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Your website is not meant to please everyone! Delaney Walker, Jennifer Ellis, and Monet Reid from Extend Web Services talk about the biggest website mistakes PHOs make, why clarity and branding matter more than you think, and how to craft … Continue reading →
今回は、火星獅子座とともある春の土用を心地よく過ごすために役立ちそうなレメディを4つ（Nux-v., Lyc., Phos., Earth）ご紹介しました。▶︎関連note：火星と土用とわたしのリズム▶︎星読みモニターセッション募集▶︎HP/SNS/メルマガなど: https://lit.link/rajatonremedies▶︎人生を180度変えたMy story: https://rajatonblog.com/digital-contents#180My_Story42
Send us a textIn this episode of the Biblical Leadership at Work podcast, host Jason Woodard interviews Brandon West, the founder and Chief Purpose Officer of PHOS Creative. Brandon details his path from a university student pursuing classical studies to establishing a successful digital marketing agency. He discusses the trials he and his wife faced early on, including the loss of their mothers and raising a family while building a business. Emphasizing purpose-driven leadership, Brandon shares how integrating faith into the workplace has shaped his company culture and his own leadership style. He also reflects on the importance of intentionality, love, and faithfulness in leadership, and offers practical advice on balancing efficiency with empathy. Highlighting his own journey to faith and his spiritual practices, Brandon speaks on the transformative power of regular retreats and scripture reading. Additionally, Brandon shares insights from his book, 'It Is Not Your Business to Succeed,' which challenges leaders to measure success through faithfulness rather than outcomes.The Intentional Father book Support the showBe sure to rate and follow our podcast!
Danielle White interviews Jeremy Dys from First Liberty Institute about a recent legal victory involving a Miami pregnancy center that was vandalized following the Dobbs decision. While we have historically seen the FACE Act weaponized against the pro-life community, this … Continue reading →
In a world increasingly dominated by artificial environments, the importance of reconnecting with nature has never been more crucial. Xander Cadisch, head of the independent research arm Light Tribe of Phos, is on a mission to illuminate the science behind biophilic design and its profound impact on human behaviour. He explores the electromagnetic spectrum explaining how light is part of the electromagnetic radiation spectrum, which includes radio waves, microwaves, infrared, and ultraviolet. - As you move from red to violet in the visible light spectrum, the wavelength gets shorter and the frequency increases. He goes on to share WHY this is important to us when we design spaces. Xander explains how we emerged out of the sea and how our eyes still carry those salt water ducts which are reminders of where we evolved from. He goes on to explain the evolutionary journey that has hardwired our brains to respond to the natural rhythms of light and colour. "We've always had these intrinsic links to the rising and setting of the sun and all these different colour variations and intensities and wavelengths that the sun gives us at night, at daytime, and then removed at night." However, the modern human now spends a staggering 90% of their time indoors, deprived of this vital connection. "It's less than the legal requirement for maximum security prisoners," he says. This disconnect has profound consequences, as our eyes and brains are wired to thrive on the sensory experiences found in the natural world. "Light is one of the main guiding forces to the world around us," he says. "Potentially 80% of how we interact with the world around us comes from what we see." From the way certain wavelengths can influence our mood and productivity, to the importance of shadows and contrast in creating a sense of harmony, the science behind lighting design is complex and often overlooked. He cites the example of a study in Sacramento, where simply turning employees' desks to face a window tripled their productivity, with the business making an additional $3,000 per employee. The solution, he believes, lies in embracing the principles of biophilic design - not just adding plants, but carefully considering texture, colour, and the interplay of light and shadow. By reintroducing the "organized chaos" of nature into our built environments, he argues, we can unlock the full potential of our senses and improve our health, wellbeing, and productivity. It's a vision that could transform the way we design the spaces we inhabit, one wavelength at a time.www.phos.co.ukHave you got a copy of the Journal? You can now subscribe to the digital edition or purchase a copy directly from us at the journalofbiophilicdesign.com or Amazon. If you like our podcast and would like to support us in some way, you can buy us a coffee if you'd like to, thank you xDid you miss the Biophilic Design Conference? Did you know you can buy a catch up ticket here and watch anytime you like on demand? www.biophilicdesignconference.comCredits: with thanks to George Harvey Audio Production for the calming biophilic soundscape that backs all our podcasts. Did you know our podcast is also on Audible, Amazon Music, Spotify, iTunes, YouTube, Stitcher, vurbl, podbay, podtail, and most if not all the RSS feeds?Facebook https://www.facebook.com/journalofbiophilicdesign/Twitter https://twitter.com/JofBiophilicDsnLinkedIn. https://www.linkedin.com/company/journalofbiophilicdesign/Instagram https://www.instagram.com/journalofbiophilicdesign
Text Rudy Now!Episode Summary: In this episode, Steve and Wayne discuss the devastating fires affecting Steve's area and the impact on local communities. They also delve into the use of fire suppressors like Phos-Chek in combating these blazes.Key Topics:Introduction and Context of the FiresWayne welcomes listeners and sets the tone for the episode.Discussion about the fires in Steve's area and their widespread impact.Impact of the Fires on Local CommunitiesSteve shares firsthand experiences and highlights the efforts of first responders.Mention of the evacuation procedures and the safety of local businesses.Understanding Phos-Chek Fire SuppressorsExplanation of Phos-Chek, a fire retardant used to combat wildfires.Discussion on how Phos-Chek is dropped by helicopters and planes over forest fires2.The chemical composition of Phos-Chek, including ammonium phosphate, which helps suppress fires by creating a barrier that slows the spread of flames2.Challenges for Pool MaintenanceAddressing the impact of fires on swimming pools and the importance of maintaining pool safety.Tips for dealing with pool contamination and phosphate levels due to fire retardants.Best Practices for Pool ServiceRecommendations for pool service professionals in fire-affected areas.Legal and safety considerations when dealing with fire retardants like Phos-Chek.Additional Resources:Phos-Chek Fire Retardant InformationFire Safety and Pool Maintenance TipsClosing Remarks:Steve and Wayne thank listeners for tuning in and encourage everyone to stay safe.A reminder to support local first responders and communities affected by the fires. Support the showThank you so much for listening! You can find us on social media: Facebook Instagram Tik Tok Email us: talkingpools@gmail.com
Support document: https://drive.google.com/file/d/1PynJkQKgOws_57mTA-NE5BhH0c2gfs2U/view?usp=drive_link Find out more about Trinity Health Hub at https://trinityhealthhub.com/.
Check out our Website! https://singularagronomics.com Check out our full product line here! https://singularagronomics.com/products/ Are you interested in any of our line of products, or want to learn more? Follow the link below to find a dealer closest to you! https://singularagronomics.com/contact/ Check out our Quarterly Newsletter: https://singularagronomics.com/newsletter/ Blog: https://singularagronomics.com/blog/ Want to become a Distributor? Email Us: info@singularagros.com Check us out on Social Media! Instagram: https://www.instagram.com/singular_agronomics/ Facebook: https://www.facebook.com/profile.php?id=100093693453465
TODAY ON THE ROBERT SCOTT BELL SHOW: RFK Jr. Polio Truth , Lisa Rooney, Kali Phos, Ditch and Switch, Homeopathy foundations, Lac Felinum Remedy, Ty Bollinger, Censorship Lawsuit, Pine Tree Oil Benefits, Drone Disbelief, Hotez Fear Porn, Mirror Life Risks and MORE! https://robertscottbell.com/rfk-jr-polio-truth-lisa-rooney-kali-phos-ditch-and-switch-homeopathy-foundations-lac-felinum-remedy-ty-bollinger-censorship-lawsuit-pine-tree-oil-benefits-drone-disbelief-hotez-fear-porn/
'Land of the Lustrous' is a masterpiece that tells a complex and multifaceted story about what it means to be human. Ionatan and Ravi dive deep into the series, breaking down Haruko Ichikawa's work by discussing both the anime adaptation by Orange and the entirety of the manga, themes of change and existentialism accompanied by Buddhist philosophy, and the journey of an incredibly compelling protagonist in Phos.
Send Dr. Caroline a MessageDO YOU HAVE CRAMPS OR SCIATICA, ESPECIALLY RIGHT SIDED? YOU WILL LIKE TO HEAR WAHT MAG PHOS 6X TISSUE SALT CAN DO FOR YOU WHEN IN THIS TYPE OF PAIN. Standard Process Whole Food Supplements, Organically Grown in the United States. "Changing lives since 1929"Order directly from Standard Process here:carolinewalrad.standardprocess.com/products
Festivali AFEKT sümfooniakontserdil tuleb esiettekandele eesti helilooja Elis Halliku esimene sümfoonia "Phos".
A struggling GP practice was allegedly told by a Te Whatu Ora committee to set up a cafe inside their clinic to bring in extra cash. In September, General Practice New Zealand surveyed Primary health Organisations or PHOs, that deliver GP services; with about 76 percent of them responding. More than 60 percent of the PHO's have clinics in their network that are facing closures, 61 percent are reducing services, and 100 percent are restricting patient access in some way. Among the reasons given; financial pressure, GPs, retention and burnout issues. In the survey, one practice revealed Te Whatu Ora's fees review committee, which makes independent recommendations about increases to GP fees - suggested one medical centre set up a cafe within their practice to ease financial pressures. Andrew Swanson-Dobbs is CEO, of WellSouth and the PHO, for the clinic who got the cafe advice, he spoke to Lisa Owen.
