Podcasts about coumadin

Today's sponsor is Freed AI! Freed's AI medical scribe listens, transcribes, and writes notes for you. Over 15,000 healthcare professionals use Freed and you should too! Learn more here! On this episode of the Real Life Pharmacology Podcast, we will cover medications 186-190 on the Top 200 Drugs List. The medications included in the podcast episode are Sonata, Zebata, Zovirax, Coumadin, and Luvox. Sonata (ezopiclone) is a Z-drug used for insomnia. It has many similar effects to benzodiazepines and a similar mechanism of action. Zebeta (bisoprolol) is a beta-blocker used for the treatment of hypertension, atrial fibrillation, and heart failure amongst other indication. Zovirax (acyclovir) is an antiviral medication used to treat various viral infection. It needs to be dosed numerous times throughout the day which is a downside to use. Coumadin (warfarin) is an anticoagulant. It is most well known for its need to have INRs drawn to assess drug levels. Luvox (fluvoxamine) is an SSRI antidepressant. It is well known for its ability to cause drug interaction and is often not a first line agent because of this reason.

In this episode of the RWS Clinician's Corner, we delve into the fascinating world of minerals with Barton Scott. Margaret Barry explores Barton's journey from a chemical engineer to a groundbreaking supplement formulator driven by personal experiences and a passion for enhancing nutrient absorption. Barton shares how his innovative magnesium product dramatically improved sleep and stress management, as well as how specific minerals express through personality and habits, emphasizing their critical role in various health aspects.   In this interview, we discuss: Barton's motivation behind creating Upgraded Formulas The nanoparticle technology behind Upgraded Formulas and its importance in absorption The importance of magnesium, specifically, and the differences in types of magnesium and their effects Mineral deficiency in our modern world/lifestyle and using Hair Tissue Mineral Analysis as a diagnostic tool The significance of other minerals like manganese, boron, and iodine Barton's approach on testing and consulting on absorption issues Connect with Barton Scott: Learn more about Upgraded Formulas at their website and connect with Barton on socials: YouTube: https://www.youtube.com/c/UpgradedFormulas/featured  Instagram: https://www.instagram.com/upgradedformulas/  Facebook: https://www.facebook.com/upgradedformulas   Looking for recommendations on products to try? We'd start with:  Upgraded Magnesium (this is the first product I tried, and what blew me away)  Upgraded Memory (a blend of 5 minerals, 4 of which over 90% of people are deficient in!)  Upgraded Charge (their electrolyte product which tastes great without any of the problematic ingredients in so many other electrolyte blends)   Barton has offered our community a special deal of 30% off your first order in their store. Simply use the code WELLNESS30 on checkout. Note: this code can't be combined with any other coupon codes and doesn't work on subscriptions.    Timestamps: 00:00 Magnesium Boosts Deep Sleep 05:12 Discovering Transformative Functional Tests 12:25 "Why Prioritize Minerals?" 17:22 "Foundational Focus on Digestion" 21:47 Maximizing Energy Through Minerals 29:38 Iodine Deficiency and Nutrient Absorption 32:53 "Iodine's Essential Role and Scarcity" 39:13 Indirect Nutrient Deficiency Detection 44:32 "Transformative Gut Health Program" 49:54 Bone Health and Calcium Imbalance 58:08 Trace Minerals in Water: Benefits 01:03:43 Special Offer Replay Email Announcement 01:08:05 Podcast Engagement & Feedback Invitation Speaker Bio: Barton Scott is a remarkable biochemist, engineer, nutritionist, researcher – and visionary founder of Upgrade Formulas, a cutting-edge supplement company that has revolutionized mineral absorption using stabilized nanoparticle technology. Barton is passionate about helping people combat the stressors of daily life, the toxicity of the modern world, the utter lack of nutrients, and the mineral absorption issues that we all face – and he has made it his mission to reduce suffering by increasing the public's understanding of the human body's interrelationships. Keywords: Restorative Wellness, functional health professionals, Barton Scott, Upgrade Formulas, nanoparticle technology, mineral absorption, magnesium, nutrient absorption, sleep improvement, OURA ring, hair tissue mineral analysis, HTMA, iodine deficiency, heavy metals, nutrient deficiencies, thyroid health, potassium supplementation, osteoporosis, K2 and Coumadin, trace minerals, fertility support, vitamin D supplementation, zinc and personality, calcium absorption, soil depletion, health testing, functional medicine, blood chemistry, sleep study, creativity challenges Disclaimer: The views expressed in the RWS Clinician's Corner series are those of the individual speakers and interviewees, and do not necessarily reflect the views of Restorative Wellness Solutions, LLC. Restorative Wellness Solutions, LLC does not specifically endorse or approve of any of the information or opinions expressed in the RWS Clinician's Corner series. The information and opinions expressed in the RWS Clinician's Corner series are for educational purposes only and should not be construed as medical advice. If you have any medical concerns, please consult with a qualified healthcare professional. Restorative Wellness Solutions, LLC is not liable for any damages or injuries that may result from the use of the information or opinions expressed in the RWS Clinician's Corner series. By viewing or listening to this information, you agree to hold Restorative Wellness Solutions, LLC harmless from any and all claims, demands, and causes of action arising out of or in connection with your participation. Thank you for your understanding.  

I have to admit, I was a bit confused when I first heard today's topic—grounding. Sure, I walk on grass and dip my toes in lakes, but I didn't quite grasp the full picture.  Luckily, our guest, Dr. Henry Ealy, is here to enlighten us. He's a naturopathic physician with a background in engineering, making him the perfect guide to explore grounding's deeper benefits. Dr. Ealy explains how we spend most of our day insulated from Mother Earth, missing out on the benefits of connecting with nature by walking barefoot or swimming in a lake. One fascinating benefit he mentions is improved sleep through grounding. He also talks about something called Zeta potential, which involves red blood cells moving more freely when we're grounded. He even called grounding “nature's Coumadin” due to its blood-thinning effects.  You really need to tune in to get the full scoop. I've been diving into the research and science he shared, and I must say, I'm hooked. I absolutely loved today's episode, and I think you will too.  Visit whydidigetcancer.com for full show notes. --- This episode is sponsored in part by ButcherBox. I LOVE HIGH-QUALITY PROTEIN. Years ago, I had no clue what I was doing in the kitchen. I asked my chef friend, Gina, "How do you make chicken taste better?" She told me, "Boneless, skinless, tasteless." She explained that cooking with the bone adds flavor, moisture, and even a nutrient boost. Fast forward to today, and finding bone-in chicken can be a challenge. That's why I love ButcherBox! They offer free-range, organic bone-in chicken thighs, checking all my boxes. And right now, you can get free bone-in chicken thighs in every box—up to three pounds for the next year! Plus, enjoy $30 off your first box. ButcherBox: Meat Delivery Subscription --- The Body Deli:  Here are my favorite products that are always in my bathroom: Creme de la Rose moisturizer. Phoenix lift face and neck oil (when I run out of this, my face gets so dry and cranky!) Blueberry Fusion Cleanser. Vitamin C Serum.  Body Deli: Use the code 'ENOS15' at checkout for 15% off! The Body Deli – Why Did I Get Cancer? --- Martinelli's Sparkling Apple Cider Let me tell you about my favorite mocktail: Martinelli's Sparkling Apple Cider. It's a fantastic substitute for champagne and perfect for summer drinks. After my breast cancer diagnosis, I became more mindful of what I consume after a 2016 study from the University of Houston revealed that alcohol can fuel estrogen, promoting breast cancer growth. According to breastcancer.org, just three drinks a week can increase breast cancer risk by 15%. You can find Martinelli's Apple Cider everywhere. Enjoy your summer and sip on some delightful mocktails!   This podcast is for informational purposes only and none of the information should be construed as medical advice. Listeners should seek guidance from their own medical team before making any medical or lifestyle changes.

In this episode, we review evidence-based guidelines for the emergency reversal of warfarin, dabigatran, and the oral Xa inhibitors (apixaban, edoxaban, and rivaroxaban). Key Concepts Reversal of anticoagulation is indicated in patients with major hemorrhage or when emergency surgery is necessary. Reversal of warfarin (Coumadin®) involves a fast-acting, short-term solution (usually prothrombin complex concentrates [PCC]) and a slower-acting, long-term solution (intravenous vitamin K). Idarucizumab (Praxbind®) is the preferred reversal strategy for dabigatran (Pradaxa®). Idarucizumab is a monoclonal antibody fragment specific that binds and inactivates dabigatran. If idarucizumab is unavailable, PCCs are recommended. Andexanet alfa (Andexxa®) is the preferred reversal strategy for oral Xa inhibitors and has FDA approval specific to apixaban and rivaroxaban. Andexanet alfa is a decoy factor Xa protein with higher binding affinity than human clotting factor Xa. There are several barriers to use with andexanet alfa that has led to low utilization in hospitals. If andexanet alfa is unavailable, PCCs are recommended. References Baugh CW, et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med. 2020;76(4):470-485. Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94(6):697-709. doi:10.1002/ajh.25475 Tomaselli GF, et al. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020;76(5):594-622.

Which of the following educational advisories is MOST warranted for a patient taking warfarin (Coumadin) following a total knee arthroplasty? Find it all out in the podcast!  Be prepared for the NPTE so that you can pass with flying colors! Check out www.ptfinalexam.com/podcast for more information and to stay up-to-date with our latest courses and projects.

A far reaching discussion btw Mandrola and Prasad on RCTs, Coumadin, ECMO and RCTs for covid shots

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Download for FREE today -  special Mnemonics Cheatsheet - so you can be SURE that you have that Must Know information down:  bit.ly/nursing-memory   Outline These Drugs Can Interact T-Theophylline D-Dilantin C-Coumadin I-llosone (Erythromycin) Description Coumadin and ilosone: Ilosone can increase the effects of Coumadin, increase risk for bleeding. Coumadin and Dilantin: potential for increased effects of both. Coumadin and Dilantin: Increased Coumadin metabolism (decreased effect). Theophylline and Dilantin: if taken orally they can interfere with absorption of each other and decrease medication effect.

This episode covers the basics of the oral anticoagulant Eliquis. The episode covers the indications, mechanism of action, common dosing, reversal, and a comparison to Coumadin. 

This episode covers the history, mechanism of action, lab monitoring, indications, reversal and special considerations for Warfarin or otherwise known as Coumadin. One of the most common oral anticoagulants seen in critical care.    For further reading: https://emcrit.org/ibcc/coag/ https://emcrit.org/emcrit/reversal-safe-smart/ https://emcrit.org/ibcc/reverse/  

Download the cheat: https://bit.ly/50-meds  View the lesson:   Generic Name warfarin Trade Name Coumadin Indication venous thrombosis, pulmonary embolism, A-fib, myocardial infarction Action disrupts liver synthesis of Vitamin K dependent clotting factors Therapeutic Class Anticoagulant Pharmacologic Class coumarins Nursing Considerations • contraindicated with bleeding, severe hypertension • can cause bleeding • aspirin and NSAIDs can increase risk of bleeding • azole antifungals increase effects of warfarin • cimetadine(Tagamet) increases warfarin levels • obtain full history of supplements and herbs • large amounts of vitamin K may antagonize effects of warfarin • assess for signs of bleeding • therapeutic levels: PT 1.3-1.5, INR 2.5-3.5 • instruct patient to report any signs of bleeding • patient should not drink alcohol • bleeding times need to be monitored frequently • vitamin K is antidote

This week, please join author Sunil Rao and Guest Editor and Editorialist Gregory Lip as they discuss the article "A Multicenter, Phase 2, Randomized, Placebo-Controlled, Double-Blind, Parallel-Group, Dose-Finding Trial of the Oral Factor XIa Inhibitor Asundexian to Prevent Adverse Cardiovascular Outcomes After Acute Myocardial Infarction" and the editorial "Factor XIa Inhibition: Is It a Novel Alternative Antithrombotic Strategy for High-Risk ACS Patients?" Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, today's feature paper is about the factor XI inhibitor asundexian. It's the trial that we've been waiting for the PACIFIC-AMI trial. You really have to listen to it because these factor XI inhibitors are super interesting. What? We're going to tell you about the other papers in today's issue first. Aren't we, Greg? Do you want to go first? Dr. Greg Hundley: You bet, Carolyn. Thank you so much. Carolyn, did you ever consider the genetic underpinnings of venous thromboembolism? Well, as you know, venous thromboembolism is a complex disease with environmental and genetic determinants. And in this study, this large investigative team represented by Dr. Nicholas Smith from the University of Washington in Seattle, and their colleagues present new cross-ancestry meta-analyzed genome-wide association study results from 30 studies with replication of novel loci and their characterization through in silicone genomic interrogations. Dr. Carolyn Lam: Wow. Sounds like a really large effort, Greg. What did they find? Dr. Greg Hundley: Right, Carolyn. In the author's initial genetic discovery effort that included 55,330 participants with venous thromboembolism: 47,000 were European, 6,000 African, and a little over 1000 Hispanic ancestry. They identified 48 novel associations of which 34 are replicated after correction for multiple testing. In their combined discovery replication analysis, so that's 81,669 venous thromboembolism participants and ancestry stratified meta-analyses from the European, African and Hispanic ethnic groups. They identified another 44 novel associations, which are new candidate venous thromboembolism associated loci requiring replication. And many of the replicated loci were outside of known or currently hypothesized pathways to thrombosis. Carolyn, in summary, these findings from this very large GWAS analysis highlight new pathways to thrombosis and provide novel molecules that may be useful in the development of anti-thrombosis treatments with reducing the risk of bleed. Dr. Carolyn Lam: Wow. Super interesting and very related to that feature paper that we just discuss. But nonetheless, this next paper I love as well, if I may say so myself. It deals with frailty and as we know, frailty is increasing in prevalence. And because frail patients are often perceived to have a less favorable benefit risk profile, they may be less likely to receive new pharmacological treatments. And so, we and led by Professor John McMurray from the University of Glasgow, decided to investigate the efficacy and tolerability of dapagliflozin according to frailty status in the DELIVER trial. Dr. Greg Hundley: The DELIVER trial. Carolyn, tell us about the DELIVER trial? Dr. Carolyn Lam: Sure. In deliver dapagliflozin compared to placebo, reduced the risk of worsening heart failure events or cardiovascular death and improved symptoms in more than 6,000 patients with heart failure and mildly reduced and preserved ejection fraction, so ejection fraction above 40%. Now in this pre-specified analysis, we examine the efficacy and safety of dapagliflozin according to frailty status. That was determined using the Rockwood cumulative deficit approach. And so, what we found was that greater frailty was associated with more impairment of health status and worse clinical outcomes in patients with heart failure and ejection fraction of 40%. The beneficial effects of dapagliflozin compared to placebo on clinical outcomes were consistent regardless of frailty class. But interestingly, the improvement in symptoms, physical function and quality of life were larger in the frailest patients. Adverse events were not more common in individuals randomized to receive dapagliflozin compared to placebo irrespective of frailty class. And so, the take home message is the benefit risk balance related to frailty in patients with heart failure with mildly reduced and preserved ejection fraction is favorable for dapagliflozin. And so, these findings should challenge any clinical reluctance to introduce dapagliflozin in patients perceived to be frail. Dr. Greg Hundley: Wow. Carolyn, really interesting. You could see with the diuretic effect in someone that's frail, the potential hesitancy, but very interesting study results in this world of frailty and the use of dapagliflozin. Well, Carolyn, this next study is very interesting and it comes to us from the world of preclinical science that takes a very interesting approach to a scientific question. Now, as you may know, RNA-binding proteins or RBPs are master orchestrators of genetic expression regulation. They regulate hundreds of transcripts at once by recognizing specific motifs, thus characterizing RBPs targets is critical to harvest their full therapeutic potential. However, such investigation has often been restricted to a few RBP targets, thereby limiting our understanding of their function. Carolyn, these investigators led by Dr. Grégoire Ruffenach from UCLA were interested in assessing pulmonary arterial hypertension and they turned to the world of cancer research. Carolyn, in cancer, the RNA-binding protein hnRNPA2B1, and we're going to abbreviate that as A2B1, promotes a pro proliferative anti-apoptotic phenotype. The same phenotype is present in pulmonary arterial smooth muscle cells and is responsible for the development of pulmonary arterial hypertension. However, the A2B1 function that's never really been investigated in pulmonary arterial hypertension. Dr. Carolyn Lam: Oh, Greg, that's not only fascinating, but so beautifully described. Thank you. What did they find? Dr. Greg Hundley: Right, Carolyn. These authors found that A2B1 expression and it's nuclear localization are increased in human pulmonary arterial hypertension, pulmonary arterial smooth muscle cells. Using bioinformatics, they identified three known motifs of A2B1 and all mRNAs carrying them and demonstrated the complimentary non-redundant function of A2B1 motifs as all motifs are implicated in different aspects of the cell cycle. In addition, they showed that pulmonary arterial smooth muscle cells and A2B1 promote the expression of its targets. Additionally, in vivo A2B1 inhibition in the lungs rescued pulmonary hypertension in rats. And so, Carolyn, through the integration of computational and experimental biology, this team study revealed the role of A2B1 as a master orchestrator of pulmonary arterial smooth muscle cells in pulmonary hypertension and that phenotype and its relevance as a therapeutic target in pulmonary arterial hypertension. Dr. Carolyn Lam: Wow, that's super, Greg. Thanks. Shall we go through what else is in today's issue? Dr. Greg Hundley: You bet, Carolyn. There's a Research Letter from Professor Mustroph entitled, “Empagliflozin Inhibits Cardiac Late Sodium Current versus Calcium Calmodulin‐dependent Kinase II.” Dr. Carolyn Lam: There's also an exchange of letters between Doctors Omarjee and Diederichsen regarding vitamin K2 and D in patients with aortic valve calcification: [an] absence of evidence might not be evidence of absence? And finally, there's an On My Mind paper by me and Scott Solomon and it's entitled, “Delivering Therapeutic Efficacy Across the Ejection Fraction Spectrum of Heart Failure.” But let's go on now to talk about the Factor XI inhibitor, shall we, Greg? Dr. Greg Hundley: You bet. Well, listeners, welcome to this feature discussion on October 18th at a very special article today. And we have with us the lead author, Dr. Sunil Rao from NYU in New York City and also our associate guest editor as well as editorialist, Dr. Gregory Lip from Liverpool. Welcome, gentlemen. Sunil, we'll start with you. Can you describe for us some of the background information that went into the preparation of your study and what was the hypothesis that you wanted to address? Dr. Sunil Rao: Yeah, great. Thanks so much, Greg. It's a real pleasure to be here with you. The background of the PACIFIC-AMI study is really rooted in the fact that patients who have acute myocardial infarction are really at risk for recurrent thrombotic events, even after their event. And this risk continues despite the fact that we have evidence based therapies that are really around targeting the platelet as well as aspects of the coagulation cascade. There have been studies that have looked at the use of dual antiplatelet therapy plus an anticoagulant or single antiplatelet therapy plus an anticoagulant. And those studies have shown a benefit. However, their clinical use is limited because of the bleeding risk. Factor XI is an interesting target, because factor XI is likely involved in the amplification of thrombin generation after plaque rupture. But it really doesn't play much of a role in hemostasis. And so, as a target in reducing events after acute coronary syndrome, activated factor XI is a very attractive one. And so, the hypothesis of this study was that a highly bioavailable oral, direct, selective activated factor XI inhibitor called asundexian would be safe and effective in the treatment of patients who experience acute coronary syndrome at reducing adverse events. Now, this is a phase two study, so it really wasn't powered for clinical events. It was really a dose-finding study, so it was really looking at adverse events and sort of bleeding complications. Dr. Greg Hundley: Very nice. Asundexian, a new factor XI inhibitor. And Sunil, can you describe for us your study design and then maybe a little bit more about the study population, how many subjects? Dr. Sunil Rao: Sure. Again, this is a phase two study. It was a randomized, double-blind, parallel-group design where patients, who were admitted with acute coronary syndrome were randomized to three different doses of asundexian and or placebo in a one-to-one to one-to-one fashion. Patients who met criteria for enrollment were: patients who were admitted with a diagnosis of acute MI; if they were older than or equal to 45 years of age; they were hospitalized in acute coronary syndrome that did not occur in the context of revascularization, so it was not a type 4 event; and they were planned to be treated with dual antiplatelet therapy after hospital discharge. Dr. Greg Hundley: Sunil, thank you for describing this very interesting study design. Now, how many subjects did you include and could you just describe for us the study population? Dr. Sunil Rao: We had a total of 1,601 patients that were randomized at 157 centers in 14 countries between June 2020 and July 2021. And in order to be eligible for enrollment into the study: patients had to be admitted with a diagnosis of acute MI, they had to be greater than or equal to 45 years of age, and be hospitalized with that acute MI that did not occur in the context of revascularization, so type 4 MIs were excluded. The other inclusion criteria was that they had to be planned to be treated with dual antiplatelet therapy after hospital discharge. Now, we allowed randomization up to five days after hospital admission and randomization occurred after patients were clinically stabilized and any planned PCI was performed. We included both patients with STEMI as well as non-ST segmental elevation ACS, but we capped the number of patients with STEMI that were included to no more than 50%. Now, the main exclusion criteria were things that you would expect for a phase two trial. Obviously, hemodynamic instability at the time of randomization, active bleeding or bleeding dialysis, severe renal dysfunction, planned use of full-dose anticoagulation. Dr. Greg Hundley: Very nice. And so, we have several doses of this new factor XI inhibitor. Describe for us your study results? Dr. Sunil Rao: Again, this was a phase two trial that was really looking at safety and adverse events as you would expect. The study groups were pretty balanced across all of the dosing arms. When we looked at the pharmacokinetic and pharmacodynamic data, we found something really interesting, which was that there was a dose relationship between the dose of asundexian and the factor XIa activity. Factor XIa is activated factor XI. The higher the dose, the more suppression of factor XI activity. In fact, the highest dose nearly eliminated factor XI activity. The drug clearly works in the way that it was intended. Now again, the clinical data, it wasn't powered for clinical data. But when we look at the bleeding results, we found that there was in fact an increase in bleeding as the dose of asundexian increased. The overall rate of bleeding in the highest dose of asundexian was in 50 milligrams was 10.5% with type 2 or 3 or 5 BARC bleeding, a placebo is about 9.02%. Again, the efficacy outcomes, very, very low rates of overall events. Again, not powered to show a difference. Essentially, very similar across all the arms. Dr. Greg Hundley: And did you find the same results for the men and the women? And what about older individuals and younger individuals? Dr. Sunil Rao: Yeah. We did look at some subgroups. And you had to be a little bit cautious because again, the trial itself is relatively small. I mean, we didn't notice any significant patterns across these subgroups. And the overall interaction p-values were really non-significant. But I think what this does show is like a phase two trial that the drug works as in the way that it's intended. Overall, safety was as expected. And I think it really sets up data for a larger study. Dr. Greg Hundley: Well, listeners, what a fantastic presentation. And now, we're going to turn to our guest editor and editorialist, Dr. Gregory Lip from Liverpool. Greg, I know working for circulation, you have many papers come across your desk. What attracted you to this particular paper? And then maybe secondly, can you help us put the results of this study in the context of other studies that have been evaluating these factor XI therapies? Dr. Gregory Lip: Thanks, Greg. Well, I think this is an important paper, because it is a phase two trial with a novel, orally bioavailable inhibitor factor XI. And this is intriguing because factor XI efficiency in humans and experimentally in animals is associated with a reduced risk of thrombotic events like stroke or venous thromboembolism. But spontaneous bleeding is rare and also bleeding in response to trauma or surgery is much milder. Really it's the holy grail of trying to get an anticoagulant that reduces thrombosis but doesn't cause an excess of bleeding. Now, this was the quest with different anticoagulants. And I think it was very exciting to see this particular paper in the patients who've had an acute coronary syndrome, because there was a lot of interest in the use of anticoagulants, particularly in combination with antiplatelet therapy from trials such as ATLAS and COMPASS, where there was certainly a reduction in adverse cardiovascular events. But a downside with those drugs and when using combination, was an excess of bleeding by the combination of the available anticoagulants now plus antiplatelets. The factor XIs agents offered the possibilities we might have combination therapy to reduce cardiovascular events but not causing an excess of bleeding. Dr. Greg Hundley: Well, listeners, what a wonderful discussion that we've had here. Let's circle back with both individuals. Sunil, we'll start with you. What do you see as the next study to really be performed in this sphere of research? Dr. Sunil Rao: I think that factor XI is a very attractive target in patients with acute coronary syndrome. Again, the rationale for why we did this phase two trial was to show that inhibition of activated factor XI should result in a low rate of ischemic events without a significant increase in bleeding. This phase two trial was really to try and decide which doses result in potent inhibition of factor XIa and potentially which doses should be carried forward into a larger study. What we found in the PACIFIC-AMI trial was that the doses of asundexian and the factor XIa inhibitor were very, very well tolerated with a low rate of adverse events. It resulted in a dose-dependent near complete inhibition of factor XIa activity without a significant increase in bleeding and a low rate of ischemic events. I think, again, it's a very attractive target in patients with ACS and this really provides support for a larger adequately powered clinical trial in patients with acute coronary syndrome that is really looking at clinical events such as MACE as well as bleeding. Dr. Greg Hundley: And Greg as an editorialist, what did you see with this paper? Maybe some unanswered questions that we'd like to pursue further? Dr. Gregory Lip: Well, I think this does raise a lot of questions in the sense that it'll be interesting because as a phase two trial, it's a relatively moderate sized trial. It's not like a phase three large outcome trial and phase two trials also testing different doses of the novel agent. We need to see the definitive phase three trial and to look at the magnitude of benefit versus potential for bleeding if in the large phase three trial and obviously, the net clinical benefit and importantly are some of the subgroups: ST elevation, myocardial infarction, undergoing primary PCI, for example, those with renal impairment. And I think particularly intriguing would be looking at the patients in this scenario who get the new antiplatelet drugs such as ticagrelor and prasugrel. And the reason I say that is what we have with warfarin or Coumadin and from the current DOACs or NOACs, depending on the risk side upon. We refer to them, that's the direct oral anticoagulants or non-vitamin K antagonist or anticoagulants. Well, if you give a more potent antiplatelet like prasugrel or ticagrelor, the risk of bleeding not surprisingly is higher. Hence, the guidelines recommend that if you use an anticoagulant or a DOAC, you use it with a P2Y 12 inhibitor clopidogrel as opposed to the more potent ones. If this new class of drugs, the factor XI inhibitors can work well in combination with one of the more potent antiplatelets without causing an excessive bleeding, again, this is going to be a substantial advance. Well, with these new class of anticoagulants, will be really interesting to see the phase three trials when applied to other chronic conditions. For example, stroke prevention and atrial fibrillation. And the other category of patients would be those who've had an embolic stroke of uncertain source or ESUS or in old terminology cryptogenic stroke. With the ESUS group of patients, they're currently treated with aspirin because the trials which tried a NOAC or DOAC, they were not showing a positive result. They'll be interesting again with the factor XI inhibitors, whether we are going to see this benefit with the reduction in recurrence stroke with no excessive bleeding. Dr. Greg Hundley: Very nice. Well, listeners, we want to thank Dr. Sunil Rao from NYU in New York City and Dr. Gregory Lip from the University of Liverpool for bringing us this study highlighting that in patients with recent acute myocardial infarction, three doses of asundexian when added to aspirin plus a P2Y 12 inhibitor resulted in dose-dependent near complete inhibition of factor XIa activity without a significant increase in bleeding and a low rate of ischemic events. And certainly, the data from this study support the investigation of asundexian at a dose of 50 milligrams daily in an adequately powered clinical trial of patients following acute myocardial infection. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week On the Run. This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

Trade – ALTEPLASE RECOMBINANT-TPAClass– Thrombolytic Agent MOA – Dissolves thrombi plugs in the coronary arteries and reestablishes blood flow.Indication – ST segment elevation greater then 1mm in 2 or more contiguous leads, New or presumed new left bundle branch block. Contraindications – ST segment depression, Cardiogenic shock, Recent major surgery, cerebrovascular disease, recent (within 10 days) GI bleeding, recent trauma, severe HTN Systolic greater then 180 diastolic greater then 110. High likely hood of left heart thrombus, acute pericarditis, severe renal or liver failure with bleeding complications, significant liver dysfunction, diabetic hemorrhagic retinopathy, septic thrombophlebitis, Patients older then 75, patients already taking Coumadin. Side effects – Bleeding, intracranial hemorrhage, stroke, cardiac arrhythmias, hypotension, bruisingDosingAdult Per medical direction.Pedi Not recommended 

Coumadin and ilosone: Ilosone can increase the effects of Coumadin, increase risk for bleeding. Coumadin and Dilantin: potential for increased effects of both. Coumadin and Dilantin: Increased Coumadin metabolism (decreased effect). Theophylline and Dilantin: if taken orally they can interfere with absorption of each other and decrease medication effect.

Many decisions in medical care are made with incomplete or imprecise information. A new series of testing and analysis called Precision Medicine is available at the Kahn Center and other advanced clinics. A focus on a blood test for 50 cancers called Galleri is presented for consideration. Dr. Kahn discusses his experience having most of these tests in the last few years. A brief discussion of the negative impacts of inhibiting vitamin K metabolism with warfarin (Coumadin) on heart valve status kicks off the weekly podcast. Welcome to our sponsor xtend-life.com and their amazing product line including CX8. Use the discount code KAHN15 on your initial order of 2 or more bottles of CX8 for free DHL shipping and a free bottle of Marine Magnesium thrown in.

