, not actual body weight. At 6 to 8 mL/kg. Jeff: Tachycardic patients should make you concerned for hypovolemia 2/2 dehydration, sepsis, leaks, and blood loss. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. A HR > 120 with abdominal pain should make you concerned enough to discuss urgent ex-lap with the surgeon to evaluate for the post op complications we discussed earlier. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. But bear in mind that ultrasound will undoubtedly be more difficult if the patient has a large body habitus, so don’t be disappointed if you’re not getting the best views. Jeff: Resuscitation should be aimed at early fluid replacement with IV crystalloids for hypovolemic patients and packed RBC transfusions for patients presumed to be unstable from hemorrhage. No real surprises there for our listeners. Nachi: Once stabilized, gather a thorough history. In addition to the usual questions, ask about po intolerance, early satiety, hematemesis, and hematochezia. Definitely also gather a thorough surgical history including name of procedure, date, known complications post op, and name of the surgeon. Jeff: You might also run into “medical tourism” or global bariatric care. Patients are traveling overseas to get their bariatric care more and more frequently. Accreditation and oversight is variable in different countries and there isn’t a worldwide standard of care. Just an important phenomenon to be aware of in this population. Nachi: On physical exam, be sure to look directly at the belly, making note of any infections especially near a port-site. Given the reorganized anatomy and extent of soft tissue in obese patients, don’t be reassured by a benign exam. Something awful may be happening deeper. Jeff: This naturally brings us into diagnostic testing. Not surprisingly, labs will be helpful in these patients. Make sure to check abdominal labs and a lipase. Abnormal LFTs or lipase may indicate obstruction of the biliopancreatic limb in bypass patients. Nachi: A lactic acid level will help in suspected cases of hypoperfusion from sepsis or bowel ischemia. Jeff: And as we mentioned earlier, these patients are often at risk for ACS given their comorbidities. Be sure to check a troponin if you suspect cardiac ischemia. Nachi: If concerned for sepsis, draw blood cultures, and if concerned for hemorrhage, be sure to send a type and screen. Urinalysis and urine culture should be considered especially for early post op patients, symptomatic patients, or those with GU complaints. Jeff: And don’t forget the urine pregnancy test for women of childbearing age, especially prior to imaging. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation. Jeff: As for imaging, plain radiographs certainly play a role here. For patients with respiratory complaints, check a CXR. In the early postoperative period, there is increased risk for pneumonia. Nachi: Unstable patients with abdominal pain will benefit from an emergent abdominal series, which may show free air under the diaphragm, pneumatosis, air-fluid levels, or even dilated loops of bowel. Jeff: Of course don’t forget that intra abd air may be seen after laparoscopic procedures depending on how recently the operation was performed. Nachi: Plain x-ray can also help diagnose malpositioned or slipped gastric bands. But a negative study doesn’t rule out any of these pathologies definitively, given the generally limited sensitivity and specificity of x-ray. Jeff: You might also consider an upper GI series. Emergent uses include diagnosis of slipped or prolapsed gastric bands as well as gastric or esophageal perforations. Urgent indications include diagnosis of strictures. These can also diagnose gastric band erosions and help identify staple-line or anastomotic leaks in stable patients. Nachi: However, upper GI series might not be easy to obtain in the ED, so it’s often not the first test performed. Jeff: This brings us to the workhorse for diagnostic evaluation. The CT. Depending on suspected pathology, oral and/or IV contrast will be helpful. Oral contrast can help identify gastric band erosions, staple-line leaks, and anastomotic leaks. Leaks can be identified in up 86% of cases with oral contrast. Nachi: CT will also help diagnose internal hernias. You might see the swirl sign on CT, which represents swirling of the mesenteric vessels. This is highly predictive of an internal hernia, with a sensitivity of 78-100% and specificity of 80-90% according to at least two studies. Jeff: While CT is extremely helpful in making this diagnosis, note that it may be falsely negative for internal hernias. A retrospective review showed a sensitivity of 76% and a specificity of 60%. It also showed that 22% of patients with an internal hernia on surgical exploration had a negative CT in the ED. Another study found a false negative rate of 32%. What does all this mean? It likely means that a negative study may still necessitate diagnostic laparoscopy to rule out an internal hernia. Nachi: While talking about CT, we should definitely mention CTA for concern of pulmonary embolism. In order to limit contrast exposure, you might consider doing a CTA chest and CT of the abdomen simultaneously. Jeff: Next up is ultrasound. Ultrasound is still the first-line imaging modality for assessing the gallbladder and for biliary tract disease. And as we mentioned previously, ultrasound should be considered for your RUSH exam and for assessing the IVC. Nachi: We also should discuss endoscopy, which is the test of choice for diagnosing gastric band erosions. Endoscopy is also useful for evaluating marginal ulcers, strictures, leaks, and GI bleeds. Endoscopy additionally can be therapeutic for patients. Jeff: When treating these patients, attempt to contact the bariatric surgeon for guidance as needed. This shouldn’t delay imaging however. Nachi: For septic patients, make sure your choice of antibiotics covers intra-abdominal gram-negative and anaerobic organisms. Port-site infections require gram-positive coverage to cover skin flora. Additionally, give IV fluids, blood products, and antiemetics as appropriate. Jeff: Alright, so this month, we also have 2 special populations to discuss. First up, the kids. Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. As obese children are at higher risk for comorbidities later in life and bariatric surgery remains one of the best modalities for sustained weight loss, these surgical procedures are also being done in children. Jeff: Criteria for bariatric surgery in the adolescent population is similar to that of adults and includes a BMI of 35 and major comorbidities (like diabetes or moderate to severe sleep apnea) or patients with a BMI 40 with other comorbidities associated with long term risks like hypertension, dyslipidemia, insulin resistance and impaired quality of life. Nachi: Despite many adolescents meeting criteria, they should be referred with caution as the long term effects are unclear and the adolescent experience is still in its infancy with few pediatric specific programs. Jeff: Still, the complication rate is low - about 2.3% with generally good clinical outcomes including improved quality of life and reducing or staving off comorbidities. Nachi: Women of childbearing age are the next special population. They are at particular risk because of the unique caloric and nutrient needs of a pregnant mother. Jeff: Pregnant women who have had bariatric surgery have an increased risk of perinatal complications including prematurity, small for gestational age status, NICU admission and low Apgar scores. However, these risks come with benefits as other studies have shown reduced incidence of pre-eclampsia, large for gestational age neonates, and gestational diabetes. Nachi: 2013 guidelines from various organizations recommend avoiding becoming pregnant for at least 12-18 months postoperatively, with ACOG recommending a minimum of 2 years. Bariatric surgery patients who do become pregnant require serial monitoring for fetal growth and higher doses of supplemental folate. Jeff: We also have 2 pretty cool cutting edge techniques to mention this month before getting to disposition. Nachi: Though these are certainly not going to be done in the ED, you should be aware of two new techniques. Recently, the FDA approved 3 new endoscopic gastric balloon procedures in which a balloon is inflated in the stomach as a means of simulating a restrictive procedure. Complications include perforation, ulceration, GI bleeding, and migration with obstruction. As of now, they are only approved as a temporary modality for up to 6 months. Jeff: And we also have the AspireAssist siphon, which was approved in 2016. With the siphon, a g tube is placed in the stomach, and then ⅓ of the stomach contents is drained 20 minutes after meals, thus limiting overall digested intake. Nachi: Pretty cool stuff... Jeff: Yup - In terms of disposition, decisions should often be made in conjunction with the bariatric surgical team. Urgent and occasionally emergent surgery is required for those with hemodynamic instability, anastomotic or staple line leaks, SBO, acute band slippage with dilatation of the gastric pouch, tight gastric bands, and infected port sites with concurrent intra abdominal infections. Nachi: And while general surgeons should be well-versed in these complications should the patient require an emergent surgery, it is often best to stabilize and consider transfer to your local bariatric specialty facility. Jeff: In addition to the need for admission for surgical procedures, admission should also be considered in those with dehydration and electrolyte disturbances, those with persistent vomiting, those with GI bleeding requiring transfusions, those with acute cholecystitis or choledococholithiasis, and those with malnutrition. Nachi: Finally, patients with chronic strictures, marginal ulcers, asymptomatic trocar or ventral hernias, and stable gastric band erosions can usually be safely discharged after an appropriate conversation with the patient’s bariatric surgeon. Jeff: Definitely a great time to do some joint decision making with the patient and their surgeon. Nachi: Exactly. Let’s close out with some Key points and clinical pearls. Jeff: Bariatric surgeries are being performed more frequently due to both their success in sustained weight loss and improvements in associated comorbidities. Nachi: There is an increased risk of postoperative myocardial infarction and pulmonary embolism after bariatric surgery. There is also an increased risk of self-harm emergencies after bariatric surgery, mostly in patients with known psychiatric co-morbidities. Jeff: Nutritional deficiencies can occur following bariatric surgery, with thiamine deficiency being one of the most common. Look for signs of beriberi or even Wernicke encephalopathy. Nachi: Staple-line leaks are an important cause of postoperative morbidity. Patients often present with abdominal pain, vomiting, sepsis, and peritonitis. Jeff: Strictures can also present postoperatively and cause reflux, epigastric discomfort, and vomiting. Nachi: Intraperitoneal or intraluminal hemorrhage is a known complication of bariatric surgery and may present as peritonitis or with hematemesis and melena. Jeff: After significant weight loss, internal hernias with our without features of strangulation are a late complication. Nachi: Late dumping syndrome is a rare complication following Roux-en-Y bypass occurring months to years postoperatively. It presents with hypoglycemia due to excessive insulin release. Jeff: Esophageal or gastric perforation are early complications of adjustable gastric band surgery. These patients require emergent surgical intervention. Nachi: Overtightening of the gastric band results in food and liquid intolerance. This resolves once the balloon is deflated. Jeff: Late complications of gastric band surgery include port-site infections, connector tubing dislodgement or rupture, band slippage or prolapse, and band erosion with intragastric migration. Nachi: Given the myriad of possible bariatric surgeries, emergency clinicians should be cognizant of procedure-specific complications. Jeff: Consider obtaining a lactic acid level for cases of suspected bowel ischemia or sepsis. Nachi: Endoscopy is the best method for diagnosing and treating gastric band erosions. Jeff: Septic patients should be treated with antibiotics that cover gram-negative and anaerobic organisms. Suspected port site or wound infections require gram positive coverage. Nachi: Pregnant patients who previously had bariatric surgery are at risk for complications from their prior surgery as well as pregnancy-related pathology. Jeff: A plain radiograph may be useful in unstable patients to evaluate for free air under the diaphragm, pneumatosis, air-fluid levels, or dilated loops of bowel. Nachi: CT of the abdomen and pelvis is the mainstay for evaluation. Oral and/or IV contrast should be considered depending on the suspected pathology. Jeff: Have a low threshold for emergent surgical consultation for ill-appearing, unstable, or peritonitic patients. Nachi: So that wraps up Episode 30! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And the address for this month’s cme credit is ebmedicine.net/E0719, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References Altieri MS, Wright B, Peredo A, et al. Common weight loss procedures and their complications. Am J Emerg Med. 2018;36(3):475-479. (Review article) Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014(8):CD003641. (Cochrane review; 22 trials) Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21 Suppl 1:S1-S27. (Society practice guidelines) Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism. 2018;79:97-107. (Review article) Contival N, Menahem B, Gautier T, et al. Guiding the nonbariatric surgeon through complications of bariatric surgery. J Visc Surg. 2018;155(1):27-40. (Review article) Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient, 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. (Society practice guidelines) Chousleb E, Chousleb A. Management of post-bariatric surgery emergencies. J Gastrointest Surg. 2017;21(11):1946-1953. (Review article) Goudsmedt F, Deylgat B, Coenegrachts K, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg. 2015;25(4):622-627. (Retrospective review; 7328 patients) Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8(1):1-7. (Society practice guidelines)

