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The weekly radio show from Salvione, blending house, funk, and tech, resulting in an unparalleled energetic dance floor vibe. Flashmob – Talkless Avision – This Time Timo Tapani – Tócame Supernova – La Nuit Dale Howard – On Lock Ammo Avenue – Gettin Real Mick Willow – Pose To Techno MTJ – Bass Kicks SWAYLÓ – Pleasure Reenday, Freenzy Music – Pump the Party Jesse Bravo, Bryan Vera – Party Starter TEKO – People In The Back Ammo Avenue – Retro Dance Loz Seka – Rude Boi
Sunspots usually stay flat and stable over time, while skin cancer often changes shape, color, texture, or sensation as abnormal cells grow and spread Melanoma warning signs follow the ABCDE rule: asymmetry, irregular borders, uneven color, larger diameter, and evolution over time, giving you a simple way to check your own skin each month Many sunspots contain lipofuscin, a waste pigment that researchers believe may form when linoleic acid from seed oils oxidizes in the presence of excess iron and sunlight Elevated ferritin and GGT levels have been associated with higher oxidative stress, which some researchers suggest may be reflected in the skin Lowering seed oil intake, reducing excess iron, using sunlight strategically, and acting quickly when a spot changes may help reduce oxidative stress on the skin and support earlier detection of changes
We've got a huge news roundup from the past few weeks, including some new ways to enjoy Bellagio Conservatory, bar and restaurant renovation plans and more The post FHBM #1013: Elevated Yo-Yos first appeared on Five Hundy By Midnight.
All Yeptide Resources DianeKazer.com/YEPTIDES Join Our Elite VIP Tribe DianeKazer.com/VIP Apply to Become a 1-on-1 Patient DianeKazer.com/PATIENT TheWarriorCleanse.com We're comparing GLP-1s, Retatrutide, SLU-PP and the new oral GLP and revealing the root causes and lab markers that should be addressed before taking ANY of these. Most people are asking the wrong question. They're asking... "Which one helps me lose the most weight?" The better question is: "Why is my metabolism broken in the first place?" Because if you don't innerstand why you're gaining weight, exhausted, inflamed, insulin resistant, or unable to build muscle... you'll keep chasing the newest shiny object. 2026 has completely changed the metabolic medicine conversation. We're no longer talking about just appetite suppression. We're talking about restoring metabolism. And two names continue to dominate that conversation:
Mark Gibbens and Matthew Maley break down GE Aerospace's (GE) post-earnings pullback despite results that topped expectations. While Maley points to elevated investor expectations and lingering supply chain challenges as potential headwinds, Gibbens argues GE's strong backlog, improving execution, and management team continue to support the company's valuation.======== Schwab Network ========Empowering every investor and trader, every market day. Subscribe to the Market Minute newsletter - https://schwabnetwork.com/subscribeDownload the iOS app - https://apps.apple.com/us/app/schwab-network/id1460719185Download the Amazon Fire Tv App - https://www.amazon.com/TD-Ameritrade-Network/dp/B07KRD76C7Watch on Sling - https://watch.sling.com/1/asset/191928615bd8d47686f94682aefaa007/watchWatch on Vizio - https://www.vizio.com/en/watchfreeplus-exploreWatch on DistroTV - https://www.distro.tv/live/schwab-network/Follow us on X – https://twitter.com/schwabnetworkFollow us on Facebook – https://www.facebook.com/schwabnetworkFollow us on LinkedIn - https://www.linkedin.com/company/schwab-network/ About Schwab Network - https://schwabnetwork.com/about
Canadian Wildfire Smoke: A Comprehensive Forecast (July 15, 2026) Timestamp Breakdown:00:00 Introduction: Tracking the Canadian wildfire smoke plume.00:30 Key message: Ground-level impact of smoke and health risks.00:58 Forecast overview: Where the smoke is now, where it's going, and weekend improvement.01:12 The big picture: Weather patterns driving smoke south.01:50 Elevated vs. surface smoke: Understanding the difference in impact.02:16 Understanding PM2.5 and the Canadian Blue Sky Smoke model.02:50 Model limitations and current severe conditions.03:19 Southern Ontario's poor air quality and US plume spread.03:50 Thursday's forecast: Upper Midwest and Great Lakes concerns.04:29 Thursday's forecast: Northeast and Mid-Atlantic impact.05:05 Specific areas highlighted for Thursday's poor air quality.05:36 Friday's forecast: Plume extension and potential for improvement.06:05 Important consideration: Heat and air quality.06:30 Weekend outlook: Chance for improvement with rain and wind.07:05 Smoke forecast confidence beyond 48 hours.07:25 Understanding the United States Air Quality Index (AQI).07:48 AQI categories and their health implications.08:05 Canada's Air Quality Health Index (AQHI).08:25 Actionable steps to reduce smoke exposure.08:50 Indoor air quality tips and respirator use.09:15 Recognizing symptoms of smoke exposure and seeking medical help.09:30 Where to find current air quality information.09:57 Recap of highest risk areas and overall outlook.10:20 Final recommendations: Check AQI and stay weather aware.20 Hashtags:#CanadianWildfires#WildfireSmoke#AirQualityAlert#PM25#GreatLakesSmoke#NortheastSmoke#MidAtlantic#OntarioSmoke#AirNow#EnvironmentalHealth#WeatherForecast#SmokeForecast#PublicHealth#BreathingClean#ClimateChangeImpact#Heatwave#StaySafe#AirQualityIndex#HealthAdvisory#WeatherAwareBecome a supporter of this podcast: https://www.spreaker.com/podcast/weather-with-enthusiasm--4911017/support.Weather with Enthusiasm is produced by Kol Simcha Productions.New episodes drop daily (B'N)— a morning forecast at 7 AM and historical deep dives Tuesdays and Thursdays. Contact: kolsimchaproductions@outlook.comHistorical content is thoroughly researched and factually verified. After it has been factually verified it often will say so in the description. Should you find any mistakes, please email kolsimchaproductions@outlook.com so we can look into it and correct it. Not affiliated with any government agency or academic institution. Presented for educational and entertainment purposes — with meaning.Support the show — exclusive bonus episodes available to subscribers for just $2/month at spreaker.com/organization/kol-simcha
Nighttime heartburn affects millions of adults, and the solution may be simpler than expected. This episode covers the science of elevated sleeping, a practice dating back thousands of years, including common setup mistakes and what research actually shows. To learn more, visit https://inclinesleep.com/ Incline Sleep City: Glendale Address: 4439 W Greenway Rd Website: https://inclinesleep.com
Market news for July 16, 2026: Asian shares fell today, led by the sell-off in semiconductor, even as chipmaking giant TSMC announced its’ record earnings beat. Meanwhile, oil prices retreated slightly after the US completed its latest round of strikes on Iran. Synopsis: Market Focus Daily is a closing bell roundup by The Business Times that looks at the day’s market movements and news from Singapore and the region. Written by: Nicole Teo (nicolet@sph.com.sg) Produced and edited by: Chai Pei Chieh & Claressa Monteiro Produced by: BT Podcasts, The Business Times, SPH Media Produced with AI text-to-speech capabilities --- Follow Market Focus Daily and rate us on: Channel: bt.sg/btmktfocus Amazon: bt.sg/mfam Apple Podcasts: bt.sg/mfap Spotify: bt.sg/mfsp YouTube Music: bt.sg/mfyt Website: bt.sg/mktfocus Feedback to: btpodcasts@sph.com.sg Do note: This podcast is meant to provide general information only. SPH Media accepts no liability for loss arising from any reliance on the podcast or use of third party’s products and services. Please consult professional advisors for independent advice. Discover more BT podcast series: BT Money Hacks at: bt.sg/btmoneyhacks BT Correspondents at: bt.sg/btcobt BT Podcasts at: bt.sg/podcasts BT Lens On: bt.sg/btlensonSee omnystudio.com/listener for privacy information.
On today's episode, Editor in Chief Sarah Wheeler talks with Lead Analyst Logan Mohtashami about the June inflation report and what it means for mortgage rates. Related to this episode: July rate hike should be off the table with big June inflation miss HousingWire | YouTube More info about HousingWire The Top 5: July rate hike should be off the table with big June inflation miss What the ROAD to Housing Act means for agents, homebuyers JMG Brings $5.9B Teamerage Platform to Keller Williams Iran Conflict Lifts Mortgage Rates but Housing Demand Stays Positive MBA analysis finds minimal pricing impact from single credit score approach Want more from Sarah? Don't forget to subscribe! The HousingWire Daily podcast brings the full picture of the most compelling stories in the housing market reported across HousingWire. Each morning, listen to editor in chief Sarah Wheeler talk to leading industry voices and get a deeper look behind the scenes of the top mortgage and real estate.
The weekly radio show from Salvione, blending house, funk, and tech, resulting in an unparalleled energetic dance floor vibe. Castion – What's Mine (feat Liah Barrett) Avision – This Time Taranco – Laugh In Your Face Jorhav – Deeper Dale Howard – On Lock Havoc & Lawn – Eyes On YouMick Willow – Pose To Techno Attilio Gerardi – Back in the House SWAYLÓ – Pleasure Manuel Ribeca, Sohail – Loui Bag Jesse Bravo, Bryan Vera – Party Starter TEKO – People In The Back Jason Detox – Tag Poppin Loco Dice – Hold Up (You Feel That)
My village said I needed to create a space and share my MOTIVATIONS, what struggles and obstacles I've OVERCOME, and how these events and situations have ELEVATED me as a person in different aspects of my life! Guests join me to share their own personal stories from hardships to triumphs and everything in between. Tune in for great conversation, thought provoking art, and inspirations for a better you, today!
Elevated Academy Radio With Salvione: Jeffery J Guest Mix Show: Elevated Academy Radio Artist: Salvione Guest: Jeffery J Air Date: 11 July 2026 Genre: House / Tech House Elevated Academy Radio is the official showcase of rising talent from Elevated Academy, hosted by Salvione. Each episode features exclusive guest mixes from up-and-coming artists making serious waves in electronic music. Whether they're topping Beatport charts, playing alongside industry heavyweights, or crafting the next big anthem, these artists are proving that Elevated Academy is the launchpad for the next generation of dance music talent. For this episode, we're turning the spotlight on Jeffrey J, a DJ with deep musical roots and a signature sound blending vocal, tech, afro, melodic, and techno influences into high-energy sets built to move a crowd. After stepping away from the scene to focus on family, Jeffrey J returned to music with a renewed vision and purpose using Elevated Academy to sharpen his sound, rebuild momentum, and step back into the scene stronger than ever. As Jeffrey J puts it: “Elevated Academy was a total game-changer for me. After taking a hiatus to raise my family, working with Mike gave me the tools, clarity, and confidence I needed to come back stronger than ever and truly define my sound. Elevated Academy isn't just a production class; it's a mindset and a community." "This mix is everything I love about electronic music and a true representation of who I've become as an artist. Expect high-energy vocal-driven tech grooves, afro rhythms, melodic layers — all with my own signature spin and that pure energy I'm known for. These are the sounds and the labels I aspire to.” Turn it up, lock it in. Jeffrey J on Elevated Academy Radio. Here. We. Go.
