Podcasts about pth

Dr. Deb Muth 0:00 Welcome back to Let’s Talk Wellness Now. I’m your host, Dr. Zab, and we are continuing our discussion this week on 0:08 peptides. And so, if you haven’t heard our first conversation about peptides, 0:13 please go back and look at that episode. We talk all about the manufacturing, the safety, the quality of peptides, and we 0:20 dove into GLP1s. And today we’re going to dive into peptides for sexual 0:26 wellness, immune function, growth hormone, and all the amazing fun things 0:32 we can do with peptides. So, as usual, grab your cup of coffee or tea, settle 0:37 in, and let’s talk wellness now. And we’re going to take a short pause from our sponsor. I know we’ve got to do 0:44 that, you guys. They’re who keep us on the air. So, I’m going to pause for just a minute and be right back after this 0:50 message from our sponsor. Ladies, it’s time to reignite your vitality. Primal 0:56 Queen supplements are clean, powerful formulas made for women like you who want balance, strength, and energy that 1:03 lasts. Get 25% off at primal queen.com. Serenity Health. That’s primalqueen.com. 1:10 Serenity Health. Because every queen deserves to feel in her prime. All 1:15 right, everybody. We are back. And are you ready? We are talking all things peptide and I am opening the show today 1:23 with sexual wellness. Yes, I’m going there, you guys. I am going there. You 1:29 know, this has really become a big issue for people um of all ages. It’s not just 1:3 4us older people. It’s younger people, too. And there’s a whole variety of reasons why we have sexual dysfunction. 1:42 And when we’re talking about sexual dysfunction, we’re not just talking about it doesn’t work, right? Or I can’t 1:48 reach orgasm. A lot of it is around desire and um the thought of it and 1:54 wanting to connect, wanting to be kinder to one another, wanting to be touching 2:00 one another. A lot of it resolves or revolves around that. And so there are some peptides that can help us and I’m 2:08 really excited to be able to talk about those today. So the first one is called PT-141. 2:14 This targets the brain not the periphery. Right? So for many women I 2:20 will always tell you sex starts between here. It is a brain thing for us. It is 2:26 not necessarily a physical thing. For guys that’s a little different. It’s very physical. For women it’s all in our 2:32 brain. So tip for you men that are listening. You have to prime your woman’s brain first if you want her to 2:38 have sex with you that night. You have to be nice to her. You have to bring her flowers. Do the dishes for her. Do 2:45 something kind. Bring her a cup of coffee or tea or a glass of wine. Take her to dinner. You have to woo her. And 2:51 I don’t care how long you’ve been married. That has to happen. And tip number two, don’t say anything stupid 2:57 that day. I’m just being honest. When you guys say things that make us upset, 3:03 that lingers with us for the rest of the day. And it’s it’s a turnoff for us. And 3:08 for a lot of women, we can’t get past that when it comes time to snuggle at night. And sex doesn’t always have to be 3:14 at night either. So, you can tell I really love talking about this conversation, but we’re going to get into the peptide part of it because this 3:21 is going to help people. So, um, PT-141 is marketed as I’m going to slaughter 3:28 this name, Vali, and it represents a fundamentally different approach to 3:34 sexual dysfunction than the PDE5s inhibitors like Slenden, Viagra, 3:40 Tedataphil, which is Seialis. And while the PDE5 inhibitors work specifically by 3:47 enhancing blood flow to the genital tissues, PT-141 works centrally in the brain by 3:54 modulating neural s neural circuits involved in the sexual desire and 4:00 arousal. Now PT-41 is a cyclic hpatipeptide. It’s seven amino acid 4:07 peptide arranged in a cyclic structure that acts as a melanoortin receptor 4:13 agonist and with particularly the infinity for MC3R and MC4R subtypes. 4:20 It’s actually a metabolite of the melanotan 2, a peptide originally 4:26 developed for tanning that was also found to enhance sexual desire in early 4:31 studies. Now the melanoortin system in the brain is involved in multiple functions including energy homeostasis 4:39 but it also is involved in sexual motivation and arousal behaviors. The FDA approved PT-141 in 2019 specifically 4:48 for the treatment of acquired generalized hypoactive sexual desire 4:54 HSDD in permenopausal women. So for the first time we have a medication that was 5:01 approved by the FDA to use for women for sexual dysfunction. We have had all of 5:07 these seialis tedataphil viagros for men but we had nothing for women. And so 5:12 this is amazing that this is available for women and approved by the FDA. It’s a big deal. This represents the first 5:19 and only FDA approved medication specifically targeting these circuits of sexual desire rather than the peripheral 5:27 arousal mechanisms. And this indication is quite specific, meaning it was developed at some point, not lifelong. 5:35 So I if you’ve had sexual dysfunction your entire life, this medication was 5:40 not approved for you. But if it’s something that you developed over time, like when you went through pmenopause or 5:46 menopause or some women have this experience happen after childirth, that’s what we’re talking about here. 5:53 Now, it’s also not just um supposed to be used if you dislike your partner, 5:59 right? If your relationship is bad and you dislike your partner, this probably isn’t going to fix a ton. It might help 6:05 a little bit, but that’s not what it’s meant for. So, you really have to know what you’re using it for and why. And 6:11 the other thing that I would say is this is something that we don’t go to if your hormones are not balanced properly. You 6:17 have to balance your hormones properly before using something like this because it still may not work. Now, the only 6:24 caveat to that is if you’re a woman that has a risk of breast cancer and can’t use hormones, then that’s a different 6:31 story and we would have that conversation about whether or not this medication would be appropriate for you. Now, the FDA label specifies PTA1 uh 6:39 PT-141 as it not being indicated for HSDD in causes where low sexual desire 6:46 is due to coexisting medical or psychiatric conditions, problems with relationships, like we had talked about, 6:53 side effects to medications or other substance use. This specifically reflects the importance of differential 6:59 diagnosis. Low sexual desire can have many root causes and PT-41 is only 7:05 appropriate when those causes have been ruled out. Now, I have I used PT41 in 7:10 people who have sexual dysfunction issues as a result of using 7:16 anti-depressants. Yes, I have. I’ve used Flynn in that effect as well. And it 7:21 does work sometimes, but it doesn’t work completely. But you need to know that that is not what the approval is for the 7:27 FDA. So that is done in something that we call off label use. So very important 7:33 to know. Now in these clinical trials leading to FDA approval, this was published by Kinsburg and colleagues in 7:40 obstetrics and gyne gynecology in 2019. PT-141 demonstrated statistically 7:46 significant improvements in sexual desire and decreases in distress related 7:51 to low desire compared to placebo. The effects manifest over 45 minutes to 7:56 several hours after the injection and the mechanisms involved modulation of dopamine and melanoorton pathways in the 8:04 hypothalamus and the brain regions that involved sexual motivation. Now cardiovascular effects of PT 141 require 8:12 careful attention. This drug causes transient increases in blood pressure about 3 to four points and transient 8:20 decreases in heart rate. And because of this, it is contraindicated in patients 8:25 with uncontrolled hypertension or known cardiovascular disease. And it has been studied in patients who’ve had recent 8:32 cardiovascular events or sorry hasn’t been studied hasn’t been studied in patients who’ve had recent 8:39 cardiovascular events. So patients need to have their blood pressures checked before starting therapy. Nausea is 8:45 extremely common. It is one of the biggest things I often will tell people to take an anti-nausea medicine if 8:52 they’re going to do this because the last thing you want to do is inject this medication and think it’s going to give 8:57 you this great time with your partner and you’re so nauseated that you can’t even perform, don’t want to kiss, don’t 9:05 want to do anything. It it can be pretty profound for some people. um it does affect about 40% of the patients in 9:12 clinical trials which is why many clinicians require or recommend an 9:17 anti-nausea medication like I had just said other common adverse effects include flushing injection site 9:24 reactions headache in about 13% of the population which I have seen worse if 9:30 people are prone to headaches and the headaches are pretty intense so I will also have them premedicate if they have 9:36 that um sensitivity ity with a Tylenol or Advil, Alie, whatever it is they 9:42 typically use for their headaches to help prevent that from occurring. Now, some patients also experience a 9:50 generalized hyperpigmentation of their skin, particularly in areas with chronic friction, and this may not be reversible 9:57 after discontinuation. So from an integrative perspective, PT-41 10:03 represents one tool in addressing female sexual dysfunction, but it should never be the first or only intervention. And 10:11 low sexual desire in women is complex. Multiffactorial involving hormonal imbalances, low testosterone, estrogen 10:18 deficiency, progesterone imbalances, thyroid dysfunction, adrenal dysfunction, and with elevated or 10:24 disregulated cortisol levels, sleep deprivation, relationship issues, unresolved trauma, including sexual 10:31 trauma, chronic pain, body image concerns, and medication side effects such as SSRIs are notorious for this. So 10:39 a comprehensive hormone panel including total and free testosterones, estradile, 10:45 progesterone, DHEA, thyroid function in cortisol assessment, ideally four-point 10:51 cortisol, salivary should precede any pharmacological intervention. And additionally, addressing the 10:57 psychological component and relationship dimensions through appropriate therapy is necessary. I have a lot of patients 11:03 that say, “This is just too much work for sex. I don’t want the side effects. I don’t want to deal with this.” and that’s totally fine. But for some 11:09 people, their sexual dysfunction is actually causing more problems on their 11:14 relationship and they want to do something to fix that. And just know that if you’re using a peptide like this 11:20 that comes with some of these side effects and you have to premedicate for it, it is not the end of the world. Um, 11:27 but it may be a possibility that you may need that. So, let’s dive into body composition and growth hormone access. 11:34 So Tesmarellin is the only FDA approved GH 11:40 analog. Tesarelin is marketed as Agrifta and Agria SV. It is a synthetic analog 11:48 of human growth hormone releasing hormone. So GH RH human growth hormone 11:53 releasing hormone. These things are such long names it’s confusing and it’s difficult to spit out, right? It 11:59 consists of 44 amino acids. The structure is identical to our own 12:05 body’s growth hormone GHR um with the addition of trans3 hexonol group which 12:14 stabilizes the molecule that extends its half-life compared to the native GHR. 12:19 The mechanism of tesmarellin is elegant in its preservation of physiological 12:24 growth hormone GH secretion patterns and rather than administering an exogenous 12:30 growth hormone directly, tesmarillin binds to the GH receptor in the anterior 12:36 pituitary gland stimulating the indogenous pulsatile release of GH. So 12:42 you know it it’s slower in that stimulation and it pulsates instead of a direct rise and fall. This pusile 12:49 pattern more closely mimics natural GH secretion which occurs in bursts 12:54 primarily during sleep. The GH then stimulates the liver to produce insulin-like growth factor IGF-1 which 13:01 exerts many of the downstream metabolic effects including lipolytic effects on 13:07 the atapost tissue. So fat atapose and how we break that down. The FDA approved 13:13 tesmarellin in 2010 for a very specific narrow indication, the reduction of 13:19 excess abdominal fat in HIV infected patients with lipodistrophe. This 13:25 condition characterized by abnormal fat redistribution with accumulation of visceral body fat and the loss of 13:32 subcutaneous fat in face and limbs developed as a complication of an 13:37 antiviral therapy particularly with older protease inhibitor reg uh 13:42 regimens. The visceral fat accumulation in patients is not just cosmetic. It’s associated with increased cardiovascular 13:49 risk, insulin resistance, and inflammatory markers. The pivotal trial that led to the FDA approval included 13:56 work by Stanley and colleagues published in the annuals of internal medicine in 2014. It demonstrated that tesmarillan 14:03 significantly reduced the visceral atapose measured by CT scan by approximately 15 to 20% which is a 14:10 significant difference to placebo over a short period of time only 26 weeks. Now, 14:16 interestingly, the total body uh weight typically remained stable or even 14:21 increased slightly as the reduction of visceral fat was sometimes offset by increases in lean body mass or 14:28 subcutaneous fat. This highlights an important point. Tesmearellin is not a weight loss drug in its conventional 14:34 sense. Its effects are specifically on body composition and fat redistribution. 14:40 Now the glucose metabolism effects of tesmarellin do require careful monitoring because GH and IGF1 can 14:47 induce insulin resistance. Tesmearellin can increase glucose levels and hemoglobin A1C and in these clinical 14:54 trials glucose tolerance and new onset diabetes occurred in some patients. So 14:59 this creates a therapeutic paradox while res reducing visceral fat we should theoretically improve metabolic health. 15:07 The GH mediated insulin resistance can worsen the glycemic control and patients 15:12 with diabetes require particularly close monitoring. The potential need for adjustment in diabetic medications can 15:19 occur. So I already know what you guys are thinking. Can I use Tesmarellin and 15:24 GLP1 at the same time? And the answer is yes. Especially in those people that we 15:30 know have an insulin resistance already or are prone to that, we can use lowd 15:36 dose micro doing GLP-1 along with tesmarellin to help prevent this from 15:42 occurring um or reduce the risk of it occurring. Now there are some other adverse related problems to growth 15:49 hormone access which include fluid retention which can uh manifest as uh 15:55 ankle swelling, joint pain, muscle pain, paristhesas, carpal tunnel syndrome is 16:01 common to see. Of course you can always see injection site reactions reported about 26 to 30% of the time in the trial 16:08 participants. And this also theoretically has a concern about IGF-1 elevation potentially promoting 16:14 malignancy through long-term data is limited. So we have to be cautious about 16:20 this but it is a growth hormone and anything that is a growth hormone can cause cells to grow and it cannot 16:26 necessarily differentiate between healthy cells and bad cells. So the drug is contraindicated is contraindicated in 16:33 patients with active cancer and in patients with the disruption of the HPA access from conditions like pituitary 16:40 tumors, pituitary surgery, head of radiation um and traumatic brain injury. 16:46 Now off label use of tesmarellin for general anti-aging or body composition 16:51 optimization in non-HIV population, it doesn’t have FDA approval. There is no 16:58 FDA studies. um that promote this, but practitioners do prescribe it for these 17:04 purposes under an experimental and not supported by FDA approved indications. 17:10 And um from an integrative medical standpoint, optimizing natural growth 17:15 hormone secretion through lifestyle interventions, high quality sleep is important. GH primarily is excreted 17:22 during sleep and deep sleep waves. So improving your deep sleep is important. Intermittent fasting can also increase 17:28 growth hormone by five-fold as demonstrated in a Hartman and colleagues uh study from the journal of clinical 17:35 endocrinology and metabolism in 1992. And highintensity interval training, adequate dietary protein, blood sugar 17:42 control, these all can help naturally increase your growth hormone. So, let’s 17:47 dive in now and talk about bone health. peptide hormones um such as oh I’m gonna 17:54 I’m gonna really slaughter this name. Terraparatide is a true bonebuilding 18:01 peptide. It’s marketed as forio. It’s a recumbent form of the first 34 amino 18:08 acids out of 85 of the human parathyroid hormone PTH. It represents a unique 18:13 approach to osteoporosis treatment because it’s one of the few truly anabolic anabolic bone therapies meaning 18:21 it actively binds new bone rather than simply preventing bone loss. The biology 18:26 of parathyroid is fascinating and seemly contraindicated or uh contradictory. 