Send Dr. Caroline a MessageHave you been exhausted and the smallest task seems like a huge task? Perhaps your memory is not at its best. Perhaps Kali Phos 6X tissue salt is your answer! Enjoy the entire series to date:#1 Calc Fluor 6Xhttps://www.buzzsprout.com/103155/15208369-tissue-salt-1-calc-fluor.mp3?download=true#2 Calc Phos 6Xhttps://www.buzzsprout.com/103155/15324941-tissue-salt-2-calc-phos.mp3?download=true#3 Calc Sulph 6Xhttps://www.buzzsprout.com/103155/15401079-tissue-salt-3-calc-sulph-6x.mp3?download=true#4 Ferrum Phos 6Xhttps://www.buzzsprout.com/103155/15464485-tissue-salt-4-ferrum-phos-6x.mp3?download=true#5 Kali Mur 6Xhttps://www.buzzsprout.com/103155/15659251-tissue-salt-5-kali-mur-6x.mp3?download=trueStandard Process Whole Food Supplements, Organically Grown in the United States. "Changing lives since 1929"Order directly from Standard Process here:carolinewalrad.standardprocess.com/products
Send us a Text Message.Brandon West - Chief Purpose Officer at PHOS Creative, Author and Speaker on Leadership and Company Culture - welcomes us into his faith journey and how it informs his life and work, including being raised in a Christian home (in name only); repenting to the bus driver; God giving fuel for the next season through relationships; protecting God's daughters; the beauty of the Christian version of imposter syndrome; adoring God in prayer; learning how to retreat; declaring for his company and for clients that they will be the light of the world; business as a ministry (BaaM); caring for their five key groups physically, emotionally and spiritually; what happens when a client's values are at odds with your company's values; explaining the Buffalo Culture and the three Ps of PHOS culture; repentance as chlorine; where Preach Where You Reach begins; explains the "Manhood Initiation Ceremony" and much more. https://brandonmichaelwest.com/https://phoscreative.com/Support the Show.
Send Dr. Caroline a MessageTISSUE SALT FERRUM PHOS 6X IS EXCELLENT FOR THE FIRST STAGES OF NOT FEELING WEEL AND A LOW GRADE FEVER. LEARN THE SYMPTOMS FOR USING IT AS THIS TISSUE SALT IS PART OF OUR NATURAL BODY. CATALYN GF (gluten free) IS STANDARD PROCESS' ALL PURPOSE organic VITAMIN FOR ALL YOUR TISSUE SALTS. LEARN ABOUT and monthly order CATALYN HERE: https://carolinewalrad.standardprocess.com/products?page=1&searchTerm=Catalyn%C2%AE&sortOrder=relevancStandard Process Whole Food Supplements, Organically Grown in the United States. "Changing lives since 1929"Order directly from Standard Process here:carolinewalrad.standardprocess.com/products
PROBLEMS WITH WEAKER BONES, GROWING PAINS, INDIGESTION, STIFF AND SORE JOINTS? PERHAPS A LITTLE TISSUE SALT CALLED, 'CALCAREA PHOSPHORICUM' OR 'CALC PHOS' for short, WILL HELP EASE YOUR SYMPTOMS.Order Standard Process Supplements: Cal Ma and Betaine Hydrochloride and Zypan here: https://www.carolinewalrad.standardprocess.com/productsStandard Process Whole Food Supplements, Organically Grown in the United States. "Changing lives since 1929"Order directly from Standard Process here:carolinewalrad.standardprocess.com/products
This episode explores the sexualisation of women in gaming— from characters to streamers— and the impact this culture has on the mental health and safety of women in the industry, featuring an interview with creator Phos. Let the Girls Game is a podcast mini-series powered by Let's Sing. Bring the karaoke experience to your living room with Let's Sing 2024, available now at all major retailers. Find Phos here: https://www.phos.live/ Find our podcast YouTube channel here: https://www.youtube.com/channel/UC18HclY7Tt5-1e3Z-MEP7Jg Subscribe to our weekly Substack: https://centennialworld.substack.com/ Join our Geneva home: https://links.geneva.com/invite/7eb23525-9259-4d59-95e3-b9edd35861a5 Follow us on Instagram: https://www.instagram.com/infinitescrollpodcast/ Follow Lauren on Instagram: https://www.instagram.com/laurenmeisner_/
Ruby & Space kick off pride this year with special guest Phos (a director of e-sports) as they discuss E-Sports in the Furry & LGBTQ+ community.If you would like to suggest a topic that you think should be discussed or would like to have a guest appear on our show, please email us at TalkToTheMuzzle@gmail.com.Join Our Telegram Group: https://t.me/StraightFromTheMuzzleFollow Us on Twitter: https://twitter.com/FromTheMuzzle
In this episode of Pophealth Week, we are honored to feature Cliff Frank, President of Healthcare Management Solutions. With over three decades of experience in the managed care sector, Cliff has worked across the spectrum, from payers and hospitals to IPAs, PHOs, and Clinically Integrated Networks (CINs). Our conversation delves into the current landscape of the managed care industry, focusing on the evolution of value-based healthcare and the potential implications of upcoming CMS risk adjustment updates for Medicare Advantage operators. Cliff's career has been dedicated to minimizing inefficiencies and enhancing the quality of patient care. He has consistently championed the cause of fostering clinical and financial harmony between providers and payers, contributing his expertise in diverse healthcare environments. Leading CINs in managing shared savings arrangements with payers and Medicare, Cliff also offers strategic consultation to organizations navigating managed care contracts, risk transfer preparation, and the creation of innovative provider-payer partnerships. Join us for an insightful exploration of managed care's future and strategies for achieving optimal healthcare delivery.
Hosts Fred Goldstein and Gregg Masters MPH meet Cliff Frank, President, Healthcare Management Solutions. Cliff has been involved in managed care programs for 30+ years working for payers, hospitals, IPAs, PHOs and Clinically Integrated Networks. They discuss the state of the managed care industry and it's latest iterations of value based healthcare including how recent and passed updates to CMS risk adjustments will likely impact on Medicare Advantage operators. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen
Each Holy Saturday, the Orthodox Patriarch of Jerusalem emerges from the tomb of Christ with the Holy Fire that goes out around the world. Jimmy Akin and Dom Bettinelli ask if the fire is lit by God or does it have a natural source and what we can learn about this historic rite. The post The Holy Fire? (Miracle, Jerusalem, Hagion Phos) – Jimmy Akin’s Mysterious World appeared first on StarQuest Media.
Each Holy Saturday, the Orthodox Patriarch of Jerusalem emerges from the tomb of Christ with the Holy Fire that goes out around the world. Jimmy Akin and Dom Bettinelli ask if the fire is lit by God or does it have a natural source and what we can learn about this historic rite.
Pregnancy center marketing has been under attack for decades, but recent legislation in some states has made more aggressive advances towards silencing the voices of those who want to provide women with alternatives to abortion. Jor-El Godsey, Tracie Shellhouse, Andrea … Continue reading →
INpowered Mind-INpowered Health - the keys to heart aligned living, with host Jayne Marquis
Have you ever wondered how simple mineral compounds can be the key to unlocking your body's natural healing abilities and enhancing your well-being? Join us in this episode of 'Meltdown to Mastery' as we explore the extraordinary world of cell salts, specifically Mag Phos and Kali Phos, and discover how they can empower you to recharge your energy, calm nervous tension, and enjoy a healthier, more vibrant life. Are you ready to embark on a journey to transform your health? Today, we'll shine a spotlight on two specific cell salts: Mag Phos and Kali Phos. These minerals are more than just supplements; they're your allies in the journey from meltdown to mastery. Mag Phos, often referred to as the star of cramp and muscle remedies, is derived from magnesium phosphate. It acts as the essential conductor between your muscles, brain, and nervous system. Whether you suffer from leg cramps, muscle tension, abdominal cramping, or the discomfort of menstrual cramps, Mag Phos can provide relief without the groggy side effects associated with many conventional remedies. But our exploration doesn't end there. We'll also uncover the remarkable potential of Kali Phos, known as the nerve nutrient cell salt. This mineral offers restorative relief for a range of issues, including stress, occasional sleeplessness, headaches, anxiety, and brain fog. If you've ever felt mentally fatigued or overwhelmed, Kali Phos can help your brain retain information, restore balance, and find calm in the midst of chaos. Join us as we unlock the secrets of Mag Phos and Kali Phos, your partners on the path to mastery. Tune in now and embark on a profound exploration of your own potential for better health and vitality. #JayneMarquis #MidLifeCrisis #Empowerment #Mindfulness #Manifestation#Subconscious #SubconsciousBeliefs #MindBody #mindbodysoul #Mindfulness#Success #Flow #Effortless #Abundance #Ease This link goes to most places Meltdown to Mastery is published, if you would like to find more episodes and engage from another platform. https://podcasters.spotify.com/pod/show/jayne-marquis This podcast is for information purposes only and represents the views and opinions of the speakers. The information presented is not meant to diagnose, treat, cure, or prevent disease. We recommend you seek the advice of a licensed healthcare practitioner before beginning any natural, complimentary, or conventional treatment.
Are you ready to explore the extraordinary journey of a purpose-driven entrepreneur? In this inspiring episode, join Elzie as he sits down with Brandon West, the Chief Purpose Officer and Founder of PHOS Creative, which is a remarkable marketing agency with a mission to restore dignity, purpose, and freedom to those impacted by extreme poverty and sex trafficking. Discover Brandon's unique insights on entrepreneurship, from building a successful business to intertwining profit with a profound mission. Explore the concept of the "care matrix" model, where revenue generation and meaningful impact converge at local and global levels. Dive into the essence of leadership, the importance of purpose, and making a difference both at work and at home.Whether you're an aspiring entrepreneur seeking a purposeful journey or an established leader aiming to create a positive impact, this episode holds valuable insights. Brandon's profound experience as a purpose-driven entrepreneur offers a blueprint for intertwining business success with transformative missions. Learn how to align your heart with your skills, discover your true purpose, and create a meaningful legacy through leadership when you tune in!Episode Highlights:03:57 - I have found that neither one of those are all that exciting for me. Neither one of those ideas of building an equity business to sell it out or a lifestyle business just so I can go play a bunch of golf, I hate golf. Top golf is like the best–I don't like fishing, like I love what I do. Neither one of those two perspectives on business have been enough to sustain me. We have built something exceptional and different at PHOS. It's a different type of business. It's not equity, It's not lifestyle. We call it business as a ministry. BAM. Business as a ministry. What if business wasn't just about equity and you living a lifestyle that you wanted to live? What if your business and your life and your leadership was actually about other people?10:52 - We had grown to such a size that I had delegated so much of my roles and responsibilities away. I was walking and going, "What do I do here again?" I had delegated so much away and people are like, "Oh, well done. A leader worth following. Delegation is such a great leadership quality." Until you're looking at it and you're just like, "I don't even know what I'm supposed to do when I wake up tomorrow morning." I went to my leadership team. I shared this with them, my executive team. I said, "Here's what I'm struggling with." And they were like, "We know exactly what you're supposed to do here, Brandon." I was like, "Well, please tell me." "You're supposed to guard our purpose." 15:19 - That's why leadership is hard. In the middle of all that, you're trying to figure out purpose. You're trying to figure out, how am I supposed to do? What am I called to? What an interesting blend of roles and responsibilities. For me, as I've tried to answer that question about purpose, one of the best tools I've seen for doing so, Andy Stanley, great leadership guy in my life, he says that purpose is found at the intersection of three things. What breaks your heart? Start there. You want to understand your purpose, then be willing to go on all. It took me years to answer that question.20:07 - I have more potential inside of me, and I choose not to pursue that because of the things that that potential for business or for leadership, or for influence or for growth, or for revenue, or for impact, or for ministry would threaten the things that are most acutely I'm called to in life. I would willingly lay aside potential for the sake of purpose, and people who God's called me to minister to. The life most wasted is not the one who wastes the most amount of potential but spends their potential on the things that they were never meant to spend it on.
