POPULARITY
21 episodes with GFR
25 episodes with GFR
7 episodes with GFR
7 episodes with GFR
8 episodes with GFR
5 episodes with GFR
2 episodes with GFR
3 episodes with GFR
2 episodes with GFR
Our guest today is Reverend Kenn Blanchard. Kenn was once known internationally as the Black Man With A Gun. Before Google and Facebook existed, he played a monumental role in laying the groundwork for national concealed carry, the Heller Decision, and HR 218, the Law Enforcement Officers Safety Act. Today, he is a musician and caregiver for his wife. He has a new book called Finding Joy in the Blues available on Amazon. 1) You were our very first guest on GFR, and much has happened in the past ten years since we first met. But, one thing hasn't changed, and that is that you have been Serving others your entire life. From your time in the Military, law enforcement, 2A Advocacy, and now your wife in her time of health needs. What drives you to show up in all of these roles? 2) Your wife is still recovering from a brain tumor. Your retirement years have not worked out the way you planned. Yet, you write a book about joy. Tell us about that. 3) One of the chapters in your book is called “A Preacher and a Rabbi”. In a time when some are trying to sew division based on every conceivable metric – race, class, religion, political ideology, etc – you two found an amazing connection and friendship. What was your common bond? 4) Where does 2A Advocacy fit in your life nowadays? 5) Having already planned for a future that didn't quite work out, how do you now make plans for what is next? 6) How do people follow you and buy your books? Originally Aired 5.16.25
View the Show Notes For This Episode Dr. Robin Rose discusses Kidney Care with Peptides with Dr. Ben Weitz. [If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.] Podcast Highlights In this episode of the Rational Wellness Podcast, Dr. Ben Weitz hosts Dr. Robin Rose to discuss crucial insights into kidney health. They explore the kidney's functions, including filtering blood, regulating electrolytes, and converting vitamin D. The conversation delves into chronic kidney disease, highlighting that symptoms can arise even in stage two when GFR drops below 60. Dr. Rose emphasizes the importance of early detection and intervention, discussing concepts such as uremic dysbiosis, endothelial damage, leaky gut, and the impact of toxins. They also touch on natural and supplemental approaches to support kidney health, like using bio-regulator peptides, nutritional therapy, and plant-based diets. Additionally, Dr. Rose shares her personal experience with kidney cancer and the insights she gained during her journey to recovery. 00:26 Understanding Kidney Functions and Chronic Kidney Disease 02:10 In-Depth Discussion with Dr. Robin Rose 02:34 The Complexities of Kidney Health 04:28 Kidney and Gut Health Connection 04:54 Challenges in Measuring Kidney Function 08:48 Managing Kidney Health Through Diet and Lifestyle 28:43 Nutritional Supplements for Kidney Health 33:23 Butyrate and Gut Health 33:56 Cardiovascular Markers and Genomics 34:59 Kidney Health Botanicals 37:31 Peptides and Their Benefits 43:06 Bio-Regulator Peptides 51:31 Personal Kidney Health Journey 52:48 Hydration and Herbal Teas 54:40 Final Thoughts and Resources ________________________________________________________________________________________________________ Dr. Robin Rose is a Medical Doctor and an expert at supporting kidney health using a wholistic approach and peptides. She has recently published a book, Renology Peptides: Kidney Success with Bioregulator Peptides. Renology Peptides is a comprehensive clinical volume that presents an evidence-guided scholarly tool to deepen understanding of regenerative kidney medicine and bioregulator peptides. Her website is Renology is Kidney Success. Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Howie and Harlan are joined by Joel Bervell, a recent medical school graduate who uses social media platforms to combat misinformation and explain racial biases in healthcare. Harlan discusses his new Wall Street Journal commentary highlighting the link between viral infections and chronic diseases; Howie reports on powerful new evidence for the effectiveness of the HPV vaccine and warns of the dangers of a vaccine-skeptical presidential administration. Links: Viral Infection and Chronic Disease Harlan Krumholz: “How to Lead a Chronic Disease Revolution” “A natural experiment on the effect of herpes zoster vaccination on dementia” “Unexplained post-acute infection syndromes” Joel Bervell Joel Bervell Joel Bervell on TikTok Joel Bervell on Instagram “TikTok's 'Medical Mythbuster' Helps Save Lives By Tackling Racial & Gender Disparities In Healthcare” “How the pulse oximeter became infamous on TikTok” “Racial Bias in Pulse Oximetry Measurement” Joel Bervell's TikTok on the pulse oximeter Joel Bervell: “The eGFR Equation” “Race Correction and the X-Ray Machine: The Controversy over Increased Radiation Doses for Black Americans in 1968” Joel Bervell: “For over 50 years, X-ray technicians were taught to administer higher radiation doses to Black patients” Joel Bervell's Instagram reel on bias in the measurement of lung capacity Made to Stick: Why Some Ideas Survive and Others Die Joel Bervell on LinkedIn Joel Bervell on YouTube: The Doctor Is In Kickstarter: The Doctor Is In “Medical mythbuster Joel Bervell, MD, on how to teach kids about medicine and address misinformation” Cleveland Clinic: Amyloidosis Joel Bervel's Instagram reel on the GFR equation “Abandoning a Race-biased Tool for Kidney Diagnosis” “OPTN Board approves elimination of race-based calculation for transplant candidate listing” “America's News Influencers” “85th Annual Peabody Awards Announce Nominees for the Arts, Children's/Youth, Entertainment, and Interactive & Immersive Categories Vaccines and the Federal Healthcare Agencies Health & Veritas Episode 165: “Aging in Bursts and Other News” “U.S. government researchers present ‘phenomenal' new data on HPV vaccines” “Invasive cervical cancer incidence following bivalent human papillomavirus vaccination: a population-based observational study of age at immunization, dose, and deprivation” “Kennedy played key role in Gardasil vaccine case against Merck” “RFK Jr. suggests some vaccines are risky or ineffective, downplays measles threat” “FDA chief says they're looking at whether to approve COVID shots for next winter” “How Marty Makary's FDA is embracing a more skeptical view of vaccines” Learn more about the MBA for Executives program at Yale SOM. Email Howie and Harlan comments or questions.
Howie and Harlan are joined by Joel Bervell, a recent medical school graduate who uses social media platforms to combat misinformation and explain racial biases in healthcare. Harlan discusses his new Wall Street Journal commentary highlighting the link between viral infections and chronic diseases; Howie reports on powerful new evidence for the effectiveness of the HPV vaccine and warns of the dangers of a vaccine-skeptical presidential administration. Links: Viral Infection and Chronic Disease Harlan Krumholz: “How to Lead a Chronic Disease Revolution” “A natural experiment on the effect of herpes zoster vaccination on dementia” “Unexplained post-acute infection syndromes” Joel Bervell Joel Bervell Joel Bervell on TikTok Joel Bervell on Instagram “TikTok's 'Medical Mythbuster' Helps Save Lives By Tackling Racial & Gender Disparities In Healthcare” “How the pulse oximeter became infamous on TikTok” “Racial Bias in Pulse Oximetry Measurement” Joel Bervell's TikTok on the pulse oximeter Joel Bervell: “The eGFR Equation” “Race Correction and the X-Ray Machine: The Controversy over Increased Radiation Doses for Black Americans in 1968” Joel Bervell: “For over 50 years, X-ray technicians were taught to administer higher radiation doses to Black patients” Joel Bervell's Instagram reel on bias in the measurement of lung capacity Made to Stick: Why Some Ideas Survive and Others Die Joel Bervell on LinkedIn Joel Bervell on YouTube: The Doctor Is In Kickstarter: The Doctor Is In “Medical mythbuster Joel Bervell, MD, on how to teach kids about medicine and address misinformation” Cleveland Clinic: Amyloidosis Joel Bervel's Instagram reel on the GFR equation “Abandoning a Race-biased Tool for Kidney Diagnosis” “OPTN Board approves elimination of race-based calculation for transplant candidate listing” “America's News Influencers” “85th Annual Peabody Awards Announce Nominees for the Arts, Children's/Youth, Entertainment, and Interactive & Immersive Categories Vaccines and the Federal Healthcare Agencies Health & Veritas Episode 165: “Aging in Bursts and Other News” “U.S. government researchers present ‘phenomenal' new data on HPV vaccines” “Invasive cervical cancer incidence following bivalent human papillomavirus vaccination: a population-based observational study of age at immunization, dose, and deprivation” “Kennedy played key role in Gardasil vaccine case against Merck” “RFK Jr. suggests some vaccines are risky or ineffective, downplays measles threat” “FDA chief says they're looking at whether to approve COVID shots for next winter” “How Marty Makary's FDA is embracing a more skeptical view of vaccines” Learn more about the MBA for Executives program at Yale SOM. Email Howie and Harlan comments or questions.
Today, we're diving into one of the most misunderstood, wrongly demonized, and yet most important pieces of your nutrition strategy: PROTEIN.We're going deep into:Why so many people still believe protein is dangerous — especially for your kidneysWhere these outdated beliefs came fromThe role of protein in muscle gain, fat loss, aging, and long-term healthWhy the RDA is setting you up for failureWhat YOU can do today to get the benefits of a high-protein lifestyleResources:1. High-Protein Diets and Kidney Function in Healthy Adults:Study: A Systematic Review of Renal Health in Healthy Individuals Consuming High Protein DietsFindings: This review analyzed multiple randomized controlled trials and found that increased protein intake led to higher glomerular filtration rates (GFR), all within normal kidney function ranges. The data suggest that higher protein consumption does not adversely affect kidney health in healthy adults. Study: Effect of a High-Protein Diet on Kidney Function in Healthy Adults: Results from the OmniHeart TrialFindings: This study concluded that a healthy diet rich in protein increased estimated GFR. However, it noted that the long-term effects of high-protein diets on kidney health remain uncertain.2. Protein Intake and Sarcopenia (Muscle Loss) in Older Adults:Study: Protein Intake and Sarcopenia in Older Adults: A Systematic Review and Meta-AnalysisFindings: The meta-analysis indicated that older adults with sarcopenia consumed significantly less protein than their non-sarcopenic peers, suggesting that inadequate protein intake may be associated with muscle loss in the elderly. Study: Role of Dietary Protein in the Sarcopenia of AgingFindings: The study suggests that moderately increasing daily protein intake beyond 0.8 g/kg/day may enhance muscle protein anabolism, potentially mitigating age-related muscle loss. Protein & Kidney Health in Healthy IndividualsSystematic Review: High Protein Diets & Renal FunctionConclusion: No negative effects on kidney function in healthy adults.
Thank you for joining us for our 2nd Cabral HouseCall of the weekend! I'm looking forward to sharing with you some of our community's questions that have come in over the past few weeks… Anne: Listen to your podcast everyday and I learned so many helpful health tips. Thank you. I have recently developed dry mouth at night while I'm sleeping. I drink a lot of water during the day and I have not started any new medication. What is the cause of dry mouth and what natural remedies would you suggest. Thank you Fred: Hi Dr Cabral My name is fred and have been listening to you for the last year I truly believe your are in this t help . I have recently purchased the vitamin. And heavy metal detox tests for my wife and myself I am 63 years old and unfortunately had h pylori and was on antibiotics for 2 weeks about 2 months ago I not sure the impact but it has seemed to have worked My concern is that I have a eGFR of 46 I have an enlarged liver I am a non drinker and starting to eat better I went off my statin and am on blood pressure medication I do not sleep well at all Hoping to afford to do the big 5 one day I am Canadian and our dollar is very bad What can I do to save my kidneys naturally Kristin: I've heard that Ashwaganda supplements are not good for those with Hashimotos. Is this accurate? I've also read and experienced so many benefits from it. Mandy: High creatinine level question. Hi, I greatly appreciate all the wonderful info that you and your team provide to those of us that want to live our best and healthy life!m Is there a causal relationship between menopause and an increase in creatinine? Recently had my labs done and my creatinine was 1.24, BUN 19, and GFR 54. Any advice and recommendations to bring my level down would be greatly appreciated. I'm an active 49 yr old. Thank you for your help. Mandy Mandy: Hi! Do you recommend mattress vacuums (specifically Jigoo, Jimmy, or Ranvoo)?Also, we just heard about the Apollo 2nd Generation Do you recommend it? Thank you for tuning into this weekend's Cabral HouseCalls and be sure to check back tomorrow for our Mindset & Motivation Monday show to get your week started off right! - - - Show Notes and Resources: StephenCabral.com/3292 - - - Get a FREE Copy of Dr. Cabral's Book: The Rain Barrel Effect - - - Join the Community & Get Your Questions Answered: CabralSupportGroup.com - - - Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - Get Your Question Answered On An Upcoming HouseCall: StephenCabral.com/askcabral - - - Would You Take 30 Seconds To Rate & Review The Cabral Concept? The best way to help me spread our mission of true natural health is to pass on the good word, and I read and appreciate every review!
N Engl J Med 2006;355:2395-407Am Heart J 2011;161:611-21Background: Registry data suggests that 10-20% of patients with a STEMI present more than 12 hours after the onset of symptoms. The optimal treatment for such patients is unknown. In some cases, the inciting event may have occurred weeks prior and been mistaken for indigestion or another non-life threatening condition. Such patients may present to the hospital with a new diagnosis of congestive heart failure or atrial fibrillation. Echocardiography often reveals a a large wall motion abnormality, perfusion testing demonstrates an infarct with peri-infarct ischemia and an occluded vessel is seen on angiography. Should we try to open it? On the one hand, the damage has been done. Attempting to open an occluded vessel is associated with higher procedural risks and the patient's themselves are more often than not sub-optimal candidates for intervention; often having some combination of heart failure, LV dysfunction, older age, multimorbidity and hemodynamic instability. But on the other hand, revascularization restores blood flow and that has to count for something, right?The Occluded Artery Trial (OAT) tested the hypothesis that a strategy of routine PCI for total occlusion of the infarct-related artery 3 to 28 days after AMI would improve cardiac outcomes compared to medical therapy alone.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients: Patients were eligible if coronary angiography, performed 3 to 28 days after MI, showed a total occlusion of the infarct-related artery with poor antegrade flow and either an EF less than 50% or the occlusion was in the proximal portion of a major coronary vessel with a large risk region, or both. The qualifying period of 3 to 28 days was based on calendar days with day 1 being the onset of symptoms and thus, the minimal time from the AMI to angiography was just over 24 hours. [This is important, readers should not take the inclusion criteria of 3 to 28 days to mean that patients were not eligible if angiography was performed 2.5 mg/dl, left main or 3 vessel disease, angina at rest, and severe ischemia on stress testing (stress testing was required if the infarct zone was not akinetic or dyskinetic).Baseline characteristics: The trial included 2,166 patients - 1,082 randomized to PCI and 1,084 to medical therapy. The average age of patients was 59 years and 78% were men. Over 80% were white. The median time between AMI and randomization was 8 days. Patients had normal kidney function with an average GFR of 81 ml/min. The mean EF was 48% with 20% of patients having an EF
Die chronische Niereninsuffizienz beschreibt einen fortschreitenden, meist irreversiblen Verlust der glomerulären, tubulären und endokrinen Funktionen der Nieren. Sie resultiert aus einer langfristigen Schädigung des Nierengewebes, die zur Abnahme der glomerulären Filtrationsrate führt. Die CNI wird in Stadien eingeteilt, wobei der Schweregrad anhand der GFR und klinischer Befunde bestimmt wird. Lerne in dieser Folge alles Prüfungsrelevante zur chronischen Niereninsuffizienz und lass uns der glomerulären Filtrationsrate auf den Grund gehen. Wir machen dich damit wieder fit für Praxis und Prüfung.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Podcast Overview The podcast, hosted by Valentin Fuster on January 21, 2025, provides an in-depth review of the FINEARTS-HF trial, which evaluated the efficacy of the non-steroidal mineralocorticoid receptor antagonist finerenone in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The episode highlights findings published in the Journal of the American College of Cardiology (JACC). Introduction to the FINEARTS-HF Trial (00:03:19 – 00:05:56) The FINEARTS-HF trial demonstrated that finerenone reduced heart failure events by 16% compared to placebo in patients with HFmrEF/HFpEF. However, cardiovascular death rates were similar between groups, making the overall clinical impact moderate. Finerenone's Impact on Quality of Life (00:05:59 – 00:12:46) The trial assessed quality of life using the Kansas City Cardiomyopathy Questionnaire (KCCQ), revealing only a slight improvement (1.62 points) with finerenone. Critics, including the FDA, questioned the clinical relevance of these results and suggested the need for simpler, more meaningful patient-reported outcome measures. Finerenone in Patients with Recent Worsening Heart Failure (00:12:58 – 00:20:30) Patients with recent worsening heart failure showed a greater absolute benefit from finerenone, as they were at higher risk of recurrent events and cardiovascular death. However, further studies are needed to confirm these findings. Finerenone's Role in Obese Patients with HFmrEF/HFpEF (00:20:31 – 00:25:20) In obese patients, the benefits of finerenone were consistent across body mass index (BMI) categories, with a possible greater effect in those with higher BMI. Nevertheless, the reliance on BMI as a metric for obesity was criticized, and alternative measures were recommended. Finerenone and Kidney Outcomes (00:25:23 – 00:40:52) Finerenone showed a modest reduction in albuminuria but did not significantly alter kidney disease progression. Initial declines in glomerular filtration rate (GFR) were noted but should not automatically lead to discontinuation of therapy. Mixed findings highlight the need for more research to understand its renal effects. Conclusion (00:40:54 – 00:44:05) The FINEARTS-HF trial was recognized as a landmark study, showcasing modest benefits of finerenone in a challenging patient population. The podcast calls for continued research to refine quality of life metrics, better understand obesity's role in HFmrEF/HFpEF, and explore finerenone's long-term renal and cardiovascular impacts.
Send us a textFacing a life-altering health crisis, Pesh discovered he was living with just one underdeveloped kidney, a revelation that propelled him into a new chapter as a patient advocate. In this episode, join the SCM nurses as Pesh Patel shares his remarkable journey through the challenges of kidney disease, including emergency blood transfusions and a failed kidney transplant. Pesh shares the customized approach he's taken with his healthcare team and the significant role his diet plays in managing his condition. His inspiring story emphasizes the empowering potential of personal advocacy and nutrition in chronic health management.Listeners will gain valuable insights into the transformative power of taking charge of one's health journey. Drawing from personal experience, Pesh delves into the importance of early detection and proactive kidney health management. Our conversation turns to the promising role of data analytics and AI in identifying undiagnosed cases, and the critical need for understanding health metrics like creatinine and GFR. We also delve into the emotional and cognitive challenges of dialysis, highlighting the significance of self-care for both patients and their loved ones.The episode moves beyond personal stories to explore broader themes, including the potential benefits of the Keto diet for kidney health, particularly for those with polycystic kidney disease. We navigate the complex terrain of balancing diet and health, reflecting on the challenges of maintaining an alkaline diet and sourcing healthy fats. As we discuss plans to broaden our advocacy efforts through interactive content, the importance of education and collaboration shines through, offering listeners a comprehensive look at managing and advocating for kidney health.