Makoto Furukawa has impressed since the start with his powerful vibrato and unique, fancy brand of jazz-pop. However, since his solo debut, he has been perfecting his control and bringing new tools to his arsenal that have elevated his singing from "good" to "stellar", making Makoto Furukawa one of the best singers among male seiyuu.Music suggestions:- BAD SKUNK "Violet Love"- Makoto Furukawa "Uso to Gekko"- RUBIA Leopard "Prisoner"Thanks to M L for inspiring this series of episodes!
How can leaders elevate their impact without sacrificing their energy, focus, and quality of life? In this episode, Kevin talks with Laurie Maddalena about what it means to become an elevated leader in today's changing world of work. Laurie challenges the outdated belief that leadership requires constant overwhelm, availability, and personal sacrifice, and instead makes the case for leading with greater intention, self-awareness, reflection, and energy. Kevin and Laurie discuss why many leaders are promoted without real preparation, how the role shifts from doing the work to developing people, and why managers must move from being fixers to facilitators. They also discuss practical ways to protect focus and manage energy rather than just time. Listen For 0:00 Intro: Why Leadership Must Elevate 1:36 Meet Laurie Maddalena 2:33 Why She Wrote The Elevated Leader 3:54 The Big Idea Behind the Book 6:08 What Defines an Elevated Leader 7:11 The Starbucks Barista Problem 8:14 Laurie's Own Leadership Wake-Up Call 10:34 Is Everyone Meant to Lead? 13:37 Overview of the Elevated Leadership Model 14:23 Self-Awareness, Sleep, and Energy 15:35 Why Reflection Is Undervalued 18:20 Creating Clarity and Caretaking the Culture 20:24 Energy Patterns and Productivity Sprints 23:57 Treat Your Calendar Like "Cardiologist Time" 26:16 The Problem With Open-Door Policies 27:29 What Organizations Should Do to Support Leaders 29:11 Training Leaders Like a True Profession 31:55 What Laurie Is Reading Right Now 32:43 Where to Find Laurie 33:16 Closing: What Action Will You Take? Laurie's Story: Laurie Maddalena is the author of The Elevated Leader: Boost Your Confidence and Transform Your Team by Mastering Coaching, Accountability, and Difficult Conversations. She is a leadership provocateur, confronting outdated leadership models that reward exhaustion over effectiveness. As the founder of Envision Excellence, she helps managers go from "The Fixer" to "The Facilitator," enabling high-achieving leaders to deliver elite results without burnout. A former VP of HR by age 30, Laurie is a Certified Speaking Professional and has worked directly with influencers like Brené Brown and Jack Canfield. Laurie intentionally caps her workweek at 40 hours—demonstrating that sustainable success and elite results are not mutually exclusive, but essential to modern leadership. https://www.lauriemaddalena.com/ https://www.instagram.com/lauriemaddalena/ https://www.linkedin.com/in/lauriemaddalena/ https://www.facebook.com/people/Laurie-Maddalena/100063864253481/ https://www.youtube.com/@lauriemaddalena Book Recommendations The Elevated Leader: Boost Your Confidence and Transform Your Team by Mastering Coaching, Accountability, and Difficult Conversations by Laurie Maddalena The Transformation Economy: Guiding Customers to Achieve Their Aspirations by B. Joseph Pine II Like this? Solving the Culture Puzzle with Mario Moussa and Derek Newberry Bringing the Art of Reflection into Your Busy Life with Joseph Badaracco Energy and Leadership with Rick Maurer Join Our Community If you want to view our live podcast episodes, hear about new releases, or chat with others who enjoy this podcast join one of our communities below. Join the Facebook Group Join the LinkedIn Group Leave a Review If you liked this conversation, we'd be thrilled if you'd let others know by leaving a review on Apple Podcasts. Here's a quick guide for posting a review. Review on Apple: https://remarkablepodcast.com/itunes
In this special edition of market signals, LPL strategists share highlights from LPL Research's Midyear Outlook 2026 publication released on July 7. They share key themes for stocks, bonds, and the economy that LPL Research believes will be determining factors of second half returns. For stocks, progress toward monetization of artificial intelligence (AI) will be a key factor in the second half. LPL Research expects gains for stocks on the back of strong earnings growth and, if the macro backdrop improves, a slight increase in valuations. AI disappointments, geopolitics, and midterm elections are among the primary risks. For bonds, LPL Research expects sticky inflation and resilient growth to keep the Federal Reserve on extended pause, leaving Treasury yields range-bound, with the 10-year likely finishing the year between 4.00% and 4.50% absent disinflation or clear economic weakening. Tight credit spreads likely to persist, though AI-driven borrowing by hyperscalers may pressure spreads modestly higher. Returns may be income-driven as Treasury yields stay rangebound and credit spreads remain tight. Finally, U.S. economic growth should moderate but remain positive in the second half, with strong business investment helping offset weakness in other sectors. Elevated household net worth will continue to provide an important buffer for consumers. Expect inflation to moderate toward 2.9% by the end of 2026 and for unemployment to edge higher but remain historically low. Tracking: #1135966
⚕️ Soranus of Ephesus (c. 98–138 CE) stands among the most important physicians of the ancient world—especially for women's health. A leading representative of the Methodic school, he practiced in Alexandria and Rome, wrote with unusual clarity, and left a lasting mark through his great treatise on gynecology and midwifery. His work addressed pregnancy, childbirth, newborn care, bandaging, fractures, and acute and chronic disease with a practical, disciplined voice.
The weekly radio show from Salvione, blending house, funk, and tech, resulting in an unparalleled energetic dance floor vibe. Marco Lys & Ben Miller – So Good Fede Aliprandi, Bruno Bona – Mira Qobra, Fran Ares – Better Life Umberto Pagliaroli – Pick Pocket LoreFox & Serite – Magalenha Flavia Paurinotto – Nocheo Shermanology, Danny Howard – Party Girl Claptone, The Mekanism – Doing The Disco Feat. Jorge Bezerra Alexander Som – Out Of My Head Lauti Mina – Loco Manuel Ribeca, Rimbano – The Block David Lowe – The Baddest OFFAIAH – I'm Out ACID HARRY, Chris Valencia – Dame
This week on Fright Flick FMK, we got elevated, poured a drink, pressed play, and watched Evil Bong — Full Moon Features' stoner horror-comedy about a cursed bong named Eebee that sends people straight into Bong World. Yes. That is the movie. Fright Flick FMK is a horror movie watch-along and reaction show for fans who like their scary movies with attitude, laughs, bad decisions, and zero fake polish. We watch horror movies in real time, react to the chaos, talk through the nonsense, and give our honest take on what worked, what flopped, what made us laugh, and what made us question everyone involved. This episode has everything: a talking evil bong, stoner chaos, Bong World, Tommy Chong, low-budget Full Moon madness, and the kind of movie night that feels like hanging out with your friends after midnight. At the end, we put Evil Bong through the only rating system that matters: FMK. Marry It means the movie is a keeper — the kind of horror flick you can come back to again and again. F@#k It means it is a good time when the mood hits — maybe not forever material, but definitely worth another late-night visit. Kill It means the movie gave us a good time, we might tell our friends about it, but we are ghosting it in the morning. So pull up a chair, pour whatever you're pouring, light whatever you're lighting, and join the Fright Flick Family. Sip. Smoke. Scream. Rate. Drop your FMK rating for Evil Bong in the comments: Would you Marry It, F@#k It, or Kill It? #EvilBong #FrightFlickFMK #HorrorReaction
Financial Times reported a surge in analyst upgrades that is pushing valuations higher and raising concerns about a 2026 earnings bubble. Consensus earnings estimates shape pricing for the S&P 500 and Nasdaq and influence institutional portfolios, lender risk appetite, and corporate budgets. Rapid upgrades can expand multiples before revenue growth confirms the outlook, a pattern seen in past cycles tracked by FactSet and Refinitiv IBES. Elevated public valuations can support private pricing and IPO plans, while reversals can trigger down rounds, tighter covenants, and delayed listings. Founders can mitigate risk by building scenarios for 2026 and 2027, securing flexible financing, and structuring multi-year contracts with price escalators. Monitoring revision rates, sector breadth, forward price-to-earnings, equity risk premiums, credit spreads, and CEO commentary can guide operating decisions.Learn more on this news by visiting us at: https://greyjournal.net/news/ Hosted on Acast. See acast.com/privacy for more information.
AP Washington correspondent Sagar Meghani reports on a sharp drop in American hiring last month.