What is an effective way to begin conversations about diet and nutrition discussions in a health care setting? This episode serves as a foundation for future podcasts, including important general concepts to keep in mind for all nutrition counseling. Articles/references: Claire P. Kelley, PsyDa, *, Geena Sbrocco, MS, RDb,c , Tracy Sbrocco, PhDa, Behavioral Modification for the Management of Obesity Dietary Guidelines for Americans. 08/08/2018; Available from: https://health.gov/dietaryguidelines/. Aspry, K.E., et al., Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians A Science Advisory From the American Heart Association. Circulation, 2018. 137(23): p. E821-E841. Brook, R.D. and S. Rajagopalan, 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American Society of Hypertension, 2018. 12(3): p. 238-238. Tete, S., et al., Nutrition and Cancer Prevention. International Journal of Immunopathology and Pharmacology, 2012. 25(3): p. 573-581. Goldstein, L.B., et al., Guidelines for the Primary Prevention of Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 2011. 42(2): p. 517-584. Sami, W., et al., Effect of diet on type 2 diabetes mellitus: A review. International Journal of Health Sciences-Ijhs, 2017. 11(2). Evert, A.B., et al., Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care, 2014. 37: p. S120-S143. Garvey, W.T., et al., American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on the 2014 Advanced Framework for a New Diagnosis of Obesity as a Chronic Disease. Endocrine Practice, 2014. 20(9): p. 977-989. Jellinger, P.S., et al., American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease - Executive Summary. Endocrine Practice, 2017. 23(4): p. 479-497.