On Episode 17 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the June 2022 issue of Stroke: “Vitamin D Enhances Hematoma Clearance and Neurologic Recovery in Intracerebral Hemorrhage” and “Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm: Prevalence and Practice Patterns.” She also interviews Dr. Bruce Campbell on his article “Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy.” Dr. Negar Asdaghi:         Let's start with some questions. 1) Is vitamin D that golden key to recovery from intracerebral hemorrhage? 2) Endovascular therapies seem to have prevailed where thrombolytics have failed. In the era of fast and furious thrombectomy, what is the role of pre-thrombectomy thrombolysis? 3) And finally, 20 years of clinical research has failed to demonstrate the superiority of anticoagulation over antiplatelet therapies for treatment of patients in sinus rhythm with low left ventricular ejection fraction, and yet, our practice patterns have not changed. Why do we remain resolute in prescribing anticoagulation despite the lack of evidence? We're back here to tackle the toughest questions with our Stroke Alert Podcast because this is the latest in Stroke. Stay with us. Dr. Negar Asdaghi:         Welcome back to another extremely motivating Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine and your host for the monthly Stroke Alert Podcast. The June 2022 issue of Stroke contains a number of interesting articles. As part of our Advances in Stroke, we have two articles, one on the topic of cost-effectiveness of stroke care to inform health policy and the second on the current state and the future of emerging stroke therapies. As part of our Original Contributions category, we have an interesting study by Dr. [Ben] Assayag and colleagues from the Department of Neurology at Tel Aviv Sourasky Medical Center, where we learned that just over 10% of patients with TIA and stroke developed post-traumatic stress disorder, or PTSD. Higher presenting stroke severity, preexisting white matter disease, and having anxious coping styles are risk factors for development of post-stroke PTSD. Dr. Negar Asdaghi:         In another Original Contribution, by Dr. Daehoon Kim and colleagues from Yonsei University College of Medicine in Seoul, South Korea, we read with interest on the topic of whether or not we should be anticoagulating frail patients with atrial fibrillation. In this large population-based cohort, which included patients with atrial fibrillation older than 65 years of age with frailty as defined by a score of equal or greater than five on Hospital Frailty Risk Score, we learned that despite their frailty, patients with atrial fibrillation still significantly benefit from oral anticoagulation therapy. In this study, those treated with anticoagulation had lower net adverse clinical events as compared to those untreated. We also learned that direct oral anticoagulants provided lower incidence of stroke, bleeding, and mortality over Coumadin. This paper really provided practical information on treatment of frail patients with atrial fibrillation. So, I encourage you to review these papers in addition to listening to our podcast today. Later in the podcast, I have the great pleasure of interviewing Dr. Bruce Campbell from University of Melbourne in Australia on an especially timely topic, that is the role of intravenous thrombolytics prior to endovascular therapy. Dr. Campbell is a leading authority on the topic, and his interview does not disappoint. But first, with these two articles. Dr. Negar Asdaghi:         In the setting of intracerebral hemorrhage, or ICH, aside from the primary brain insult that occurs at the time of hemorrhage, secondary brain injuries continue for days and sometimes to months mostly due to the pathological response of the brain to byproducts of hematoma lysis or RBC degradation products. Today, the majority of spontaneous ICH cases are not surgically evacuated, so we rely on the body's own ability to clear blood for hematoma clearance, and obviously the faster the clearance, the better the outcome. Erythrophagocytosis by monocyte-derived macrophages contributes to hematoma clearance and ultimately to the functional recovery from ICH. So, it's conceivable that therapeutic approaches to enhance the endogenous erythrophagocytosis can potentially improve ICH outcomes. Vitamin D has been known to have variety of functions within the central nervous system, and it turns out that it may also be one such therapeutic option to improve the much needed erythrophagocytosis in intracerebral hemorrhage. Dr. Negar Asdaghi:         In the current issue of the journal, in the study titled "Vitamin D Enhances Hematoma Clearance and Neurologic Recovery in Intracerebral Hemorrhage," a group of researchers led by Dr. Jiaxin Liu from the Department of Surgery at Queen Mary Hospital at the University of Hong Kong studied the effects of oral vitamin D administered two hours after the induction of hematoma in a rodent model of ICH using direct collagenase injection into the striatum of the mouse. Eighty-nine young mice and 78 middle-aged mice were included in the study and randomly divided into three groups. Group one were sham-operated mice; group two, ICH mice treated with vehicle, which was corn oil; and group three, vitamin D-treated ICH mice. In the third group, 1000 international unit per kg of vitamin D diluted in corn oil was administered orally using a pipette two hours after the induction of ICH to mice, and then daily afterwards. And here are their top three findings of this study. Dr. Negar Asdaghi:         Number one, vitamin D-treated mice did better than vehicle on two neurobehavioral tests that were completed in the study. On the cylinder test, treatment with vitamin D significantly alleviated the asymmetric usage of four limbs at day seven, and vitamin D elongated the duration that the mice could run on the accelerated rod at day 10 on the rotarod test. Dr. Negar Asdaghi:         Number two, in terms of hematoma resolution and perihematoma edema, it's an issue that we deal with, with ICH, they used MRI imaging for edema measurement on T2-weighted images, and then sacrificed the mice and used digital quantification of hematoma volume with fresh brain specimens. And they found that treatment with vitamin D significantly alleviated both the ICH-associated brain swelling on MR and resulted in significant reduction in hematoma volume on the fresh brain specimens when compared with the vehicle-treated group at day three and day five. Dr. Negar Asdaghi:         And finally, their third main finding is in terms of erythrophagocytosis. So, the pathway that is mediated by the monocyte-derived macrophages is an endogenous pathway, that is, PPAR-γ (which stands for peroxisome proliferator-activated receptor γ) and its downstream scavenger receptor CD36 mediated. This pathway is essential for directing the endogenous erythrophagocytosis. Using flow cytometry, they found that vitamin D-treated mice had more mature macrophages expressing the scavenger receptor CD36, which was not expressed by the undifferentiated monocytes. Dr. Negar Asdaghi:         Western blot analysis confirmed that vitamin D treatment increased the tissue levels of CD36 and the upstream PPAR-γ levels in the brain at day five after collagenase model. Locally, vitamin D-enriched phagocytes that were positive for PPAR-γ and CD36 in the perihematoma regions. So, in summary, vitamin D increased the number of mature macrophages rather than undifferentiated monocytes in the perihematoma region and accelerated the differentiation of reparative macrophages from bone marrow-derived monocytes. So, bottom line is that in vitamin D, we have a simple, accessible, and well-tolerated agent to improve both the ICH outcomes and enhance hematoma resolution, but this we all observed in rodents. So, we stay tuned with interest to find out whether the same success will be seen in humans treated with vitamin D after intracerebral hemorrhage. Dr. Negar Asdaghi:         Patients with depressed left ventricular ejection fraction, or low EF, are at risk of development of ischemic stroke even if they remain in sinus rhythm. The optimal antithrombotic treatment for these patients is still unknown. Over the past two decades, we have a number of randomized trials studying the efficacy of oral anticoagulation, predominantly Coumadin, over aspirin therapy in prevention of all forms of stroke, that is ischemic and hemorrhagic, and death in patients with a low EF in sinus rhythm. Dr. Negar Asdaghi:         The meta-analysis of WASH, HELAS, WATCH, and WARCEF trials showed that treatment of low ejection fraction patients in sinus rhythm with Coumadin does reduce the subsequent risk of stroke, but it comes at the cost of a higher major bleeding risk in this population. The COMMANDER HF clinical trial published in New England Journal of Medicine in October 2018 studied whether low-dose rivaroxaban at 2.5 milligram BID was superior to placebo in patients with recent worsening of chronic heart failure, reduced ejection fraction, coronary artery disease, but no atrial fibrillation, and very similar to its prior counterparts, it did not show that rivaroxaban was associated with a lower rate of combined death, myocardial infarction, or stroke as compared to placebo. But very similar to prior studies, it also showed that rivaroxaban-treated patients had a lower risk of subsequent ischemic stroke. This poses a conundrum for stroke neurologists treating patients with this condition, especially after they present with an embolic-appearing stroke. So, the question is, how often do we encounter this situation, and what do we do in routine practice? We know that when there is equipoise, there's practice variation. Dr. Negar Asdaghi: In the current issue of the journal, in the study titled "Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm," Dr. Richa Sharma from the Department of Neurology at Yale School of Medicine and colleagues examined the prevalence of heart failure with sinus rhythm among hospitalized patients with acute ischemic stroke and the physician's practice patterns with regard to the choice of antithrombotics in this population. Dr. Negar Asdaghi:         So, let's look at their study. The study was comprised of five separate study cohorts of hospitalized acute ischemic stroke patients in the Greater Cincinnati Northern Kentucky Stroke Study for the year 2005, 2010, and 2015, and then four additional academic hospital-based cohorts in the United States during different timeframes. These were the Massachusetts General Hospital from 2002 to 2016, Rhode Island Hospital from 2016 to 2018, Yale-New Haven Hospital 2015 to 2017, and Cornell Acute Stroke Academic Registry from 2011 to 2018. All of these cohorts combined contributed to the 19,155 total number of patients in this study, which included over 14,000 patients that had documented left ventricular ejection fraction. Amongst those, 1,426 had a depressed EF and were included in this study. The investigator obviously excluded those with documented atrial fibrillation and flutter. And so the sample size for this analysis was 805 patients. And here are their main results. Dr. Negar Asdaghi:         The overall prevalence of this condition, that is low ejection fraction and sinus rhythm, among hospitalized acute ischemic stroke patients was 5%. It varied slightly between the different cohorts in this study from 4 to 6%. In terms of the antithrombotic treatment patterns, this information was available in close to 500 patients in the cohort. Overall, 59% of patients were discharged on an antiplatelet treatment alone, and 41% on anticoagulation. But these percentages significantly varied between the different institutions and was as low as 22% in one of the cohorts and as high as 45% in another cohort. Dr. Negar Asdaghi:         So, what were the factors that were associated with the use of anticoagulation at discharge? They found that the absolute percentage of left ventricular ejection fraction and the presenting NIH Stroke Scales were associated with anticoagulation use. That is, the lower the percentage of EF and the higher the presenting NIH Stroke Scale, the more likely physicians were to discharge the patients on an anticoagulation in univariate analysis, but in multivariate analysis, only the study site and presenting NIH Stroke Scale over eight were independently associated with anticoagulation use. Dr. Negar Asdaghi:         Now, interestingly, 2002 to 2018, which was their overall study period, was a time during which some of the largest and neutral randomized trials on the topic of anticoagulation versus antiplatelet were published, including the WATCH and the WARCEF trial. But the authors found no temporal variation in anticoagulation practice patterns before and after the publication of the results of these trials. So, it appears that we didn't change our minds. So, overall, we have some important takeaway messages from this study. We learned that 5% of hospitalized acute ischemic stroke patients have low left ventricular ejection fraction and remain in sinus rhythm without atrial fibrillation. Today, over 40% of patients with this condition are anticoagulated at discharge despite the results of the randomized trials, but the practice is widely variable among different institutions, and a higher presenting NIH Stroke Scale is a significant predictor of anticoagulation use at discharge in this population. Dr. Negar Asdaghi:         Almost 20 years after the approval of intravenous thrombolysis for treatment of patients with acute ischemic stroke, endovascular therapy was approved for treatment of select ischemic stroke patients with a large vessel occlusion. The two treatments are, therefore, entangled, as one was the standard of care while the second one was being tested. Therefore, all endovascularly treated patients enrolled in randomized trials would've received intravenous thrombolysis if eligible. Now, with the overwhelming success of endovascular therapy in achieving reperfusion in areas where IV thrombolysis has drastically failed, there're still critical questions regarding the added value of IV thrombolysis to endovascularly treated patients. The critical question remains as to whether eligible ischemic stroke patients who have immediate access to endovascular thrombectomy should receive prior IV thrombolysis, or should we skip the thrombolysis step altogether and just move to the angio suite as fast as possible. And there are, of course, arguments for and against each approach. Dr. Negar Asdaghi:         In this issue of the journal, in an invited topical review titled "The Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy," we learn about these arguments as the authors go through a comprehensive review of the current literature on this issue. I'm joined today by the first author of this review, Dr. Bruce Campbell, to discuss this paper. Dr. Campbell absolutely needs no introduction to our Stroke listeners. He's a professor of neurology and head of neurology and stroke at Royal Melbourne Hospital, University of Melbourne, in Australia. He's a pioneer in the field of acute stroke therapies and acute neuroimaging. He has served as the lead investigator of multiple landmark randomized trials, including EXTEND-IA and EXTEND-IA TNK, and holds multiple leadership roles. He's the clinical director of the Stroke Foundation and co-chairs the Australian Stroke Guidelines Working Party and the coordinator of the National Brain School Training Program for Neurologists in Training. And, of course, last but not least, he's my friend. So, I'm delighted to welcome him to our podcast today. Top of the morning to you, Bruce, 6:00 a.m. in Melbourne. That's quite some dedication. Thank you for being here. Dr. Bruce Campbell:       It's great to be with you. Thanks for the invitation. Dr. Negar Asdaghi:         Congrats on the paper, really exciting topic. So, let's just start with this question as part of a case. We have a patient with an M1 occlusion, a large clinical syndrome presenting two hours out from their symptom onset, and we are at a hospital where the angio suite is ready. What are some of the benefits of basically spending time in giving IV thrombolytics first rather than quickly going to the angio suite? Dr. Bruce Campbell:       I think a key element of this case is that the patient has presented directly to a hospital with immediate access to thrombectomy. Thrombolytic used in drip-and-ship transfer patients really isn't controversial, and the recent randomized trials excluded them. So, the debate's all about this context of bridging thrombolytics in patients presenting directly to a comprehensive stroke center. And you mentioned spending time giving lytics, but in fact, if you do things in parallel, that shouldn't be the case. It shouldn't delay thrombectomy if you go and give thrombolysis. Dr. Bruce Campbell:       So, the general principle is that getting the artery open faster by any means is better, and IV thrombolytic certainly has the potential to open the artery before thrombectomy in a proportion of patients, perhaps not that many, but it may also facilitate the thrombectomy. So, in the randomized trials, reperfusion after the thrombectomy was significantly better when patients had had bridging thrombolytic despite a low rate of pre-endovascular reperfusion. Other reasons for giving the lytics are the potential safety net it provides if the thrombectomy procedure is unexpectedly delayed or fails to get the artery open, and there's also this potential for lytics to dissolve distal embolic fragments and perhaps improve microvascular reperfusion. Dr. Negar Asdaghi:         So, great. So, let me summarize for our listeners what you mentioned. First off, so these are arguments in favor of giving lytics. As you mentioned, we're not really wasting time. These processes occur in parallel, so it's not like we're wasting time in giving a therapy that is potentially not as efficacious as thrombectomy is. And number two, we have improved the possibility of early reperfusion, perhaps, with the lytics. And if there are some fragments or distal clots that thrombectomy wouldn't have reached, then the lytics would. And then also there is also the chance that the thrombectomy might have failed in difficult access, and so on and so forth, and at least the patient has some chance of revascularization with the lytics. So, if these are the arguments for giving lytics, what are the arguments against giving lytics in this scenario? Dr. Bruce Campbell:       The main argument is the potential to reduce both the intracerebral and systemic hemorrhagic complications. There's also potential cost saving by skipping thrombolytics. That's probably more relevant in low-resource settings, particularly when relatives may have to pay for the thrombolytic before treatment is initiated, and that can be burdensome and also potentially delay the thrombectomy. There's a theoretical concern about thrombus fragmentation with lytics and potential migration of the clot out of reach of the thrombectomy or to new territories. But final reperfusion, as I mentioned, was, on average, better with the patient having a lytic on board in the randomized trials. Dr. Negar Asdaghi:         Perfect. And I want to highlight this issue of thrombus fragmentation because I think our readers will read more and more about this idea of, as you mentioned, fragmentation will potentially make an accessible clot for thrombectomy inaccessible. But I see that later in our questions, we're going to address that as part of the findings of randomized trials as well. So, these are some of the arguments for and against. And before we go to the randomized trials, I'd like to get an overview of what we knew as part of observational studies and non-randomized studies prior to more recent randomized trials on this topic. Dr. Bruce Campbell:       There've been a couple of nice systematic reviews and meta-analyses of the observational data, and notably in most of these studies, the direct thrombectomy patients had contraindications to lytics, and that introduces confounding factors that are difficult to adjust for. For what that's worth, the functional independence, mortality outcomes were better in the bridging patients. Hemorrhage rates weren't always higher with the lytic, and one study by Jonathan Coutinho in JAMA Neurology for the SWIFT and STAR studies showed the opposite despite them having really careful adjustment for all the confounders they could think of. And the meta-analysis by Eva Mistry in Stroke did not detect a difference in symptomatic ICH between the direct and bridging strategies. One thing that should be less affected by the patient characteristics would be the technical efficacy outcomes, and it was interesting that in the observational data, the patients who'd had bridging lytic had higher mTICI 2b-3 rates and also fewer device passes. Dr. Negar Asdaghi:         Okay. And now we do have further information with all of these new randomized trials. So, why don't we start with some of the earlier studies, the three, SKIP, DEVT, and DIRECT-MT, and start with those studies first before we move to some more recent European trials. Dr. Bruce Campbell:       SKIP was performed in Japan, and it used the lower 0.6 milligram per kilogram dose of alteplase that's standard there, and DEVT and DIRECT-MT were performed in China. All three of them showed numerically similar functional outcomes with slight trends favoring direct thrombectomy. SKIP had a smaller sample size and did not meet its non-inferiority criteria, and the other two trials did meet their specified non-inferiority margin, but it could be argued those margins were overly generous. If you think about non-inferiority trials, we generally try to set a margin for non-inferiority such as lower 95% confidence interval for the trial intervention would sacrifice up to 50% of the reference treatment effect. And it's difficult to estimate the effect of alteplase in this specific population. But if you think of the Emberson meta-analysis of alteplase, overall zero to three hours alteplase versus placebo has a 10% effect size and mRS 0-1, three to four and a half hours of 5% effect size. And we regard that as clinically important. So, half of 5%, 2.5%, is a lot tighter margin than any of the direct randomized trials employed. Dr. Negar Asdaghi:         So, Bruce, let me recap what you just mentioned. Two out of the three earlier trials seem to suggest that perhaps skipping IV therapy is the way to go rather than bridging as these two trials met the non-inferiority criteria if we believe that non-inferiority margins you mentioned. And now we have a couple of more trials, more recent trials. Can you tell us about these trials please? Dr. Bruce Campbell:       MR CLEAN-NO IV in a European population did not demonstrate non-inferiority, and the point estimate slightly favored bridging. Interestingly, in that trial, the symptomatic intracerebral hemorrhage risk, which was one of the main drivers for trying this strategy, was 5.9% in the direct and 5.3 in the bridging group. So, there's no hint of benefit from dropping the lytic on that metric. SWIFT-DIRECT was more selective in only enrolling internal carotid and M1 occlusions, which had a lower chance of early recanalization with lytic. But the protocol also specified giving the full dose of lytic. In the other trials, it seems the alteplase infusion was often stopped once the patient was in the angio suite, so the full dose may not have been delivered. And despite very low pre-endovascular recanalization in that selected group in SWIFT-DIRECT, the end of procedure reperfusion was significantly better in the bridging group, which is a consistent finding across the trials and suggests that the lytic may improve the thrombectomy outcome. Dr. Bruce Campbell:       DIRECT-SAFE, the final of those trials, was interesting in that the patients were enrolled roughly 50:50 from Australia, New Zealand, versus Asia. And in contrast to the original three randomized trials in Asian patients, DIRECT-SAFE found a significant benefit of bridging lytic in Asian patients. So, it'd be very interesting to see the results of the IRIS individual patient data meta-analysis, but we may not find a difference in Asian versus Caucasian patients despite those initial trials and despite substantial differences in the prevalence of intracranial atherosclerosis, which has often been proposed as something that would increase the risk of having bridging thrombolytic on board. Dr. Bruce Campbell:       The original study level estimate of symptomatic hemorrhage had a borderline significant 1.8% absolute reduction in the direct group. Whether those data were not all core lab adjudicated and the final analysis may show a smaller difference than that. Notably, given that trend with symptomatic intracerebral hemorrhage, mortality did not differ significantly, and, in fact, the trend favored bridging patients. So, the symptomatic hemorrhage slight trend into increase did not translate into any hint of increased mortality. Dr. Negar Asdaghi:         So, Bruce, a lot of information, and I need a recap for me. So, let me try to recap some of the things you said, and please jump in. So, so far, the newer data really basically don't show us any convincing evidence that skipping is the way to go, and direct endovascular we really don't have data in favor of going directly to the angio suite. And the jury is still out regarding an increase in the symptomatic intracerebral hemorrhage rate amongst those that actually are pre-treated with IV therapy. Is that correct? Dr. Bruce Campbell:       That's correct. So, none of the three recent trials met their non-inferiority margins. And again, we had this issue of relatively generous non-inferiority margins, and the symptomatic hemorrhage, it would make sense that there's a small difference, but it's not really been borne out in the data to be statistically significant at this stage. And again, this individual patient data meta-analysis is keenly awaited to get the most accurate estimate on that. Dr. Negar Asdaghi:         So, while we wait that, I'm going to digress a little bit and ask you a question that's not addressed in the paper that you have in this issue of the journal, and that's the CHOICE trial. So, by now, we have the results of CHOICE trial. Do you mind first give us a brief overview of what CHOICE was and how you feel that the results of CHOICE would affect this field of direct versus bridging in general? Dr. Bruce Campbell:       CHOICE is a very interesting study in that it tested giving the intra-arterial lytic at the end of a thrombectomy procedure that had achieved an mTICI 2b or better, which is what we traditionally regarded as angiographic success. The idea was to improve microvascular flow, and that may be the case. The trial was terminated early due to logistic reasons and showed a very large effect size that requires replication. The subgroup analyses are interesting in that the benefits seem to mostly accrue in patients who'd not already had intravenous lytic. Dr. Bruce Campbell:       So, perhaps giving the IV lytic before thrombectomy can still benefit patients after the thrombectomy, as well as achieving early recanalization in a proportion of patients and perhaps facilitating the thrombectomy. The other issue to address with the DIRECT trials is that with the exception of a few patients in DIRECT-SAFE, the comparator was alteplase and not tenecteplase. And we have data from EXTEND-IA TNK that tenecteplase bridging is not just non-inferior, but superior to alteplase bridging. There's an ongoing Brazilian trial of exactly that, tenecteplase versus the direct approach, which will be very interesting. Dr. Negar Asdaghi:         So, great, Bruce. I just want to repeat this segment again for our listeners. So, CHOICE is a very interesting study, looked at giving intraarterial alteplase to patients after endovascular therapy was completed and after they'd already achieved the complete and successful revascularization, and the trial was terminated early because of logistic reasons. So, we have to keep in mind, this was a smaller study, early termination, but the effect size was pretty large in favor of giving lytics. Dr. Negar Asdaghi:         So, what you mentioned is interesting, and I think that it's really worth paying attention to, that the majority of the benefits seem to have occurred from intraarterial thrombolytics in patients that have not been given intravenous lytics prior to endovascular therapy. So, in other words, you need some sort of lytics either before or after the endovascular thrombectomy to achieve that ultimate improved outcome. So, moving forward now from the randomized trials that we have on bridging versus direct thrombectomy, you have mentioned in the paper some interesting subgroups that may benefit or not benefit as much from bridging versus direct thrombectomy. Do you want to elaborate a little more about those subgroup analyses? Dr. Bruce Campbell:       The idea of precision selection or individualized treatment is being talked about a lot given there didn't seem to be much overall difference between strategies in the randomized trials, but it's important to note that the randomized trial actually disadvantages the bridging group by delaying lytic until the patient was firstly confirmed eligible for thrombectomy and then consented and randomized. Putting that aside, if we could identify a subgroup who clearly benefit from skipping lytic and, importantly, identify them without delaying lytic for those who likely benefit, that's clearly attractive. Dr. Bruce Campbell:       Currently, I'd say we have not identified that kind of subgroup, and the planned IRIS individual patient data meta-analysis will be critical for that. Patients with a large ischemic core are one potential group where there's a high risk of bleeding hypothesized. To date, there is no definitive data to indicate the risk is lower with the direct approach. Patients who need stents certainly may benefit from not having a lytic on board because they often need adjuvant antithrombotics that could increase the bleeding risk. But the question there is whether we can confidently identify those patients before the procedure, and I think that's unclear at this stage. Patients with really large clot burdens and proximal occlusions have sometimes been said not to benefit from IV lytic based on the low rates of pre-endovascular reperfusion, but the randomized trials really hinted other benefits like this potential facilitative thrombectomy. So, that hypothesis may be insecure as well. Dr. Negar Asdaghi:         And how about age? Have you come across and has there been any signal towards an impact or interaction between age and benefit from pre-endovascular thrombectomy and thrombolytics? Dr. Bruce Campbell:       It's an interesting question because age has not generally been a treatment effect modifier in previous stroke studies with thrombolytics and thrombectomy, and the individual direct thrombectomy trials that have reported subgroups haven't shown any convincing heterogeneity by age. There's certainly no indication that older patients are at risk from bridging in what I've seen so far. Dr. Negar Asdaghi:         So, this question comes up in clinical practice all the time, that a person's older, perhaps more atrophy, more vascular risk factors and white matter disease, and they're more prone, so to speak, of having a symptomatic intracerebral hemorrhage. So, what you're saying is, from the data we have, there's really no signal in favor of withholding pre-thrombectomy lytics in this population. So, it's important to know this. Bruce, what should be our final takeaway message from this study? Dr. Bruce Campbell:       I tend to agree with the recent European Stroke Organization and ESMINT guideline that for now, patients should receive lytic as early as possible and in parallel with the decision to perform thrombectomy such that neither treatment delays the other. I think if we can identify a subgroup that benefits from direct thrombectomy, and that's confirmed in the individual patient data and meta-analysis, and we can identify them without disadvantaging the majority of patients, and also that the ongoing improvements in IV lytic strategies don't render the existing trial data obsolete, then we may, in future, skip lytic for some patients, but we are not there yet. Dr. Negar Asdaghi:         So, that's amazing, Bruce. We look forward to reviewing the paper and individual data meta-analysis and interviewing you, hopefully at a better hour your time, on that. Thank you very much for joining us on the podcast today. Dr. Bruce Campbell:       Thanks again for the invitation. It's been great talking to you. Dr. Negar Asdaghi:         Thank you. Dr. Negar Asdaghi:         And this concludes our podcast for the June 2022 issue of Stroke. Please be sure to check out this month's table of contents for the full list of publications, including three very interesting images that are presented as part of a new article type, Stroke Images, and a special report in Comments and Opinions section on "Bias in Stroke Evaluation: Rethinking the Cookie Theft Picture." June is the month of Pride, and in spirit of equality, we hope to do our part to reduce all biases in stroke processes of care, diagnosis, and outcomes as we continue to stay alert with Stroke Alert. Dr. Negar Asdaghi:         This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit AHAjournals.org.

Bugs & Drugs: The Controversy Surrounding Prophylaxis Episode #350 with Dr. Tom Viola, R.Ph., C.C.P. Imagine causing an accident while trying to prevent said accident. That is where prophylaxis stands in dentistry. By prescribing them unnecessarily to prevent infections, it can actually create resistance and increase infection risk. But there are ways to prevent this! And Dr. Tom Viola returns with Kirk Behrendt to teach you everything you need to know about prophylaxis to help you prescribe them appropriately and effectively. For the best practices on being a steward for antibiotics, listen to Episode 350 of The Best Practices Show! Main Takeaways: Dentists are overprescribing unnecessary antibiotics. Overuse of antibiotics can lead to resistance. Antibiotics and antibacterials can have adverse effects. Overusing clindamycin can increase the risk of C. diff infection. For the average patient, there is no evidence that prophylaxis is necessary. Guidelines for antibiotic prophylaxis are constantly evolving.  Quotes: “[Why prophylaxis is controversial] boils down to two main points. And the first one is, is antibiotic prophylaxis even necessary? If I have to ask that question, I have to ask a preview question to that. What the heck is prophylaxis and why is it necessary? Well, we know that there are certain vectors under which bacteria that normally reside in the mouth can end up causing trouble in other parts of the body. Obviously, one of the issues is infective endocarditis. That is where bacteria from the mouth have found a way into the endocardium and may cause issues that can ultimately lead to bad outcomes for our patients.” (3:20—4:03) “Bacteria in the mouth can find a way to where we've had replacement joints, plates, knee replacements, hip replacements, and so on. And that can lead to joint replacement failure. These are pretty significant events in people's lives and, certainly, we want to try everything we can in dentistry to avoid that from happening. So, one of the ways we avoid bacteria that normally resides in the mouth to find other places or other ways into the body cavities is to prophylax with antibiotics, to kill them before they have a chance to establish residence elsewhere. But it's controversial because everybody knows that when you overuse an antibiotic, it increases the risk of infection.” (4:05—4:47) “There is that whole aspect of antibiotic stewardship, which is, we should be the stewards. We should be the lookouts for making sure that antibiotics are used both effectively and efficiently, but also appropriately so we're not overusing them and therefore causing resistance to occur.” (4:47—5:04) “I can run down the list pretty easily, of antibiotics, that we normally use in dentistry. And that's the problem, in and of itself, is that we have a great arsenal of antibiotics that we use in dentistry, but unfortunately, it's a very small arsenal. And they're not really all antibiotics. We use the term colloquially but, really, they're antibacterials.” (5:14—5:33) “Penicillins are our favorite antibacterials. That would include penicillin VK and amoxicillin, specifically, in dentistry. And I'd be hard-pressed to find a general dentist and any dental specialist as well that hasn't prescribed amoxicillin at some point in their practice. And the reason for that is because it works, because it has great efficacy and great coverage against the bugs we find in the mouth. Now, the penicillins are bactericidal, which means that they destroy the cell wall and, therefore, they kill the bacteria. Which would sound great if you're treating virulent bacteria that you want to get rid of. But remember, they don't just kill the bad guys; they also kill the good guys. And that can lead to problems with things like opportunistic infections and even the potential for increasing the risk of bleeding in patients who are using drugs like Coumadin. So, they're great drugs, but they do have their...