18:32 Continuously sustained elevations of PTH as occurs in hyperarathyroidism 18:37 is catabolic to bone. So people who have hyperarothyroidism typically have significant bone loss 18:44 especially before it’s diagnosed and it causes causes increased bone 18:49 reabsorption loss of bone density increased fracture risk and however 18:55 intermittent exposure to PTH as achieved with once daily uh injections of forio 19:01 has the opposite effect. This intermittent exposure preferentially stimulates osteoblasts bone building 19:08 cells over osteoclasts bone reabsorbing cells and it leads to 19:13 the net bone formation. So terraparatide binds to the PTH receptors on 19:20 osteoblasts and renal tubular cells in bone. It increases the number of 19:25 activity of osteoblasts stimulating the differentiation of osteoblast precursor cells and may 19:32 reduce osteoblast apoptosis basically programmed cell death allowing this bone 19:37 building cell to work longer. The result is increased bone formation, improved bone architecture and tbacular 19:45 connectivity and ultimately increased bone mineral density um particularly in the hip and the spine which is so 19:51 difficult to regain. The FDA approved this medication in 2002 based on pivotal 19:57 studies by Near and colleagues published in the New England Journal of Medicine in 2001 which demonstrated significant 20:05 reductions in vertebral and non-vebral fractures in post-menopausal women with 20:11 osteoporosis. specifically uh reduced new vertebral fractures by 20:17 65% and nonvettebral fragility fractures by 53% 20:23 compared to placebo over a median followup of 21 months. This is really 20:29 incredible because we have not seen this kind of um change uh in other 20:35 medications that we’ve used for osteoporosis. So current FDA approval 20:40 indicates uh this for post-menopausal women with osteoporosis at high risk for 20:46 fracture, men with primary or hypoconatal osteoporosis at high risk for fracture 20:53 and men and women with glucocord cord glucocordide 21:00 induced osteoporosis at high risk for fracture. The high risk qualifier is 21:05 important. uh terrapeptide is reserved for patients with severe osteoporosis, 21:11 multiple fractures, very low low bone density and those who have failed or are 21:16 intolerant of other therapies. The most significant concern for this medication 21:21 is highlighted in a boxed warning with rat toxicology studies where it caused 21:27 osteioaroma which is a bone cancer in a dose dependent and treatment duration dependent manner. The revolence of this 21:34 finding to humans is debated. Rats have fundamentally different bone biology than humans with continuous bone growth 21:41 throughout life and different PTH receptors. Now post marketing 21:46 surveillance in humans hasn’t shown a clear increase in osteocaroma risk but 21:51 theoretically concerns persist and because of this terapeptide is 21:57 contraindicated in patients at risk baseline risk for osteioaroma 22:02 including those with pageantss disease of the bone unexplained elevations of alkaline phosphate prior skeletal 22:10 radiations bone metastases or skeletal malignancies and pediatric patients or young adults 22:16 with open hyes. There’s also a lifetime treatment duration of only 2 years and 22:22 terrapeptide can cause transient hypercalcemia. So an elevated blood calcium and as PTH normally increases 22:31 calcium levels by enhancing bone reabsorption, increasing renal calcium 22:36 reabsorption and promoting activation of vitamin D which increases intestinal calcium absorption. Some patients 22:43 experience orthostatic hypotension within 4 hours of injecting requiring 22:48 caution in at risk populations for blood pressure. Common side effects include 22:53 muscle pain, joint pain, pain in the limbs, nausea, headache, and dizziness. So from an integrative bone health 23:00 perspective, terrapeptides should be part of a comprehensive strategy. Adequate calcium intake, 500 to a,000 23:08 milligrams of calcium a day from food and supplements combined. and vitamin D. 23:13 Getting vitamin D levels of at least 50 to 80 are essential for the drug to work 23:20 optimally. But beyond this, bone health requires vitamin K2, which directs calcium into the bones rather than soft 23:27 tissues, magnesium as a co-actor in bone metabolism, trace minerals like boron, 23:33 copper, silica, and of course, adequate protein intake, which many of us, especially as women, don’t do 0.8 8 to 1 23:42 gram of protein per kilogram of body weight, weightbearing exercise. Of 23:47 course, these all provide mechanical signals that complement the biochemical 23:52 symbol uh signals of terrapeptide. Sequential therapy is also critical. The 23:58 bone mass gains from terraparatide can be lost if patients don’t transition to 24:05 an anti-resorbbitive agent a bisphosphinate after completing this therapy and the anabolic effects to 24:12 build bone but maintaining the new bone requires preventing excess reabsorption. 24:18 So positive things about this but there are definitely some concerns as well. So 24:23 the next one we’re going to talk about is Lu Prolrooide. It is marketed under 24:29 the multiple brand names of Lupron, Depo, Eligard, and it’s a synthetic 24:34 nonapeptide analog of naturally occurring ginonadotropen releasing 24:39 hormone G&R, also called luteinizing hormone releasing hormone, LHR. 24:46 It’s a fascinating example of how manipulating natural hormonal feedback systems can create therapeutic effects. 24:53 So, G&RH is normally secreted in a pulsatile fashion by the hypothalamus 24:59 and travels to the anterior pituitary where it binds to G&R receptors and 25:05 stimulates the release of luteinizing hormone LH and follical stimulating hormone FSH. These ginatotropins signal 25:13 the ovaries or the testes to produce sex hormones, estrogen, progesterone in 25:18 women, testosterone in men. Uh, luoprololi lupron as a GNR agonist 25:26 initially mimics the action of natural G&R causing an acute flare response with 25:33 uh increased LHFSH secretion which temporarily increases sex hormone 25:38 production. However, the continuous administration which is in the depo 25:44 formulations, the GNR receptors in the pituitary become desensitized and 25:50 downregulated. And after about 2 to four weeks of continuous exposure, LH and FSH 25:56 secretion is profoundly suppressed, leading to what’s termed as chemical 26:01 castration. Testosterone levels in men drop to castrated levels less than 50 26:08 and estrogen production is marketkedly suppressed in women. This bifphasic 26:13 response creates both therapeutic applications and management challenges in prostate cancer where tumor growth is 26:20 typically androgen dependent and the ultimate goal is testosterone suppression. However, the initial 26:27 testosterone surge during the flare phase can temporarily worsen symptoms potentially causing increased bone pain, 26:34 urinary obstruction, or even spinal cord compression in patients with metastatic 26:40 disease. This is why uh luoprolide is often started with an anti-ad androgen 26:47 like bicladamide for the first two to four weeks to block the effects of the 26:52 testosterone surge. The FDA has approved lupalide for multiple indications across 26:59 formulations. In oncology, it’s used for palletive treatment of advanced prostate cancers. In gynecology, various 27:06 formulations are approved for endometriosis, for pain management and lesion reduction and for fibroids. 27:13 Typically for pre-operative uh hematological improvement in anemic patients. In pediatrics, it’s used for 27:20 central precocious p puberty basically to halt the premature sexual development of these young people. Now, there are 27:28 adex uh adverse effect profile that reflects profound hormonal suppression. 27:34 In men treated for prostate cancer, hot flashes affect about 59% of the patients. Other common effects include 27:41 general pain, swelling, bone pain. Um long-term use of these medications leads 27:47 to metabolic changes. It increases fat mass. It decreases lean mass. It worsens 27:53 insulin sensitivity, disrupts the cholesterol uh lipid panels, increases 27:59 diabetic risk, has some concerns over cardiovascular disease. And the metaanalysis have shown increased risks 28:06 of heart infarction, myocardial inffection, sudden cardiac death, and stroke in populations receiving 28:13 long-term androgen deprivation therapy. The bone effects are particularly dramatic. Without sex hormones, bone 28:20 density decreases significantly, typically 3 to 4% per year during the 28:26 first two to three years of therapy. And this bone loss may not fully be reversible after the the therapy 28:32 discontinues. The American Society of Clinical Oncology recommends bone density monitoring and consideration of 28:39 bisphosphinates uh in men receiving long-term androgen deprivation. In women treated for 28:46 endometriosis or fibroids, the estrogen suppression creates a hypoestrogenetic state similar 28:54 to menopause. Hot flashes affect 90% of patients with other common effects 29:00 including headaches, emotional irritability, decreased sex drive, vaginal dryness, bone density loss. And 29:08 because of these bone concerns and treatment duration with endometriosis, typically limited to six months, though 29:14 some formulations allow for longer use with adback hormonal therapy to 29:20 partially mitigate these side effects. The mood and cognitive effects can be s 29:25 significant. I’ve seen it over the years. the depression, the memory impairment, difficulty focusing and 29:31 concentrating. It can be very very traumatic and the quality of life that 29:37 happens for these uh women and men can be unbearing for many of them. Um, from 29:44 an integrative perspective, patients receiving this medication need comprehensive support care. Bone health 29:51 interventions using calcium, vitamin D, vitamin K2, weightbearing exercise, 29:58 cardiovascular risk management becomes critical, including blood pressure monitoring, lipid management, diabetes 30:05 screening. For hot flashes management, some patients respond to black coohos, 30:10 sage, or vitamin E. Though evidence is mixed and individual response varies, 30:16 omega-3s may help with the mood and the inflammation, resistance training becomes specifically important to 30:22 preserve lean muscle mass in the face of hormonal suppression. 30:27 Now there’s something called calcetonin salamon which is marketed as miaelin. 30:34 It is a nasal spray. It is now discontinued. And foral is the new 30:39 synthetic polyeptide hormone of 32 amino acids identical to calcetonin of salamon 30:47 origin. It represents an interesting case study in how initial promise gives 30:52 way to safety concerns that regulate a therapy to historical footnote status. 30:58 Calcetonin is naturally occurring hormone in humans. It’s secreted by the paraphalicular sea cells in the thyroid 31:04 gland. Its primary physiological role is to lower blood calcium levels by 31:10 directly inhibiting osteoclast activity, reducing bone reabsorption, increasing 31:16 renal calcium secretion or excretion, and possibly reducing the intestinal 31:21 calcium absorption. So, salamon calcetonin is used therapeutically because it’s more potent and longer 31:27 acting than human calcetonin. The FDA initially approved calceton and salmon 31:34 for several indications post-menopausal osteoporosis in women more than five 31:39 years post-menopausal when alternative treatments are not sustainable. Padet’s 31:44 disease for bone and hypercalcemium as emergency treatments. The nasal spray formulation is particularly popular for 31:53 osteoporosis because it offered a non-injectable alternative to bisphosphinates. 31:58 However, in 2012, the European Medicine’s Agency, EMA, conducted a 32:05 comprehensive safety safety review after a poolled analysis of 21 clinical trials 32:10 involving over 10,000 patients showed a statistically significant increase in 32:15 malignancy risk in patients treated with calceton salamon compared to compared to 32:21 placebo. The overall malignancy rate was 4.1% in calcetonin treated patients 32:28 versus 2.9% in placebo patients. The types of cancer 32:34 varied with no single cancer type predominating, making it difficult to establish a clear mechanistic link. 32:41 However, the signal was concerning enough that the EMA restricted the use of calcetonin containing medicines. In 32:48 the United States, the FDA issued communications about malignancy signal and conducted its own review. While they 32:56 didn’t fully withdraw the drug, the cons consensus shifted dramatically. The nasal spray formulations miaelson was 33:03 voluntarily discontinued by the manufacturer and current clinical practice guidelines now consider 33:10 calcetonin salamon as a second line or lower option for osteoporosis. While 33:15 behind bisphosphinates, dennism mob, uh, terrapeptide, the analesic effect of 33:21 calcetonin in bone pain, particularly in acute vitibbral, uh, compression 33:26 fractions from osteoporosis or pageantss disease may still provide a role for short-term use in these selected 33:32 patients. The mechanism of this pain relief is unclear, but may involve 33:38 effects of endorphin systems and/or direct actions on pathways. The history serves as an important reminder in 33:45 peptide medicine. Initial approval and early clinical use does not guarantee 33:50 long-term safety effects. Post marketing surveillance and poolled analysis of the clinical trial data can reveal adverse 33:58 effects that weren’t apparent in initial studies. It also underscores why newer 34:04 agents with better safety profiles um have largely replaced calcetonin in 34:10 clinical practice. So this is really an important thing. Not one thing stays the same forever. We have to change as we 34:18 identify new and better products as we identify problems and concerns. I will 34:24 always tell my patients if you are uncertain of taking a new drug which we 34:30 all should be wait five years. Within five years we are going to find the 34:36 problems that they didn’t find in the clinical studies. Remember, a lot of these clinical studies are small, small 34:43 groups, short periods of time. It’s expensive to do these trials. So, if you 34:49 wait for five years, in the first two to three years, you will see the problem start to emerge. And what are you going 34:55 to look for? You’re going to look for the the news um commercials from lawyers 35:02 suing a drug. And they will tell you what the problem is. and then you can decide, is this something that I want to 35:09 use or not. Don’t jump on bandwagon and be the first one to do this, especially 35:14 if you’re sensitive. You know, give it time so you can see exactly what’s going on. So, I’m going to end our show on 35:22 this and we are going to pick up on part three of peptide therapy in our next 35:28 segment where we’re going to talk about the investigational peptides and some 35:34 exciting things that are happening with that. So, I want to thank you for joining me today on Let’s Talk Wellness 35:39 Now. It’s always a pleasure having a conversation with you guys and I hope this brings value to you with what we’re 35:45 talking about. If you have ideas for topics that you want me to discuss, 35:51 please message us, you can share your comments on Facebook, you can email us, 35:58 um you can get a hold of us however you would like to share that. I do look at the comments below in the episodes as 36:04 well. So you can place your comments there. And once again, one of the best things you can do for me is like, 36:11 subscribe, and share so that we can spread the messages of what we’re doing. 36:16 I do this at no cost. I don’t make any money out of this. I do this as an 36:21 educational purpose for everybody else. I love doing it, but it really helps us 36:28 on the algorithms if you would be just willing to like, subscribe, and share. 36:33 So, thank you for spending your time with me. I know time is important.The post Episode 257 – Peptides for Sexual Wellness & Hormonal Health: PT-141, Growth Hormones, Bone Health & More! first appeared on Let's Talk Wellness Now.