The American College of Physicians' 2018 HbA1c guidelines, which recommended achieving an HbA1c level between 7% and 8% in most patients with type 2 diabetes, were met with controversy, eliciting criticism from organizations like the American Diabetes Association and American Association of Clinical Endocrinologists. In this podcast, board-certified nurse practitioner Lucia Novak reflects on how these guidelines have impacted the landscape of diabetes care over the past year, and discusses the importance of individualized treatment. For more, visit www.consultant360.com.

In this video lecture, we discuss the imaging appearance of lipid-rich and lipid-poor adrenal adenomas, explain the CT washout calculation, and review the choice of CT vs. MRI for the evaluation of adrenal nodules. Also, we compare the 2017 ACR (American College of Radiologists) Incidental Findings Committee recommendations to the AACE/AAES (American Association of Clinical Endocrinologists and American Association of The post Imaging of Adrenal Adenomas & Incidentalomas appeared first on radiologist HeadQuarters.

Controversy and Clinical Insights into the Health Effects and Breast Cancer Today on Couch Talk I am talking with Dr. Edwin Lee. He is a past Couch Talk guest and one of the best physicians I know. And we're talking about one of my favorite topics, the use of bio-identical hormones in the treatment of menopausal symptoms in women. Dr. Lee believes that the best way to treat hormonal imbalance is by natural bio-identical hormone therapy. Natural hormones are the exact and identical hormones that are made in your body (versus synthetic hormones which are not chemically structured the same as in your body). He feels that the use of bioidentical hormones with estradiol, estriol, progesterone and or testosterone in women is essential, whereas the use of testosterone in men is crucial to prevent early mortality. Dr. Lee combines functional medicine to determine the root problem with the use of bioidentical hormones to help his patients achieve wellness – along with an emphasis on improving on diet, lifestyle, and nutrition. Listen to the interview: A Great Way to Kick off Breast Cancer Awareness Month! It's the start of Breast Cancer Awareness month, so this Couch Talk interview was very well timed! We talked a lot about our own patient and clinical outcomes over our decades of combined practices in using bio-identical hormones to treat hot flashes, depression, anxiety, mood swings, vaginal atrophy and other symptoms commonly seen in menopause. We also talked a lot about the confusion relating to breast cancer risk. In thisinterview, you will learn, Why Dr. Lee tells his menopausal patients that menopause itself is a dangerous disease with a higher rate of Alzheimer's or dementia, heart disease, and osteoporosis…and what he feels they can do to prevent all of this. The importance of both an individual patient's ability to detox and their current lifestyle (diet, exercise, sleep, etc.) in determining the right menopausal treatment plan for them. Why he doesn't recommend oral estrogen therapy (Premarin, Prempro) ever be used. Why bio-identical progesterone is truly the “wonder hormone” that helps with sleep, anxiety, irritability, PMS…and more…and how it is protective against breast cancer (and could save your marriage!) Why oral synthetic progesterone (Provera) is a bad choice, clearly linked to increasing the risk of strokes and heart disease. Why just taking a hormone is never enough (hint: you need to improve your lifestyle decisions)! What plant-based estrogen SERM (Selective Estrogen Receptor Modulator) Dr. Lee has recommended that helps with hot flashes (and is safe). And We Covered So Much More! Why is it that less than 1% of women who have taken HRT therapy in his clinical practice have developed breast cancer (compared to 11% of women developing breast cancer in the general population)? We discussed both of our clinical observations as to what the answer to this might be. Finally, we talked about our “polite disagreements” with the American Association of Clinical Endocrinologists (of which Dr. Lee is a member) recently stating in a position paper that they do not recommend the use of bio-identical hormone therapy in many cases… What? Well...we both feel that endocrinologists already use bio-identical hormone therapy all of the time for standard care with insulin, cortisol, thyroid, progesterone, testosterone, transdermal estradiol, etc.! So what is going on in this position paper? Is it the definition of what is “synthetic” versus “natural”? Is it a bit of bias from the Big Pharm companies? Such an interesting discussion with my favorite endocrinologist! Meet Dr. Edwin Lee A little bit about Dr. Edwin Lee, and I hope you'll listen to our interview in the audio posted above! He's board-certified in internal medicine, endocrinology, diabetes, and metabolism, and has completed special training in regenerative and functional medicine. He is an author and an international speaker and educator. Dr. Lee founded the Institute for Hormonal Balance in 2008. Currently, he is the Assistant Professor of Internal Medicine at the University of Central Florida College of Medicine. In addition to writing his books, including two awesome children's books, one called, Your Awesome Brain, and the other is Your Amazing Heart—I highly recommend these—he's written, for those of us that really want to get a better understanding on hormones, a couple of other books. One is called Feel Good, Look Younger: Reversing Tiredness Through Hormonal Balance, and the book, Your Best Investment: Secrets to a Healthy Body and Mind.  Dr. Lee has also published many articles on internal medicine and endocrinology. He is an author in the fourth edition of Textbook of Critical Care. He's an active member of the Age Management Medicine Group and the American Association of Clinical Endocrinology. Find out more about Dr. Lee at http://instituteofhormonalbalance.com/

Controversy and Clinical Insights into the Health Effects and Breast Cancer Today on Couch Talk I am talking with Dr. Edwin Lee. He is a past Couch Talk guest and one of the best physicians I know. And we’re talking about one of my favorite topics, the use of bio-identical hormones in the treatment of menopausal symptoms in women. Dr. Lee believes that the best way to treat hormonal imbalance is by natural bio-identical hormone therapy. Natural hormones are the exact and identical hormones that are made in your body (versus synthetic hormones which are not chemically structured the same as in your body). He feels that the use of bioidentical hormones with estradiol, estriol, progesterone and or testosterone in women is essential, whereas the use of testosterone in men is crucial to prevent early mortality. Dr. Lee combines functional medicine to determine the root problem with the use of bioidentical hormones to help his patients achieve wellness – along with an emphasis on improving on diet, lifestyle, and nutrition. Listen to the interview: A Great Way to Kick off Breast Cancer Awareness Month! It’s the start of Breast Cancer Awareness month, so this Couch Talk interview was very well timed! We talked a lot about our own patient and clinical outcomes over our decades of combined practices in using bio-identical hormones to treat hot flashes, depression, anxiety, mood swings, vaginal atrophy and other symptoms commonly seen in menopause. We also talked a lot about the confusion relating to breast cancer risk. In thisinterview, you will learn, Why Dr. Lee tells his menopausal patients that menopause itself is a dangerous disease with a higher rate of Alzheimer’s or dementia, heart disease, and osteoporosis…and what he feels they can do to prevent all of this. The importance of both an individual patient’s ability to detox and their current lifestyle (diet, exercise, sleep, etc.) in determining the right menopausal treatment plan for them. Why he doesn’t recommend oral estrogen therapy (Premarin, Prempro) ever be used. Why bio-identical progesterone is truly the “wonder hormone” that helps with sleep, anxiety, irritability, PMS…and more…and how it is protective against breast cancer (and could save your marriage!) Why oral synthetic progesterone (Provera) is a bad choice, clearly linked to increasing the risk of strokes and heart disease. Why just taking a hormone is never enough (hint: you need to improve your lifestyle decisions)! What plant-based estrogen SERM (Selective Estrogen Receptor Modulator) Dr. Lee has recommended that helps with hot flashes (and is safe). And We Covered So Much More! Why is it that less than 1% of women who have taken HRT therapy in his clinical practice have developed breast cancer (compared to 11% of women developing breast cancer in the general population)? We discussed both of our clinical observations as to what the answer to this might be. Finally, we talked about our “polite disagreements” with the American Association of Clinical Endocrinologists (of which Dr. Lee is a member) recently stating in a position paper that they do not recommend the use of bio-identical hormone therapy in many cases… What? Well...we both feel that endocrinologists already use bio-identical hormone therapy all of the time for standard care with insulin, cortisol, thyroid, progesterone, testosterone, transdermal estradiol, etc.! So what is going on in this position paper? Is it the definition of what is “synthetic” versus “natural”? Is it a bit of bias from the Big Pharm companies? Such an interesting discussion with my favorite endocrinologist! Meet Dr. Edwin Lee A little bit about Dr. Edwin Lee, and I hope you’ll listen to our interview in the audio posted above! He’s board-certified in internal medicine, endocrinology, diabetes, and metabolism, and has completed special training in regenerative and functional medicine. He is an author and an international speaker and educator. Dr. Lee founded the Institute for Hormonal Balance in 2008. Currently, he is the Assistant Professor of Internal Medicine at the University of Central Florida College of Medicine. In addition to writing his books, including two awesome children’s books, one called, Your Awesome Brain, and the other is Your Amazing Heart—I highly recommend these—he’s written, for those of us that really want to get a better understanding on hormones, a couple of other books. One is called Feel Good, Look Younger: Reversing Tiredness Through Hormonal Balance, and the book, Your Best Investment: Secrets to a Healthy Body and Mind.  Dr. Lee has also published many articles on internal medicine and endocrinology. He is an author in the fourth edition of Textbook of Critical Care. He’s an active member of the Age Management Medicine Group and the American Association of Clinical Endocrinology. Find out more about Dr. Lee at http://instituteofhormonalbalance.com/