In this episode, Co-Owners of Kornetti & Krafft Health Care Solutions, Dee Kornetti and Cindy Krafft, talk about all things maintenance therapy and care. Today, they talk about maintenance therapy in the home, diversifying revenue, and they bust a few maintenance therapy myths. How can maintenance patients have a goal statement if they're never going to get better? Hear about home-based therapy, teaching patients to self-manage, Medicare part B, and their book The Guide to Delivery of Home-Based Maintenance Therapy, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “It's never been that if you don't improve, then services aren't covered.” “Rehab potential is the responsiveness to care.” “The myth of coverage has some roots in the denial issue.” “If there's room for improvement, a restorative or improvement course of care is what your skills would be indispensable for. That's what would make your care medically necessary under the Medicare benefit.” “If someone else can do it just as well as I can then this is no longer considered skill.” “We are helping patients be accountable for their chronic disease management.” “There are times that we are indispensable to help people improve and recover function back to a prior level or maybe beyond, and then there's times we are needed to preserve and stabilise their exiting function so that their quality of life can continue on in the fashion that it currently is.” “Be a bit more open-minded with how physical therapy really works in reality. Don't assume that what your path at the moment is THE path and can't vary and can't change. There are many other ways you can utilise your skill to benefit those around you.” “Don't be afraid to ask questions, and don't think you have to know it all.” “If you've got a great idea, or you have something that is a passion, and you've got that intersection of your passion and your skill set, go for it. Start to explore that. The possibilities are endless.”   More about Dee Kornetti Dee, a physical therapist for 35 years, is a past administrator and co-owner of a Medicare-certified home health agency. Dee now provides training and education to home health industry providers as Owner/Founder of a consulting business, Kornetti & Krafft Health Care Solutions, with her business partners Cindy Krafft and Sherry Teague. Dee is nationally recognized as a speaker in the areas of home care, standardized tests and measures in the field of physical therapy, therapy training and staff development, including OASIS, coding, and documentation, in the home health arena. Dee is the current President of the American Physical Therapy Association's Home Health Section and serves on the APTA's national Post-Acute Work Group. She serves as the President of the Association of Homecare Coding and Compliance, and a member of the Association of Home Care Coders Advisory Board and Panel of Experts.  She has served as a content expert for standard setting for Decision Health's Board of Medical Specialty Coding (BSMC) home care coding (HCS-D) and OASIS (HCS-O) credentialed exams. She holds current credentials in Home Health Coding (HCS-D) and Compliance (HCS-C) from this trade association.  Dee is also on Medbridge's Advisory Board for development of educational content on its  home health platform, and has authored several courses related to OASIS, Conditions of Participation (CoPs) and therapy. Dee is a published researcher. on the Berg Balance Scale, and has co-authored APTA's Home Health Section resources related to OASIS, goal writing and defensible documentation for the practicing therapist. Dee has contributed chapter updates to the Handbook of Home Health Care Administration 6th edition, and co-authored a book, The Post-Acute Care Guide to Maintenance Therapy published in 2015, along with an update in 2020 titled, The Guide to Delivery of Home-Based Maintenance Therapy that includes a companion electronic workbook. Dee received her B.S. in Physical Therapy from Boston University's Sargent College of Allied Health Professions, and her M.A. from Rider University in Lawrenceville, NJ. Her clinical focus has been in the area of gerontology and neurological disease rehabilitation.   More about Cindy Krafft Cindy Krafft PT, MS, HCS-O is an owner of Kornetti & Krafft Health Care Solutions based in Florida. She brings more than 25 years of home health expertise that ranges from direct patient care to operational / management issues as well as a passion for understanding regulations. For the past 15 years, Cindy has been a nationally recognized educator in the areas of documentation, regulation, therapy utilization and OASIS. She has and currently serves on multiple Technical Expert Panels with CMS Contractors working on clinical and payment reforms and bundled payment care initiatives. Cindy is an active member of the National Association of Home Care and Hospice (NAHC) and currently serves on multiple committees. She has written 3 books – The How-to Guide to Therapy Documentation, An Interdisciplinary Approach to Home Care and the Handbook to Home Health Therapy Documentation – and co-authored her fourth, The Post-Acute Care Guide to Maintenance Therapy with her business partner Diana Kornetti PT, MA, HCS-D.   Suggested Keywords Maintenance, Therapy, PT, Physiotherapy, Improvement, Assessment, Goals, Home Care, Rehabilitation, Accountability, Medicare, Myths, Health, Healthcare, Sustainability,   Book Discount Code (10% OFF): KK2021 The Guide to Delivery of Home-Based Maintenance Therapy   To learn more, follow Dee and Cindy at: Email:              kornetti@valuebeyondthevisit.com Website:          https://www.valuebeyondthevisit.com Facebook:       Kornetti Krafft HealthCare Solutions Twitter:            @Dkornetti                         @KornettiKrafft LinkedIn:         Kornetti Krafft HealthCare Solutions   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:01): Hi, D N Cindy. Welcome to the podcast. I'm happy to have you guys on. Welcome. Welcome. Thanks for having us happy to be here. Glad to be here. Excellent. So today we are going to be talking about maintenance therapy. So when a lot of physical therapists think about maintenance therapy, they often think that, well, this is something that's not reimbursed. This is something that maybe the patient doesn't quote unquote need. So today we're going to talk about what it is, some of the myths and a lot of other stuff surrounding maintenance care. So my first question is, can you define what maintenance care is or maintenance therapy? Speaker 2 (00:47): Okay. Karen, this is Cindy. I'll take that one. I think, you know, just as you were saying, the word maintenance, I'm sure at least one listener twitched, a little, the eye Twitch, the uncomfortable many times when you say the word maintenance, it looks like, you know, people react like you swore in church to like, oh, I don't do that. Or I, you know, somebody does that and get in trouble. And, and I think even the word has become a barrier. So Dee and I have tried to reframe the conversation by getting to the heart of what it is by referring to it as stabilization of function. So putting aside that baggage and the history of the word, the approach to care is saying I'm utilizing all the wonderful things I know as a therapist, my ability to assess and all of those great things and develop a care plan. But the end result that I'm going for is a stabilization or preservation of their functional level or slowing of decline. I think maintain can get people tied up in knots and miss the point or think that we have to do all kinds of different things, which we'll talk about in a moment with the myths. But I really think it helps to, to approach it as we're talking about stabilizing someone's function. Speaker 1 (01:58): That makes a lot more sense. And I really like that word. And you're right. I feel like maintenance care does kind of give people that, oh, I don't know if that's quite my lane, but when you say stabilization of function, preservation, decreased speed of decline. I think physical therapists are like, yeah, of course that's what we do. We'll think about it. We, we, we treat patients that have these chronic diseases right there. We don't share them. They go to doctors, numerous doctors, you know, cardiologists primary care, right. With their, with our heart conditions, they see nursing, right. They see all kinds of disciplines and all kinds of professionals. But they're never getting cured. They're it's management of their symptoms, right? So, so it's to like Cindy said, we are, we're going to preserve function. We're going to, you know, optimize their ability. Speaker 1 (02:50): We're gonna re hopefully use our skills, knowledge, and ability to reduce their demand or their requirement, higher cost centers of care. What happens when you have poorly managed symptoms of chronic disease, like COPD or CHF or diabetes, these people use urgent, emergent care. These people go in the hospital. This is extremely costly to our, to our medical system. And it's, it's not sustainable as an aging pie, you know, as we age as the population. And so this idea that there's things we can do to have people function optimally, no matter what phase or stage of this chronic condition they're in too, so that they're not as dependent or on higher cost centers of care, or they don't realize the kind of sequella, you know, think about a diabetic with poorly managed blood sugar, you know, that starts to develop retinopathy Neff, prophecy, peripheral neuropathy, right? All these other problems that happen. You know, that's all very manageable. If we can get an early and often and preserve an optimized, I even say optimize function. So we're not improving people necessarily because sometimes they haven't already experienced a decline. A lot of times we're just going in there to share what we know so that they can be accountable and manage these chronic diseases themselves. Yeah. That makes so much Speaker 2 (04:16): Karen. I would add to that, you know, for your listeners, cause some folks, you know, D and I have been talking about this for years. Some folks have a difficult time with this conversation, not just the word, but the concept. It sounds good. It sounds valuable. But I think we have to take a moment and acknowledge how deeply as therapists. We have defined ourselves by that word improvement. You can see it in our documentation. If you're going to get physical therapy, you're going to walk five feet more or 10 feet more, every time I get near you because that's, that's what I have to do. And that if I'm not improving you, we've all been told that if, you know, after a certain number of visits or certain number of treatments, if you don't see improvement, you're obligated to discharge people. When you start finding out that, that isn't really true and it hasn't really ever been true. Speaker 2 (05:06): I think we've got to give ourselves a little bit of grace here and realize that this can be quite the seismic shift internally about how we value ourselves as therapist, how we define ourselves and how we're defining ourselves to our patient populations. I think to the patients, to the potential patients, to our other members of the interdisciplinary team, we've done such a bang up job, talking about improvement, that when they don't feel that they're going to improve as, as the beneficiary or other members of the team say, well, that's patient, isn't going to get better. They don't even refer them to us. They don't even come to us because we've created this wall of you have to be able to get better, or you can't come to physical therapy. Speaker 1 (05:47): Yeah. Oh, I'm sorry. I was going to say, Cindy, what's your favorite line? When you talk about how we are addicted, like we, we are ingrained with improvement. What is your favorite line to say? Speaker 2 (05:57): Oh, well, I created a little, self-assessment like you answer these questions to get these points about how addicted are you. Because it, I feel very comfortable using that word because this challenge is a lot of those core beliefs. And we have identified ourselves by this. So tightly that it's like, okay, we, we have to step outside of our comfort zone a bit. And then as we see therapists start to do that, then we get the questions. Then we get the, okay. I kind of understand it, but what about this? And what about that? And what about this other thing? And that's when the myths all start to bubble up to the surface with where did that even come from? Speaker 1 (06:40): Yeah. So let's talk about some of those myths and see if we can bust them. So I will, I'll take, I'll throw it over to you guys. Either one of you can start, but let's talk about a couple of myths of maintenance therapy for me. One big one is, well, it's not covered. Speaker 3 (06:58): It's not covered by insurance. Speaker 1 (07:00): I'll take that one. This is thing. Yeah. Well you know, maintenance has been part of the Medicare benefit under any Medicare beneficiary part a or part B, since you can find it in the Medicare benefit policy manual, as far back as the, as the 1980s. So it's been around forever. This is not new, that Jimmo V Sebelius case that was brought forward. Just kinda shine the light on it, but it's never been that if you don't improve and services aren't covered or you don't have no, this idea that rehab potential is the ability to improve no rehab potential that we all typically document at some point is the responsiveness to care, right? That's what rehab potential is. Whether the care is going to allow you to improve from where you are at the baseline of assessment or to maintain or stabilize your function from where you are now without any unforeseen event in the next three, six, nine, 12 months, two years, are you going to be able to manage this condition and not decline, right? Speaker 1 (08:13): Or if you're in a progressive type of disease process, are you functioning optimally? And are we slowing that deterioration or decline? That is a normal part of the condition. So Cindy, I can pop a punch it over to you. And since we talk about it being paid, I think we busted that Karen. Right? We busted that pretty good. Okay. So, so other payers, I don't know, but anybody that is a Medicare provider, so under part a or part B, it, it is part of the benefit. Okay. So Cindy, talk to me about what are the type of conditions that are covered by maintenance as if the diagnosis determines it? What do we know about that? Speaker 2 (09:00): Well, very often what we hear is, okay, I understand maintenance therapy. I know what it's for. It's for people who have progressive neurological conditions. So it would make sense for Parkinson's. It makes sense for Ms. It makes sense for ALS. So it must be those three patient populations that are maintenance. Okay. We got to step back for a minute. There are patients with those three conditions that benefit and have the ability to improve with therapy. So it's not Parkinson's is synonymous with maintenance. And there's nothing in the coverage criteria that is diagnosis specific. Diagnosis is only one piece of the conversation. It is where are they functionally? What are the, what is the impact of this diagnosis and their resorted comorbidities on their functional ability? And what does a therapist know? What does that skill that you bring to the table that is unique to that discipline that is indispensable to this patient? Speaker 2 (09:56): But I think the myth of coverage has some roots in the denial issue. We, we can't go past this point without acknowledging that therapists have seen denials for providing maintenance therapy, that you did not show improvement in wham. They took away payment for part of this care, which is what drove the Jim versus civilians conversation that led to the court settlement with CMS to basically say, you know, Hey, we've looked at this benefit. It doesn't say you have to improve to get services. And, and we're, we're good friends with Judah Stein who was the lead attorney in that case, and still has the ability to call CMS back on the carpet and the legal sense about how that settlement has played out since, because CMS basically approached it with a oops, you're right. It doesn't say that shame on us, but it's like, wait a second. Speaker 2 (10:48): You've been denying coverage of services for a long time. And so it's very hard to say, yes, it's in there. And we understand it's in there. And D and I've explained the fundamental pieces of that, but there's still that I got denied, or I know somebody who got denied this can't possibly be true and it's unfortunate. And my personal opinion is I have a really hard time with CMS, just kind of Oop, seeing it versus, you know, ownership. And we saw a subsequent event to the initial Jimmo case that compelled CMS to put on their resources, particularly on their website, where they had to quote disavowal the improvement standard. So not just say oopsies, but say you have to flat out say that does not exist. And if beneficiaries qualify for these services, they absolutely should get them. Speaker 1 (11:36): Yeah. The, the, the woopsies sees that my bad defense never, ever seems to go over well, does it? No, no, no. Okay. So we talked about, is it covered? We talked about diagnoses covered. What other big myths are there surrounding maintenance therapy? All right. I Speaker 2 (11:59): Got one for you. D I got, you know, where I'm going. We very often hear they say, okay, so if it's not about their diagnosis, I need to assess the patient. Right. Figure this out. So now looking at what I typically do in an assessment, oh, test and measures. Well, those must not apply. Then I wouldn't be using tests and measures on a maintenance patient. And we would say, well, why not? Well, why would I measure something if I measure it again later? And it's the same, then why did I measure it to begin with? So any thoughts on those tests and measures in the maintenance patient D Speaker 1 (12:32): Yeah. Well, and, and I'm going to tie it to goal statements too, from there, right? So, so this idea, why do we take objective measurements of patients to establish a baseline, right? And we need to do that regard, you know, based on the presentation of the patient, regardless of their diagnoses and comorbidities, because we want to see if they're functioning at, or near where we would expect them think of a class three heart failure patient, are they functioning where you would expect, you know, a class three heart failure patient to function, or are they functioning like end stage, right. Class four, are they functioning below where you would expect them to function? And so obviously if there's room for improvement, a restorative or an improvement course of care is what your skills would be indispensable for. That's what would make your care medically necessary under the Medicare benefit part a part B that's what it would do so that the tests and measures, establish that baseline. Speaker 1 (13:30): And you compare, this is how the patient's functioning. This is how we'd expect them to function. Now, when you get a patient who is functioning at, or near where you would expect them to function with, with their PR their presentation, the question you have to ask yourself, as you don't just jump right to maintenance, right? You can't just say, okay, this a maintenance patient. They need me. Yeah. Basket. What do they need me for? You know, is there something I can teach them, train them, provide them so that they continue to stay, be stabilized, maintain, be accountable for their care over longer period of time. Right? And if the answer is yes, then you absolutely should pick them up on, on, on a maintenance course of care, because there's some sort of skills, your knowledge, your expertise, that which makes you, you, what I like to call the magic, that is me as a PT, right. Speaker 1 (14:21): And we've all had those magic. That is me moments. When you ever, whenever you walk or, or you, you readjust a, an assisted device to properly fit a patient and people look at you like, oh my gosh, why didn't we think of that? And it's just like, because you're not the magic. That is me. I mean, I, and we take it for granted. So the idea is that tests and measures absolutely help you establish a baseline and determine if there's room for improvement or they're functioning at, or near where you would expect them to function based on the severity, the course, the interplay of these disease processes. And then that helps you pick which course of care restorative or improvement, stabilization, or maintenance. And then you have to say, this is what my skills are going to be medically necessary for. So, so I'm going to tie that now to the next thing that comes, because if we get people this far down the myth-busting trail, Karen, the next thing they say is, well, how am I going to write a goal for that? I mean, if I'm not going to write something to improve, I mean, our, our documentation is called progress notes. I mean, you want to see how addicted we are. That's Cindy's line, right? We write on progress notes you know, Cindy, talk to us about goal statements. How can, how can maintenance patients actually have a goal statement if they're never going to get better? Speaker 2 (15:43): Well, I think, you know, we talked, we talked about coverage criteria, and then the documentation piece goes with that because I can't, and I'm going to kind of work backwards because what we'll see at times is therapists kind of go, okay, I understand it. And then you go to the goal statements and every one of them says, maintain this to maintain that I'm maintaining strength to maintain ADL's. And it's kind of like, okay, let's, let's take maintenance out of it for a minute. That that doesn't measure anything. What ADL's are you talking about? You didn't give any sort of quantifiable way to say what you're trying to maintain. So the goal solution is not to stick the word maintain in there as many times as humanly possible. It's still looking at it as we should be looking at it is what is that quantifiable element? Speaker 2 (16:29): How am I measuring something so that I can demonstrate whether or not we've improved it or stabilized it or slow the decline. And then the end piece is how was this functionally relevant to the patient? So I think what happens at times when D and I work with agencies about writing goal statements for maintenance, the by-product is actually their goal writing overall gets better. Because I think we've lost focus. We think, oh my gosh, I have to have an HCP goal, right? Because that's another addiction, you know, patient will have, you know, visual be independent with Hep. Well, it doesn't say what it's for. Why do you tend for them to do it forever? We don't know, but you have to have that goal. Then you have to have a strength goal. So, oh gosh, this has maintenance. I'm going to put, you know, increase a quarter grade. And yes, Karen, I have seen that documentation, the plan to increase one quarter grade, it's like, can you just go to maintenance and stop trying to improve in minuscule, teeny tiny amounts? Speaker 1 (17:27): How, how is that measured? I Speaker 2 (17:30): Have no idea. I thought half a grade was bad, but then we get into quarter grades. We see assessments that contain the terminology of severely poor. I thought poor was like the basement. I didn't know there was a tunnel under the basement. So this goal writing is really a good place to say, am I focusing in on, what am I quantifying? Why is this functionally relevant to this individual? Then we're setting the stage as to why therapy is in fact necessary for this person. I think the, I will maintain this to maintain that. Doesn't really speak to that. And then we'll go see, I got a denial. That means this whole thing is, is self fulfilling prophecy. They don't pay for maintenance. I will never do this again. And it's like, yeah, but did you really cover what you needed to cover and speak to why the therapy was important and why they needed to have it now? Yeah. Oh God, Speaker 1 (18:24): No. I was going to say, that's great. Thank you for that. Speaker 2 (18:29): But I think the extension of that, and I guess my way to push the ball back to D here as it were, is okay. So I've assessed them. I did my test and measures that wrote some goals. Now the issue becomes, I got to establish a care plan. So how often am I going to see them? And this is where at times, you know, when we had the ability to see folks in person, I swear people's heads are going to start spinning around in confusion because we start talking about things like you don't necessarily see these folks every week. You may see them once a month. And then D what about PRN visits? Can, can therapy use visit frequency? I mean, don't, we have to go or see them or interact with them at least once a week or else this won't be paid for. Speaker 1 (19:14): So talking about service utilization, you know, it's my answer is it depends. What does the, what does the beneficiary, what does the patient need, right? And so do I have to go three times a week for them to stabilize function? Do I have to go once every three weeks? What does it take? What is it that I'm doing that is indispensable for them that only can be provided by a therapist? You know, they can't go to the local you know, green, orange theory and have somebody work out with them in the gym and get the same benefit. What, why, why do you know, why does it have to be me? And so we, so we have to have an understanding of what's it going to take? How often do I have to go? And so when Cindy's talking about PRN visits, that's like a big no-no in home care for therapists, right? Speaker 1 (20:04): Under the Medicare part, a benefit in reality, it's not nurses do it all the time. You know, when they have to adjust Coumadin levels, right? For, or blood thinners, when they have to, if people still even on Coumadin, when they have to do sliding scale insulin adjustments, when they have to run labs, when they update or they're changing wound care orders, they write PRN visits all the time, but supposedly therapists can't do that. Well, that's not true because think about it. I think in, when I'm making this care plan, I'm not writing everybody for three weeks for I'm writing this person in five times a week, because they just got out of the hospital for an elective surgery. And I'm going to go every day, because if they went to an ER for SNIF, rather than home, they'd probably get daily therapy. Right. Okay. And this person was referred from maybe from their physician. Speaker 1 (20:54): And, and we're in the second episode of care, if you will, the second certification period. And there were still as ensuring that they are being, that they're stabilizing function. They're still teaching training oversight, checking, following up on 30 day reassessments to confirm that our interventions are actually working well, if I'm waiting on a piece of equipment, maybe that I decided, okay, we're going to get them a splint or something to meet, or we're going to get them this, this device. And we have to go through all the machinations with DME. I could write that I'm going to go out one time a week for four weeks. But what if that device doesn't come in for two weeks, what am I going to do? Just go, yada, yada yada. And the second week of that 30 day period, or do I just write like a PRN visit that says, you know, when the device comes, if it's not a, you know, when I would normally go out, if it's not going to be there, when I'm planning to go out, I'm not going to let it sit in my office or the back of my, you know, the boot of my car for another week. Speaker 1 (21:52): Or I'm not going to write an add on order. I'm going to have this PRN, but well, it's come in. I wasn't planning on seeing you for a week. I'll bring it out there, fit, adjust it, set it up, teach you how to put it on Don and doff it, you know, check your skin, how to wear it, everything you need to do. It's the same thing. Think about when you think about Karen, when you tell your patients, oh, Hey, if you have a problem with this exercise program, give me a call. How many calls do you get? I don't get that many calls. And then I go back out there and they're doing like rhythmic gymnastics with the Sarah band. And I'm like, that's not what we taught you. Right. That's not the correct exercise. So, so this is a way this, this kind of go out as often as you need to, and not one visit more is appropriate, not just for maintenance, right? Speaker 1 (22:37): So, so writing, writing utilization is really hard for people to understand, because they're used to seeing their patients every week and that doesn't sometimes have to happen. How long do you have to wait to see if the exercise program was efficacious two weeks, three weeks, four weeks, how long, you know, you've got to base it on what, you know, what the evidence shows us? What, what, what our, you know, our, our scientific literature says that's important. So, so I have one more myth to kind of finally push the ball back to Cindy since utilization depends. So now we've got people test to measure some kind of goals that aren't just written, maintain. We have utilization. That seems to be very beneficiary specific, Cindy now, cause they're on maintenance. I got to see them for the rest of their life, right? Speaker 2 (23:29): Yeah. That that's, that's very common and, and it kind of splits into different ways. Karen, sometimes it's the, I made a lifelong commitment because they could decline at any point in time. So by that standard, this is forever or there's the gleeful hot maintenance, a great way to go for patients that don't want to be discharged. So as opposed to them crying, when I talk about discharge or the daughter runs back to the doctor and keeps getting orders, I'll just put them on maintenance and then everybody's happy. Okay. You can't do either one of those things you still are accountable to skilled, reasonable, unnecessary. So the benefit is clear. You can't just keep going or having them come to see you at the clinic, just because you're nice. This does need to require the skills of a therapist. We're still accountable to all of those criteria. Speaker 2 (24:19): And as di said earlier, if there's nothing left to teach, train, or do I can't just do it because you either don't want to, unless I stand here or the caregiver doesn't want to have someone else can do it just as well as I can, that this is no longer considered skilled. And that's what drives the decision to discharge as well is when I have taught you what I, everything that I can the program I've given you is effective. It is in fact stabilizing function. There are no more adjustments to make. There are no things that need to be changed, then you really don't need me anymore. And that's where I think that it comes back to again, how are we finding our value that I think we've gotten very used to. They come to see us X number of times per week for this number of weeks in a row. Speaker 2 (25:07): Then we say, okay, you're done. The order is done. If anything goes wrong, then come back again. Where maintenance really makes us think about a term we use very often is how are we dosing ourselves? So thinking about ourselves, like a medication, when do they actually need that encounter with a therapist? And when we've reached a point where you don't need it, there's nothing I'm doing that is uniquely therapy, then we need to stop. But I think the hard part in that, Karen is some of our skill and touched on one, oh, I had just a piece of equipment in the family looks amazed because that is a skill. You, you know how to do that because of your training. I think sometimes the decision to discharge, we jumped the gun too fast, whether it's a maintenance approach to care or restorative by this. Oh yeah. Speaker 2 (25:53): They got it. They understand it. I don't really, you know, they're just doing the same thing, but are you still contributing something? Are you still making any sort of adjustments? Are you convinced? Because on the restorative side, I've never understood these, you know, lofty strength and improvement goals for a two week care plan that suddenly, you know, the, the they've gained a whole muscle grade in two weeks. I don't know what literature I missed, but this, this, this will be great because I'm going to go join a gym for two weeks when it's safe for me to do so. And then I will be fixed in two weeks. It's all done. So I think it, again, challenges us to think about, have we done everything that we can, are we confident as do? You've said more than once. I mean, we've taken care of mitigating concerns. Speaker 2 (26:37): I mean, if they may have a completely unexpected stroke next week, I'm not expected to be telepathic, but I have looked at your condition, given you the tools and resources. And in fact, whether there is nothing left for me to adjust to do, I am going to discharge. So there is active discharge, planning and maintenance care. We are, we are not saying because of this decline risk, then I'm here forever. And we also have to be careful because a lot of beneficiary advocacy groups have done a great job, educating our patients about this, who will then come at us with the resource. You can't discharge grandma because I've got this GMO thing. And it says, you have to, that's where I think some therapists have gotten caught and been like, oh, okay. That looks like an official document. I'm going to keep having you come to the clinic. I'm going to keep seeing you in the home. And it's like, wait a minute. That's why you have to know what the rules really are because yes, beneficiaries should be educated, but they don't necessarily understand the coverage criteria very well, just because they want this to continue. Doesn't mean it's automatic because of that, Jim. Okay. Speaker 1 (27:43): Yeah. And I think that that is where your judgment as a physical therapist and as the authority figure in that situation, you really have to come down from on that and, and be able to explain exactly why you're making that decision instead of just being like, oh, okay. I guess I'll just keep seeing the men, even though it's at this point, not medically necessary. So what, what advice do you have for the physical therapist who might be in that situation? How do they then speak to the caregiver, the patient, et cetera. So that's, that's happened to me cause I've been providing maintenance therapy. When I had my Medicare certified agency in central Florida, way back 2008, 2009, been doing it a long time because we get tired of people. We get them better and then they'd go off and then they decline and then they come back on. Speaker 1 (28:41): I'm like, we're missing something. We have to be able to monitor these people. I watched nurses do it all the time with the monthly catheter changes, right? Because most people are not good at self cathing and preventing infection and doing it accurately. So they'd end up in the hospital, you know, with some sort of puncture or something or an infection. So, you know, monthly catheter changes can happen for years and years with nurses. So what were we missing here? Here is the bottom line for clinicians. I, when I have taught and trained everything and my skills are no longer necessary. You ask yourself, is there somebody that could oversee that could carry this out with you? Because it really just requires sometimes the assistance of another person or a cheerleader or somebody to motivate you or supervise you. What we have a lot of patients that might have cognitive and limitations. Speaker 1 (29:31): And even if that person isn't available, just imagine, just ask yourself the question. If that person holographically appeared in the room, right, and said, teach me train. And they were capable. Would you give it to them? And if the answer is yes, then you should no longer be going anymore. So what I tell patients is I will say to them, I understand that you want me to come, but as a licensed physical therapist, I have a fiduciary responsibility to the payer and the payer has requirements. And one of them is medical necessity. And at this point you need to do this, but you don't need me as a physical therapist to do this. So I can teach and train you, your spouse, your family member, a paid caregiver, or you can pay me to come, right. But I cannot bill your insurance for this because I would be in essence, fraudulently saying, it's still required. Speaker 1 (30:27): My skills, knowledge and ability when I'm telling you it doesn't, it just requires another pair of hands or somebody that could be shown a lay person, how to do this. And so they're like, oh, well you calm. And then I'll tell them, this is what it costs to privately to pay for a physical therapist. And some people take me up on it. And some people say, oh no, I'll get my grandson to come over. Can you show him how to do it? And I'm like, that's great. So, so I think we have to, like Cindy was saying, we have to understand the regs. We have to understand this. Doesn't go on forever. We have to understand that when we are going to sign our name with our credentials, so hard earned right through through education and practice that we are basically signing an affidavit. If you will. Speaker 1 (31:13): That says, I attest that this meets the requirement of this third-party payer. If Benny therapists stopped, many clinicians heck stopped and thought about that. They might not provide some of the services that they're told they have to provide or do the things they have to do, but it's really comes down to our license. So when I sign that and say, this is medically necessary, I I'm going to make sure that I show that my skills and my contribution to that visit is a billable visit. If I no longer have needed for that, then I can teach and train someone else, or I can discharge them from the third-party payer and they can pay me privately. They could, it can be a cash based service. And that has happened. Speaker 3 (31:56): Yeah. Yeah. That Speaker 1 (31:57): Makes so much sense, guys. This was so good. I just know that therapists are going to have a much better idea of what stabilization care is versus maintenance care. We won't use that term anymore. Maybe we can, we can change that preservation of function, care stabilization of function, carrot just, it sounds it's. I think it sounds better for the therapist and quite honestly, like more humane, more human for the person that we're caring for. Instead of just maintaining someone, you know, we're preserving their function, we're their ability to do the things that they want to do. Just sounds so much more, I don't know, human than maintenance care. It sounds so cold and sterile. I don't know. Maybe it's just me. No, I think, you know, for me, when you say that, it makes me think that we are helping patients be accountable for their chronic disease management. Speaker 1 (33:01): Right. We are teaching them what we know and how important it is for people with aerobic impairments that they have to maintain that lung capacity you know, within the confines or the constraints of that disease process so that they can continue to do their self care, which is metabolically demanding. Right. So, so it, it really, it really shifts responsibility. I think maintenance is a very passive sort of thing that, you know, we're, we're maintaining range. You know, I, I think you know, people that were doing stuff to versus where we're in we're we're arming people with the ability to manage and be accountable for their chronic disease and to, and to function optimally within the constraints of those, that disease or those diseases through a stabilization or preservation of function. Yeah. Speaker 2 (33:55): And I think it's important to, to just kind of circle back a minute that we don't want the visual now to always be maintenance patients or stabilization patients are very debilitated, have to have a caregiver, very ill individuals. These, we can teach these types of programs to the patients themselves, for them to self manage. I think sometimes, you know, okay, I'll give it up. It's not Parkinson's ALS and Ms. I got that point, but these must be like really sick, bad off people. They might be, but they might not be, they might be the heart failure patient that's functioning pretty well right now, but has a history of pushing themselves too hard. So the now kicks in the fluid overload. It ends up back in the hospital because they're overdoing. How do you better task plan? How do you help someone understand when their disease process gives them good days and bad days? Speaker 2 (34:45): What, what do we want them to do on a good day? What do we want them to do on a bad day? Because we know many of our folks that are receiving therapy. Cause they basically think that we're gym instructors, we're gonna, you know, show up for the treatment, wearing spandex and tell them to drop and give us 20 anyway. So we're trying to get past that, but on a bad day, too many of our patients, regardless of diagnosis, sit and wait until they feel better, maybe, you know, with a recent orthopedic surgery, a little bit arrest, okay. We encourage some rest. That's not a problem. And some of these chronic diseases, you're one day turns to two days, turns to a week, you haven't done much of anything and now you've compounded the problem. So I think you're right. It does feel like we're utilizing our skills in a more person focused way meeting them where they are. Speaker 2 (35:34): But I think, you know, very often just briefly we'll get the, well, what are the treatment interventions for maintenance you didn't in this whole conversation, give us any treatment strategies because it's not about the treatment. It's not about the assessment. We do what we do. We have the tools in the toolbox, but what, what are we trying to get to? What is the end vision for this individual? And then I'm going to utilize what I know how to do best in that context. I just think for a lot of us, we felt that door was never open. That you were not supposed to do that. That if you could not show significant improvement that you had to discharge and Dee and I have seen therapists, when you see the wheels turning, I've said a couple of times we need to develop like a stages of grief equivalent for the discussion of maintenance, because we'll have people get mad. Speaker 2 (36:21): Like I can't believe nobody told me this. And then you'll see guilt, you know, oh my gosh, I've had patients and I discharged them. I thought I was doing the right thing. I'm a horrible therapist. What am I going to do now? And it's like, okay, let's just start looking at the information and change what we do going forward and not go backward and be all upset and think we're horrible or mad about who lied to me. It didn't tell me about this before, but we do need to start making a difference. Cause D and I heard far too often, you know what? That was interesting ladies, but we don't do that here in this clinic. We're not going to do maintenance therapy. And it's like, wow, you just get to unilaterally, decide you're out. If you want to be out, that's fine. But then you want to direct them to a clinic that does do it because if they need it and they qualify for it, then find them a provider who will, but this kind of, oh, I never heard of it. I'm not participating thing is, is very frustrating in the current environment. Speaker 1 (37:14): It's, it's not correct. I mean, we have to understand beneficiaries have paid into this benefit. They are entitled to it. And if their presentation is such, that stabilization of function is the appropriate course of care. They are entitled to it. It is part of their benefit package. You don't have a right to say, oh, we'll take you on care. But you know, you're not going to get that. That that's that's you, you can't do that. I mean, you either provide the care that is within the insurance. Right? I mean, think about it. If you went to Jiffy lube for your 32 point checkup and they charged you 90, 95 and, and you only got 10 of them because that, oh, we don't do those other 22. Would you be paying for, I wouldn't as like, listen, I'm entitled to this. This is what I'm appropriate for. Speaker 1 (38:07): It's part of my benefit. Maybe you don't do it, but you can't determine that I don't get it if it's part of my benefit package. So it really comes back to the beneficiary. If they're entitled to it, we, as professionals are not ones to say, we can recommend and say, I don't think that's the appropriate course of care. But to literally say, we're, you're not getting that component of your benefit. I don't think that would go over very well. Do you care? Do you not? No, not at all. Not at all. Especially with, you know, like you said, people have been paying into this, their whole working lives. If it is part of the benefit you should offer it. For sure. And if you're a physical therapist who says, I don't know how to do that, well, you better get educated and learn how to do it. Speaker 1 (38:56): Exactly. The things that I am not the most gifted at as a therapist. So I'm not just going to start dabbling in dry needling. Okay. That's that's not my area. Oh yeah. Just give me some, you know, go into the pin cushion and let me start working on you. It's a skill set and it's something that you have to understand the rules and regs. You have to understand what the payer source requirement is, but we as clinicians don't need any other evaluation skills. We don't need any other tests and measures. We don't need special interventions. What we need to understand is that there are times that we are indispensable to help people improve and recover function back to a prior level or maybe beyond. And then there's times we are, we are needed. We are indispensable to preserve and stabilize their existing function so that their quality of life can continue on in the fashion that it currently is perfect. I was going to say, do you want to button it up? But I feel like that did it, but now listen, before we wrap things up, let's talk about the book, the guide to the two delivery of home-based maintenance therapy. So talk about the book, where can people find it? And what will they get out of the book? If people go and purchase this book, what are they getting? Speaker 1 (40:16): Well, they're going to get DNA, Cindy. That's what I'm going to start with. They're going to get us, they're going to get us. They're going to get an updated version. I think it's the only book. And actually it's our second edition and really focused on community-based care part a and part B for Medicare, right? Whether it's part B in a clinic or part B in the patient's home. And we really focus on the rules and the regs. And we and, and literally walk you through common case scenarios. We try to myth bust, and we try to give you a how to like how to start to think about this, because I think theoretically or conceptually when, Cindy and I talk about this and we've been talking about this for eight or nine years now. And teaching on this, people don't disagree with this. They fundamentally understand, they just don't know how to operationalize it. They don't know how to, if they see it. Okay. Well, I understand what you're saying. I understand. I, I agree with you. That would be, I could see where that would happen, but then how do I do these things we've talked about? So Cindy, what does this second edition really afford them? This time around that, you know, it was kind of like a value. Speaker 2 (41:30): Well, I think part of it came from, we were folks, as you just said, understand the concept, but then struggling to say, I got chew on this for awhile. This is really going to change my core, that I am not just defining myself by improvement. I got to work through some stuff and figure out how to do that. And so our first edition started out. We have a consistent scenario throughout to really talk about assessment and goal writing and detail and all of those pieces. But then as we looked at the second edition, we said that that's a good place to go. You got a nice, consistent scenario. It builds throughout the entire book. So you have opportunity to do that. But then this time around you know, I think you got the sense. I tend to be more in the regulatory nitpicky, wheelhouse, and D tends to go toward the operationalization side. Speaker 2 (42:18): And so she brought up, why don't we put a workbook with it? Why don't we add to that idea of a consistent scenario and say, what are some additional knowledge application activities? How do you comment that same thing about assessment or goal writing a little bit differently than one scenario to really get the juices flowing about how to do this. Now, the challenge is, is there a right answer? Like, do I just go to the answer key? And there was only one way that could have been done while listening to this conversation. There was quite a few, it depends. How often would I go? What would I focus on? So the answers give you some context, some suggestions, some validation, but it was not meant to be, there's only one way to do this. And in a scenario, you know, five sentences long, you better figure out exactly what you would do all the way through this only one path, but it's really to help kind of put those guard rails on and say, well, did you think about this? Speaker 2 (43:14): Or what about that element to, to be able to say, okay, I am understanding this. So I could use that as an individual to go through that process, or I could use it in an organization and do it as a group activity, but to really help people continue to process what sounds like. Yeah, I got it. But now I have a patient in front of me and, and I'm still stuck. Old habits die hard. I still struggle with the goal. I still think I can fix this. I, I still feel that voice in my head. That's telling me if they're not getting better, you're not supposed to be here. So people need that opportunity. So we wanted to provide that in a tangible way that, you know, doesn't really lend itself to an educational event unless the thing was days and days long, and people camped out with us, which nobody wants to do. But gives them that opportunity to come to step away, think about and come back to it at their own pace. Speaker 1 (44:07): Awesome. And just so everyone, all the listeners out there the book, the guide to delivery of home-based maintenance therapy, it's on the Kornetti and craft website, but we will have a link that takes you directly to the book and, and listeners. If you use the coupon code KK 2021, you'll save percent on your purchase. We will have all of that at the show notes at podcasts on healthy, wealthy, smart.com under this episodes, you don't have to remember it. You don't have to send everybody DMS and things like that. Just go to podcast at healthy, wealthy, smart.com click on this episode, it'll be under the resource section in the show notes. So we will make it very, very easy. That's all you got to do is one click, and it'll take you right there. So now before we wrap things up, the question I ask everyone on the podcast is knowing where you are now in your life and in your career. What advice would you give to your younger self? Speaker 2 (45:19): Come on Cindy? I would say, well, I, I would say to my younger self to be a bit more open-minded with how physical therapy really works in reality. I think career-wise would come out. I came out very, this is what I'm going to do. And, and briefly my goal is I'm going to work in a traumatic brain injury unit. I loved working with that population as a student, I'm going to be a famous therapist in a big old rehab facility. And now I'm going on nearly 30 years in home health and have never actually worked in a, in a fancy schmancy rehab clinic. I started this kind of on the side, fell in love with it and never went back. I tell, I tell students all the time, don't assume that what your path is at the moment is the path and can't vary and can't change whether you go into teaching, whether you go into other avenues there's a lot more possibilities and it took me a little while to process that piece to say there, there are many other ways you can utilize your skill to benefit those around you. Speaker 1 (46:28): Excellent. D I would say to my younger self I may not come across that way now 30 going into my 36 years a PT, but I would say don't be afraid to ask questions and don't think you have to know it. All right. So I, I think that I kind of stayed in my box a little bit more and got really, really good at what I did. Some of that time, Cindy was in a traumatic brain injury a locked unit and I got very good at what I did, but I had a lot of questions about, but what if, but why not? Right. And I think sometimes I kind of just that maybe I shouldn't ask that question. I was a little bit too con you know, self-conscious about it. And so I, I think the idea is ask those questions, be fearless. Speaker 1 (47:18): And, and instead of asking, why would I do that? You know, look around. Why not? You know, I'm a big, why not, if you've got a great idea, you have something that is like a passion, and you've got that intersection of your passion and your skillset go for it. Right. A good friend of Cindy and mine Dr. Tanya Miller started event camp for kids. Like when she was like a new grad PT. It's like in it's what, 27th year. And she's written grants for it. And, you know, they take these kids on ventilators out in kayak. I mean, you can do it, you can do it. So be fearless and don't be afraid to ask questions. Don't don't, don't think, oh, well, I don't know as much as Karen Litzy or I don't know as much as Cindy craft, you know, start to explore that the possibilities are endless. That's what I would have told myself when I was younger, fabulous advice from both of you. And I couldn't agree more. Thank you so much for coming on for sharing all of this great information and your book, and it's just sounds great. So thank you so much, Dee, and thank you so much, Cindy, for coming in. Thanks for having us, Karen. It's always nice talking to you. Pleasure. We had a great time. Excellent. All right. And everyone who's listening. Have a great couple of days and stay healthy, wealthy and smart.  