This week, the gang get taken to the island by Dylan alongside some familiar guests from across PTH's episodes as they all compete in the third round of Survivor. Which guest podcaster ends up being a challenge beast? Who will be the only person to participate at every pre-merge Tribal Council? Tune in to find out! Hosted by Steve Wright, Brian "BC" Chapman and Ryan "BB" Bannon Produced by Dylan Wright Music by Mark Sutorka Facebook: htttps://www.facebook.com/PTHpodcast 

Supports local review of Fjord Trail project New York State has rejected a claim that it should review a proposed renovation of a Route 9D events space tied to the Hudson Highlands Fjord Trail, rather than the Town of Fishkill. HHFT wants to convert Dutchess Manor into a visitor's center, offices and parking for the proposed trail. The Fishkill Planning Board has scheduled a public hearing on Thursday (Dec. 11) that will continue in January to hear feedback. At its Nov. 13 meeting, the Planning Board spent an hour discussing recent revisions to HHFT's plan for the site, especially concerns about traffic and parking. It also addressed arguments that HHFT should not be allowed to "segment," or separate, Dutchess Manor's restoration from the larger, 7.5-mile Fjord Trail, which is undergoing a state environmental review. Under New York's State Environmental Quality Review Act, segmenting projects to avoid a comprehensive review of its impacts "may result in legal action." In an Oct. 28 letter addressed to the Planning Board, the state parks department said that because the Dutchess Manor property is located within Fishkill, "it is appropriate for the town to analyze the potential impacts arising from its specific land use actions." The agency also said that Dutchess Manor, which is projected for completion in 2027, will have "independent utility" from the trail, which is scheduled for completion in 2031, and support the existing recreational trail system. It added that its review of the overall project will incorporate the visitor center's impact on traffic, parking and community character. Dominic Cordisco, the Planning Board attorney, called the letter "a very clear statement from state parks" and advised the board to focus "on the particulars of the Dutchess Manor proposal - this particular site - rather than the trail." Protect the Highlands, a group that opposes the trail as proposed, has been trying to convince the Planning Board that HHFT improperly segmented the project. Its president, former Cold Spring Mayor Dave Merandy, wrote in a Nov. 12 letter to the board that because state parks is leading the review of the Fjord Trail and is HHFT's "partner" in the project, its position on segmentation "isn't surprising." "That claim is flawed, as argued in the many letters and comments you have received from PTH [Protect the Highlands], PTH members, concerned neighbors and residents of the Hudson Highlands," he said. "We ask that you revisit and carefully consider those letters and comments during your deliberation." Extended discussions about segmentation and the trail's impact on traffic and residents have subsumed deliberations about HHFT's plans for the actual building, which call for demolishing three additions to the original 1868 residence and restoring the structure, which is on the national and state registers of historic places. In addition to a first-floor visitors' center with exhibit space and 181 parking spaces (including 29 for staff), HHFT's proposal calls for a store where hikers can buy snacks, water and other items, said Amy Kacala, HHFT's executive director. Food trucks would be available, along with shuttles to ferry hikers from the parking lot to trailheads. There would also be public restrooms, a lawn for picnicking and events, and new landscaping and lighting. HHFT is asking the Planning Board to approve its site plan and a special-use permit. It will also seek Town Board approval to rezone 14 Coris Lane, an adjacent residence that HHFT bought to use for its offices. HHFT said it expects Dutchess Manor to draw 36,000 visitors annually. In response to questions from Planning Board members about traffic, a representative of AKRF, a consulting firm hired by HHFT, said it projected that 85 vehicles would enter the property each weekday, rising to 154 on Saturdays and Sundays. That would constitute "an acceptable service level," even after the trail is completed, the representative said. At the board's requ...