This episode of the podcast features the practical and poetic wisdom from the one and only legendary Deepak Chopra! What an honor and thrill it was to sit down with Deepak to do a podcast that surfed many planes of consciousness, mysticism and science. Our conversation dealt primarily with the success of the scientific revolution over the course of the last 300 years and how that turned humanity away from it's mystic roots and quest for spiritual understanding. Deepak provides a roadmap on how to cultivate the spiritual heart while not turning ones back on science and logic. Sit back and settle into a download from one of the great icons of the modern spiritual movement. INTRO RANT - The American Spiritual Experience as seen through "Wild Wild Country" and "Come Sunday" Deepak Chopra, MD, FACP, Founder of The Chopra Foundation and the Chopra Center for Wellbeing, is a world-renowned pioneer in mind-body medicine and personal transformation, and is Board Certified in Internal Medicine, Endocrinology and Metabolism.  He is a Fellow of the American College of Physicians and a member of the American Association of Clinical Endocrinologists. Chopra has authored more than 80 books, published in more than 43 languages, including 22 New York Times best sellers. Two of his books, Ageless Body, Timeless Mind (1993) and The Seven Spiritual Laws of Success (1995) have been recognized on The Books of The Century Bestsellers List. For the last three years, Greatist.com recognizes Dr. Chopra as one of “The 100 Most Influential People in Health and Fitness “.  The World Post and The Huffington Post global internet survey ranked him #17 influential thinker in the world and #1 in Medicine Fitness. TIME magazine has described Dr. Chopra as “one of the top 100 heroes and icons of the century”.

Learn how to reverse thyroid symptoms and regain your health.According to the American Association of Clinical Endocrinologists, 27 million Americans have thyroid disease, and about 13 million of them are undiagnosed. A whopping 95% of people that have hypothyroidism may actually have an autoimmune disease called Hashimotos. Number-one New York Times bestselling author, Dr. Isabella Wentz, joins Dr. Friedman to share how to reverse thyroid symptoms and regain your health.