For decades, Polycystic Ovary Syndrome has been the name attached to one of the most common hormonal conditions affecting women worldwide. But the name was always problematic. It pointed to the ovaries as the origin of the condition and created a widespread misunderstanding that led to missed diagnoses, fragmented treatment, and millions of women leaving their appointments with more confusion than clarity. In this episode we unpack exactly why the name failed women and what has finally changed.PCOS Is Now Officially Called PMOSThe American Society for Reproductive Medicine has endorsed a new name for the condition previously known as PCOS. It is now called PMOS, Polyendocrine Metabolic Ovarian Syndrome. The name was developed through a global engagement process involving 56 patient organisations, a survey with 22,000 responses, and workshops with healthcare professionals and women with lived experience. Women with the condition were the biggest drivers of the change. This episode breaks down what the new name means and why every word in it matters.Metabolism and Hormone Communication: The Real Story of PMOSPMOS is not an ovary condition. It is a whole-body metabolic and endocrine condition. That distinction is everything. In this episode we explore how metabolism, insulin physiology, stress response, and hormone communication across the entire body are the real drivers of PMOS symptoms and why understanding this changes the entire approach to healing.Insulin and Reproductive Hormones: The Connection Nobody Told You AboutOne of the most important and most overlooked pieces of the PMOS puzzle is the relationship between insulin and the ovaries. When insulin levels are chronically elevated, as happens with insulin resistance, it signals the ovaries to produce more androgens. Elevated androgens then drive a significant cluster of PMOS symptoms including acne, irregular cycles, hair changes, and weight regulation challenges. This episode explains that connection in clear, accessible language.Why Your Symptoms Overlap and What That Actually MeansAcne. Fatigue. Cravings. Irregular cycles. Mood changes. Weight shifts. For women with PMOS these symptoms can feel random and disconnected. They are not. In this episode we walk through how every major PMOS symptom connects back to the same underlying physiological drivers and why understanding that connection is one of the most empowering things a woman with this condition can do.Why Many Women Feel Confused After a PCOS DiagnosisBeing handed a diagnosis is not the same as being given an education. Most women with PCOS were told very little about what was actually happening in their bodies. Some were given the pill. Some were given a pamphlet. Many were referred to multiple specialists who each addressed one symptom without ever looking at the whole picture. This episode validates that experience and offers the explanation that should have come at diagnosis.Understanding PMOS Beyond Cysts: A Whole Body ApproachMany women diagnosed with PCOS never had ovarian cysts at all. The diagnostic criteria includes three markers and only two are needed for diagnosis. Cysts are just one of those markers. This episode reframes PMOS as what it actually is: a polyendocrine metabolic condition that requires a whole-body, root-cause approach to genuinely support healing.You can take the quiz to discover your root cause hereThe PCOS Supplement GuideLet's continue the conversation on Instagram! What did you find helpful in this episode and what follow-up questions do you have?The full list of Resources & References Mentioned can be found on the Episode webpage at: https://nourishedtohealthy.com/ep-187
As a holistic and functional psychiatrist, I see many people who are highly sensitive. Most are deep divers into information and able to connect a lot of dots. Many are gifted. Many struggle with overwhelm and low stress tolerance. Some struggled with anxiety, inner tension, or feeling “too much” for as long as they can remember. Some feel different - that they don't fit in.As a holistic and functional psychiatrist with over twenty years in practice, I've worked with thousands of highly sensitive adults and children. Most are deep divers into information, able to connect a lot of dots — many are gifted. And yet many struggle with overwhelm, low stress tolerance, anxiety, or inner tension that has been there for as long as they can remember. Many feel different, like they don't quite fit in. What I've found is that sensitivity itself is rarely the problem — it's the seeming vulnerability to brain-related or physical conditions. Over the years I've found three different models to be especially useful in explaining some of the vulnerabilities and the strengths of those of us who are highly sensitive: Dr. Elaine Aron's work on the Highly Sensitive Person (HSP), the nutritional medicine concept of Pyrrole Disorder, and Dr. Sharon Meglathery's RCCX Theory. Each looks at a similar group of traits through a different lens — psychological, biochemical, and genetic, respectively.Before I start, I want to emphasize that sensitivity is not a pathology or a diagnosis. It is actually a trait that has existed across human history for a reason. My goal is not to pathologize it, but to understand it — and to offer tools to those who have these traits but who are struggling with a condition more prevalent in those with these traits. As I go through these three frameworks, the overlap will be obvious and I'll highlight what each of these has to offer that the others don't.What You'll Learn* The HSP model provides validation and a language for sensitive individuals.* Pyrrole Disorder involves an overproduction of pyrroles, leading to nutrient depletion of nutrients critical for neurotransmitter functioning.* Pyrrole Disorder is common in brain-related conditions.* RCCX Theory connects genetic vulnerabilities to sensitivity and chronic illness.* Stress amplifies the experiences of highly sensitive individuals.* Understanding these models can lead to effective treatment options.* There are meaningful paths forward for those who are highly sensitive.Chapters* 00:00 Understanding High Sensitivity* 02:26 The Highly Sensitive Person (HSP) Model* 10:23 Exploring Pyrrole Disorder* 18:18 RCCX Theory Explained* 30:11 Intersecting Models: HSP, Pyrrole Disorder & RCCX Theory* 34:40 Conclusion and Path ForwardI. THE HIGHLY SENSITIVE PERSONIn the early 1990s, psychologist Dr. Elaine Aron identified a personality trait she called Sensory Processing Sensitivity (SPS) — and the people who score high in it she called Highly Sensitive Persons, or HSPs.This is not a diagnosis. It is a trait, present in roughly 15–20% of the population. It has been found across more than 100 species — from fruit flies to primates. This tells us it is evolutionarily conserved — it confers survival advantages. In any social group, having members who are wired to notice subtle cues, process information deeply, and detect threats before others do is extremely valuable. Fitting with this, many of these individuals, who also struggle with complex chronic health issues are considered the “canaries in the coal mine” since their bodies react to environmental triggers (environmental toxins, chemicals, or stressors) long before the rest of the population.Dr. Aron captured the core features of this trait in an acronym she called DOES:D — Depth of processing: HSPs think deeply, reflect before acting, and notice subtleties that others miss.O — Overstimulation: Because they process so thoroughly, HSPs reach their threshold more quickly in high-stimulation environments.E — Emotional reactivity and Empathy: HSPs feel emotions intensely and are highly attuned to the emotions of those around them.S — Sensitivity to subtle stimuli: They pick up on things — in their environment, in social dynamics, in the body — that others simply don't register.As you can see, traits that are super powers, can become liabilities. The deep diver who loses sight of the big picture. The empath who absorbs everyone else's energy as their own energy becomes depleted. The person who withdraws from the world because the stimulation has simply become too much.HSP ResearchBeyond the clinical observations, there is now a growing body of neuroscience and genetic research supporting this trait. There is evidence that the brains of sensitive people are doing more, processing more and feeling more.fMRI studies (Acevedo, Aron et al., 2014) have shown that when HSPs view emotional images — particularly photos of loved ones expressing happiness or sadness — their brains show significantly greater activation in regions associated with awareness, empathy, and sensory integration.Twin studies show that Sensory Processing Sensitivity (SPS) as defined by Dr. Aron is approximately 47% heritable. Small studies as opposed to large genome wide studies have focused on genetic variants involving dopamine and serotonin systems, such as a serotonin transport gene, a dopamine receptor gene, and COMT, which codes for the enzyme that metabolizes dopamine and norepinephrine.While this hints at a biochemical dimension, the HSP framework doesn't address this as directly as the other two models I'll discuss, nor does it explain the higher prevalence of physical health conditions in those who are highly sensitive.Research published in 2026 (Matsuzawa et al.) found that individuals high in SPS had substantially higher rates of depression (13.8%), anxiety disorder (10.5%), and developmental disorders, such as ADHD and ASD, compared to the general population.Despite this overlap with developmental disorders: unlike, ADHD, HSPs typically have excellent concentration in quiet environments. And unlike the social deficits described in ASD, HSPs tend to have heightened social attunement. They often feel too much of what's happening in social situations, not too little, even if they respond awkwardly at times.Research shows that high sensory processing sensitivity is associated with more frequent physical symptoms — back pain, fatigue, digestive issues, frequent illness.What This Framework OffersThe HSP model has given millions of people validation and a language for these traits that has allowed them to shift from “what is wrong with me” to “this is how I am wired.”It also offers an evolutionary reframe. High sensitivity is not a mistake and is not pathologic. It is a feature of the human population that has served us.What it doesn't offer is a biological explanation for why some sensitive people suffer so acutely — or a path toward biochemical intervention. II. PYRROLE DISORDERPyrrole disorder is a biochemical imbalance that has been recognized for decades, though it remains largely unknown in mainstream psychiatry. It involves an overproduction of pyrroles — metabolic byproducts that, on their own, are not a problem. When they are high, however, they can result in a depletion of zinc, B6 and a few other nutrients.First identified in the 1950s and first treated with zinc and B6 in the 1980s, pyrrole disorder is one of the most common nutrient imbalances found in brain-related conditions — and one of the most treatable. Yet most people who have it have never heard of it. I learned about pyrroles in 2014 when I first trained with the Walsh Research Institute.The Importance of Zinc, B6 & MagnesiumVitamin B6 is required to synthesize dopamine, serotonin, and GABA — three of the most critical neurotransmitters for mood regulation, anxiety, and stress response. Zinc plays a profound role in the central nervous system, the immune system, gastrointestinal tract (which we now know has its own significant influence on brain health) and connective tissue (joints and skin).Pyrrole Disorder Traits & SymptomsThe most consistent feature is low stress tolerance. People with elevated pyrroles are often described as those for whom life seems harder than it should be, every transition can be destabilizing and every large group or new environment feels like too much.The overlap with the HSP profile is striking, but here, we start to see not only traits, but symptoms.