Step into a transformative episode and prepare to be inspired by Brandon West as he talks about the powerful lessons and goals that drive his life and leadership. Discover Brandon's profound realization that leadership at home should be just as much of a passion project as his work. Explore the profound impact this perspective shift has had on his personal and professional life, emphasizing the importance of prioritizing family and creating a positive influence within his own household. Brandon shares that they are opening three care centers in Rosita, Nicaragua with the aim of serving 500 children annually. His commitment to this cause is a testament to his unwavering determination and desire to bring tangible change to communities in need. He is also off to Guatemala with Compassion International, where he will explore existing care centers and seek opportunities for further involvement. Get ready to be amazed by Brandon's goal of launching 30 care centers worldwide to support women and children affected by extreme poverty and sex trafficking. Learn about the passion that fuels this mission and the unwavering dedication to making a real difference in the lives of those who need it most. Tune in to gain insights into the incredible work being done on the ground and how individuals can make a meaningful impact on the lives of those in vulnerable situations.Episode Highlight:04:33 - I want my life to count for something and not just because I gave my money. We talk about at PHOS, the acronym, LIFE. You gave it to me. Didn't you give me this acronym, LIFE? I don't know. Maybe you did. LIFE, Labor, Influence, Finances, and Expertise. If you're to give away your LIFE, it's not just about you opening your wallet. Sometimes that's much easier for me. Sometimes it's easier for me to take out my wallet, write a check, and just say, "I've done my due diligence for the day." I'm supposed to give my labor, my influence, my finances, and my expertise away. As much as that's hard because it fights my selfishness, it's also so life-giving because it leans into my purpose.Connect with ElzieLinkedInConnect with Brandon WestLinkedInWebsiteMentioned in this episode:Podcast TownCheck out our services for your B2B brand! Grow With Podcast Town
On today's show, Craig Kelly Vindicated in his AEC case, ︎The Commissioner of the Australian Electoral Commission, Tom Rogers must apologise to Australian taxpayers for AEC abusing their powers & shredding the AEC's reputation and wasting taxpayers money by running such a frivolous & malicious prosecution over a font size. Later, Roland Crystal discusses why the voice yes vote is problematic for law enforcement. GUEST 1 OVERVIEW: Craig Kelly is United Australia Party National Director. Kelly initially entered politics as a member of the Liberal Party of Australia, and was elected to the Australian House of Representatives at the 2010 federal election, as a member of parliament (MP) for the division of Hughes. He resigned from the Liberal Party in February 2021 to sit on the crossbench as an independent politician, before announcing that he was joining the United Australia Party in August of that year, and was appointed as the party's leader. GUEST 2 OVERVIEW: Roland Chrystal joined the NSW Police Force as a fresh faced 19 year old in 1990 yet walked out unceremoniously in July 2021 after 31 years, well before the mandates, but unwilling to enforce PHOs and what he considered the destruction of human rights. He finally reluctantly resigned on 5th of October 2021 to stand with the public who are rightly in distress over the vaccine mandates, and the police enforcement of the Public Health Orders. There are many decent police, but they are effectively gagged. It is for that reason, along with the now coercion of those remaining to accept the vaccine, that I have chosen to resign and be able to honour my Oath to protect the public without fear or favour. Our cause must always be peaceful, based in love, empathy, wisdom and uncensored fact.
In this episode, Dr. Brian Nielsen, expert on bone physiology from Michigan State University, weighs in the use of Os Phos in young horses. In this wide ranging talk, we discuss many issues of young horse health, from building better bone and minds, to the importance of pain. We even get into the nitty gritty of bone biology and osteoporosis in women.
INpowered Mind-INpowered Health - the keys to heart aligned living, with host Jayne Marquis
Welcome to "Meltdown to Mastery," the podcast that empowers you to unlock your true potential. I'm your host, Jayne Marquis ND. In today's episode, we delve into the fascinating world of tissue salts, focusing on the incredible power of Ferrum Phos and how it can be combined with Calc Phos for a synergistic affect. Ferrum Phos offers a dynamic benefits, from 1. Boosting oxygen levels and combating fevers, colds and flus to 2.Addressing anemia and 3. reducing inflammation. Join me as we explore the healing powers of this tissue salt Ferrum Phos and unlock the secrets to vitality and well-being. I'm Jayne Marquis ND, your guide on this transformative journey. Get ready to harness the remarkable potential of Ferrum Phos as we embark on another episode of "Meltdown to Mastery." #JayneMarquis #MidLifeCrisis #Empowerment #Mindfulness #MindBody #mindbodysoul #Mindfulness #Success #Flow #Effortless #Abundance #Ease To dive deeper into these topics, don't forget to check out Jayne's INpowered Handbook, a comprehensive guide to the 12 cell or tissue salts and 17 homeopathic remedies. Start your journey towards self-empowerment and healing today! - https://inpoweredhealth.com/books/ https://inpoweredhealth.com/books/ For more Meltdown to Mastery episodes, linktree connects to my website, and many platforms where Meltdown to Mastery is published - - My Linktree: https://linktr.ee/INpoweredhealth https://inpoweredhealth.com/ This podcast is for information purposes only and represents the views and opinions of the speakers. The information presented is not meant to diagnose, treat, cure, or prevent disease. We recommend you seek the advice of a licensed healthcare practitioner before beginning any natural, complimentary, or conventional treatment.
INpowered Mind-INpowered Health - the keys to heart aligned living, with host Jayne Marquis
In this enlightening episode of "Meltdown to Mastery" with host Jayne Marquis ND, we uncover the remarkable healing properties of Calc Phos, also known as calcium phosphate. As the building block comprising 57 percent of our bones, Calc Phos not only provides solidity and strength but also offers a range of benefits for our overall well-being. Discover how Calc Phos acts as a restorative tonic, helping rebuild and strengthen bones, teeth, and organs while increasing vitality. Jayne Marquis ND explores its effectiveness in healing broken bones and fractures, providing much-needed relief and support for the recovery process. Join us as we delve into the role of Calc Phos in addressing growing pains in children, offering a natural remedy for discomfort and promoting healthy development. We'll also explore how Calc Phos aids in easing teething troubles, providing gentle relief for children during this milestone. Uncover the fascinating ability of Calc Phos to rebalance calcium deficits, making it an invaluable ally for children experiencing any kind of calcium deficiency during crucial stages of growth. Additionally, we'll delve into its potential in preventing and supporting the treatment of osteoporosis, offering hope for maintaining bone density and mitigating risks. Embark on this journey of understanding the remarkable power of Calc Phos, as Jayne Marquis ND reveals its potential to enhance well-being and promote strength from within. Tune in to "Meltdown to Mastery" and unlock the transformative benefits of this essential tissue salt. (Note: This episode of "Meltdown to Mastery" with host Jayne Marquis ND is for informational purposes only. Please consult a qualified healthcare professional for personalized advice and guidance.) #JayneMarquis #MidLifeCrisis #Empowerment #Mindfulness #Manifestation #Subconscious #SubconsciousBeliefs #MindBody #mindbodysoul #Mindfulness #Success #Flow #Effortless #Abundance #Ease To dive deeper into these topics, don't forget to check out Jayne's INpowered Handbook, a comprehensive guide to the 12 cell or tissue salts and 17 homeopathic remedies. Start your journey towards self-empowerment and healing today! - https://inpoweredhealth.com/books/ https://inpoweredhealth.com/books/ For more Meltdown to Mastery episodes, linktree connects to my website, and many platforms where Meltdown to Mastery is published - - My Linktree: https://linktr.ee/INpoweredhealth https://inpoweredhealth.com/ This podcast is for information purposes only and represents the views and opinions of the speakers. The information presented is not meant to diagnose, treat, cure, or prevent disease. We recommend you seek the advice of a licensed healthcare practitioner before beginning any natural, complimentary, or conventional treatment.
Today I go in depth on gray leaf spot, also looking at phos levels all across FL based on soil test data and end with a fascinating interview with Shawn Langton, founder of Kujo Yard Wear. https://www.kujo.com/
GUEST OVERVIEW: Roland Chrystal is a former NSW Police Officer. By mid 2021 it became apparent that the NSWPF had lost its way and no longer complied with its own Statement of Values, nor its Code of Conduct and Ethics in relation to the manner in which it coerced its own staff to be vaccinated even prior to mandate. He also objected to the ruthless manner in which the force sought to coerce compliance from the public through fear and over zealous enforcement of draconian PHOs. By refusing to partake in any such enforcement and due to being unable to voice his opposition publicly and try to provide an alternate view as a serving officer, he felt compelled to resign. Mr Chrystal has spoken publicly on numerous platforms as well as public rallies and community meetings about his perceptions of police actions and the direction of government policy relating to the so called pandemic.