In this episode of the RWS Clinician's Corner, Margaret Floyd Barry talks with Margie Bissinger – a powerhouse physical therapist, integrative health coach, author, and happiness trainer, with more than 25 years of experience helping people with osteoporosis and osteopenia reclaim their bone strength. Margie shares not only the common missteps she sees in osteoporosis management, but also the most effective, science-backed strategies to build bone density safely. Margie is known for her truly holistic approach, blending the latest research on exercise and nutrition with mindset and happiness training to empower clients and prevent fractures.    In this interview, we discuss:       Common misconceptions and risks in exercise for osteoporosis      Safe and effective resistance training for osteoporosis       The role of medication in osteoporosis management      Underlying contributors and root causes of bone loss (like gut health)      Addressing mindset, happiness, and emotional health in clinical practice      Margie's four-step process for prevention and treatment The Clinician's Corner is brought to you by Restorative Wellness Solutions.  Follow us: https://www.instagram.com/restorativewellnesssolutions/    Join us for a FREE 3-Part Fertility Masterclass Series: Precision Nutrition for Fertility Grab your spot now!    Connect with Margie Bissinger: Website: https://margiebissinger.com Facebook: https://www.facebook.com/p/Margie-Bissinger-MS-PT-CHC-100063542905332/ Instagram: https://www.instagram.com/margiebissinger/ LinkedIn: https://www.linkedin.com/in/margiebissinger YouTube: https://www.youtube.com/channel/UC3-1i9q8ls5FbjOOVeJRW2g   Here is your unique link for Margie's Osteoporosis Exercises, designed to strengthen bones and prevent fractures. *Note, once you sign up for these exercises, you'll be on her mailing list and will receive future correspondence about her one-of-a-kind practitioner program!   Other Bone Health Resources: The Onero Bone Clinic in Australia List of physical therapists who've been trained in the Bone Fit program/methodology  Tribecular Bone Scan - click this link to find places that do DEXA scans with the TBS Dr. Deva Boone's Parathyroid Disease Analysis Tool (enter PTH and blood calcium levels to assess risk for parathyroid disease).   Timestamps: 00:00 "Happiness Habits for Healing" 08:56 Lack of Exercise Guidance Harms 10:54 "Effective Resistance for Bone Density" 20:01 "Expert Training Beyond Gym Workouts" 22:09 Bone Health: Medication and Movement 28:40 Medication Guidance for Bone Health 34:43 Integrative Approaches to Arthritis 40:07 Focus on Solutions, Not Problems 46:47 Bone Health: Causes and Evaluations 49:36 Calcium, Diet, and Bone Health 55:39 Certification Program for Health Testing 01:02:52 Clinician's Corner: Listener Engagement Message 01:03:38 The Clinician's Corner Preview Speaker bio: Margie Bissinger is a physical therapist, integrative health coach, author, and happiness trainer. Margie has over 25 years of experience helping people with osteoporosis and osteopenia improve their bone health through a comprehensive integrative approach. She hosts the Happy Bones, Happy Life Podcast and has hosted four summits on Natural Approaches to Osteoporosis and Bone Health. Margie oversees all the osteoporosis initiatives for the state of New Jersey as a physical therapy representative to the NJ Interagency Council on Osteoporosis.   Margie has lectured to Fortune 500 companies, government agencies, hospitals, and women's groups throughout the country. She has been featured in the New York Times, Menopause Management, OB GYN News and contributed to numerous health and fitness books. Keywords: osteoporosis, bone health, osteopenia, resistance training, bone density, physical therapy, integrative health, functional health, happiness training, stress reduction, spine fractures, exercise for osteoporosis, forward bending spine, weight bearing exercises, DEXA scan, trabecular bone score (TBS), parathyroid hormone, hyperparathyroidism, gut health, inflammation, menopause, nutrition for bones, supplements for bone health, calcium intake, vitamin K2, protein intake, balance training, PT BoneFit, medication for osteoporosis, root cause analysis Disclaimer: The views expressed in the RWS Clinician's Corner series are those of the individual speakers and interviewees, and do not necessarily reflect the views of Restorative Wellness Solutions, LLC. Restorative Wellness Solutions, LLC does not specifically endorse or approve of any of the information or opinions expressed in the RWS Clinician's Corner series. The information and opinions expressed in the RWS Clinician's Corner series are for educational purposes only and should not be construed as medical advice. If you have any medical concerns, please consult with a qualified healthcare professional. Restorative Wellness Solutions, LLC is not liable for any damages or injuries that may result from the use of the information or opinions expressed in the RWS Clinician's Corner series. By viewing or listening to this information, you agree to hold Restorative Wellness Solutions, LLC harmless from any and all claims, demands, and causes of action arising out of or in connection with your participation. Thank you for your understanding.  

Six more - NRL round 17 wrap up - Was last Thursday's game, BUL vs PTH a grand final preview? Is Turbo a permanent centre? Warriors with key injuries, which teams are pushing for the top 8? Cynical Cowboys? The NRLW starts this coming week, who will win? Plus, Origin squads; and quickfire tipping for NRL Round 18 and NRLW Round 1. We also look ahead to Round 18.All that and more is covered by ABC Sport's Patrick Stack and Andrew Moore.

This week, the gang craft a playlist featuring songs with animals in the title. Will BC get everyone to appreciate Danny Vaughn? Which song has the longest title in PTH history? Tune in to find out! Hosted by Steve Wright, Brian "BC" Chapman and Ryan "BB" Bannon Produced by Dylan Wright Music by Mark Sutorka Spotify: https://open.spotify.com/playlist/4zw5EsEZK4XwhM7XnYoBca?si=debdb179221a4749 Facebook: https://www.facebook.com/PTHpodcast   

Revoyez avec Pr Georges Weryha, les points clefs à retenir concernant l'ostéoporose en pratique quotidienne de MG.Au cours de ce podcast, vous reverrez : ✅ Chez qui rechercher une ostéoporose ?✅ Comment faire le diagnostic ? ✅ Quel bilan étiologique en plus de l'ostéodensitométrie ne jamais oublier ?✅ Quel traitement mettre en place : activité physique, Calcium-VitD, acide zolédronique, dénosumab, PTH like ? ✅ Comment surveiller une ostéoporose après un traitement ?

Beim Hyperparathyreoidismus handelt es sich um eine Überfunktion der Nebenschilddrüsen, die zu einer gesteigerten Produktion von Parathormon – kurz PTH – führt. Das kann für den Körper einige unschöne Folgen haben. Stichwort: „Stein, Bein, Magenpein“. Nebenschilddrüsen haben wir normalerweise vier, manchmal auch mehr – das sind kleine, linsenförmige Drüsen, die hinter der Schilddrüse sitzen, das hast du ja schon gelernt.Erfahre in dieser Folge alles zu diesem wichtigen Krankheitsbild und lass dich damit wieder fit machen für deine Prüfungen und die praktische Arbeit auf Station.

In this replay, Spencer and Brad dive into lateral movement, discussing various techniques like RDP, RATs, Impacket tools, PsExec, PTH, PTT, and PowerShell Remoting. They explain how attackers use these methods to gain unauthorized access, evade detection, and enable malicious activities. They also discuss precursors to lateral movement and strategies to restrict it, such as least privilege access, network segmentation, and monitoring. The podcast emphasizes the importance of understanding lateral movement and implementing comprehensive security measures to mitigate these threats.Resourceshttps://www.reddit.com/r/cybersecurity/comments/1ellylu/what_lateral_attacks_have_you_been_seeing/The DFIR ReportLateral Movement, Tactic TA0008 - Enterprise | MITRE ATT&CK®Blog: https://offsec.blog/Youtube: https://www.youtube.com/@cyberthreatpovTwitter: https://x.com/cyberthreatpovSpencer's Twitter: https://x.com/techspenceSpencer's LinkedIn: https://linkedin.com/in/SpencerAlessiWork with Us: https://securit360.comBlog: https://offsec.blog/Youtube: https://www.youtube.com/@cyberthreatpovTwitter: https://x.com/cyberthreatpov Spencer's Twitter: https://x.com/techspenceSpencer's LinkedIn: https://linkedin.com/in/SpencerAlessi Work with Us: https://securit360.com

Die Schilddrüse, lateinisch Glandula thyreoidea, ist eine schmetterlingsförmige Drüse, die sich an der Vorderseite des Halses, unterhalb des Kehlkopfs, um die Luftröhre herum erstreckt. Trotz ihrer geringen Größe – sie wiegt nur etwa 20 bis 25 Gramm – ist ihre hormonelle Funktion essentiell für den Stoffwechsel, das Wachstum und zahlreiche andere Prozesse im Körper.Die Nebenschilddrüsen spielen eine entscheidende Rolle für den Kalziumhaushalt im Körper. Sie produzieren das Parathormon, kurz PTH. Und dieses Hormon ist sozusagen der Hauptregulator des Kalziumspiegels im Blut. Lerne in dieser Folge alles wichtige zur Anatomie und Physiologie der Schilddrüse und zu den Nebenschilddrüsen und deren wichtige Rolle im Hormonhaushalt.

¡Hola!En el episodio de hoy os degrano en detalle el mineral calcio, concretamente os cuento:Como absorbemos el calcio de los alimenotsQué factores nutricionales influyen en cuánto calcio absorbemosQué farmacos interfiern con su absorcion y pueden predisponernos a perder calcio a pesar de estar ingiriendo cantidades adecuadasQué hormonas controlan el calcio que absorbemos y cuales permiten que el calcio en sangre se mantengan en niveles estrechamente controlados: presentando a las hormonas PTH y calcitonina.Qué funciones cumple el calcio en nuestro cuerpo: mas alla del hueso, su papel clave en la sintesis de enzimas como al fosfodiesterasa, NO sintasa, fosfolipasa A2...Qué alimentos son los mas ricos en calcio por raciónEn qué casos puede estar justificado la toma de suplementos de calcio; siendo el ideal en estos casos el citrato calcicoPor qué la vitamina K2 (menaquinona) es clave en el manejo del calcioOjala os guste :)Para mas información ya sabéis que me tenéis en mi instagram @isabelvina dónde te comparto contenido diario Mi TikTok @isabelvinabasEn mi canal de YouTube https://www.youtube.com/channel/UC-dfdxLBcvfztBvRAKZSXGQY los suplementos formulados por mi https://ivbwellness.com

-Thủ tướng Phạm Minh Chính và Phu nhân cùng đoàn đại biểu cấp cao Việt Nam đến thủ đô Abu Đa-bi, bắt đầu chuyến thăm chính thức Các Tiểu Vương quốc Ả-rập Thống nhất (UAE).-Bão số 6 sau khi đổ bộ vào các tỉnh từ Quảng Trị đến Quảng Nam đã suy yếu thành áp thấp nhiệt đới, cảnh báo nguy cơ có mưa cục bộ cường suất lớn tại các địa phương Hà Tĩnh, Quảng Ngãi, Bình Định, Bắc Tây Nguyên.- Chủ quan khi nghe dự báo bão chuyển hướng, người dân Lăng Cô – Thừa Thiên Huế chịu thiệt hại nặng nề.-Lễ kỷ niệm 70 năm đồng bào, cán bộ, chiến sĩ và học sinh miền Nam tập kết ra Bắc sẽ diễn ra tối nay tại thành phố Sầm Sơn, tỉnh Thanh Hóa.- Cuộc đua vào Nhà Trắng đang tiến vào giai đoạn nước rút với các diễn biến theo hướng công kích - đáp trả đầy kịch tính giữa hai ứng cử viên Tổng thống Mỹ.-Tấn công khủng bố xảy ra tại Ixraen khiến hàng chục người thương vong. Chủ đề : VOV1,, Thủtướng,, UAE,, TiểuVươngquốc,, Ả-rậpThốngnhất --- Support this podcast: https://podcasters.spotify.com/pod/show/vov1thoisu0/support