Warfarin is an anticoagulant that is also known by the brand name Coumadin. It is used in the treatment of myocardial infarction and thromboembolic complications. There is a wide variety of tablet strengths from 1 mg to as high as 10 mg. When dosing warfarin it is very patient-specific. The therapeutic goal is based on various factors and treatment nomograms may vary from institution to institution. Prior to initiation it is wise to establish the patient's genetic variant for CYP2C9 since this will play a large role in predicting their drug sensitivity. When attempting to reach a therapeutic target the healthcare professional uses INR readings to determine the level of anticoagulation. Generally a range between 2-3 is common with 2.5-3.5 when a high level of intensity is required. Other factors that may help determine patient response are age, race, and diet. The mechanism of action for warfarin lies in the antagonism of Vitamin K which leads toward the inhibition of coagulation factors 2, 7, 9, and 10. The rate-limiting factor can be seen as factor 2 due to it's long half-life of 60-72 hours. Although INR elevation can be seen in 24-48 hours, therapeutic benefits are not achieved until around 5-7 days after initiation. There is a black box warning for bleeding risk so a patient's INR should be monitored regularly. Go to DrugCardsDaily.com for episode show notes which consist of the drug summary, quiz, and link to the drug card for FREE! Please SUBSCRIBE, FOLLOW, and RATE on Spotify, Apple Podcasts, or wherever your favorite place to listen to podcasts are. The main goal is to go over the Top 200 Drugs with the occasional drug of interest. Also, if you'd like to say hello, suggest a drug, or leave some feedback I'd really appreciate hearing from you! Leave a voice message at anchor.fm/drugcardsdaily or find me on twitter @drugcardsdaily --- Send in a voice message: https://anchor.fm/drugcardsdaily/message

In questo podcast si parla dei tempi da rispettare tra la sospensione dei principali farmaci Anticoagulanti, Antiaggreganti e Fibrinolitici e le tecniche di Anestesia Neuroassiale (Anestesia Subaracnoidea o spinale, peridurale, combinata). I tempi di sospensione sono tratti dagli Special Article del 2018: Interventional Spine and Pain Procedures in Patients onAntiplatelet and Anticoagulant Medications (Second Edition)Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and theWorld Institute of Pain (Reg Anesth Pain Med 2018;43: 225–262)Regional Anesthesia in the Patient ReceivingAntithrombotic or Thrombolytic TherapyAmerican Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) (Reg Anesth Pain Med 2018;43: 263–309)I farmaci trattati sono: coumadin, acenocumarolo, eparina non frazionata, eparine a basso peso molecolare, fondaparinux, rivaroxaban, apixaban, edoxaban, dabigatran, eptifibatide e tirofiban, abciximab, clopidogrel, prasugrel, ticagrelor, , cangrelor, ticlopidina, desirudina e bivalirudina, aspirina e i fibrinolitici alteplase e tenecteplase.Questo video costituisce solo uno strumento di studio e di ripasso di un argomento molto mnemonico. Non esaurisce l'argomento. NON SOSTITUISCE IL PARERE DI UN MEDICO. È dedicato a tutti gli Specializzandi di Anestesia, Rianimazione, Terapia Intensiva e del Dolore.

Strokes are the #1 cause of significant long-term disability, the #5 (or #3) cause of death. 55,000 more women have strokes each year. It's decreasing due to better management of blood pressure - the biggest risk factor.But the new challenge in stroke prevention is atrial fibrillation. Paroxysmal (occasional, undiagnosed) atrial fib is becoming recognized as one of the new leading causes of stroke. So, it is becoming far more important to look for atrial fib.Now, it has become clear that there are better ways to prevent a stroke if medication is needed. Aspirin does help. But Plavix is better. Warfarin or Coumadin is even better. But Elliquis, Xarelto, dabigatran--the NOACs (new oral antiCoagulants)--are even far more effective at preventing a stroke.For more information, contact us at 859-721-1414 or myhealth@prevmedheartrisk.com. Also, check out the following resources: PrevMed's article on stroke & atrial fibPrevMed's websitePrevMed's YouTube channelPrevMed's Facebook page

A look at the top medical headlines for the week of September 13, 2020 including: Having COVID-19 may not provide protection against getting it again, at least not for very long. Then, an experimental drug combination is showing some promise against A-L-S. Then, about 10 percent of Americans have diabetes, according to the American Diabetes Association, and many of them are undiagnosed. Then, if you’re working at home because of the pandemic,  experts say there are really only two ways to handle it. And finally… the increase in states where recreational marijuana is legal is raising the alarm among physicians who say pot can cause interactions with other drugs.

Fun conversation on episode 217 of the Outdoor Biz Podcast with long time JanSport president and master of fun every day Paul Delorey Facebook Twitter Instagram   The Outdoor Biz Podcast   Please give us a rating and review HERE   Show Notes   Let's start off with how you got introduced to the outdoors. Growing up in a big family, my mom and dad had eight kids and it was an unusually small house. So being outside was a big deal and family vacations were camping. If you wanted your own room, you had to get a small tent. So as a kid my dad got me a pup tent. When we'd go, I'd find a spot off by myself and pitch my tent and have my own space.   What kind of activities did you do?   You know, kid camp stuff, fishing, and making pancakes on the Coleman stove. That kind of thing, just exploring state parks. Growing up in Wisconsin, there were some beautiful state parks that there to this day.   How did you connect with Skip Yowell and JanSport?   In 1977, I had gone back to school to finish a master's degree. When I went back one of the things open at the time was the bookstore. They were looking for a bookstore manager. So I took the job and one of the benefits was free tuition. So in 1977, I'm going to a college bookstore trade show in New York City. And I was really familiar with the JanSport brand from my local outdoor store. I saw they were on the list of vendors. So one of the first places I went to was the JanSport booth. I told them who I was and they said, well, we'll have somebody with you in a minute. And this guy comes out and he's wearing a fringed buckskin jacket with a Bolo tie and pressed white shirt, jeans, and cowboy boots. He's got long hair and a foo man choo mustache. He kind of stood out you know? And it was Skip Yowell. I was immediately impressed and, I looked at Skip and I really had a feeling this is one of the reasons this brand is so cool. So we started talking and they were basically there just to take a look at the market and see if they wanted to start selling in it yet. At the time there were other brands selling backpacks in the college bookstore market. I told Skip, I said, man, I'll give you an order right now. And he said, well, we're just not sure we're gonna sell in this market yet. So, you know, a few months went by and I called him up and I said, Hey Skip, I don't know if you remember me. I met you in New York. He said, yeah, yeah. I said, you know, I'm still interested. And he said, well, we just don't have the capacity right now. He said, so we're going to have to pass. So one thing led to another, I stayed at the university for about two or three years. And in 1979, I met this guy who was running a company up in Wisconsin that sold tee shirts and sweatshirts to the colleges. We had kind of struck up a relationship and he asked me if I'd come up and go to work for him to start a division to sell colleges. You know, I was ready for a change. So I went to work for this company called Downers. Kim Vander Heiden and Dan Spalding owned it. In any case, I got up there and got started. I told the guys that owned the business, I said, you know, we really should be selling day packs in addition to T-shirts and sweatshirts. So we ended up going over to China or someplace in the orient and trying to source packs and basically looked at JanSport day pack designs and tried to copy them. In 1982 JanSport was owned by Sitka corporation, which owned K2 skis and a bunch of other outdoor businesses. And they had gone through a real bad ski season. They were short on cash. So their bankers told them they need to raise some money, so they put JanSport up for sale. And at the time the guys that own Downers were starting to realize Downers was a very difficult trade name to try to peddle. So JanSport had come up for sale, they decided to buy it. And one of the first assignments I had with that, they sent me out on a diligence team to Seattle to study the business and see what was going on. The first office I walked into was Skips. And I looked at him, I said, Hey man. I said, do you remember me? And he scratches head sitting here. And he says you look familiar. He says, but I'm really not sure. I said I tried to buy backpacks from you in 1977 in New York City, you wouldn't sell me. And I said, buddy, it looks like I'm going to get all I want now Skip and I hit it off and just became forever friends. And you know, all through the years we had a lot of adventures all over the world and a lot of fun too. This was 1982. So at the end of 1986, the guys that bought JanSport had gone through two corporate takeovers. In 1984, JanSport was bought by a corporation called Bluebell. Then in 1986, Bluebell was bought by VF Corporation. So the guys that originally owned the company stayed around a little while but eventually decided they didn't want to be there anymore and they made me president.   How many years did you end up staying with JanSport?   A little over 22 years and then they had me consult for them for a couple of years as you know. So the thing for me, especially at that time, Rick was the guy that had preceded me was really just a business genius. He had a great mind for numbers and math was never my strong suit. So, you know, I'm sitting in his office the first day after he left and I thought, how am I going to do this? And you know, we all use what we have in the toolbox. My toolbox included, I just want to have fun. So you know, I just figured if I could make the environment enjoyable and everybody has fun, you know, good things would happen. And they did, they really did.   JanSport went through some really significant growth. Those were some pretty heady times. Was the biggest challenge trying to make enough packs?   Well, yeah, I mean, absolutely. You know, we expanded our sewing capacity domestically for many years and built several plants in Washington. But then as you know, the competitors started to go offshore to Mexico or China. We had to follow suit as well, just to keep up cost-wise. But it was an exciting time trying to keep up with warehouse facilities and making sure we had enough space. The JanSport business went from the like under 20 million to, by the time I left was over 300 million in total. I was working at A16 at the time with Tim McGuire and was a huge JanSport fan. All the packs I carried were JanSport packs. When you did the Everest program I had all the T-shirts and stuff, It was great. When you mentioned A16, I met Timmy in 1984 on the JanSport dealer climb. It was the first time I tried anything like that. So, you know, you're a little unsure of yourself. You've trained and you think you're ready to go. So Skip told me, come on, let's go. We got me all the gear that I would need to get up and get down. And so the first day you go from Paradise up to Camp Muir and it's a long slog. You know you get, get up there and get settled. So I get up to Camp Muir and I look around and there are two young guys from A16, and they've both carried a full case of Rainier to Camp Muir. I'm sitting there, I'm saying, man, it'd be great to have a beer. So Skip walks by and a kid says, you know, Mr. Yowell, would you like a beer and Skips says sure. So he takes it, grabs a Caribiner, and snaps off the top and drinks it. And I'm standing there and I'd say, Hey, you know, you guys, uh, would you mind sharing another beer? The kid says, well, no, we, uh, we really don't have enough for ourselves. No, we're not gonna. We're not gonna do that. So many years later, uh, we had recruited Tim McGuire to come work at JanSport. And so I'm sitting in my office and, uh, he doesn't remember this, well, he does now. I'm looking at him and I said, Hey man, I said, I know you. In 1984 up at Camp Muir, you were from A16 and you wouldn't give me a beer. Well, I had a picture of that climb up on my wall and so I pointed to him, I said, there you are. And I sit there. There I am in the back row and I'm really looking like I could have used that beer.   Your mission now is to convert the outdoor industry to totally sustainable fabrics and coatings through your Polycore venture, how'd that come about?   Another old JanSport connection from the time I was there. I got a call a couple of years ago from a guy named Arthur Chen who had done a lot of work for us back in the day. And in addition to doing sourcing and manufacturing, Arthur was also a material scientist. His expertise is he studied the solidification process of polymers for over 40 years. So he had patented a process to coat fabrics that are water-based as opposed to solvents. And the first thing he talked about was the fact that it would make the fabrics up to 500% more abrasion-resistant. So, immediately you think about it in your world and JanSport. You know, we sold millions of bags that little kids would drag on sidewalks and rub holes in them. You think about warranty service, but the bigger issue with it was it was a water-based PU as opposed to solvent-based. And I like to explain it in the sense that, when you used to paint and you opened a can of paint and it was solvent-based, those fumes filled the house and you know, would make you sick and that type of thing. But it changed and it all became latex or water-based. So you didn't have the fumes escaping into the environment. So you guys go to the trade shows, you have a booth there. Okay. I didn't know about this until, uh, I was looking up your, your bio. That's great. Yeah, we were at the last three outdoor retailers and it was a good start and things were really rolling along. Then the virus hit and it changed a lot of people's plans.   So have any of the brands adopted your products?   They're starting to. We've come up with a couple of other products through those conversations. You know you sit down with people and they say, well could you do this? And one of the things was some people want to just to reinforce certain areas. So we came up with this process of turning the PU into a film that can be heat sealed onto fabrics, into different stress spots. We call that spot welding if you saw it on the website.   I love your fun everyday philosophy, where did that come from?   When I was a kid, my mother used to ask me if I wanted to grow up and be a big man and go to work every day like my daddy. And, uh, I'd always tell her, “Mom, I don't want to, I want to just be a little boy and just play”. But the thing there, especially all of those years at JanSport was, I mean it was a real company and it made a lot of business, made a lot of profit. But one of the things for us as a group, we had a lot of fun. If you think back to some of those parties, the ‘Shake n Bake'. I think back to some of those times, Rick, and I don't know if you remember the one we had in Salt Lake at the Delta Center? It was a thing where they always say, it never rains in Salt Lake at that time, in the summer. And so we got up there and we'd had a lineup of like three or four bands and the opening act was John McCune, The Nitty Gritty Dirt Band. So they had played their sets and then The Fabulous Thunderbirds were due to come up on stage and the skies just opened up. And if you recall next to the Delta center was a parking garage and people started rolling barrels of beer into the parking garage. I went and asked Jimmy Vaughn, I said, Hey, you know, we found some power over there, would you consider coming over and playing? And he says, no. He says, we're not doing that, but John McCune was standing there and he says, hell, he says, we'll play. So he came over with his band and played for probably an hour, hour and a half. I don't know how many people we had in that parking garage. We used to have them at a place called the Little Waldorf Saloon there in Reno. And the owner's name was Louis Chatel. And one of the things that I always liked to do with those deals was become a bartender and just stand behind the bar and serve people. Get to know people. And so a lot of the times it was somebody you didn't know and they'd be standing there at the bar and they'd order something and tell you to hurry up or whatever. And somebody would say, Hey, you know who that is? No, it's the bartender. They'd say, no, it's the President of JanSport. And embarrass them a little bit.   Tim McGuire wanted me to ask you about your high school football career. Did you play high school football?   I did. As a matter of fact. I went to a pretty small high school, I think it was about 175 kids in total. During my freshman year, I was five foot one and 86 pounds. You know, it was a tradition in my family that you play. I was definitely the runt of the litter. My next oldest brother was six feet. My coach would say, you know, you're not big but you're slow. So that first year the smallest cleats I could find were seven and a half. And I think I wore about five and a half or six. So I stuffed paper in the toes and you lace them up real tight. And I can tell you there were several times that year that I got knocked right out of my shoes, hold the tackling dummy. At the end of my freshman year, I'm sitting on the bench, which was my normal spot at the end. And the coach, you know, turns to me. We're winning like 48 to nothing. Uh, the coach, he says Delorey, get in there and he says, I want you to be mean. I want you to growl at somebody. So it ended up I got in there, I start growling and we lost, 48 to 70. The next play went right over the top of me and all I remember was the bottom of cleats. My older brother told me, he said, you know, if you're going to do this, you're going to have to get bigger and stronger. So that summer I ate, ran, lifted weights. And I grew to the height I am now, which is short at five, six, but I put on almost 50 pounds of weight, now 135 going back my sophomore year, I was still slow, but I thought I was a world-beater and my best friend was about six, five and he was almost 300 pounds and he was the right tackle. So I was the right guard. Anything I couldn't handle, we used to call him gentle Ben, he would just lean on my guy, knock him down, and tell him to stay down.   You're also involved with the Skip Yowell Future Leadership Academy. What is your role there?   The big thing with that is, you know, just making sure that Skip's memory stays alive. And so at the start of every class the past couple of years at the leadership Academy, they asked me to come in and give a talk to people about Skip. And you know, he was my friend, but he was also probably one of the most unique people I think I've ever known in my life. I mean, Skip had a mind like a rusted trap. Once he knew your name, he never forgot it. Then if he, if he did for a second, he had a lyric or used to say Hey Slugger or something like that, then all of a sudden memory would kick in. He'd get up and just give presentations to people and I sat there and I think, how can he just be so calm and cool about this as he's doing it? And a wide variety of groups, right? I mean it's like how does he know what to say to these people? You know, he just did it off the cuff. I watched him do it in groups of two or three as we'd go around doing clinics and in shops. I saw him do it in settings where he'd be in front of thousands of people, you know, so pretty amazing guy. We stayed friends right up until the end. The year or so before he died, we were out in St Peter with him and had a party at the saloon, invited everybody in the town, all nine of them. And I think seven of the nine showed up. The other two were mad at somebody else in the town and so they didn't come. But you know, just had a, a good time just hanging out together. But we did that with him and Winnie, you know, all over the world.   I have another wildcard question that came in from somebody else who wanted to know if you really got rousted by security in a five-star hotel in Paris because they thought you were a homeless guy sleeping in the lobby.   Who asked that? Do you sense that person's initials would be Jim Thomsen? Jim and I also had a number of great adventures all over the world. And, you know, some of them included late-night pub crawling around certain cities and, you would not get much sleep. So I can remember falling asleep in a chair. You know, they came and told me that, uh, no sir, you cannot do this. You must go to your room. And I was just waiting for Jim to come down to get ready to leave for a flight, I think. So they, they rousted me. But the deprivation of sleep was well-deserved by hanging with Jim Thomsen.   What outdoor activities do you participate in these days?   You know, we're there paddling on the Lake and down here. I like to think of the little area that we live in, As I tell people, it's like a geriatric JanSport. A lot of my neighbors remind me a lot of those people. And so we started playing a form of tennis that we call funiss. Funniss is full contact tennis. And the object of the game is to hit, the opponent on the opposite side of the net, as hard as you can, physically with the ball, rocket shots each other. We play five days a week, and usually, at the end of the season, which would be around now, we have an annual banquet where we hand out awards. There are usually six or eight guys that play through the course of the winter, but there are usually 20 or 30 people that show up to the banquet to see the awards and, watch us do an exhibition match after we drink beer and eat pizza. Some of the awards we always have most injured, you know, there's one of the guys for the past few years was on Coumadin, so if he got hit, he would bleed. So, you have most home runs for who hits them out of the court, you know, you have a most improved player, those kinds of things.   Do you have any suggestions or advice for folks wanting to get in the outdoor biz or the adventure biz?   Well, the thing I would tell you, and you know this Rick, from being in the industry, it's, probably one of the greatest places that you can go to work because the fabric of the people involved in the outdoor industry is everybody's cool. And you know, usually, everybody will help everybody else out. And, those are the things that, for me when I started it just impressed me, you know, and it's an impression that has never gone away. I mean, there's that core of those people that I worked with that I'm still friends with. I've been retired now 19 years basically, you know, other than these consulting jobs, and there's a whole group of them that, you know, will be friends for life. It'll be five years now that Skip passed, and they had me come out and do a eulogy type tribute, you know, for him. And I had not been back to the show in those 14 years. But you know, you start walking around and it's like, Oh my God, Paul and I say, yeah, I'm what's left of him. You know, you, you just walk around and all of a sudden like no time has passed, right. Because you're seeing all these people that you hung out with and those events and had a lot of fun. And it's the same thing, you know, doing this Polycore thing. There was a little pause there for a couple of years and then, you know, you come back, you're walking the show or you're in a booth, people say, Oh my God, it's Paul Delorey.   What's your favorite outdoor gear purchase under a hundred dollars?   I have two, both of them surprisingly enough given my history, have to do with drinking. One is my LifeStraw. You know, you think about when you're outdoors and you need something to drink, more than anything, you need good water. So that is a great tool. That, and then the other is just a good Yeti mug. Which, you know, in the morning you can have a cup of coffee or tea and then at night you can have a martini in it and the ice doesn't melt for days.   If you could have a huge banner at the entrance to or what would it say?   Well, I would tell you, Rick, it would be a picture of the planet and it would say over the top, “We Gotta Fix This”. And for so many years a lot of people ignore the signs. I've told a lot of people that I think there's truly a connection between, you know, what's going on with things like this virus and a change in the climate. I mean, you watch species are starting to migrate differently and you know, germs are morphing. It's like, guys, we gotta do something about this. And we all have a part a, so, you know, the sooner the better and the more the better. So yeah, we got, we gotta make some changes. I think one of the things, especially these last couple of years going back to OR, that I find encouraging, I see all these new young companies, they get it. And you know, are consumer-focused and are gonna deliver on that promise. Making a product that's more sustainable, doing it right. Start to finish. Those are the companies that, if we make it as a world are going to be the ones that are gonna lead the way.   As we wrap up here, is there anything else you'd like to say to our listeners?   Get outside and enjoy it. And support companies that reflect your, your personality, and your causes. And right now, support your local businesses. Cause there's a lot of 'em that are struggling. We have a couple of them here, there's a favorite breakfast spot called Mrs. Mac's and a couple of the guys in the neighborhood and me, we have a little band. So we go down there every Wednesday morning and play for an hour in the parking lot for breakfast and get the waitresses and the people coming by for pickups singing and you know, just try to make sure they're still going after this is all over.   If people want to find you, what's the best way to reach out?   I've got a website which is fun-every-day-dot-org. funeveryday.org It's got all my information on it. And you can also reach me at Paul D at poly core dot net. pauld@polycore.net