ReferencesWe considered the complexity of the machinery to excrete ammonium in the context of research on dietary protein and how high protein intake may increase glomerular pressure and contribute to progressive renal disease (many refer to this as the “Brenner hypothesis”). Dietary protein intake and the progressive nature of kidney disease: the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal diseaseA trial that studied low protein and progression of CKD The Effects of Dietary Protein Restriction and Blood-Pressure Control on the Progression of Chronic Renal Disease(and famously provided data for the MDRD eGFR equation A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study GroupWe wondered about dietary recommendations in CKD. of note, this is best done in the DKD guidelines from KDIGO Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment.Joel mentioned this study on red meat and risk of ESKD. Red Meat Intake and Risk of ESRDWe referenced the notion of a plant-based diet. This is an excellent review by Deborah Clegg and Kathleen Hill Gallant. Plant-Based Diets in CKD : Clinical Journal of the American Society of NephrologyHere's the review that Josh mentioned on how the kidney appears to sense pH Molecular mechanisms of acid-base sensing by the kidneyRemarkably, Dr. Dale Dubin put a prize in his ECG book Free Car Prize Hidden in Textbook Read the fine print: Student wins T-birdA review of the role of the kidney in DKA: Diabetic ketoacidosis: Role of the kidney in the acid-base homeostasis re-evaluatedJosh mentioned the effects of infusing large amounts of bicarbonate The effect of prolonged administration of large doses of sodium bicarbonate in man and this study on the respiratory response to a bicarbonate infusion: The Acute Effects In Man Of A Rapid Intravenous Infusion Of Hypertonic Sodium Bicarbonate Solution. Ii. Changes In Respiration And Output Of Carbon DioxideThis is the study of acute respiratory alkalosis in dogs: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC293311/?page=1And this is the study of medical students who went to the High Alpine Research Station on the Jungfraujoch in the Swiss Alps https://www.nejm.org/doi/full/10.1056/nejm199105163242003Self explanatory! A group favorite! It Is Chloride Depletion Alkalosis, Not Contraction AlkalosisEffects of chloride and extracellular fluid volume on bicarbonate reabsorption along the nephron in metabolic alkalosis in the rat. Reassessment of the classical hypothesis of the pathogenesis of metabolic alkalosisA review of pendrin's role in volume homeostasis: The role of pendrin in blood pressure regulation | American Journal of Physiology-Renal PhysiologyInfusion of bicarbonate may lead to a decrease in respiratory stimulation but the shift of bicarbonate to the CSF may lag. Check out this review Neural Control of Breathing and CO2 Homeostasis and this classic paper Spinal-Fluid pH and Neurologic Symptoms in Systemic Acidosis.OutlineOutline: Chapter 11- Regulation of Acid-Base Balance- Introduction - Bicarb plus a proton in equilibrium with CO2 and water - Can be rearranged to HH - Importance of regulating pCO2 and HCO3 outside of this equation - Metabolism of carbs and fats results in the production of 15,000 mmol of CO2 per day - Metabolism of protein and other “substances” generates non-carbonic acids and bases - Mostly from sulfur containing methionine and cysteine - And cationic arginine and lysine - Hydrolysis of dietary phosphate that exists and H2PO4– - Source of base/alkali - Metabolism of an ionic amino acids - Glutamate and asparatate - Organic anions going through gluconeogenesis - Glutamate, Citrate and lactate - Net effect on a normal western diet 50-100 mEq of H+ per day - Homeostatic response to these acid-base loads has three stages: - Chemical buffering - Changes in ventilation - Changes in H+ excretion - Example of H2SO4 from oxidation of sulfur containing AA - Drop in bicarb will stimulate renal acid secretion - Nice table of normal cid-base values, arterial and venous- Great 6 bullet points of acid-base on page 328 - Kidneys must excrete 50-100 of non-carbonic acid daily - This occurs by H secretion, but mechanisms change by area of nephron - Not excreted as free H+ due to minimal urine pH being equivalent to 0.05 mmol/L - No H+ can be excreted until virtually all of th filtered bicarb is reabsorbed - Secreted H+ must bind buffers (phosphate, NH3, cr) - PH is main stimulus for H secretion, though K, aldo and volume can affect this.- Renal Hydrogen excretion - Critical to understand that loss of bicarb is like addition of hydrogen to the body - So all bicarb must be reabsorbed before dietary H load can be secreted - GFR of 125 and bicarb of 24 results in 4300 mEq of bicarb to be reabsorbed daily - Reabsorption of bicarb and secretion of H involve H secretion from tubular cells into the lumen. - Thee initial points need to be emphasized - Secreted H+ ion are generated from dissociation of H2O - Also creates OH ion - Which combine with CO2 to form HCO3 with the help of zinc containing intracellular carbonic anhydrase. - This is how the secretion of H+ which creates an OH ultimately produces HCO3 - Different mechanisms for proximal and distal acidification - NET ACID EXCRETION - Free H+ is negligible - So net H+ is TA + NH4 – HCO3 loss - Unusually equal to net H+ load, 50-100 mEq/day - Can bump up to 300 mEq/day if acid production is increased - Net acid excretion can go negative following a bicarb or citrate load - Proximal Acidification - Na-H antiporter (or exchanger) in luminal membrane - Basolateral membrane has a 3 HCO3 Na cotransporter - This is electrogenic with 3 anions going out and only one cation - The Na-H antiporter also works in the thick ascending limb of LOH - How about this, there is also a H-ATPase just like found in the intercalated cells in the proximal tubule and is responsible for about a third of H secretion - And similarly there is also. HCO3 Cl exchanger (pendrin-like) in the proximal tubule - Footnote says the Na- 3HCO3 cotransporter (which moves sodium against chemical gradient NS uses negative charge inside cell to power it) is important for sensing acid-base changes in the cell. - Distal acidification - Occurs in intercalated cells of of cortical and medullary collecting tubule - Three main characteristics - H secretion via active secretory pumps in the luminal membrane - Both H-ATPase and H-K ATPase - H- K ATPase is an exchange pump, k reabsorption - H-K exchange may be more important in hypokalemia rather than in acid-base balance - Whole paragraph on how a Na-H exchanger couldn't work because the gradient that H has to be pumped up is too big. - H-ATPase work like vasopressin with premise H-ATPase sitting on endocarditis vesicles a=which are then inserted into the membrane. Alkalosis causes them to be recycled out of the membrane. - H secretory cells do not transport Na since they have few luminal Na channels, but are assisted by the lumen negative tubule from eNaC. - Minimizes back diffusion of H+ and promotes bicarb resorption - Bicarbonate leaves the cell through HCO3-Cl exchanger which uses the low intracellular Cl concentration to power this process. - Same molecule is found on RBC where it is called band 3 protein - Figure 11-5 is interesting - Bicarbonate resorption - 90% in the first 1-22 mm of the proximal tubule (how long is the proximal tubule?) - Lots of Na-H exchangers and I handed permeability to HCO3 (permeability where?) - Last 10% happens distally mostly TAL LOH via Na-H exchange - And the last little bit int he outer medullary collecting duct. - Carbonic anhydrase and disequilibrium pH - CA plays central role in HCO3 reabsorption - After H is secreted in the proximal tubule it combines with HCO# to form carbonic acid. CA then dehydrates it to CO2 and H2O. (Step 2) - Constantly moving carbonic acid to CO2 and H2O keeps hydrogen combining with HCO3 since the product is rapidly consumed. - This can be demonstrated by the minimal fall in luminal pH - That is important so there is not a luminal gradient for H to overcome in the Na-H exchanger (this is why we need a H-ATPase later) - CA inhibitors that are limited tot he extracellular compartment can impair HCO3 reabsorption by 80%. - CA is found in S1, S2 but not S3 segment. See consequence in figure 11-6. - The disequilibrium comes from areas where there is no CA, the HH formula falls down because one of the assumptions of that formula is that H2CO3 (carbonic acid) is a transient actor, but without CA it is not and can accumulate, so the pKa is not 6.1. - Bicarbonate secretion - Type B intercalated cells - H-ATPase polarity reversed - HCO3 Cl exchanger faces the apical rather than basolateral membrane- Titratable acidity - Weak acids are filtered at the glom and act as buffers in the urine. - HPO4 has PKA of 6.8 making it ideal - Creatinine (pKa 4.97) and uric acid (pKa 5.75) also contribute - Under normal cinditions TA buffers 10-40 mEa of H per day - Does an example of HPO4(2-):H2PO4 (1-) which exists 4:1 at pH of 7.4 (glomerular filtrate) - So for 50 mEq of Phos 40 is HPO4 and 10 is H2PO4 - When pH drops to 6.8 then the ratio is 1:1 so for 50 - So the 50 mEq is 25 and 25, so this buffered an additional 15 mEq of H while the free H+ concentration increased from 40 to 160 nanomol/L so over 99.99% of secreted H was buffered - When pH drops to 4.8 ratio is 1:100 so almost all 50 mEq of phos is H2PO4 and 39.5 mEq of H are buffered. - Acid loading decreases phosphate reabsorption so more is there to act as TA. - Decreases activity of Na-phosphate cotransporter - DKA provides a novel weak acid/buffer beta-hydroxybutyrate (pKa 4.8) which buffers significant amount of acid (50 mEq/d).