The FiltrateJoel TopfSwapnil HiremathAC GomezJordy CohenNayan AroraSpecial Guest Brendon NuenEditing bySimon Topf and Nayan AroraShow NotesFINEARTS-HF in NEJM FINEARTS Kidney outcomes in JACCFINE-HEART pooled analysis of cardiovascular, kidney and mortality outcomes in Nature Medicine discussion in NephJC BARACH-D: Low-dose spironolactone and cardiovascular outcomes in moderate stage chronic kidney disease: a randomized controlled trial (Nature Medicine)Live Freely Filtered at KidneyWkSwapnil comes out as a SpiroStan post to NephJC TOPCATTOPCAT primary publication TOPCAT North American results TOPCAT funny business explained AHA/ACC/HFSA Heart Failure Guidelines (PDF)SGLT2i are 2aMRA are a 2bARBs are a 2bARNI are a 2bClinical Phenogroups in Heart Failure With Preserved Ejection Fraction: Detailed Phenotypes, Prognosis, and Response to SpironolactoneKansas city cardiomyopathy questionnaire in patients with CKD without a diagnosis of heart failure: https://pubmed.ncbi.nlm.nih.gov/21187260/GFR slope with steroidal MRAs in HF: https://onlinelibrary.wiley.com/doi/10.1002/ejhf.2635Why Has it Been Challenging to Modify Kidney Disease Progression in Patients With Heart Failure? (JACC)Tubular SecretionsSwap: Disclaimer on Apple TVAC: Duo Lingo Plushy (Amazon)Nayan: The Puzzle BoxJordy: Project Hail MaryBrendon has a podcast, The Kidney Compass with Shikha Wadhwani. And he recommends singer-songwriter, Maggie Rogers (YouTube)Joel: The Singularity Is Nearer: When We Merge with AI by Ray KurzweilClosing music, Tim Yau with The Kidney Connection
“The nurse's role in monitoring the lab values really depends on the clinics you're working at, but really when our patients are receiving treatment, especially in the infusion center, the nurses should be looking at those lab values prior to treatment being started,” Clara Beaver, DNP, RN, AOCNS®, ACNS-BC, clinical nurse specialist at Karmanos Cancer Center in Michigan told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS during a conversation about how to monitor and educate patients with cancer. Music Credit: “Fireflies and Stardust” by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0 Earn [#] contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by November 29, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: The learner will report an increase in knowledge related to monitoring labs and educating patients with cancer. Episode Notes Complete this evaluation for free NCPD. Oncology Nursing Podcast™ episodes: Episode 319: Difficult Conversations About Pregnancy Testing in Cancer Care Episode 311: Standardized Pregnancy Testing Processes in Cancer Care Episode 183: How Oncology Nurses Find and Use Credible Patient Education Resources Episode 179: Learn How to Educate Patients During Immunotherapy Episode 87: What Are the Biggest Barriers to Patient Education? Episode 43: Sharing Patient, Provider, and Caregiver Resources ONS Voice articles: Patient Education Reduces Barriers and Increases Adherence Rates Nurses Must Understand Health Disparities to Provide Effective Patient Education Oncology Nurses Can Improve Oral Medication Management With Patient Education Program ONS Course: ONS Fundamentals of Chemotherapy and Immunotherapy Administration™ Oncology Nursing Forum article: Antineoplastic Therapy Administration Safety Standards for Adult and Pediatric Oncology: ASCO-ONS Standards Clinical Calculations—ANC Huddle Card To discuss the information in this episode with other oncology nurses, visit the ONS Communities. To find resources for creating an Oncology Nursing Podcast club in your chapter or nursing community, visit the ONS Podcast Library. To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org. “Your traditional chemotherapy agents are the ones that we see the most lab abnormalities with, and we can predict those a little bit more with the advent of more of the advanced targeted therapies and immunotherapies, we still see lab values that are altered because of the way that the treatment works, but they may differ a little bit than what we traditionally saw with our normal chemotherapy agents.” TS 2:51 “I talked about the lifespan of all the other cells, and Neutrophils are usually what stop treatment, and part of that is, is that the lifespan of a neutrophil is 48 hours. It is proliferated very frequently in the bone marrow. But that is usually what we see. The cells that we see that stop treatment, and as you mentioned earlier, classic chemotherapy really the types of treatment that historically, we've been given and we have given to patients, and we've seen those blood counts really significantly impacted.” TS 6:21 “Kidney function, or renal function tests, are really determined whether the kidneys are functioning the way they should be. We look at an estimated glomerular filtration rate, or GFR, which is really based on the patient's protein level, their age, gender, and race. And the test really looks at how efficiently the kidneys are clearing the waste from the body. So that's really one that we need to look at, especially as we're giving agents that are excreted through the kidneys.” TS 12:23 “I think it's important for nurses to start looking at lab results with their patient very early on, you know, even before treatment starts, so they understand what the normals look like. So when they do get those lab results, because now pretty much everybody has patient portals, right? So the labs are reported in there, and they're seeing the labs before they're talking to their providers. if we can start early on and talk to them about what the normal lab values are, what they mean, and what we're looking at when we're drawing these labs. I think it's really important for the patient.” TS 27:00
SummaryJazrome Coulter shared his journey as a stand-up comedian, highlighting his battle with kidney disease and the impact of his difficult childhood on his personal growth. He emphasized the importance of choosing to grow from grief after the death of his twin brother in 2018 and his mission to educate others about kidney disease. Additionally, he discussed the significance of his kidney transplant and encouraged people to consider becoming organ donors.Key PointsJazrome Coulter shares his journey as a stand-up comedian, revealing that he has been dealing with kidney disease for almost a decade and expressing gratitude for the experience despite its challenges. 5:06Jazrome Coulter discusses his difficult childhood, including his mother's struggles with addiction, being shuffled between family members, and the impact of these experiences on his life choices and personal growth. 6:00Jazrome Coulter reflects on the death of his twin brother in 2018 as a turning point in his life, emphasizing the choice to grow from grief rather than be broken by it. 21:00Jazrome Coulter concludes by expressing his mission to educate others about kidney disease and inspire hope, emphasizing that every day presents a choice for individuals facing challenges. 26:31Jazrome Coulter shares his journey of self-discovery through comedy, detailing how he processed grief after his brother's death and the impact it had on his life. 40:22Sam Knickerbocker prompts Jazrome Coulter to discuss his experience with kidney failure and how it relates to his past health issues, including performance problems and back pain. 48:22Jazrome Coulter explains the significance of his kidney transplant and how his GFR levels have improved over two years, indicating a strong match with the donor. 1:06:38Jazrome Coulter provides information on various organizations for kidney donations and encourages people to consider becoming organ donors. 1:08:36
The show opens with Adam talking to Jason “Mayhem” Miller about once again getting flipped off on the freeway, the glorious end to Mike August's “Brisket Quest”, and AOC & Tim Walz's reaction to Tony Hinchcliffe's appearance at a Donald Trump rally. Next, comedian Bret Ernst returns to the show to talk about his new special, Uncaged. They also discuss how songs about being in a band tend to be good, while songs about evil women are always bad. Then, Jason “Mayhem” Miller reads the news including stories about how Burlington, Vermont leadership is now calling for more officers after admitting that defunding the police was a mistake, towns setting an age limit on trick-or-treaters, and Philadelphia's D.A. suing Elon Musk to stop his million dollar giveaway. Finally, Mark Farner from Grand Funk Railroad joins the show to talk about his new solo album, why GFR isn't in the Rock & Roll Hall of Fame, what it's like hearing covers of his songs, opening for Led Zeppelin, his songwriting process, and the potential of a GFR reunion. For more with Bret Ernst: ● NEW SPECIAL: Pete Davidson Presents: Bret Ernst Uncaged - available on YouTube ● INSTAGRAM: @breternst ● TIKTOK: @breternst ● WEBSITE: bretcomedy.com For more with Mark Farner: ● NEW SOLO ALBUM: Closer to My Home - available November 8th ● INSTAGRAM: @farner_nine ● TWITTER/X: @farner_nine ● WEBSITE: markfarner.com Thank you for supporting our sponsors: ● http://SimpliSafe.com/Adam ● BotanicTonics.com, use code ADAM ● QualiaLife.com/Adam ● http://Sendthevote.org/Adam or text ADAM to 33022 ● http://OReillyAuto.com/Adam
Imagine a treatment that not only helps manage diabetes but also holds the potential to reverse kidney failure — what was once thought to be impossible. The recent FLOW study has remarkable groundbreaking evidence that GLP-1 receptor agonists can significantly improve kidney function in chronic kidney disease (CKD) patients. And while researchers try to understand the full implications of these findings, one thing is clear: the landscape of kidney disease treatment may never be the same again. In this podcast, we'll dive into the results of the FLOW trial and explore what they may mean for people at risk for kidney failure. What are GLP-1 Agonists? GLP-1 (glucagon-like peptide-1) agonists are a class of drugs that mimic the effects of the natural hormone GLP-1. They enhance insulin secretion, inhibit glucagon release, and slow gastric emptying, improving blood sugar control. Beyond their primary use in diabetes management, GLP-1 agonists have been studied for various conditions, including obesity and cardiovascular disease prevention. The Study Overview The FLOW trial, which stands for "Fasting and Long-acting GLP-1 Receptor Agonist in Patients with Chronic Kidney Disease," focused on the impact of GLP-1 receptor agonists, specifically semaglutide, on patients with chronic kidney disease (CKD) and type 2 diabetes (those most at risk for kidney failure). Researchers observed a remarkable trend: patients receiving semaglutide demonstrated stabilization of kidney function and signs of renal recovery. This was groundbreaking, as reversing kidney damage has long been considered a near-impossible feat. Study Objectives The primary goal was to determine whether treatment with GLP-1 receptor agonists could improve kidney outcomes in patients with CKD. Study Design Participants: The study enrolled >3500 adults with type 2 diabetes and CKD. Intervention: Participants were randomized to receive either semaglutide or a placebo. Primary Outcomes: The main outcomes included changes in glomerular filtration rate (GFR) and the incidence of major adverse kidney events (kidney failure- need for transplantation or dialysis). Key Findings Renal Function Improvement: Patients on semaglutide showed significant improvements in glomerular filtration rates (GFR), a key indicator of kidney function. Reduced Inflammation: The drugs appeared to lower levels of inflammatory markers associated with kidney damage, suggesting a protective effect. Metabolic Benefits: Improvements in blood sugar control and weight loss were also observed, contributing to overall health and potentially alleviating stress on the kidneys. Adverse Events: The treatment was generally well-tolerated, with a favorable safety profile. Ethical Considerations As the results began to emerge, the ethical landscape of the study shifted dramatically. The control group, which was not receiving semaglutide, was found to be at a significantly higher risk of kidney deterioration. With compelling evidence that the GLP-1 agonist was safe and potentially life-saving, the ethics committee determined withholding treatment from any participants was no longer justifiable. Consequently, the study was halted prematurely to allow all participants access to the medication, prioritizing patient welfare over the continuation of research under an inequitable framework. This decision underscores the ethical responsibility of researchers to ensure that all patients receive the best possible care, especially when clear benefits are identified. Implications for Future Research While the early termination of the study raises questions about the completeness of the data collected, it also opens new avenues for further research. The findings encourage more extensive clinical trials to explore the mechanisms behind the renal protective effects of GLP-1 agonists. Additionally, there is a growing interest in investigating these drugs' long-term effects on kidney health and their potential role in preventing disease progression. As further studies unfold, there is hope that GLP-1 agonists will become a standard part of kidney disease management, potentially transforming outcomes for millions affected by this condition. Thanks again for listening to The Peptide Podcast. We love having you as part of our community. If you love this podcast, please share it with your friends and family on social media, and have a happy, healthy week! We're huge advocates of elevating your health game with nutrition, supplements, and vitamins. Whether it's a daily boost or targeted support, we trust and use Momentous products to supercharge our wellness journey. Momentous only uses the highest-quality ingredients, and every single product is rigorously tested by independent third parties to ensure their products deliver on their promise to bring you the best supplements on the market.
DISCOUNT CODES BELOW! Welcome to Episode 64 with 3D Ground force reaction specialist Steve Furlonger. We discussed the development in technology, common issues with players GFRs, using drills that specifically target improving a players GFRs. Steve is often hosting educational seminars fro coaches to help develop their knowledge in GFR's for more information be sure to follow him on his Instagram page below. Information on my online coaching programs: https://skillest.com/app/profile/toby-mcgeachie Interested in being a partner of Podcast? Email me at toby@tmgolf.com.auWATCH THE PODCAST ON YOUTUBE: https://www.youtube.com/@TMGOLFMAJOR SPONSOR SKILLEST:STUDENTS: Download the https://skillest.com/ and use code TOBYM to get 20% off your first lesson package with any coach!COACHES: Use code TOBYM to get your first 2 months free https://skillest.com/PUTTING SEGMENT SPONSOR:BACK 2 BASICS - Putting Mirror accessories included use Code TM15 for 15% https://tinyurl.com/Back2Basics-DiscountTRAIN AT HOME SPONSOR:Net Return Australia - #1 Net trusted by Bryson DeChambeau use Code TMGOLF for 10% off https://www.tmgolf.com.au/the-net-return/FIND Steve on IG: https://www.instagram.com/sfgolfperform/?hl=enTOBY'S SOCIALS: Instagram: https://www.instagram.com/tmgolf_/ instagram: https://www.instagram.com/thegolfcoachpodcast/?hl=en Facebook: https://www.facebook.com/TMGolfCoach/ Linkedin: https://www.linkedin.com/in/toby-mcgeachie-7a74488a/ Youtube: https://www.youtube.com/c/TMGOLF Take Care,
A 77-year-old man is in for a routine follow up visit. He has its twenty-year history of type 2 diabetes and hypertension as well as a 5-year history of stage 3B chronic kidney disease, or CKB. At this visit, his A1C is 8.4% and his estimated GFR is 42 mL per minute. His BP is 128/76. He states he's feeling well and denies headache, visual changes, dizziness and hypoglycemic episodes. His medications include metformin, amlodipine, lisinopril and rosuvastatin. In reviewing his current medication, the NP considers which of the following options?A. Prescribe glipizideB. Add pioglitazone C. Continue on his current medication without adjustment D. Initiate therapy with Canagliflozin---YouTube: https://www.youtube.com/watch?v=rOuR7ATNdMQ&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=92Visit fhea.com to learn more!
Listener Q: "What is the difference between eGFR and GFR? Is one better than the other for getting tested for PKD, or should I ask for both? I am worried I am not getting the labs I need to stay informed about my kidneys." Answer: Tune in and find out: What GFR is What eGFR is If there are the same What you need to know about each and if you need to get both tested for Polycystic Kidneys MASTER YOUR LABS FOR PKD Yes, Sign Me Up! Learn More - https://www.thepkddietitian.com/masteryourlabs RESOURCES Episode #33 What is Cystatin C and Should You Get it Tested? https://www.thepkddietitian.com/podcasts/the-pkd-dietitian-podcast/episodes/2148345282 NKF's eGFR Calculator https://www.kidney.org/professionals/gfr_calculator LET'S CONNECT INSTAGRAM: https://www.instagram.com/the.pkd.dietitian/ FACEBOOK: https://www.facebook.com/PKDdietitian EMAIL: https://www.thepkddietitian.com/site/contact DISCLAIMER The PKD Dietitian Podcast is meant for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your healthcare provider with any medical questions or concerns.
In this episode, we follow the remarkable story of a 72-year-old man who was on the verge of starting dialysis due to advanced stage 4 kidney disease. Faced with a grim prognosis, he embraced an unconventional treatment plan involving daily sauna sessions, a diet of boiled foods, and rigorous lifestyle changes. Over time, his kidney function dramatically improved, with his GFR rising from 21 to 54, and his overall health transformed. The episode explores the science behind his recovery and offers practical tips for supporting kidney health through diet, exercise, and holistic therapies.
Legendary career singer/songwriter Mark Farner of Mark Farner's American Band returns with “Closer To My Home” celebrating the 55th anniversary of the classic song “(I'm Your Captain) Closer To My Home” made famous by Grand Funk Railroad plus “Anymore”, “The Prisoner”, “Same Game”, “Façade”, the bonus track “Friends Forever” and more! Mark also gives us an update on the last release “From Chile with Love” where $3 for every DVD goes towards Veteran's Transitional Housing Services plus the stories behind the music and how GFR sold over 30M worldwide with 16 gold & platinum albums and selling out faster than the Beatles at Shea Stadium still a record to this day! Check out the amazing Mark Farner and his latest release coming Friday, Nov. 8th on many major platforms and www.markfarner.com ! #markfarner #markfarnersamericanband #GFR #grandfunkrailroad #closertomyhome #55thanniversary #imyourcaptain #anymore #theprisoner #samegame #facade #friendsforever #fromchilewithlove #spreaker #iheartradio #spotify #applemusic #youtube #anchorfm #bitchute #rumble #mikewagner #themikewagnershow #mikewagnermarkfarner #themikewagnershowmarkfarner --- Support this podcast: https://podcasters.spotify.com/pod/show/themikewagnershow/support
Legendary career singer/songwriter Mark Farner of Mark Farner's American Band returns with “Closer To My Home” celebrating the 55th anniversary of the classic song “(I'm Your Captain) Closer To My Home” made famous by Grand Funk Railroad plus “Anymore”, “The Prisoner”, “Same Game”, “Façade”, the bonus track “Friends Forever” and more! Mark also gives us an update on the last release “From Chile with Love” where $3 for every DVD goes towards Veteran's Transitional Housing Services plus the stories behind the music and how GFR sold over 30M worldwide with 16 gold & platinum albums and selling out faster than the Beatles at Shea Stadium still a record to this day! Check out the amazing Mark Farner and his latest release coming Friday, Nov. 8th on many major platforms and www.markfarner.com ! #markfarner #markfarnersamericanband #GFR #grandfunkrailroad #closertomyhome #55thanniversary #imyourcaptain #anymore #theprisoner #samegame #facade #friendsforever #fromchilewithlove #spreaker #iheartradio #spotify #applemusic #youtube #anchorfm #bitchute #rumble #mikewagner #themikewagnershow #mikewagnermarkfarner #themikewagnershowmarkfarner --- Support this podcast: https://podcasters.spotify.com/pod/show/themikewagnershow/support
Legendary career singer/songwriter Mark Farner of Mark Farner's American Band returns with “Closer To My Home” celebrating the 55th anniversary of the classic song “(I'm Your Captain) Closer To My Home” made famous by Grand Funk Railroad plus “Anymore”, “The Prisoner”, “Same Game”, “Façade”, the bonus track “Friends Forever” and more! Mark also gives us an update on the last release “From Chile with Love” where $3 for every DVD goes towards Veteran's Transitional Housing Services plus the stories behind the music and how GFR sold over 30M worldwide with 16 gold & platinum albums and selling out faster than the Beatles at Shea Stadium still a record to this day! Check out the amazing Mark Farner and his latest release coming Friday, Nov. 8th on many major platforms and www.markfarner.com ! #markfarner #markfarnersamericanband #GFR #grandfunkrailroad #closertomyhome #55thanniversary #imyourcaptain #anymore #theprisoner #samegame #facade #friendsforever #fromchilewithlove #spreaker #iheartradio #spotify #applemusic #youtube #anchorfm #bitchute #rumble #mikewagner #themikewagnershow #mikewagnermarkfarner #themikewagnershowmarkfarner Become a supporter of this podcast: https://www.spreaker.com/podcast/the-mike-wagner-show--3140147/support.
Welcome to Guilders-Ford Radio, a Necromunda podcast broadcasting from the East Gate Docks of Hive Primus (via Guildford Games Club, Surrey, UK).In Episode 24 - ‘Warp Portal or Body Shop', after many months of anticipation, the GFR team have finally play-tested the Spyrers - and are ready to share the Spire-born sociopath's strengths, weaknesses and counters.The Necromunda community continue to submit their queries to our High Arbitrator, and the latest installment of #DearDixie sees James and the gang do their best to field *your* burning rules and background questions.In the final segment of the episode, take malicious joy in listening to Rosco and Leigh's panic with the imminent arrival of SumpCon 2024 - where we discover they've done next to nothing in terms of preparation.We'd like to take the opportunity to thank all our listeners who have chosen to support us on Patreon & Buzzsprout. Your contributions help us make a better show! • Jason • Joseph Serrani • Billy • Phil • Stephen Griffiths • Søren D • Spruewhisperer • Kevin Fowler • Scott Spieker • Andy Tabor • TheMichaelNimmo • Tucker Steel • Dave Shearman • Shaughn • Stewart Young •Damien Davis • Wayne Jeffrey • Frawgenstein • Matthey Mulcahy • William Payne •Thomas Laycock • Stephen Livingston • Tyler Anderson • McGobbo • Jed Tearle • Gene Archibald • James Marsden • John Haynes • Ryan Taylor • Yuki van Elzelingen • Dick Linehan • Rhinoxrifter • Shawn Hall • Eric McKenzie • Paul Shaw • Jenifer • Drew Williams • Greg Miller • Andy Farrell • Nate Combrink • Don Johnson • Michael Yule • Joe Roberts • TheRedWolf • Lukasz Jainski • Aaron Vissers • One Punch Orlock (Tom) • Matt Price • Shnubuts • Christopher Næss • Rob Harrison • Colm Kiely • Dave • Grant • Stephen Briley • Szymon Brzozowski • Angus Lee • Mykola Romaniuk • Jason Turner • Janner558 • Christian Jansch • Joe Reynolds • Xavier Lamrecht • Matt R • Andrew Gomes • Iain Torrance • Mark Southerd • Ben • James Dix • Eddie Turner Support the showHelp us make better content, and download free community resources!www.patreon.com/guildersfordradioAny comments, questions or corrections? We'd love to hear from you! Join the Guilders-Ford Radio community over at;https://linktr.ee/guildersfordradiowww.instagram.com/guildersfordradiowww.facebook.com/guildersfordradioGuildersFordRadio@Gmail.com ** Musical Attribution - Socket Rocker by (Freesound - BaDoink) **
Send us a textCan understanding the hidden dangers of obesity save your kidneys? Join us this week as Kimberlee, a registered nurse and VP of Clinical Services with Specialty Care Management, shares the profound impact obesity has on chronic kidney disease. From hormonal imbalances to increased insulin resistance, Kimberlee breaks down how excess body mass sets off a cascade of health issues that not only jeopardize your kidneys but also pave the way for diabetes, hypertension, and heart disease. You'll learn how your BMI and waist-to-hip ratio can be crucial indicators of your kidney health and why monitoring these metrics is vital.Kimberlee delves into the mechanics of hyperfiltration, explaining how our kidneys go into overdrive to manage increased body mass, potentially leading to harmful conditions like glomerulomegaly and proteinuria. She offers actionable advice on tracking essential markers like creatinine and GFR to keep tabs on your kidney function. Don't miss this educational and practical session packed with insights and tips to help you take control of your kidney health and prevent the progression to dialysis. Tune in and empower yourself with the knowledge to make healthier choices!
The draft order:Sophia AmbrusoNayan AroraSwapnil HiremathAC GomezJoel TopfEditor Nayan AroraShow NotesPrevious drafts:2021 KDIGO Hypertension —Joel, Sophia, Swap, Nayan, Josh2021 ASN Kidney Week Draft—Joel, Sophia, Swap, Nayan, Jennie2022 The ISPD Peritonitis Guideline— Joel, Sophia, Swap, Nayan2022 ASN Kidney Week Draft—Joel, Sophia, Swap, Nayan2023 ASN Kidney Week Draft—Joel, Sophia, Swap, Nayan, AC, Josh2024 KDIGO CKD Clinical Practice Guideline —Joel, Sophia, Swap, Nayan, Josh, ACThe guidelineThe NephJC discussion Part 1 | Part 2First RoundSophia's Pick 3.7.1 We recommend treating patients with type 2 diabetes (T2D), CKD, and an eGFR ≥20 ml/min per 1.73 m2 with an SGLT2i (1A).Not Nayan's Pick 3.7.3: We suggest treating adults with eGFR 20 to 45 ml/min per 1.73 m2 with urine ACR
CardioNerds (Drs. Gurleen Kaur and Richard Ferraro) and episode FIT Lead Dr. Saahil Jumkhawala (Cardiology Fellow at the University of Miami) discuss SGLT inhibitors, focusing on the biology of SGLT and its inhibition, with Dr. Katherine Tuttle (Executive Director for Research at Providence Healthcare, Co-Principal Investigator of the Institute of Translational Health Sciences, and Professor of Medicine at the University of Washington). Show notes were drafted by Dr. Saahil Jumkhawala. The episode audio was engineered by CardioNerds intern Christiana Dangas. This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals. CardioNerds Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - The Biology of SGLT Inhibition with Dr. Katherine Tuttle SGLT inhibitors, while initially developed as antidiabetic medications, have been shown to be beneficial for cardiovascular and renal outcomes. These benefits result from their on-target glucosuric effects and additional off-target effects. The side effect profiles of SGLTis are primarily mediated by glucose reabsorption in their target tissues. The side effect profile of SGLTis must be considered when prescribing these medications and is generally favorable for SGLT2is versus SGLT1is. Once SGLTis are prescribed, patients should be given specific attention to their eGFR, serum potassium, and clinical evaluations of volume status and blood pressure. Strategies to increase implementation of and reduce clinical inertia for these important class of medication remain an area of active investigation Show notes - The Biology of SGLT Inhibition with Dr. Katherine Tuttle What should prompt consideration of starting an SGLT inhibitor? Considerations for SGLT inhibitor initiation are based on a history of heart failure, kidney disease, and diabetes status. In the EMPA-KIDNEY trial, empagliflozin improved cardiovascular and kidney outcomes in those with low GFR (regardless of level of albuminuria). What is the mechanism of action of SGLT2 inhibitors? SGLT2 inhibitors improve glycemic control by blocking SGLT2 receptor-mediated reabsorption of glucose in the proximal convoluted tubule, where 80-90% of this reuptake occurs, and increased downstream excretion of glucose and sodium chloride. SGLT2 inhibitors provide only a modest glucose-lowering effect, particularly for patients with GFR
Dr Jill Valerius and Lee Henrikson discuss different kidney diseases, signs, symptoms and screening. The discussion continues with stages and GFR. Also important dietary modifications if you have kidney disease.