All right. Welcome to the gut check project. I'm here with your host, Dr. Kenneth Brown. I'm Eric Rieger. This is gut check project, Episode Number 26. We're going to wind up 2019 with some awesome info. What's up, Ken?What's going on Eric? How are you doing, man? Episode 26. Unbelievable. I apologize if I'm a little too sexy today because I'm just coming off of a small cold. I think the hottest people are those that are sick.Well, I'm not sick. I'm post sick. Remember, the viral prodrome. The reason why we always like pass so many viruses is that you tend to pass the virus before you even know that you're sick by the time you're actually sick. You're probably okayYeah. At that point you can go back and say I heard you might be sick. I was too back then.Yeah, exactly. Good to see you?Well, today's episode is going to be pretty awesome. We're going to tackle number one, we've received tons of email in your clinic because you also sell the KBMD CBD at your clinic, you get these questions. These have been coming in Fast and Furious over the last little over 14 days. And it's questions about the safety of CBD oil and its application. So we're going to tackle that I do need to tell everyone. Thank you. We're on episode 26 because the first 25 shows were so well supported by all of you who've been keeping up with a gut check project. We grow every single day. Paul, the guy who's helping us put together the production now and helping us spread the word. We just hung up the phone with him. We've gotten more and more downloads each week. So thank thank you every single one of you for liking, sharing, emailing, telling your friends about it. We sincerely appreciate it.We learned so much about it like today we have a new a different guests we do Instead of gutsy our little mascot or green frog, but since we do film on a green screen, he gets blocked out did not know that didn't even realize that. So now we're going to go with a dung beetle, right here? Yeah, yeah, we did. So that's Dilbert, the dung beetle,Dilbert, the dung beetle. So one of my favorite things is whenever we're bringing any patients back and somebody sees you, and they're like, hey, you're Eric, I watch your show that just warms my heart. So if you happen to be a patient and show up and you watch the show, if you say that it just makes us both feel really, really well...needed wanted, appreciated.Yeah. At least outside of me putting you to sleep. Take five or six good deep breaths. Exactly. Today's episode is sponsored by Atrantil. Your bloating relief, it's what we do. So go to Atrantil.com or lovemytummy.com/KBMD. Today it's also sponsored by KBMD CBD oil. You can find your own KBMD CBD oil at kbmdhealth.com which of course, the initials KB, Kenneth Brown, it's endorsed by the guy who's sitting across the table from me. So Ken, why is...What does MD stand for? Well, I'm not really sure.I thought it was your buddy Mike Doyle, but I don't know.Yeah, it's probably. So tell us a little bit about KBMD CBD. Alright, so KBMD CBD oil. I got involved with the science of CBD because I saw the beneficial effect with my patients when we developed Atrantil I then learned that the science of Atrantil the polyphenols in it actually augment CBD. So I'm seeing this combination do incredible things for people. So this particular CBD is one that we have researched, I've seen it work clinically. And we know that it comes with a certificate of analysis. It is organically grown, it is naturally extracted with co2, so it meets all the criteria that you want in your CBD because this is important. The rest of this podcast is going to be all about the dangers of CBD.Definitely and It's really interesting since we do have so many people who have begun to purchase CBD find benefit. It's really kind of weird what's occurred over the last two weeks. And what I would say is a little bit of misinformation. But it's more or less probably just misunderstood information and or or misapplied information. But regardless, the benefits of CBD used correctly, have been undeniable with the people who've come back through the clinic with people that we've scoped, and how well that they are doing. And so, hopefully today, we're going to provide some context on why more or less the dangers that you may or may not have read about in the news recently are really a little concerned. But we'll, we'll see. We'll see how far along we get in at the last. The last thing. Our last sponsor is the KBMD health box. You can find KBMD health box by going to kbmdbox.com. Now last week we did a full unboxing which is something I think we're going to try to do at least once a month. But essentially, if you want almost $300 of physician vetted supplements that can help you benefit your life and get them for only $147 which you would spend, not you would spend more than $147 worth of time driving somewhere to pick them out for yourself and having someone handpick them for you. Go to KBMDbox.com. What was one of the things that we had a patient come through just earlier this week, who showed us his lab results that he took to his primary care physician? So we're starting to make a difference in the landscape of health here in the DFW Metroplex and different places. I've been getting emails and calls from people around the country that will actually hear the podcast and then they'll want to sign up for the box. And what we're seeing is that these vetted supplements actually are making a difference with both subjective how they feel and objective the labs. So the reason why I chose these things is they all have third party analysis. And they all have some scientific background that actually explains how they're going to help you. So much so that I'm thinking of ordering my household, another box. So although it is the KBMD Health box, I actually I love the fact that I can get these things that I'm going to purchase anyways, they come into my house, so my whole family's on it. Now we're running out of stuff. So I'm gonna end up having to double up on everything. So it's one of those things that I feel really good that we can look at different aspects. And when somebody says, Oh, I tried X, Y, and Z, I didn't notice anything. I'm like, oh, did you try one that had a third party analysis? No. And then they do and they're like, Oh my gosh, big difference. Same thing with CBD. I mean, a lot of CBD out there doesn't really have what's on the label. And we're going to get into that because we're going to talk about what the FDA thinks about it. We're going to talk about the different media and what they're doing, and hopefully get into all that but that's the whole point of that box is I want to deliver these vetted things to your house monthly so that you can continue to improve your health. Hundred percent. So without further adieu, be sure to like and share the gut check project. We certainly appreciate all of the support to date. We're going to hop right into it. So what we've received here recently is a lot of speculation and concern from people who have said, Hey, I'm interested in CBD. I know that you and Dr. Brown have heavily studied, been entrenched with CBD and its application over the last few years. I just learned that the FDA is associated or made public a study that says that it may be hepatic toxic or bad for my liver. It's, unfortunately, it's a weird jump off point. So I'm going to kick it to you. Because immediately I had lots of different thoughts and instead of getting emotional, what did we do? We went and tried to find the sources of where this information came from. We want to backtrack on how they got to that conclusion. And I think that we can put a lot of questions at ease and even help people learn how to be a little bit more critical with the data that they receive when they receive it. Because let's face it, lots of stuff that we see on the internet, or that we hear on the news or reading the paper, it's basically clickbait. It's basically things to keep you engaged, whether or not the actual substance is worth the headlines that are written so...So what you're referring to is recently the FDA put out a statement, a consensus statement in the news and it's making all kinds of traction in the news that they're saying that CBD is not as safe as people think not only that it can be harmful. Now this has bled onto TV and my patients have been asking me about this FDA statement. Then there's been other news articles like the one that Forbes published, read said that CBD causes liver failure. Failure. That was the title liver failure caused by CBD. I want to get into all that I wanted to take a really deep dive into the science of all of this as a gastroenterologist, I'm board certified gastroenterologist, which means not only am I a simple country, butt doctor from Texas, but we actually have to learn liver disease, hepatology, I'm not a hepatologist like some of my other friends where I send like really complex things, but we at least have to understand the liver, how it works and what it does. So a lot of these articles discuss this but they don't clarify so many little things. Because and they shouldn't it's a it's a journalist writing an article they want they want it to be shared. And anytime you mentioned CBD, anytime that that is thrown out there, you're going to get some clicks, you're going to get a whole lot more clicks. If you say you're going to die from taking CBD. It reminds me of the I remember Jerry Seinfeld was on Saturday Night Live one time and they were making fun of the nightly news where they always do the promo at like three o'clock. Like five household items that are guaranteed to kill you, tonight at six.You're like what? If it was so important, they probably wouldn't make you wait.No, I'm gonna die before you put this on the air. So what I'd like to do is talk about the briefly the science of the endocannabinoid system and CBD, then do a little bit deeper dive into the liver. So everyone's going to get a primer on the liver 101 here, because these studies don't make sense unless you know, some of this knowledge. It's just sensationalism. For some of it, some of it is a little bit unfair. I think some of it is for what the FDA got, and it's there. But I just want this podcast today to be something that can be useful for industry people that can be useful for patients or people that are thinking about taking CBD and it can be useful for a subset a small subset of people that may be should not consider taking it. Yeah. So all of this is kind of, you know, for the future of this podcast, It's almost going to be a bit of a rebuttal. Not necessarily a defense of hemp derived CBD. But let's just buckle up and kick some science. This might be a little bit I don't know how long we're going to go where we're going to go with this. We're just going to feel it out and see what happens. But I at least want to be able to explain why I still believe that a lot of people should be taking CBD even though Forbes is like you're gonna die from this.Yeah. It's not arsenic people. No it isn't and I think another cool application here is there are people out there who have been on the fence on whether or not I should try CBD or is this something that's good for a family member for me? And unfortunately, there you hit this intersection, where a news headline is written that CBD causes liver failure. Well, if they've been on the fence, that's a pretty big No, no, right? So now you've taken away maybe an avenue that they were considering to help them out. What I hope that we can do with this particular episode is basically let's temper and let's see things in context. I think context is a word that as you get into sensationalism is something that is kind of the rescue item. If I could put something into context, then at least I'm giving someone a fair chance to understand the information that's before them. I don't feel like sensationalized headlines do things like that. Then again, I also don't feel like someone who shakes, hand picked or cherry pick studies is doing that either. So what I think today that we can do is fairly evaluate and talk about the process of how the liver works, and why some of these studies are or are not applicable to the nature they were presented.Absolutely. So the first one we got to discuss is what what what the heck did the FDA say? Sure. So the FDA came out and they mentioned that they've got several issues with the safety of CBD. The two main ones that they're really concerned about are potential for liver injury, and interactions with other drugs. What they actually said is that they're concerned that people may mistakenly believe that trying CBD can't hurt the agency wants to be clear that they have seen only limited data about CBD safety. And these data point to two real risks that need to be considered as part of the drug review and approval process for the prescription drug containing CBD. Interesting. Now, what I say this is because the FDA is referring to the data that was presented to them by GW Pharmaceuticals, who has a epid... eipdi..x you know?E-p-i-d-i-o-l-e-xYes, which is the first FDA approved prescription CBD isolate,Right,for seizure disorders.It's important to point out that is not full spectrum. Correct. That is not full spectrum. And there's some that's important because here later in the podcast, and think we're going to draw some comparisons and just if you're listening, just remember, epidiolex is a CBD Only isolate it is not a full spectrum product.So let's talk about what the FBA what the FDA actually does. So the FDA has a really daunting task. The Food and Drug Administration is responsible for protecting the public health by ensuring the safety, efficacy and security of products. So it is super daunting because there's a lot of products hitting the market, and the FDA has tried keep up with this to try and protect people. And let's be honest, let's look at the elephant in the room. The elephant in the room is that there are a lot of bad CBD products out there. Yep. In fact, in a jam article 2017 showed that 70% of the CBD products that they looked at did not have what was on the label and what was there could be higher levels of CBD could be lower levels of CBD. So it's a gamesmanship that's going on right now. So it is totally true that you need to make sure that you've done your homework on what type of CBD that you're actually taking. There currently is little to no regulation in the CBD industry. There is the President and CEO of Natural Products Association NPA. His name is Daniel Fabricant. He's a PhD. I love this quote. He's quoted as saying it is well past time to bring science into the equation, as federal rules require safety and Consumer Protection must come first. I agree. And we all agree with that. Sure. And I think that all companies that have reputable CBD companies, they all want that. Problem is when you have these different stories leaking out, which gain much more traction, it just starts creating a little bit of confusion misconception, and then people don't really know where to turn. So the feeling is, is that possibly statements by the FDA saying that it creates this narrative that questions the safety of CBD overall, strictly to address a few number of companies which are producing quite frankly, some crap products.What was the number that we learned the last time that we were in Utah at meeting I believe it was one out of every 23 to 24, I could be off it was definitely in the 20s. But every to every 23 or 24,25, CBD labels available for retail purchase. One is seen as a reputable well marketed or correctly labeled product, which means that even if it happens to be off a little bit, you've got 23 or 24 other labels which are just not truthful or probably not correct, don't have a certificate of analysis or are blatantly, just not even what's in the bottle.100%. There's a lot of people out there trying to take advantage of this wave that's coming. So I do not. I believe that the FDA is doing their job by looking at the data that was actually presented to them Agree. So let's take some time and break all this down for the consumers, health care providers, industry personnel. Starting with the question, does CBD cause liver damage? Unfortunately, or fortunately, because I like science we really need to talk about what the endocannabinoid system is. Because if somebody's listening to this, they're like, Well, I was thinking about taking this but I'm worried becasue it can cause liver failure. I don't know why I'm taking it. Why in the world should I be taking it? So let's do a quick one minute discussion of the endocannabinoid system. Let's do it!All right, the endocannabinoid system. The endocannabinoid system is a system which was discovered in the 90s that we now realize it's probably everywhere in the body. There's primarily two different types of receptors, but essentially, the way that I try to explain it to my patients, it's concentrated more so in the neural areas, nerves, brain and the immune areas. Although we now know it's in every single organ, that's where all the original research was. We now realize that its job, the endocannabinoid system is to produce these products called endocannabinoids. Which work as traffic cops. They just kind of get your body to get back to an area of balance. If you've got too much activity, they go Whoa, slow down a little bit. If it's not enough, they go, come on. Let's go ahead and get some more going here. So you have this fantastic system in your body that really just tries to keep balanced. Think of it that way. And you're going to hear a little bit later why I think most of America is out of balance. I think most of America needs some replenishment of their own endocannabinoid system. So that's the important thing is is that there's a dire need to try and get us all back to a certain balance, because the reality is we're getting sicker as a nation. And one of the causes could be that we took hemp derived foods out of our diet and out of our livestock diet. And there's a theory on that, that possibly that's one of the reasons why we're having more autoimmune diseases, why we're having more of the other problems that we're seeing, Well at least contributing factor.Certainly at least a contributing factor. So keep this in mind. So the the primer on the endocannabinoid system is if you're, if you have ears and you're hearing this, you also have an endocannabinoid system, and you have a higher than likely chance that you are out of balance with that. And if you are out of balance with that, then you probably could benefit from some of this. Sure. So right now you're going well, I'm out of balance, I'm going to probably benefit but I'm going to go into liver failure if I do this. So let's talk about what liver failure means. You have a genius living within you. You probably have multiple geniuses living within you.Thank you. That feels great. Sometimes the voices in your head don't say to do bad things.The evil genius. Yeah.Well, one of the geniuses living within you as this beautiful origin called your liver. So you have this and it's amazing. So to understand where they're going with this, let's talk about what the liver actually does. So we all have livers. And they work differently in every single person, and they can continue to adapt, evolve and change. One of the only organs that you can transplant a partial portion of it and it will grow into a full liver. So the nephrologist think that the kidneys, the smartest organ, the neurologists will think that the brain is the smartest organ The cardiologist says if you don't have blood, you can't think so It must be the heart. Yeah, yeah, exactly. I'm gonna say, well, for health span, smartest organ in the body is the endocannabinoid system. So eventually, we're going to have Endocannabinoidologists. Because what ends up turning out is that the endocannabinoid system is in all these different organs.Correct.They're not completely separated. So let's talk about the liver. The liver is responsible if you ever wonder what the liver does. So do you have any idea what the liver does? I've got a little bit of an idea... Little bit of an idea. So the liver is responsible for selective uptake, concentration, metabolism, and excretion of the majority of drugs and toxins, also known as xenobiotics. So let me just say that again. Basically, the liver takes the crap that you bring into the world. And it says, I'm going to convert it to something useful, or I'm gonna get rid of it for you. Yeah, it can detoxify it, or it can say, Oh, you need to be this and then you're useful. That's why I say it's a genius in your body. And it the liver figures this out, it figures out what you need, and it determines if it's a drug, or if it's a toxin, and it can turn into a better form. Now, one of the problems I have with these different articles that I've been reading, is that they discuss that then enzymatic process called the P 450 system, and they just write it like that they're like, CBD has been shown to affect the P 450 system. What doesn't affect the P450? So that's the issue. So let me break that down, I bring up the P 450 because in the lay literature without even describing what it is, it is a complex. It's called a phase one metabolism of the liver. Under p 450. It's an umbrella term that has over 60 different genes, that code for hundreds of enzymes to break down anything that comes your way. So the P 450 enzyme is like saying, Oh, I don't even know an analogy, but it's top of the funnel down. It's like you just so generic,  that you can't just say that. So but they write it in the lay literature almost as a sounds sciency so I'm sure that it's, I'm sure that it's right. That's kind of my feeling on I'm like, why would and all these people it's almost like these news articles parrot each other. And nobody's stopping going, wait a minute, because as it turns out, the P450 system, not the P450 enzyme, the system breaks down almost everything that we put in our bodies. Yeah, no joke. So a lot of going back to the pharmaceutical days, I remember that was one of the biggest challenges with with any of the drugs that we detailed a physician on was, how is it affecting the P 450. And that would be something that they would be all salespeople be coached on that before they would go on calling a physician. But the truth is, it doesn't have to be a compound. It doesn't have to be a medical pharmaceutical compound for that to be somewhat important. Something as simple as grapefruit juice. Also, detectibily inhibits the metabolic ability of the P 450. So there's all there's a handful of different drugs that people who are elderly, maybe caution, don't drink grapefruit juice, because it will inhibit your ability for your body to clear this particular drug. And I say that to say this. It's not nothing is inherently just special because it does or does not directly affect the P450, almost everything you take into your body is either cleared quickly or slowly by that same system.Yeah, so they kind of imply like CBD is the only thing that gets...Not even close....that gets processed in the in the P450 system. In fact, we know that there are multiple medications that can be altered by certain foods. Grapefruit is the most common one, and that really affects like immunosuppressants tremendously and that's where it really came up. When they realized, oh my gosh, you have these different drugs, let's say blood thinners and immunosuppressants, which have a very narrow therapeutic window, you have to have these things like right dialed in. Yeah. And then people talk about grapefruit but you know, other things that have actually been shown to do this cranberry juice, black tea, pepper, even chocolate Yep. has been shown to affect drug absorption and they have been shown to affect certain pharmaceuticals. We don't even know the tip of the iceberg on this because you have to do the study on it. You have to do the pharmaco kinetics, the PK is what it's called to actually determine that which is so funny because they say oh CBD is metabolized by the P450 system. That means nothing. And so if you take CBD and or chocolate and or drink tea, be careful. I mean...I think a good analogy a seriously a good analogy is it the P450 being metabolized by the P450. It may be good for base knowledge, but the truth is, is does it overwhelm that, as you put it system, if it is overwhelming that system, chocolate, for instance, for most intents and purposes would be like a single car driving down a six lane highway by itself. It's not really if the highway was a P450 and the car was the chocolate. It doesn't take anything to funnel that that car through.Correct.The problem is is whenever you happen to overwhelm that system. And that is important to know. But I would say in terms of context, kind of the way that we started this discussion in context. It's not my belief through what I've read and seen that CBD inherently overwhelms or becomes more than a single car down that six lane highway.So not only is it just one single car going down the highway, remember that not only foods but drugs, nobody's talking about drug drug interaction.Right.So there's a reason. So I see a lot of patients that one drug may be very effective one thing may be very effective, but there's so many variables like for instance, drugs, the sex of the person plays a role, you may have different levels, the age of the person and any diseases can all affect this whole system called the P 450 which produces enzymes. So not only that, but then genetics play a huge factor, alcohol intake.Alcohol intake, all of that. I mean, genetically, this may be why some drugs work on certain people and why they don't work and others fact there's a whole field of science right now where people are trying to determine the genetics ato go, Oh, you're going to need a higher level of whatever Plavix which is one that they've actually looked at. Or you can, you're going to take less. So we this is a whole field of this beautiful science where we can go Okay, genetically, you're going to be predisposed to need more medications. So when these enzymes get used up, basically if you've got this one chocolate, which is a car, one on six lane highway, and then you add fluconazole, which is an antifungal, that's an but that's not a car, that's a semi now and then you add alcohol, which is a minivan could be ccould be a couple minivansand then you do whatever something else, but you can see that the liver has to try and process this right. So what happens is it becomes this once it becomes a traffic jam. Then people start getting angry, they start honking their horn that is a rise in your what we call lfts liver function panels liver function test Yeah, so AST and ATL are the two ones that we always talk about, that's exactly what the FDA was referencing. So I want everybody hear this. When you overwhelm the liver with multiple cars using your analogy, then honking starts and the honking the warning sign is this rise in AST and ALT. So, for instance, your body can adapt to it. We've seen this all the time. If you drink alcohol on a regular basis. you build more lanes, you build more lanes, you get really good at metabolizing alcohol. Build tollways. I'll use myself as an example.Not with alcohol.With coffee, Okay.I always have to laugh. Whenever I go to the my own doctor. They say how much coffee do you take? I just write obscene amount because I've down regulated by receptors or I've had the ability to ramp up my my livers ability to convert that coffee into an inert thing and there it is. So you see it as an anesthesiologist or as a crna. I mean, describe what your experiences whenever you try and put somebody to sleep using propofols, different medications.Yeah, well, I mean, definitely, if someone says that they happen to be a large consumer of or a consumer of large amounts of alcohol, it generally takes anywhere between 20 and 30% more of an agent to put them to, to sleep safely, say, But back to your point of body habitus, for whatever reason, even just something as simple as someone being a redhead fair skinned, those people generally take more agent to make them go to sleep. Yeah, let's go ahead and clarify this. This is a well known thing in anesthesia. You're not being prejudiced? No, not at all. No, they literally just for whatever reason, the metabolism rate of someone who's fair skinned with red hair is typically higher than the average calculation and you can go through any types of weight based medications that we use to bring sedation to someone and generally fair skin redhead folks just take more. Is that interesting?Yeah, it is. So that is more than just anecdotal like they've actually done some studies on this and they've actually shown probably because whatever lineage, they come from Scotland, Ireland, they have a higher P450 to metabolize that particular or a higher subset of the P450 systems. So just keep that in mind. So when you take certain foods or drugs, everything's competing for your liver, to do to just say, hey, fix me, you know, figure out what's going on. Fortunately, it is a badass organ and the liver is tough and it can handle a lot, the largest solid organ that we have in the body. So usually it can handle everything. Now the most common example like we've talked about, if you take grapefruit juice with certain immunosuppressants and things then that particular combo because those drugs need exact or how they were manufactured need exact metabolism numbers. Not only that, did you know that like nutrition plays a big role. So, high protein diet will actually affect your P 450 and malnutrition will affect it. of course it will. So those are all of our paleo friends over at paleo FX and such those guys have revved up p 450s. Eating a lot of protein working out a whole lot, they're able to do this. Unfortunately, malnourished people probably can't tolerate as muchNo and they aren't they aren't they honestly they don't have the supply to rebuild the enzymes that are that are used within the P 450 I mean it's just malnutrition is going to deplete all different types of systems, not just the liver.So in the intro, I kind of mentioned that we're getting sicker. And so let's use nutrition as an example. federal policies tightened by the controlled substance act of 1970 essentially banned the production of industrial hemp during the war on drugs effectively we made hemp CBD illegal and put it under the umbrella of cannabis cultivation. Now what were we were talking with Will Clyden of O-hi energetics right, who actually discussed this and he said some cool stuff on this. He back before this when they were they were using hemp and hemp has been used for ever like since we landed in America, hemp has been using hemp has been used in China for thousands of years and all this other stuff that we were feeding because it's a fantastic crop. It's it detoxifies the soil. And it actually works. It grows quick. It's a great crop industrial. What were we thinking making it a banned substance, I don't know, separate discussion. But they've got data to show that when they were feeding chickens, so for everybody out there I had a patient today who said I said Oh, she was suffering from some things and I think CBD would help with and I mentioned Hey, have you ever considered CBD Oh, I would never ever, ever, ever do anything like that. I am not like that. I said, Okay, that's cool. said hey, let me tell you something. Do you know that before 1970 we were actually feeding animals like chickens and cattle. One of the primary things that we would feed them would be hemp, and it's been shown that you can take a chicken egg and it had over 250 milligrams of CBD, right so right now if you're somebody that just spent $200 on your CBD that has 300 milligrams in 1968 you could've just had an egg.A three cent egg.I know 3 cent egg. And I looked at the literature and I and I could not find anything that said death by egg otoxicity. It didn't so everybody that's sitting there thinking oh my gosh, no. I'm not going to do CBD. We were having CBD in our diet. A great Great example, to learn a lot more about this and do a deep dive. Our friend Chris kresser had Will Clyden and the CEO of O-hi, O-hi energetics on and he went into this tremendously. It was so cool. It was just like I just it's crazy that we stopped like, and I as a physician have seen that we are getting sicker as a country. So in 1970, we've got since 1970. We've got more chronic disease, we've got more dementia, we've got more autoimmune disease. coincidence, like we said in the intro, maybe it's at least a contributing factor. And now we have the FDA saying that CBD can be harmful yet it was in our food supply up until 1970.That's nuts, dude.It is nuts. And it doesn't make sense and if you look at mean hemp seed, birds eat seeds, birds consume seeds, they do all kinds of things where they can they take in product, What's the matter? No, I'm just looking at I'm trying to make sure we get through everything.Okay good, but I mean they eat everything and people have been consuming eggs from not just chickens they've been consuming eggs from all different birds on the planet for that long. The fact that we've restricted hemp growth etc has only taken away one of the natural things that birds were eating.If you're if you're really interested in this like I said go to Chris Cressors podcast where he's got Will Clyden on there is really cool wills smart dude Chris is super smart dude. So those guys those guys kick some crazy knowledge.Right?So that is it's weird that we're talking on this episode about CBD causing hepatotoxicity. And we've already shown that the liver's pretty badass, right? It can do a whole lot and we've already shown that the endocannabinoid system is necessary and since 1970, or up until 1970. We are taking in significant amounts of CBD in our dietRight.Weird.It is weird, but it's not so weird when we get down to why everyone's alarmed. So you want to get into a...Now let's go ahead and look at the studies. So that is sort of the phase one of this podcast because now we're going to start geeking out a lot. So I hope I didn't hope I didn't lose everybody with a but you kind of need that background to understand what we're going to talk about next.Sure, you definitely that background.Alright. So what they're talking about is the FDA published this revised consumer update. So this is the consumer update that they put out there for everybody detailing the safety concerns about CBD products. Now, this was based on the studies provided by GW Pharmaceuticals, GW Pharmaceuticals has done multiple different studies looking at different things to get their FDA approval. And I'm going to say right now, that kudos to GW for being the first company to step up and really try and make something for a group of people with intractable seizures have an alternative. Kudos to the FDA for doing their job and looking at the data that was presented to them. What I'm going to do is go next level and say, Well, you didn't look at everything. That's the bottom line here. So I'm not bashing anybody. Let's make let's make certain of this. Sure. So there have been several randomized, controlled and open label trials that studied the effects of epidolex, I'm going to call it epidolex from now on it's just easier, which is a 99% pure oral CBD extract on patients with refractory epilepsy. So this in turn led to the FDA approval for two diseases, dravet syndrome and Lennox-Gestaut syndrome. So if you recognize those names, bless you, because you're dealing with some serious stuff, It's a serious seizure issue. If you don't know those. Count your blessings. It's one of those times to go well, no matter where you're at in life. It's like well, thank goodness that I don't have to Deal with a child that has this because that's, that's a really big deal. These are intractable seizures. So they looked at the data on that. And in these studies, the kicker here is I'm going to say it again, getting back to the lane highway, the patients maintained on their stable drug regimen with a median of three anticonvulsant drugs. That's important. It's super important. Three anticonvulsant drugs. So when we use the analogy of the car on the road, imagine a six lane road. And three of those roads. Three of those lanes are double semis.Yeah, that are closed construction... Or closed, Yeah, that's more likely or closed. So let's talk about that. So when we're talking about three different agents used to control seizures, some of those agents would be and I'm assuming here, but probably Depakote, probably Dilantin, also known as phenytoin, or fosphenytoin, which is seravex. There's a handful of anti seizure medications and through my knowledge, all of them, all of them have been recorded as raising the enzyme levels used by the liver which of course would lead to ALT and AST elevation, showing that the liver is essentially working overtime to long term process these drugs right or wrong?Correct. Correct, which is exactly what the FDA is supposed to do. They're supposed to look at this data and go Okay, so let's just look at the study that they're talking about. So the FDA accumulated this data, and they looked at what GW presented GW presented in isolette of CBD, not a full spectrum. And the dose they ramped up to 20 mg's per kick 20 mg's per kick. What that means is a guy like me would take 1954 milligrams a day.That's a lot more...of CBD isolate. Now I see the effects, beneficial effects of taking KBMD health CBD 15 milligrams twice a day,that's 30 milligrams,that's 30 milligrams.The exact dose of what makes people feel better is very argued because all the data coming out of Israel shows that a lot higher doses, but I'm seeing effects at these doses So let's be real quick let's stop for context. So right now at this intersection what we're what you're saying is with a full spectrum and we said this at the beginning of the podcast that what GW Pharmaceuticals has with epidiolex is a CBD isolate and what they've done...You're saying epidiolex now that's funny. Yeah, whatever it is, Well, because I started with that. Then you told me no, that's not how you say it.I think we should switch it up the whole time. EPA max the way it was edimax. What they did is they were able to establish that almost 2000 milligrams for you would be the ideal dosage however, you...isn't that correct? That's the dosage that they went for or the dosage that they felt was safe, Safe. Okay, I'm sorry. So but but on the upper end of... That was what they were aiming for on everybody. In essence, though, from where you have had beneficial effects, you're talking 60 times that amount, two months worth, is what they are saying the safe level would be in one day where you're finding the beneficial spectrum. So just just in terms of context, full spectrum, CBD, one 60th of the dose that they're saying it's a it's a safe level is really all that you need from our experience.Yeah. Now in GW's defense, let's look at the data. So in dravet syndrome, seizures dropped 39% and in Lennox-Gestaut 42%. So... that's good. So they probably did their homework and said, well, we need to get up that high to actually help that so I don't know anything about that. I'm not a neurologist. That's where it's at. But I'm just saying that when we look at that dose, no average consumer is going to be able to consume that Much CBD in a single day, unless it comes through this 2 full grams a day is more than most take Yes,yeah. Now here's the problem 94% of the people had side effects. Okay 94% at the highest dose compared to 75% placebo, kind of weird. So there's just a huge placebo side effect profile that doesn't get discussed at all.Did they say what it just had a curiosity do they state with the placebo was for the control,They did not stay with the placebo was oh, I take that back. I don't know what they use, but basically they left people on the same medications. So, essentially, let's just look at this and say okay, but the good news is, most of it was not a big deal. Most of it was what the FDA also discussed beyond the liver tests and beyond the drug metabolism. They also said Oh, CBD can cause nausea. It can cause drowsiness. It can cause all these other kind of nuisance things. That's what they're referring to right here. It's interesting though, that have a side effect profile assigned to a placebo that's that exceeds around the 30% range, because that's generally the throwaway number. Yeah. So we've gone twice away from the throwaway number. And they've had they've had reported side effects, which I'm not trying to over draw conclusions here, but it could at least indicate that side effect profiles assigned to CBD in this study probably weren't solely to CBD, Well, you're dealing with one of the highest risk populations you can get your hands on, when I did clinical research and when we would do a moderate to severe Chron's study. The placebo arm would have tons of side effects because the disease is bad. That's what's going on here also. So most was not a big deal, upper respiratory tract infection, somnolence, decreased appetite, diarrhea, blah, blah, blah, blah, blah. But the one that they focused on is the increase in amino transferase concentrations. This once again was a revised consumer update, they put this out to the public and their statement is increase in liver amino transferase concentrations when I just got done explaining what the liver does. Did I ever say amino transferase concentrations? No. I said liver enzymes. right? frickin talk to the public if you're going to release a consumer paper. yeah, liver enzymes. AST ALT. This is hiding behind scientific garbaly goop. It's like you're doing half science half anyway. But but whatever. So a patient show up and they're like, I need you to check my amino transferase concentrations. I'm like, Whoa, why? They Hand me this, this, this news article. Right? This is what we're trying to address right here. So what they found is that in the higher dose, 20 mgs per kg, there was a rise in some patients in three times the level which is significant, so if your normal is 20. You can be 60 if your normal is 40 it can be 120. When patients come into me and it's three times the level it sounds alarming. Do you know what happens when somebody gets hepatitis A acute infection? It's way more than that thousands of times the level when somebody goes into foaming at failure there AST and ALT will go from 40 to 10,000.AST and ALT have risen for almost everyone who's listened here, way more than three times throughout their lifetime multiple times in acute or in very isolated settings. It happens with illness.So getting back to your highway analogy, which I think is really cool analogy. I'm glad you came up with that. Thank you .Getting back to the highway analogy. 80% of them were taking a drug called valproic it matters Depakote Yeah, that matters. That matters a lot.It's when you take these medications, which is why at the beginning of the show, I said you're more likely don't have to worry about it. But if you're on certain medications, keep it in mind. Now that being said at the lower dose didn't see this stuff. So there is a dose dependent usage of the P450 enzyme you can if I give you one drink, or if I give you a bottle of tequila 512 which in my opinion is really one of the tastiest, most fantastic tequilas you can ever get your hands on. It is delicious. It's delicious. I'm gonna I'm gonna digress right here. Oh my God, Tequila 512... Also sponsored by Tequila 512Tt was really good seriously, ummm in every single person with liver test rose.They went back to normal if they decreased the anticonvulsant or decreased the CBD. So either one it went back to normal. So it wasn't number one, it wasn't permanent liver damage. More than likely correct they were able to  return back to normal. And number two, it was simply A case of an overwhelmed P450 pathway more more than likely.So you want to get really confusing? Not really but we might as well try. I don't want to but here's what's really interesting, then they kind of get a little geeky. So GW presented their their stuff and then they showed that the P450 in this enzymes and they went into will, the CYP to, 2c19 CYP three a four can inhibit the CYP blah, blah, blah. Those are all just cytochromes people. Those are all just cytochromes It's under the umbrella of P 450. That's how complex this is. Yeah,It is nuts how complex. The highest plasma concentration to CBD occurs within two to three hours after exposure to the Epidolex. With medication, so timing of these medications going to play a role, which actually got me down a weird rabbit hole where i started thinking. We haven't done this much analysis on what happens if you take your Ace inhibiter and you take your cholesterol medicine, timing wise PK analysis on different people and everything. Because when they do these pharmacokinetics, they do it to get the FDA approval, they do it on people that are healthy, that they can understand it. Let's put this into context again, if you're listening to this you've ever taken tagamet. Have you ever thought about when you take your tagamet, you probably only take it whenever you're afraid that you're going to have acid problems, right? Cimetidine?Yeah, guess what? It's also known as a high level p 450 inhibitor if it's over consumed. So I guess what I'm saying here is, there's probably way more alarms being driven over something that yes, is handled by the P 450 system, but is far less invasive or it's much it's a much smaller vehicle on this highway than some of the other things that the alarms are not sounding over.And then surprise surprise after I just got done talking about the liver and the genetic variability and all these other things. When they looked at the pharmacokinetics there was tremendous variation. Hmm. Weird. Yeah. Odd, right? So and anybody that's listening to this that is a, a pharmacist or is a scientist or like Well, yeah, duh. Like I know, duh. But why put out such an alarming statement? Yeah. Without context.Yeah, yeah, you're right. So it for Okay, so it's a little bit of clickbait stuff, right. And so maybe even the journalist who wrote it doesn't understand specifically, the implication, they may have only seen P450, written somewhere turned to a health care provider and said, What is this? Well, that's indicating that things are rising up, they freak out. They write a headline that says CBD causes liver failure. I just learned that from this health care provider. So I'm going to write this piece.Well, that we're going to get into that. The liver failure. This is still just the FDA. Oh, yeah. To the consumer. So I hope that the FDA looks at this and says, You know what? That's right. All that stuff that was just being said it's right. But we didn't have the time to do it. We couldn't sit there put that on paper, we'd lose everybody. I get it. It's quite true. We all we all but we all have a responsibility, much like any doctor to try and explain. You and I have this ability to have this forum to reach hundreds of trillions of people.Yeah. It eflects in our subscriptions on YouTube. They so many trillions of people subscribed, they started his back over to about 200. Yeah, so every time we got trillions, they start back over. Yeah. So So anyways, so what what you're realizing here is exactly what we're talking about. When you put stress on the liver. The liver honks its horn and does a little rise and the lfts goes, Well, hey, guys, maybe not so much. Can we just back off the traffic a little bit and see what's happening here. So additional studies have shown that levels of the anticonvulsant drugs actually caused the daily effects. So now we start wondering that the that the CBD may actually rise some of the anticonvulsants and then you have more side effects from that comes down to the same thing we're talking about how many things do you want to tax your liver, that's the bottom line. To summarize high dose of a pure CBD isolate, not full spectrum, while using a mean of three other anticonvulsants can cause temporary rise in liver tests and affect the metabolism slightly of the anticonvulsant. Of note, it did not happen at lower doses. So one more time, if you are on an anticonvulsant discuss with your doctor and make sure that you stay well below the 2000 milligrams a day. Yep. So this whole thing of Oh We're going to block the P 450 the P450 is So frickin complex, it is nuts. So anything you want to add to that, because I'm going to move on to the thing that I really want to, like kind of make fun of No, not really, I just want to say that I think that the FDA, unfortunately, is a very important and serious organization within our government. And I think that for all of the flack that they take their, unfortunately, with any other entity, there are limitations on what it is that they can do. And I do believe that they try their best to fairly ascertain and address situations as they are presented to them. Regardless of how frustrated that one of this may get is we don't get a result from them. A lot of it is just simply because there's not enough manpower. Oh, absolutely. They get thrown everything think about, think if you're in an organization where you know that 70% of the crap that's out there needs to be pulled off the shelves and you're limited. It's a government organization. These people making these statements are MD's. I'm really limited fortunately, I have well, we have the show where I kind of enjoy looking up some of this stuff. Fortunately, we have some friends of ours that are that work in the nutrition industry that are fantastic at researching articles. And some of that gets gets brought to me I want to make sure that we all get better this is the whole purpose of this.Hundred percent.I want to help the FDA and help GW I want to help the CBD industry. I want to help all of it. But let's just talk about this because something super weird happened. And this is the one that got the most press A Forbes article came out that promoted a mouse study and made the sensational claim that CBD causes liver failure.Yeah, that's kind of what I was referencing earlier. I may steal the thunder but yeah, you're right.Yeah, so this is you're exactly right. In the intro, you said it was clickbait. I really after looking at this study after pulling the study, because how many people read that article are actually going to pull the study.Well is the is the person who wrote this study that well versed in reading studies like that. I mean, that's that's an important thing. I mean, they I think that probably even the author of the article feels like that they are doing a service to the reader, but probably doesn't understand. And if they do, then shame on them, but if they don't, I think that would be a better explanation doesn't fully understand how to read the study and the quality and the qualifications of that study to make a statement like that.Yeah. And you know, this, this could be an arguable point, I'm sure that the person that that wrote this feels very strongly that what they said was right, the bottom line is the goal of this study was to investigate CBD cannabidiol hepatic toxicity, meaning liver issues in an eight week old male mouse. So they they took a group of eight week old male mice, and then they gave them a CBD that they produced. The CBD that they produced and Will Clyden will just jump up and down when he hears this because he decided Is this on Chris Cresser's podcast. The CBD that they produced was used to extract using hexane, which is a molecule that is known to be hepatotoxic. Yeah, you're not supposed to have heaxane. Don't do that! Will Clyden talked about the fact that if you find a CBD with an outrageously high amount of of CB, if you find a full spectrum CBD with an outrageously high amount of CBD more so and the price ranges, okay? Because what they did is they extracted that with hexane in a cheap way and threw it in their bottle and said, there you go. Now you can check that's got 10,000 milligrams of CBD or whatever. And it's really interesting because there's so much going on in the industry like this. So this particular study out of the University of Arkansas, took the CBD, or they made their own CBD using hexane which is a hepatotoxic in itself and in their certificate of analysis. It was there and then they gave it to these mice. Second thing neatI don't even know there has to be a second but we can hear it. Because I mean seriously, that's, that's like saying, I know your stomach hurts. You should take this Pepto bismol. And then I don't tell you that I've broken up some glass shards and have you drink it and you're like i'm bleeding now! What's going on? I'm like, I don't know. Yeah, but you only paid half the price.I made it myself.Which, by the way, that last batch of propophol that you did in your bathtub is working phenomenally. I'm sure it is. Now we do not make propophol in our bathtubs.Alright, so the second issue. If we have any mice that are subscribers to our show, or listening, I would like you to have your children removed from the room at this moment. Because they took these poor mice, and they gavaged to them. Would you mind defining what gavaged is? I think it's when you kind of force feed somebody I don't think it's willing. That's your I think gavaged something you kind of threw one at me there I think to gavaged someone you basically introduce a funnel to the esophagus and well you kind of get after it, don't you? Yes, I'm currently gavaging my mic right now trying to figure it out. I just undid everything. You're gavaging our ears with your, your microphone adjustments?All right, so gavage is they forcibly give these mice?The CBD extract? Yeah, I don't think it's comfortable nor pleasant.No typically through a tube feeding or down the throat to the stomach is how they generally gavage things. A quick side note, now because I'm now all of a sudden I feel like I'm living in a glass house when I was an undergraduate student. I actually did my first surgery on a rat and we took out their adrenal glands. And I'm just saying that so I don't want to sit there and pretend like I'm not done mean things to an animal. But that was when I knew immediately I could not be a bench researcher. I did not like that. At all, now I was like, I need to, I want to heal. I want to heal. I don't want to hurt these animals, but it's it's a whole separate discussion. So anyways, so they gavage these animals with different doses, and it's really interesting. Now in what they call their defense, they call it allometric dosing, which means they're trying to get the body weight to human weight ratio appropriate. I've read some rebuttals of this article where it is a joke, you just can't do that. And when I read vitamin weed Michelle Ross? Michelle Ross, when I read vitamin weed she dis... she specifically discusses why research on CBD versus mice is very difficult to do because the weight basing the endocannabinoid system is different, all these other things. So allometric dosing being said, assuming that they're saying it's right, so the dose would be the equivalent of what they gave and What a human would give So I'm doing the allometric dosing, which I think is actually higher than what it actually is separate thing. They took mice and they gavaged them with zero milligrams of hexane derived CBD 246 milligrams per kilogram 738 milligrams per kilogram or 2460 milligrams per kilogram of dirty CBD. It doesn't make sense dirty CBD isolate. So for instance, in a horrible alternate universe where humans are now the test subjects and we have large mice which are running tests on us, and they decided to gavage me with the same thing. That would be the equivalent at the highest dose of 241,080 milligrams of hexane derived CBD isolate. I'm not even sure what the hexane would do it 240,000 milligrams 242,000 milligrams.No I mean that being the more or less than now at this point, it's just an additive. It's just I mean it's it's not an excipient It's a straight up additive. That would not make sense at all. Oh, it's crazy.It's poison.This article came out in Forbes and said CBD causes hepatotoxicity. Also hexane causes hepatotoxicity.It is nuts. Alright, spoiler alert. The mice suffered hepatic toxicity and death at the highest dose. Shocking... You know what? I also hear it's bad to have breakfast cereal with not milk but drain-o. Just something that I'm gonna go out on a whim. Don't think you're supposed to do that. It just doesn't make sense. It's It's It's not. That is not an apples to apples comparison if you're talking Okay, so we talked about it earlier. reputable CBD source there is no reputable CBD producer that's going to have and Will special shout out to you it's going to have hexane as a byproduct or an excipient in their full spectrum COA approved which is also why KBMD Health with powered by olyxenol hundred percent is does not have that. I mean they do co2 extraction, which is the important thing which is a reason why we partnered with them to make that product. So we are the one out of the 23 or 24 that is the safe and trusted COA back no hexane etc etc. Doing this study is not an apples to apples comparison on what would happen because who knows? Who Okay, I don't get it because GW we already did that study. They determined that 20 Meg's per kg which is still a shit ton. It's a lot. It's a lot. Yeahis the safe maximum dose. These guys went times it by 100.Yeah, they did.And see what happens? Yeah, it's it's a bad it's a bad comparison. I mean, yeah, honestly, if you wanted to find out if CBD plus hexane causes liver toxicity at a ridiculous amount, top to bottom, then that's a great study outside of that, since nobody does it, I would say it's a bad study. Speaking of road, that's a road to nowhere.Yeah. And so study like this, uh, like you had mentioned is essentially it's not science. It's clickbait. Yeah. And right now that that author, that journalist is just kind of laughing. He's like, I know, and now you're bringing it up, and I'm going to get another whatever, because that's what people are trying to do. They're trying to get attention at this point.So at that point, good for you, you got to click but I would be truly interested if possibly that particular journalists would say, you know what, I didn't fully understand it. I mean, that's okay. Let's look reading studies, right? There's there's a study to reading studies. I mean, we heard that we heard the breakdown that kresser did on Joe Rogan is he Twice had to address his approach to completely different topic about the the plant based diet and then how he had to re approach that with the rebuttal. All that just simply to say, there is a science to reading studies and being really good at understanding what is and is not applicable and then how to find studies that you can compare to each other for good meta analyses. So what we're doing right now is I'm telling you that maybe sometimes there aren't studies, but my anecdotal evidence, I have a busy practice, you hear the patients, we hear them talk I listen to them, when they say that doesn't work. I go, Okay, I'm not publishing it. I don't have time to do that. I wish I did. If I published everything that we're gathering data on, if we're looking at, you know, just so many different things, CBD is just one of them. We've got I love I'm a huge fan of brain.FM for the ability to use sound to change your mood. I Would love to they're unpublished, a lot of studies on stuff like that. There's, there's tons of stuff. So when people go, oh, the studies aren't out there, there is something to be said about the Socratic method, or I'm sorry, the paternalistic method, the way that medicine used to be where the guy in front of you that saw thousands of patients, this is the method that he has. You see me scope, I mean, there's a difference in scope techniques.So they, although some may even still say it qualifies as anecdotal, I will say that there's objective data in both in a scope, somebody can't just come, anybody can come to you say I feel better. Anybody can even if they don't mean it. But they can't make the disease disappear from the imaging that we see in their colonoscopy, or the the mucosal samples that you take. And that's something that's completely objective data. That we see. So those are the everyday results that we see from these types of applications where you just, look it's not made up whenever we okay full pleasure when we first started looking at CBD, I thought was bullshit. Who you looking at?Just anybody who's out there. But when we first started talking about it, I didn't believe it. I was like, man, let's see, because we've been down this road before but we tried new, new without throwing a bunch of things under the bus. We tried new or innovative different things and high hopes. And unfortunately, low expectations and the expectations get met and the hopes are never never realized. The opposite for me personally occurred with CBD over the last three and a half years. And that is it actually stinking works.Dude, I knew that we were onto something with Atrantil, because after we did the initial studies,  everybody came back and said, I want more. I knew that I was onto something or I was not on something. I knew that CBD had a viable place in my practice, because I bought and the story goes all the way back which is why we work with which is why it's powered by elyxenol right now, when we went to paleo FX, and I ordered a couple cases and I just gave them away to patients. That was not cheap. Not because I was sitting there trying to be altruistic, not because I was doing charity. I'm like, I don't know. I didn't. And I told everybody, I don't have a clue. I haven't even looked at this yet. All I know is try this. Tell me what happens. And when about 80% of them came back said I want more. And I went, Okay, we're onto something. And that's when I took my clothes off the deep dive into the science and went, holy cow. Yeah,this is crazyUp until that point, I just didn't know there was a whole lot to it. I mean, it really didn't. And then the fact is, oh, and to clarify, it's not like Brown just handed out CBD to just anybody who came to the clinic. You literally just like we did with Atrantil you found very diseased patients to say and who had gone through a gamut of different pharmaceuticals and weren't finding relief, and suddenly they're like, this is working for me. Tell me more about it. And I was, I was blown away.So let's talk a little bit. So we're I'm over here going well studies I haven't published and everything. Let's talk about a few studies. So I've got a Mendeley account, I know how to look at PubMed. I know how to get a Google Scholar, I just want to talk about a couple studies have come out recently. And let's kind of compare it and see if it still makes people concerned that they're going to die of liver failure.Sure. Alright. So in the Journal of Clinical Pharmacology published in 2019, the this was actually a study, also sponsored by GW Pharmaceuticals, as part of the process of getting the FDA approval that the FDA did not reference the best I can tell they did not reference this. This is way more complex and it gets super cool, because what they're looking at is the pharmacokinetics or how CBD is actually metabolized by that beautiful genius called a liver. In high doses in people with liver disease. Yeah, they went through the trouble to take high doses of CBD and give it to people People that did not have liver disease had mild liver disease moderate and severe. This was ballsy to say the least, because using a product like this in somebody with liver disease is is risky. This thing could backfire and it could shut down the whole process. Here's what's nuts, the pharmacologic and safety of a single oral dose of 200 milligrams of epidolex, which is the CBD isolate. They were assessed in subjects they had eight people with moderate or with mild disease, six people with moderate and eight people with severe and then they had this collection of normal people. Blood samples were collected to check for the pharmacokinetics This is how drugs are looked at. They give you a drug and then they check your levels. Basically, the blood concentration was higher in the hepatic impairment and they describe it in nanograms. So the nanogram comparison is that it's a little bit higher in those with severe hepatic impairment. But this is what's nuts there was no increase in adverse reactions. There was no change in blood levels. So basically, the only adverse reaction that they found was a little bit of diarrhea. And it all happened in the mild hepatic impairment. So the FDA had mentioned Oh, studies have shown that it causes diarrhea. What was really funny about