- Ammonium Excretion - Ability to excrete H+ as ammonium ions adds an important amount of flexibility to renal acid-base regulation - NH3 and NH4 production and excretion can be varied according to physiologic need. - Starts with NH3 production in tubular cells - NH3, since it is neutral then diffuses into the tubule where it is acidified by the low pH to NH4+ - NH4+ is ionized and cannot cross back into the tubule cells(it is trapped in the tubular fluid) - This is important for it acting as an important buffer eve though the pKa is 9.0 - At pH of 6.0 the ratio of NH3 to NH4 is 1:1000 - As the neutral NH3 is converted to NH4 more NH3 from theintracellular compartment flows into the tubular fluid replacing the lost NH3. Rinse wash repeat. - This is an over simplification and that there are threemajor steps - NH4 is produced in early proximal tubular cells - Luminal NH4 is partially reabsorbed in the TAL and theNH3 is then recycled within the renal medulla - The medullary interstitial NH3 reaches highconcentrations that allow NH3 to diffuse into the tubular lumen in the medullary collecting tubule where it is trapped as NH4 by secreted H+ - NH4 production from Glutamine which converts to NH4 and glutamate - Glutamate is converted to alpha-ketoglutarate - Alpha ketoglutarate is converted to 2 HCO3 ions - HCO3 sent to systemic circulation by Na-3 HCO3 transporter - NH4 then secreted via Na-H exchanger into the lumen - NH4 is then reabsorbed by NaK2Cl transporter in TAL - NH4 substitutes for K - Once reabsorbed the higher intracellular pH causes NH4 to convert to NH3 and the H that is removed is secreted through Na-H exchanger to scavenge the last of the filtered bicarb. - NH3 diffuses out of the tubular cells into the interstitium - NH4 reabsorption in the TAL is suppressed by hyperkalemia and stimulated by chronic metabolic acidosis - NH4 recycling promotes acid clearance - The collecting tubule has a very low NH3 concentration - This promotes diffusion of NH3 into the collecting duct - NH3 that goes there is rapidly converted to NH4 allowing more NH3 to diffuse in. - Response to changes in pH - Increased ammonium excretion with two processes - Increased proximal NH4 production - This is delayed 24 hours to 2-3 days depending on which enzyme you look at - Decreased urine pH increases diffusion of ammonia into the MCD - Occurs with in hours of an acid load - Peak ammonium excretion takes 5-6 days! (Fig 11-10) - Glutamine is picked up from tubular fluid but with acidosis get Na dependent peritublar capillary glutamine scavenging too - Glutamine metabolism is pH dependent with increase with academia and decrease with alkalemia - NH4 excretion can go from 30-40 mEq/day to > 300 with severe metabolic acidosis (38 NaBicarb tabs) - Says each NH4 produces equimolar generation of HCO3 but I thought it was two bicarb for every alpha ketoglutarate?- The importance of urine pH - Though the total amount of hydrogren cleared by urine pH is insignificant, an acidic urine pH is essential for driving the reactions of TA and NH4 forward.- Regulation of renal hydrogen excretion - Net acid excretion vary inverse with extracellular pH - Academia triggers proximal and distal acidification - Proximally this: - Increased Na-H exchange - Increased luminal H-ATPase activity - Increased Na:3HCO3 cotransporter on the basolateral membrane - Increased NH4 production from glutamine - In the collecting tubules - Increased H-ATPase - Reduction of tubular pH promotes diffusion of NH3 which gets converted to NH4…ION TRAPPING - Extracellular pH affects net acid excretion through its affect on intracellular pH - This happens directly with respiratory disorders due to movement of CO2 through the lipid bilayer - In metabolic disorders a low extracellular bicarb with cause bicarb to diffuse out of the cell passively, this lowers intracellular pH - If you manipulate both low pCO2 and low Bicarb to keep pH stable there will be no change in the intracellular pH and there is no change in renal handling of acid. It is intracellular pH dependent - Metabolic acidosis - Ramps up net acid secretion - Starts within 24 hours and peaks after 5-6 days - Increase net secretion comes from NH4 - Phosphate is generally limited by diet - in DKA titratable acid can be ramped up - Metabolic alkalosis - Alkaline extracellular pH - Increased bicarb excretion - Decrease reabsorption - HCO3 secretion (pendrin) in cortical collecting tubule - Occurs in cortical intercalated cells able to insert H-ATPase in basolateral cells (rather than luminal membrane) - Normal subjects are able to secrete 1000 mmol/day of bicarb - Maintenance of metabolic alkalosis requires a defect which forces the renal resorption of bicarb - This can be chloride/volume deficiency - Hypokalemia - Hyperaldosteronism - Respiratory acidosis and alkalosis - PCO2 via its effect on intracellular pH is an important determinant of renal acid handling - Ratios he uses: - 3.5 per 10 for respiratory acidosis - 5 per 10 for respiratory alkalosis - Interesting paragraph contrasting the response to chronic metabolic acidosis vs chronic respiratory acidosis - Less urinary ammonium in respiratory acidosis - Major differences in proximal tubule cell pH - In metabolic acidosis there is decreased bicarb load so less to be reabsorbed proximally - In respiratory acidosis the increased serum bicarb increases the amount of bicarb that must be reabsorbed proximally - The increased activity of Na-H antiporter returns tubular cell pH to normal and prevents it from creating increased urinary ammonium - Mentions that weirdly more mRNA for H-Na antiporter in metabolic acidosis than in respiratory acidosis - Net hydrogen excretion varies with effective circulating volume - Starts with bicarb infusions - Normally Tm at 26 - But if you volume deplete the patient with diuretics first this increases to 35+ - Four factors explain this increased Tm for bicarb with volume deficiency - Reduced GFR - Activation of RAAS - Ang2 stim H-Na antiporter proximally - Ang2 also stimulates Na-3HCO3 cotransporter on basolateral membrane - Aldosterone stimulates H-ATPase in distal nephron - ALdo stimulates Cl HCO3 exchanger on basolateral membrane - Aldo stimulates eNaC producing tubular lumen negative charge to allow H secretion to occur and prevents back diffusion - Hypochloremia - Increases H secretion by both Na-dependent and Na-independent methods - If Na is 140 and Cl is 115, only 115 of Na can be reabsorbed as NaCl, the remainder must be reabsorbed with HCO3 or associated with secretion of K or H to maintained electro neutrality - This is enhanced with hypochloridemia - Concurrent hypokalemia - Changes in K lead to trans cellular shifts that affect inctracellular pH - Hypokalemia causes K out, H in and in the tubular cell the cell acts if there is systemic acidosis and increases H secretion (and bicarbonate resorption) - PTH - Decreases proximal HCO3 resorption - Primary HyperCard as cause of type 2 RTA - Does acidosis stim PTH or does PTH stim net acid excretion
My guest this week has a very intense musical background, with proficiency in four different instruments: piano, saxophone, oboe, and double base. He currently performs to this day and makes a concerted effort to have a very strong presence in what he calls the four F's of life: family, fitness, fintech, and flavor! Phos CEO Brad Hyett has a passion for trying new things, going new places, meeting new people, saying yes to things outside of his comfort zone and doing it all with a fintech spin in company socks!For those of you who may not know, Phos is a softPOS technology platform enabling contactless payments onto mobile devices with no requirement for exclusive payments specific hardware. They offer a softPOS payments orchestration platform to complement the pain points typically associated with going to market through softPOS solutions and they target their main verticals (mobility, charity, and retail) with commercial-off-the-shelf (COTS) devices that are not specifically certified for EMV usage. How do they make it work? They replicate an EMV level certification in the cloud to enable these products to offer integrated an optimized contactless options.As for their competitive advantage, Brad will be the first to say that they offer a customizable solution that enables them to meet their customers where they are and take them where they want to go, in a way that offers much more flexibility and potential than their current competition.Tune in this week to hear Brad talk about his journey to CEO, including a “predestined alignment of the stars” that enabled his wife to replace him at his previous company, prior to his tenure with Phos. We also talk about the evolution of contactless within our global ecosystem, as well as the upcoming M&A spree Brad expects within the industry over the next several years.
On this episode, Brandon West shares how his company operationalizes business as a ministry throughout their organization. Brandon West founded PHOS Creative at the age of 26 out of his home office. A strategy-first digital marketing agency headquartered in Florida, PHOS' growth and culture have been highlighted in the Inc. 5000, Gator100, and Florida Trend Magazine. PHOS' driving passion is to fulfill its mission: to be a company that team members never want to leave, clients can't do without, and the world is better for and, in so doing, exemplify the love of Jesus Christ. https://phoscreative.com/ https://open.spotify.com/show/3Mp3mqkhhpYDSEFnFVeQ0z?si=76703b8cb6a64e9b&nd=1 Christianity in Business is the show that helps Christian business leaders to integrate biblical values into business. | Entrepreneurship | Marketing | Nonprofit | Church | Author | Startups | Marketplace | Ministry | Business as Mission | Faith and Work | Faith | Success | Leadership | www.ChristianityInBusiness.com
On this episode, Brandon West shares how his company operationalizes business as a ministry throughout their organization. Brandon West founded PHOS Creative at the age of 26 out of his home office. A strategy-first digital marketing agency headquartered in Florida, PHOS' growth and culture have been highlighted in the Inc. 5000, Gator100, and Florida Trend Magazine. PHOS' driving passion is to fulfill its mission: to be a company that team members never want to leave, clients can't do without, and the world is better for and, in so doing, exemplify the love of Jesus Christ. https://phoscreative.com/ https://open.spotify.com/show/3Mp3mqkhhpYDSEFnFVeQ0z?si=76703b8cb6a64e9b&nd=1 Christianity in Business is the show that helps Christian business leaders to integrate biblical values into business. | Entrepreneurship | Marketing | Nonprofit | Church | Author | Startups | Marketplace | Ministry | Business as Mission | Faith and Work | Faith | Success | Leadership | www.ChristianityInBusiness.com
Host Jacob Hollabaugh is joined by the CEO of phos, Brad Hyett to discuss the growing demand for contactless retail payments that don't require additional hardware, how technologies like phos address the security concerns inherent in such transactions for both merchant and consumer, and how the ability to turn any smart phone into a contactless mobile POS is changing the landscape of retail business in both the first and third world. Check out the show notes here: https://www.soarpay.com/2023/03/phos