The Filtrate:Joel TopfSwapnil HiremathPriya Yenebere Nayan AroraWith Special Guest:Brendon Neuen Super smart guy and clinical trialistMichelle Rheault Lead author of DUPLEX and friend of the podShow NotesSparsentan versus Irbesartan in Focal Segmental GlomerulosclerosisNephJC Summary | PubMed | NEJMKDIGO FSGS Guidelines 2021 (PDF)Characterization of the Clinical Evidence Supporting Repository Corticotropin Injection for FDA-Approved Indications, A Scoping Review (JAMA Internal Medicine)DUET: A Phase 2 Study Evaluating the Efficacy and Safety of Sparsentan in Patients with FSGS (PubMed)Vlado Perkovic, mentor and sponsor extradenoire (UNSW Sydney)Shimer Its a floor wax and a desert topping (TikTok)SONAR: Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease: a double-blind, randomised, placebo-controlled trial. (NephJC)Travere Therapeutics Announces FDA Accelerated Approval of FILSPARIᵀᴹ (sparsentan), the First and Only Non-immunosuppressive Therapy for the Reduction of Proteinuria in IgA Nephropathy (Travere press release)GFR Slope: Chronic vs Total slope: A meta-analysis of GFR slope as a surrogate endpoint for kidney failure (Nature Medicine)There are dozens of us! Dozens! (Know your Meme)Brendon's Neuen's tweet about total versus chronic slope (X | Twitter)Julie R. Ingelfinger, deputy editor for the New England Journal of Medicine (Wikipedia)You know nothing, John Snow (YouTube shorts)Tubular SecretionsSwapnil Foundation season two on Apple TV Wheel of Time season two Amazon PrimeBrendon Andor Priya Poverty, by America Mattew DesmondNayan The Armor of Light: A Novel by Ken FollettMichelle Lessons in Chemistry: A Novel by Bonnie Garmus
Life happens and half the crew is out this week, but GFR and chadthemark are here to help through this lull in sports. But is it really a lull? The wrestling icon Sting retired, March Madness is creeping in, and Jake Paul and Mike Tyson are going to fight on Netflix. Go tell someone that statement 10 years ago! If you're dealing with depression from not having the NFL, we got you.
OutlineChapter 14- Hypovolemic States- Etiology - True volume depletion occurs when fluid is lost from from the extracellular fluid at a rate exceeding intake - Can come the GI tract - Lungs - Urine - Sequestration in the body in a “third space” that is not in equilibrium with the extracellular fluid. - When losses occur two responses ameliorate them - Our intake of Na and fluid is way above basal needs - This is not the case with anorexia or vomiting - The kidney responds by minimizing further urinary losses - This adaptive response is why diuretics do not cause progressive volume depletion - Initial volume loss stimulates RAAS, and possibly other compensatory mechanisms, resulting increased proximal and collecting tubule Na reabsorption. - This balances the diuretic effect resulting in a new steady state in 1-2weeks - New steady state means Na in = Na out - GI Losses - Stomach, pancreas, GB, and intestines secretes 3-6 liters a day. - Almost all is reabsorbed with only loss of 100-200 ml in stool a day - Volume depletion can result from surgical drainage or failure of reabsorption - Acid base disturbances with GI losses - Stomach losses cause metabolic alkalosis - Intestinal, pancreatic and biliary secretions are alkalotic so losing them causes metabolic acidosis - Fistulas, laxative abuse, diarrhea, ostomies, tube drainage - High content of potassium so associated with hypokalemia - [This is a mistake for stomach losses] - Bleeding from the GI tract can also cause volume depletion - No electrolyte disorders from this unless lactic acidosis - Renal losses - 130-180 liters filtered every day - 98-99% reabsorbed - Urine output of 1-2 liters - A small 1-2% decrease in reabsorption can lead to 2-4 liter increase in Na and Water excretion - 4 liters of urine output is the goal of therapeutic diuresis which means a reduction of fluid reabsorption of only 2% - Diuretics - Osmotic diuretics - Severe hyperglycemia can contribute to a fluid deficit of 8-10 Iiters - CKD with GFR < 25 are poor Na conservers - Obligate sodium losses of 10 to 40 mEq/day - Normal people can reduce obligate Na losses down to 5 mEq/day - Usually not a problem because most people eat way more than 10-40 mEq of Na a day. - Salt wasting nephropathies - Water losses of 2 liters a day - 100 mEq of Na a day - Tubular and interstitial diseases - Medullary cystic kidney - Mechanism - Increased urea can be an osmotic diuretic - Damage to tubular epithelium can make it aldo resistant - Inability to shut off natriuretic hormone (ANP?) - The decreased nephro number means they need to be able to decrease sodium reabsorption per nephron. This may not be able to be shut down acutely. - Experiment, salt wasters can stay in balance if sodium intake is slowly decreased. (Think weeks) - Talks about post obstruction diuresis - Says it is usually appropriate rather than inappropriate physiology. - Usually catch up solute and water clearance after releasing obstruction - Recommends 50-75/hr of half normal saline - Talks briefly about DI - Skin and respiratory losses - 700-1000 ml of water lost daily by evaporation, insensible losses (not sweat) - Can rise to 1-2 liters per hour in dry hot climate - 30-50 mEq/L Na - Thirst is primary compensation for this - Sweat sodium losses can result in hypovolemia - Burns and exudative skin losses changes the nature of fluid losses resulting in fluid losses more similar to plasma with a variable amount of protein - Bronchorrhea - Sequestration into a third space - Volume Deficiency produced by the loss of interstitial and intravascular fluid into a third space that is not in equilibrium with the extracellular fluid. - Hip fracture 1500-2000 into tissues adjacent to fxr - Intestinal obstruction, severe pancreatitis, crush injury, bleeding, peritonitis, obstruction of a major venous system - Difference between 3rd space and cirrhosis ascities - Rate of accumulation, if the rate is slow enough there is time for renal sodium and water compensation to maintain balance. - So cirrhotics get edema from salt retension and do not act as hypovolemia - Hemodynamic response to volume depletion - Initial volume deficit reduced venous return to heart - Detected by cardiopulmonary receptors in atria and pulmonary veins leading to sympathetic vasoconstriction in skin and skeletal muscle. - More marked depletion will result in decreased cardiac output and decrease in BP - This drop in BP is now detected by carotid and aortic arch baroreceptors resulting in splanchnic and renal circulation vasoconstriction - This maintains cardiac and cerebral circulation - Returns BP toward normal - Increase in BP due to increased venous return - Increased cardiac contractility and heart rate - Increased vascular resistance - Sympathetic tone - Renin leading to Ang2 - These can compensate for 500 ml of blood loss (10%) - Unless there is autonomic dysfunction - With 16-25% loss this will not compensate for BP when patient upright - Postural dizziness - Symptoms - Three sets of symptoms can occur in hypovolemic patients - Those related to the manner in which the fluid loss occurs - Vomiting - Diarrhea - Polyuria - Those due to volume depletion - Those due to the electrode and acid base disorders that can accompany volume depletion - The symptoms of volume depletion are primarily related to the decrease in tissue perfusion - Early symptoms - Lassitude - Fatiguability - Thirst - Muscle cramps - Postural dizziness - As it gets more severe - Abdominal pain - Chest pain - Lethargy - Confusion - Symptomatic hypovolemia is most common with isosmotic Na and water depletion - In contrast pure water loss, causes hypernatremia, which results in movement of water from the intracellular compartment to the extracellular compartment, so that 2/3s of volume loss comes from the intracellular compartment, which minimizes the decrease in perfusion - Electrolyte disorders and symptoms - Muscle weakness from hypokalemia - Polyuria/poly dips is from hyperglycemia and hypokalemia - Lethargy, confusion, Seizures, coma from hyponatremia, hypernatremia, hyperglycemia - Extreme salt craving is unique to adrenal insufficiency - Eating salt off hands ref 18 - Evaluation of the hypovolemic patient - Know that if the losses are insensible then the sodium should rise - Volume depletion refers to extracellular volume depletion of any cause, while dehydration refers to the presence of hypernatremia due to pure water loss. Such patients are also hypovolemic. - Physical exam is insensitive and nonspecific - Finding most sensitive and specific finding for bleeding is postural changes in blood pressure - I don't find this very specific at all! - Recommends laboratory confirmation regardless of physical exam - Skin and mucous membranes - Should return too shape quickly - Elastic property is called Turgur - Not reliable is patients older than 55 to 60 - Dry axilla - Dry mucus membranes - Dark skin in Addison's disease Frim increased ACTH - Arterial BP - As volume goes down so does arterial BP - Marked fluid loss leads to quiet korotkoff signs - Interpret BP in terms of the patients “normal BP” - Venous pressure - Best done by looking at the JVP - Right atrial and left atrial pressure - LV EDP is RAP + 5 mmHg - Be careful if valvular disease, right heart failure, cor pulmonare, - Figure 14-2 - Shock - 30% blood loss - Lab Data - Urine Na concentration - Should be less than 25 mmol/L, can go as low as 1 mmol/L - Metabolic alkalosis can throw this off - Look to the urine chloride - Figure 14-3 - Renal artery stenosis can throw this off - FENa - Mentions that it doesn't work so well at high GFR - Urine osmolality - Indicates ADH - Volume depletion often associated with urine osm > 450 - Impaired by - Renal disease - Osmotic diuretic - Diuretics - DI - Mentions that severe volume depletion and hypokalemia impairs urea retension in renal medulla - Points out that isotonic urine does not rule out hypovolemia - Mentions specific gravity - BUN and Cr concentration - Normal ratio is 10:1 - Volume depletion this goes to 20:1 - Serum Na - Talks about diarrhea - Difference between secretory diarrhea which is isotonic and just causes hypovolemia - And osmotic which results in a lower electrolyte content and development of hypernatremia - Talks about hyperglycemia - Also can cause the sodium to rise from the low electrolyte content of the urine - But the pseudohyponatraemia can protect against this - Plasma potassium - Treatment - Both oral and IV treatment can be used for volume replacement - The goal of therapy are to restore normovolemia - And to correct associated acid-base and electrolyte disorders - Oral Therapy - Usually can be accomplished with increased water and dietary sodium - May use salt tablets - Glucose often added to resuscitation fluids - Provides calories - Promotes intestinal Na reabsorption since there is coupled Na and Glucose similar to that seen in the proximal tubule - Rice based solutions provide more calories and amino acids which also promote sodium reabsorption - 80g/L of glucose with rice vs 20 g/L with glucose alone - IV therapy - Dextrose solutions - Physiologically equivalent to water - For correcting hypernatremia - For covering insensible losses - Watch for hyperglycemia - Footnote warns against giving sterile water - Saline solutions - Most hypovolemic patients have a water and a sodium deficit - Isotonic saline has a Na concentration of 154, similar to that of plasma see page 000 - Half-isotonic saline is equivalent to 550 ml of isotonic saline and 500 of free water. Is that a typo? - 3% is a liter of hypertonic saline and 359 extra mEq of Na - Dextrose in saline solutions - Give a small amount of calories, otherwise useless - Alkalinizing solutions - 7.5% NaHCO3 in 50 ml ampules 44 mEq of Na and 44 mEq of HCO3 - Treat metabolic acidosis or hyperkalemia - Why 44 mEq and not 50? - Do not give with calcium will form insoluble CaCO3 - Polyionic solutions - Ringers contains physiologic K and Ca - Lactated Ringers adds 28 mEq of lactate - Spreads myth of LR in lactic acidosis - Potassium chloride - Available as 2 mEq/mL - Do not give as a bolus as it can cause fatal hyperkalemia - Plasma volume expanders - Albumin, polygelastins, hetastarch are restricted to vascular space - 25% albumin can pull fluid into the vascular space - 25% albumin is an albumin concentration of 25 g/dL compare to physiologic 4 g/dL - Says it pulls in several times its own volume - 5% albumin is like giving plasma - Blood - Which fluid? - Look at osmolality, give hypotonic fluids to people with high osmolality - Must include all electrolytes - Example of adding 77 mEw of K to 0.45 NS and making it isotonic - DI can be replaced with dextrose solutions, pure water deficit - Case 14-3 - Diarrhea with metabolic acidosis - He chooses 0.25 NS with 44 mEq of NaCl and 44 NaHCO3 - Talks about blood and trauma - Some studies advocate delaying saline until penetrating trauma is corrected APR about to. Keep BP low to prevent bleeding. Worry about diluting coagulation factors - Only do this if the OR is quickly available - Volume deficit - Provides formula for water deficit and sodium deficit - Do not work for isotonic losses - Provides a table to adjust fluid loss based on changes in Hgb or HCTZ - Says difficult to estimate it from lab findings and calculations - Follow serial exams - Serial urine Na - Rate of replacement - Goal is not to give fluid but to induce a positive balance - Suggests 50-100 ml/hr over what is coming out of the body - Urine - Insensibles 30-50 - Diarrhea - Tubes - Hypovolemic shock - Due to bleeding - Sequesting in third space - Why shock? - Progressive volume depletion leads to - Increased sympathetic NS - Increased Ang 2 - Initially this maintains BP, cerebral and coronary circulation - But this can decrease splanchnic, renal and mucocutaneous perfusion - This leads to lactic acicosis - This can result in intracellular contents moving into circulation or translocation of gut bacteria - Early therapy to prevent irreversible shock - In dogs need to treat with in 2 hours - In humans may need more than 4 hours - Irreversible shock associated with pooling of blood in capillaries - Vasomotor paralysis - Hyperpolarization of vascular smooth muscle as depletion of ATP allows K to flowing out from K channels opening. Ca flows out too leading to vasodilation - Glyburide is an K-ATP channel inhibitor (?) caused increased vasoconstriction and BP - Pluggin of capillaries by neutrophils - Cerebral ischemia - Increased NO generation - Which Fluids? - Think of what is lost and replace that. - Bleeding think blood - Raise the hct but not above 35 - Acellular blood substitutes, looked bad at the time of this writing - Di aspirin cross linked hemoglobin had increased 2 and 28 day mortality vs saline - Colloids sound great but they fail in RCTs - SAFE - FEAST - Points out that saline replaces the interstitial losses why do we think those losses are unimportant - Pulmonary circulation issue - Pulmonary circulation is more leaky so oncotic pressure less effective there - Talks about the lungs be naturally protected from pulmonary edema - Rate of fluid - 1-2 liters in first hour - Suggests CVP or capillary wedge pressure during resuscitation - No refs in the rate of fluid administration section - Lactic acidosis - Points out that HCO can impair lactate utilization - Also states that arterial pH does not point out what is happening at the tissue level. Suggests mixed-venous sample.ReferencesJCI - Phenotypic and pharmacogenetic evaluation of patients with thiazide-induced hyponatremia and a nice review of this topic: Altered Prostaglandin Signaling as a Cause of Thiazide-Induced HyponatremiaThe electrolyte concentration of human gastric secretion. https://physoc.onlinelibrary.wiley.com/doi/10.1113/expphysiol.1960.sp001428A classic by Danovitch and Bricker: Reversibility of the “Salt-Losing” Tendency of Chronic Renal Failure | NEJMOsmotic Diuresis Due to Retained Urea after Release of Obstructive Uropathy | NEJMIs This Patient Hypovolemic? | Cardiology | JAMAAnd by the same author, a textbook: Steven McGee. 5th edition. Evidence-Based Physical Diagnosis Elsevier Philadelphia 2022. ISBN-13: 978-0323754835The clinical course and pathophysiological investigation of adolescent gestational diabetes insipidus: a case report | BMC Endocrine DisordersSensitivity and specificity of clinical signs for assessment of dehydration in endurance athletes | British Journal of Sports MedicineDiagnostic performance of serum blood urea nitrogen to creatinine ratio for distinguishing prerenal from intrinsic acute kidney injury in the emergency department | BMC NephrologyThe meaning of the blood urea nitrogen/creatinine ratio in acute kidney injury - PMCLanguage guiding therapy: the case for dehydration vs volume depletion https://www.acpjournals.org/doi/10.7326/0003-4819-127-9-199711010-00020?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmedValidation of a noninvasive monitor to continuously trend individual responses to hypovolemiaReferences for Anna's voice of God on Third Spacing : Shires Paper from 1964 (The ‘third space' – fact or fiction? )References for melanie's VOG:1. Appraising the Preclinical Evidence of the Role of the Renin-Angiotensin-Aldosterone System in Antenatal Programming of Maternal and Offspring Cardiovascular Health Across the Life Course: Moving the Field Forward: A Scientific Statement From the American Heart Association2. excellent review of RAAS in pregnancy: The enigma of continual plasma volume expansion in pregnancy: critical role of the renin-angiotensin-aldosterone systemhttps://journals-physiology-org.ezp-prod1.hul.harvard.edu/doi/full/10.1152/ajprenal.00129.20163. 10.1172/JCI107462- classic study in JCI of AngII responsiveness during pregnancy4. William's Obstetrics 26th edition!5. Feto-maternal osmotic balance at term. A prospective observational study
“The search for daunorubicin's sister really led to this discovery of doxorubicin, which is an analog with much greater activity. The discovery of doxorubicin can be coined kind of as, ‘one of the best drugs born in Milan, Italy.' And after that, a few analogs were developed and tested, and two that we currently use today, are idarubicin and epirubicin,” Puja Patel, PharmD, BCOP, clinical oncology pharmacist at the Delnor Hospital Northwestern Medicine Cancer Center in Geneva, IL, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a discussion about anthracyclines and other antitumor antibiotics. This episode is part of a series about drug classes, which we'll include a link to in the episode notes. You can earn free NCPD contact hours after listening to this episode and completing the evaluation linked below. Music Credit: “Fireflies and Stardust” by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0 Earn 0.75 contact hours of nursing continuing professional development (NCPD), which may be applied to the nursing practice, oncology nursing practice, symptom management, palliative care, supportive care, or treatment ILNA categories, by listening to the full recording and completing an evaluation at myoutcomes.ons.org by January 26, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: The learner will report an increase in knowledge of anthracyclines and antitumor antibiotics. Episode Notes Complete this evaluation for free NCPD. Oncology Nursing Podcast: Pharmacology 101 series ONS Voice oncology drug reference sheets IV Cancer Treatment Education Sheets ONS Voice articles: The Evidence Is Building for ACE Inhibitors in Anthracycline-Associated Cardiotoxicity Outpatient Oncology Drug Series: Doxorubicin Is the Infamous Red Devil Clinical Journal of Oncology Nursing articles: Nursing Alchemy: Transforming R-CHOP Information Into Essentials Dyspnea: Common Side Effect Cardiac Toxicity: Using Angiotensin-Converting Enzyme Inhibitors to Prevent Anthracycline-Induced Left Ventricular Dysfunction and Cardiomyopathy Oncology Nursing Forum article: Symptom Clusters in Lymphoma Survivors Before, During, and After Chemotherapy: A Prospective Study ONS Huddle Card: Antitumor Antibiotics Additional healthcare professional resources: Blindspot: Hidden Biases of Good People Harvard University Implicit Association Test OncoPharm Podcast ASCO Education Podcast Additional patient resources: National Comprehensive Cancer Network patient resources National Comprehensive Cancer Network patient webinars National Cancer Institute resources for patients To discuss the information in this episode with other oncology nurses, visit the ONS Communities. To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library. To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org. Highlights From Today's Episode “Anthracyclines are kind of categorized as topoisomerase II inhibitors, and these agents are very powerful in that they have—it's really like three drugs in one—they have various mechanisms.” TS 3:55 “We need to create a stable environment, and so we actually cut one of the cords, and that's exactly what topoisomerase is doing. It's cutting one of the DNA strands. And in this case, it's cutting two strands, and that's why it's called topoisomerase II, so it's cutting both of the strands. It's cutting the DNA, releasing some of that tension, allowing for replication, and then rejoining that portion. So, it's a very important enzyme, and it'll go about doing this for the entire strand of DNA.” TS 4:50 “The other second mechanism is kind of the effect on DNA. So, you'll come across reading the term ‘DNA intercalation.' So, what does that word mean? When you take the word ‘intercalate,' the definition of it means ‘intrusive inserting of something in an existing series or sequence.' The analogy that I could think of here is simple: It's thinking about too many passengers squeezing in the backseat of your car. There could be safety issues, there's weight issues, there's instability maybe while driving. And that's what this doxorubicin is doing. It's sliding right in between the base pairs of the DNA double helix, destroying hydrogen bonds between those two bases, which then change the shape of that double helix. And by changing the shape, topoisomerase II, which we just talked about, can no longer go in and bind to DNA. It can't relax that super coil. And so, DNA synthesis doesn't happen.” TS 6:02 “So, the main toxicity that our listeners might be familiar with is cardiotoxicity. And also with cardiotoxicity, breaking it down a little bit, there's an onset that occurs during treatment or even years to decades, and that's kind of this delayed cardiotoxicity. Signs and symptoms of acute cardiotoxicity could vary from EKG changes present as tachycardia, tachyarrhythmia. Delayed cardiotoxicity is anything from heart failure to left ventricular ejection fraction decrease.” TS 9:41 “We're worried about heart failure in these patients. So, we might see EKG changes, we might see LVEF [left ventricular ejection fraction] changes, and we're kind of tracking these agents based on what is called cumulative dose tracking or lifetime dose. So, all of these agents have specific lifetime maximums that we need to be aware of.” TS 14:53 “So, smoking, hypertension, diabetes, dyslipidemia, obesity, or you're older in age, or perhaps you have a compromised cardiac function—you're at greater risk for developing these cardiotoxicities. An example that I've had in my clinic is I've identified some of these patients that have these risk factors, and we go into a little bit more aggressive monitoring for the echocardiogram or MUGA [multigated acquisition]. And when we put in those orders, we often get denials from insurance. We submit the guidelines in, kind of, appeals to help those patients kind of proactively realize if we're putting them in a greater cardiac risk.” TS 15:47 “One of the biggest things is for nurses to kind of look over their policies for administration for vesicants and specifically checking blood return for these agents, because many of them are given, you know, IV push. So, checking blood return every 2–5 ml is really important to make sure that you are in the right space. And then these agents, some of them can also be given continuously. So, you're thinking about, first of all, you should have a central line in for these agents because they're vesicants. But if it's being given continuous, there is something that's called anthracycline streaking, and it's not the same as an extravasation. So, I think being able to decipher the difference between the two is really, kind of, comes with experience.” TS 20:36 “I think awareness is really essential. And thankfully, you know, thankfully or not, I guess, you were with the patient for this entire time, right? Because you're pushing every 2–5 ml, you're checking. So, it's a very kind of intimate experience in and of itself. So, I think just being very vigilant is very important.” TS 22:24 “So, to talk about bleomycin here, for example, kinetically, two-thirds of this drug is eliminated renally. And so, we would think that there would need to be renal adjustments if there's renal changes. So, for creatinine clearance greater than 50, there are no renal dose adjustments. But after that, every 10 ml per minute decrease in GFR [glomerular filtration rate], there are dose reductions that are required. And this drug, in particular, has a lot of gradations in terms of renal dysfunction that I've seen.” TS 27:30 “Thinking about bleomycin, it's IV over 10 minutes, and you want to think about the lifetime maximum dose. So, when you are working up your patient, that's something to kind of think about. Dactinomycin is highly emetogenic, so making sure that there's antibiotics on board. It's also a vesicant, so thinking about vesicants precautions. Cold compresses is how you would help treat that if there is an extravasation.” TS 33:14 “I think trust is the foundation oncology really because we are asking our patients to do so many things outside of our infusion center, picking up medications, taking medications, calling us about signs and symptoms, going and getting all these imaging know. So, if there isn't that foundation of trust, having this perfect curative treatment plan may be more challenging to really be carried out.” TS 38:06 “We've developed these very powerful agents, and they're non–cell specific. So, I think the next step would be, how can we reformulate them to make them less toxic and provide more of a targeted approach? And so, perhaps an antibody-drug conjugate that is specifically attacking the lymphoma or the breast cell can deliver this chemotherapy with a cytotoxic payload is there in the horizon.” TS 39:07 “I think the misconception that ‘I will develop heart damage' is really important. Doxorubicin has the infamous name of the red devil, but I think it's important to let your patients know that heart failure increases with cumulative dosing. You know, talking to them about 300 mg/m2 is associated with a 1.5% heart failure risk. Whereas going all the way across to 500 mg/m2, now you're looking at 6%–20% probability of developing heart failure.” TS 42:30 “I think taking the time and understanding the literature. Typically, we don't start these agents with LVEF less than 50–55. There's some great review articles in JCO [Journal of Clinical Oncology] that kind of define what cardiomyopathy decrease looks like and decreases in LVEF over 10% to a value below the institutional limit of normal, I think, is a nice point to have as a value, a number to kind of work with.” TS 43:53 “Working with your nurse educator and leader to help achieve OCN®, oncology certified nurse, certification is really important. And I think live simulated experiences are really beneficial, maybe even looking at extravasations or having an infusion-related reaction, because here in the acute setting, we're really kind of in this like responsive mode. But if we practice, we can respond more deliberately and more calmly.” TS 45:05
Welcome back to our weekend Cabral HouseCall shows! This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track! Check out today's questions: Taran: Hi Dr. Cabral! You are amazing and I truly appreciate your willingness to share your knowledge with the world. I was diagnosed with ichthyosis vulgaris when I was born. I have had very dry skin since birth. It was a lot worse when I was younger. It is much better, however would still be classified as very dry for a normal person. I have to regularly apply moisturizers on my entire body at least 2x daily. Thanks to your recommendation , I discovered my moisturizer was toxic (7 on ewg skin deep) I have 2 questions: 1. Can I do anything from the inside to heal my skin in the long run rather than relying on moisturizers? 2. What is the best for applying topically on skin? Oils? Moisturizers? Aleisha: Hi Dr Cabral, thank you so much for everything you do and your generosity and energy in this world. I know you don't like to discuss specific brands on the podcast however I was wondering what your thoughts are on the ‘recovery' formula from the ‘Osmosis Skincare' Wellneas range. It says it can rebuild the fat pads lost with aging, I am 33 however due to a pretty intense health journey I have lost much of the volume in my fat pads and feel I look as if have aged dramatically and am considering giving this a go. The main basis of it is that it contains omegas 3,6,7 &9 from sea buckthorn fruit, oil & pulp and some macadamia oil. It is a very expensive product and the claim is that it takes 3 bottles to see changes and 7 bottles for best results. Is there an alternative to this you recommend? Anouk: Hi there, Thanks for all the information you give out so generously. in July I tested pos. for ( ureaplasma, gardnerella, and candida alb) I took one round of doxy 7 days and a few months later I caught strep and re-tested for everything I still had the Urea +candida but I took clarithromycin for the strep. Of course all of these antibiotics were screwing up my vaginal microbiome.. I since have had a pap that came back HPV pos. ( LSIL) not sure if it the the stress of all of this but for the past few weeks i've had unbearable lower tailbone butt bone / pelvic floor aching and leg cramping, I can feel my vaginal muscles are almost in a permanent kegel and it's very hard to relax down there. Regardless of the pain i'd really like to do what I can to eradicate ALL of these things! Glenn: What is the difference between caffeine and caffeine anhydrous as found in pre workout drinks and how bad is thus compound for the body. I've found info online on preworkouts and energy drinks but they all seem to revolve around the sugars/ artificial sweeteners in them rather than the other compounds. I enjoy taking these daily and found one that's pretty clean and devoid of sugars so are these really that bad long term? Thank you Noel: What is you opinion on cupping therapy? I am not talking about wet cupping but just regular cupping. I am a 67 year old female and like 50 lbs overweight so probably have metabolic syndrome so may be prone to heart issues, stroke. But I am most concerned about my kidneys. A few years back I was diagnosed with kidney failure, GFR was 11! Now it is over 60 for the last several years. I understand if there is toxic removal it would get removed through my kidneys ( and liver) and don't want to overtax my kidneys. I am very active otherwise and don't have any aches and pain anywhere. Would also love to minimize my cellulite. Thank you for tuning into today's Cabral HouseCall and be sure to check back tomorrow where we answer more of our community's questions! - - - Show Notes and Resources: StephenCabral.com/2899 - - - Get a FREE Copy of Dr. Cabral's Book: The Rain Barrel Effect - - - Join the Community & Get Your Questions Answered: CabralSupportGroup.com - - - Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - Get Your Question Answered On An Upcoming HouseCall: StephenCabral.com/askcabral - - - Would You Take 30 Seconds To Rate & Review The Cabral Concept? The best way to help me spread our mission of true natural health is to pass on the good word, and I read and appreciate every review!