Text us feedback!In this episode, Spencer and Brad dive into lateral movement, discussing various techniques like RDP, RATs, Impacket tools, PsExec, PTH, PTT, and PowerShell Remoting. They explain how attackers use these methods to gain unauthorized access, evade detection, and enable malicious activities. They also discuss precursors to lateral movement and strategies to restrict it, such as least privilege access, network segmentation, and monitoring. The podcast emphasizes the importance of understanding lateral movement and implementing comprehensive security measures to mitigate these threats.Resourceshttps://www.reddit.com/r/cybersecurity/comments/1ellylu/what_lateral_attacks_have_you_been_seeing/The DFIR ReportLateral Movement, Tactic TA0008 - Enterprise | MITRE ATT&CK®Blog: https://offsec.blog/Youtube: https://www.youtube.com/@cyberthreatpovTwitter: https://twitter.com/cyberthreatpovWork with Us: https://securit360.com

This episode of the Real Science Exchange podcast was recorded during a webinar from Balchem's Real Science Lecture Series.Dr. Goff sees three main challenges for transition cows: negative energy and protein balance, immune suppression, and hypocalcemia. About half of all older cows experience hypocalcemia, and around 3% will experience milk fever. Cows develop hypocalcemia if they are unable to replace the calcium lost in milk from either their bone or diet. Compared to the day before calving, a cow needs around 32 extra grams of protein the day of calving to meet her increased requirements. (2:00)Dr. Goff reviews the pathways of calcium homeostasis and the actions of parathyroid hormone (PTH). Aged cows may have a harder time maintaining calcium homeostasis due to the loss of vitamin D receptors in the intestine with age and fewer sites of active bone resorption capable of responding quickly to PTH once they have finished growing. Blood pH plays a role in calcium homeostasis: when blood pH becomes alkaline, animals become less responsive to PTH. Dr. Goff reviews the impacts of high vs low DCAD diets and reviews the amount of time it takes for the kidney and bone to respond to PTH. (4:20)There are several strategies to reduce the risk of hypocalcemia. One is to reduce dietary potassium so the cow is not as alkaline. Using forages from fields that have not had manure applied to them is one way to accomplish this. In addition, warm-season grasses (corn) accumulate less potassium than cool-season grasses, and all grasses contain less potassium as they mature (straw). A second strategy is to add anions such as chloride or sulfate to the diet to acidify the blood to improve bone and kidney response to  PTH. Research has shown that sulfate salts acidify about 60% as well as chloride salts. The palatability of anionic diets has led to commercial products such as Soychlor. (13:06)Dr. Goff then discusses the over- and under-acidification of diets and gives his opinion on the appropriate range of urine pH for proper DCAD diet management, including a new proposed DCAD equation to account for alkalizing and acidifying components of the diet. He also gives some options for pH test strips to use for urine pH data collection. (18:30)Dr. Goff's lab has found that as prepartum urine pH increases, the calcium nadir decreases. The inflection point is right around pH 7.5, where above 7.5 indicates a higher risk of hypocalcemia. Data from other researchers suggests that urine pH lower than 6.0 may result in lower blood calcium, indicating an overall curvilinear response. Low urine pH (under 6.0) has also been associated with a higher incidence of left-displaced abomasum. (29:02)Moving on to other minerals, Dr. Goff discusses phosphate homeostasis and how that interacts with calcium in the close-up cow. Feeding too much phosphorus can decrease calcium absorption and feeding low phosphorus diets before calving can improve blood levels of calcium. He recommends less than 0.35% phosphorus in close-up cow diets. For magnesium,he recommends 0.4% prepartum and immediately postpartum to take advantage of passive absorption across the rumen wall. (31:08)Another strategy to reduce milk fever risk is to reduce dietary calcium prior to calving to stimulate parathyroid hormone release well before calving. A zeolite product that binds calcium is now available and may make this much easier to achieve. (42:59)In closing, Dr. Goff reminds the audience that some level of hypocalcemia post-calving is normal and in fact, is associated with higher milk production. The key is making sure that the cow's blood calcium levels can bounce back to normal by day two after calving. (51:23)Please subscribe and share with your industry friends to invite more people to join us at the Real Science Exchange virtual pub table.  If you want one of our Real Science Exchange t-shirts, screenshot your rating, review, or subscription, and email a picture to anh.marketing@balchem.com. Include your size and mailing address, and we'll mail you a shirt.

With all the talk around Thyroid health, we often forget or overlook the "Parathyroid". This is a mistake because PTH can be directly influenced by stress and in turn can cause leaching of calcium from the bones and increase swelling or fluid retention in the body. The research also shows us that people with with an overactive parathyroid, also have issues with their weight. Take a listen to this solo episode to understand the parathyroid more, and understand your body more! Let me know if you have any questions in the comments or reach out to me at support@chemainesmodelhealth.com As always, please like, share and subscribe if you haven't already. :)

Unlock the secrets to effective osteoporosis treatment in this super speedy review from the Dr Journal Club podcast. Dr. Joshua Goldenberg highlights key medications from a recent BMJ systematic review and network meta-analysis. Discover why PTH agonists are the most effective for preventing clinical fractures in postmenopausal women and see how other medications compare.With over 80,000 women in 69 randomized controlled trials, the study offers crucial insights into the efficacy and safety of various osteoporosis medications, with no significant harm outcomes reported. Whether you're a healthcare professional or a concerned family member, this episode is packed with valuable information. Don't miss the basic and in-depth versions of the review available on our platform!Learn more and become a member at www.DrJournalClub.comCheck out our complete offerings of NANCEAC-approved Continuing Education Courses.

This week, the gang each bring in an acoustic album to praise or condemn. Steve brings Night Ranger's "24 Strings and a Drummer," BB offers up Dokken's "One Live Night", Dylan from his sick bed submits Metallica's "Helping Hands" and BC finishes the selection off with Russ Dwarf's "Wireless." Which album has a banjo solo? Can the PTH gang dig acoustic versions of some of their favorite songs? Tune in to find out! Hosted by Steve Wright, Brian "BC" Chapman and Ryan "BB" Bannon Produced by Dylan Wright Music by Mark Sutorka Spotify Playlist: https://open.spotify.com/playlist/3lPPO4s0U8FebYmT6FPWx5?si=351d64ac6293437f Facebook: https://www.facebook.com/PTHpodcast 