- Socially anxious, shy, or fearful since childhood, with severe inner tension- Sensitive to bright light, loud noises, textures, and odors- Avoids crowds, strangers, and new situations- History of reading difficulty- Poor short-term memory- Underachievement- Irritability, mood swings, bouts of depression- Tends to stay up late; little or no dream recall; morning nausea- White spots on fingernails; very dry skin; stretch marks; poor wound healing- Joint pain- Frequent infections or autoimmune tendenciesMost people with pyrrole disorder don't have all of these symptoms — but the inner tension, the high sensitivity, and low stress intolerance are very common.What the Data ShowsThe Walsh Research Institute has collected data on over 30,000 patients. Elevated pyrroles were found in:* 18% of those with ADHD* 24% of those with depression* 28% of those with behavioral disorders* 35% of those with autism* 35% of those with bipolar disorder* 30% of those with schizophrenia* 12% of those with PTSDAnd in only 8% of healthy controls — meaning those with no psychiatric diagnosis.What Causes Pyrrole Disorder?For many, there appears to be a genetic component, but for others, pyrroles appear to have increased due to high physiologic or emotional stress. Examples include candida overgrowth or other forms of gut microbial imbalances, mold toxicity, heavy metals, chemical exposures, illness, emotional trauma, major life transitions or even growth spurts in children.What This Framework Brings UsRelative to the HSP framework, an understanding of pyrroles gives a specific, treatable biological mechanism. When zinc, B6, Magnesium and other nutrients are depleted, we know how the brain's neurotransmitter functioning is affected — and we know what to do about it.Treatment from a Walsh Research Institute trained practitioner typically involves a nutrient protocol of zinc (based on zinc and copper testing), B6 or its active form P5P, and other nutrients for pyrrole disorder and other nutrient imbalances identified. For many patients, a lifetime of chronic inner tension and fearfulness begins to shift within days to a couple of weeks of starting the nutrients.Treatment doesn't change one's personality, but it can improve social discomfort, overwhelm, the anxiety, the depression that has been layered on top of that sensitivity.Where zinc deficiency can impact a lot of the physical conditions that appear to be more common in those who are hypersensitive, it doesn't fully explain the significant hormonal, inflammatory, connective tissue symptoms and autoimmunity we see in many who are hypersensitive.III. RCCX THEORYRCCX theory has been proposed by Dr. Sharon Meglathery, MD — a psychiatrist and internist whose own complex health history (which is very similar to my own) led her to one of the most compelling explanations I've encountered for why hypersensitivity, neurodivergence, psychiatric conditions, MCAS (Mast Cell Activation Syndrome), EDS (Ehlers Danlos Syndrome), POTS (Postural Orthostatic Tachycardia Syndrome), CIRS (Chronic Inflammatory Response Syndrome) and/or CFS (Chronic Fatigue Syndrome) and autoimmunity tend to cluster together in certain individuals and families.RCCX refers to a module of four genes on chromosome 6. Three of them appear to be particularly important to our health, and two of those have very high rates of mutation.The Three Key Genes(1) TNXB codes for a protein involved in connective tissue. Variants range from subtle joint hypermobility to Ehlers-Danlos Syndrome. But connective tissue isn't just about joints — it's also about the permeability of the gut-blood barrier, the blood-brain barrier, and vulnerability to upper cervical (neck) instability, which can put tension on the vagus nerve and affect the entire autonomic nervous system.(2) CYP21A2 is the most important gene in the module when it comes to psychiatric conditions. It codes for 21-hydroxylase, an enzyme needed to convert 17-hydroxyprogesterone into cortisol. When there is a mutation — and there can be many, of varying degrees — the body may struggle to meet the demand for cortisol under stress. A weakness on this gene could have two primary effects:First — The theory holds that many people with CYP21A2 mutations, even without hypermobility, may develop what Dr. Meglathery calls a “brain wired for danger” — essentially, a nervous system calibrated toward threat detection from early in life, with minimal trauma required. A mutation on CYP21A2 may essentially result in relatively higher androgens impacting the amygdala — the brain's fear and emotional center. Studies have found that hypermobile individuals (who often carry TNXB mutations) have a larger-than-normal amygdala.Second — because of this mutation, the body may not be able to keep up with the body's need for cortisol (especially when under stress). This deficit causes the brain to release corticotropin releasing hormone (CRH) to signal the adrenal glands to produce more cortisol. CRH binds to mast cells and activates the immune system — leading to secondary brain inflammation. This is the inflammatory pathway that can result in a number of secondary health issues including MCAS, CIRS, POTS, CFS and more.(3) C4 is involved in immune response and autoimmunity, and has been linked to schizophrenia. This gene variant is not as common as the first two referenced, though I do see a number of families who also have autoimmunity impacting multiple family members.The CAPS Psychological ProfileDr. Meglathery uses the term CAPS — CYP21A2 Mutation Associated Neuropsychiatric Spectrum — to describe the psychological profile she has observed in people with this genetic vulnerability. These traits can exist long before any formal psychiatric diagnosis, and they are not inherently pathological. - Anxiety and over-arousal during times of stress — high adrenaline, insomnia, sometimes manic-like characteristics- Under-arousal during low-stress periods — leading to ADD presentations, compulsive behaviors, or thrill-seeking to raise arousal- High emotionality, sensitivity, and reactivity to environmental stimuli- Sensory processing difficulties — typically over-stimulation in loud or chaotic environments- A strong ability to read emotions in others, paired with social awkwardness in response- Easily affected by events others would consider minor — an offhand comment, a disturbing movie- A tendency toward nonconformity- Special abilities: gifted musicians, scientists, creatives, systems thinkers- Hyper-focus and obsession with areas of deep interest, often leading to remarkable accomplishments- High tenacity and determination, when not derailed by overstimulation or past trauma- Strong emotions — positive or negative — that can manifest as obsessional worrying, harm avoidance, OCD tendencies, or very high standards for self and othersDr. Meglathery also notes — and I have observed this clinically — that people with this profile tend to find each other through friendships, partnerships and marriage. They are drawn together by shared sensitivities, emotional depth, and intellectual gifts. This means children are likely to receive a tendency towards CAPS from both sides.Women who are appear to have CYP21A2 mutations often have a male-pattern finger length ratio — the ring finger longer than the index finger — a possible marker of androgen exposure during development.What RCCX OffersRCCX theory offers the broadest biological framework we have for understanding why sensitivity, psychiatric vulnerability, and complex chronic illness so often travel together in the same people and families. It connects the nervous system, the immune system, the hormonal system, and connective tissue under one genetic umbrella.It also points toward specific interventions: nervous system regulation (limbic retraining, vagal work), mast cell management, and addressing the downstream biochemical consequences of cortisol dysregulation.The limitation is that genetic testing for variants on the gene for 21-hydroxylase is not yet widely available, which is why this isn't a gene that you'll see referenced when it comes to HSP, though I would argue it is likely the most prevalent. RCCX remains a clinical theory — but one that explains the constellation of traits and symptoms of most of the people that I in my practiceIV. WHERE THESE MODELS INTERSECTWhere Might Pyrrole Disorder and RCCX Theory Meet?The symptom overlap is almost complete: poor stress tolerance, sensory sensitivities, anxiety, inner tension, connective tissue symptoms, frequent infections, autoimmune tendencies. Relatively low zinc would impact most of these shared symptoms, but there may be a potentially deeper connection.21-hydroxylase contains a pyrrole-like structure — heme — within it. Could a mutation resulting in abnormal 21-hydroxylase lead to a buildup of abnormal heme-like compounds, contributing directly to pyrrole disorder? This is not proven, but in an exchange about this with Dr. Meglathery, she indicated that she also believes there is a strong association, and the biochemical logic is compelling.This matters, because we know what helps pyrrole disorder. We have a treatment — treatment that can complement what RCCX theory makes evident — that the stress response has to be addressed.Stress (again from any cause - physiologic or emotional) is the great amplifier across all three models. Stress worsens the HSP experience, and tips the CYP21A2 mutation from manageable to destabilizing (through the hormonal consequences and the inflammatory cascade) and yes, it even causes pyrroles to increase.BRINGING IT TOGETHERFor someone who is highly sensitive, and struggling with brain related or physical symptoms or conditions, pyrrole disorder and even RCCX theory are worth considering because they offer tools and start to answer, “What Can We Do About It?”The three frameworks work together:The HSP model offers validation and language. It shifts the frame from deficit to difference. It reminds us that sensitivity is not pathology — it is a trait with evolutionary value, and it comes with great strengths.The Pyrrole model offers a treatable nutrient imbalance. It explains, at the neurotransmitter level, why stress hits harder for these individuals. Treatment doesn't take away the sensitivity; it lifts the weight that has accumulated on top of it.The RCCX model offers the broadest systems view. It connects the dots between what the body is doing — the immune activation, the hormonal dysregulation, the connective tissue involvement — and the psychiatric and psychological profile that tends to accompany it. It also provides additional tools: nervous system regulation, mast cell support, hormonal awareness.If any of this resonates — the sensitivity, the inner tension, the feeling of always being at the edge of overwhelm — please know that there are roots to explore and meaningful paths forward.If you are looking for someone trained by the Walsh Research Institute knowledgeable in assessing for and treating pyrrole disorder (and other common nutrient imbalances impacting brain health), or learning more about Dr. Aron's work on HSP and Dr. Meglathery's RCCX theory, I am providing those links below.And as always, I welcome your thoughts, experience and questions.Until next time,CourtneyAbout the AuthorDr. Courtney Snyder MD is a Holistic and Functional Child and Adult Psychiatrist who offers non-patient consultations to individuals and practitioners nationally and internationally in addition to her treatment practice serving FL, IN, KY, OH. Her educational content, shared through her website, Substack Newsletter, the Holistic Psychiatry Podcast and YouTube Channel reaches readers and listeners in over 160 countries.ResourcesWalsh Research Institute: walshinstitute.orgRCCX Theory — Dr. Sharon Meglathery: rccxandillness.comDr. Elaine Aron — The Highly Sensitive Person: hsperson.comOther Sources: Acevedo et al. 2014, “The Highly Sensitive Brain,” Brain & Behavior | Matsuzawa et al. 2026, Psychiatry & Clinical Neurosciences ReportsMedical Disclaimer:This newsletter is for educational purposes and not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment for either yourself or others, including but not limited to patients that you are treating (if you are a practitioner). Consult your physician for any medical issues that you may be having. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit courtneysnydermd.substack.com/subscribe
The weekly radio show from Salvione, blending house, funk, and tech, resulting in an unparalleled energetic dance floor vibe. Julio Torres, Ketoots - I Belong HereGruuvElement's - Call Me CrazyChica - C'vest La VieEros (RO), Dario Christian - Disco MusicJuan (AR), Geovanni - TripianoAndrea Rdam - Sexy FirstSupernova, Marco Lys, House Of Molly - Kente FlowEmanuele Inglese - Shake ItKess - ShineVince Monte - Groove TalkBrandon Caballero - Not Supposed ToFran Ares, Lexlay - Super CoolViktør, Morena Prudente - Deep From UndergroundNokari, GIOC - Late Night Call
Episode Overview In this episode, we explore the alarming surge in cardiac care demand and its direct link to systemic leadership stress. Featuring insights from Michael D. Levitt, Founder and Chief Burnout Officer of Breakfast Leadership, we move beyond the idea of "bad luck" to examine how broken organizational systems are literally breaking the hearts of executives. Key Highlights & Statistics The Cardiac Surge: Demand for outpatient cardiology procedures is projected to increase by 25% over the next decade, while the industry itself is growing at a 4% compound annual rate. A Workforce Crisis: Cardiovascular disease claims a life every 33 seconds in the U.S.. Crucially, one in five cardiovascular deaths occurs in adults younger than 65—working-age leaders who are often high-performing until the moment of a health crisis. The Physician Shortage: While demand spikes, the Association of American Medical Colleges projects a shortfall of over 7,000 cardiologists by 2034. Physiology of Stress: Chronic workplace stress is not just a "feeling." It triggers a physiological chain reaction: Elevated cortisol leads to chronic inflammation, which accelerates cardiovascular disease. The "Leadership OS" Failure Michael Levitt shares his personal journey of surviving a 2009 cardiac event and the 369 days of "worst-case scenarios" that followed. He argues that you "cannot meditate your way out of a broken system" and identifies three structural pillars that, when missing, create toxic stress: Decision Clarity: Without it, leaders operate in permanent ambiguity, causing sustained cortisol elevation. Operational Rhythm: A lack of rhythm means the nervous system never fully recovers between demands. Culture Infrastructure: Broken culture forces individuals to absorb systemic dysfunction rather than the system holding it. Actionable Solutions for Executives and HR To prevent leadership health events from becoming business continuity crises, organizations must make three structural commitments: Measure Stress Drivers: Track decision fatigue, role ambiguity, and "always-on" communication norms. Design for Recovery: Treat recovery as a prerequisite for performance, not a reward for it. Preventive Investment: View leadership health as a business continuity issue; it is cheaper to protect a leader than to replace one. Featured Resources Book: 369 Days: How To Survive The Worst Year Of Your Life by Michael D. Levitt. Organization: Breakfast Leadership Network – Specializing in burnout prevention and leadership strategy. Featured Practice: San Diego Cardiac Center – A model for specialized, patient-centered cardiovascular care. Tool: Schedule a Leadership Diagnostic to identify structural stress points in your organization. The Bottom Line "Your leadership system either protects the people inside it, or it quietly depletes them. There is no neutral position".