Thyroid cancer is one of the fastest growing cancers in the United States, especially among women. In Florida, thyroid cancer trails only melanoma skin cancer as the state’s fastest rising cancer. Today’s guest on episode 38 of STEM-Talk has made it his mission to not only treat thyroid cancer, but also raise awareness about the disease. Dr. Mark Lupo is founder and medical director of the Thyroid and Endocrine Center of Florida which is based in Sarasota. A graduate of Duke University, he went on to earn his medical degree at the University of Florida where he worked with the world-famous thyroid expert, Dr. Ernie Mazzaferri. Dr. Lupo also did his internship and residency in internal medicine at Florida and then won a fellowship in endocrinology, metabolism and nutrition at the University of California San Diego and the Scripps Clinic. Dr. Lupo’s research and practice are particularly focused on thyroid nodules, which are abnormal growths of thyroid cells that form a lump within the thyroid gland. Although the vast majority of thyroid nodules are benign, a small proportion do contain thyroid cancer. His practice is centered on diagnosing and treating thyroid cancer at the earliest stage and helping people avoid unnecessary surgeries. He also is very involved in teaching neck ultrasound, thyroid cancer and general thyroid disease to other physicians at the national level.  He has published book chapters and several articles on thyroid disease and thyroid ultrasound.  In addition to his work as the medical director of the Thyroid and Endocrine Center of Florida, he also is a clinical assistant professor on the faculty of the Florida State University College of Medicine. Dr. Lupo also was named the 2017 recipient of the Jack Baskin Endocrine Teaching Award, which is annually presented by the American Association of Clinical Endocrinologists.  You can learn more about the Thyroid and Endocrine Center of Florida by visiting http://www.thyroidflorida.com. Show notes: 3:21: Ken and Dawn welcome Mark to the show and ask him what led him to study medicine at Duke. 4:52: Dawn asks Mark how he ended up choosing endocrinology with a particular interest in thyroid nodules and cancer as a specialty. 6:40: Dawn asks Mark how he found the time to go on incredible adventures, such as climbing Mount Kilimanjaro as he worked to establish a practice. 8:40: Mark provides an overview of the thyroid. 9:46: Dawn asks Mark to clarify about whether a thyroid nodule is the same thing as a goiter. 10:25: Ken comments on how thyroid nodules and cancer seem to be epidemic and how there has been an increase of instances in the United States. He asks Mark if there is a greater incidence of disease or if there is just better detection or a combination of both. 14:33: Dawn asks if we know why thyroid nodules and cancer seems more prevalent in women. 15:01: Dawn inquires about the survival rate for those diagnosed with thyroid cancer, and whether or not it has changed over the years. 17:45: Dawn comments on how she has been looking forward to this interview as a result of a thyroid scare she had in graduate school where there was an inconclusive biopsy. She asks Mark how common it is to have an inconclusive finding and unclear results about a sample. 20:52: Ken comments on his personal experience with thyroid nodules that led to surgery and a positive outcome, and how he met Mark early in this experience after hearing him on a podcast discussing fine needle aspiration. After hearing this podcast, Ken concluded that he most likely needed this procedure. Ken asks Mark to talk about this. 23:37: Dawn asks Mark how often the thyroid nodules are discovered incidentally. 27:34: Dawn asks if there are certain characteristics you can see by ultrasound that give you an idea as to whether you are looking at a benign or malignant nodule. 29:53: Dawn asks what the histological differences are between a benign ...

In this special mini-season, we are unlocking the vaults to bring you exclusive, in-depth conversations between Tony and four truly outstanding achievers and impressive innovators. These dynamic individuals are not just experts in their respective fields — they are pioneers. They are charting new territory and breaking new ground. And their insights, ideas and drive are shaping the world we live in. With each episode, you will be privy to a wealth of powerful ideas and strategies that you can use immediately to increase income, influence others more effectively, advance your career, enhance your personal relationships, improve your health, eliminate fears, and experience more joy and fulfillment in your life. In this episode, you will hear an exciting conversation between Tony and Deepak Chopra, as they discuss the principles of lifelong health, the spiritual forces that shape our lives, and the immense power of the mind-body connection. Renowned for blending Eastern philosophy with Western medicine, Dr. Chopra is the author of best-sellers such as Ageless Body, Tireless Mind; The Seven Spiritual Laws of Success; and Grow Younger, Live Longer. He is also a Fellow of the American College of Physicians, a member of the American Association of Clinical Endocrinologists, an adjunct professor of Executive Programs at the Kellogg School of Management at Northwestern University and an adjunct professor at the Columbia University Business School. TIME magazine has described him as “one of the top heroes and icons of the century.” And The Huffington Post global internet survey ranks him as the #17 influential thinker in the world and #1 in medicine. He has authored more than 80 books, which have been translated into over 43 languages, including numerous New York Times bestsellers.   This episode of the Tony Robbins Podcast is brought to you by Tony Robbins Results Coaching. Are you ready to experience an extraordinary quality of life? Or maybe you're already doing well, but you know you can take your life to whole new level. To do that, you have to set yourself up to win. You need a process, a way to consistently grow and produce the results you need. And that's what a Tony Robbins results coach can do for you. Whatever area in your life you want to change -- your relationship, your health, your career, or your business -- coaching is one of the most valuable tools you can have. It's an investment in yourself, and it can yield some of the highest returns. Tony Robbins Results Coaches are hand-selected and trained by the master of coaching -- Tony Robbins himself -- to have the skills that will empower you with supreme focus, powerful insight and the accountability needed to achieve everything you've ever dreamed.  