ReferencesWe considered the effect of a high protein diet and potential metabolic acidosis on kidney function. This review is of interest by Donald Wesson, a champion for addressing this issue and limiting animal protein: Mechanisms of Metabolic Acidosis-Induced Kidney Injury in Chronic Kidney DiseaseHostetter explored the effect of a high protein diet in the remnant kidney model with 1 ¾ nephrectomy. Rats with reduced dietary acid load (by bicarbonate supplementation) had less tubular damage. Chronic effects of dietary protein in the rat with intact and reduced renal massWesson explored treatment of metabolic acidosis in humans with stage 3 CKD in this study. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rateIn addition to the effect of metabolic acidosis from a diet high in animal protein, this diet also leads to hyperfiltration. This was demonstrated in normal subjects; ingesting a protein diet had a significantly higher creatinine clearance than a comparable group of normal subjects ingesting a vegetarian diet. Renal functional reserve in humans: Effect of protein intake on glomerular filtration rate.This finding has been implicated in Brenner's theory regarding hyperfiltration: The hyperfiltration theory: a paradigm shift in nephrologyOne of multiple publications from Dr. Nimrat Goraya whom Joel mentioned in the voice over: Dietary Protein as Kidney Protection: Quality or Quantity?We wondered about the time course in buffering a high protein meal (and its subsequent acid load on ventilation) and Amy found this report:Effect of Protein Intake on Ventilatory Drive | Anesthesiology | American Society of Anesthesiologists Roger mentioned that the need for acetate to balance the acid from amino acids in parenteral nutrition was identified in pediatrics perhaps because infants may have reduced ability to generate acid. Randomised controlled trial of acetate in preterm neonates receiving parenteral nutrition - PMCHe also recommended an excellent review on the complications of parenteral nutrition by Knochel https://www.kidney-international.org/action/showPdf?pii=S0085-2538%2815%2933384-6 which explained that when the infused amino acids disproportionately include cationic amino acids, metabolism led to H+ production. This is typically mitigated by preparing a solution that is balanced by acetate. Amy mentioned this study that explored the effect of protein intake on ventilation: Effect of Protein Intake on Ventilatory Drive | Anesthesiology | American Society of AnesthesiologistsAnna and Amy reminisced about a Skeleton Key Group Case from the renal fellow network Skeleton Key Group: Electrolyte Case #7JC wondered about isolated defects in the proximal tubule and an example is found here: Mutations in SLC4A4 cause permanent isolated proximal renal tubular acidosis with ocular abnormalitiesAnna's Voiceover re: Gastric neobladder → metabolic alkalosis and yes, dysuria. The physiology of gastrocystoplasty: once a stomach, always a stomach but not as common as you might think Gastrocystoplasty: long-term complications in 22 patientsSjögren's syndrome has been associated with acquired distal RTA and in some cases, an absence of the H+ ATPase, presumably from autoantibodies to this transporter. Here's a case report: Absence of H(+)-ATPase in cortical collecting tubules of a patient with Sjogren's syndrome and distal renal tubular acidosisCan't get enough disequilibrium pH? Check this out- Spontaneous luminal disequilibrium pH in S3 proximal tubules. Role in ammonia and bicarbonate transport.Acetazolamide secretion was studied in this report Concentration-dependent tubular secretion of acetazolamide and its inhibition by salicylic acid in the isolated perfused rat kidney. | Drug Metabolism & DispositionIn this excellent review, David Goldfarb tackles the challenging case of a A Woman with Recurrent Calcium Phosphate Kidney Stones (spoiler alert, many of these patients have incomplete distal RTA and this problem is hard to treat). Molecular mechanisms of renal ammonia transport excellent review from David Winer and Lee Hamm. OutlineOutline: Chapter 11- Regulation of Acid-Base Balance- Introduction - Bicarb plus a proton in equilibrium with CO2 and water - Can be rearranged to HH - Importance of regulating pCO2 and HCO3 outside of this equation - Metabolism of carbs and fats results in the production of 15,000 mmol of CO2 per day - Metabolism of protein and other “substances” generates non-carbonic acids and bases - Mostly from sulfur containing methionine and cysteine - And cationic arginine and lysine - Hydrolysis of dietary phosphate that exists and H2PO4– - Source of base/alkali - Metabolism of an ionic amino acids - Glutamate and asparatate - Organic anions going through gluconeogenesis - Glutamate, Citrate and lactate - Net effect on a normal western diet 50-100 mEq of H+ per day - Homeostatic response to these acid-base loads has three stages: - Chemical buffering - Changes in ventilation - Changes in H+ excretion - Example of H2SO4 from oxidation of sulfur containing AA - Drop in bicarb will stimulate renal acid secretion - Nice table of normal cid-base values, arterial and venous- Great 6 bullet points of acid-base on page 328 - Kidneys must excrete 50-100 of non-carbonic acid daily - This occurs by H secretion, but mechanisms change by area of nephron - Not excreted as free H+ due to minimal urine pH being equivalent to 0.05 mmol/L - No H+ can be excreted until virtually all of th filtered bicarb is reabsorbed - Secreted H+ must bind buffers (phosphate, NH3, cr) - PH is main stimulus for H secretion, though K, aldo and volume can affect this.- Renal Hydrogen excretion - Critical to understand that loss of bicarb is like addition of hydrogen to the body - So all bicarb must be reabsorbed before dietary H load can be secreted - GFR of 125 and bicarb of 24 results in 4300 mEq of bicarb to be reabsorbed daily - Reabsorption of bicarb and secretion of H involve H secretion from tubular cells into the lumen. - Thee initial points need to be emphasized - Secreted H+ ion are generated from dissociation of H2O - Also creates OH ion - Which combine with CO2 to form HCO3 with the help of zinc containing intracellular carbonic anhydrase. - This is how the secretion of H+ which creates an OH ultimately produces HCO3 - Different mechanisms for proximal and distal acidification - NET ACID EXCRETION - Free H+ is negligible - So net H+ is TA + NH4 – HCO3 loss - Unusually equal to net H+ load, 50-100 mEq/day - Can bump up to 300 mEq/day if acid production is increased - Net acid excretion can go negative following a bicarb or citrate load - Proximal Acidification - Na-H antiporter (or exchanger) in luminal membrane - Basolateral membrane has a 3 HCO3 Na cotransporter - This is electrogenic with 3 anions going out and only one cation - The Na-H antiporter also works in the thick ascending limb of LOH - How about this, there is also a H-ATPase just like found in the intercalated cells in the proximal tubule and is responsible for about a third of H secretion - And similarly there is also. HCO3 Cl exchanger (pendrin-like) in the proximal tubule - Footnote says the Na- 3HCO3 cotransporter (which moves sodium against chemical gradient NS uses negative charge inside cell to power it) is important for sensing acid-base changes in the cell. - Distal acidification - Occurs in intercalated cells of of cortical and medullary collecting tubule - Three main characteristics - H secretion via active secretory pumps in the luminal membrane - Both H-ATPase and H-K ATPase - H- K ATPase is an exchange pump, k reabsorption - H-K exchange may be more important in hypokalemia rather than in acid-base balance - Whole paragraph on how a Na-H exchanger couldn't work because the gradient that H has to be pumped up is too big. - H-ATPase work like vasopressin with premise H-ATPase sitting on endocarditis vesicles a=which are then inserted into the membrane. Alkalosis causes them to be recycled out of the membrane. - H secretory cells do not transport Na since they have few luminal Na channels, but are assisted by the lumen negative tubule from eNaC. - Minimizes back diffusion of H+ and promotes bicarb resorption - Bicarbonate leaves the cell through HCO3-Cl exchanger which uses the low intracellular Cl concentration to power this process. - Same molecule is found on RBC where it is called band 3 protein - Figure 11-5 is interesting - Bicarbonate resorption - 90% in the first 1-22 mm of the proximal tubule (how long is the proximal tubule?) - Lots of Na-H exchangers and I handed permeability to HCO3 (permeability where?) - Last 10% happens distally mostly TAL LOH via Na-H exchange - And the last little bit int he outer medullary collecting duct. - Carbonic anhydrase and disequilibrium pH - CA plays central role in HCO3 reabsorption - After H is secreted in the proximal tubule it combines with HCO# to form carbonic acid. CA then dehydrates it to CO2 and H2O. (Step 2) - Constantly moving carbonic acid to CO2 and H2O keeps hydrogen combining with HCO3 since the product is rapidly consumed. - This can be demonstrated by the minimal fall in luminal pH - That is important so there is not a luminal gradient for H to overcome in the Na-H exchanger (this is why we need a H-ATPase later) - CA inhibitors that are limited tot he extracellular compartment can impair HCO3 reabsorption by 80%. - CA is found in S1, S2 but not S3 segment. See consequence in figure 11-6. - The disequilibrium comes from areas where there is no CA, the HH formula falls down because one of the assumptions of that formula is that H2CO3 (carbonic acid) is a transient actor, but without CA it is not and can accumulate, so the pKa is not 6.1. - Bicarbonate secretion - Type B intercalated cells - H-ATPase polarity reversed - HCO3 Cl exchanger faces the apical rather than basolateral membrane- Titratable acidity - Weak acids are filtered at the glom and act as buffers in the urine. - HPO4 has PKA of 6.8 making it ideal - Creatinine (pKa 4.97) and uric acid (pKa 5.75) also contribute - Under normal cinditions TA buffers 10-40 mEa of H per day - Does an example of HPO4(2-):H2PO4 (1-) which exists 4:1 at pH of 7.4 (glomerular filtrate) - So for 50 mEq of Phos 40 is HPO4 and 10 is H2PO4 - When pH drops to 6.8 then the ratio is 1:1 so for 50 - So the 50 mEq is 25 and 25, so this buffered an additional 15 mEq of H while the free H+ concentration increased from 40 to 160 nanomol/L so over 99.99% of secreted H was buffered - When pH drops to 4.8 ratio is 1:100 so almost all 50 mEq of phos is H2PO4 and 39.5 mEq of H are buffered. - Acid loading decreases phosphate reabsorption so more is there to act as TA. - Decreases activity of Na-phosphate cotransporter - DKA provides a novel weak acid/buffer beta-hydroxybutyrate (pKa 4.8) which buffers significant amount of acid (50 mEq/d).