The June 25 edition of Commodity Week featured analysis from Arlan Suderman of StoneX, Curt Kimmel of AgMarket .net, and Greg Johnson of Total Grain Marketing. The panel evaluated the impending June 30 USDA acreage and quarterly grain stocks reports, noting that these figures, alongside developing weather patterns, will establish the primary direction for the markets. Expectations for corn acreage generally reflect a slight decrease from March intentions, while soybean acreage is anticipated to be marginally higher.Weather remains a dominant factor as the corn crop approaches its critical July pollination window. Elevated temperatures will accelerate growing degree days, but sustained heat combined with high overnight temperatures could negatively impact final yields. The panel also highlighted specific agronomic risks moving into the latter half of the summer. These include the eastward drift of smoke from western wildfires and the potential for southern mold spores to increase disease pressure, making fungicide application decisions crucial for producers this season (CropProtectionNetwork.org).Significant uncertainty persists regarding international trade commitments on the demand side. The market is closely monitoring China's purchasing pace to determine if the nation will meet its stated targets by the end of the calendar year. Additionally, potential agricultural shipments to Iran, facilitated by the use of frozen assets, represent another unresolved variable that could substantially tighten the overall balance sheet. Until these international demand factors and late-season weather impacts are clarified, producers are exhibiting notable reluctance to make new crop sales at current price levels.Panelists - Greg Johnson, Total Grain Marketing - Curt Kimmel, AgMarket.net - Arlan Suderman, StoneX ★ Support this podcast ★
Answering your questions again this month. And this time we had a theme of Client-Facing questions.You asked about an elevated client experience, what to include in your FAQs and more in this episode of May's Ask Away.This month's Ask Away is Friday June 26th at 11am CST. Would love to see you there and answer your questions.Join the Patreon Community for Ask Aways, group coaching calls, teachings, and ad-free episodeshttps://patreon.com/wittpod----Follow the showPatreon: https://patreon.com/wittpodWebsite: https://podcast.allheartphoto.comInstagram: https://instagram.com/witt.podYouTube: https://www.youtube.com/@wisdominthetangents
The Federal Reserve's latest policy shift under new governor chair Kevin Warsh marks a significant regime change for global markets. With the dot plot revealing two potential rate hikes and a shift away from forward-looking guidance, investors face heightened market uncertainty across stocks, crypto, and real estate. This discussion cuts through the media noise to analyze macro data points, including the geopolitical resolution with Iran, falling energy prices, and the approaching $930 billion commercial debt maturity wall. While mainstream capital retreats to the stock market, sophisticated investors recognize that slow, stale, and sideways markets offer generational opportunities. This episode explains the math behind negative leverage, the critical role of the 10-year Treasury note, and why the absolute best real estate deals are historically secured before rate cuts occur, not after. Discover how to build defensive buffers into your underwriting parameters to transform macroeconomic headwinds into asymmetric long-term wealth. KEY TOPICS DISCUSSEDMacroeconomic analysis of Fed Chair Kevin Warsh's first FOMC meeting and monetary policy adjustments Geopolitical implications of the US-Iran memorandum of understanding and its impact on global crude oil volatility Understanding the "Fed Trap" and balancing the risks of reigniting inflation versus fracturing economic growth Technical evaluation of the 10-year Treasury note as the foundational gravitational force for commercial lending benchmarks Financial underwriting frameworks for identifying and avoiding negative leverage in a 6% to 7% interest rate environment Strategic management of the upcoming $930 billion maturing commercial real estate debt wall Asset allocation rotation from overvalued equity sectors into distressed, undervalued real estate opportunities KEY TAKEAWAYSLock in your real estate opportunities before the Federal Reserve cuts interest rates. Historically, the most profitable assets are acquired when market sentiment is deeply depressed and capital sits passively on the sidelines. Treat the Federal Reserve's policy decisions as macroeconomic weather rather than an absolute indicator of deal viability. Successful investing relies on strict individual deal underwriting rather than relying on central bank rescue parameters. Address floating-rate debt maturities 12 to 18 months in advance. Initiating proactive refinancing and restructuring conversations with lenders prevents forced liquidations when interest rate environments shift. Implement structural buffers of 50 to 100 basis points above current market rates when modeling new investments. Ensuring a deal cash-flows under restrictive conditions turns future monetary easing into pure financial upside. Monitor the 10-year Treasury note on a weekly basis to filter out short-term market noise. A sustained technical break below the 4% threshold serves as the primary signal that institutional debt conditions are turning positive. CONNECT & TAKE ACTIONSchedule a professional portfolio review with Ryan's team: Text "X-ray" to 844-447-1555 Build steady mailbox money with the Imagos Income Fund: Text "income" to 844-447-1555 Join the exclusive newsletter for unfiltered market insights: Text "WIB" to 844-447-1555 Access institutional investor resources and trackers: thewiseinvestorvault.com Gain direct access to accredited private placement deal flow: Text "deals" to 844-447-1555 Review comprehensive media notes and digital resources: millionairemindcast.com Connect directly with Matty A on corporate social channels: @officialmattya
The weekly radio show from Salvione, blending house, funk, and tech, resulting in an unparalleled energetic dance floor vibe. Gaba – Spin Doctor GruuvElement's – Call Me Crazy Chicks Luv Us – EyeLove Eros (RO), Dario Christian – Disco Music Juan (AR), Geovanni – Tripiano Andrea Rdam – Sexy First Supernova, Marco Lys, House Of Molly – Kente Flow Emanuele Inglese – Shake It Kess – Shine Umberto Pagliaroli, Sohail – Anybody Else Brandon Caballero – Not Supposed To Fran Ares, Lexlay – Super Cool LOVRA, WeMart – Elevate Chicks Luv Us – Funké Funké
Smart, Not Spoiled: The 7 Money Skills Kids Must Master Before Leaving the Nest by Chad Willardson https://www.amazon.com/dp/1544524250 Chadwillardson.com Two-thirds of American parents today think their children are spoiled. From toys and laptops to smartphones and cars, our kids have grown increasingly entitled in what they believe we should do for them. Kids may not appreciate the value of a dollar, but it's hard to blame them. After all, what have they learned about money? Managing finances is rarely covered in schools, and as a parent, you probably don't know where to start. How do you provide a strong foundation of financial knowledge for your kids with these gaps? What should they learn each year? How do you teach a skill set you never received yourself? In Smart, Not Spoiled, financial expert and bestselling author Chad Willardson provides you with practical tools, tips, and stories that will help you teach the kids in your life how to think about money. Chad explores the seven skills your kids should know—and master—before they're adults and helps you improve the financial literacy of everyone in your household. When it comes to financial success, you want your kids informed and prepared. This book is your chance to learn together so that the new path you forge for future generations is the right one. About the author Chad Willardson, CFF, CRPC, AWMA, is the President of Pacific Capital (a fiduciary wealth advisory firm he founded in 2011 that serves entrepreneurs and families) and ELEVATED (a coaching program for a select group of growth-focused entrepreneurs). He is the author of six best-selling books, creator of a new banking app that helps kids manage money, and Co-Host of The Smart Money Parenting Show, number 2 Podcast on Apple worldwide for Parenting, Kids & Family. Before founding Pacific Capital, he spent 9 years at Merrill Lynch, where he ranked in the top 2 percent of over 16,000 Financial Advisors nationally. In addition to serving the family office clients of Pacific Capital, Chad also manages the 650 million dollar investment portfolio as the elected City Treasurer in his community. Chad is recognized as one of the top wealth management experts in the country and has appeared in The Wall Street Journal, Forbes, Inc., NASDAQ, Yahoo Finance, U.S. News & World Report, InvestmentNews, Entrepreneur, and Financial Advisor Magazine. He lives in Southern California with his wife, Amber, and their five children.
Welcome to the re-launch of Elevated Frequencies FHz.In this inaugural return episode, we honor Juneteenth by reflecting on the meaning of freedom, the importance of remembering our history, and the interconnected legacies of Black and Indigenous communities.Together, we explore freedom not only as a historical event, but as a daily practice—one that invites us to heal, reflect, reclaim our voices, and become more intentional about how we live.This conversation is for anyone navigating growth, healing, identity, and the journey back to themselves.Topics discussed:• The significance of Juneteenth• Black and Indigenous history and legacy• Freedom beyond physical liberation• Healing, remembrance, and self-discovery• The return and vision of Elevated Frequencies FHzTake a deep breath, settle in, and join the conversation.Supreme rising, beautiful souls. Welcome home.