Episode 3: James Horowitz interviews Rachel Rosovsky on DOACs. Dr. Rosovsky is the Director of Thrombosis Research in the Division of Hematology at Mass General Hospital. She is also an Assistant Professor at Harvard and a member of the Board of Directors of the PERT Consortium.  Dr. Horowitz is the Director of the CCU at NYU Langone Health and the Co-Chair of the Interdisciplinary Resuscitation Committee. He is also an Assistant Professor or Medicine and a member of the Board of Directors of the PERT Consortium. Directly acting oral anticoagulants.   FDA approved DOACS: Xarelto (rivaroxaban), Eliquis (apixaban), Savasya (edoxaban), Pradaxa (dabigatran). All DOACs have similar efficacy in terms of VTE occurrence and better safety profile compared compared to Coumadin. MOA: Dabigatran: directthrombin inhibitor.   Rest of the DOACs: factor X inhibitors. DOACS usually do not need monitoring. Most common interaction noted with drugs like ketoconazole (CYP3A4). Dosing: Dabigatran and Edoxaban: Overlap with parenteral enoxaparin for 5 to 10 days is needed. Apixaban and Rivoraxaban: Need loading dose. For apixaban it is 10 mg 2 times a day for 7 days followed by 5 mg 2 times a day.  Rivaroxaban: 15 mg 2 times a day for 21 days followed by 20 mg once a day. (Xarelto need to be taken with food) Only 55% of the patients with Coumadin remain in therapeutic range. Drug reversal agents for DOACs Dabigatran reversal: Idarucizumab Xarelto and Eliquis reversal: Andexenat Alpha. Factors in deciding candidacy for DOACs: DOACs in patients with Child-Pugh score B/C cirrhosis should not be used. Renal failure with CrCl 120 kg, based on ISTH guidelines. (higher the BMI may have increased risk of bleeding with better efficacy, potentially due to absorption issues-- levels can fluctuate) Drug monitoring for DOACs: No standardized methods. Not routinely done. It should be considered in patients with extremes of weight and patients who have gone gastric/bariatric surgeries, because all DOACs are absorbed get into upper GI tract. Pregnancy and Venous thromboembolism: No DOACs in pregnancy. Enoxaparin is the treatment of choice -1 mg/kg every 12 hours up to week 36 followed by changing them to unfractionated heparin. (subcutaneous calculated dose). Patients who had prior DVTs/PEs and become pregnant may need prophylactic dose of enoxaparin (40 mg subcutaneous once a day) Cancer and VTE: VTE is a second leading cause of death in cancer patients. Drug of choice was enoxaparin over warfarin. Edoxaban Vs Enoxaparin: Edoxaban with less recurrent VTE, but worse bleeding profile (most bleeds in gastric cancer patients) Rivaroxaban Vs Enoxaparin: Rivaroxaban with less recurrent VTE, but worse bleeding profile (most bleeds in gastric cancer) Cancer patients who may not be good candidate: a) GI cancer b) needing many procedures c) liver/renal failure d)brain mets.  Provoked vs Unprovoked and extended a/c: Unprovoked PE: Two-year risk of recurrence 25% or higher. Provoked by surgery [mainly orthopedic surgery, pregnancy, long hospital stay]: risk of recurrence 1% at one year, 3% at 5 years. Flying is a weak risk factor to be considered as provoked. Amplify-Ext trial: 70% decrease risk of recurrence with low dose apixaban without an increased risk of bleeding in unprovoked VTE. Einstein Choice trial: 70% decrease risk of recurrence with low dose rivaroxaban without an increased risk of bleeding. 60% of patients had provoked VTE with ongoing risk factors. (i.e. Obese patients, patients who are immobile, and are still immobile). Cancer screening following PE: 5-10% of patients with VTE would be diagnosed with malignancy in next 5 years. Recommendation is to do age appropriate cancer screening. Valves and DOACS: (increase risk of ischemic events)   Reference: Rali P, Gangemi A Moores A et al. Direct-Acting Oral Anticoagulants in Critically Ill Patients. Chest. 2019 Sep;156(3):604-618.