I am thrilled to introduce you to Midge Bowers.Not only is Midge a Clinical Professor and Director of the cardiovascular specialty at Duke University School of Nursing, she practices as a nurse practitioner in a Heart Failure Access Clinic.She's an expert in cardiology, a seasoned healthcare educator, and shares so much incredible knowledge in this jam-packed episode.In this episode, we covered:The importance of looking beyond creatinine levelsHow to focus on practical aspects of echosDemystifying anticoagulation choicesPractical tips on adjusting Warfarin dosagesReversal agents and safety measuresThis barely scratches the surface of the wealth of information Midge provides.0:00 - 3:35 - Introduction and Overview3:36 - 8:39 - Importance of Monitoring Creatinine and GFR 8:40 - 15:06 - Impact of New Medications on Kidney Function15:07 - 20:30 - Understanding Echo Results: Akinesia, Hypokinesia, and EF20:31 - 25:01 - Interpreting Trends in Echo Reports25:02 - 31:17 - Anticoagulation Choices: Warfarin vs. DOACs 31:18 - 38:15 - Adjusting Warfarin Dosages and INR Monitoring38:16 - 42:42 - Assessing Bleeding Risks with CHADS-VASc and HAS-BLED 42:43 - 46:03 - Reversal Agents and Safety in Anticoagulation46:04 - 53:41 - Managing DOACs in Different Clinical Scenarios Read the full blog here.______________________________Please note: This episode is intended only for medical providers and students learning to be medical providers. Hosted on Acast. See acast.com/privacy for more information.
The NP is seeing a 60-year-old woman with a 10 year history of T2DM. Her current medications include oral metformin and an oral SGLT2-I, and states she is feeling well, without report of blurred vision, excessive thirst or polyuria. She has not had any laboratory tests done in the past 6 months. Which of the following represents the best choice of test to determine her overall glucose control? A. Fasting plasma glucoseB. Serum creatinine/ e GFR (estimated glomerular filtration rate)C. Hemoglobin A1cD. Random blood glucose ---YouTube: https://www.youtube.com/watch?v=yz94zsqABG8&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=42Visit fhea.com to learn more!
One of the biggest challenges is identifying kidney disease in the early and middle stages, says Prabir Roy-Chaudhury. He works to emphasize the importance of simple blood and urine tests for high-risk populations for earlier diagnosis, but also strives for better treatment once kidney failure sets in. He discusses: Why his main interest is dialysis vascular access dysfunction, What are common issues, such as cardiovascular complications in kidney disease patients, How current tests like the GFR and albumin amounts are calculated and why they determine the kidney failure risk equation, and What should patients prioritize in treatment, from Vitamin D importance to new drugs and technologies. Prabir Roy-Chaudhury is a professor of medicine in the Division of Nephrology and Hypertension and co-director of UNC Kidney Center and specializes in uremic vascular biology. He brings listeners online with the basics of kidney disease, who's at risk, and what's being done to make treatment better. We need our kidneys to rid our bodies of toxic byproducts and fluid, he says. If the kidneys can't rid us of our byproducts, these uremic solutes accumulate in the blood and our systems suffer. That's why doctors turn to other ways of filtrating these out of our bodies through dialysis. That's also where Dr. Roy-Chaudhury would like to see improvement. He explains both types of dialysis—hemodialysis and peritoneal dialysis—describing their strengths and weaknesses. He adds that “my dream definitely would be for us to be in a slightly different place” with dialysis. He shares some good news towards that end: that the American Society of Nephrology has partnered with the FDA and Health and Human Services to produce public and private partnerships, such as the Kidney Health Initiative and the Kidney Innovation Accelerator, to improve these treatments. Listen in to learn about these exciting projects that hope to dramatically change the quality of life for patients with kidney disease. Episode also available on Apple Podcasts: apple.co/30PvU9C
Clinical trials exist to help prevent, screen for, diagnose, or treat diseases and other health problems. Without them, we would not have new treatments or other advances in health and medicine. But how are the clinical trial endpoints, or the preferred outcomes of these trials determined? Today, Anthony Gucciardo NKF's Senior Vice President of Strategic Partnerships, Dr. Joseph Vassalotti, NKF's Chief Medical Officer, and Kent Bressler, a Patient advocate and FSGS patient, discuss this and more. In this episode we heard from: Dr. Joseph Vassalotti MD Dr. Vassalotti is the Chief Medical Officer of the National Kidney Foundation (NKF) and Clinical Professor of Medicine in the Division of Nephrology, at Icahn School of Medicine at Mount Sinai. At NKF, his major focus is implementation of evidence-based clinical practice guidelines in chronic kidney disease (CKD). He led collaborations to develop the Kidney Health Evaluation for Adults with Diabetes quality measure to improve evidenced based estimated glomerular filtration rate and albuminuria testing to guide detection, risk stratification and interventions proportional to risk in the U.S. He also served as PI for an AARP-funded Kidney Health Evaluation for Adults with Diabetes to analyze quality measure satisfaction with detection, evidenced-based therapies and health equity. Currently, he serves as Principal Investigator for the Kidney Score Platform, an NKF educational project funded by the Veterans Administration Center for Innovation to improve awareness and education among Veterans with and at risk for CKD in the primary care setting. He is also a co-investigator for the Center for Disease Control and Prevention's CKD Surveillance Project. Dr. Vassalotti typically sees approximately 40 patients per week and has over 100 publications in peerreviewed journals. Anthony Gucciardo Anthony is responsible for forging and maintaining relations with key external stakeholders across a wide range of industries, to advance NKF's mission and objectives, along with those of its partner organizations. Anthony oversees two national Corporate Development Teams, focused on securing revenue necessary to ensure NKF programmatic excellence and impact. He has been with the Foundation since 2002. Prior to NKF, Anthony was a Hematopoietic Stem Cell Technologist at Memorial Sloan-Kettering Cancer Center in New York City, where he was responsible for processing autogeneic/allogeneic bone marrow and peripheral blood stem cells for transplantation. He holds a master's degree in Biochemistry from Columbia University. Kent Bressler Kent is a retired RN who was diagnosed with FSGS in 1984, and received a living donor transplant from his brother Kip in 1987. Kent is an active advocate for preemptive kidney transplant and has on the recommendation of NKF worked closely with the DoD and PCORI as a consumer peer reviewer. He is an NKF peer mentor and advocate who has collaborated on an editorial “Change in Albuminuria and GFR as End Points for Clinical Trials in Early Stages of Chronic Kidney Disease,” published in AJKD in 2019. He will also be participating in the development of the new NKF Patient Network serving on the Data Input and Integration Committee. He has been an active hill advocate for the NKF for six years and was the proud recipient of the 2017 Richard K. Salick Advocacy Award. Kent is also an Army Veteran and retired from the Veterans administration as an RN. He is the co-founder of Kidney Solutions a not for profit program in Texas that assists patients and families in the transplant process and in finding a donor. He is currently an assistant team leader for Region 7. Kent and Cathy Bressler have been married for 50 years and their family consists of Gretchen and Todd Rossington and their son Colt and Celeste and Alex Brown and their children John Banks, Catherine and Alexis Brown. Additional Resources: Find Clinical Trials Clinical Trial Q&A Xenotransplantation Info Do you have comments, questions, or suggestions? Email us at NKFpodcast@kidney.org. Also, make sure to rate and review us wherever you listen to podcasts.
Zarinah El-Amin is an award-winning anthropologist, author and TEDx speaker whose company, Book Power Publishing, revolves around helping clients create cultural change through books and global experiences. What is the dumbest decision you've ever made in your life?For this special replay episode that we're releasing on both audio and as a video on my YouTube channel, Zarinah is back with an update on what's happened since she first appeared on the GFR Show and opened up about the “dumbest decision” she ever made. She talks about another major loss she's experienced these last couple years, and shares what she's learned around acceptance and letting go.Being raised a Muslim, Zarinah was surrounded by family friends from many cultures, but as a student in Detroit and later at Howard University, she wasn't exposed to a lot of different people. Find out what “clicked” that made her know she was a “person of the world.” And how that led to eye-opening experiences like living in Egypt and dating someone in a different caste, and revitalizing orphan programs in Sierra Leone.You'll also hear the lessons she learned in her 40th year—a spiritual year of revelations for many Muslims—which came in a series of GFR moments including losing her mom, divorcing her husband of 14 years, and moving in with her father after his stage 4 cancer diagnosis. Plus, you'll hear the transformational lesson Zarinah learned when she repressed her true nature to try to make her marriage work. ResourcesGrab Zarinah's gift here: The Complete Self- Publishing Checklist The 12 GFR Commandments - download your own copy nowTo watch on YouTube
Bicarbonate did not slow the loss of GFR in this well done Swiss, single-blind study of transplant patients.The Filtrate:Joel TopfNayan AroraSwapnil HiremathPirya YenebereWith Special Guest:Nav Tangri nephrologist and epidemiology at the University of ManitobaEditor:Nayan AroraShow Notes:Arsenal FCThe London study that kicked it all off!de Brito-Ashurst, I., Varagunam, M., Raftery, M. J., & Yaqoob, M. M. (2009). Bicarbonate supplementation slows progression of CKD and improves nutritional status. Journal of the American Society of Nephrology: JASN, 20(9), 2075–2084.The multi center (but unblinded) UBI Study with mortality benefit!Di Iorio, B. R., Bellasi, A., Raphael, K. L., Santoro, D., Aucella, F., Garofano, L., Ceccarelli, M., Di Lullo, L., Capolongo, G., Di Iorio, M., Guastaferro, P., Capasso, G., & UBI Study Group. (2019). Treatment of metabolic acidosis with sodium bicarbonate delays progression of chronic kidney disease: the UBI Study. Journal of Nephrology, 32(6), 989–1001.The BiCARB Study: Double blinded and negativeBiCARB study group. (2020). Clinical and cost-effectiveness of oral sodium bicarbonate therapy for older patients with chronic kidney disease and low-grade acidosis (BiCARB): a pragmatic randomised, double-blind, placebo-controlled trial. BMC Medicine, 18(1), 91.The initial Veverimer StudyWesson, D. E., Mathur, V., Tangri, N., Stasiv, Y., Parsell, D., Li, E., Klaerner, G., & Bushinsky, D. A. (2019). Long-term safety and efficacy of veverimer in patients with metabolic acidosis in chronic kidney disease: a multicentre, randomised, blinded, placebo-controlled, 40-week extension. In The Lancet (Vol. 394, Issue 10196, pp. 396–406). doi.org/10.1016/s0140-6736(19)31388-1The Valor CKD trial is still unpublished. But here is the press release. VALOR-CKD design manuscriptThe study of the night: Sodium bicarbonate for kidney transplant recipients with metabolic acidosis in Switzerland: a multicentre, randomized, single-blind, placebo-controlled, phase 3 trialNephJC | PubMed | LancetAlkali with normal bicarb? Sure, take a look at: Goraya, N., Simoni, J., Jo, C., & Wesson, D. E. (2012). Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney International, 81(1), 86–93.Metforminator!The BASE Trial: Raphael, K. L., Isakova, T., Ix, J. H., Raj, D. S., Wolf, M., Fried, L. F., Gassman, J. J., Kendrick, C., Larive, B., Flessner, M. F., Mendley, S. R., Hostetter, T. H., Block, G. A., Li, P., Middleton, J. P., Sprague, S. M., Wesson, D. E., & Cheung, A. K. (2020). A Randomized Trial Comparing the Safety, Adherence, and Pharmacodynamics Profiles of Two Doses of Sodium Bicarbonate in CKD: the BASE Pilot Trial. Journal of the American Society of Nephrology: JASN, 31(1), 161–174.Tubular SecretionsSwap The Three-Body Problem (novel) | NetflixNayan Women's World CupTangri English Premier Soccer and InflationPriya Silo on Apple TVJoel Live Podcast recording at ASN Kidney
ReferencesJC mentioned that the diagnostic accuracy of 24 hour urine collection increases with more collections! Metabolic evaluation of patients with recurrent idiopathic calcium nephrolithiasisWe didn't refer to a particular study on sodium intake and the 24 hour urine but this meta-analysis Comparison of 24‐hour urine and 24‐hour diet recall for estimating dietary sodium intake in populations: A systematic review and meta‐analysis - PMC 24‐hour diet recall underestimated population mean sodium intake.Anna looking up ace i and urinary sodium Effects of ACE inhibition on proximal tubule sodium transport | American Journal of Physiology-Renal PhysiologyThe original FENa paper by Espinel: The FeNa Test: Use in the Differential Diagnosis of Acute Renal Failure | JAMA | JAMA NetworkSchreir's replication and expansion of Espinel's data: Urinary diagnostic indices in acute renal failure: a prospective studyHere's a report from our own JC on the Diagnostic Utility of Serial Microscopic Examination of the Urinary Sediment in Acute Kidney Injury | American Society of NephrologyJC shared his journey regarding FENa and refers to his recent paper Concomitant Identification of Muddy Brown Granular Casts and Low Fractional Excretion of Urinary Sodium in AKIAnd Melanie's accompanying editorial Mind the Cast: FENa versus Microscopy in AKI : Kidney360 (with a great image from Samir Parikh)JC referenced this study from Schrier on FENa with a larger series: Urinary diagnostic indices in acute renal failure: a prospective studyNonoliguric Acute Renal Failure Associated with a Low Fractional Excretion of Sodium | Annals of Internal MedicineUrine sodium concentration to predict fluid responsiveness in oliguric ICU patients: a prospective multicenter observational study | Critical Care | Full TextA classic favorite: Acute renal success. The unexpected logic of oliguria in acute renal failure Marathon runners had granular casts in their urine without renal failure. Kidney Injury and Repair Biomarkers in Marathon RunnersCute piece from Rick Sterns on urine electrolytes! Managing electrolyte disorders: order a basic urine metabolic panelThe Urine Anion Gap: Common Misconceptions | American Society of NephrologyThe urine anion gap in context CJASNExcellent review from Halperin on urine chemistries (including some consideration of the TTKG): Use of Urine Electrolytes and Urine Osmolality in the Clinical Diagnosis of Fluid, Electrolytes, and Acid-Base Disorders - Kidney International ReportsRenal tubular acidosis (RTA): Recognize The Ammonium defect and pHorget the urine pH | SpringerLinkOutlineChapter 13- New part: Part 3, Physiologic approach to acid-base and electrolyte disorders - Do you remember the previous two parts? - Renal physiology - Regulation of water and electrolyte balance- Chapter 13: Meaning and application of urine chemistries - Measurement of urinary electrolyte concentrations, osmolality and pH helps diagnose some conditions - There are no fixed normal values - Kidney varies rate of excretion to match intake and endogenous production - Example: urine Na of 125/day can be normal if patient euvolemic on a normal diet, and wildly inappropriate in a patient who is volume depleted. - Urine chemistries are: - Useful - Simple - Widely available - Usually a random sample is adequate - 24-hour samples give additional context - Gives example of urinary potassium, with extra renal loss of K, urine K should be < 25, but if the patient has concurrent volume deficiency and urine output is only 500 mL, then urine K concentration can appropriately be as high as 40 mEq/L - Table 13-1 - Seems incomplete, see my notes on page 406 - What is Gravity ARF?- Sodium Excretion - Kidney varies Na to maintain effective circulating volume (I'd say volume homeostasis) - Urine Na affected by RAAS and ANP - Na concentration can be used to determine volume status - Urine Na < 20 is hypovolemia - Says it is especially helpful in determining the etiology of hyponatremia - Calls out SIADH and volume depletion - Used 40 mEq/L for SIADH - Also useful in AKI - Where differential is pre-renal vs ATN - In addition to urine Na (and FENa) look at urine osmolality - Again uses 40 mEq/l - Mentions FENa and urine osmolality - Urine Na can estimate dietary sodium intake - Suggests doing this during treatment of hypertension to assure dietary compliance - 24 hour urine Na is accurate with diuretics as long as the dose is stable and the drugs are chronic - Diuretics increase Na resorption in other segments of the tubule that are not affected by the diuretic - Points to increased AT2 induced proximal Na resorption and aldosterone induced DCT resoprtion - In HTN shoot for less than 100 mEq/Day - Urine Na useful in stones - Urine uric acid and urine Ca can cause stones and their handling is dependent on sodium - Low sodium diet can mask elevated excretion of these stone forming metabolites - 24-hour Na > 75 and should be enough sodium to avoid this pitfall - Pitfalls - Low urine sodium in bilateral renal artery stenosis or acute GN - High urine sodium with diuretics, aldo deficiency, advanced CKD - Altered water handling can also disrupt this - DI with 10 liters of urine and urine sodium excretion of 100 mEq is 10 mEq/L but in this case there is no volume deficiency - Opposite also important, a lot of water resorption can mask volume deficiency by jacking up the urine sodium - Advises you to use the FENa - THE FENA - < 1% dry - >2-3% ATN - It will fail with chronic effective volume depletion - Heart failure, cirrhosis, and burns - Suggests that tubular function will be preserved in those situations - Also with contrast, rhabdo, pigment nephropathy - Limitations - Dependent on the amount of Na filtered - Goes through the math of a normal person with GFR of 125/min and Na of 150 has filtered sodium of 27,000/day so if they eat 125-250 mEq their FENa will be 600-800 - Urine osm < plasma osm in face of hypernatremia indicates renal water loss due to lack of or resistance to ADH - In ATN urine OSM < 400 - In pre-renal disease it could be over 500 - Specific but not sensitive due to people with CKD who are unable to concentrate urine- Specific gravity - Plasma is 8-10% igher than plasma so specific gravity is 1.008 to 1.010 - Every 30-35 mOsm/L raises urine Osm of 0.001 - so 1.010 is 300-350 mOsm/L H2O - Glucose raises urine specific gravity more than osmolality - Same with contrast - Carbenicillin- pH - Normally varies with systemic acid-base status - PH should fall before 5.3 (usually below 5.0) with systemic metabolic acidosis - Above 5.3 in adults and 5.6 in children indicate RTA - PH goal 6.0-6.5 - Separate individual RTAs through FR of HCO3 at various serum HCO3 levels - Also can monitor urine pH to look for success in treating metabolic alkalosis - Look for pH > 7 - In treatment of uric acid stone disease - Want to shift eq: H + urate – uric acid to the left because urate is more soluble - PH goal 6.0-6.5
Market Proof Marketing · Ep 299: One Stop ShopIn this episode, Kevin Oakly, Beth Russell and Julie Jarnagin marvel that they're only one episode away from episode 300! They discuss Zillows new "Super App" which promises to be the one-stop shop for everything by cutting out the middleman and how the one group that will struggle with the change is realtors. Together, they celebrate kids going back to school and discuss the difference between highlighting scarcity and creating artificial scarcity.Story Time (04:45)Julie says she gave her son “bad parenting advice” by telling him he doesn't need to do his best in school…other than math.Kevin helped a builder problem solve: 6 leads to 54 (18 walk-ins + 36 online leads) Beth has another house update: their house is nearing completion and have a closing date of Sept. 5th!Kevin says AI is not going to solve your “people problem” or make them adapt to change.News (21:38)Zillow Group to acquire Spruce, a tech-enabled title and escrow company, as a building block in the housing super app (https://www.zillowgroup.com/news/zillow-group-to-acquire-spruce/)Real estate agents grapple with cyberattack on Rapattoni (https://www.housingwire.com/articles/real-estate-agents-grapple-with-cyberattack-on-rapattoni/)Strained housing affordability is a ‘manufactured crisis' created by bad zoning—just look at L.A. (https://fortune-com.cdn.ampproject.org/c/s/fortune.com/2023/08/13/los-angeles-housing-affordability-manufactured-crisis-through-oning/amp/)Self-driving cars were supposed to take over the road. What happened? (https://www.cnn.com/2022/11/01/business/self-driving-industry-ctrp/index.html)Favorites/Hates (55:03)Julie is propagating her house plants.Beth hates when one person can taint an organization, that one friend or family member who can taint a room.Kevin's favorite is his peek design wallet.Questions? Comments? Email show@doyouconvert.com or call 404-369-2595 and we'll address them on the next episode. More insights, discussions, and opportunities can be found at Do You Convert All Access or on the Market Proof Marketing Facebook group.Subscribe on iTunesFollow on SpotifyListen On StitcherA weekly new home marketing podcast for home builders and developers. Each week Kevin Oakley, Andrew Peek, Jackie Lipinski, Julie Jarnagin, and other team members from Do You Convert will break down the headlines, share best practices and stories from the front line, and perform a deep dive on a relevant marketing topic. We're here to help you – not to sell you!Transcript: KevinWelcome to episode 297. I'm Kevin Oakley. And with me today is Julie Jarnagin and Andrew Peek, because Beth Russell went full on Miley Cyrus with her voice today. I didn't know thats a thing.AndrewAnd?KevinWe were conversing this morning. And I was like, huh, You're talking about you've gone for Miley Cyrus and she's like, Sorry, that was a mom joke, which I didn't realize mom jokes were a thing. So I just was happy that we have equal opportunity bashing adult jokes.AndrewI, I support it. Yeah. Miley has a pretty low voice, little boy raspy. It's not that. Well.JulieHer kid has been sick and so apparently it got passed down.AndrewIt's this is the beginning. Schools just started. So.JulieYeah, that's true. That's true. It's going to hit all of us.AndrewIt will only get worse.KevinNo one else in my family got an apology covered. That was shocking.JulieGood.AndrewGood.KevinTotally. Totally in the clear. All right, story time. Who's going first?JulieI can go.AndrewOh your first.JulieMine is kind of. Kind of random. So just randomly in my email, I got an email, like a marketing email from Hidden Valley Ranch. I was like, How in the world did I end up on this list? Is it a really, really old list I was on from like, maybe I got a recipe or maybe they sold