  Dr. Jane Cases is a board certified endocrinologist and leader in regenerative medicine.  Her work focuses on endocrinology, diabetes and metabolism as well as stem cell therapy, platelet-rich plasma (PRP) therapy, aesthetics and much more. Her passion for total wellness and weight management led her to start Wellness 360 Comprehensive Lifestyle Center in Marietta, Ohio, where she serves as Chief Medical Officer.   The development of Healing Saint™ products came from her passion for regenerative medicine to help patients who want to fully address or prevent lifestyle diseases. After a horrific road bike accident, Dr. Jane was left with terrible scars on her face and arm. Unwilling to settle for the traditional approach to wound care which would have had less-than-desirable results, Dr. Jane was driven to learn even more about wound healing technology and to better understand its ability to enhance the body’s self-repair and self-renewal potentials. The result was the Healing Saint Luminosity Skin Serum, a proprietary formula to better heal damaged and aging skin.   A leading researcher on cell medicine, Dr. Jane offers American Medical Association approved training courses for fellow physicians and has authored dozens of peer-reviewed articles and studies in numerous scientific and medical journals. She holds active professional memberships with the American Board of Internal Medicine, Endocrine Society USA, American Thyroid Association, American Association of Clinical Endocrinologists, European Association for the Study of Diabetes, American Academy of Anti-aging Medicine and the International Cell Medicine Society. In addition, she has served as an Assistant Professor at Ohio University’s School of Osteopathic Medicine.   JJ Flizanes is an Empowerment Strategist. She is the Director of Invisible Fitness, an Amazon best-selling author of Fit 2 Love: How to Get Physically, Emotionally, and Spiritually Fit to Attract the Love of Your Life, and author of Knack Absolute Abs: Routines for a Fit and Firm Core. She was named Best Personal Trainer in Los Angeles for 2007 by Elite Traveler Magazine.     JJ vividly reminds us that the word ‘fitness’ is not just about the state of one’s physical body, but also the factors which determine a person’s overall well being.   And, for JJ, the key components in all these areas are ‘invisible’ — balanced support structures of nutrition, emotional centeredness and health. A favorite of journalists and the media for her depth of knowledge and vibrant personality, JJ, a contributing expert for Get Active Magazine, has also been featured in many national magazines, including Shape, Fitness, Muscle and Fitness HERS, Elegant Bride, and Women’s Health as well as appeared on NBC, CBS, Fox 11 and KTLA. She is also a video expert for About.com and regular contributor for The Daily Love.   JJ launched her professional career in 1996 as the Foundations Director for the New York Sports Club, where she designed curriculum and in-house certification for new and previously uncertified fitness trainers. She has also been certified by the American Council on Exercise (ACE), International Sports Science Association (ISSA), and the Resistance Training Specialist Program (RTS).       With a focus on biomechanics, JJ has lectured for The Learning Annexand as a featured speaker for New York Times Bestselling Author of The Millionaire Mind, T. Harv Ecker’s Peak Potentials seminars, as well as corporate clients, including Pacific Gas and Electric, Hanson Engineering, and Jostens, Inc. She is the Wellness Expert for KFC International, the Health and Fitness Expert for the National Association of Entrepreneur Moms, and a Fitness Expert for Nourishing Wellness Medical Center.    She has been working in the health and wellness industry for 15 years, as a fitness trainer with a knack for helping her clients become more self-aware and self-empowered through her ability to quickly identify and pinpoint problem areas, and then create simple solutions involving exercise, nutrition and mindset changes. She is the Host of the new iTunes Podcast Show Fit 2 Love: Physical, Emotional and Spiritual Fitness for the Happy Life You Deserve which is six day a week video and audio show.   What sets JJ apart from her Celebrity Fitness counterparts is the holistic approach to getting results. Over the last fourteen years she has studied, used and applied Positive Psychology, Neuro-Linguistic  Programming (NLP), Eye Movement Desensitization and Reprocessing (EMDR), Emotional Freedom Technique (EFT), Law of Attraction, Quantum Physics, Non Violent Communication, Imago Therapy, and Hypnotherapy. JJ Flizanes has proven that she’s not only an expert in matters of the body and fitness—she’s an insightful and provocative author who delivers a timely message about matters of the heart.  