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Stephanie Gray on the show to discuss bone health.  Dr. Stephanie Gray, DNP, MS, ARNP, ANP-C, GNP-C, ABAAHP, FAARFM, is a functional medicine provider who helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them. She is co-founder of Your Longevity Blueprint nutraceuticals with her husband, Eric. They own the Integrative Health and Hormone Clinic in Hiawatha, Iowa. In this episode, we discuss: -What is functional medicine and integrative medicine? -Hormones that impact your bone density as you age and how to find your deficiencies -The difference between natural and synthetic hormones -Your Longevity Blueprint: a guide to mastering each of your body systems -And so much more!   Resources: Integrative Health and Hormone Clinic Website Your Longevity Blueprint Free gift: 10% off using code healthy10 Stephanie Gray Facebook Integrative Health and Hormone Clinic Facebook Stephanie Gray Instagram Your Longevity Blueprint Instagram Stephanie Gray Twitter Your Longevity Blueprint Youtube   For more information on Dr. Gray Stephanie Gray, DNP, MS, ARNP, ANP-C, GNP-C, ABAAHP, FAARFM, is a functional medicine provider who helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them! She has been working as a nurse practitioner since 2009. She completed her doctorate focusing on estrogen metabolism from the University of Iowa in 2011. Additionally, she has a Masters in Metabolic Nutritional Medicine from the University of South Florida’s Medical School. Her expertise lies within integrative, anti-aging, and functional medicine. She is arguably one of the midwest's’ most credentialed female healthcare providers combining many certifications and trainings. She completed an Advanced fellowship in Anti-Aging Regenerative and Functional medicine in 2013. She became the first BioTe certified provider in Iowa to administer hormone pellets also in 2013. She is the author of the FNP Mastery App and an Amazon best-selling author of her book Your Longevity Blueprint. She is co-founder of Your Longevity Blueprint nutraceuticals with her husband, Eric. They own the Integrative Health and Hormone Clinic in Hiawatha, Iowa.   Read the full transcript below: Karen Litzy:                   00:01                Hi, Dr. Stephanie Gray. Welcome to the podcast. I'm happy to finally have you on. This is taken forever between the two of our schedules. Stephanie Gray:            00:09                Thank you for having me on. I'm excited to speak with you today. Karen Litzy:                   00:12                Yeah, I'm very excited. And we had met, Gosh, last year, maybe Stephanie Gray:            00:17                October. Karen Litzy:                   00:18                Yeah, October of last year. Holy Cow. Yes. Well, I'm very excited to have you on because when we met at unfair advantage and I remember hearing your story and hearing you speak and I thought I need to talk to this woman because I think she's doing some really great work, so I'm happy to have you on and share all about what you're doing. We'll talk about your book, the longevity blueprint in a little bit, but first, can you let the audience know a little bit about your journey from your BS to your MS in nursing to doctorate to all these certifications and how that happened in the why behind it? Stephanie Gray:            00:58                Sure. Well, maybe the short version is that I was born and raised in the Midwest and I grew up in a very healthy family and I wasn't quite sure what I wanted to do with my life as many people are I’m sure. My parents always took us to see a chiropractor, not a regular doctor. They were self employed, had a really high deductible. So they wanted to keep us healthy and growing up, I wanted to get into medicine. I kind of grew up wanting to be a doctor. I'd play with my doctor Kit, but I didn't necessarily want to prescribe drugs. And so I thought, well maybe I'll go into nursing. Right? So I went through the nursing program at University of Iowa and I love nurses, man, they're so important. We have a shortage, we need more nurses. But I thought I wanted to have more autonomy and more independence and I wanted to still be able to diagnose and treat patients. Stephanie Gray:            01:43                And so I did continue on to become a nurse practitioner and I ended up going through the master's and then the doctorate program. And I still was a little unsatisfied. I felt like, man, there's gotta be more to life than prescribing medications. Right? Nursing is a more holistic approach in general. And that's why I'm biased to nurse practitioners as primary care providers because I think they do provide a more holistic approach. I wanted some additional trainings so that I could incorporate nutrition, that I would have some credentials behind recommending things other than drugs. So I did also then pursue a master's in metabolic nutritional medicine, which taught me a lot about, you know, using supplements and herbs and whatnot, which I heavily applied in my practice. And then I also did complete the advanced fellowship in anti-aging, regenerative and functional medicine which helped me tremendously. I learned a lot about use of bioidentical hormones as well. And I really just became on fire for integrative and functional medicine and thought, this is it. This is what, especially my community in Iowa needs, because there weren't a lot of providers offering this sort of care. So that's, I guess that's kind of my story. Karen Litzy:                   02:50                Well, that's a great story. I love it. Now you mentioned functional medicine and Integrative Medicine. Can you kind of help us out and talk about what those branches of medicine are? Stephanie Gray:            03:01                Sure. So integrative medicine combines or integrates conventional medicine with natural, uneven, complimentary forms of medicine. It's not, I'll say functional medicine also really more works to get to the root cause of the problem. That's kind of more of the definition of functional medicine. And I use both in my practice. I use functional medicine to kind of discover the why, but I also use integrative medicine because there is a time and place for medication use. Sometimes patients do need antibiotics or surgery. I've had to partake in them myself. But I want to provide my patients with the best of all worlds combined. So do I think chiropractic is important? Yes. Acupuncture? Yes. Use of supplements. Yes. Medications, all of the above. I think the major difference in the analogy I use with my patients that I did not create a colleague, Patrick, he mentions conventional medicine as being more of the fire department approach. Right? We need conventional medicine. If you have a big bad ugly tumor or whatnot, you need the fire department to put that out to remove it. But conventional medicines tools are drugs and surgery. Functional medicine is a little different. We described that in my practice as being more of like a carpenter approach and that's what I describe in my book. Really helping to repair and rebuild the body, figure out why the fire happened in the first place and try to get to that root cause of the problem, not just provide a bandaid approach. Karen Litzy:                   04:16                Right. And that's a great analogy. Thank you for that. That’s definitely clear. It makes functional and integrative medicine a little bit clearer for everyone. Hopefully. So now I mentioned the book longevity blueprint and again we'll talk about that a little bit later, but there's a chapter in the book, Chapter Four where you discuss the importance of fixing nutritional deficiencies and specifically when it comes to our bones. So as mainly women, we all know as we get older and as we go through menopause, our hormones change and bone density can change along with that. So what nutrients I guess are specifically important for our bones? Stephanie Gray:            05:09                So I'll discuss several nutrients. So many women think calcium is a number one most important nutrient for their bones. And the truth is that your bones need a lot more than calcium. So vitamin D, magnesium, vitamin K2 and strontium are all nutrients that I recommend to my patients. I mentioned vitamin D in several different chapters of my book and that as many people know, helps your body absorb calcium and phosphorus from the foods you eat. And it helps with bone remodeling. Maybe I don't know how deep we should get into that. Maybe you shouldn't, but without enough magnesium though calcium can also collect in the wrong places in soft tissues and cause arthritis. And so magnesium is just as important as calcium. There have been several studies of women with Osteopenia or osteoporosis showing they're actually not deficient in calcium deficient, they’re deficient in magnesium yet. Stephanie Gray:            05:58                What's the number one most prescribed supplement? Menopausal woman. Again, it's calcium. I personally have had a kidney stone and they are not fun. So calcium can not only gain weight, it can cause bone spurs, but it can cause kidney stones. It can calcify our arteries. We don't want it getting absorbed in to the wrong places of our body. And that's where vitamin K2 comes in also. So vitaminK is really overlooked nutrient. It's one of the four fat soluble nutrients. So it really helps prevent calcium from accumulating in our vessels. And it can even, some people believe can help remove dangerous calcifications too. We know that low levels of k2 can directly be related to poor bone mineral density. So I like analogy. Stephanie Gray:            06:45                So here's another analogy on what vitamin K2 really does, and vitamin D. So vitamin D is the doorman that opens the door for calcium to enter the bloodstream. But once it's in the bloodstream, it could go anywhere. So I think if K2 is being that usher that's going to direct the calcium from the lobby, if we think of a hotel or whatnot, directing him to the appropriate seat in our bone matrix. So do we need vitamin D? Yes. Do we need magnesium? Yes. We also need vitaminK2. So there are different sort or different types of vitamin K. So vitaminK is broken down to K1 and K2. So if you are purchasing a supplement, if it just says vitaminK , you don't necessarily know what you're getting. Stephanie Gray:            07:26                You want to make sure that the label is really differentiating if specifying what is in that product. So vitamin K1 isn't as much needed to be supplemented. It's the deficiency is pretty rare. It's found in leafy Greens. Hopefully you're all getting your leafy Greens. But vitamin K2 comes from very specific foods and also bacterial synthesis. So think of it. Think of yourself as you know, if you don't have a healthy gut, unfortunately your body's not going to be able to convert. K1 to K2 in the gut if you've taken antibiotics, whatnot, if you have a lot of food sensitivities and gut inflammation. And so you really want to think about consuming foods with K2 and possibly supplementing in that as well. So vitamin K2 comes from fermented soybeans, which many of us probably are not consuming and also from the fat milk and organs of grass fed animals. Stephanie Gray:            08:16                So things like egg yolk, butter, and even liver with why we're coming, we're becoming more vitamin K deficient is that you are where you're what you eat, eat. So if you've heard of what Michael Poland has said, and I think that's really true with K2. So when we removed animals from the pasture, right? If we don't eat animals that are eating greens, they're not getting the K2 themselves and then we're not getting it from our products. So you want to make sure you are eating grass fed animals and think of wild game. Wild game is really what's can usually consuming the ingredients. So try to consume more pheasant, duck rabbit, venison, elk, or wild Turkey. I mean these are things that we don't all have access to, but that would actually help increase our K2 levels. So if you can't get some of those foods into your diet, then you could consider supplementing that. Stephanie Gray:            09:06                It could literally again consume the fermented soy beans. But MK7 has a pretty long half life, longer than MK4. So I recommend my patients take MK7, MK4 is actually extracted from a tobacco plant, which I don't like either, sometimes will come from fermented soybeans, geranium or chickpea. And the source that we use for our production is chickpea. It has a longer half life, so a single daily dose can provide longer protection. So many of my patients, we're putting on 45 90 or even 180 micrograms of MK7 per day. It's great to incorporate foods that have, you know, consumed grass Greens. You hit the chlorophyll to get the vitamin K and to have a great healthy gut that convert can indicate too, but if you can't, and supplementing with MK7 is what I recommend. Karen Litzy:                   09:56                Yeah. And, just so people know, are you doing blood tests on people to find these levels? I just want to point that out so that people listening are like, well, I'm just going to go buy all this stuff, but you have to go and be evaluated first. Stephanie Gray:            10:15                Yeah. So in my book in chapter four I talk about, well, every chapter of the book discusses a functional medicine testing option that's available. And chapter four is all about examining micronutrient deficiencies. Which even my patients who eat organic, who grow their own food in their backyard are still nutritionally deficient because our food sources are just not as nutrient dense as they used to be. I mean, the magnesium content in our foods has been on a decline since the 1950s. It keeps going down and down and down, which is very sad. But because of that, we can see that evidenced on a test that we run on our patients. So one of the first tests for my patients with osteoporosis or Penia that we would run is this nutritional analysis, which is looking at vitamin, mineral, amino acid, antioxidant, and even Omega levels. And if you have the access to a functional medicine practitioner, definitely I would recommend getting this test because then you don't have to guess how much magnesium, how much do I need? It's better to really get the test to see what you need. Karen Litzy:                   11:12                Right. Yeah, no, that makes a lot of sense. And I just wanted to point that out to people so that they know. I guess also, are there any dangers of taking these vitamins if you don't need them? Stephanie Gray:            11:28                So vitaminK to a high dose just can cause blood thinning. So if patients are taking anticoagulants, if they're on medications like Warfarin, you know, Coumadin, then this could potentiate those effects at really high dosages. So if you're listening to this and you want to take some K2, you probably need it. But talk to your doctor or nurse just so that they know so that they can monitor your levels. So that would the biggest, biggest side effects. Stephanie Gray:            12:04                The last nutrient for bone mineral density that I recommend to my patients is strontium. This was one of the first minerals that I really learned about for bone density. So I heavily used it initially even before I learned about the importance of K2. There have been randomized double blind placebo controlled clinical trials showing that strontium in a dose of about one gram per day could be equally as effective as a lot of the bisphosphonate medications without getting those nasty side effects. But I have seen this be effective in my patients too. Granted, I'm recommending they take minerals, optimize their hormones, reduce their stress, exercise, right? So all of those interventions are going to have an additive effect for improving bone density. But strontium can be very, very helpful for bone density as well. Karen Litzy:                   12:48                Nice. All right, so we have vitamin D, vitaminK2, strontium and magnesium. Stephanie Gray:            12:56                And then calcium of course calcium. I don't put calcium on the top of the list, but yes. Karen Litzy:                   13:01                But it's there. Okay. All right. Now you mentioned hormones for a quick second there, but is there value in optimizing hormones for bone density? Stephanie Gray:            13:13                You Bet. So about 25 well, I think it's 27% of women over 50 can have osteoporosis, right? Like a fourth of those patients of that population, which is pretty scary. Yeah. And I'll go 40% have osteopenia. There's also, I'm referencing women over 50 so what's the other common dominator for women over 50 usually you're going through menopause around that declining and this, the danger here is that this can increase risk for fractures. Of course, Osteoporosis Foundation says at 24% of those with hip fractures die within a year. That's, that's terrible. Very cool. So absolutely, I run a hormone clinic and I strongly believe that improving estrogen, progesterone, and even testosterone levels in women can help with bone density. And I can talk a little, I can go into depth with each of those hormones. Karen Litzy:                   14:06                Yeah, I think I would like a little bit more in depth conversation on that and also the difference between synthetic and natural hormones. Stephanie Gray:            14:15                Sure, sure. So maybe first we'll talk a little bit about estrogen. So estrogen literally helps with a proper bone remodeling process. Progesterone helps promote osteoblastic activity. So osteoblast help build your bones while osteoclast break it down, right? So progesterone is going to help with the bone builders and testosterone has been proven to actually stimulate new bone growth and inhibit or block the osteoclastic that breaking down activity. Progesterone, I've even been heard called one time I heard it called a bone trophic hormone. Like it literally seems to promote bone formation, which is wonderful. So it's one of the first hormones I'll start my patients on even before their menopausal many peri-menopausal or younger are taking progesterone. And when I mentioned testosterone for women, some women kind of look at me sideways like, well I don't want to grow a beard or I don't think I need to. Stephanie Gray:            15:12                But actually it's extremely important if you even think of how testosterone helps with muscle mass, it can help strengthen the patient also, right? To improve balance, to minimize falls. Testosterone is great for many reasons. In my book I actually mentioned a study. I feel so strongly about how important testosterone can help really because of the study, because I've seen this, testosterone has shown an 8.3% improvement in bone mineral density, which is like unheard of. It's just dramatic. I've had patients who have received hormone replacement therapy, not overnight, but over a year, go from having osteoporosis, Osteopenia to even having normal bone density because after a year, their bones are improving and that is amazing. But conventional medicine, many times putting patients on drugs, we're just hoping that they don't have a decline. We're just hoping that they stabilize, not that they actually build bone density and hormones can really help do that. Stephanie Gray:            16:08                But in reference to your other question, anytime we talk about hormones, the cancer word is going to come up. So that's where I can differentiate between the synthetics and the naturals. And in my book in chapter six actually show the molecular structure of synthetic hormones like I synthetic progestin and natural progesterone aesthetic is faster on molecule and natural testosterone cause the hormones really need to fit like a key fitting in a key hole, right? And that's what the molecular structure of natural or bioidentical hormones are. I mean, they should fit like a key fitting in and thus caused your side effects. So most of the studies that showed hormones cause cancer were studies like the women's health initiative study, which was done on a lot of women, but they use synthetic horse urine and they use Premarin. Stephanie Gray:            16:54                That's literally what Premarin stands for, pregnant Mare's urine. So naturally I try to not replicate what was done in that study with my patients. I don't want to use synthetic hormones. I don't want to use oral estrogen either. That means estrogen taken by mouth in a pill form, right? Which is going to have to be cleared through the gut and the liver. So who was trained through, I should say in addition to the fellowship program that I went through was bio t, they're a hormone pellet company. They're the biggest hormone pellet company in the nation who very well trained their providers and their practitioners and they keep us up to date on all the current research and what's happening in Europe as well with hormones. And so they strongly believe that hormone is given an appellate version, which is an actual subcutaneous little implant that we put under the fatty tissue, kind of in the lower back. Stephanie Gray:            17:44                Upper bottom area is by far the safest. And that's what we're going for with our patients, right? We want to improve on density. We want them feeling better. We want to give them the safest version of the safest dosage. And so pellet therapy specifically is what can improve bone density the most. But again, we're using natural hormones that are plant-based, not synthetic. They should bind to your hormone receptors appropriately. And therefore the risks of, you know, what were shown in the women's health initiative study just can't be compared to what practitioners like myself use. Cause we're using natural hormones, not the synthetics and not by mouth. Karen Litzy:                   18:19                And so what are the side effects or the downside of using these natural hormones versus a synthetic? Stephanie Gray:            18:26                Sure. So all of us are already making, well we should be making hormones, right? Which when we grow up we go through adolescence, our hormones peak and then in our twenties and thirties and forties and 50s we start seeing this decline. So really if hormones are dosed appropriately, patients shouldn't have side effects. However, if you think of younger women when they're cycling, sometimes before bleeding they may have some fluid retention or a little bit of breast tenderness or whatnot. And sometimes those symptoms can reoccur as we give patients hormones. The goal is that those would be very short lived. They wouldn't last once we refined the dose. But too much of estrogen can definitely cause fluid retention, breast tenderness, potentially some weight gain. Too much testosterone could cause acne, oily skin, hair growth. Too much. Progesterone can make you feel a little tired. Most menopausal women need help sleeping. So they like that effect, kind of calms them down. Or if women are real PMSing they need or have anxiety, they need some progesterone to calm them down. But we don't want to overdose patients. Right? We don't want to get them to high levels of the hormones, but we want to give them high enough levels that will protect their bones, that will help them sleep. Right. That will provide benefit. Karen Litzy:                   19:34                Are there instances of cancer with the natural hormones? Stephanie Gray:            19:41                So there are always instances of cancer? I can't say definitively that. No, I've never seen it. I'd never had a patient ever have cancer. But from my experience, they're very rare. And Bio T are great to have as a resource because they track all of that. I mean, they're tracking all these hundreds and hundreds of thousands of patients with pellets and they're tracking the rights and if they confidently say the rates are extremely low. Karen Litzy:                   20:07                Well, you know, cause we wanna give the listeners sort of like a balanced view of everything. So we want to give the, you know, as you know, and I'm sure this is the exact questions that your patients probably ask you. Stephanie Gray:            20:23                Yes. Karen Litzy:                   20:25                Or hopefully that's what they ask you. Let's put it that way, So now talking about these hormones, how would one know if they are low on these hormones? Stephanie Gray:            20:37                Good question. Really get tested. Does every postmenopause woman with osteoporosis need testosterone? No, I can't say that I'm speaking to what has helped my patients. But the beauty of functional integrated medicine is that we personalize treatment, right? We test hormone levels to see what our patients need and we test them at the beginning of therapy and through the therapy and annually, right. To make sure we're not under or overdosing our patients. So, I recommend that women, even young women, and I should say men too, but we're kind of speaking to women today, get their hormone levels tested in their twenties, thirties, forties. Right? So they can get a baseline. They can track changes. So they start to feel different, start to feel something has gone awry, we can compare to see where their hormones were before. I think that's really important. But basic blood tests can tell you where your hormone levels are. Stephanie Gray:            21:27                And now that's for postmenopausal women and for men. Now if you're younger, another test that I utilize in my practice is saliva hormone testing. So for younger women whose hormones fluctuate, whose hormones fluctuate on a daily basis, many times I'll have them spit into a tube every couple of days over the course of a month so we can really see what's happening. Maybe they're getting headaches for population or maybe they're getting headaches before bleeding or having pms or whatnot. If we can correlate their labs with their symptoms, then we know exactly what's happening, which hormones fluctuation is triggering that, and then we can intervene appropriately. So that's the beauty of testing and not guessing. Really being able to examine on paper what's happening and match it with what the patient's plan. Karen Litzy:                   22:09                And with osteoporosis or Osteopenia, let's say you are getting tested when you're younger to find out, you know, what are you deficient in vitamin or mineral wise and where are your hormones levels at? Can you through this process help to let's say ward off osteoporosis or Osteopenia even if it's a genetic thing within your family. Stephanie Gray:            22:40                I guess the easy answer there would be sure. That would be the goal of course. So we want to ward off all chronic disease. Karen Litzy:                   22:47                Yeah, exactly. Stephanie Gray:            22:49                I'm sure there could be some rare genetic disorder. I'm not aware of that. Maybe, you know, we couldn't influence, but yes, that would absolutely be the goal is intervene soon. Absolutely. Karen Litzy:                   23:03                Got It. And is there anything else when you're seeing patients coming to you with Osteopenia, osteoporosis, anything else that you're looking at or any other treatments that you may suggest? So that if anyone is listening to this, and let's say they are concerned that maybe they have osteoporosis or Osteopenia or they are post-menopausal or reaching that post-menopausal phase and they want to go to their doctor and they want to ask them about these tests, is there anything else aside from what we've already talked about that you would suggest? Stephanie Gray:            23:37                Oh, all kinds of things. So I'm back to the micronutrient deficiency possibility. Well, especially if that occurs, we're going to be looking at diet with the patient, right? I had a young woman my age who was drinking like six or seven cups of coffee per day. And I said, you know, that's just basically leaching minerals from your bones, right? It's a diuretic. It's essentially robbing you of all important nutrients, even nutrients you're supplementing with. So you still need to examine diet with all of our patients and make sure that we're eating well. Right? And not just drinking tons of carbonated beverages or caffeine or whatnot. So definitely looking at diet is important. Sometimes we do look at heavy metal toxicity with our patients, with these patients specifically. I don't want to say it's rare, but it's much more common and more easy to treat the patients, you know, by fixing the nutritional deficiencies and the hormones. Stephanie Gray:            24:32                But there are times where it is really important to look at heavy metals as well. And then I definitely always ask my patients about their stress, right? So if they have low hormone levels, that's part of that's natural, right? Your hormones are going to decline as you age, but you're super stressed out. Stress is your body's biggest hormone, hijacker stresses not helping your situation or your bombs. So we do need to think about lifestyle and really getting stressed under control, deep breathing, Yoga, meditation, and then examine if they're doing weight bearing activity as well. Yeah, of course. Needs to start really young, right? You build your phone mineral density in your 20s. So know that needs to start at a very young age. But I do want to make sure my patients are exercising as well. Karen Litzy:                   25:20                Awesome. Well, I think that gives us a really nice holistic view of kind of looking at Osteopenia and osteoporosis from sort of bridging the gap really between that functional medicine and traditional medicine. As a physical therapist, I often get patients referred to me for osteoporosis to do those exactly what you said, those weight bearing exercises, stress reduction, things like that. And so it's good to know that as a physical therapist that we can team up with other healthcare professionals with our patient's wellbeing at the center. Stephanie Gray:            25:54                Absolutely, I would say that that's also a belief for functional medicine, that we need interdisciplinary care for our patients. You know, I don't have time during my visits to teach patients exercise for strength and balance. We have our own strengths, but we can work together as a team and really have a multidisciplinary approach for our patients, which is going to provide them with better outcomes. Karen Litzy:                   26:17                Yeah, no question. I agree 100%. And now we had mentioned the book a little bit, it's called the longevity blueprint, can you tell the listeners a little bit more about the book and where they can find it? Stephanie Gray:            26:30                Maybe I'll go off on a little tangent here and just say why I wrote the book first. I think sometimes patients or consumers may think, oh, so-and-so just wrote a book, but she doesn't know because she hasn't experienced such and such or whatnot. And I'm definitely a provider who has gone through my own health challenges, unfortunately. But fortunately I've used them to my advantage to write this book. So I personally, I've struggled with a lot of things. The most challenging really was fast heart rate or a tachnocardic episodes, which, landed me at Mayo Clinic actually, well, firstly to be in the emergency room, but I eventually landed me at Mayo and conventional medicine's approach to my issue was to take a medication to control my heart rate. And although that could have worked and could have helped, I thought I need to figure out what's happening to me. Stephanie Gray:            27:25                I needed to figure out why my body's gonna ride, right, why my heart is racing like this. And so around the same time, my husband is actually our office manager at our clinic. We have integrated health clinic in Iowa and he said, you know, you should really use this to try to streamline the process as far as what we recommend to our patients. Can you outline all of what we offer? Because sometimes patients would come see a functional medicine practitioner who only offered gut health or only offered hormone health or detoxing or whatnot. And we really offered the whole Shebang. And so he said, why don't we try to create some sort of analogy to outline all of what we can offer patients really to provide them hope. And so I created this blueprint outlining a functional medicine and all the different principles of what we can offer patients with every organ system of the body. Stephanie Gray:            28:14                And then I kind of laced through my personal story as well as far as what I had to utilize to regain back my health. And so what I'm doing with the book is I'm trying to at least create this analogy between how we maintain our homes and the compare that to our body, right? So with our home, we have, well I have hair in my drain, right? I don't want hair clogging my drain. You probably mow your lawn. If you have a lawn, you probably change the furnace filters on your home right there. Just things you'd have, you know, you have to do to maintain your home. But we don't always know how to maintain our body. We don't know how to rebuild our body if we're sick or build that health period. And so I'm taking a room in each of our homes, right? Stephanie Gray:            28:55                And I'm comparing that to an organ system in the body. So chapter one is all about gut health because I believe that gut is the most important piece of our health, most important organ system that we have. And I'm comparing that to the foundation of the home. You have to have the strong foundation upon which to build good health. So then I go chapter by chapter. I'm comparing, you know, organ system. So we were talking a lot about chapter four today and chapter six, chapter six I'm comparing the heating and cooling in your home, right? And you don't want to be too cold, you want to be too hot, you have to have a good thermostat there. But I'm comparing that to the endocrine system in the body. And so I try to help patients rebuild their body, rebuild every organ system using functional medicine principles. So I talk about the tests that are important. I talk about the nutrients that are important and offer patients resources as well. Karen Litzy:                   29:42                That's awesome and that's really great for patients. And just so everyone knows, we'll have a link to the book in the show notes over at podcast.healthywealthysmart.com. So if you're interested and you can go over, click a link and it'll take you right to Stephanie's books, you can read more about it and see if it's for you. And now, Stephanie, I ask everyone this question at the end of the podcast and that is knowing where you are now in your life and in your business, what advice would you give to yourself and in your case, since you have a plethora of degrees, let's say right after your bachelor degree, after you graduated with that bachelor's in nursing. Stephanie Gray:            30:26                Okay, so that's tough. I think what part of what I've learned through my health situation, I had to change my diet and nutrition and what not, but I also had to reduce stress big time. And so I think one I really recommend to all, well everyone but including the youth, I wish I would have as happy I as I am to be where I am and to have the knowledge I have so that I can ultimately help others. My health suffered along the way and so I could have, you know, done this over a longer period of time and instead of jamming it into fewer years, I think the advice to myself would be to physically set time in my calendar to deep breathe. Deep breathing has been extremely important to me to calm my nervous system. I'm obviously a fast talker and I needed to set aside time for my body to just mend and relax, rest and digest. So I think that's what my advice would be to take time for myself. As hard as it would've been, it probably would've been very difficult for me to do yoga. I probably couldn't have sat still, but I needed it. Yeah. That's probably the advice to just slow down, breathe slowly, take time. Karen Litzy:                   31:39                Yeah. And that's great advice and it's advice that I give to a good majority of my patients as well. And so now is there anything else, I know that you had mentioned that you have an offer for listeners. Do you want to share that now? Stephanie Gray:            31:54                Sure. So if you're hearing about functional medicine for the first time today, I'd highly recommend you check out my book just because I think that it could provide you hope or hope for a loved one. I think many patients are just so dissatisfied, they keep going to the doctor, they keep being told that everything's normal and they know they don't feel normal and they know there are answers out there and there's a good potential that a functional medicine provider could help you. So I would definitely recommend grab a copy of my book, which is loaded with resources but also look for a functional medicine practitioner in your area. So the code on our website that can be used to purchase the book, although it's available at Barnes and noble and Amazon and everywhere books are sold is yourlongevityblueprint.com. So if you use the code healthy10, you can get 10% off order on the book or any of the supplements like vitamin K2 or anything you feel like you need. But after, you know, when you think of a home being built, there's always a contractor overseeing that process. And, that's what the last chapter of my book is about. Finding your contractor to help you personally as a community build your health. The book can help, but you do need a guide. You need a contractor. Karen Litzy:                   33:01                Well thank you so much. This was great. I love learning different ways to kind of keep myself healthy and as I get older and I start, I mean I think I have a little while left, but kind of entering the phase of my life where a lot of this stuff is going to be very pertinent to me. So I thank you for sharing it all. Stephanie Gray:            33:25                Well, thank you for having me on. I hope this helps many of your viewers Karen Litzy:                   33:28                And I think it will. Thank you so much Stephanie and everyone out there listening. Thanks so much. Have a great couple of days and stay healthy, wealthy, and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Thank you for joining us for our 2nd Cabral HouseCall of the weekend! I’m looking forward to sharing with you some of our community’s questions that have come in over the past few weeks… Let’s get started!    Anton: Hi Dr. Cabral.If you only knew how much you have affected my life in a positive way you would be proud of yourself ;-)! I have listened to every episode of The Cabral Concept and I'm a IHP L1 & L2 student of yours :-)!Because I'm a client of your private concierge practice I could access to the Dosha breakdown. I have to say that I was a little bit surprised about my score.Not in a bad way I just thought that my dominant body type/dosha type was Vata, but it was Pitta.You have spoken about that the body type and mind can differ. You for an example have said that your mindset is 99% Pitta. But Pitta isn't you dominant quality in your physical body constitution.I don't know if this question make senses but do you have any tips or ideas how a person can find out their"Dosha- Mindset"?I understand that self awareness is a big one here, but I think this is really interesting and I would love to hear your view on this type of question. Susan: Hi I wanted to know if you recommend the detox as a starting point for everyone, regardless of what health issues they're dealing with. I was diagnosed several years ago with Lyme disease and candida and my major symptoms now are chronic fatigue, brain fog and trouble staying asleep at night. Also, I'm 54 years old and going through menopause. I could lose around 5 pounds but I wouldn't want to lose much more than that. If I should start with the detox, would you suggest the 7, 14 or 21 days? Thank you Susan Mark:Hi Dr. Cabral, I have listened to hundreds of your podcasts and have learned so much from you. I appreciate the fact that you portion your time out in the endeavor of passing on the wealth of health knowledge you have gained over the decades to ensure more people can be helped. I can't thank you enough.I would like to ask you a question about a health issue my wife is having. First, some background: She is 71 years old, has had chronic back pain for 40 years and her pain has gotten the worse it has ever been this past year. Opioids no longer provide more than 5-10% of pain relief. She had an intrathecal pump implanted in her back a month ago. She is getting some better pain relief from the Prialt in the pump and has hopes that as the dosage of the Prialt is slowly raised, that she will get even more pain relief--enough to actually allow her to lead a more productive life and work on other health issues (gut) that have needed attention for years. Getting closer to the question: She had neck fusion surgery in 2010 that required her to be in the hospital for weeks. She was in a hospital bed for two weeks with no walking at all due to the intense post surgical pain. At the end of the two weeks, she had a Pulmonary Embolism that required a 14" blood clot be removed from her pulmonary artery. She was given a 5% chance of living through the emergency surgery and she beat the odds. She had no history of blood clots--we feel that she developed the clot from being bedridden for two weeks. She was put on Coumadin by her PCP and has continued to take it to this day. We have asked multiple conventional doctors if she needs to continue taking the blood thinner for life, and they never really answer the question. We assume they don't want to assume liability if she were told she could discontinue blood thinning medication but then formed another clot.. Here's the question: I'm not going to ask you if she could stop taking Coumadin. What I would like to ask you is if you have ever had this type of question come up with a past patient of yours, and if so, were you able to help your patient decide whether or not to stop taking a blood thinner, and what types of considerations did you discuss to make the decision? Any feedback would be most helpful. Thank you again for taking my question, and thank you for being the giving person that you are. Josh: What is more beneficial for a holistic diet approach, blueberries or cranberries? Therese: Hi,Just finished the candida and sibo protocol. Feeling much better! Going forward what supplements should I take to best support my digestive system. Thanks! Best,Therese Nick: H Dr Cabral,you have become the foundation for my health and wellness and I use you as a mentor to help me make the right choicesI have had 4 kids now and we have decided that that's enough, so I was looking into vasectomy's or natural options I listened to your house call 848 pod cast where it was touched on. What Iv taken from that is that although the procedure is 95% safe (1 in 2000 people have failure ) there are small failure risks with the procedure. Still you don't really want to be having operations if there's natural ways to do the same thing. you alluded to this in his pod cast, but didn't actually say what they were? just that any natural alternatives vs a physical operation would be better than having a vasectomy. I just hoped that he or you might be able to provide some info or a link on what the Natural alternatives are?Regards Nick Amanda: Cabral Team, I have really enjoyed listening to the podcast and hearing about the great work you all do. I am a 25 years old, female and was diagnosed with Ulcerative Colitis at 18. I have been taking my prescribed dose of 4.8G Lialda Mesalamine daily my entire diagnosis. I’m hoping to be pointed in the right direction. My most recent blood work shows elevated levels of bilirubin in my liver and am concerned that my rain barrel is almost full. Many thanks, Amanda. Jay: Hi Dr Cabral. I am a professional athlete and I am wondering what you think about taking Essential Amino Acids for building muscle? Thanks!   Thank you for tuning into this weekend’s Cabral HouseCalls and be sure to check back tomorrow for our Mindset & Motivation Monday show to get your week started off right! - - - Show Notes & Resources:  http://StephenCabral.com/1241 - - - Dr. Cabral's New Book, The Rain Barrel Effect https://amzn.to/2H0W7Ge - - - Join the Community & Get Your Questions Answered: http://CabralSupportGroup.com - - -   Dr. Cabral’s Most Popular Supplements: > “The Dr. Cabral Daily Protocol” (This is what Dr. Cabral does every day!) - - - > Dr. Cabral Detox  (The fastest way to get well, lose weight, and feel great!) - - - > Daily Nutritional Support Shake  (#1 “All-in-One recommendation in my practice) - - - > Daily Fruit & Vegetables Blend  (22 organic fruit & vegetables “greens powder”) - - - > CBD Oil  (Full-spectrum, 3rd part-tested & organically grown) - - - > Candida/Bacterial Overgrowth, Leaky Gut, Parasite & Speciality Supplement Packages - - - > See All Supplements: https://equilibriumnutrition.com/collections/supplements  - - -   Dr. Cabral’s Most Popular At-Home Lab Tests: > Hair Tissue Mineral Analysis (Test for mineral imbalances & heavy metal toxicity) - - - > Organic Acids Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Thyroid + Adrenal + Hormone Test  (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Adrenal + Hormone Test (Run your adrenal & hormone levels) - - - > Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Omega-3 Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - > Stool Test (Use this test to uncover any bacterial, h. 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http://keywebco.strikingly.com/blog/kidney-stones-lithotripsy-and-what-to-expect Your body gives these signs when your kidneys are in danger. Changing of Your Urinary Function Difficulty or Pain While Urinating Blood in the Urine Foamy Urine Swelling or Oedema Extreme Fatigue Dizziness and Inability to Concentrate Feeling Constantly Cold Skin Rashes and Itching Ammonia Breath and Metallic Nausea and Vomiting Shortness of Breath For those who have suffered, are suffering or know someone suffering from liver disease know that it is a silent killer. What makes it even more dangerous is that it gets diagnosed at very late stages for most people. Not many individuals are educated enough to know that the symptoms of kidney disease are not silent, but are redundant enough to not care. Unfortunately, in some cases, the symptoms may not even become present until the condition is critical. So this makes knowing and recognizing the symptoms that much more crucial. Lithotripsy Treatment It may sound harsh- but many people are choosing to blast or obliterate their kidney stones rather than undergo surgery. Using a tried and true method of directing shock waves. "The shock wave treatment is called ESWL. A long name- extracorporeal shock wave lithotripsy - we usually just call it lithotripsy," says Dr. James Borden, urologist on Lee Memorial Health System's medical staff. It is shocking, but patients aren't exposed to electricity. It's a machine-generated energy wave that passes through the skin without hurting it. "We focus the energy to a very concentrated point. We know where that point is. We put the patient in position on an x-ray table over where that high energy is. And that energy travels from the outside, it doesn't hurt your skin, it travels to that point where the stone is and it breaks the stone into smaller crystals that can then pass," says Dr. Borden. Lithotripsy is an outpatient procedure, performed under anesthesia. Relatively painless, the recovery time is minimal. Making it a popular choice among people who have frequent, recurring kidney stones and those who are taking time off from work to get treatment. "If someone has a very large stone that will not be the treatment. In those situations, we'll actually make a small incision in the skin and go into the kidney and put a small tube into it about the diameter of my finger and through that tube, we'll work inside that kidney and remove very large stones," says Dr. Borden. Under the right conditions, lithotripsy is helping patients get quick relief from a painful condition. What to expect: Rest as much as you need to after you go home. You may do your regular activities. But avoid hard exercise or sports for about a week or until there is no blood in your urine. Diet You can eat your normal diet after lithotripsy. Continue to drink plenty of fluids, enough so that your urine is light yellow or clear like water. If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase the number of fluids you drink. Medicines Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructions about taking any new medicines. If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. He or she will tell you if and when to start taking those medicines again. Make sure that you understand exactly what your doctor wants you to do. If you take medicine to stop the burning when you urinate, take it exactly as recommended. Call your doctor if you think you are having a problem with your medicine. This medicine may color your urine orange or red. This is normal. You will get more details on the specific medicine your doctor recommends. If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics. Be saf --- Send in a voice message: https://anchor.fm/roger-keyserling/message Support this podcast: https://anchor.fm/roger-keyserling/support

In this podcast, Drs. Matt Herold and Dave Larson address the ever increasingly important issue of geriatric emergency care, and how a geriatric emergency department may be the wave of the future. This is another installment in the Ridgeview CME Lehmann lecture series. Enjoy the podcast! Objectives: Upon completion of this CME event, program participants should be able to: Describe demographic trends impacting emergency care. Recognize 'geriatric syndromes' and their role in the evaluation and management of seniors in the emergency department. Review current national and local strategies for developing care coordination for seniors in the emergency department. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2-weeks.  You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit:  CME Evaluation: 2019 Lehmann Lecture: Innovations in Emergency Care for Seniors (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.” FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.   Show Notes: Drs. Matt Herold and Dave Larson address the ever increasingly important issue of geriatric emergency care and how a geriatric ED may be the wave of the future. This is another installment in the Lehmann lecture series. Dr. Jim Lehmann is a retired internist at Ridgeview and Lakeview Clinic, and this series commemorates his many years of incredible patient care. Enjoy the podcast!   CHAPTER 1:   1. There are a lot of elderly people now.   2. They are unique.   The fastest growing demographic in this country are people over the age of 65. In Minnesota, the average age of emergency patients will dramatically increase. This equates to an even larger proportion of our patients being elderly. But not just elderly patients — significantly more ill patients in this age group than previously recognized and addressed.    Our current system is not sustainable, and we need to plan around this, and one of the ways is how we address our senior patient population. Primary care shortages, patient complexity, reimbursement issues and less time with patients in the clinic leads to more ED visits. In our Ridgeview Waconia campus, 1/3 of our patients are over the age of 65. In a few years it will be 75 years and older. Admit and transfer rates are more than 40% in those 65 and over. They also sit in the ED much longer due to this. Patients also bounce back more frequently in this population and this also affects reimbursement. What are the challenges in this patient population: medical complexity, social issues that go beyond a short ED evaluation, atypical presentations and the ubiquity of polypharmacy.    There is a paradigm difference. Our senior patients require, and actually deserve a different setting than the more "fast-food" experience of patient comfort offerings. For our more straight forward patients, throughput is vital. In our older patients who may be spending more time in the ED, how do we make it more agreeable and comfortable.    Dr. Herold illustrates three cases:    In case number one, an elderly gentleman presents with a fall. Upon evaluation he has a rib fracture. He is admitted. Treated with tylenol and morphine. Sent home because he’s doing well. At home he can’t get out of bed. He is readmitted. Develops fever, SOB. Pneumonia, IV antibiotics. Sent home on Levaquin. He returns to the ED now delirious.    Another elderly patient comes in with abd pain and urinary symptoms. Takes warfarin. Labs look okay with UTI noted on UA. CT abdomen is c/w cystitis. Cipro x 1 week prescribed. Coumadin held 2 days (although he didn’t actually hold the med). He returns with frank hematuria and urinary retention. Hospitalized for CBI.      Another patient, an 89 yo female with COPD. Nebs, prednisone, watched in ED and discharged. Returned next night and is SOB. Doxycycline added. Sent home again and her daughter states she is anxious. She's placed on low dose lorazepam, just for at bedtime. Two days later she is somnolonent and in acute resp distress. Placed on bipap and improves, once again discharged. 4 days later she fell because of being lightheaded. As it turns out, she gets caught up on her many feet of O2 tubing, and brakes her arm. Another fall happens in the hospital. Her Hgb is 7.8, down from 10. A bleeding ulcer is found.     More to come on these patients and how we can better care for them in the context of a geriatric emergency department. Stay tuned for Dr. Larson, who will talk about this very subject, and how to help make it come to fruition.   CHAPTER 2:     Dr. Larson discusses a paradigm shift in how we care for our senior patients. Coordination of care must improve and build a better system overall. Geriatric EDs are an innovative direction in emergency care. A new team approach specifically for our older patients who require different services. Comfortable beds, better lighting, noise improvement, etc. So, how is it actually working and currently being done well?  An ED in Patterson, NJ, at a large urban hospital was of the very first to develop a geriatric ED.  Dr. Mark Rosenberg spearheaded this endeavor. It was motivated by an experience he had in a ED with his own mother.     Goals in mind include:  1. Improve care of geriatric patients.  2. Better discern who will benefit from impatient care.  3. For those who do not require inpatient, to better coordinate their care at home. The overall goal is: reducing hospitalization.     Staff and provider education, coordination of care from both the medical and the community sides are all crucial. Interestingly, they were able to achieve these goals by staying budget neutral. Comfort in the ED is a priority. All patients 65 or over from home or assisted living facilities are placed in cohorted rooms in the ED that are quieter. It is staffed 12-hours a day, but it actually correlates with most geriatric presentation times to an ED. Natural lighting, wall murals or windows if possible. The role of a navigator, typically a nurse or nurse practitioner, is vital. Screening evaluations for falls, dementia and delirium help set the stage for all further care. Contacting the patient on 1, 3 7 and 30-days post-discharge is done by the navigator as well.     Social services' role in the patient's care is much needed as well. Polypharmacy was even recognized by Dr. Seuss. So pharmacy review of medications and the use of the BEERS criteria are of utmost importance.    Staff education and ongoing education of the many parameters of the special needs of our senior patients is an essential part of maintain a geriatric ED. A guideline by ACEP and AGS, as well as ENA, was published and is a critical resource for geriatric emergency care. Cost containment is key here as well.  We must address this elephant in the room, and the goal here is to reduce admissions and bounce backs with this new program. Attracting patients to a specialty center and improving the triple aim: improved patient care experience, improved health populations and reduced per capita cost of care.  Why the ED?     It is where patients go when things are going wrong, acutely, but also sub-acutely and chronically. Physician and nurse champions, patient advisor, nurse navigator, PT/OT, social work and pharmacy in the ED. Education for patients, protocols and a QI process are needed to actually become accredited as a geriatric ED.   CHAPTER 3:    Geriatric syndrome is a real thing. It may involve a combination of fall, delirium, frailty, and dehydration. It is a broad topic and concept. It relates to multifactorial conditions that lead to an older person being vulnerable to situation challenges. Dr. Herold used a lot of big words, like sarcopenia, and hemostenosis, to describe this. Essentially he points out that with more stressors placed on an elderly patient, the more likely one or more systems will break down. There is a disparity between mechanism of stress or injury and severity of the physiologic outcome. Distilled down, there are 8-domaigns of geriatric emergency medicine. They include: 1. Atypical presentation.  2. Cognitive/behavioral disorder.  3. Emergent intervention modifications.  4. Medication management.  5. Transitions of care.    6. Pain management. 7. Palliative care.  8. Effect of co-morbid conditions on all of the above.  This was from a paper cited from about 10-years ago. So, how can we now do better with the original patients Dr. Herold presented?  1. Our rib fracture gentleman is followed by RT. A better assessment than a "road test" with proper screening for overall function.  2. How about better [bigger] font for discharge instructions, improved ability to schedule an outpatient lab test as well as a post visit or check-in by the Nurse Navigator.  3. Screening resources for mental health and neglect. Is she anxious because she doesn't want to be home alone? Pharmacy integration and home care coordination may prevent the inevitable bounce back.   FINAL COMMENTS: Final comments were made by Dr. Jim Lehmann, the namesake for this special CME series, at Ridgeview Medical Center, where he practiced for many years.  Thanks to Drs. Matt Herold, Dave Larson, and Tara McMichael for presenting this today.  Also special gratitude goes to Dr. Jim Lehmann, and his many years of service and excellent patient care. Emergency care is stressful and complex. There is much to consider when tending to older patients and their inherent special circumstances. All the more reason to continue to be innovative with our care strategies going forward; not only in the ED, but in all departments, and at home.  

Oussama Wazni, MD, Section Head, Cardiac Electrophysiology and Pacing, and electrophysiologist Walid Saliba, MD, discuss atrial fibrillation stroke prevention, and the role of left atrial appendage occlusion. Drs. Wazni and Saliba also discuss outcomes noted at Cleveland Clinic, what to do in patients that are unable to take Coumadin due to the risk of bleeding, FDA indications, new technology available and the role of LAA occlusion in light of the newer anticoagulants.