Shiru - שירו by Romemu: Jewish Life, Elevated
Mizmor L'David - מזמור לדוד by Romemu: Jewish Life, Elevated
Lecha Dodi - לכה דודי by Romemu: Jewish Life, Elevated
Ma Gadlu - מה גדלו by Romemu: Jewish Life, Elevated
Barchu - ברכו by Romemu: Jewish Life, Elevated
Mi Chamocha - מי כמוך by Romemu: Jewish Life, Elevated
The housing market in 2026 is defined by contradictions. Demand remains strong, yet affordability challenges persist. Builders continue to innovate, even as uncertainty clouds the economic outlook. Meanwhile, demographic shifts and changing consumer preferences are reshaping what Georgians want from their homes. In part two of Atlanta Real Estate Forum Radio‘s mid-year market update, Jim Jacobi of Parkland Communities, Tim Arnold of D.R. Horton and Cara Lavender of John Burns Research and Consulting (JBREC) join Host Carol Morgan to discuss the forces driving today’s market. From the evolution of build-to-rent communities to construction costs and changing buyer expectations, the panel explored how industry leaders are adapting to a rapidly evolving landscape. Demographic Shifts Will Shape the Next Decade While much attention is focused on mortgage rates and affordability, longer-term demographic changes deserve equal consideration. An aging population, later marriages, declining birth rates and multigenerational living are altering housing demand. These shifts could influence everything from home design and community amenities to product mix and location strategies over the next decade. “I think it’s kind of those changing demographics that are going to change what products we need, what type of housing we need, where we need it,” Lavender said. Buyers Want More Choice & Better Value Buyer priorities have evolved significantly since the post-pandemic housing boom. During the height of the market, consumers were eager to purchase almost any available home. Today, buyers are more selective and focused on maximizing value. “They want to see more options, they want to have more choices,” Arnold said. Rather than concentrating solely on purchase price, buyers increasingly evaluate value through the lens of square footage, functionality and available floor plans. Builders are responding by offering a wider variety of products within communities and across submarkets. Affordability Means More Than Home Price “Affordability is not just the house price,” Jacobi said. “Affordability is everything across the board.” Emerging mortgage products designed to reduce barriers to homeownership are also helping expand access, including programs featuring zero down payments, no private mortgage insurance and reduced closing costs. As lenders introduce more creative financing solutions, these tools could help more buyers achieve homeownership despite elevated rates. Build-to-Rent Communities Continue to Evolve Build-to-rent communities are entering a new phase of maturity, with developers moving away from one-size-fits-all approaches. Mixed-product developments featuring townhomes, single-family homes and ranch-style offerings designed for aging renters are becoming increasingly common. Research from JBREC points to the same trend. “When we look at that delivery pipeline, it’s pretty clear that townhomes and those mixed-product communities are going to be what dominates BTR deliveries in 2027,” Lavender said. At the same time, renters are prioritizing practical value over luxury amenities. While amenities such as pools and fitness centers remain desirable, residents place greater emphasis on low-maintenance living, responsive management teams and services such as lawn care. Construction Costs Remain a Daily Challenge Although slowing housing starts have eased some labor pressures, construction costs continue to fluctuate. “We work on it every day,” Arnold said. “It just continues to be a shift.” Lumber pricing, tariffs and petroleum-based products all contribute to ongoing volatility. However, reduced apartment construction has expanded the available labor pool for residential projects. That increased competition among trades may help stabilize pricing moving forward. Data Centers Create New Competition Another emerging factor is the rapid growth of data center development. Large-scale investments from companies such as Amazon, Google, Meta and Microsoft could eventually impact residential construction by competing for labor and land. According to broker surveys conducted by JBREC, approximately one-third of respondents reported seeing residential land transactions redirected toward data center projects. While not yet widespread, it is a trend the industry is watching closely. The New Reality: Lower Velocity & Greater Uncertainty Builders and developers have adjusted expectations in response to a more cautious environment. Sales pace, lease-up rates and incentives are increasingly built into underwriting models. Rather than anticipating rapid improvement, many operators are planning for a prolonged period of moderation extending into 2027. The Grind Before the Next Growth Cycle The defining characteristic of today’s housing market may ultimately be its complexity. Elevated interest rates, rising costs, shifting regulations and global economic uncertainty have forced builders, developers and researchers to rethink long-held assumptions and adapt in real time. Rather than waiting for a return to the conditions of the past, industry leaders are learning to operate in an environment where flexibility, discipline and execution matter more than ever. Growth may come more slowly, and success may require a greater willingness to adjust strategies as conditions evolve. Yet beneath the headlines about affordability challenges and market headwinds, the industry’s core mission remains unchanged. Housing is about more than economics and forecasts. It is about creating places where people build their lives, raise families and invest in their futures. Even amid uncertainty, the enduring value of homeownership continues to provide both purpose and optimism for those shaping the next chapter of the housing market. Ready to hit rewind on Part 1? Listen to the full episode here. About Parkland Communities Parkland Communities, Inc., the parent company of build-to-rent home builder, Parkland Residential, is a privately owned, multifaceted real estate development and investment firm specializing in residential properties. With over 20 years of experience in the industry, Parkland Communities Inc. uses the latest market data, technology and established relationships to strategically secure new development opportunities in Atlanta's most desirable locations. The company's hands-on philosophy has made it a proven leader in the industry with a trusted reputation among elected officials, municipal staff, neighborhood associations, bankers and home builders. For more information on Parkland Communities, visit www.ParklandCo.com. About D.R. Horton As one of metro Atlanta’s leading home builders, D.R. Horton offers new homes across a variety of price points, product types and locations throughout the region. The company builds communities designed to meet the needs of first-time homebuyers, move-up purchasers and those seeking low-maintenance living, with a focus on quality construction, thoughtful design and attainable homeownership opportunities. Backed by the resources of America’s largest home builder, D.R. Horton continues to play a significant role in expanding housing options across Georgia’s growing markets. Learn more about D.R. Horton at https://www.DRHorton.com/. About John Burns Research and Consulting John Burns Research and Consulting provides data-driven insights across every housing sector, including new home construction, resale, single-family rental and build-to-rent. It helps companies make informed decisions and mitigate risk in order to identify opportunities in a complex market. From M&A projects to consumer surveys, the firm covers every aspect of the housing industry. Learn more about John Burns Research and Consulting at https://JBREC.com/. Podcast Thanks Thank you to Denim Marketing for sponsoring Atlanta Real Estate Forum Radio. Known as a trendsetter, Denim Marketing has been blogging since 2006 and podcasting since 2011. Contact them when you need quality, original content for social media, public relations, blogging, email marketing and promotions. A comfortable fit for companies of all shapes and sizes, Denim Marketing understands marketing strategies are not one-size-fits-all. The agency works with your company to create a perfectly tailored marketing strategy that will suit your needs and niche. Try Denim Marketing on for size by calling 770-383-3360 or by visiting www.DenimMarketing.com. About Atlanta Real Estate Forum Radio Atlanta Real Estate Forum Radio, presented by Denim Marketing, highlights the movers and shakers in the Atlanta real estate industry – the home builders, developers, Realtors and suppliers working to provide the American dream for Atlantans. For more information on how you can be featured as a guest, contact Denim Marketing at 770-383-3360 or fill out the Atlanta Real Estate Forum contact form. Subscribe to the Atlanta Real Estate Forum Radio podcast on iTunes, and if you like this week's show, be sure to rate it. Atlanta Real Estate Forum Radio was recently honored on FeedSpot's Top 100 Atlanta Podcasts, ranking 16th overall and number one out of all ranked real estate podcasts. The post What's Really Changing in Housing Right Now? appeared first on Atlanta Real Estate Forum.
In this episode, Ayesha and Andrew discuss the June 17, 2026 issue of JBJS, along with an added dose of entertainment and pop culture. Listen at the gym, on your commute, or whenever your case is on hold! Link: JBJS website: https://jbjs.org/issue.php Sponsor: This episode is brought to you by JBJS Clinical Classroom. Subspecialties: Orthopaedic Essentials, Hip, Basic Science, Spine, Infection, Foot & Ankle, Education & Training, Shoulder Chapters (00:00:02) - Your Cases On Hold(00:01:42) - Top 10 in Orthopedic Surgery: The Legacy of Aaron Rosenberg(00:06:38) - Robinson on Research Expectations(00:18:12) - The role of research in the medical student curriculum(00:19:09) - Residency and the role of research in surgery(00:21:02) - Bone metabolic activity after total hip arthroplasty(00:29:19) - Periprosthetic Joint Infection after total knee arthropl(00:40:37) - Patients with pneumonia after total knee arthroplasty(00:48:57) - Deep Learning System for Lengthy Classification in Adolescent Idiopath
Nationwide Mutual's Senior Vice President and Chief Economist Kathy Bostjancic says the Fed may be approaching a neutral stance, but inflation is expected to remain above the 2% target through year-end. She sees the Fed holding steady for now, with rate cuts likely pushed into next year, while noting that reduced Fed communication could spark volatility even as the labor market and AI investment signal underlying economic strength.======== Schwab Network ========Empowering every investor and trader, every market day.Subscribe to the Market Minute newsletter - https://schwabnetwork.com/subscribeDownload the iOS app - https://apps.apple.com/us/app/schwab-network/id1460719185Download the Amazon Fire Tv App - https://www.amazon.com/TD-Ameritrade-Network/dp/B07KRD76C7Watch on Sling - https://watch.sling.com/1/asset/191928615bd8d47686f94682aefaa007/watchWatch on Vizio - https://www.vizio.com/en/watchfreeplus-exploreWatch on DistroTV - https://www.distro.tv/live/schwab-network/Follow us on X – https://twitter.com/schwabnetworkFollow us on Facebook – https://www.facebook.com/schwabnetworkFollow us on LinkedIn - https://www.linkedin.com/company/schwab-network/About Schwab Network - https://schwabnetwork.com/about
In this episode of State of the Republic, we break down Sacramento Republic FC's hard-fought 1–0 road win over Colorado Springs Switchbacks FC. The victory not only secured three valuable points, but also snapped Sacramento's recent stretch of away frustrations after back-to-back road losses. We discuss the key moments from the match, what stood out from the performance, and what this result could mean moving forward. We also preview Republic's upcoming matchup against New Mexico United, one of the toughest tests on the schedule, and discuss what Sacramento will need to do to continue its momentum. Plus, we talk about the latest disappointing developments surrounding the proposed Modesto soccer stadium project, and we recap recent results from local Central Valley clubs competing in the USL W League and USL League Two. Intro/Outro Music: "The Descent" Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 4.0 License http://creativecommons.org/licenses/by/4.0/ Podcast Winner Dinner Music: The following music was used for this media project: Fliegen by Sascha Ende Free download: https://filmmusic.io/song/2936-fliegen License (CC BY 4.0): https://filmmusic.io/standard-license Golazos of Gratitude Music: The following music was used for this media project: Music: Nice Light Of Happiness by MusicLFiles Free download: https://filmmusic.io/song/7421-nice-light-of-happiness License (CC BY 4.0): https://filmmusic.io/standard-license Image: Sac Republic Support State of the Republic by contributing to their tip jar: https://tips.pinecast.com/jar/state-of-the-republic
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The weekly radio show from Salvione, blending house, funk, and tech, resulting in an unparalleled energetic dance floor vibe. Alessio Mosti – No Puedo Seguir I.g.n.a., Lady Vale – Club Life Byred & Sandro Martins – You Know Me Peter Romero – Wanna Talk Paluma & Tyson O'Brien – In The AirBryan Vera – No Drama Fran Ares, Sergiodnine – Starlight Luka Kuhnow, Manuel De La Mare – Make Me (Manuel De La Mare Remix) Most Some – Mustang (Blas Miller Mix) MartinoResi, Carlos Arresa – Get That MartinoResi, Esteban Angel – Who Is Karretero – No Man Davide T, Cyava – Pocket Sam Frandisco – Gotta Have It
Elevated issuance is still being met with strong investor demand Follow Us Twitter @NYLInvestments Twitter @MacKayMuniMgrs Facebook @NYLInvestments LinkedIn: New York Life Investments LinkedIn: MacKay Municipal Managers Presented by New York Life Investmentswww.newyorklifeinvestments.com MacKay Municipal Managers is a team of portfolio managers at MacKay Shields. MacKay Shields is 100% owned by NYLIM Holdings, which is wholly owned by New York Life Insurance Company. “New York Life Investments” is both a service mark, and the common trade name, of certain investment advisors affiliated with New York Life Insurance Company. Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.