it.JulieSomebody? I don't know. I just thought it was funny that I got it because I was like, That's random. Then I woke up the next morning. I had two from them overnight, so that was my third. Then within the span of like less than 48 hours, I had six different marketing emails from Hidden Valley Ranch, and I would try to and I would try to unsubscribe and I would keep getting them.JulieAnd so finally I just had to hit the like, this is spam button in my email, you know, quit sending them to me because it's just a reminder, not that you're Hidden Valley Ranch, but don't if you have a list and you haven't sent any emails and you just start spamming, don't do that. You need to send emails consistently on some kind of normal basis so people are expecting them.JulieAnd don't just send six in a day about Hidden Valley Ranch because.AndrewIt's like they're it's like a marketing automation just exploding.JulieCrazy.AndrewThe more, you know, thank me. What could they even promote? Like, do you get like a 36 pack of of all these.KevinOh no they they cross promote using recipes like sour cream or something. Yeah. Like you know you can ads you can add a ranch packet to sour cream and make them.JulieIt was a lot of recipes, I think. So I don't know how I ended up on it, but they were aggressive fun.KevinIs there a preferred email cadence like as well? I got this email today from someone said, Hey, my onsite team doesn't ever want marketing to send emails because they said, We don't want to overwhelm our customers with too much communication when it comes to too from marketing, what do what do we think?JulieI personally, I say twice a month from from marketing, maybe once a month. If you can't do two good once a month, do one good one a month, and probably no more than two a month. That's me. You all may have a different.KevinNumber two is my cap from marketing.AndrewLike and I like that I gave props to Opendoor a while ago where they gave a lot of value in their email. They're like, your new offer. Your new offer. I think it's every three weeks and it's there's value in there. They probably see that I open it. And so that's why they're giving me maybe I have an accelerated cadence compared to someone else.AndrewYeah, I think twice. And then maybe some type of like trigger that helps you slow down that cadence. Like, okay, now they're a purchased let's not give them all of the marketing emails, maybe they switch different list whatever maybe. But I think we all agree lean on less versus more from marketing.JulieWell, less as long as it's not non or randomly have a new just when we think that everybody needs some, I feel like it needs some kind of plan and strategy around it instead of when we get to it, because that usually means never until we're panicking. And then people get it and they're like, Wait, who is this?JulieWhat is this? If you do have a cadence, they at least are used to seeing you pop up in their inbox and it's not so insulting. I don't know if it's things are awkward, but with Hidden Valley Ranch Spammy.AndrewYeah.KevinYeah. It's one of those areas that as an industry we still don't use data properly, I think, to clearly find like, you know, from the time something becomes a lead to the time they decide to go on an appointment, I would argue that you you could if you to your point, if you had the great content, Julie, if you had, let's say, 15 amazing in-depth articles, slash blogs with photo galleries and or videos or virtual walkthroughs, about 15 different stories of customers who chose your homes and love them.KevinI think you could send one of those a month if they're good enough or sorry, one of those a week if they're good enough over 15 weeks. But the signal of once they once you go to an appointment, you're kind of transitioned to another phase. And while it might still be interesting to get those, you might then have to do the work of saying where are the best three that they haven't already seen and spacing them out more because there's now it's it's still going to be interesting just like people love watching issue TV even though they already know where they're going to move or you know, they just bought something.KevinThey still want to, but they don't need to be deluged with it in the same way. And of course, all those ideally would have the signal of go here in view more if you want, let the customer binge them, but then know not to send them because they've already seen them in an ideal world.AndrewSo maybe.KevinI'll write. Mine comes from a call early this week because I feel like this is happening a lot, not just with the builders that we work with, but but around the country where traffic is still high. In fact, the aggregate data set from homebuilder data, it's about the same as where it was in February, March in terms of traffic to homebuilder websites, lead volume depending on the price point an area some some places are down.KevinBut if you look at year over year, most people are still up tens. And so you're talking about a struggling neighborhood. And this last month in June, they had six leads in there. So this particular better uses lasso. When you use lasso and you're analyzing lead volume, a reminder that you typically have to go look in two places.KevinYou have to go look into the individual community project. And that's going to let you see all of the online leads that have transitioned to on site through an appointment as well as walk in traffic. And then you're going have to go to the online sales bucket project and look at the leads that have come in just for that neighbor.KevinThen you have to add the two together. So we started out looking in the project folder. First thing was that no one on the call immediately kind of already had their finger on the pulse of what the lead volume was for the community, which is marketers. We should always, especially the ones that are high focus, like this is a neighborhood that I taken over the call from Jacqui, the Penske issue on maternity leave, but they're like, Oh yeah, we talk about this one like every time.KevinSo cool, so many leads that we have. Last month. It's okay. Like, you know, they didn't know it, but we looked it up and they had 38 leads in the onsite project. And I was like, okay, cool. Well, we looked at where the lead sources were coming from, both in terms of like just phone call form submission as well as actual marketing source.KevinAnd then we go to June and there were six. It's like, Wow, that's a statistically significant difference. Like something changed what happened? And we go through the list and you want to guess what changed? Actually, I'm going to make a guess. You probably don't want to because you're like, I don't know, but.AndrewWhat's the number.KevinOf 6 to 38 leads just in the onsite project? What do you think.AndrewSix up to 38.JulieMM Oh, they increased more finished quick movements listed or I.KevinGuess.AndrewI think they just added them. They were there before that at everybody their close like they register them like, like they're like this. They had the same number. Maybe the number didn't change but they just decided like, well everyone's looking at me, I'm in the hot seat. I better add something in here.KevinWhich. Okay, so that's your final clue. For those of you playing at home, when leads start being put in the system by onsite agents, after there has been five or six months of intense scrutiny of said onsite agents, what's happened is there is a new one. There is a new onsite agent who doesn't know the game to be played and silly, silly salesperson.KevinYou're putting all of your walk in leads in the system. They don't know better. It's like I always go back to when I first started playing golf. It was the best golf I've ever played in my life, in my life, because I was just playing. I wasn't overthinking it. And then you start overthinking it. You start doing all these adjustments that are wrong.KevinTypically when you're new, you start playing worse, you get in your head. And so new salesperson now in the online bucket, we went back and there were 36 online leads for July for this neighborhood. And and so then we went back to the onsite project and just ran only the walk ins and there was eight of them. And then I'm really bad at Mass.KevinIt took me about 45 seconds to figure out that the total lead count for this struggling neighborhood was 54 in a 30 day period.JulieWow. Well.KevinThe one thing I always like to remind everyone is the way that we approach marketing and advertising and do you convert means that we don't have to consider at all unless our builder partner has chosen to do something that we don't recommend. We never have to wonder to ourselves. I wonder if those 54 people are interested or qualified in any sense of the word.KevinWhy don't we have to do that? And again, this is a really big deal because every ad we ever run talks about the location, price point and type of products that you are selling. So when those leads come across, they're not just like, you know, trying to collect a $50 scratch off ticket by entering in their contact information or entering to win a car or whatever the like.KevinSo to bring it all back down to the now that I've told you that journey, it was just like, wow, we don't have a struggling community from an advertising problem. We don't have a struggling community from a lead problem. What we have is an appointment to sale conversion challenge and with 54 people in a 30 day period, someone needs to give the sales team permission to screw it up.KevinAnd what I mean by that is just start getting sales. You know, they were like, Well, this is a hiring neighborhood. And we always get the feedback that a lot of customers are concerned about selling their existing home. I go make up and make up an existing home sale package incentive. Hey, no problem. What will we'll create? What is that?KevinMake it up. Just say, Well, will partner with three agents that we know are great agents and they're they've promised to do an enhanced listing package on any referral that we send over so you can pick any of those three agents. And then as the builder, you might have to pay an extra couple hundred bucks to them to make sure you get the best photographer that they typically would use an on site or do a little bit more advertising, whatever it is.KevinBut just say, yeah, we're just putting together the finishing touches of our list. Your home VIP experience. Let's just sign contingent upon using the details of that program and feeling comfortable selling your house or whatever. But something there's too much like, yeah, it's price. Yeah, but it and I think I talked about this last time so I'm not going to go into it but that builder that had a 6% performance sell ratio really changed some things around and got to a 20% that 11 sales to 51 sales.AndrewThat's a lot of.KevinNew cumulative leads for that incentive for people that are already in their system. And I was on a call with Jesse Suggs, online sales coach for another builder this morning. She did analysis for a builder and something like 80% of their sales were to people who had been in the system for over three months. All of the friction that's preventing sales is coming from the middle and the bottom of the funnel right now.KevinAnd that's likely to continue through the end of the year. And so just wake up, smell the coffee smell and then start adjusting accordingly because you're not. I have not. Maybe one of you two have. I haven't seen any promotion that anyone has done. 80 different builders, almost every state in the country over the last three months. That has significantly increased their lead volume.KevinAnd again, the only aspects there would be qualified leads, not just leads that are from performance max campaigns and mostly spam.AndrewDon't do that.KevinYou're not you're not going to convince anyone that today is the first day that they should start thinking about buying a house or moving.AndrewNo. And we'll we definitely have some news lined up to really support that.KevinLet's just jump into that one. Oh, we got it. So from a Business insider, over 80% of Americans think it's a bad time to buy a house, which coincidentally also means that the majority of Americans also think it's a bad time to sell a house. So sellers are also buyers and so they don't want to sell if they think it's a bad time to buy because most of them are going to have to buy.KevinSo 82% think it's a bad time to buy a new home. Affordability has plunged. So unless there is a reason to move, like even this goes back to I mean, you're someone text me this right now and I'm just I'm overdoing this point because it is so important. For the second half of this year, someone said, hey, what's your thoughts about success and failures around special inventory events, i.e. showcase of homes, liquidation event, year end sales, event, everything must go, etc. It's like, well, let's not call it everything must go or liquidation sale.KevinBut even in a good market, doing that consistently once a year and then at Heartland, we just that was the only incentive we did all year. Everything else was adjusting pricing to market. But every year we did basically a December to remember sales event. It was the only sales event of the year and that trick will work once.KevinSo I was just saying, you know, maybe end of summer and fall is a better time to get your stuff sold before the end of the year when everyone else is panicking. I kind of I don't mind that, but I said, Hey, just remember 70% of the buyers are probably already in the system. So it's communicating to those people you already know.KevinAnd they said back, we were thinking of doing this event for 75 to 90 days. What's your reaction to that?AndrewI I'm trying to figure out what I want to say out loud, but it feels like it's not a real event. Then it's garbage. Like it like I'm I view it negatively. Like it's not a real deal. It's just a fake promotion.KevinIt's too long. I feel like it's too long, especially knowing that the majority of people who will take advantage of that opportunity will be people they already know. So I said, Hey, probably doesn't need to be that long, you know, just heads up and said, Well, I think we're going to have to do longer because we don't do well.KevinFostering leads long term too, which I just wanted to say that's, that's an unacceptable.AndrewThat I misunderstand that they need it longer because they're not good at fostering leads.KevinBecause they think that, yeah, they're not good at nurturing leads longer term.AndrewOkay?KevinAnd so they feel like the salesman has to go for 90 days so that new leads can come in, have time to absorb the opportunity.AndrewEtc.. So they lose people after that when they're all leads aren't useful anymore, right? And you're like, No, no, no, that's your mortgage sitting there. You have your revenue.KevinEver been right now?AndrewYeah. Yeah. Interesting.KevinYeah. Back to the article. I kind of like merging story time. Article time.AndrewYeah, that's one's perfect. Unplanned. So that's fun.KevinThe average 30 year fixed mortgage rate has risen from under 5% to nearly 7%, according to Freddie Mac. With the Federal Reserve's most aggressive interest rate hiking campaign since the 1980s. I was born in 81, so the it's been a while and everyone's still kind of pessimistic now. But that doesn't mean that but that does mean by default the people who have to are more urgent.AndrewRight?JulieYeah, they have to. And I think it's such a good opportunity to just agree with them. But yeah, it is a terrible time to buy an existing house like. Yes, absolutely. You are completely right. It is a terrible time to buy an existing house. It's a great time to buy a new house because look at this great thing.JulieWe can do to help you and look how our how they hold their value. And it just is a good opener to a conversation to talk through these things. So I don't think you're ever going to convince all these people that, oh, 80% of people are wrong. You know, everybody because they.KevinThink about the think about the psychology here of you think it's a bad time to buy and you see an ad that a builder runs that says 50, 75 grand off if you buy by the other month. I think I think your negativity bias is like, see, I told you it's bad time to buy. You don't think you're so much money.AndrewYeah, I.KevinWasn't going to buy, but now I can save 75 grant like again. It doesn't mean it doesn't work, but it doesn't work for the reason we tell ourselves. It works. When someone buys something that's on sale, that's because that's what they believe it's actually worth. Or they believe that there's some that like it's not the savings we justify that we tell our spouse, Hey, don't get mad at me.KevinI just saved us $100. But in our minds, we knew that that's not what we did.AndrewYeah, that's what it should be paid. I can see that reaction being like, oh, desperation. It's still overpriced. This as far as like if you're being kind of indoctrinated with like these articles like this where like 80% say it's bad time to buy, your reaction is to be correct with the rest of society. And so you're like, Well, I'll go along with that.AndrewI feel like they'll make me look smart. And like you said, Julie, like, well, the builders are the ones offering like these great incentives 5.25, five and a half, 4%, whatever. Like that's different than 7%, significantly different. So.KevinWell, and the other thing that's interesting about interest rates. Barbara Corcoran, you all know her from Shark Tank. Well, she's kind of got a thing that's going viral around the the U.S home industry right now because she's like everyone. You've got to buy a house now that rates are at 7% because when rates go down, the prices are going to go up.KevinSo what she's correlating to and it's not a crazy thought at all, is when rates were at four and a half and they went down to three. It took it took too long for most builders to figure this out. But builders are like, wait a minute, I can you know, I still remember people were like, how much should we raise prices by Kevin?KevinI mean, they just keep selling. What should we raise? And so I go, Just do the math of exactly what is the same payment and you can go there. Now it's the affordability around payment. You can just go to that price. You have to look at your cost, just go to that price. And so her argument is if you buy now and take that pain, you'll be better off because the rates go down, the prices of everything will go higher.KevinThat's not a guarantee, by the way, because if rates go down, it still means that there's bad things going on in the economy and the job market. It's earned.AndrewBut it's, I think to say kind of rudely my brain like that's like privilege problems, right? Like she's like I have X amount a bank account like I'm I'll deal with this and two years I'm out of the situation. But if you're stuck at 7% forever, you can't refi. Your financial situation doesn't change or drastically go up. Then you're kind of you could be stuck.AndrewSo for normal people, maybe not. But I, I definitely understand what she's what she's saying there. What's interesting is do we know anyone This is going way back. Remember Daw d0r the.KevinYork tracking the infrared tracking tool?AndrewYeah, I remember. They weren't that expensive to implement. And then, like, as we kind of got used to that and I'm not sure if there's any builders still using it, but there's a recommendation like put it, don't put it at the front door. But like in the primary bathroom or something or whatever, it'd be like, okay, real people and the model home will definitely go here versus someone going in and out, in and out deliveries, mail, etc., etc..AndrewInteresting. Having that data to kind of normalize like the salesperson. This is back to the first part of your story. Like leads went up. Now it's just a new you'll see a new sales agent on site. It's like, well, we've had 300 people come in, 200 people, a hundred people, whatever it is, that person has six, six. So that just kind of like normalize the data.AndrewBe interesting. So my little story is just like maybe it's it'll make you feel comfortable. J4 is still quirky. I don't, I don't like it. I don't get it. I was just on a call about an hour and a half ago. Really intelligent guy is like, Hey, we're seeing this like what is happening? And I'm sitting there like, Man, I wish I could be super smart right now and have the answer to this.AndrewI'm like, I have no idea. Like, let me just rebuild that report for you and maybe that will fix it. Like, I do not know, like essentially it was only charting one campaign, but the other campaigns were down here. The numbers were making sense. The ad and like, you know, everyone has the delay of the data. It seems like 24, 36, 48 hours.AndrewThere seems to be a little bit longer than that. It's a lot of fun and they have a lot of data. So it's not like we've seen some where like at the sampling a smaller is could be goofy, but it just seems to be inconsistent all over the place and it's not much fun. Thank you. Google it's not fun at all.KevinYeah it's well and the inconsistencies fortunately are not. It'd be one thing if it was just Google but it's implementation still up for on some web environments that you know it's yeah and that's where you can't I mean you will because you're human you'll get mad at the web developer but it's it's multiple web developers that are having this issue it's not just one.KevinAnd sometimes it's for a bit of code that really should have nothing to do with causing any interference with GFR. So I feel like I use this a lot. But you know, WordPress is a great format for a blog, but trying to build a website with WordPress, in fact, again, just this morning talked with a large organization, multistate organization that still uses WordPress for their and we were talking about they are having a spam issue.KevinAnd I said, well, a lot of times WordPress is something that doesn't help that and they're like, Oh really? Why go? Because you don't often update WordPress as often as you should when you've got 20 different plug ins that are connected to that. Yeah. So then we'll potentially break when you update it. Like, yeah, we're on a really old version.KevinI go, Yeah, you're going to get spammed.AndrewIt's been hacked.KevinSo it's that same kind of issue though that WordPress has where you're using the same website you always have go for said, Hey, no big deal, just put in this line of code and put it here exactly where we tell you and everything will be fine. But there's interaction with other lines of code that really shouldn't be affecting it, that that are for some people, thankfully, it's only about 5% that are still working through that issue.KevinAnd also, thankfully, I just saw an article posted yesterday like for 90% of people, UK is still alive and kicking and I.AndrewDidn't see it. I'm like, I want to use it. But then I. Principal Mike, I don't think I could be the one that says I.KevinFinally converted all of my little stars on Google Analytics over to Jay for accounts versus UK. But it is terrible.JulieI have to say I've gotten more use to die for than I thought because the other day I was in there and I was like, Oh shoot, I'm using you. Like just because it looked familiar to me. And I was like, Oh, I'm not. I'm just used to this now. So that's good. And Andrew, the most frustrating thing is when a piece of data is showing up in one place, like randomly, but