Posttraumatic headache is an increasingly recognized secondary headache disorder. Posttraumatic headaches begin within 7 days of the causative injury and their characteristics most commonly resemble those of migraine or tension-type headache. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Todd Schwedt, MD, FAAN, author of the article “Posttraumatic Headache,” in the Continuum April 2024 Headache issue. Dr. Berkowitz is a Continuum® Audio interviewer and professor of neurology at the University of California San Francisco, Department of Neurology and a neurohospitalist, general neurologist, and a clinician educator at the San Francisco VA Medical Center and San Francisco General Hospital in San Francisco, California. Dr. Schwedt is a professor of neurology at Mayo Clinic in Phoenix, Arizona. Additional Resources Read the article: Posttraumatic Headache Subscribe to Continuum: continpub.com/Spring2024 Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @AaronLBerkowitz Guest: @schwedtt Transcript Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members: stay tuned after the episode to hear how you can get CME for listening.      Dr Berkowitz: This is Dr Aaron Berkowitz, and today, I'm interviewing Dr. Todd Schwedt about his article on post-traumatic headache from the April 2024 Continuum issue on headache. Dr. Schwedt is a Professor of Neurology at Mayo Clinic in Phoenix, Arizona. Welcome to the podcast today, Dr. Schwedt.    Dr Schwedt: Well, thanks so much. It's a real pleasure to be here.    Dr Berkowitz: Thanks. We're very happy to have you. So, head trauma is common, and headache following head trauma is also very common. Let's say you're seeing an otherwise healthy young patient in your clinic who had a minor car accident a few weeks ago with some head strike and whiplash, presenting now for evaluation of headache again a few weeks out from the accident. Walk us through your approach to the history and exam here when you're seeing one of these patients. Dr Schwedt: Yeah, absolutely. I'd be happy to do so. I'll start by saying, as you mentioned, this is such a common problem - patients that are coming in with post-traumatic headache). Of course, like almost everything in neurology, it's super important to get a detailed history to start with (so, doing the appropriate interview), and I usually like to start by getting some information about the injury itself - the mechanism of the injury, and the severity, and, of course, the symptoms that went along with the potential traumatic brain injury – so things we all know about. Then, of course, it's very important to understand how the patient felt prior to the injury because we know that, amongst people presenting with post-traumatic headache, oftentimes they might have had headaches even prior to their injury, and that's because having preinjury headaches is a risk factor for developing post-traumatic headache, as well as the persistence of that post-traumatic headache. If someone had headaches prior to their injury, then of course we want to know if that actually changed or not - is there a difference in the severity, or the frequency, or in the characteristics of the headaches they've been experiencing since their injury? Then, of course, you're going to ask about exactly what the symptoms are they're having now and what's concerning them the most, realizing that for a diagnosis of post-traumatic headache, it's very important to understand the timing of the onset of these headaches in relation to the injury. By definition, post-traumatic headache should have onset within seven days of the inciting traumatic brain injury - so the diagnosis of PTH, I mean, really is dependent upon that timing -  so, using ICHD (which is International Classification of Headache Disorders) criteria, it's got to start (or be reported to have started) within seven days. It's important to realize there are no specific headache characteristics that help to actually rule in or rule out post-traumatic headaches; the criteria themselves just say “any headache,” as long as it was within that seven-day period. Having said that, though, the vast majority of people who come into the clinic for evaluation - their post-traumatic headache is going to be very similar to migraine. So, like, in other words, if they didn't tell you and you didn't ask about when the headache started and you just asked about symptoms, it would seem a lot like migraines – so, very common for the headache to be moderate and severe in intensity, be associated with light sensitivity and sound sensitivity and nausea, be worse with physical and mental exertion (very much the migraine-type characteristics). As far as diagnosis, it's also, of course, important to think about other sequelae of traumatic brain injury that could be causing the headache. For example, if you're under the impression it's a mild traumatic brain injury, but in fact, there's an intracranial hemorrhage - it wouldn't necessarily be mild any longer, but of course, that could cause headaches. We should be thinking about whether there could have been injuries to the cervical spine or the musculature of the neck that could be causing more of a muscular, cervicogenic-type headache. Think about rare possibilities, like if there was a cervical artery dissection, or if there's actually a spinal fluid leak, or, again, other things that after an injury could be causing headache. Most of the time, that's not going to be the case and you would move forward with your diagnosis of post-traumatic headache.  Dr Berkowitz: Fantastic. That's very helpful to hear your approach. You just mentioned, as you said, most patients who've had minor head trauma and are presenting with headache, fortunately, have not suffered a cervical artery dissection or CSF leak or have an evolving subdural. But when you're in this early stage (just a few weeks after the initial injury) and there is headache, what features of the history or exam would clue you into thinking that this patient does need neuroimaging to look for some of these less common, but obviously very serious, sequelae of head trauma?  Dr Schwedt: So, it's things that, as neurologists, we all know about, right? But certainly, if you're concerned about a spinal fluid leak, then really someone who has a prominent orthostatic component to their headache (so, you know, much worse when they sit up or stand up, compared to lying down) could be concerning. With a cervical artery dissection, almost always you're going to have focal neurologic deficits in addition to the headaches. With intracranial hemorrhage - again, usually it's going to be fairly obvious, in that the symptoms that someone's presenting with are much more diffuse and more severe, and maybe they're actually having progression of symptoms over time rather than stability or even early improvement. Then, as we would always say, the exam is essential, right? I mean, certainly someone who's had a mild traumatic brain injury might have very subtle deficits in things like their cognition and memory of events around the injury itself - and perhaps some ocular motor deficits and some vestibular dysfunction - but they should be relatively minor compared to somebody who has one of these other etiologies for a postinjury headache. We'll point out, of course, not everyone requires imaging, again, as there's all these decision rules out there about who needs CT, for example, after an injury (and certainly not everyone does). But, you know, if people have red flags, then of course it makes sense to initially get a CT of the head, and then if symptoms persist, perhaps an MRI. Dr Berkowitz: So, once you're confident that this is a primary headache disorder - and presuming again (as in the example I gave to start us off here) that we're just a few weeks out from the initial trauma - and the patient's presenting to you for evaluation of their headache, how do you approach treatment in these patients? Dr Schwedt: Yeah, so the specificity of your question, I think, is actually quite important - so considering the timing of when you're seeing that patient really is essential. So, if we're a couple weeks out or a few weeks out and the person is still having symptoms, that tells us something to start. The majority of people who have postconcussion symptoms are going to have resolution within a few days, or a week or two, so if someone's still having symptoms at, let's say, two weeks, three weeks, four weeks, well, then that's an indicator that, unfortunately, they're likely to continue to have symptoms for some time - when we want to be a little more aggressive, if you will, with the diagnostics and management of that patient. So, like, very early on - let's say within the first few days, or even the first week or two - some patients won't require any treatment. So, if they're having mild headaches, and maybe they take something over the counter every once in a while as it gets a little more severe, that's oftentimes fine, actually. If someone's having much more severe problems with headache (even in that very acute setting), then maybe we would give them a prescription medicine just to take for their more severe headaches. But then as symptoms progress and persist, then we should of course be thinking about other ways to - in more of a preventive approach of how to - help the patient, because, unfortunately, we don't have high-quality evidence for how to treat both acute and persistent post-traumatic headaches. The recommendation for many years (and it continues to be) is that you determine the other headache type that the PTH most resembles and you treat it like that. For example, if someone has PTH and a lot of migraine symptoms, well, then you would treat it like migraine. That might mean actually giving people specific acute migraine medications. It might mean, perhaps, putting them on migraine-preventive medications. Certainly, using other forms of therapy besides medications - maybe physical therapy is needed if someone has a lot of muscular involvement of the neck. And if they're having vestibular dysfunction from the injury, maybe they need vestibular rehab. Cognitive behavioral therapies - there's some evidence, at least, to suggest that can be helpful after an injury - so, kind of the multimodal approach. We need to make sure that people are getting good sleep, or doing what we can for that to occur (we know that sleep problems, including insomnia, are quite common after a concussion, for example), and really making sure that we're treating the whole patient. The person who is still having headaches at multiple weeks after their injury - likely they're still having other symptoms, too (some of which I just named, but other symptoms as well), like symptoms of autonomic dysfunction are quite common (like orthostatic problems; autonomic type of orthostatic problems) after an injury, cognitive problems, emotional issues - people probably are anxious and not feeling well. A lot of these folks are quite healthy prior to their injury, and all of a sudden, they have, really, a significant problem, and maybe they're missing work and missing school, and so we really have to treat the patient as a whole, of course. Dr Berkowitz: Along those same lines, I was wondering - at this early stage - the patient has had still relatively recent head trauma (they are a few weeks out from this initial injury) but still having symptoms which, as you importantly highlighted, can go well beyond headache and a number of other neurologic symptoms they might have. Very common for the patient to ask, “How long is this going to last? How long am I going to feel like this?” How do you counsel patients? Obviously, the outcomes are very variable. How do you counsel patients as an expert here,  based on seeing so many of these patients a few weeks out - as you said, an otherwise healthy patient, minor head trauma, having headache, and potentially even other concussion symptoms as you mentioned - how do you counsel them on what to expect?  Dr Schwedt: I'll start by saying that this is an area of really high interest to me and my research team, as well as my clinical team - so we're not good enough yet in being able to actually predict recovery and the timing of that recovery - but this is an absolutely essential point, and for multiple reasons. The main reason is based on the question you just asked. Of course, our patients want to know, “When am I going to get better? How long is it going to take? When can I get back to my normal life (whether that be work, or playing sports, or military, or other scenarios)?” – so, that's the most important reason. And it's important as well, because from the clinician's standpoint, if you know (or if you think you know) based on prediction that someone's highly likely to continue to have symptoms – well, again, that might help you make the decision about how (you know, I'll use the word aggressive) to be with their treatment and how closely to have them follow up, and this type of thing. It's also important for research. I already mentioned that, unfortunately, there really isn't decent quality evidence (for example, for what treatments to use for post-traumatic headache), and part of that reason for that is that there have been attempts at large clinical trials, and they've failed in a sense, and I think part of the reason for that is because there is, fortunately, such a high rate of natural resolution of symptoms that if you end up enrolling those patients into these prospective clinical trials, it makes it difficult to actually study any difference you might see between a treatment and your placebo. So, if we can have and develop good, clinically useful predictive models, that would really help in each of those domains. So what do I do now? I mean, basically, it's a little bit of a cop-out answer, but what I do is, I try to look at the trajectory that the patient has had thus far (and so, you know, this is all just logical and obvious), but if a patient is already having some degree of improvement - even if they still have symptoms, but they're having some improvement over those first three weeks - well, you would more or less consider the slope of that recovery to persist more or less at the same level. On the flip side, though, if someone's there and it's been multiple weeks - and they've just had absolutely no recovery and maybe they're even feeling worse - then I'm more concerned that this might be a longer-term issue. Dr Berkowitz: That's helpful to understand both your approach and the challenges in making a firm statement on counseling our patients and using (as has been a theme in many of your helpful responses today) just, sort of, the clinical trajectory and what information that patient's giving you to try to help with the prognosis (however ambiguous it may be) and just needing time to see how the patient does. Dr Schwedt: I might just add as well, though, that there are studies that have suggested there are certain risk factors for prolonged recovery from post-traumatic headache (and there's some limitations to these studies, so, really, validation is needed), but for post-traumatic headaches specifically, I mean, probably the biggest risk factor for persistence of the post-traumatic headache is having headaches prior to the injury. So, for example, people who have migraine before TBI that then are having an exacerbation or a new headache after the injury - unfortunately, they're less likely to have resolution during the acute phase. Other factors include the severity of the injury itself - so there are certain features of the injury that if, you know, it is seemingly more severe, maybe their likelihood for resolution in the acute phase is lower. And then there are multiple other factors that have been suggested as well, including the patient's own expectations for recovery, which I find to be quite an interesting one.  Dr Berkowitz: Yeah - very important points. So, let's say that, unfortunately, the patient does continue to have headache now several months out after the trauma; how do you approach these patients with respect to treatment? Dr Schwedt: Yeah. Once someone's gotten to that point, they probably really are going to need more in the way of preventive measures (and, you know, I did mention some of these). So, if someone's having migraine-like PTH, well, then I'm probably going to end up putting them on medicines that I would use for prevention of migraine. You know, you do have to be especially careful, though, in these individuals who have had TBIs, because you want to make sure that the treatments you're starting aren't going to actually exacerbate their other symptoms, right? So, of course we know some of our migraine preventives can cause things like hypotension, or, you know, cause things like insomnia or cognitive problems, as side effects, and if people are already having those issues from their TBI, then we could actually make them overall feel worse even if we make some progress for their headaches. So, you know of course, we're always careful when thinking about side effects from these medications, but especially so, perhaps, in the patient with a concussion who's having some of these symptoms anyway. And then again - just to highlight, it's not all about medication - that's one small aspect here (one important, but perhaps small, aspect here). So, really, trying to get at lifestyle measures that can be helpful - so, again, sleep, and trying to help people to moderate their stress levels, and making sure that they have an environment that's going to facilitate the recovery (meaning, if they're having a lot of light sensitivity and sound sensitivity and these types of things, you know, doing what we can to help these individuals to be in environments that will allow them to recover). Dr Berkowitz: Yeah, all very important points - medication being just one part of treatment for these patients, as you said. But to just ask another question about medication so our listeners can learn from your expertise - I'm a general neurologist, and my experience with patients with post-traumatic headache and migraine and otherwise is that it's hard to predict who will respond to which medication (and some patients who failed many pharmaceutical medications will have an amazing response to riboflavin and vice versa) - in your experience (acknowledging that we are very limited in terms of data here), are there any migraine prophylactic agents that you feel, anecdotally, have been particularly helpful in patients with post-traumatic headaches or similar to the general migraine/tension headache population? It's very hard to predict, and it's trial and error and picking the right medication and finding the right dose (just depends on the patient). It requires the patient's patience - and our patience as well - as we sort of go through some trial and error. Dr Schwedt: Yeah, I guess. You can hardly even imagine how much I want to answer this question by saying, "Yes, with my experience, I've found that it's these two classes of medications that really work the best for folks with acute or persistent post-traumatic headache,” - but that would be disingenuous. It's so much like it is in migraine, where there is some trial and error, and, you know, again, as you say, it's so difficult to predict exactly which one is going to be the right pharmacologic agent for which patient. If access was no issue, I would go to medications that have the least side effects (which tend to be some of the newer medicines that we have for migraine), but we all know the realities of practice, and oftentimes, that's not a possibility due to access issues. Almost all of our patients that have significant postconcussion symptoms are also being managed by our neuropsychologists - and so, again, they're getting things like cognitive behavioral therapy and getting things like cognitive rehab, and they also are very helpful when it comes to workplace or school-place recommendations and accommodations. Many of our patients are being seen by our vestibular audiologists, as well, to work on their vestibular dysfunction, and vestibular rehab with physical therapy and occupational therapy. And so, you know, as you say, once you get out to multiple months, this is really a multidisciplinary, comprehensive type of treatment approach.  Dr Berkowitz: Let's say the patient has now gone one to two years out from their initial injury and you had started them on a prophylactic agent (or found the one that works for them maybe after a few trials), and they're doing great (no headaches for several months; otherwise young, healthy person), and they ask you, “Well, do you think I can just go ahead and try coming off these medications now? My injury is a long time ago. While those first few months were awful - thank you for helping me to get these headaches under control - do you think if I go off this medicine, that my headaches will come back, or am I sort of in the clear now?” How do you think about tapering patients off of preventive medications when they've had a good response at a year or so out? Dr Schwedt: That's so important, right? I mean, I think we all see patients that we inherit that end up kind of being left on medications that perhaps aren't even needed anymore, and it's certainly a mistake we wouldn't want to make. Post-traumatic headache - unlike primary headaches like migraine that tend to be present for decades - they can go away; they can resolve, and they usually do. I mean, we can't lose sight of that, right? Usually, it's going to go away on its own (as I mentioned, you know, within the first few days or weeks), and even after it's become persistent, if you can get a good treatment response, then, absolutely, after several months of that good treatment response, we should be tapering people off. Just like with any headache patient who's on a preventive, I would recommend tapering off of the effective treatment slowly, so if that's a medication, I'm usually very slowly just reducing the dose over several weeks or months (depends on how long they've been on it), usually not because I'm concerned about side effects of withdrawing the medication, but you're just testing it to make sure that the headaches aren't starting to creep back as you reduce the dose of that medication. So, it's a test, and if headaches do start to come back as you're lowering the dose, well, then, presumably you can more quickly get control of it again by elevating the dose back to where it was previously effective. For medications and treatments that don't really have dosing, the other way of doing it - so, you know, some of our medicines, of course, are given at one dose but given at intervals (like, let's say, each month or every three months) where you can't really reduce the dose - you can increase the interval between treatments. So, if you're supposed to have a treatment every month, well, if someone's doing really well, then maybe you say, “You know what? Give it an extra week.” Maybe do it in five weeks instead of four or six weeks. In that same way, you're kind of testing whether or not the medication is still really needed. Dr Berkowitz: Yeah, that makes sense as an approach here. In addition to your clinical expertise, Dr Schwedt, you're also a researcher in this area. Tell us, what's on the horizon for the future of diagnosis and treatment of patients with post-traumatic headache?  Dr Schwedt: There's a lot of exciting things on the horizon. It's really encouraging that despite, for example, the lack of evidence currently that we have for treatment, and perhaps not as much preclinical and clinical research into post-traumatic headache as we need, the exciting part is that there's a lot going on. Fortunately, the funding environment for such research has been decent over the past so many years, and so, again, there's almost certainly going to be meaningful breakthroughs here in the near future. Some of our own work - for example, we do a lot of neuroimaging research of post-traumatic headache. One of the main areas of controversy in the headache field is whether or not post-traumatic headache and migraine are really the same thing or are they truly distinct headache disorders? And so, like, a lot of our work has gone towards addressing that - both through neuroimaging, as well as just examining outcomes and symptoms and whatnot - to see where there are similarities and differences. And I'm absolutely biased when it comes to addressing this, but I feel strongly that they really are distinct headache disorders. And that's important, because that means that we need to continue to study them as distinct disorders and we can't just fall back to the idea of saying, “Well, PTH of a migraine phenotype is migraine, and we already have migraine therapy, so let's just use those,” because I think all of us that see patients with PTH in clinical practice realize that our migraine treatments don't work as well for PTH as they do for migraine. So, we really need to continue down the path of understanding the mechanisms underlying PTH, the mechanisms of what makes PTH persist (you know, why it persists in some people and not others), and then what we can do to intervene. I think a major topic, I believe, in determining best treatment approaches is also kind of related to the way you were asking me these questions - it's related to the timing of the intervention. Much of what's been done in studying treatment of PTH is done after it's already persistent, and so in some of these studies, including ours (I mean, it's not a criticism; including ours) - sometimes, these people have had post-traumatic headache for five years or ten years at the time that you enroll them into a study. And, you know, at that point, that's probably a very different population as far as mechanisms and who might respond to which treatments (compared to if you were studying those folks, let's say, in the first few weeks or in the first couple months). There's preclinical evidence (from rodent models of mild traumatic brain injury and post-traumatic headache) that the earlier you intervene, the more effective that intervention is going to be in treating that headache and preventing its persistence, and I would think we could logically presume that's probably the case in people as well. But, of course, we don't want to expose everybody early on to treatments if they don't need it (I mean, if they're going to have natural resolution, then that would actually be inappropriate [to expose them to treatments]). And that's where the prediction comes in. If we had good predictive models of - oh, you know, even though they're only a week into their headache, based on their pre-TBI factors and other characteristics, that they're very likely to have persistence - well, maybe that's the patient where they should have an earlier intervention, and, you know, in another patient, maybe not.  Dr Berkowitz: It's great to hear about your work and the work of others to help us understand this very, very common condition (and that's been a theme in many of our questions), one in which we do our best, but are often limited by, our scientific understanding and the data on how to best manage these patients' headaches. I've learned a lot from our discussion - both clinically, and I'm excited to have learned more about your work and what's on the horizon to help us take care of these patients. Thank you very much, Dr Schwedt, for joining me on Continuum Audio today. Again, for our listeners, I've been interviewing Dr Todd Schwedt, whose article on posttraumatic headache appears in the most recent issue of Continuum on headache. Be sure to check out other Continuum Audio podcasts from this and other issues. Thank you so much to our listeners for joining today.    Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. And right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024, or use the link in the episode notes, to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.    