When Dr. Jane Cases relocated to Marietta, OH in 2005, she started her practice in Endocrinology, Diabetes, and Metabolism and became part of the Faculty of Ohio University, College of Medicine where she continued basic science research in the field of Insulin Resistance, Obesity, and Diabetes. Her interest in this field had been tremendous since her time at Einstein College of Medicine in New York where she had been part of the research team on Diabetes, Obesity, Aging, and Longevity. After a year of basic science research and clinical practice, she decided to focus on her clinical practice and became the Medical Director of the Diabetes Center for the Marietta Health Systems.  Her passion for total wellness and weight management served as the driving force when she started Wellness 360 Comprehensive Lifestyle Center. Now pursuing cutting-edge technology in the field of Regenerative Medicine, she yearns to provide total care to patients who want to fully address or prevent lifestyle diseases (e.g., Diabetes, some cancers, obesity, chronic joint pain and heart disease). She knows the potential use of cell medicine in clinical practice and has continuously sought out the optimum way to isolate adipose-derived stem cells and platelet-rich plasma (PRP) by collaborating with biotech companies and various clinicians.  A leading researcher on cell medicine, Dr. Jane offers American Medical Association approved training courses for fellow physicians and has authored dozens of peer-reviewed articles and studies in numerous scientific and medical journals. She holds active professional memberships with the American Board of Internal Medicine, Endocrine Society USA, American Thyroid Association, American Association of Clinical Endocrinologists, European Association for the Study of Diabetes, American Academy of Anti-aging Medicine and the International Cell Medicine Society. In addition, she has served as an Assistant Professor at Ohio University’s School of Osteopathic Medicine.       JJ Flizanes is an Empowerment Strategist. She is the Director of Invisible Fitness, an Amazon best-selling author of Fit 2 Love: How to Get Physically, Emotionally, and Spiritually Fit to Attract the Love of Your Life, and author of Knack Absolute Abs: Routines for a Fit and Firm Core. She was named Best Personal Trainer in Los Angeles for 2007 by Elite Traveler Magazine.     JJ vividly reminds us that the word ‘fitness’ is not just about the state of one’s physical body, but also the factors which determine a person’s overall well being.   And, for JJ, the key components in all these areas are ‘invisible’ — balanced support structures of nutrition, emotional centeredness and health. A favorite of journalists and the media for her depth of knowledge and vibrant personality, JJ, a contributing expert for Get Active Magazine, has also been featured in many national magazines, including Shape, Fitness, Muscle and Fitness HERS, Elegant Bride, and Women’s Health as well as appeared on NBC, CBS, Fox 11 and KTLA. She is also a video expert for About.com and regular contributor for The Daily Love.   JJ launched her professional career in 1996 as the Foundations Director for the New York Sports Club, where she designed curriculum and in-house certification for new and previously uncertified fitness trainers. She has also been certified by the American Council on Exercise (ACE), International Sports Science Association (ISSA), and the Resistance Training Specialist Program (RTS).   With a focus on biomechanics, JJ has lectured for The Learning Annexand as a featured speaker for New York Times Bestselling Author of The Millionaire Mind, T. Harv Ecker’s Peak Potentials seminars, as well as corporate clients, including Pacific Gas and Electric, Hanson Engineering, and Jostens, Inc. She is the Wellness Expert for KFC International, the Health and Fitness Expert for the National Association of Entrepreneur Moms, and a Fitness Expert for Nourishing Wellness Medical Center.    She has been working in the health and wellness industry for 15 years, as a fitness trainer with a knack for helping her clients become more self-aware and self-empowered through her ability to quickly identify and pinpoint problem areas, and then create simple solutions involving exercise, nutrition and mindset changes. She is the Host of the new iTunes Podcast Show Fit 2 Love: Physical, Emotional and Spiritual Fitness for the Happy Life You Deserve which is six day a week video and audio show.   What sets JJ apart from her Celebrity Fitness counterparts is the holistic approach to getting results. Over the last fourteen years she has studied, used and applied Positive Psychology, Neuro-Linguistic  Programming (NLP), Eye Movement Desensitization and Reprocessing (EMDR), Emotional Freedom Technique (EFT), Law of Attraction, Quantum Physics, Non Violent Communication, Imago Therapy, and Hypnotherapy. JJ Flizanes has proven that she’s not only an expert in matters of the body and fitness—she’s an insightful and provocative author who delivers a timely message about matters of the heart.  

This week on Mom Talk Radio, we are joined by Dr. Mark Harrell, President Elect of the American Association of Clinical Endocrinologists, shares tips for reducing your risk of thyroid cancer. Spotlight on Moms features Maria Casey of mariahcasey.typepad.com/leadermom. Drew Banks, head of marketing for Prezi, talks about developing children’s creativity. Jackie Walker, author of Expressionista, talks about how a tween, teen or woman can find out her internal fashion persona. Richard Greenberg, author of Raising Children that Other People Like to Be Around, talks about the S.M.A.R.T. parenting system.

Host: Farhad Zangeneh, MD Guest: Yehuda Handelsman, MD Dr Farhad Zangeneh is joined by Dr. Yehuda Handelsman, Medical Director at the Metabolic Institute of America; President of the American Association of Clinical Endocrinologists; and, Chair & Program Director, "Annual World Congress on Insulin Resistance, Diabetes & CVD". Dr. Handelsman will discuss the recent growing concerns between diabetes, anti-diabetes agents, and the increased prevalence of various cancers. Currently available data are limited, controversial, and confusing. The AACE and health care providers believe that this is a critically important area that needs further clarification.

Guest: Yehuda Handelsman, MD Host: Farhad Zangeneh, MD Dr Farhad Zangeneh is joined by Dr. Yehuda Handelsman, Medical Director at the Metabolic Institute of America; President of the American Association of Clinical Endocrinologists; and, Chair & Program Director, "Annual World Congress on Insulin Resistance, Diabetes & CVD". Dr. Handelsman will discuss the recent growing concerns between diabetes, anti-diabetes agents, and the increased prevalence of various cancers. Currently available data are limited, controversial, and confusing. The AACE and health care providers believe that this is a critically important area that needs further clarification.

Tune in for highlights from the American Association of Clinical Endocrinologists' 18th Annual Meeting and Clinical Congress, which took place May 13th through the 17th in Houston.

Tune in for highlights from the American Association of Clinical Endocrinologists' 18th Annual Meeting and Clinical Congress, which took place May 13th through the 17th in Houston.

On this week's show, we welcome Fred G. Toffel, MD. FACE. Dr. Toffel, a board certified endocrinologist, is the Medical Director of the Diabetes Treatment Center at Desert Springs Hospital, and also runs a private Endocrinology practice in Las Vegas. Dr. Toffel is Vice President of the Nevada Chapter of the American Association of Clinical Endocrinologists.If you have any questions or comments for any of our team or would like to hear your voice on one of our upcoming shows, call our special voicemail line or email us. You might soon be a podcast star. Comment Line: (206) 888-0444 email: feedback @diabetespowershow.com