it's showing up in the place it needs to show up.JulieYou're like, I know it's there, it exists, I just can't make it. So that was where it needs to show.AndrewI think that was Tuesday. Julie and I were troubleshooting Google Tag Manager and J4 and like everything was correct, it just wouldn't show up in both places. For certain events. We're setting up to support conversion tracking. Yeah, there's no certainty. Which by the way, I look above my head. The site added. You look right, that perfect.JulieWill.AndrewColor my room. It's stuff that's that's all my story is but I get the 5% of of all of it so like 90% of my world is it's it's broken J for I'm like are you kidding?KevinAndrew is our level five tech support. Yeah.AndrewSo it all rolls sideways and uphill and diagonally to me. It's great.KevinWe don't have a perfect tracker here to fixing everything, but we are, I think, nearly perfect on identifying the cause. Like if it's something that we can't touch, like a website or a server issue or whatever. But we can, we can usually help sometimes.JulieI'm actually happy when Andrew can't fix it out, so I feel like it was a dumb question. It was like, This might be stupid. Andrew And then when you can't and I'm like, Yes, it's a real.AndrewProblem and sometimes that's enough is like, okay, cool. I'm not going crazy anymore. Like we all agree this is just weird and quirky. We're not going to worry about it for a little bit. And then sure enough, I'll just fix itself on its own.KevinNext up, I guess we'll link to my tweet. We still call it that. I don't know. But Zillow is hiring over 100 photographers around the country like to continue to enhance their enhanced listings product. And so what's really cool about this is Zillow. If you've missed somewhere, been under a rock over the last six months or so, showing shown time plus which they purchased, which is like the centralized scheduling platform and then they've kind of built around that enhanced listing features, 3D tours, photos, basically everything you need to get your listing to look better.KevinYou get a better layer on the actual map as well. They're going all in on this and I think it's the right call for any syndication company to do so because, you know, Julie wrote a book and that's great, but content's still hard for builders, harder than it maybe should be. A lot of times it's just because they are still doing something really stupid, like connected TV advertising or billboards or whatever.KevinLike you have the money to solve this problem, but you're using it for for less efficient purposes. But I, I have a feeling this is going to be huge when they start to roll it out. And I have no idea when they'll be doing this. But the moment the builders can just say are already advertising on Zillow and it's like, yeah, for X amount more or I don't know if they're going to include it, but you want to just come take pictures of this house, like really good pictures and it's also a good box out move for home XCOM, which is trying to come in and disrupt.KevinAlthough I read an article that basically they even know they're not going to be Zillow, it's like where our goal is to be a really good number two and keep Zillow honest. But we're not going to we're not going to take over.AndrewI mean, there's there's being ads to Google ads. So there's always the number two. I wonder if they'll even have the photographers edit, Which would be.KevinI think so. I mean, basic basic edits. Yeah, basic cleanup.AndrewAnd that's like, imagine that.KevinBe really smart about this from a strategic perspective. And homes while Costar Homes parent company started this on the commercial side they can take these pictures and again I haven't seen any paperwork so I have no clue how this will work. But my hunch is it will work similar to Costar. And that Costar lets the commercial agents use the imagery that they shoot for anything except to send to other commercial real estate syndication portals.KevinSo this whole concept Inman Connect in Vegas has gone on this week, and one of the panels with Robert Rifkin, the CEO of Compass and someone from Redfin and the CEO of Next Next Home, I think is the name of the company. They're all talking about how like pocket listings or like listings that are unique to to a company are just so incredibly important right now because there's not enough of them.KevinAnd that's why we talked about Howard Hanna's move in the Cleveland area to be like, Nope, we're not sharing our listings with other offices in the same way we have been. This is just like, again, it's in the technology world. They call it like getting closer to the bare metal. You're talking about taking pictures of listings, You're getting closer to boxing out competitors in like the most bare metal approach, like here, like it's where the rubber meets the road.KevinLike you don't have pictures. Great. So you're listing on homes that com says that the house is 2000 square feet but it has no pictures.AndrewYeah, it's pretty simple.KevinNo one's going to care, Alison.AndrewEspecially the beat, I'm sure. Great pictures to like. They'll be standardized and like, that would be the look for real estate photography. Whatever Zillow decides, if they end up being like they set the mood, they set the tempo of it. So that's, that's pretty cool. Good for them.KevinYeah. I just think what good for everyone if it's done right and we don't know if it will be done right, but anything that helps a builder solve a problem at a reasonable price and help Zillow like that's doesn't happen often again. But win win wins are really good.AndrewYeah, I like it again.KevinAll right. Back to bad news that we're we're going. I think so.AndrewIt's like bad news I think it's bad.KevinFrom from Redfin dot com housing market Update The typical U.S. homebuyers monthly payment is up nearly 20% from a year ago as prices rise.AndrewThat's a big 20%.KevinThe average price of a home is only up 3.2%, but the average payment is up 20. Thank you. Interest rates?AndrewYeah. Interest rates, do you think? Obviously lower down payments, I would assume so. That's affecting it. Yes. Is it my mind on this goes to everything outside of housing like this does affect housing, but I'm like, so I'm in Florida right here by the water 5 minutes away. I'm thinking like, oh, like a lot of people on a boat.AndrewYou got a boat show. You do not see a price. You see a monthly payment on every boat. And you're like, yeah, boats 229 a month bring a boat warranty and include seats. So all this stuff here, like I'll be looking at Lindsay 229 month, like we just don't have to go to Chick-Fil-A six times. Like that's not bad.AndrewLet's sacrifice that. We could get a boat, bring boat. But as things like this go up, I'm like, Oh, that's not an option anymore. Let's not do that. And now the person that's selling the boat, they have less commission now they're making less money. That's kind of like a cascading effect of like if you're what's the phrase like house house for like eventually I feel like that long term, I don't have the data on this and not on The Economist info on this like you eventually that affects other industries and it's this full circle of like, that's not good.AndrewI'm sure there's like a perfect number to be at, right? That I don't know. Maybe there isn't where if it's too high, then it affects you spend less in other places. If it's too low, then there should be more spend and housing. You could afford more as that keeps prices lower, keeps demand lower, if that makes any sense in my head.AndrewThis makes perfect sense.KevinI think it makes it just like, I don't know, 2000 people who work for the Fed, who are trying to figure out like answer that question extremely complicated. That's why rates are moving around and I'm just I got a little bit distracted because I'm looking at this chart, which is on the video version on on YouTube. For those of you watching or on do, you can become yeah, home listings are down 21% year over year look at so 2022 the red line this is when everyone's like see I told you so the world is going to end because listing listings started reappearing and then June, July they fell off and they I mean, the yellowKevinline for 2023 is just I mean, it's it's in the range, let's just say, of 2020 COVID lows, like April, May, number of new homes that hit the market was at an all time low for April May. But we've kind of been hanging around there all of 20, 23. It's just incredible, like the amount of pain on the used home side of the world for these folks who don't have the number of transactions is crazy.KevinAnd I am hearing again, we got to get an agent or a broker on the program to talk about this because I'm getting more emails and texts as well from builders who are like, what is going on with real estate agents? They are losing their their mind. Every deal is like a huge there. I mean, some of the words they use to describe the behavior, I don't know if I can say on air, but.AndrewYou need a little sensor.KevinBut they're like, please tell us that you have something happen at the summit in September talking about how to handle agents and what to do because it's just it's but I mean, you have to understand the pain that a lot of them are going through here. It's not it might be irrational behavior, but it's irrational behavior caused by irrational source, if that makes.JulieSense. That's why I just had a conversation with a builder that I'm like, Why? What did you do? Why are your walk ins so much higher? And it's somebody who they have never wanted to bother with realtors. They never needed realtors. They were just a pain in their side. And she was like, What? Honestly, we've been Dylan more with realtors and open to working with them now just because they need they need listings and we've got the listings.JulieSo we're like, okay, so what's kind of even changing how some people are open to working with realtor.AndrewRealtors.JulieI'm sure.AndrewPursuing.JulieIt's going to make things more crazy for them for sure.KevinYeah. Interesting. All right. I don't think there's anything else really that I want to talk about from the news. It's more like we know that stuff. Elon Musk is trying to win back advertisers with brand safety technology. I mean, I'm I don't even want to think.AndrewAbout it for. That's my thought. I'm then I have this for this this new or old news I don't know.KevinFirst of all the whole the whole thing, I mean, maybe it settles down and in some ways it has because thread thread who like, what's that thing? All the users that I and the community is alive and well they're most of the people I interact with are not have not gone away or stopped actually on. Okay but like advertisers are so fact I do want to read this I pulled up another thing that we can't share the link to because it's a subscription to Digiday plus they called me in to like a $200 subscription for the year because I really wanted to read get you again a point for like great content wins.KevinBut advertisers are so fickle and right now they're such pressure to perform that experimentation on a platform that's been there, done that, and not much has changed. It's like now we all tried. Remember, everyone was going to boycott Instagram and Facebook and never used them again and they were going to go on LinkedIn and Twitter and Pinterest and all these other places.KevinWell, guess what? They're back because they need things that actually deliver qualified people in revenue. So this article is here's what ad and media execs really mean when they commented on their queue to earnings. This is hilarious to me. So and so far so good. I'll try to use different voices just for entertainment value. So these are all things that that high level executives said on their earnings call.KevinThe is Doug Horn, the CFO at Gannett. For those of you who are born in the last 35 years, that's a newspaper company who tries to do digital media as well. But here's what he said. Despite secular headwinds, the decrease in print advertising revenue was limited to 8.9% year over marking the smallest decline observed in the past year.KevinAnd then here's what he actually meant. That quarter could have been a lot worse, except for the fact that our print advertising sucked less than expected. I think people are still dumb enough to buy print ads. Spence Newman, the CFO at Netflix, said. Our overall ad arm subscription plus ads continue to be higher than basic ad free globally, same as the statement on standard Bore.KevinHere's what he meant. Advertising is not a major moneymaker for Netflix, yet we made all of our money by just not letting people share subscriptions. I'm not even going to say what they actually said, just what they meant, because it's it's to me, it's just a really good insight into the chaos that is the traditional advertising world. Zaslav Warner Brothers CEO said.KevinWho needs a massive subscriber base When you can focus on a handful of loyal customers and make millions, am I right? So basically it's like we're not even going to try to grow the number of subscribers we have there. Just charge them a heck of a lot of money for not a lot of content, and it's working just fine.KevinMichael CAVANAUGH Comcast president. There are too many moving parts that would need to align for a deal of the magnitude to come together of being sold or swapping business units. See, I think there's one other one in here that was really interesting. Bob Bakish, CEO of Paramount Global, talking about the whole writers strike and labor dispute. Basically, whoever has the goal tends to make the rules and we've got the gold.KevinAnd they also by the way, it's been interesting just hearing all of the AI generative AI discussions around like, could you pick a worse time to have a strike over something that.AndrewSo yeah.KevinIt just is really interesting. So I mean, Mark Zuckerberg, this is pretty good. Rails plays exceeded 200 billion per day across Facebook and Instagram. We're seeing good progress on real monetization as well with the annual revenue run rate across our apps now exceeding $10 billion up from 3 billion last fall. What he actually meant is we're about to make a whole crap ton of money from short form videos.KevinVery soon.AndrewYeah.KevinBut like people in the print industry, I mean, even TV again, I've hinted at a couple of times, but connected TV advertising sounds awesome. And like Disney Plus right now is pivoting their last call. Iger just said, You know what? We don't want people like we're going to up the price of Disney Plus because we will make way more money.KevinIf we can sell ads, then if we make people pay what they're willing to pay for the platform. So their goal is actually to grow the ad supported subscriptions more than anything else. And if if they and others convince more people to do that and you can start affordably, that's the key. Affordably targeting households with TV advertising on streaming services, that would be great for right now.KevinIt's the only way that people like Disney can make money. They can sell the that because the concept of it is so good in an actual performance it it's not worth the expense being paid except for those people who are making money from the ads being being bought.AndrewYeah, I mean, essentially it is Go ahead.JulieDoes it it feel weird that we're like subscriptions? No more ads. And then the pendulum is swinging other way, right? It's like our kids aren't going to understand. No, no, we're just going back to cable. Like, we already had this, and then we didn't have this, and now we have this again. It's just the way things cycle through is interesting to me.KevinWell, I think it's a cat and mouse game of we as advertisers. We want this ability to target at the household level. What screen streaming accounts allow that cable accounts didn't I used to do cable TV advertising at Heartland and you could pick a zip code. That was it like you could you can say target all of the Time Warner or Comcast subscribers in the zip code.KevinThat was the most you could target. Now that you can target accounts and you know who those accounts are, and that data gets blended with other data sources, it's the right thing that advertisers want. Whether consumers will put up with it is another thing, because it's it's hard to go back to like we use YouTube TV. Big brother is out.KevinMy wife loves Big brother. That's usually I get her the subscription to like the all access thing for Big Brother for her birthday. We missed the first two episodes, so we have to go back and watch YouTube, TV records, everything. But you have to. If you don't put it in your own DVR tool, you have to watch it with ads.KevinAnd I kid you not like every ad break is 8/32 commercials and they ad and like double it's like punitive. It's like you missed it haha we got you.AndrewYou want it.KevinAnd it's just painful to watch that stuff.AndrewPainful. I mean, at the end of the day, it's revenue per user, right? Just like you look at Facebook when they deliver their quarterlies, you read the PDFs and you're like, okay, okay. Like, all right, a average U.S. user is worth $23.54 per quarter. So you're like, Oh, well, I'll just pay $15 a month. I have no ads on my Facebook for them.AndrewYou know, they're not making that choice to do that. But that's what it is. That's at least that's why I interpret it like, right, we could go this way or this way. Revenue per user and then revenue at the end. But then they get into like, well, we need longevity, we need retention of these users. We can have attrition and dying off.AndrewSo they have to factor in all those things. But a fun, fun analysis for billions of dollars and and revenue to do. And like, here's what I'm presenting shaking your hands like I'm nervous to tell this to someone.KevinBut okay favorites.AndrewOh man. Oh man.KevinYeah. Andrews. Andrews again filling in for Beth last second. Let's see I think.AndrewFavorite.KevinAnd you can skip if you need to.AndrewActually you.KevinGot everything.JulieI got one. So my son just turned 15. He's starting high school, so for his birthday, he wanted us to take him shopping at the backpacker, which is like a it's more expensive than we're like usually for school clothes we would do like Target and all Navy because it's very everybody knows that I'm thrifty like that, so it's more expensive.JulieBut they had the they got the coolest school backpacks there to him out of the loop but they're there have an insulated pocket in the front for their lunches. So you know, you're 15 at high school. You don't want to carry a lunch bell. You must have like, built into the cool little backpack. So watch me cringe. Like it.JulieYes. Made me cringe a little bit when we.AndrewYeah, these are up there. I'm looking at them.JulieWhat we paid for all his clothes there. But, you know, he's getting older. He wanted the the cooler clothes.AndrewYeah. Yeah.KevinI'll just I'm wondering, I think your favorite should be the kids are back in school.AndrewThat is. That is my favorite. Yeah, that's great. It's my favorite. That's that. You want to do it this year. But yeah, I started This will be our next so like two weeks ago they started I time this is out I think or a week ago, whatever it may be. But yeah, I'm excited for that. But the fun challenge though is record 330 Eastern day at home.AndrewLike right now I want at 4:00 but I want to start is when they get home. So I'm like mute, unmute, mute because I have to walk through the door, which is, you know, 15 feet that way with my door shut and all that stuff is fine. But yeah, that was fun shopping for them. We have three so that you have to but you went to the backpacker, which Looks like a super sweet spot to go to.JulieFor a few things not have.AndrewYou think about.JulieEverything.AndrewBut it's yeah, our kids are in uniforms which is great, but you still like they got to get the dry fit ones otherwise, like the collared shirts shrink and then so they don't last long time. But yeah, so it's expensive starting back up school but I'm glad they're gone. It's quite the power bill will definitely go down because Fortnite and the Ps5, the Xbox and desktop are not running upstairs all day.AndrewRight. I'll take that. Forgot about that.KevinBut I am. I'm late to the game here. I feel like food shown up in boxes has come and gone for most people. They're like, Yeah, I tried Blue Apron, all that stuff. This is factor 75. I don't know if you've heard of this, but their refrigerated meals, they're all fully, fully prepared.AndrewOkay.KevinAnd the quality of the meat in particular is incredible. Like it is. It's like going to Cardinals, which is the premier butcher here in town. If you're going to make ribs or steak for special occasion, you're going to craft onions. All the meat is really, really good. It's not I guess some people use it for like dieting or whatever, but there's four or five categories like keto or like low calorie vegetarian, vegan or whatever.KevinIt's all really good. There is a pork chop thing that my wife had because she did it first and I was like, What are we doing? This is dumb. And I tried it. I thought it was filet mignon covered with like a cheese sauce. It was some pork chop thing. And I was like, okay, I'm sold. They can make pork chop tastes like filet mignon.KevinI'm in. I don't I'm sure it's expensive. But here's the thing. Everyone's going to school for the first time. No more home schooling for the Oakley's. And that means there's not lunches that are going to be downstairs and I won't eat anything. Like, I'll just eat a a a protein bar for lunch.AndrewKevin.KevinAnd it's way better for my body if I just eat actual meal.AndrewIt does a good and it's, yeah, we do some meal meal prep like this as well. It's definitely worth it. It's still cheaper than going to cheaper as in, if I do leave the office, I go pick up Chick-Fil-A, then I wait in line and then I drive back and then I sit at it like there's 45 minutes right there.AndrewEven though chick flies 10 minutes and this is maybe a dollar two because.KevinIt's all refrigerated, there's really no prep time for every single one of these entrees is 2 minutes.AndrewYes. And it's real food. Like, it's not like the ingredients are like chicken.KevinIn the bath. It does take up a little bit of fridge space. But yeah, that's some surprisingly because this is not really my thing.AndrewSecond fridge, I'm thinking that's well. Oh, have you had their blueberry buttermilk pancakes or.KevinIt's not done any breakfast. It's just purely a lunch thing. So Melanie doesn't have to mess with extra groceries for lunch for either of us. We just. And the portion sizes. I'm not. I'm not hungry.AndrewWith a smoky bacon and cheddar egg bites. Four of them looks pretty good.KevinFor those of you who may not be familiar, Andrews to all of the sessions are food and clothes.AndrewShorts, shopping for short.KevinOr shopping for shirts.JulieSpecifically shorts.AndrewIt's hot. It's hot and miserable. Yeah. I'll just move to like, not unlike the cold either. I'm stuck here.KevinAll right, That'll do it for this week. Thanks again for tuning in and joining us every week. We've got some fantastic guest episodes coming out shortly, one including Julie, talking a little bit more in-depth about her book. For those of you who haven't order in yet, you get a little bit of a preview. So check that out. We'll see you next time. The post Ep 299: One Stop Shop appeared first on Online Sales and Marketing for Home Builders - DYC.