Matthew Tuttle remains a buyer of oil stocks, even as headlines Friday point to a U.S.-Iran deal never being closer. He sees the headwinds lasting for months, causing prices to stay elevated. Matt tells investors to keep an eye on "bottleneck names" and explains his stock picks in Rocket Lab (RKLB), Occidental Petroleum (OXY), and Solar Edge (SEDG).======== Schwab Network ========Empowering every investor and trader, every market day.Subscribe to the Market Minute newsletter - https://schwabnetwork.com/subscribeDownload the iOS app - https://apps.apple.com/us/app/schwab-network/id1460719185Download the Amazon Fire Tv App - https://www.amazon.com/TD-Ameritrade-Network/dp/B07KRD76C7Watch on Sling - https://watch.sling.com/1/asset/191928615bd8d47686f94682aefaa007/watchWatch on Vizio - https://www.vizio.com/en/watchfreeplus-exploreWatch on DistroTV - https://www.distro.tv/live/schwab-network/Follow us on X – https://twitter.com/schwabnetworkFollow us on Facebook – https://www.facebook.com/schwabnetworkFollow us on LinkedIn - https://www.linkedin.com/company/schwab-network/About Schwab Network - https://schwabnetwork.com/about
Elevated GP - Click here to join Elevated.GP Follow @dr.melissa_seibert on Instagram Dr. Peter Milgrom is Professor of Oral Health Sciences and Pediatric Dentistry in the School of Dentistry and adjunct Professor of Health Services in the School of Public Health at the University of Washington. He directs the Northwest Center to Reduce Oral Health Disparities. He holds academic appointments at Case Western University, University of Rochester, and University of California, San Francisco. He maintains a dental practice limited to the care of fearful patients and served as Director of the UW Dental Fears Research Clinic. Dr. Milgrom's work includes research on xylitol, the effectiveness of fluoride varnish and iodine in preschoolers, clinical efficacy and safety of diammine silver fluoride, motivational strategies to increase perinatal and well child dental visits in rural communities, and studies of cognitive interventions in pediatric and adult dental fear. The NIH, Maternal and Child Health Bureau, HRSA, and the Robert Wood Johnson Foundation support his work. Dr. Milgrom is author of 5 books and over 300 scientific articles. His latest book, Treating Fearful Dental Patients, was published in 2009. Dr. Milgrom was Distinguished Dental Behavioral Scientist of the International Association for Dental Research for 1999. In 1999, and again in 2000, his work was recognized by the Giddon Award for research in the behavioral sciences in Dentistry. He received the Barrows Milk Award from IADR in 2000, recognizing his work for public health including the development of the Access to Baby and Child Dentistry (ABCD) program in Washington State. In 2003, Dr. Milgrom received a Special Commendation Award from the National Legal Aid and Defenders Association and the University of Washington Medical Center Martin Luther King, Jr. Community Service Award. In 2010, he received the Aubrey Sheiham Research Award for his work on xylitol. He serves on scientific review committees for the NIDCR, NIMHHD, NINDS, Center for Scientific Review at NIH and as a consultant to the FDA. In 2005, Dr. Milgrom was appointed the SAAD Visiting Professor of Pain and Anxiety Control at the King's College Dental Institute, University of London, UK for a six-year term. In 2008 he was awarded the degree of Doctor Honoris Causa from the University of Bergen, Norway in recognition of his work in social and behavioral dentistry. In 2012, he received the University of California, San Francisco Dental Alumni Gold Medal for his contributions to Dentistry. In 2012 he was also awarded the Norton Ross Award for Excellence in Clinical Research by the American Dental Association. In 2013, he was appointed to the Council of Scientific Affairs of the American Dental Association. In 2014, he received the Irwin M. Mandel Distinguished Mentor Award from the IADR. In 2015, he served as HMDP Expert in Dental Public Health for the Singapore Ministry of Health. Dr. Milgrom received his DDS from the University of California, San Francisco in 1972 and had a previous position at the National Academy of Sciences, Engineering, and Medicine. In the last few years, Dr. Milgrom has spoken to dental associations in Argentina, Colombia, Peru, Philippines, and USA and at major universities in USA and abroad.
A guide to diagnosing, imaging, and managing acute renal colic and nephrolithiasis in the ED. Hosts: Brian Gilberti, MD Avir Mitra, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Nephrolithiasis.mp3 Download Leave a Comment Tags: Kidney Stones, Urology Show Notes 1. CLINICAL CORE & PHYSIOLOGIC FRAMEWORK Epidemiologic Risk Profiles Lifetime incidence parameters hover around 1 in 11, presenting with a prominent male sex skew. Peak demographic manifestation concentrated within the 30–60 age band. High-yield temporal parameter: 50% recurrence vector within a 5-year post-initial-insult window. Mineralogical Composition Vectors Calcium oxalate crystals represent the predominant structural matrix. Struvite configurations (magnesium ammonium phosphate matrix) account for 1–2% of cohorts. Struvite stones function explicitly as infection-driven configurations secondary to upper tract proliferation; higher distribution index noted in female cohorts. Etiological & Modifiable Relational Dynamics Profound systemic dehydration or low baseline fluid throughput states. High-sodium diet structures and heavy animal-protein consumption loads. Positive genetic/familial history variables. Relative risk modulation: Each variable independently operates to expand baseline risk by a factor of 2x to 3x. Pathophysiologic Symptom Complexes Acute, sudden-onset, maximum-intensity (10/10) unilateral flank pain. Classic structural radiation vector tracking downward toward the ipsilateral groin/genitourinary dermatomes. Distinctive behavioral marker: Renal colic pacing/writhing behavior with zero antalgic position availability. Concomitant autonomic triggers: Nausea and emesis manifest in 50% of acute presentations. Physical Exam Discordance Metrics Severe subjective distress contrasted with a characteristically soft, completely non-tender abdominal palpation exam. CVA tenderness is completely variable and lacks reliable negative predictive value. Atypical Presentation Classifications Vague, poorly localized abdominal pain presentations occurring in up to 20% of active cases. Isolated lower urinary tract irritative signs including acute frequency or severe urgency. Incidental & Asymptomatic Dynamics Silent intrarenal or ureteral stones found incidentally. Longitudinal tracking demonstrates up to 33.3% of initially asymptomatic cohorts convert to fully symptomatic renal colic within a multi-year tracking window. 2. EXCLUSION DIAGNOSES & CRITICAL PATHWAY RED FLAGS Vascular Mimics: AAA rupture/expansion. This is a mandatory exclusion pathway in elderly cohorts presenting with acute flank or back pain. Physical tracking requires active exploration for an expansile, pulsatile abdominal mass. Gynecologic Emergencies: Ruptured ectopic pregnancy. Demands universal screening protocols via rapid beta-hCG testing in all female patients of childbearing potential presenting with lower abdominal/pelvic localization. Infectious Upper Tract Decompensation: Acute uncomplicated pyelonephritis. Differentiated via persistent high spikes, high fevers, systemic shaking chills, and profound pyuria. Genitourinary Structural Crises: Acute testicular torsion. Mandates a thorough, explicit scrotal/testicular structural exam if the flank pain radiates into the scrotum. Gastrointestinal and Adnexal Torsional Confounds: Acute appendicitis variants, acute mesenteric/bowel ischemia, and ovarian torsion syndromes. 3. LABORATORY TESTING & PHYSIOLOGIC EVALUATION Urinalysis Interpretation Nuances Microscopic or gross hematuria presents in approximately 66% to 90% of acute cases. Critical Pathological Caveat: Complete absence of hematuria documented in 20% to 33.3% of confirmed, acute obstructing ureteral stones. Diagnostic rule: A pristine urinalysis with zero red blood cells is entirely insufficient to exclude acute ureterolithiasis. Urinary pH as a Composition Clue Consistently low urinary pH parameters (pH < 5.5) point strongly toward a uric acid crystalline composition. Elevated urinary pH parameters (pH > 7.5) indicate the presence of urease-producing microbial pathogens, pointing toward a struvite infection stone. Infectious Screening Metrics Active tracking for marked pyuria, positive leukocyte esterase, and bacterial nitrites to rule out an obstructed, infected upper urinary tract system. BMP Immediate quantification of baseline serum creatinine to establish accurate eGFR values. Targeting detection of post-renal AKI from bilateral obstruction, unilateral obstruction in a single functioning kidney, or severe volume depletion. CBC Evaluation for marked leukocytosis. Physiologic Nuance: Mild-to-moderate white blood cell count elevations frequently represent non-specific stress demargination driven by severe pain and repetitive vomiting. High-grade white blood cell shifts demand immediate exclusion of systemic bacteremia or an infected, obstructed urinary system. Adjunctive Lab Pathways Rapid qualitative urine hCG testing. Reflex urine culture execution whenever urinalysis metrics display significant inflammatory profiles or clinical suspicion of UTI is high. 4. IMAGING MODALITIES & ALGORITHMIC CLINICAL SELECTION Non-Contrast CT Diagnostics Gold standard; diagnostic sensitivity and specificity parameters exceed 95% for stones >2 mm. Provides precise quantification of stone diameter (mm), exact localization (proximal, mid, or distal ureter), and degree of secondary hydronephrosis. Excellent structural visualization for detecting or ruling out alternate retroperitoneal, vascular, or intra-abdominal pathologies. Contrast-Enhanced CT Protocols Indicated when alternative intra-abdominal surgical pathology is highly suspected over isolated renal colic. Retains diagnostic capability to identify urinary tract stones >3 mm even within contrast-enhanced phases. NCCT Structural Architecture Limitations Standard stone protocol CT scans are executed in a prone position without IV contrast enhancement. It does not opacify the ureteral lumen. Presents a cumulative radiation exposure penalty when utilized serially across recurrent ED presentations. POCUS / Radiology Ultrasound Direct stone visualization capabilities are modest, operating at approximately 50% to 60% sensitivity, and is highly dependent on anatomical positioning at the extreme proximal ureter or the UVJ. Secondary obstruction tracking: Demonstration of hydronephrosis operates at a high sensitivity of approximately 80%. POCUS Clinical Utility Metrics Eliminates ionizing radiation exposure and allows immediate, rapid real-time execution directly at the patient’s bedside. Confirmation of significant hydronephrosis within a classic clinical presentation yields high post-test probability for stone presence while lowering suspicion for vascular catastrophes like a AAA. KUB Radiography Extremely poor overall diagnostic sensitivity, hovering around 57%. Fails to image radiolucent configurations (pure uric acid matrices) or small stones measuring
Joe's Premium Subscription: www.standardgrain.comGrain Markets and Other Stuff Links —Apple PodcastsSpotifyTikTokYouTubeFutures and options trading involves risk of loss and is not suitable for everyone.Corn futures fell for a third straight session with the Dec26 contract settling near $4.67/bu—its lowest since late February—pressured by favorable Corn Belt weather and no Chinese buying since the mid-May summit.