I veckans avsnitt diskuterar vi ifall män har en skyldighet att dölja sitt paket in public, vad PTV & PTH betyder, ifall man kramar en grabb som är nere, vad som anses vara rimlig tid innan man introducerar sin baby för päronen och ifall det är olika beroende på ursprung, prioritet av ens relation kontra ens egna intressen och vänner, hur närvarande man behöver vara när man spenderar quality time med sin baby, den kortes resa mot ett hälsosamt 2024 och mycket mer!Glöm inte att följa oss på instagram @Sagdetbara samt @sdbevents då vi har en fullspäckad vår med kul eventsSupport till showen http://supporter.acast.com/sagdetbara. Hosted on Acast. See acast.com/privacy for more information.

The parathyroid glands may be small, but their impact on our health is monumental. These four tiny glands regulate blood calcium levels via parathyroid hormone (PTH), vital for the optimal functioning of our brain, muscles, nerves, and many bodily processes. Primary hyperparathyroidism is more common than most people realize and is often misdiagnosed. This occurs when the parathyroid glands secrete too much PTH, causing elevated blood calcium levels.While it can happen at any age, the risk increases as you get older, and it is most common in postmenopausal women. Unfortunately, because of that, it often flies under the radar, with the symptoms mistakenly being attributed to menopause.Today, I'm joined by Dr. Deva Boone, one of the most experienced parathyroid surgeons in the U.S. She was the Medical Director and Senior Surgeon at the Norman Parathyroid Center until 2020, when she left to open the Southwest Parathyroid Center in Phoenix, Arizona. In this conversation, Dr. Deva and I discuss how the parathyroid glands regulate calcium levels in your bloodstream, the role of calcium in the body, the prevalence of primary hyperparathyroidism, the importance of vitamin D in calcium metabolism, challenges of diagnosing parathyroid issues, the necessity of experienced surgeons for parathyroid surgery, and more. Enjoy the episode!To learn more, visit the show notes at https://savemythyroid.com/podcast/what-you-need-to-know-about-the-parathyroid-glands-with-dr-deva-boone-133/. Do You Want Help Saving Your Thyroid? Access hundreds of free articles at www.NaturalEndocrineSolutions.com Visit Dr. Eric's YouTube channel at www.youtube.com/c/NaturalThyroidDoctor/ To work with Dr. Eric, visit https://savemythyroid.com/work-with-dr-eric/

In this episode, The PKD Dietitian talks about three labs she wants you to ask for each year - Vitamin D, PTH, and Uric Acid. Learn more about the labs, why they are important for your kidney health, and your next steps to be a proactive member of your healthcare journey. RESOURCES: EPISODE 17: Vitamin D and PKD: How To Supplement Safely BLOG: The Ultimate Guide to Vitamin D and Polycystic Kidney Disease JOIN: The PKD Nutrition Academy Do you have a question for the PKD Dietitian or a topic you would like covered? >>> Contact The PKD Dietitian

Absorb all (but not too much) of the Calcium for your brain hole as Dr. Carl Pallais (Brigham and Women's Hospital) walks us through his approach to Hypercalcemia. We learn about how tightly our body regulates calcium and what to do when that regulation goes awry.  Not to mention that PTH is the name to remember (and phosphorus, if you need a quick stand-in while that PTH is pending).   Claim CE credit at curbsiders.vcuhealth.org. It's free for all healthcare professionals! Absorb all (but not too much) of the Calcium for your brain hole as Dr. Carl Pallais (Brigham and Women's Hospital) walks us through his approach to Hypercalcemia. We learn about how tightly our body regulates calcium and what to do when that regulation goes awry.  Not to mention that PTH is the name to remember (and phosphorus, if you need a quick stand-in while that PTH is pending).  Show Segments Intro, disclaimer, guest bio Dr. Pallais One-Liner Case from Kashlak Definitions: What's a Normal Calcium Level, and how to adjust for Albumin Causes of hypercalcemia How Lithium works!  Testing for Hypercalcemia: Get that PTH, and that phos  Symptoms of Hypercalcemia, and Questions on History  Indications for Surgery for Parathyroidectomy  Management of Hypercalcemia and Hypercalcemic Emergency  Outro Credits Producer, Writer, Infographic, Cover Art: Nora Taranto MD  Hosts: Matthew Watto MD, FACP; Nora Taranto MD   Reviewer: Yan Emily Yuan MD, MSc Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com Guest:  Carl Pallais MD, MPH  Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com Sponsor - Glass Health Glass Health was founded in 2021 and has the mission of empowering doctors with AI-powered clinical decision support.  Glass helps clinicians to draft differential diagnoses and draft clinical plans using physician-validated context.  You can also use Glass to capture knowledge of all the schemas, scripts, cases, and pearls that you encounter and leverage them to take better care of patients.  Try Glass for yourself by visiting https://glass.health Personal knowledge management features are completely free and with Glass Pro, you get access to their powerful AI. You can get one month of Glass Pro free by signing up at https://glass.health and using the code CURBSIDERS. Glass, like a clinical reference text or podcast, should never replace clinician judgment.  Sponsor - PatternAt Pattern, we give you a quick, simple way to compare and buy disability insurance. Busy doctors shouldn't have to worry about whether or not they are getting the best rates and discounts. Trying to research all your options and make the right decision while in training can make the process even more overwhelming. That's why thousands of doctors trust Pattern to help them compare and understand the disability insurance they are buying.  We do this in three simple steps: First off, request your quotes online at patternlife.com/curbsiders. Second, compare your options and ask questions. And third, secure your policy! So check disability insurance off your list today! Be confident that you have the right policy so that your income is protected. With huge discounts for doctors in training, now is truly the best time to request your disability insurance quotes with Pattern at patternlife.com/curbsiders.

This week on BackTable Urology, Dr. Manoj Monga (UC San Diego) invites Dr. Margaret Pearle (UT Southwestern) to discuss kidney stone prevention with lifestyle changes and medical therapy. --- SHOW NOTES First, the doctors reflect on Dr. Pearle and Dr. Yair Lotan's paper from 2008 that predicted the impact of climate change on kidney stones. Dr Pearle then shares her recommendations for lifestyle changes to prevent kidney stones, such as increasing fluid intake and reducing sodium and animal protein intake. She also advises on reducing oxalate intake in diets and maintaining adequate calcium intake to ensure bone health. Next, the doctors discuss strategies for treating and preventing stones with medical therapy. They explore the use of thiazides and potassium citrate for both calcium oxalate and calcium phosphate stones, as well as the importance of evaluating PTH levels and serum uric acid levels in these patients. They also discuss the role of dietary oxalate and bowel disease in determining when to order genetic testing. Additionally, they explore the nuances of treating hypercalciuria with thiazide holidays and the use of potassium citrate as a second line therapy. Potassium citrate is beneficial for alkalinization and citrate supplementation. There are different benefits when comparing the liquid formulation to the tablets. Finally, they discuss the use of urinary pH and xanthine oxidase inhibitors, the importance of genetic testing, and the importance of fluid intake and potassium citrate for cystine stones. --- RESOURCES Brikowski TH, Lotan Y, Pearle MS. Climate-related increase in the prevalence of urolithiasis in the United States. Proc Natl Acad Sci U S A. 2008 Jul 15;105(28):9841-6. doi: 10.1073/pnas.0709652105. Epub 2008 Jul 14. PMID: 18626008; PMCID: PMC2474527.