Amy turns to the carnivore diet amidst struggles with chronic kidney disease and weight challenges. The diet reverses her kidney issues, and she finds camaraderie in a community of fellow carnivores. As she navigates this lifestyle, Amy discovers it's affordable. Her transformation, both physical and mental, becomes an inspiration to many. Setting short-term fitness goals, she remains committed to her health journey. Amy's story underscores the power of determination, community, and embracing change, offering hope to those facing similar health battles. Timestamps: 00:00:00 Trailer and introduction. 00:01:04 Metabolic sickness, kidney disease, brain fog, fasting. 00:08:08 Sugar addict finds stress relief through engagement. 00:13:56 Extreme carnivore lifestyle motivated by life or death. 00:16:46 Family scared, extreme diet changes, no community. 00:21:43 No sugar cravings, occasional cashews addiction. 00:24:52 Priorities: health, appearance, strength, and progress. 00:31:29 Weight training helps at any age. 00:33:42 Steak and butter program helped me evolve. 00:40:18 Cystatin-C test to measure GFR. 00:44:02 Short-term fitness goals; sprinting and fasting protocol 00:46:50 Carnivore Instagram, introverted, struggles with social media. 00:49:50 Closing. See open positions at Revero: https://jobs.lever.co/Revero/ Join Carnivore Diet for a free 30 day trial: https://carnivore.diet/join/ Carnivore Shirts: https://merch.carnivore.diet Subscribe to our Newsletter: https://carnivore.diet/subscribe/ . #revero #shawnbaker #Carnivorediet #MeatHeals #HealthCreation #humanfood #AnimalBased #ZeroCarb #DietCoach #FatAdapted #Carnivore #sugarfree
Market Proof Marketing · Ep 297: Less is MoreIn this episode, Kevin Oakly, Andrew Peek and Julie Jarnagin discuss the lack of data being used by large corporations in regards to their marketing strategies as well as their frustrating experience with GA4 so far. They muse on the cascading effect on the economy of monthly mortgage payments being 20% higher than they were a year ago and how the low used homes inventory is causing realtors in a frenzy to reach out to builders for their listings.Story Time (04:41)Julie is being spammed by Hidden Valley Ranch emails.Kevin helped a builder problem solve: 6 leads to 54 (18 walk-ins + 36 online leads) Andrew finds that GA4 is still pretty clunky and has odds and ends to work out.News (31:10)Housing Market Update: The Typical U.S. Homebuyer's Monthly Payment Is Up Nearly 20% From a Year Ago As Prices Rise (https://www.redfin.com/news/housing-market-update-monthly-mortgage-payments-near-record-high/) Mortgage demand drops again after FHA loan interest rate hits 21-year high (https://www.cnbc.com/2023/08/09/mortgage-demand-drops-again-after-fha-loan-interest-rate-hits-21-year-high.html) Over 80% of Americans think it's a bad time to buy a house (https://www.businessinsider.com/house-price-outlook-homes-real-estate-investing-fannie-mae-survey-2023-8)Elon Musk's X aims to win back advertisers with new brand safety technology deal (https://www.cnbc.com/2023/08/08/elon-musks-x-aims-to-win-back-advertisers-signs-deal-with-ias.html)Favorites (48:45)Andrew's favorite is the kids are back to schoolKevin: Is loving his new refrigerated meals and especially is impressed with the quality of the meat.Julie loves the new backpack she got for her son to go back to school with that has an insulated pocket in the front for lunch.Questions? Comments? Email show@doyouconvert.com or call 404-369-2595 and we'll address them on the next episode. More insights, discussions, and opportunities can be found at Do You Convert All Access or on the Market Proof Marketing Facebook group.Subscribe on iTunesFollow on SpotifyListen On StitcherA weekly new home marketing podcast for home builders and developers. Each week Kevin Oakley, Andrew Peek, Jackie Lipinski, Julie Jarnagin, and other team members from Do You Convert will break down the headlines, share best practices and stories from the front line, and perform a deep dive on a relevant marketing topic. We're here to help you – not to sell you!Transcript: KevinWelcome to episode 297. I'm Kevin Oakley. And with me today is Julie Jarnagin and Andrew Peek, because Beth Russell went full on Miley Cyrus with her voice today. I didn't know thats a thing.AndrewAnd?KevinWe were conversing this morning. And I was like, huh, You're talking about you've gone for Miley Cyrus and she's like, Sorry, that was a mom joke, which I didn't realize mom jokes were a thing. So I just was happy that we have equal opportunity bashing adult jokes.AndrewI, I support it. Yeah. Miley has a pretty low voice, little boy raspy. It's not that. Well.JulieHer kid has been sick and so apparently it got passed down.AndrewIt's this is the beginning. Schools just started. So.JulieYeah, that's true. That's true. It's going to hit all of us.AndrewIt will only get worse.KevinNo one else in my family got an apology covered. That was shocking.JulieGood.AndrewGood.KevinTotally. Totally in the clear. All right, story time. Who's going first?JulieI can go.AndrewOh your first.JulieMine is kind of. Kind of random. So just randomly in my email, I got an email, like a marketing email from Hidden Valley Ranch. I was like, How in the world did I end up on this list? Is it a really, really old list I was on from like, maybe I got a recipe or maybe they sold it.JulieSomebody? I don't know. I just thought it was funny that I got it because I was like, That's random. Then I woke up the next morning. I had two from them overnight, so that was my third. Then within the span of like less than 48 hours, I had six different marketing emails from Hidden Valley Ranch, and I would try to and I would try to unsubscribe and I would keep getting them.JulieAnd so finally I just had to hit the like, this is spam button in my email, you know, quit sending them to me because it's just a reminder, not that you're Hidden Valley Ranch, but don't if you have a list and you haven't sent any emails and you just start spamming, don't do that. You need to send emails consistently on some kind of normal basis so people are expecting them.JulieAnd don't just send six in a day about Hidden Valley Ranch because.AndrewIt's like they're it's like a marketing automation just exploding.JulieCrazy.AndrewThe more, you know, thank me. What could they even promote? Like, do you get like a 36 pack of of all these.KevinOh no they they cross promote using recipes like sour cream or something. Yeah. Like you know you can ads you can add a ranch packet to sour cream and make them.JulieIt was a lot of recipes, I think. So I don't know how I ended up on it, but they were aggressive fun.KevinIs there a preferred email cadence like as well? I got this email today from someone said, Hey, my onsite team doesn't ever want marketing to send emails because they said, We don't want to overwhelm our customers with too much communication when it comes to too from marketing, what do what do we think?JulieI personally, I say twice a month from from marketing, maybe once a month. If you can't do two good once a month, do one good one a month, and probably no more than two a month. That's me. You all may have a different.KevinNumber two is my cap from marketing.AndrewLike and I like that I gave props to Opendoor a while ago where they gave a lot of value in their email. They're like, your new offer. Your new offer. I think it's every three weeks and it's there's value in there. They probably see that I open it. And so that's why they're giving me maybe I have an accelerated cadence compared to someone else.AndrewYeah, I think twice. And then maybe some type of like trigger that helps you slow down that cadence. Like, okay, now they're a purchased let's not give them all of the marketing emails, maybe they switch different list whatever maybe. But I think we all agree lean on less versus more from marketing.JulieWell, less as long as it's not non or randomly have a new just when we think that everybody needs some, I feel like it needs some kind of plan and strategy around it instead of when we get to it, because that usually means never until we're panicking. And then people get it and they're like, Wait, who is this?JulieWhat is this? If you do have a cadence, they at least are used to seeing you pop up in their inbox and it's not so insulting. I don't know if it's things are awkward, but with Hidden Valley Ranch Spammy.AndrewYeah.KevinYeah. It's one of those areas that as an industry we still don't use data properly, I think, to clearly find like, you know, from the time something becomes a lead to the time they decide to go on an appointment, I would argue that you you could if you to your point, if you had the great content, Julie, if you had, let's say, 15 amazing in-depth articles, slash blogs with photo galleries and or videos or virtual walkthroughs, about 15 different stories of customers who chose your homes and love them.KevinI think you could send one of those a month if they're good enough or sorry, one of those a week if they're good enough over 15 weeks. But the signal of once they once you go to an appointment, you're kind of transitioned to another phase. And while it might still be interesting to get those, you might then have to do the work of saying where are the best three that they haven't already seen and spacing them out more because there's now it's it's still going to be interesting just like people love watching issue TV even though they already know where they're going to move or you know, they just bought something.KevinThey still want to, but they don't need to be deluged with it in the same way. And of course, all those ideally would have the signal of go here in view more if you want, let the customer binge them, but then know not to send them because they've already seen them in an ideal world.AndrewSo maybe.KevinI'll write. Mine comes from a call early this week because I feel like this is happening a lot, not just with the builders that we work with, but but around the country where traffic is still high. In fact, the aggregate data set from homebuilder data, it's about the same as where it was in February, March in terms of traffic to homebuilder websites, lead volume depending on the price point an area some some places are down.KevinBut if you look at year over year, most people are still up tens. And so you're talking about a struggling neighborhood. And this last month in June, they had six leads in there. So this particular better uses lasso. When you use lasso and you're analyzing lead volume, a reminder that you typically have to go look in two places.KevinYou have to go look into the individual community project. And that's going to let you see all of the online leads that have transitioned to on site through an appointment as well as walk in traffic. And then you're going have to go to the online sales bucket project and look at the leads that have come in just for that neighbor.KevinThen you have to add the two together. So we started out looking in the project folder. First thing was that no one on the call immediately kind of already had their finger on the pulse of what the lead volume was for the community, which is marketers. We should always, especially the ones that are high focus, like this is a neighborhood that I taken over the call from Jacqui, the Penske issue on maternity leave, but they're like, Oh yeah, we talk about this one like every time.KevinSo cool, so many leads that we have. Last month. It's okay. Like, you know, they didn't know it, but we looked it up and they had 38 leads in the onsite project. And I was like, okay, cool. Well, we looked at where the lead sources were coming from, both in terms of like just phone call form submission as well as actual marketing source.KevinAnd then we go to June and there were six. It's like, Wow, that's a statistically significant difference. Like something changed what happened? And we go through the list and you want to guess what changed? Actually, I'm going to make a guess. You probably don't want to because you're like, I don't know, but.AndrewWhat's the number.KevinOf 6 to 38 leads just in the onsite project? What do you think.AndrewSix up to 38.JulieMM Oh, they increased more finished quick movements listed or I.KevinGuess.AndrewI think they just added them. They were there before that at everybody their close like they register them like, like they're like this. They had the same number. Maybe the number didn't change but they just decided like, well everyone's looking at me, I'm in the hot seat. I better add something in here.KevinWhich. Okay, so that's your final clue. For those of you playing at home, when leads start being put in the system by onsite agents, after there has been five or six months of intense scrutiny of said onsite agents, what's happened is there is a new one. There is a new onsite agent who doesn't know the game to be played and silly, silly salesperson.KevinYou're putting all of your walk in leads in the system. They don't know better. It's like I always go back to when I first started playing golf. It was the best golf I've ever played in my life, in my life, because I was just playing. I wasn't overthinking it. And then you start overthinking it. You start doing all these adjustments that are wrong.KevinTypically when you're new, you start playing worse, you get in your head. And so new salesperson now in the online bucket, we went back and there were 36 online leads for July for this neighborhood. And and so then we went back to the onsite project and just ran only the walk ins and there was eight of them. And then I'm really bad at Mass.KevinIt took me about 45 seconds to figure out that the total lead count for this struggling neighborhood was 54 in a 30 day period.JulieWow. Well.KevinThe one thing I always like to remind everyone is the way that we approach marketing and advertising and do you convert means that we don't have to consider at all unless our builder partner has chosen to do something that we don't recommend. We never have to wonder to ourselves. I wonder if those 54 people are interested or qualified in any sense of the word.KevinWhy don't we have to do that? And again, this is a really big deal because every ad we ever run talks about the location, price point and type of products that you are selling. So when those leads come across, they're not just like, you know, trying to collect a $50 scratch off ticket by entering in their contact information or entering to win a car or whatever the like.KevinSo to bring it all back down to the now that I've told you that journey, it was just like, wow, we don't have a struggling community from an advertising problem. We don't have a struggling community from a lead problem. What we have is an appointment to sale conversion challenge and with 54 people in a 30 day period, someone needs to give the sales team permission to screw it up.KevinAnd what I mean by that is just start getting sales. You know, they were like, Well, this is a hiring neighborhood. And we always get the feedback that a lot of customers are concerned about selling their existing home. I go make up and make up an existing home sale package incentive. Hey, no problem. What will we'll create? What is that?KevinMake it up. Just say, Well, will partner with three agents that we know are great agents and they're they've promised to do an enhanced listing package on any referral that we send over so you can pick any of those three agents. And then as the builder, you might have to pay an extra couple hundred bucks to them to make sure you get the best photographer that they typically would use an on site or do a little bit more advertising, whatever it is.KevinBut just say, yeah, we're just putting together the finishing touches of our list. Your home VIP experience. Let's just sign contingent upon using the details of that program and feeling comfortable selling your house or whatever. But something there's too much like, yeah, it's price. Yeah, but it and I think I talked about this last time so I'm not going to go into it but that builder that had a 6% performance sell ratio really changed some things around and got to a 20% that 11 sales to 51 sales.AndrewThat's a lot of.KevinNew cumulative leads for that incentive for people that are already in their system. And I was on a call with Jesse Suggs, online sales coach for another builder this morning. She did analysis for a builder and something like 80% of their sales were to people who had been in the system for over three months. All of the friction that's preventing sales is coming from the middle and the bottom of the funnel right now.KevinAnd that's likely to continue through the end of the year. And so just wake up, smell the coffee smell and then start adjusting accordingly because you're not. I have not. Maybe one of you two have. I haven't seen any promotion that anyone has done. 80 different builders, almost every state in the country over the last three months. That has significantly increased their lead volume.KevinAnd again, the only aspects there would be qualified leads, not just leads that are from performance max campaigns and mostly spam.AndrewDon't do that.KevinYou're not you're not going to convince anyone that today is the first day that they should start thinking about buying a house or moving.AndrewNo. And we'll we definitely have some news lined up to really support that.KevinLet's just jump into that one. Oh, we got it. So from a Business insider, over 80% of Americans think it's a bad time to buy a house, which coincidentally also means that the majority of Americans also think it's a bad time to sell a house. So sellers are also buyers and so they don't want to sell if they think it's a bad time to buy because most of them are going to have to buy.KevinSo 82% think it's a bad time to buy a new home. Affordability has plunged. So unless there is a reason to move, like even this goes back to I mean, you're someone text me this right now and I'm just I'm overdoing this point because it is so important. For the second half of this year, someone said, hey, what's your thoughts about success and failures around special inventory events, i.e. showcase of homes, liquidation event, year end sales, event, everything must go, etc. It's like, well, let's not call it everything must go or liquidation sale.KevinBut even in a good market, doing that consistently once a year and then at Heartland, we just that was the only incentive we did all year. Everything else was adjusting pricing to market. But every year we did basically a December to remember sales event. It was the only sales event of the year and that trick will work once.KevinSo I was just saying, you know, maybe end of summer and fall is a better time to get your stuff sold before the end of the year when everyone else is panicking. I kind of I don't mind that, but I said, Hey, just remember 70% of the buyers are probably already in the system. So it's communicating to those people you already know.KevinAnd they said back, we were thinking of doing this event for 75 to 90 days. What's your reaction to that?AndrewI I'm trying to figure out what I want to say out loud, but it feels like it's not a real event. Then it's garbage. Like it like I'm I view it negatively. Like it's not a real deal. It's just a fake promotion.KevinIt's too long. I feel like it's too long, especially knowing that the majority of people who will take advantage of that opportunity will be people they already know. So I said, Hey, probably doesn't need to be that long, you know, just heads up and said, Well, I think we're going to have to do longer because we don't do well.KevinFostering leads long term too, which I just wanted to say that's, that's an unacceptable.AndrewThat I misunderstand that they need it longer because they're not good at fostering leads.KevinBecause they think that, yeah, they're not good at nurturing leads longer term.AndrewOkay?KevinAnd so they feel like the salesman has to go for 90 days so that new leads can come in, have time to absorb the opportunity.AndrewEtc.. So they lose people after that when they're all leads aren't useful anymore, right? And you're like, No, no, no, that's your mortgage sitting there. You have your revenue.KevinEver been right now?AndrewYeah. Yeah. Interesting.KevinYeah. Back to the article. I kind of like merging story time. Article time.AndrewYeah, that's one's perfect. Unplanned. So that's fun.KevinThe average 30 year fixed mortgage rate has risen from under 5% to nearly 7%, according to Freddie Mac. With the Federal Reserve's most aggressive interest rate hiking campaign since the 1980s. I was born in 81, so the it's been a while and everyone's still kind of pessimistic now. But that doesn't mean that but that does mean by default the people who have to are more urgent.AndrewRight?JulieYeah, they have to. And I think it's such a good opportunity to just agree with them. But yeah, it is a terrible time to buy an existing house like. Yes, absolutely. You are completely right. It is a terrible time to buy an existing house. It's a great time to buy a new house because look at this great thing.JulieWe can do to help you and look how our how they hold their value. And it just is a good opener to a conversation to talk through these things. So I don't think you're ever going to convince all these people that, oh, 80% of people are wrong. You know, everybody because they.KevinThink about the think about the psychology here of you think it's a bad time to buy and you see an ad that a builder runs that says 50, 75 grand off if you buy by the other month. I think I think your negativity bias is like, see, I told you it's bad time to buy. You don't think you're so much money.AndrewYeah, I.KevinWasn't going to buy, but now I can save 75 grant like again. It doesn't mean it doesn't work, but it doesn't work for the reason we tell ourselves. It works. When someone buys something that's on sale, that's because that's what they believe it's actually worth. Or they believe that there's some that like it's not the savings we justify that we tell our spouse, Hey, don't get mad at me.KevinI just saved us $100. But in our minds, we knew that that's not what we did.AndrewYeah, that's what it should be paid. I can see that reaction being like, oh, desperation. It's still overpriced. This as far as like if you're being kind of indoctrinated with like these articles like this where like 80% say it's bad time to buy, your reaction is to be correct with the rest of society. And so you're like, Well, I'll go along with that.AndrewI feel like they'll make me look smart. And like you said, Julie, like, well, the builders are the ones offering like these great incentives 5.25, five and a half, 4%, whatever. Like that's different than 7%, significantly different. So.KevinWell, and the other thing that's interesting about interest rates. Barbara Corcoran, you all know her from Shark Tank. Well, she's kind of got a thing that's going viral around the the U.S home industry right now because she's like everyone. You've got to buy a house now that rates are at 7% because when rates go down, the prices are going to go up.KevinSo what she's correlating to and it's not a crazy thought at all, is when rates were at four and a half and they went down to three. It took it took too long for most builders to figure this out. But builders are like, wait a minute, I can you know, I still remember people were like, how much should we raise prices by Kevin?KevinI mean, they just keep selling. What should we raise? And so I go, Just do the math of exactly what is the same payment and you can go there. Now it's the affordability around payment. You can just go to that price. You have to look at your cost, just go to that price. And so her argument is if you buy now and take that pain, you'll be better off because the rates go down, the prices of everything will go higher.KevinThat's not a guarantee, by the way, because if rates go down, it still means that there's bad things going on in the economy and the job market. It's earned.AndrewBut it's, I think to say kind of rudely my brain like that's like privilege problems, right? Like she's like I have X amount a bank account like I'm I'll deal with this and two years I'm out of the situation. But if you're stuck at 7% forever, you can't refi. Your financial situation doesn't change or drastically go up. Then you're kind of you could be stuck.AndrewSo for normal people, maybe not. But I, I definitely understand what she's what she's saying there. What's interesting is do we know anyone This is going way back. Remember Daw d0r the.KevinYork tracking the infrared tracking tool?AndrewYeah, I remember. They weren't that expensive to implement. And then, like, as we kind of got used to that and I'm not sure if there's any builders still using it, but there's a recommendation like put it, don't put it at the front door. But like in the primary bathroom or something or whatever, it'd be like, okay, real people and the model home will definitely go here versus someone going in and out, in and out deliveries, mail, etc., etc..AndrewInteresting. Having that data to kind of normalize like the salesperson. This is back to the first part of your story. Like leads went up. Now it's just a new you'll see a new sales agent on site. It's like, well, we've had 300 people come in, 200 people, a hundred people, whatever it is, that person has six, six. So that just kind of like normalize the data.AndrewBe interesting. So my little story is just like maybe it's it'll make you feel comfortable. J4 is still quirky. I don't, I don't like it. I don't get it. I was just on a call about an hour and a half ago. Really intelligent guy is like, Hey, we're seeing this like what is happening? And I'm sitting there like, Man, I wish I could be super smart right now and have the answer to this.AndrewI'm like, I have no idea. Like, let me just rebuild that report for you and maybe that will fix it. Like, I do not know, like essentially it was only charting one campaign, but the other campaigns were down here. The numbers were making sense. The ad and like, you know, everyone has the delay of the data. It seems like 24, 36, 48 hours.AndrewThere seems to be a little bit longer than that. It's a lot of fun and they have a lot of data. So it's not like we've seen some where like at the sampling a smaller is could be goofy, but it just seems to be inconsistent all over the place and it's not much fun. Thank you. Google it's not fun at all.KevinYeah it's well and the inconsistencies fortunately are not. It'd be one thing if it was just Google but it's implementation still up for on some web environments that you know it's yeah and that's where you can't I mean you will because you're human you'll get mad at the web developer but it's it's multiple web developers that are having this issue it's not just one.KevinAnd sometimes it's for a bit of code that really should have nothing to do with causing any interference with GFR. So I feel like I use this a lot. But you know, WordPress is a great format for a blog, but trying to build a website with WordPress, in fact, again, just this morning talked with a large organization, multistate organization that still uses WordPress for their and we were talking about they are having a spam issue.KevinAnd I said, well, a lot of times WordPress is something that doesn't help that and they're like, Oh really? Why go? Because you don't often update WordPress as often as you should when you've got 20 different plug ins that are connected to that. Yeah. So then we'll potentially break when you update it. Like, yeah, we're on a really old version.KevinI go, Yeah, you're going to get spammed.AndrewIt's been hacked.KevinSo it's that same kind of issue though that WordPress has where you're using the same website you always have go for said, Hey, no big deal, just put in this line of code and put it here exactly where we tell you and everything will be fine. But there's interaction with other lines of code that really shouldn't be affecting it, that that are for some people, thankfully, it's only about 5% that are still working through that issue.KevinAnd also, thankfully, I just saw an article posted yesterday like for 90% of people, UK is still alive and kicking and I.AndrewDidn't see it. I'm like, I want to use it. But then I. Principal Mike, I don't think I could be the one that says I.KevinFinally converted all of my little stars on Google Analytics over to Jay for accounts versus UK. But it is terrible.JulieI have to say I've gotten more use to die for than I thought because the other day I was in there and I was like, Oh shoot, I'm using you. Like just because it looked familiar to me. And I was like, Oh, I'm not. I'm just used to this now. So that's good. And Andrew, the most frustrating thing is when a piece of data is showing up in one place, like randomly, but it's showing up in the place it needs to show up.JulieYou're like, I know it's there, it exists, I just can't make it. So that was where it needs to show.AndrewI think that was Tuesday. Julie and I were troubleshooting Google Tag Manager and J4 and like everything was correct, it just wouldn't show up in both places. For certain events. We're setting up to support conversion tracking. Yeah, there's no certainty. Which by the way, I look above my head. The site added. You look right, that perfect.JulieWill.AndrewColor my room. It's stuff that's that's