CardioNerds (Dr. Billy-Joe Mullinax, Dr. Dinu Balanescu, and Dr. Jane Ehret) discuss risk stratification in acute pulmonary embolism with Dr. Stavros Konstantinides, Chair of the 2019 ESC Pulmonary Embolism Guidelines. Using a real-world case, this episode explores how modern PE care has moved beyond “massive” and “submassive” labels toward a dynamic, physiology-based approach. The discussion highlights the limitations of static risk scores, the importance of right ventricular dysfunction and biomarkers, and why normotension does not imply stability. Special emphasis is placed on intermediate-high risk PE, early identification of impending hemodynamic collapse, and the role of lactate, serial reassessment, and PERT teams in guiding escalation of care. Audio editing by CardioNerds intern, Joshua Khorsandi.The 2026 American multi-society PE guidelines were published after this episode was recorded. Dr. Dinu Balanescu and Dr. Billy-Joe Mullinax are Co-chairs for the CardioNerds PE Series, developed in collaboration with the PERT Consortium. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. CardioNerds Pulmonary Embolism PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls Stable blood pressure does not mean low risk in PEHypotension is a late finding. Patients may have severe RV failure, hypoxia, and tissue hypoperfusion while remaining normotensive — a key concept behind “normotensive shock.” Risk stratification in PE must be dynamic, not staticLegacy scores like PESI and Bova provide a snapshot and predict 30-day mortality, but they do not capture short-term trajectory or impending hemodynamic collapse. Intermediate-high risk PE is a dangerous and heterogeneous groupPatients with RV dysfunction, positive biomarkers, tachycardia, hypoxemia, and elevated lactate may have in-hospital mortality approaching 15%, rivaling STEMI. Lactate is a critical but underutilized marker in PEElevated lactate reflects tissue hypoxia and early circulatory failure and may identify patients at risk for collapse before blood pressure declines. PERT enables physiology-driven, patient-centered PE carePERT teams operationalize continuous reassessment, integrate imaging, labs, and clinical trajectory, and allow timely escalation — shifting PE management from rigid categories to real-time decision-making. Notes Drafted by Dr. Jane Ehret. 1. What is the contemporary framework for risk stratification in acute pulmonary embolism? Modern PE risk stratification prioritizes hemodynamics and right ventricular (RV) function rather than clot burden. The 2019 ESC Guidelines classify PE into high risk, intermediate risk (low vs high), and low risk, based on: Hemodynamic status, RV dysfunction on imaging, and Cardiac biomarkers. This framework emphasizes early mortality risk but requires clinical context to guide escalation decisions. 2. Why is normotension insufficient to define “stability” in PE? Blood pressure is a late marker of circulatory failure in PE. Patients can maintain normal BP through Tachycardia, Increased sympathetic tone, and RV compensation. Many patients with preserved BP may already have shock physiology, including hypoxemia, elevated lactate, and RV failure — sometimes referred to as “normotensive shock.” 3. How should intermediate-risk PE be conceptualized clinically? Intermediate-risk PE is heterogeneous, ranging from patients who do well on anticoagulation to those who deteriorate rapidly. Intermediate-high risk PE is defined by RV dysfunction on imaging and positive cardiac biomarkers. Clinical features such as tachycardia, increasing oxygen requirement, and elevated lactate identify patients at highest risk within this group. 4. What are the strengths and limitations of commonly used PE risk scores? Legacy scores are useful for initial risk categorization but are static and limited in predicting short-term deterioration. Most scores were developed to predict mortality or complications at fixed time points rather than dynamic clinical trajectory. 5. What are the commonly used risk scores and clinical tools in PE, and what is each designed to predict? ESC Risk Stratification Algorithm: Identifies high-risk PE by hemodynamics. Uses PESI or sPESI in normotensive patients to distinguish low-risk from non–low-risk PE. Uses RV dysfunction and biomarkers to differentiate intermediate-low from intermediate-high risk. Forms the basis of many institutional PE pathways. PESI and sPESI: Validated to predict 30-day mortality. Widely used to identify low-risk patients appropriate for outpatient management. Heavily influenced by age and comorbidities. Bova Score: Predicts 30-day PE-related complications in normotensive patients. Composite PE Shock Score (CPES): Predicts normotensive shock in hemodynamically stable PE patients. Pulmonary Embolism Progression (PEP) Score: Predicts progression from intermediate-risk to high-risk PE within 72 hours of diagnosis. PE Short-term Clinical Outcomes Risk Estimation (PE-SCORE): Predicts clinical deterioration or death within 5 days of PE diagnosis. Hestia Criteria: Identifies low-risk PE patients safe for outpatient treatment. Wells' Criteria and Revised Geneva Score: Determine pretest probability for diagnostic triage. PERC Score: Rules out PE in very low-risk patients. 6. What is the role of biomarkers in PE risk stratification? Troponin and natriuretic peptides reflect RV myocardial injury and strain. Current guidelines treat biomarkers as binary (positive vs negative), despite risk being continuous. Biomarkers are most helpful for: Initial risk classification. They are less useful for: Short-interval monitoring and Detecting rapid clinical deterioration. 7. Why is lactate an important physiologic marker in PE? Lactate reflects global tissue hypoxia and impaired perfusion. Elevated lactate may identify patients with: Early circulatory failure and Increased risk of imminent hemodynamic collapse. Lactate is not currently included in ESC risk algorithms but may add important prognostic information in intermediate-risk patients. 8. How does trajectory influence decision-making in PE management? Risk stratification should be viewed as a dynamic process, not a one-time label. Worsening clinical trajectory may include: Rising heart rate, Increasing oxygen needs, Rising lactate, and Progressive RV dysfunction. Serial reassessment is essential for timely escalation of care. 9. What role do Pulmonary Embolism Response Teams (PERT) play in risk stratification? PERT facilitates: Multidisciplinary decision-making and Integration of imaging, biomarkers, and clinical physiology. PERT is most valuable for: Intermediate-risk and high-risk PE and Patients with complex comorbidities or uncertain trajectory. PERT enables a shift from category-based to physiology-driven PE care. References 1. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019;54(3):1901647. Published 2019 Oct 9. doi:10.1183/13993003.01647-2019 2. Leidi A, Bex S, Righini M, Berner A, Grosgurin O, Marti C. Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives. J Clin Med. 2022;11(9):2533. Published 2022 Apr 30. doi:10.3390/jcm11092533 3. Choi WH, Kwon SU, Jwa YJ, et al. The pulmonary embolism severity index in predicting the prognosis of patients with pulmonary embolism. Korean J Intern Med. 2009;24(2):123-127. doi:10.3904/kjim.2009.24.2.123 4. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-1389. doi:10.1001/archinternmed.2010.199 5. Chen X, Shao X, Zhang Y, et al. Assessment of the Bova score for risk stratification of acute normotensive pulmonary embolism: A systematic review and meta-analysis. Thromb Res. 2020;193:99-106. doi:10.1016/j.thromres.2020.05.047 6. Zhang RS, Yuriditsky E, Zhang P, et al. Composite Pulmonary Embolism Shock Score and Risk of Adverse Outcomes in Patients With Pulmonary Embolism. Circ Cardiovasc Interv. 2024;17(8):e014088. doi:10.1161/CIRCINTERVENTIONS.124.014088 7. Zhang RS, Alam U, Sharp ASP, et al. Validating the Composite Pulmonary Embolism Shock Score for Predicting Normotensive Shock in Intermediate-Risk Pulmonary Embolism. Circ Cardiovasc Interv. 2024;17(2):e013399. doi:10.1161/CIRCINTERVENTIONS.123.013399 8. Ehret J, Wakefield D, Badlam J, Antkowiak M, Erdreich B. Development of the Pulmonary Embolism Progression (PEP) score for predicting short-term clinical deterioration in intermediate-risk pulmonary embolism: a single-center retrospective study. J Thromb Thrombolysis. 2025;58(2):243-253. doi:10.1007/s11239-024-03051-5 9. Weekes AJ, Raper JD, Lupez K, et al. Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE). PLoS One. 2021;16(11):e0260036. Published 2021 Nov 18. doi:10.1371/journal.pone.0260036 10. Zondag W, Hiddinga BI, Crobach MJ, et al. Hestia criteria can discriminate high- from low-risk patients with pulmonary embolism. Eur Respir J. 2013;41(3):588-592. doi:10.1183/09031936.00030412 11. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98-107. doi:10.7326/0003-4819-135-2-200107170-00010 12. Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44(5):503-510. doi:10.1016/j.annemergmed.2004.04.002 13. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144(3):165-171. doi:10.7326/0003-4819-144-3-200602070-00004 14. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247-1255. doi:10.1111/j.1538-7836.2004.00790.x 15. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772-780. doi:10.1111/j.1538-7836.2008.02944.x
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