- Ammonium Excretion - Ability to excrete H+ as ammonium ions adds an important amount of flexibility to renal acid-base regulation - NH3 and NH4 production and excretion can be varied according to physiologic need. - Starts with NH3 production in tubular cells - NH3, since it is neutral then diffuses into the tubule where it is acidified by the low pH to NH4+ - NH4+ is ionized and cannot cross back into the tubule cells(it is trapped in the tubular fluid) - This is important for it acting as an important buffer eve though the pKa is 9.0 - At pH of 6.0 the ratio of NH3 to NH4 is 1:1000 - As the neutral NH3 is converted to NH4 more NH3 from theintracellular compartment flows into the tubular fluid replacing the lost NH3. Rinse wash repeat. - This is an over simplification and that there are threemajor steps - NH4 is produced in early proximal tubular cells - Luminal NH4 is partially reabsorbed in the TAL and theNH3 is then recycled within the renal medulla - The medullary interstitial NH3 reaches highconcentrations that allow NH3 to diffuse into the tubular lumen in the medullary collecting tubule where it is trapped as NH4 by secreted H+ - NH4 production from Glutamine which converts to NH4 and glutamate - Glutamate is converted to alpha-ketoglutarate - Alpha ketoglutarate is converted to 2 HCO3 ions - HCO3 sent to systemic circulation by Na-3 HCO3 transporter - NH4 then secreted via Na-H exchanger into the lumen - NH4 is then reabsorbed by NaK2Cl transporter in TAL - NH4 substitutes for K - Once reabsorbed the higher intracellular pH causes NH4 to convert to NH3 and the H that is removed is secreted through Na-H exchanger to scavenge the last of the filtered bicarb. - NH3 diffuses out of the tubular cells into the interstitium - NH4 reabsorption in the TAL is suppressed by hyperkalemia and stimulated by chronic metabolic acidosis - NH4 recycling promotes acid clearance - The collecting tubule has a very low NH3 concentration - This promotes diffusion of NH3 into the collecting duct - NH3 that goes there is rapidly converted to NH4 allowing more NH3 to diffuse in. - Response to changes in pH - Increased ammonium excretion with two processes - Increased proximal NH4 production - This is delayed 24 hours to 2-3 days depending on which enzyme you look at - Decreased urine pH increases diffusion of ammonia into the MCD - Occurs with in hours of an acid load - Peak ammonium excretion takes 5-6 days! (Fig 11-10) - Glutamine is picked up from tubular fluid but with acidosis get Na dependent peritublar capillary glutamine scavenging too - Glutamine metabolism is pH dependent with increase with academia and decrease with alkalemia - NH4 excretion can go from 30-40 mEq/day to > 300 with severe metabolic acidosis (38 NaBicarb tabs) - Says each NH4 produces equimolar generation of HCO3 but I thought it was two bicarb for every alpha ketoglutarate?- The importance of urine pH - Though the total amount of hydrogren cleared by urine pH is insignificant, an acidic urine pH is essential for driving the reactions of TA and NH4 forward.- Regulation of renal hydrogen excretion - Net acid excretion vary inverse with extracellular pH - Academia triggers proximal and distal acidification - Proximally this: - Increased Na-H exchange - Increased luminal H-ATPase activity - Increased Na:3HCO3 cotransporter on the basolateral membrane - Increased NH4 production from glutamine - In the collecting tubules - Increased H-ATPase - Reduction of tubular pH promotes diffusion of NH3 which gets converted to NH4…ION TRAPPING - Extracellular pH affects net acid excretion through its affect on intracellular pH - This happens directly with respiratory disorders due to movement of CO2 through the lipid bilayer - In metabolic disorders a low extracellular bicarb with cause bicarb to diffuse out of the cell passively, this lowers intracellular pH - If you manipulate both low pCO2 and low Bicarb to keep pH stable there will be no change in the intracellular pH and there is no change in renal handling of acid. It is intracellular pH dependent - Metabolic acidosis - Ramps up net acid secretion - Starts within 24 hours and peaks after 5-6 days - Increase net secretion comes from NH4 - Phosphate is generally limited by diet - in DKA titratable acid can be ramped up - Metabolic alkalosis - Alkaline extracellular pH - Increased bicarb excretion - Decrease reabsorption - HCO3 secretion (pendrin) in cortical collecting tubule - Occurs in cortical intercalated cells able to insert H-ATPase in basolateral cells (rather than luminal membrane) - Normal subjects are able to secrete 1000 mmol/day of bicarb - Maintenance of metabolic alkalosis requires a defect which forces the renal resorption of bicarb - This can be chloride/volume deficiency - Hypokalemia - Hyperaldosteronism - Respiratory acidosis and alkalosis - PCO2 via its effect on intracellular pH is an important determinant of renal acid handling - Ratios he uses: - 3.5 per 10 for respiratory acidosis - 5 per 10 for respiratory alkalosis - Interesting paragraph contrasting the response to chronic metabolic acidosis vs chronic respiratory acidosis - Less urinary ammonium in respiratory acidosis - Major differences in proximal tubule cell pH - In metabolic acidosis there is decreased bicarb load so less to be reabsorbed proximally - In respiratory acidosis the increased serum bicarb increases the amount of bicarb that must be reabsorbed proximally - The increased activity of Na-H antiporter returns tubular cell pH to normal and prevents it from creating increased urinary ammonium - Mentions that weirdly more mRNA for H-Na antiporter in metabolic acidosis than in respiratory acidosis - Net hydrogen excretion varies with effective circulating volume - Starts with bicarb infusions - Normally Tm at 26 - But if you volume deplete the patient with diuretics first this increases to 35+ - Four factors explain this increased Tm for bicarb with volume deficiency - Reduced GFR - Activation of RAAS - Ang2 stim H-Na antiporter proximally - Ang2 also stimulates Na-3HCO3 cotransporter on basolateral membrane - Aldosterone stimulates H-ATPase in distal nephron - ALdo stimulates Cl HCO3 exchanger on basolateral membrane - Aldo stimulates eNaC producing tubular lumen negative charge to allow H secretion to occur and prevents back diffusion - Hypochloremia - Increases H secretion by both Na-dependent and Na-independent methods - If Na is 140 and Cl is 115, only 115 of Na can be reabsorbed as NaCl, the remainder must be reabsorbed with HCO3 or associated with secretion of K or H to maintained electro neutrality - This is enhanced with hypochloridemia - Concurrent hypokalemia - Changes in K lead to trans cellular shifts that affect inctracellular pH - Hypokalemia causes K out, H in and in the tubular cell the cell acts if there is systemic acidosis and increases H secretion (and bicarbonate resorption) - PTH - Decreases proximal HCO3 resorption - Primary HyperCard as cause of type 2 RTA - Does acidosis stim PTH or does PTH stim net acid excretion
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Thanks for tuning in to Agronomic Monday! Today’s show is brought to you by Nufarm. You’ll hear from Peter Johnson, resident agronomist with RealAgriculture, Arti Singh of Iowa State University on a new weed ID app, and Sam Markell with North Dakota State University (NDSU) on soybean cyst nematode. As well, don’t miss our spotlight... Read More
Thanks for tuning in to Agronomic Monday! Today’s show is brought to you by Nufarm. You’ll hear from Peter Johnson, resident agronomist with RealAgriculture, Arti Singh of Iowa State University on a new weed ID app, and Sam Markell with North Dakota State University (NDSU) on soybean cyst nematode. As well, don’t miss our spotlight... Read More
Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode of a 4-day-old with jaundice and vomiting. Here's the case presented by Rahul: A full-term 4-day-old boy presents to the ED after recently being discharged from the newborn nursery. Per mom, the patient "look yellow" and was having difficulty with feeding. The mother states that the patient would be increasingly sleepy, and will only latch to the breast for five minutes. The patient has been having decreased wet diapers, and the stool is loose and non-bloody. Mother was concerned today as the child continue to look yellow, especially in the eyes, had four episodes of vomiting, and overall was acting lethargic. The patient presented to the emergency room afebrile, tachypneic, and tachycardic. The patient was noted to have initial serum glucose of 70. As the patient was increasingly dehydrated, laboratory testing was difficult to obtain. The infant was fussy for the caregivers. The patient was resuscitated with 2 x 10 per kilo boluses and responded well. Point of care ultrasound noted normal four-chamber cardiac anatomy and squeeze. Given the instability of the patient, a RAM cannula was initiated, and the patient presented to the PICU. To summarize key elements from this case, this 4-day-old infant has: an acute presentation of jaundice and poor feeding Prominent GI symptoms and dehydration A sepsis-like presentation with hemodynamic instability responsive to fluids All of which brings up a concern for inborn error of metabolism, likely galactosemia. This episode will be organized… Clinical Presentation Laboratory Findings & Biochemistry Management of Galactosemia Rahul, let's start with a short multiple choice question: Of the following biochemical enzymes, which of the following is deficient in classic galactosemia? A. UDP Glucoronyl Transferase B. Aldolase B C. Galactose 1 Uridyl Transferase D. Galactokinase The correct answer is C. Galactose 1 Uridyl Transferase aka GALT. Classic galactosemia is caused by a complete deficiency of galactose-1-phosphate uridyl transferase (GALT). We should contrast this with galactokinase deficiency. These two present quite differently — GALT deficiency presents like our patient with jaundice, vomiting, hepatomegaly, renal dysfunction, and sepsis. Galactokinase deficiency has less of systemic symptoms and these patients similar to GALT deficiency have cataracts that are usually bilateral and resolved with dietary therapy. To go through our other answer choices, remember that Aldolase B is the rate-limiting enzyme in fructose metabolism, thus a deficiency in this enzyme would cause hereditary fructose intolerance. With this lead in question, let's pivot into the biochemistry of galactose and review key lab findings in our patient with galactosemia. Rahul, can you give us a quick summary of how galactose is metabolized in our body? Galactose is a sugar found primarily in human milk and milk products as part of the disaccharide lactose. Lactose is hydrolyzed to glucose and galactose by the intestinal enzyme lactase. The galactose then is converted to glucose for use as an energy source, however it needs a series of reactions: Galactokinase → which catalyzes the rxn galactose to galactose 1 PO4 Our rate limiting enzyme Galactose-1-phosphate uridyl transferase (GALT). GALT helps place a sugar moiety on galactose 1 PO4 to turn it into glucose 1 Phos which can then be utilized in glycolysis or glycogenesis. A complete deficiency in GALT is known as classic...
In this episode, we continue our conversation with Mike Grodus, Chief Administrative Officer at Professional Medical Corp., a Physician Health Organization (PHO). He addresses recent trends in commercial payer contracts such as “value-based” contracts, cost and quality provisions and telehealth adoption. We also discuss AMA's recent work and overall thoughts on innovative contracting opportunities and advantages for private practices and PHOs.
In this episode, our guest Mike Grodus, Chief Administrative Officer at Professional Medical Corp., a Physician Health Organization (PHO), discusses recent trends in commercial payer contracts such as “value-based” contracts, cost and quality provisions and telehealth adoption. We also discuss AMA's recent work and overall thoughts on innovative contracting opportunities and advantages for private practices and PHOs.