all my story is but I get the 5% of of all of it so like 90% of my world is it's it's broken J for I'm like are you kidding?KevinAndrew is our level five tech support. Yeah.AndrewSo it all rolls sideways and uphill and diagonally to me. It's great.KevinWe don't have a perfect tracker here to fixing everything, but we are, I think, nearly perfect on identifying the cause. Like if it's something that we can't touch, like a website or a server issue or whatever. But we can, we can usually help sometimes.JulieI'm actually happy when Andrew can't fix it out, so I feel like it was a dumb question. It was like, This might be stupid. Andrew And then when you can't and I'm like, Yes, it's a real.AndrewProblem and sometimes that's enough is like, okay, cool. I'm not going crazy anymore. Like we all agree this is just weird and quirky. We're not going to worry about it for a little bit. And then sure enough, I'll just fix itself on its own.KevinNext up, I guess we'll link to my tweet. We still call it that. I don't know. But Zillow is hiring over 100 photographers around the country like to continue to enhance their enhanced listings product. And so what's really cool about this is Zillow. If you've missed somewhere, been under a rock over the last six months or so, showing shown time plus which they purchased, which is like the centralized scheduling platform and then they've kind of built around that enhanced listing features, 3D tours, photos, basically everything you need to get your listing to look better.KevinYou get a better layer on the actual map as well. They're going all in on this and I think it's the right call for any syndication company to do so because, you know, Julie wrote a book and that's great, but content's still hard for builders, harder than it maybe should be. A lot of times it's just because they are still doing something really stupid, like connected TV advertising or billboards or whatever.KevinLike you have the money to solve this problem, but you're using it for for less efficient purposes. But I, I have a feeling this is going to be huge when they start to roll it out. And I have no idea when they'll be doing this. But the moment the builders can just say are already advertising on Zillow and it's like, yeah, for X amount more or I don't know if they're going to include it, but you want to just come take pictures of this house, like really good pictures and it's also a good box out move for home XCOM, which is trying to come in and disrupt.KevinAlthough I read an article that basically they even know they're not going to be Zillow, it's like where our goal is to be a really good number two and keep Zillow honest. But we're not going to we're not going to take over.AndrewI mean, there's there's being ads to Google ads. So there's always the number two. I wonder if they'll even have the photographers edit, Which would be.KevinI think so. I mean, basic basic edits. Yeah, basic cleanup.AndrewAnd that's like, imagine that.KevinBe really smart about this from a strategic perspective. And homes while Costar Homes parent company started this on the commercial side they can take these pictures and again I haven't seen any paperwork so I have no clue how this will work. But my hunch is it will work similar to Costar. And that Costar lets the commercial agents use the imagery that they shoot for anything except to send to other commercial real estate syndication portals.KevinSo this whole concept Inman Connect in Vegas has gone on this week, and one of the panels with Robert Rifkin, the CEO of Compass and someone from Redfin and the CEO of Next Next Home, I think is the name of the company. They're all talking about how like pocket listings or like listings that are unique to to a company are just so incredibly important right now because there's not enough of them.KevinAnd that's why we talked about Howard Hanna's move in the Cleveland area to be like, Nope, we're not sharing our listings with other offices in the same way we have been. This is just like, again, it's in the technology world. They call it like getting closer to the bare metal. You're talking about taking pictures of listings, You're getting closer to boxing out competitors in like the most bare metal approach, like here, like it's where the rubber meets the road.KevinLike you don't have pictures. Great. So you're listing on homes that com says that the house is 2000 square feet but it has no pictures.AndrewYeah, it's pretty simple.KevinNo one's going to care, Alison.AndrewEspecially the beat, I'm sure. Great pictures to like. They'll be standardized and like, that would be the look for real estate photography. Whatever Zillow decides, if they end up being like they set the mood, they set the tempo of it. So that's, that's pretty cool. Good for them.KevinYeah. I just think what good for everyone if it's done right and we don't know if it will be done right, but anything that helps a builder solve a problem at a reasonable price and help Zillow like that's doesn't happen often again. But win win wins are really good.AndrewYeah, I like it again.KevinAll right. Back to bad news that we're we're going. I think so.AndrewIt's like bad news I think it's bad.KevinFrom from Redfin dot com housing market Update The typical U.S. homebuyers monthly payment is up nearly 20% from a year ago as prices rise.AndrewThat's a big 20%.KevinThe average price of a home is only up 3.2%, but the average payment is up 20. Thank you. Interest rates?AndrewYeah. Interest rates, do you think? Obviously lower down payments, I would assume so. That's affecting it. Yes. Is it my mind on this goes to everything outside of housing like this does affect housing, but I'm like, so I'm in Florida right here by the water 5 minutes away. I'm thinking like, oh, like a lot of people on a boat.AndrewYou got a boat show. You do not see a price. You see a monthly payment on every boat. And you're like, yeah, boats 229 a month bring a boat warranty and include seats. So all this stuff here, like I'll be looking at Lindsay 229 month, like we just don't have to go to Chick-Fil-A six times. Like that's not bad.AndrewLet's sacrifice that. We could get a boat, bring boat. But as things like this go up, I'm like, Oh, that's not an option anymore. Let's not do that. And now the person that's selling the boat, they have less commission now they're making less money. That's kind of like a cascading effect of like if you're what's the phrase like house house for like eventually I feel like that long term, I don't have the data on this and not on The Economist info on this like you eventually that affects other industries and it's this full circle of like, that's not good.AndrewI'm sure there's like a perfect number to be at, right? That I don't know. Maybe there isn't where if it's too high, then it affects you spend less in other places. If it's too low, then there should be more spend and housing. You could afford more as that keeps prices lower, keeps demand lower, if that makes any sense in my head.AndrewThis makes perfect sense.KevinI think it makes it just like, I don't know, 2000 people who work for the Fed, who are trying to figure out like answer that question extremely complicated. That's why rates are moving around and I'm just I got a little bit distracted because I'm looking at this chart, which is on the video version on on YouTube. For those of you watching or on do, you can become yeah, home listings are down 21% year over year look at so 2022 the red line this is when everyone's like see I told you so the world is going to end because listing listings started reappearing and then June, July they fell off and they I mean, the yellowKevinline for 2023 is just I mean, it's it's in the range, let's just say, of 2020 COVID lows, like April, May, number of new homes that hit the market was at an all time low for April May. But we've kind of been hanging around there all of 20, 23. It's just incredible, like the amount of pain on the used home side of the world for these folks who don't have the number of transactions is crazy.KevinAnd I am hearing again, we got to get an agent or a broker on the program to talk about this because I'm getting more emails and texts as well from builders who are like, what is going on with real estate agents? They are losing their their mind. Every deal is like a huge there. I mean, some of the words they use to describe the behavior, I don't know if I can say on air, but.AndrewYou need a little sensor.KevinBut they're like, please tell us that you have something happen at the summit in September talking about how to handle agents and what to do because it's just it's but I mean, you have to understand the pain that a lot of them are going through here. It's not it might be irrational behavior, but it's irrational behavior caused by irrational source, if that makes.JulieSense. That's why I just had a conversation with a builder that I'm like, Why? What did you do? Why are your walk ins so much higher? And it's somebody who they have never wanted to bother with realtors. They never needed realtors. They were just a pain in their side. And she was like, What? Honestly, we've been Dylan more with realtors and open to working with them now just because they need they need listings and we've got the listings.JulieSo we're like, okay, so what's kind of even changing how some people are open to working with realtor.AndrewRealtors.JulieI'm sure.AndrewPursuing.JulieIt's going to make things more crazy for them for sure.KevinYeah. Interesting. All right. I don't think there's anything else really that I want to talk about from the news. It's more like we know that stuff. Elon Musk is trying to win back advertisers with brand safety technology. I mean, I'm I don't even want to think.AndrewAbout it for. That's my thought. I'm then I have this for this this new or old news I don't know.KevinFirst of all the whole the whole thing, I mean, maybe it settles down and in some ways it has because thread thread who like, what's that thing? All the users that I and the community is alive and well they're most of the people I interact with are not have not gone away or stopped actually on. Okay but like advertisers are so fact I do want to read this I pulled up another thing that we can't share the link to because it's a subscription to Digiday plus they called me in to like a $200 subscription for the year because I really wanted to read get you again a point for like great content wins.KevinBut advertisers are so fickle and right now they're such pressure to perform that experimentation on a platform that's been there, done that, and not much has changed. It's like now we all tried. Remember, everyone was going to boycott Instagram and Facebook and never used them again and they were going to go on LinkedIn and Twitter and Pinterest and all these other places.KevinWell, guess what? They're back because they need things that actually deliver qualified people in revenue. So this article is here's what ad and media execs really mean when they commented on their queue to earnings. This is hilarious to me. So and so far so good. I'll try to use different voices just for entertainment value. So these are all things that that high level executives said on their earnings call.KevinThe is Doug Horn, the CFO at Gannett. For those of you who are born in the last 35 years, that's a newspaper company who tries to do digital media as well. But here's what he said. Despite secular headwinds, the decrease in print advertising revenue was limited to 8.9% year over marking the smallest decline observed in the past year.KevinAnd then here's what he actually meant. That quarter could have been a lot worse, except for the fact that our print advertising sucked less than expected. I think people are still dumb enough to buy print ads. Spence Newman, the CFO at Netflix, said. Our overall ad arm subscription plus ads continue to be higher than basic ad free globally, same as the statement on standard Bore.KevinHere's what he meant. Advertising is not a major moneymaker for Netflix, yet we made all of our money by just not letting people share subscriptions. I'm not even going to say what they actually said, just what they meant, because it's it's to me, it's just a really good insight into the chaos that is the traditional advertising world. Zaslav Warner Brothers CEO said.KevinWho needs a massive subscriber base When you can focus on a handful of loyal customers and make millions, am I right? So basically it's like we're not even going to try to grow the number of subscribers we have there. Just charge them a heck of a lot of money for not a lot of content, and it's working just fine.KevinMichael CAVANAUGH Comcast president. There are too many moving parts that would need to align for a deal of the magnitude to come together of being sold or swapping business units. See, I think there's one other one in here that was really interesting. Bob Bakish, CEO of Paramount Global, talking about the whole writers strike and labor dispute. Basically, whoever has the goal tends to make the rules and we've got the gold.KevinAnd they also by the way, it's been interesting just hearing all of the AI generative AI discussions around like, could you pick a worse time to have a strike over something that.AndrewSo yeah.KevinIt just is really interesting. So I mean, Mark Zuckerberg, this is pretty good. Rails plays exceeded 200 billion per day across Facebook and Instagram. We're seeing good progress on real monetization as well with the annual revenue run rate across our apps now exceeding $10 billion up from 3 billion last fall. What he actually meant is we're about to make a whole crap ton of money from short form videos.KevinVery soon.AndrewYeah.KevinBut like people in the print industry, I mean, even TV again, I've hinted at a couple of times, but connected TV advertising sounds awesome. And like Disney Plus right now is pivoting their last call. Iger just said, You know what? We don't want people like we're going to up the price of Disney Plus because we will make way more money.KevinIf we can sell ads, then if we make people pay what they're willing to pay for the platform. So their goal is actually to grow the ad supported subscriptions more than anything else. And if if they and others convince more people to do that and you can start affordably, that's the key. Affordably targeting households with TV advertising on streaming services, that would be great for right now.KevinIt's the only way that people like Disney can make money. They can sell the that because the concept of it is so good in an actual performance it it's not worth the expense being paid except for those people who are making money from the ads being being bought.AndrewYeah, I mean, essentially it is Go ahead.JulieDoes it it feel weird that we're like subscriptions? No more ads. And then the pendulum is swinging other way, right? It's like our kids aren't going to understand. No, no, we're just going back to cable. Like, we already had this, and then we didn't have this, and now we have this again. It's just the way things cycle through is interesting to me.KevinWell, I think it's a cat and mouse game of we as advertisers. We want this ability to target at the household level. What screen streaming accounts allow that cable accounts didn't I used to do cable TV advertising at Heartland and you could pick a zip code. That was it like you could you can say target all of the Time Warner or Comcast subscribers in the zip code.KevinThat was the most you could target. Now that you can target accounts and you know who those accounts are, and that data gets blended with other data sources, it's the right thing that advertisers want. Whether consumers will put up with it is another thing, because it's it's hard to go back to like we use YouTube TV. Big brother is out.KevinMy wife loves Big brother. That's usually I get her the subscription to like the all access thing for Big Brother for her birthday. We missed the first two episodes, so we have to go back and watch YouTube, TV records, everything. But you have to. If you don't put it in your own DVR tool, you have to watch it with ads.KevinAnd I kid you not like every ad break is 8/32 commercials and they ad and like double it's like punitive. It's like you missed it haha we got you.AndrewYou want it.KevinAnd it's just painful to watch that stuff.AndrewPainful. I mean, at the end of the day, it's revenue per user, right? Just like you look at Facebook when they deliver their quarterlies, you read the PDFs and you're like, okay, okay. Like, all right, a average U.S. user is worth $23.54 per quarter. So you're like, Oh, well, I'll just pay $15 a month. I have no ads on my Facebook for them.AndrewYou know, they're not making that choice to do that. But that's what it is. That's at least that's why I interpret it like, right, we could go this way or this way. Revenue per user and then revenue at the end. But then they get into like, well, we need longevity, we need retention of these users. We can have attrition and dying off.AndrewSo they have to factor in all those things. But a fun, fun analysis for billions of dollars and and revenue to do. And like, here's what I'm presenting shaking your hands like I'm nervous to tell this to someone.KevinBut okay favorites.AndrewOh man. Oh man.KevinYeah. Andrews. Andrews again filling in for Beth last second. Let's see I think.AndrewFavorite.KevinAnd you can skip if you need to.AndrewActually you.KevinGot everything.JulieI got one. So my son just turned 15. He's starting high school, so for his birthday, he wanted us to take him shopping at the backpacker, which is like a it's more expensive than we're like usually for school clothes we would do like Target and all Navy because it's very everybody knows that I'm thrifty like that, so it's more expensive.JulieBut they had the they got the coolest school backpacks there to him out of the loop but they're there have an insulated pocket in the front for their lunches. So you know, you're 15 at high school. You don't want to carry a lunch bell. You must have like, built into the cool little backpack. So watch me cringe. Like it.JulieYes. Made me cringe a little bit when we.AndrewYeah, these are up there. I'm looking at them.JulieWhat we paid for all his clothes there. But, you know, he's getting older. He wanted the the cooler clothes.AndrewYeah. Yeah.KevinI'll just I'm wondering, I think your favorite should be the kids are back in school.AndrewThat is. That is my favorite. Yeah, that's great. It's my favorite. That's that. You want to do it this year. But yeah, I started This will be our next so like two weeks ago they started I time this is out I think or a week ago, whatever it may be. But yeah, I'm excited for that. But the fun challenge though is record 330 Eastern day at home.AndrewLike right now I want at 4:00 but I want to start is when they get home. So I'm like mute, unmute, mute because I have to walk through the door, which is, you know, 15 feet that way with my door shut and all that stuff is fine. But yeah, that was fun shopping for them. We have three so that you have to but you went to the backpacker, which Looks like a super sweet spot to go to.JulieFor a few things not have.AndrewYou think about.JulieEverything.AndrewBut it's yeah, our kids are in uniforms which is great, but you still like they got to get the dry fit ones otherwise, like the collared shirts shrink and then so they don't last long time. But yeah, so it's expensive starting back up school but I'm glad they're gone. It's quite the power bill will definitely go down because Fortnite and the Ps5, the Xbox and desktop are not running upstairs all day.AndrewRight. I'll take that. Forgot about that.KevinBut I am. I'm late to the game here. I feel like food shown up in boxes has come and gone for most people. They're like, Yeah, I tried Blue Apron, all that stuff. This is factor 75. I don't know if you've heard of this, but their refrigerated meals, they're all fully, fully prepared.AndrewOkay.KevinAnd the quality of the meat in particular is incredible. Like it is. It's like going to Cardinals, which is the premier butcher here in town. If you're going to make ribs or steak for special occasion, you're going to craft onions. All the meat is really, really good. It's not I guess some people use it for like dieting or whatever, but there's four or five categories like keto or like low calorie vegetarian, vegan or whatever.KevinIt's all really good. There is a pork chop thing that my wife had because she did it first and I was like, What are we doing? This is dumb. And I tried it. I thought it was filet mignon covered with like a cheese sauce. It was some pork chop thing. And I was like, okay, I'm sold. They can make pork chop tastes like filet mignon.KevinI'm in. I don't I'm sure it's expensive. But here's the thing. Everyone's going to school for the first time. No more home schooling for the Oakley's. And that means there's not lunches that are going to be downstairs and I won't eat anything. Like, I'll just eat a a a protein bar for lunch.AndrewKevin.KevinAnd it's way better for my body if I just eat actual meal.AndrewIt does a good and it's, yeah, we do some meal meal prep like this as well. It's definitely worth it. It's still cheaper than going to cheaper as in, if I do leave the office, I go pick up Chick-Fil-A, then I wait in line and then I drive back and then I sit at it like there's 45 minutes right there.AndrewEven though chick flies 10 minutes and this is maybe a dollar two because.KevinIt's all refrigerated, there's really no prep time for every single one of these entrees is 2 minutes.AndrewYes. And it's real food. Like, it's not like the ingredients are like chicken.KevinIn the bath. It does take up a little bit of fridge space. But yeah, that's some surprisingly because this is not really my thing.AndrewSecond fridge, I'm thinking that's well. Oh, have you had their blueberry buttermilk pancakes or.KevinIt's not done any breakfast. It's just purely a lunch thing. So Melanie doesn't have to mess with extra groceries for lunch for either of us. We just. And the portion sizes. I'm not. I'm not hungry.AndrewWith a smoky bacon and cheddar egg bites. Four of them looks pretty good.KevinFor those of you who may not be familiar, Andrews to all of the sessions are food and clothes.AndrewShorts, shopping for short.KevinOr shopping for shirts.JulieSpecifically shorts.AndrewIt's hot. It's hot and miserable. Yeah. I'll just move to like, not unlike the cold either. I'm stuck here.KevinAll right, That'll do it for this week. Thanks again for tuning in and joining us every week. We've got some fantastic guest episodes coming out shortly, one including Julie, talking a little bit more in-depth about her book. For those of you who haven't order in yet, you get a little bit of a preview. So check that out. We'll see you next time. The post Ep 297: Less Is More appeared first on Online Sales and Marketing for Home Builders - DYC.
The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks.Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center, where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology's Cardiovascular Disease Prevention Leadership Council.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #32 Mr. Daniel Collins is a 58-year-old man with hypertension, chronic kidney disease (CKD), and obesity who presents to your clinic for a routine physical examination. Vitals are as follows: BP 143/79 mmHg, HR 89 bpm, O2 99% on room air, weight 106 kg, BMI 34.5 kg/m2. Recent laboratory testing revealed: creatinine 1.24 mg/dL, total cholesterol 203 mg/dL, HDL 39 mg/dL, LDL 112 mg/dL, TG 262 mg/dL. His current medications include lisinopril and rosuvastatin. You recommend increasing the dose of lisinopril to treat uncontrolled hypertension. What additional step(s) are indicated at this visit? A Order urine albumin-to-creatinine ratio B Ask the patient how often they have been bothered by trouble falling or staying asleep, or sleeping too much C Perform depression screening D All of the above Answer #32 Explanation The correct answer is D – all of the above.Answer A is correct. The ESC gives a Class I (LOE C) indication that all CKD patients, with or without diabetes, should undergo appropriate screening for ASCVD and kidney disease progression, including monitoring for changes in albuminuria. Cardiovascular disease is the leading cause of morbidity and death among patients with CKD. Even after adjusting for risk factors, including diabetes and hypertension, there is a linear increase in CV mortality with decreasing GFR below ~60-75 mm/min/1.73m2. Specific CKD-related risk factors include uremia-mediated inflammation, oxidative stress, and vascular calcification.Answer choice B is also correct. In patients with ASCVD, obesity, and hypertension, the ESC gives a Class I (LOE C) indication to regularly screen for non-restorative sleep by asking the question related to sleep quality as follows: “‘How often have you been bothered by trouble falling or staying asleep or sleeping too much?”. Additionally, if there are significant sleep problems that are not responding within four weeks to improving sleep hygiene, referral to a specialist is recommended (Class I, LOE C). However, despite the strong association of OSA with CVD, including hypertension, stroke, heart failure, CAD, and atrial fibrillation, treatment of OSA with CPAP has failed to improve hard CVD outcomes in patients with established CVD. Interventions that focus on risk factor modification, including reduction of obesity, alcohol intake, stress, and improvement of sleep hygiene, are important.Answer choice C is also correct. The ESC gives a Class I (LOE C) recommendation that mental health disorders with either significant functional impairment or decreased use of healthcare systems be considered as influencing total CVD risk. All mental disorders are associated with the development of CVD and reduced life expectancy. Additionally, the onset of CVD is associated with an approximately 2-3x increased risk of mental health disorders compared to a ...
Please Subscribe and Review: Apple Podcasts | RSS Submit your questions for the podcast here News Topic: Type 1 diabetes and low carbohydrate diets—Defining the degree of nutritional ketosis Show Notes: Association of Immune Thrombocytopenia and Celiac Disease in Children: A Retrospective Case Control Study Questions: Diet and Digestion Andrew writes: Hi Robb! I'm loving the podcast! Just started listening and got your information from the lady who started the Debug Your Health blog which goes over diet and parasite elimination. She recommended for diet just doing grass fed meat and veggies. I did that for a few days but had severe leg cramps and sleep disturbances. Also, I've been constipated for awhile now and just can't seem to find the right diet for addressing this issue. I will go to the bathroom once every three days and my gut just doesn't feel right whatsoever. Also, I have A- blood type so I should be having more frequent bowel movements but that is not the case. I am only 21 years old and want to live my life. My suspicion is that it may be related to parasites, heavy metals, and maybe nutritional deficiencies. Any suggestions on how to get rid of this constipation with diet, parasite cleansing, or even enemas? Keep up the great work and I am excited to hear your response! Immune thrombocytopenia ITP Allen writes: Hello, My wife has an immune system disorder called Immune thrombocytopenia ITP. It is triggered by pregnancy. Her platelet count drops, which means she is at greater risk for hemorrhaging. The underlying cause of ITP is unknown according to our doctors and what I've read. For her first pregnancy, the doctors prescribed two treatments to ameliorate the platelet count: prednisone and IVG (this is standard treatment AFAICT) but these treatments had minimal/no effect. As the disease is evidently related to immune system health, I wondered if there are any dietary or environmental things we might look at which could help. Any advice getting pointed in the right direction would be much appreciated. Thank you! eGFR results while on a high protein diet Richard writes: I went to the doctor for a full feeling in my throat that was affecting my voice. Nothing was found but some of the bloodwork results have me a little worried.Creatinine 1.3, Total bilirubin 2.1, GFR 60. Should I be concerned with high meat intake? I follow a ketovore diet that averages less than 20g of carbs per day. Protein falls between 150 and 250 per day. The day of the test I had about a pound of meat for breakfast 6:00AM and nothing else before the bloodwork at 2:00PM. The doctor didn't express any concern over the results but a GFR of 60 is kidney disease according to all the charts on the web. I'm going to get retested but I'm wondering if my diet makes these tests unreliable. How would you prepare for the second test to insure that the results are accurate? Sponsor: The Healthy Rebellion Radio is sponsored by our electrolyte company, LMNT. Proper hydration is more than just drinking water. You need electrolytes too! Check out The Healthy Rebellion Radio sponsor LMNT for grab-and-go electrolyte packets to keep you at your peak! They give you all the electrolytes want, none of the stuff you don't. Click here to get your LMNT electrolytes Transcript: Coming soon at Robbwolf.com
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