Today I am discussing why Warfarin, or Coumadin as it is more commonly known, is quickly becoming recognized as the most dangerous drug in America. This particular blood thinning medication can have severe side effects that everyone should know about, including fever, headaches, lethargy, angina and fainting. You can find show notes and more information by clicking here:  http://thedigestiondoctor.com/83 

Talk to a Dr. Berg Keto Consultant today and get the help you need on your journey (free consultation). Call 1-540-299-1557 with your questions about Keto, Intermittent Fasting, or the use of Dr. Berg products. Consultants are available Monday through Friday from 8:30 am to 9 pm EST. Saturday & Sunday 9 am to 5 pm EST. USA Only. Take Dr. Berg's Free Keto Mini-Course! Intermittent Fasting Basics: https://www.messenger.com/t/drericberg Acceptable Vegetables if on Warfarin(Coumadin): https://www.youtube.com/watch?v=kEc30... Dr. Berg talks about vitamin K1. It is a co-factor or a helper nutrient to make Prothrombin (clotting factor) and very important for making bone. There are also many different types of proteins like C and S in vitamin K1 which are anti-clotting. If you're in Coumadin, you can't take vitamin K1 because you have a blood thinner and couldn't consume a lot of leafy greens. He also discussed the other medication called Eliquis, which can allow you to consume leafy greens. Things That Block the Absorption of Vitamin K1 • Constipated • Liver Problem – Fatty Liver, Cirrhosis • Insulin Resistance • Gallbladder Problems • IBS - Damage within the Colon • Gastric Bypass Best Sources of Vitamin K1 • Leafy Greens • Spinach • Kale Dr. Eric Berg DC Bio: Dr. Berg, 51 years of age is a chiropractor who specializes in weight loss through nutritional & natural methods. His private practice is located in Alexandria, Virginia. His clients include senior officials in the U.S. government & the Justice Department, ambassadors, medical doctors, high-level executives of prominent corporations, scientists, engineers, professors, and other clients from all walks of life. He is the author of The 7 Principles of Fat Burning. ABOUT DR. BERG: https://bit.ly/2FwSQQT DR. BERG'S STORY: https://bit.ly/2RwY5GP DR. BERG'S SHOP: https://bit.ly/2RN11yv DR. BERG'S VIDEO BLOG: https://bit.ly/2AZYyHt DR. BERG'S HEALTH COACHING TRAINING: https://bit.ly/2SZlH3o Follow us on FACEBOOK: https://www.messenger.com/t/drericberg TWITTER: https://twitter.com/DrBergDC YOUTUBE: https://www.youtube.com/user/drericberg123 Send a Message to Dr. Berg and his team: https://www.messenger.com/t/drericberg

Oussama Wazni, MD, Section Head, Cardiac Electrophysiology and Pacing and electrophysiologist Walid Saliba MD discuss atrial fibrillation stroke prevention, and the role of left atrial appendage occlusion: outcomes noted at Cleveland Clinic, what to do in patients that are unable to take Coumadin due to risk of bleeding, FDA indications, new technology available and the role of LAA occlusion in light of the newer anticoagulants.

This week on "Life After Stroke with Christopher Ewing", we chat with Dr. Ambooj Tiwari, a Stroke Neurologist and Neurointerventional Radiologist/Surgeon. Board certified in Neurology and stroke, Dr. Tiwari has actively participated and presented at various local, national and international neurology and neuro-endovascular conferences. He's published in various areas including both stroke epidemiology as well as endovascular treatments of stroke. He has also participated in various national registries for new and state-of-the art therapeutic endovascular options for stroke treatment. Dr. Tiwari has a specific interest in the endovascular management and treatment of patients with stroke, subarachnoid hemorrhage, AVM and aneurysms. Topics covered in this episode include: - Recurring strokes - Most common reasons for a stroke - Dangers of stroke related to seeing a chiropractor - The role the heart plays in causing a stroke - How many strokes each year are repeat strokes? - Diabetes and stroke - Alcohol, smoking and stroke - What is A-Fib? - Important side effects of some stroke drugs - What is Coumadin (aka Warfarin) - Foods to be aware of if you are on Coumadin - Dangers of cracking your neck - Incidences of stroke among young people - Family history of stroke - Foods that are good for you to help prevent a stroke - Allergic reactions to certain drugs - Post-stroke pain - Time frame of stroke recovery - Regaining your physical confidence following a stroke and more! "Life After Stroke" is a hit radio show hosted by Emmy Award winning TV host, motivational speaker, and stroke survivor, Christopher Ewing. Each episode is recorded during an actual stroke support group and features interviews with doctors and therapists, as well as the chance for stroke survivors to be able to share what's on their mind. Clothes provided by Zappos Adaptive. From shirts with magnetic buttons to tennis shoes with zippers by top designers like Tommy Hilfiger, Nike, Levi’s and more! Shop ZapposAdaptive! For more information, just go to www.TheStrokeChannel.TV, or download The Stroke Channel TV app, FREE in the Google Play and iTunes App stores!

The post Warfarin (Coumadin) Nursing Pharmacology Considerations appeared first on NURSING.com.

We are winding down 2017 with an exciting encore of our premiere episode featuring Dr. Elliott Antman’s explanation of Coumadin’s complex history. From farm cows and sweet clover hay to a rat poison antidote, learn the interesting chain of events that gave modern day medicine one of its most commonly prescribed blood thinners.

Glucosamina y sulfato de condroitina La glucosamina y la condroitina son suplementos nutricionales y como tales no están sujetos a las mismas estrictas reglamentaciones requeridas para los fármacos de venta libre y sin receta. Por consiguiente, si decides tomar cualquiera de estos suplementos, te recomendamos preguntar a un especialista antes. ¿Qué son la glucosamina y el sulfato de condroitina? • Ambas son sustancias que se producen naturalmente en el cuerpo, presentes en el cartílago y que ayudan a mantener su elasticidad, lubricado las articulaciones. Glucosamina: • La glucosamina es un aminosacárido que desempeña un papel importante en la formación y reparación del cartílago. • Y como suplemento, se extrae de los crustáceos (como langostas,camarones o cangrejos). Sulfato de condroitina: • El sulfato de condroitina forma parte de una molécula proteica grande (proteoglicano) que proporciona elasticidad al cartílago. • El sulfato de condroitina se extrae, en la mayoría de los casos, del cartílago de la tráquea de reses, pero en Japón también se lo extrae del cartílago de tiburón. Al igual que la glucosamina, se puede sintetizar en el laboratorio por lo que recomendamos que cuando vayáis a tomar un producto prestéis atención a que sea de origen natural y no sintético. ¿Para qué se utilizan estos suplementos? • Estos suplementos se han utilizado para tratar la osteoartritis (OA) en caballos y perros durante muchas décadas, pero no os asustéis. Desde 1980, en Europa, la glucosamina y el sulfato de condroitina se han utilizado para tratar la OA. ¿Qué características debe tener el suplemento? • La glucosamina viene en diversas formas, siendo las más comunes el sulfato de glucosamina y el hidrocloruro de glucosamina. Aunque ambas tengan la misma eficacia, la mayoría de los estudios emplearon la sal de sulfato. • Los productos de cartílago de tiburón contienen sulfato de condroitina, pero la cantidad y la calidad del mismo no es consistente. ¿Cómo se toman estos suplementos? • Si decide probar estos suplementos, los expertos recomiendan tomar la cantidad utilizada en la mayoría de los estudios clínicos: • Glucosamina: cápsulas, tabletas, líquido o polvo, 1,500 mg (miligramos) al día. • Condroitina: cápsulas, tabletas y en polvo, de 800 a 1,200 mg por día dividido en dos a cuatro dosis. • Si esta dosis alivia los síntomas, puede disminuir la cantidad gradualmente después de los primeros meses. Puede tardar un mes antes de que note cualquier mejoría. • Generalmente se recomienda ingerir la glucosamina y el sulfato de condroitina juntos. • Debe planificar el consumo de los suplementos junto con los medicamentos que toma actualmente durante 6 a 8 semanas. Si el dolor baja, consulte con su médico si debe disminuir o interrumpir los otros medicamentos durante un tiempo, para verificar si se realiza algún cambio en los niveles de dolor y rigidez. • ¿Qué estudios se han hecho? • Un estudio realizado en 2012 mostró mejoría de los síntomas al usar glucosamina junto con antiinflamatorios no esteroideos, y un menor, pero significativo alivio cuando los pacientes tomaron glucosamina sola. • En 2015 se han efectuado un par de estudios más sobre el uso de glucosamina y condroitina para el manejo del dolor de rodilla asociado a OA. En el primero, se comparó la efectividad y la seguridad del suplemento con la del celecoxib (medicamento comercializado como Celebrex). Se encontró que el suplemento en cuestión mostró una eficacia comparable al fármaco en reducción del dolor, rigidez, limitaciónes funcionales e inflamación articular tras el uso prolongado de seis meses. ¿Qué hacen estos suplementos? • En estudios realizados principalmente en Europa, algunas personas con OA leve a moderada que tomaron glucosamina o sulfato de condroitina evidenciaron cierto alivio del dolor y un mejor funcionamiento de la articulación. OTROS ESTUDIOS CIENTIFICOS Efectos de la suplementación con N-acetil glucosamina y sulfato de condroitina sobre el dolor en la rodilla y la función de la rodilla autoinformada en adultos japoneses de mediana edad y mayores: un ensayo aleatorizado, doble ciego, controlado con placebo Aging Clinical and Experimental Research April 2016, Volume 28, Issue 2, pp 197–205 Para investigar los efectos de la administración oral de 24 semanas de N-acetil glucosamina y la suplementación con sulfato de condroitina sobre el dolor en la rodilla producida por la actividad física. Se asignaron aleatoriamente 11 hombres y 39 mujeres (de 52 a 87 años) para recibir 100 mg de N-acetil glucosamina y 180 mg de sulfato de condroitina diariamente (grupo Glu / Cho) o un placebo (grupo control, grupo C) durante 24 semanas. Hemos observado que disminuyó significativamente (es decir, mejoró la función de la rodilla) del seguimiento de 4 a 12 semanas en el grupo Glu / Cho y la puntuación del grupo Glu / Cho fue significativamente menor que el grupo C en el grupo 12 semanas de seguimiento. Los resultados del presente estudio fueron consistentes con estudios previos realizados principalmente en países europeos y americanos. Estos resultados sugieren que el consumo de N-acetilglucosamina y condroitina sulfato durante 12 semanas o más tiene un efecto positivo en la función de la rodilla autoinformada y en la actividad física del hogar en adultos de mediana edad y mayores con dolor de rodilla y / o rigidez. Efectos a largo plazo de la glucosamina y el sulfato de condroitina en la progresión de los cambios estructurales en la osteoartritis de rodilla: datos de seguimiento de seis años de la Iniciativa de Osteoartritis Arthritis Care & Research Los participantes fueron estratificados en 2 grupos principales basados en si tenían o no la extrusión meniscal medial en la línea de base. El grupo con extrusión meniscal se estratificó adicionalmente en subgrupos basándose en la exposición o sin exposición a Glu / CS. El volumen de cartílago se evaluó utilizando tecnología de RMN. Resultados La prueba de tendencia de Jonckheere-Terpstra indicó que el tratamiento con Glu / CS redujo significativamente la pérdida de volumen del cartílago en la rodilla globa. El análisis multivariante demostró además, que el alcance del efecto positivo del tratamiento estaba relacionado con el tiempo de exposición al tratamiento, siendo el efecto protector a los 6 años más significativo en los participantes expuestos a más de 2 años de tratamientos. Las personas que presenten las afecciones enunciadas a continuación deben ser cautelosos con estos suplementos: Glucosamina: • Diabetes, dado que la glucosamina es un aminosacárido, los diebéticos deben controlar los niveles de azúcar en sangre con más frecuencia al tomar estos suplementos. • Individios bajo anticoagulantes como warfarina (Coumadin) en combinación con clorhidrato de glucosamina con o sin condroitina deberán abstenerse de ingerir el suplemento. • Alergia a los mariscos, si es alérgico, consulte a su médico antes de comenzar a tomar glucosamina. En la mayoría de los casos, las alergias son causadas por las proteínas que se hallan en los mariscos, no por la quitina, carbohidrato del cual se extrae la glucosamina. • Glaucoma, un nuevo estudio sugiere que las personas con este trastorno o con hipertensión intraocular podrían empeorar la presión del ojo si toman glucosamina. Otros efectos secundarios son aumento de triglicéridos y colesterol. Sulfato de condroitina: • Este suplemento puede incluir componentes de estructura similar a la heparina, fármaco anticoagulante, por lo que ingerirlo junto con un AINE, como por ejemplo, la aspirina, podría aumentar el riesgo de hemorragia. En este caso es aconsejable tomarse el tiempo de protrombina y coagulación con más frecuencia. • Ciertas tabletas pueden contener niveles altos de manganeso (Mn), lo que podría provocar envenenamiento del sistema nervioso a largo plazo (si sobrepasa 11 mg Mn/día). Además, como la condroitina proviene de ganado bovino, existe la posibilidad remota de contaminación asociada a la enfermedad de las vacas locas. • Si es alérgico a las sulfonamidas, evítelo, o empiece con dosis pequeñas de condroitina y esté alerta a los efectos secundarios. Otros efectos son diarrea o estreñimiento. Gracias de nuevo, hasta el siguiente episodio. Podcast de salud, nutrición y bienestar en Ivoox. Podcast de Tulcop Trade e Internacionalfarma. Patrocinador de colágenos: http://tulcoptrade.com/ Web: https://www.internacionalfarma.com/ Canal de Soundcloud: https://soundcloud.com/user-837726583 Canal de Youtube: https://www.youtube.com/channel/UCl16xs1I8oHKthSeZUEOEnw Página de Google Plus: https://plus.google.com/communities/105557399913056882293

Wilson Lam is a board certified cardiologist who specializes in adult congenital cardiology and rhythm disorders. In this program Dr. Lam outlines the advancements which have been made in the field of electrophysiology. He shares with Anna the changes that have occurred in life-saving devices such as implantable cardioverter-defibrillators or ICDs and pacemakers, the new medications changing the lives of those who were dependent on Coumadin and talks about new monitoring devices which provide more information while being less difficult to work with. He also talks about new procedures to prevent sudden cardiac death and gives Anna an idea of where this field is headed in the future. Although some of the things Dr. Lam talks about may be what we've only seen before in movies like Star Trek, Dr. Lam assures Anna this this segment is anything but science fiction -- it's science fact!Support the show (https://www.patreon.com/HearttoHeart)

Participa en nuestro sorteo de productos de la marca Tulcop y Galius dejándonos vuestro email al WhatsApp 679596432 o déjanos un audio con cualquier duda que tengas sobre salud, fitness o nutrición. Resolveremos tus dudas durante los programas :) ¿Qué es la glucosamina? El sulfato de glucosamina es una sustancia natural que se encuentra en el cuerpo. La glucosamina es un azúcar natural modificado, precursor de los glucosaminoglicanos (GAG). Es necesaria para la formación del colágeno. Los condrocitos (las células del tejido cartilaginoso) sintetizan la glucosamina a partir de la glucosa y la glutamina (un aminoácido). Es el mayor componente del cartílago articular. Es un amino-azúcar que actúa especialmente como precursor en la glicosilación de las proteínas y de los lípidos. (La glucosilación es un proceso bioquímico en el que se adiciona un glúcido a otra molécula). La glucosamina se encuentra principalmente en el exoesqueleto de los artrópodos, en la pared celular de los hongos y en otros muchos organismos, siendo el monosacárido más abundante. (Hidrato de carbono que no puede descomponerse en otro más sencillo.). El cuerpo la usa para producir una variedad de otras sustancias que están involucradas en la formación de tendones, ligamentos, cartílago, y el líquido espeso que rodea las articulaciones (liquido sinovial). La glucosamina que se utiliza en los suplementos dietéticos proviene a menudo de las conchas de los mariscos. La glucosamina, como suplemento, se extrae de los crustáceos (como langostas,camarones o cangrejos). La glucosamina como suplemento dietético puede ser capturado por los condrocitos y utilizado para la construcción del cartílago nuevo. La glucosamina puede ser completamente absorbida por los intestinos y pasar al sistema sanguíneo, llegando al líquido sinovial y a los vasos sanguíneos del tejido óseo, donde penetra al cartílago, los condrocitos la absorben y así comienza la síntesis de nuevo colágeno y glucosaminoglicanos. ¿Para qué sirve la glucosamina? La glucosamina ayuda a mantener el cartílago sano en las articulaciones sanas. Según diversos estudios, la glucosamina ha demostrado aliviar las siguientes enfermedades: ? Osteoartritis En 2015 se han efectuado un par de estudios más sobre el uso de glucosamina y condroitina para el manejo del dolor de rodillaasociado a OA. En el primero, se comparó la efectividad y la seguridad del suplemento con la del celecoxib (medicamento comercializado como Celebrex). Se encontró que el suplemento en cuestión mostró una eficacia comparable al fármaco en reducción del dolor, rigidez, limitaciónes funcionales e inflamación articular tras el uso prolongado de seis meses. Un estudio reciente, realizado en Bélgica por más de tres años, mostró que pacientes con osteoartritis de rodilla de leve a moderada que tomaron 1,500 mg de glucosamina tuvieron entre un 20% y un 25% menos de dolor y limitación que los que tomaron placebo. Los investigadores también encontraron que la glucosamina, disminuyó el progreso de la enfermedad y redujo la pérdida de cartílago. Estudio: Combined chondroitin sulfate and glucosamine for painful knee osteoarthritis: a multicentre, randomised, double-blind, non-inferiority trial versus celecoxib. MOVES Investigation Group. ? Artritis reumatoide ? Enfermedad inflamatoria intestinal ? Asma ? Alergias ? Lesiones deportivas ? Dolor de espalda Favorece al desarrollo de los tejidos cartilaginosos y tomado como suplemento alimenticio se emplea también en la reconstrucción de los cartílagos. Su empleo en la osteoartritis es aparentemente seguro, como muestran los resultados obtenidos hasta el momento en diversos ensayos clínicos. Biggee BA, Blinn CM, McAlindon TE, Nuite M, Silbert JE. "Low levels of human serum glucosamine after ingestion of glucosamine sulphate relative to capability for peripheral effectiveness," Ann Rheum Dis. Natural Medicines Comprehensive Database (La Base Exhaustiva de Datos de Medicamentos Naturales) clasifica la eficacia, basada en evidencia científica, de acuerdo a la siguiente escala: Eficaz, Probablemente Eficaz, Posiblemente Eficaz, Posiblemente Ineficaz, Probablemente Ineficaz, Ineficaz, e Insuficiente Evidencia para Hacer una Determinación. La clasificación de la eficacia para este producto es la siguiente: Osteoartritis. La mayoría de las investigaciones sobre glucosamina ha medido su eficacia en la osteoartritis de la rodilla. Sin embargo, hay algunas pruebas de que también puede ayudar a la osteoartritis de la cadera o de la columna vertebral. Alivia el dolor de la misma manera como lo hacen los medicamentos anti-inflamatorios no esteroides como el ibuprofeno.) Síndrome de vejiga dolorosa Dolor de rodilla Artrosis • Glaucoma. • Pérdida de peso. ¿Existen interacciones con medicamentos? Serias - No tome esta combinación Warfarina - La warfarina (Coumadin) se usa para retardar la coagulación sanguínea. - aumenta el efecto . Moderadas - Tenga cuidado con esta combinación Medicamentos para el cáncer Menores - Preste atención a esta combinación Acetaminofeno, Medicamentos para la diabetes (Antidiabéticos) • Alergia a los mariscos, si es alérgico, consulte a su médico antes de comenzar a tomar glucosamina. En la mayoría de los casos, las alergias son causadas por las proteínas que se hallan en los mariscos, no por la quitina, carbohidrato del cual se extrae la glucosamina. • Glaucoma, un nuevo estudio sugiere que las personas con este trastorno o con hipertensión intraocular podrían empeorar la presión del ojo si toman glucosamina. Otros efectos secundarios son aumento de triglicéridos y colesterol. conclusiones ¿Se puede encontrar glucosamina en los alimentos? Aunque los suplementos de sulfato de glucosamina a menudo se fabrican a partir de las capas exteriores de los mariscos, no hay fuentes de alimentos naturales de glucosamina. Crustáceos La mayoría de los suplementos de glucosamina están hechos de los exoesqueletos, o las capas exteriores, de los crustáceos. La colas y los caparazones de los camarones, langostas, cangrejos y cangrejos de río proporcionan pequeñas cantidades de glucosamina. En las tradiciones culinarias más occidentales, estos exoesqueletos duros se descartan porque son difíciles de masticar y digerir, pero tú puedes molerlos e incluirlos en las sopas, guisados, salsas para pastas y estofados. Ten en cuenta que la carne de los moluscos contiene poco o nada de glucosamina, por esto no puedes consumir cantidades medicinales del compuesto comiendo sólo la carne del animal. Menudencias La glucosamina se produce naturalmente en todas las formas sanas de cartílago, según NIH. Las orejas de un animal descuartizado, el hocico y los tejidos articulares contienen glucosamina, pero estas formas rara vez se consumen en Estados Unidos. Las carnes y embutidos tradicionales campesinos, tales como el queso de cabeza de cerdo, pueden proporcionar cantidades importantes de glucosamina. Los restos cartilaginosos también podrían ser utilizados en guisos o sopas. La glucosamina incrementa la cantidad de cartílago y líquido que rodea las articulaciones y prevenir su desgaste. La glucosamina es uno de los constituyentes del ácido hialurónico, que es uno de los componentes del cartílago. Las investigaciones confirman la importancia del sulfato de glucosamina. La mayoría de personas en el mundo que sufren de artritis o dolores óseos relatan un aumento de funcionamiento en sus articulaciones y disminución del dolor con el uso de la glucosamina. En muchos casos incluso se ha restaurado el cartílago dañado mientras que en otros pacientes ha reducido la necesidad de medicación contra el dolor. Además de los beneficios y aplicaciones ya antes mencionados, la glucosamina tiene los siguientes beneficios: • Combate la osteoporosis en varias articulaciones del cuerpo, como en la rodilla y el codo. Igualmente es efectiva contra los síntomas de la artritis. • Actúa sobre la inflamación de las venas varicosas en las piernas, aliviando el dolor y la picazón. • Tiene propiedades terapéuticas sobre las articulaciones. • Útil para aliviar lesiones en los codos, rodillas, manos y caderas como producto del ejercicio o actividad física. • Evita el desgaste de los tejidos articulares. • Se utiliza de manera complementaria en tratamientos clínicos. • El consumo de glucosamina es bien tolerado por el organismo. • Algunas investigaciones demuestran que el tomar sulfato de glucosamina para aliviar dolores de la mandíbula funciona del mismo modo que un medicamento anti-inflamatorio. • Además de aliviar el dolor la glucosamina, cuando se toma a largo plazo, podría también retardar el desgaste de las articulaciones. Gracias de nuevo, hasta el siguiente episodio. Podcast de salud, nutrición y bienestar en Ivoox. Podcast de Tulcop Trade e Internacionalfarma. Patrocinador de colágenos: http://tulcoptrade.com/ Web: https://www.internacionalfarma.com/ Canal de Soundcloud: https://soundcloud.com/user-837726583 Canal de Youtube: https://www.youtube.com/channel/UCl16xs1I8oHKthSeZUEOEnw Página de Google Plus: https://plus.google.com/communities/105557399913056882293

In our first episode Dr. Elliott Antman, Associate Dean of Clinical and Translational Research at Harvard Medical School, shares the fascinating story of how medical issues in cows led to the discovery of one of the most widely used drugs in America today. For more information please visit our site: http://catalyst.harvard.edu/services/thinkresearch/

What's new with anticoagulants? What should adults with congenital heart defects know about anticoagulants? What should adults with CHDs know about Coumadin? Pharmacist Rebekah Brunell shares her knowledge about anticoagulants with us and what new drugs are available which might change the lives of those in the congenital heart defect community.Support the show (https://www.patreon.com/HearttoHeart)

Click Here Or On Above Image To Reach Our ExpertsUS. Can Learn From China's Spot-The-Spy ProgramPeople can respond to drugs very differently. A medication that brings relief for some patients might show no benefit at all in others, or even cause harmful side effects.A growing array of genetic tests is designed to help predict how people are likely to respond to many common medications, from antidepressants and antihistamines to pain relievers and blood thinners. The tests, which are controversial, look for tiny variations in genes that determine how fast or slow we metabolize medications.Because of such gene variations, codeine, frequently prescribed to relieve pain, has little effect on as much as 20% of the population, while 2% of people have such a strong reaction that a normal dose can be life-threatening. About 25% of people can't effectively absorb Plavix, a clot-busting drug, putting them at increased risk for a heart attack or stroke. PRO-DTECH II FREQUENCY DETECTOR(Buy/Rent/Layaway)Even everyday drugs such as Advil and Motrin, for pain relief, and Zocor, to lower cholesterol, can have widely varying effects. Testing patients for gene variations could avoid some of the 700,000 serious drug reactions in the U.S. each year, some experts say. Proponents of the tests, which are done with a cheek swab, say they also could help doctors rely less on trial and error in choosing the right drug and the right dosage for individual patients.CELLPHONE DETECTOR (PROFESSIONAL)(Buy/Rent/Layaway)The Food and Drug Administration has included cautionary information for people with certain gene variations on the labels of more than 100 prescription medications. As yet, only about 20% of doctors order such tests, according to a survey by the American Medical Association, and many patients don't know they exist.PRO-DTECH III FREQUENCY DETECTOR(Buy/Rent/Layaway)Some major medical associations, including the American College of Cardiology and the American Psychiatric Association, have been slow to endorse the testing, mainly because there are no large, randomized controlled trials showing the technique significantly improves patient care. And the tests, which range from $500 to $2,000, are only covered by some insurers in some cases.PRO-DTECH III FREQUENCY DETECTOR(Buy/Rent/Layaway)NOT RIGHT FOR EVERYONEMany common medications can affect people differently depending on minor variations in the genes that regulate key enzymes. The variations can make people metabolize certain drugs either more slowly or rapidly than normal. Some examples:DRUGSPain relievers codeine or oxycodone, including Tylenol 3 and PercocetENZYME PATHWAY AT WORKCYP2D6IMPACTA standard dose can have little effect in up to 20% of people, while as many as 2% can have a life-threatening reaction.DRUGSBlood thinner Plavix (clopidogrel) and acid reducers Prilosec (omeprazole) and Prevacid (lansoprazole)ENZYME PATHWAY AT WORKCYP2C19IMPACTUp to 15% of people metabolize these drugs very slowly, resulting in a higher effective dose and greater risk of side effects.DRUGBlood thinner Coumadin (warfarin)ENZYME PATHWAY AT WORKCYP2C9IMPACTPeople with some gene variants have twice the risk of severe bleeding, but other factors are involved and population percentages are unclear.DRUGCholesterol reducer Zocor (simvastatin)ENZYME PATHWAY AT WORKSLCO181IMPACTUp to 40% of people have impaired ability to metabolize this drug, giving them increased risk of muscle pain and other side effects.Source: Clinical Pharmacogenetics Implementation ConsortiumAlan Pocinki, an internist in Rockville, Md., says he orders gene testing for patients who have a history of unexplained symptoms or who haven't gotten relief from drugs in the past. In many cases, he is able to find a better treatment based on their DNA, he says. “It makes a huge difference clinically among people I see every day.”PRO-DTECH III FREQUENCY DETECTOR(Buy/Rent/Layaway)How people's genes affect their response to medic

Options for ER reversal of Coumadin.

In this part 1 of 2 episode on the non-Vitamin K oral anticoagulants, The Curbsiders discuss these novel medications and other changes associated with the updated 2016 CHEST guidelines for anticoagulation. 

Listen in as Dr. Mike provides the answers to a wealth of health and wellness questions.Here you'll find the answers to a wealth of health and wellness questions posed by Healthy Talk fans.Listen in because what you know helps ensure healthy choices you can live with. Today on Healthy Talk, you wanted to know:I read from your website to take fish oil and put it in a bowl to help it get oxidized and take some of the smell away. You said that all fats are like that and have a stability question to them. I was refrigerating my Nordic Natural omega-3's for a long time and according to Nordic Natural, it's not necessary to do that. What do you recommend?You are using a great product and there's no reason to change. Personally, Dr. Mike believes there are two other important ingredients to have in addition to omega-3s. They are: sesame lignans and olive oil.I've been taking Vitamin K2 for my bone health, but Life Extension has said "If you're taking anticoagulants such as Coumadin, please consult with your physician before taking supplemental vitamin K." I also remember listening to one of your shows on RadioMD where you also said something like taking vitamin K2 is for those taking blood thinners. However, I'm taking Vitamin K2 to make my bones stronger. What exactly is Vitamin K2? Is it for bone health or blood health?What Dr. Mike means by those taking blood thinners and vitamin K2 is that vitamin K2 is a safe form of vitamin K for people on blood thinners to take.Life Extension had that statement on their website as a standard disclaimer. Dr. Mike wants you to talk to you doctor about taking vitamin K2.Do vitamins or any other supplements deteriorate over time? For instance, I took a glucose support product from 2013 for my sugar levels. It worked for a little while but then it stopped. I then switched to a cinnamon extract, and that worked for a while but no longer seems to be working. I am wondering if I should be switching my supplements from time to time?There are many other questions that Dr. Mike has, for instance, what made you start taking a glucose support pill, what is your lifestyle like, etc. If truly nothing changed and the product wasn't working as well, Dr. Mike suggests doubling the dose, even if just every other day.Following up with a blood test is a great way to see if a supplement or medication is truly working or not.If you have a health question or concern, Dr. Mike encourages you to write him at askdrmikesmith@radiomd.com or call in, toll-free, to the LIVE radio show (1.844.305.7800) so he can provide you with support and helpful advice.

Vitamin K Depletion especially related to the drug Coumadin

In this episode, we discuss the therapeutic drug monitoring and dose adjustments for warfarin (Coumadin) and phenytoin (Dilantin).

A heartfelt wish for holiday cheer from the Tower crew, along with a dire warning for safety in the kitchen. Show Notes: Cumin - http://en.wikipedia.org/wiki/Cumin Coumadin - http://en.wikipedia.org/wiki/Warfarin

In this episode, we'll talk about a recent article in Annals of Emergency Medicine that has a lot of people talking. This is a study that looked at patients on coumadin (warfarin) who had minor head injuries. The patients were admitted for 24 hours of observation and had a repeat head CT. The study looked at how many patients had bleeding on a repeat head CT and the conclusions were suprising. Should this be our new standard of care?  Maybe but maybe not.

The single most requested topic is for shows on Frequently Asked Questions.  In this episode Dr. Ron answers some of the most frequently asked questions that he gets from across the country on alternative and integrative medicine. From Cluster Migraines to Cancer, alternative medicine has more answers than most people are aware of.  Tune in and find out! Heart to Heart -- Dr. Ron Cherubino shares from his 25 years of clinical practice in Alternative Medicine and Nutritional Therapies.  He'll show you how to regain your health and take back control of your life. Whether you're looking for specific answers to health related problems, ways to take the mystery out of nutritional supplementation, or the secrets to a long and healthy life, we invite you to join us for an entertaining and informative hour each week on the Ask Dr. Ron Radio Show. Thrust into hopelessness, despair and eventual total disability following an automobile accident at the age of 19, Ron Cherubino emerged as living proof of the value of natural health-care.  Read his story!Dr. Ron Cherubino has gone on to become one of the nation's leaders in the natural health-care movement.  Doctor of Alternative Medicine, Chiropractic Physician, Educator, Pioneer, Clinician, Researcher and Advocate for the inclusion of alternative health care methods and techniques in the world medical system. Dr. Ron challenges each and every person to evaluate the current paradigm of medical science, pharmacology and traditional western medical procedures, with an intellectually honest and open mind. Join us online anytime at www.AskDrRon.com The Ask Dr. Ron Radio Show is an outreach of Cherubino Health Center and is sponsored in part by proceeds from CherubHealth Products.  The show is dedicated to the principles of hope, healing and health, for patients, their families, friends and loved ones, and for all those who have an interest in attaining and maintaining a high level of health.  Alternative and integrative medicine techniques, principles and procedures are explored in the hope that people in need will seek help at Cherubino Health Center and/or similar progressive health care establishments in this country and around the world. The Ask Dr. Ron Radio Show broadcasts live from Boston, WBIX 1060 AM, each Saturday afternoon from 12 to 1 p.m.