Join host Shaun Haney on today’s Agronomic Monday edition of RealAg Radio! You’ll hear: Peter “Wheat Pete” Johnson, RealAgriculture’s resident agronomist, with an agronomy update from the east; Warren Ward of the Canola Council of Canada, on starter fertilizer research; and The top ag news stories of the day. Thoughts on something we talked about... Read More
✨ SUBSCRIBE TO THE AIRDROP SHOW ✨ https://airdropshow.xyz/ (airdropshow.xyz) TIME TO REVIEW: What is an NFT Project? In this episode Rawion & Phos reflect over the last 20 weeks in the NFT space. In this episode we cover 1) What is an NFT Project? 2) How NFT projects start on the wrong foot & how that can cause them to falter later on? 3) & How You as a Project can start on the right foot & decern what your core values are before you start. JOIN THE AIRDROP CREW: Come Create Everyday with us: https://discord.gg/AZtHEJJdjP (https://discord.gg/AZtHEJJdjP) Twitter: https://www.youtube.com/redirect?event=video_description&redir_token=QUFFLUhqbHFna0dyX3lrUHEtN0M1ODF2ZF9xUklSN0pVd3xBQ3Jtc0tsczBaSTBqMElDZ3Rva1BzYXJ1Wm5VSXFla2xOaElwWm1SanEyLUtJVURQVE5wSHZJSXZpbmhBcm1wVGEtZ2Zyd1hDTFpmb2JXM1dmYmVBWFA5RklCdHhEbDlrY0dYckQ4RVNiT0RrcHlIUUt1Rkxqbw&q=https%3A%2F%2Ftwitter.com%2FAIRDROPshow&v=XaYsUI4v4l8 (https://twitter.com/AIRDROPshow) HOW TO FIND YOUR CORE VALUES BLOG: https://app.sigle.io/airdropxyz.id.stx/pXi7TVDbrfS2kXYllB7Ts (https://app.sigle.io/airdropxyz.id.stx/pXi7TVDbrfS2kXYllB7Ts)
Episode 94: Elevated Alk Phos. Akhil explains what to do when the alkaline phosphatase is elevated, including labs, imaging and other studies. This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.Elevated Alk Phos. By Akhil Patel, MS4, American University of the Caribbean. Comments by Hector Arreaza, MD. Serum alkaline phosphatase: When you find elevated serum alkaline phosphatase, you must consider the two most common sources: the liver and bones. Other sources to consider include the third-trimester placenta, intestine, and kidneys. To determine if the abnormal elevation of alkaline phosphatase has clinical significance, you need to consider if it is a physiological or pathological elevation first. Ruling out physiological concerns: Typically, you should rule out physiological causes first as they are fewer and easier to determine via patient history. This can be even quicker to determine but also sometimes bypassed if a patient's history and labs present with more concerning etiologies of pathological elevation.Common causes of physiological elevations in alkaline phosphatase include pregnancy, patients with blood type O and B after eating a fatty meal, and younger children. Pregnancy: During pregnancy women in their third trimester will have elevated serum alk phos from the placenta. Blood type: During digestion, alk phos is released from the intestines in patients of blood type O and B. A postprandial increase can be 1.5 to 2 times the upper limit of normal in these patients, however, there is no clinical significance. Children: Younger children tend to have higher alk phos due to increased bone turnover. You can find a reference range chart online for different age groups. It is possible for alk phos to be up to three times higher in infancy and adolescence reflecting the ages with the highest bone growth velocity. Fun fact: Alkaline Phosphatase (also known as ALP) is a natural enzyme present in raw milk. Complete pasteurization will inactivate the enzyme in milk, therefore, presence of alkaline phosphatase in milk is an indicator of failed pasteurization. This is because the most heat-stable bacteria found in milk, Mycobacterium paratuberculosis, is destroyed by temperatures lower than those required to denature ALP.Evaluation of pathological alkaline phosphatase: Degree of elevation: Another consideration is the level of alk phos elevation. If alk phos is at least four times the upper limit of normal, then cholestasis is the likely cause with many specific etiologies to consider. If alk phos is not markedly elevated (four times the upper limit) then the cause is likely not as specific and many different etiologies should be considered whether hepatic or non-hepatic. Liver source: Common symptoms: Jaundice, abdominal pain, ascites, easy bruising, nausea and/or vomiting, choluria, acholia or hypocholia, unexplained weight loss, fatigue, or anasarca.If alk phos is elevated along with liver function testing and bilirubin, it is easier to determine the liver etiology (hepatitis, cirrhosis). However, if it is an isolated elevation in alkaline phosphatase, then other sources must be considered more carefully. A helpful test at this point is to look at is GGT or serum 5'-Nucleotidase for elevation. Typically, these will be elevated with alk phos if it is of liver origin. If they are not increased, you should consider bone-related etiologies.-If a hepatic cause is determined, a right upper quadrant ultrasound is the best initial test to determine intrahepatic or extrahepatic causes. This imaging will look at the hepatic parenchyma and bile ducts. Biliary dilation on ultrasound suggests an extrahepatic cause while no dilation suggests an intrahepatic cause. Liver source with biliary dilation: CBD is considered dilated when >6mm. If biliary dilation is present suggesting an extrahepatic cause, ERCP or MRCP is the next best step in visualizing the cause with choledocholithiasis being the most common cause. Other causes to consider: malignant obstruction, primary sclerosing cholangitis strictures, chronic pancreatitis causing strictures, and AIDS cholangiopathy. Malignant obstructions can be from the pancreas, gallbladder, ampulla of vater, bile duct, or distant metastasis. If the results of these tests are inconclusive the next best step is to consider a liver biopsy. Liver source without biliary dilation: Without biliary dilation on ultrasound, there is a larger pool of etiologies to consider for intrahepatic causes: drug toxicity, primary biliary cirrhosis, primary sclerosing cholangitis, viral hepatitis, cholestasis of pregnancy, and total parenteral nutrition (TPN). Tests: Antimitochondrial antibody (AMA) testing is a good place to start at this point which would suggest primary biliary cirrhosis (PBC) and indicate confirmation with a liver biopsy. Other tests to order at this point include hepatitis panel, EBV and CMV, and possibly pregnancy testing. If patient history and these tests are all negative, the next best step to consider is a liver biopsy if alk phos is significantly elevated more than two times the upper limit of normal. Summary: GGT, Liver US, Dilated? -> MRCP, ERCP, CT scan of abdomen and pelvis. Non dilated? AMA, Hepatitis panel, EBV, CMV, pregnancy test.Fun fact: When Alkaline phosphatase is elevated you can order the test called Alkaline Phosphatase isoenzymes. You will get a result with percentages for each isoenzyme: ALPI – intestinal, ALPL – nonspecific, but mainly expressed in liver, bone, and kidney; ALPP – placental, and ALPG – germ cells. Nonhepatic evaluation:With an isolated alkaline phosphatase elevation and normal GGT or serum 5'-Nucleotidase, the first thing to consider is bone-related pathologies involving high bone turnover: Healing fractures, osteomalacia, Paget's disease of bone, osteogenic sarcoma, bone metastasis, hyperparathyroidism, and hyperthyroidism. Patient history, ordering thyroid and parathyroid function testing, imaging with bone scintigraphy are all important in sorting through the differential of bone-related pathologies. Other extrahepatic diseases to consider that have shown elevated alkaline phosphatase include myeloid metaplasia, peritonitis, diabetes mellitus, subacute thyroiditis, uncomplicated gastric ulcer, and sepsis. Each of these has its own work up and an elevated alk phos level has little significance clinically.Paget's disease of bone: Paget disease of bone is a benign disorder that presents with focal areas of increased bone turnover in one or more skeletal sites. Mostly affects male older adults, but female patients can also be affected. Commonly affects the bones of the pelvis, spine, skull, and long bones. Pain is the most common symptom, and the presentation of the disease may depend on which bones are affected, the extent of involvement, and the presence of complications. Paget's disease of bone may be asymptomatic, incidental elevated serum alkaline phosphatase levels on routine labs or abnormal imaging tests performed for other reasons can point to Paget's disease of bone. Other common symptoms include deafness, and tight hats. Diagnosis is normally done by plain radiography and serum alkaline phosphatase. Radionuclide scans is used to determine the extent of disease. Treatment with nitrogen-containing bisphosphonates (zoledronic acid, risedronate, and alendronate).Complications of the disease include arthritis, gait changes, hearing loss, nerve compression syndromes, and osteosarcoma. Use serum alkaline phosphatase for assessing treatment response. Early diagnosis of Paget disease of bone is key in the management and patients have a better prognosis when treatment is initiated before complications. Consult with a specialist to confirm the diagnosis and start treatment.__________________________Conclusion: Now we conclude our episode number 94 “Elevated Alk Phos”. Elevated Alk Phos can be normal in some circumstances, mainly in pregnancy and childhood. You can start a workup when the alk phos is persistently elevated 4 times above the upper limit of normal. The most common causes can be grouped as hepatic and non-hepatic, and the bones is the most common non-hepatic source. Even without trying, every night you go to bed being a little wiser.This week we thank Hector Arreaza, and Akhil Patel. Audio edition: Suraj Amrutia. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Williams, J., & Nieuwsma, J. (2016). Screening for depression in adults. In J. A. Melin (Ed.), UpToDate. Retrieved February 1, 2017, from https://www.uptodate.com/contents/screening-for-depression-in-adults. Lawrence S Friedman, MD (2020). Approach to the patient with abnormal liver biochemical and function tests. Shilpa Grover (Ed.), UpToDate. Retrieved Maye 12, 2022 from https://www.uptodate.com/contents/approach-to-the-patient-with-abnormal-liver-biochemical-and-function-tests. Lawrence S Friedman, MD (2020). Enzymatic measures of cholestasis (eg, alkaline phosphatase, 5'-nucleotidase, gamma-glutamyl transpeptidase). Shilpa Grover (Ed.), UpToDate. Retrieved Maye 12, 2022 from https://www.uptodate.com/contents/enzymatic-measures-of-cholestasis-eg-alkaline-phosphatase-5-nucleotidase-gamma-glutamyl-transpeptidase.
Brandon West is the Chief Purpose Officer at PHOS Creative in Gainesville, Florida. PHOS is a digital marketing agency—but that's not all they are. Sure, their goal is to help clients around the country grow the right way. And yes, they're experts in their field. Beyond that, they're life-changers, donating a percentage of profits to help restore dignity, purpose, and freedom to women and children who've been impacted by extreme poverty and sex trafficking. Brandon hasn't always had this as his "why," and he walks Will and Chris through his realization journey. It's a fascinating story, and one that most Christian entrepreneurs can relate to. Check it out and let us know what you think! Recommended Resource: • The Five Dysfunctions of a Team by Patrick Lencioni Learn more about Phos Creative here: www.phoscreative.com Listen via Android devices: https://bit.ly/eternal-roi-google Listen via Apple devices: https://bit.ly/eternal-roi Learn more about His Way at Work at www.HWAW.com
Join me on this episode as we discuss the remedy Mag Phos (Magnesia Phosphorica) and why the keyword to remember for this remedy is CRAMPS. I will share some personal examples of how I have used homeopathy in my home this week to help myself and my family using cell salts and how a particular remedy has benefited me during my pregnancy. I will also talk about how me and my family are growing our own food this season and encourage you to do the same. Feel free to reach out to me with any questions or comments at honesthomeopathypodcast@gmail.com I would love to hear from you and for us to journey together! If you have benefited from this podcast please take a moment to rate and leave a review for this podcast on whatever platform you are listening from. Thank you so much for listening! --- Support this podcast: https://anchor.fm/honest-homeopathy/support
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