Welcome back to our weekend Cabral HouseCall shows! This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track! Check out today's questions:    Carol: Can staying in a hot car get similar benefits to sauna? Hot cars are common. Saunas are not. Since it's summer, cars get hot. Can I get similar benefits to sauna by staying in a hot car? How would I modify the temperature in the car?   Alicja: Hi Dr.Cabral, I hope you are doing well. I have question about Leptin hormone. I'm 40yo, BMI 18. I recently put on 15 lbs (I was underweight before) I noticed it is very difficult for me to get full. When I'm done eating my meals, I keep going back to kitchen for more food, because I still feel hungry. Sometimes it feels like I need to eat half of my kitchen to finally satisfy my hunger. I recently run some lab tests. They showed that my leptin levels are out of range, very very low. How can I balance my leptin levels? I'm happy with my current weight and don't want to put on any more lbs. My diet is very clean and I'm very active physically. I hope you have some advice for me. Thank you in advance for all your help.   Jennifer: I searched your podcasts for hyperparathyroidism. Didn't find any. For 12-13 years now my PTH has been 225-370. My serum calcium is low-low normal and my Vitamin D is 40-70. Hx insomina, worsening severe chronic constipation and brain fog/memory, vision that is more blurry but eye dr says it isn't changing, fatigue. Hx Stage III Lobular Breast Cancer (Dx in 3/2012) and 1 month after my bilateral hysterectomy and complete hysterectomy (so 5/2012) my PTH actually dropped to 81. However, 3-6 months later it was quite elevated again. Has your program helped anyone in my situation?? I've been to so many doctors, homeopaths, herbalists and no changes. Need help! Thank you for your time!!   Karen: My mother is 74 and was diagnosed with Parkinson's around 2.5 years ago. She is still fully capable of moving around (albeit with some pain from Parkinson's and Rheumatoid Arthritis) and she started seeing a trainer around 9 months ago who has really helped her. What other things can we try to help minimise the onset of Parkinson's symptoms both physically (the shakes combined with Arthitis) and mentally (eg anxiety and depression)?   Terra: Hi, Dr. Cabral! Thank you for everything you do. My question is about R-CPD. I was wondering if you've heard of it? Basically I cannot burp. The only way to relieve the pressure is to stick my hand down my throat and press down on my sphincter. It causes tremendous discomfort and I think contributes to issues digesting and absorbing nutrients. I brought this up to a health coach and they seemed to dismiss this, but after filtering through all my issues, this seems to be the root cause. As of now the only treatment I know of is for a doctor to inject botox to paralyze the sphincter so you can retrain the muscle. So, my question is, what do you think is the best way to go about this? Is there alternative solutions? Or is the botox the best and safest way? Thanks!   Thank you for tuning into today's Cabral HouseCall and be sure to check back tomorrow where we answer more of our community's questions!    - - - Show Notes and Resources: StephenCabral.com/2815 - - - Get a FREE Copy of Dr. Cabral's Book: The Rain Barrel Effect - - - Join the Community & Get Your Questions Answered: CabralSupportGroup.com - - - Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - Get Your Question Answered On An Upcoming HouseCall: StephenCabral.com/askcabral - - - Would You Take 30 Seconds To Rate & Review The Cabral Concept? The best way to help me spread our mission of true natural health is to pass on the good word, and I read and appreciate every review!  

Host Aaron Lohr talks with two researchers at ENDO 2023, Kyle Horlen, DVM, and Joshua Myers, both from Rani Therapeutics, about two presentations they made about an oral treatment of teriparatide for the treatment of osteoporosis. The two presentations are titled, “Pharmacokinetics (PK) and Pharmacodynamics (PD) of the Parathyroid Hormone Analog PTH (1-34) (Teriparatide) Delivered via an Orally Administered Robotic Pill (RT-102),” and “An Orally Administered Robotic Pill (RP) Reliably And Safely Delivers the Human Parathyroid Hormone Analog hPTH(1-34) (Teriparatide) With High Bioavailability in Healthy Human Volunteers: A Phase 1 Study.” For helpful links or to hear more podcast episodes, visit https://www.endocrine.org/podcast.

Host Aaron Lohr talks with two researchers at ENDO 2023, Kyle Horlen, DVM, and Joshua Myers, both from Rani Therapeutics, about two presentations they made about an oral treatment of teriparatide for the treatment of osteoporosis. The two presentations are titled, “Pharmacokinetics (PK) and Pharmacodynamics (PD) of the Parathyroid Hormone Analog PTH (1-34) (Teriparatide) Delivered via an Orally Administered Robotic Pill (RT-102),” and “An Orally Administered Robotic Pill (RP) Reliably And Safely Delivers the Human Parathyroid Hormone Analog hPTH(1-34) (Teriparatide) With High Bioavailability in Healthy Human Volunteers: A Phase 1 Study.” Show notes are available at https://www.endocrine.org/podcast/enp73-a-robotic-teriparatide-pill-to-treat-osteoporosis — for helpful links or to hear more podcast episodes, visit https://www.endocrine.org/podcast

Host Aaron Lohr talks with two researchers at ENDO 2023, Kyle Horlen, DVM, and Joshua Myers, both from Rani Therapeutics, about two presentations they made about an oral treatment of teriparatide for the treatment of osteoporosis. The two presentations are titled, “Pharmacokinetics (PK) and Pharmacodynamics (PD) of the Parathyroid Hormone Analog PTH (1-34) (Teriparatide) Delivered via an Orally Administered Robotic Pill (RT-102),” and “An Orally Administered Robotic Pill (RP) Reliably And Safely Delivers the Human Parathyroid Hormone Analog hPTH(1-34) (Teriparatide) With High Bioavailability in Healthy Human Volunteers: A Phase 1 Study.” Show notes are available at https://www.endocrine.org/podcast/enp73-a-robotic-teriparatide-pill-to-treat-osteoporosis — for helpful links or to hear more podcast episodes, visit https://www.endocrine.org/podcast

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

This week, Paul breaks down his latest set of bloodwork from March 2023. He not only reviews his own levels and ratios, but gives you an idea of what blood work you may want to order, and how to interpret it. 00:04:20 Why you may consider getting your own blood work done 00:11:00 What Paul eats in a day 00:13:40 Fasting insulin & prolactin 00:19:55 Cortisol to DHEA-S ratio 00:27:42 Sex hormones & phlebotomy 00:37:35 DHT 00:40:35 How to help (or hurt) your testosterone 00:48:45 Uric acid & GGT 00:50:30 Hemoglobin A1c & Comp. Metabolic Panel 00:53:20 Urinalysis  00:54:50 Amenorrhea profile, Prostate-Specific Ag, IGF-1, Reverse T3, Vitamin D, Lipoprotein (a), C-Reactive Protein 00:58:17 TMAO: is it harmful? 00:59:25 Homocysteine, Magnesium,  and TSH & Free T4 01:00:50 Lipids: do they matter? 01:05:20 CBC 01:06:20 Conclusions about blood work 01:07:45 NAFLD Paul's recommendations for what labs you should get: CBC Comprehensive Metabolic Panel Fasting Insulin PTH Full thyroid panel, TSH, antibodies, Free T3, Free T4, Testosterone, Free Testosterone, Sex hormone LH, FSH, Prolactin, DHT, Estrogens, Progesterone, Preglinulone, Cortisol, DHEA-S, HSCRP, Liver enzymes, Lipid panel, (Coronary Artery Calcium Scan), PTH. Sponsors: Heart & Soil: www.heartandsoil.co Carnivore MD Merch: www.kaleisbullshit.shop Make a donation to the Animal Based Nutritional Research Foundation: abnrf.org  Animal-based 30 Challenge: https://heartandsoil.co/animalbased30/ Earth Runners: www.earthrunners.com, use code PAUL for 10% off your order  Eight Sleep: $150 off the PodPro cover at www.eightsleep.com/carnivoremd Zero Acre: www.zeroacre.com/PAUL or use code PAUL for free shipping on your first order Bon Charge: boncharge.com, use code CARNIVOREMD for 15% off your order

María H. Bascuñana, especializada en Inmunonutrición, docente y también autora del libro "VitaminaDos", rompe mitos con datos actualizados sobre la Vitamina D. La Vitamina D es vital en nuestra salud porque se ha relacionado con trastornos autoinmunes, infecciosos, alérgicos, cardiovasculares, neurológicos, óseos, inflamatorios, depresión y cáncer, además mejora la absorción de calcio, magnesio, fósforo y zinc.Esta es la Parte I de una entrevista reveladora. Entra el código COMOCURAR y recibe un 10% de descuento en tu primera compra: https://store.dracocomarch.com/es/inicio/472-825-silkface.html#/191-cant-1_unidadhttps://store.dracocomarch.com/es/inicio/475-835-happy-tummy.html#/191-cant-1_unidadhttps://store.dracocomarch.com/es/inicio/80--vitamin-d-10000-iu.htmlGuía del episodio:05:55 Cómo saber si tienes déficit de Vitamina D09:00 El gran engaño sobre los niveles necesarios16:30 Qué es el PTH y por qué es tan importante24:00 ¿Deberías incluir calcio para unos huesos fuertes?34:20 Los 3 suplementos que No te pueden faltar35:55 Cuánta Vitamina D necesitas al díahttps://www.facebook.com/CocoMarchNMDhttps://www.instagram.com/cocomarch.nmd/https://www.youtube.com/channel/UCyT1tdUjfnbA-4Cqrz8BwFghttps://blog.dracocomarch.comhttps://store.dracocomarch.com/es/https://podcast.comocurar.com/

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

In this episode of BackTable, Dr. Ashley Agan and guest co-host Dipan Desai (Johns Hopkins) interview David Goldenberg (Penn State) about evaluation and surgical management of parathyroid disease. --- SHOW NOTES First, the doctors discuss the typical primary parathyroid disease presentation. Patients often report non-specific symptoms, such as fatigue, abdominal pain, sleep issues. Primary hyperparathyroidism is most common in perimenopausal women and is easily misdiagnosed. However, Dr. Goldenberg notes that an elevated serum calcium and PTH level on labs without other causes are diagnostic of primary hyperthyroidism. It is important to rule out other reasons for an elevated calcium level, such as malignancy, thiazides, and lithium. For borderline patients with slightly high parathyroid and calcium levels, the diagnosis is a clinical decision. Dr. Goldenberg may order more imaging studies or check labs again in 6 months. Furthermore, secondary parathyroidism is related to kidney disease and should be treated medically first. Dr. Goldenberg utilizes a 4D CT scan to localize the overactive parathyroid gland. He notes that a majority of patients will have a single adenoma. Some may have multiple parathyroid glands affected (e.g. 4 gland hyperplasia), and 1% of his patients will have an aggressive parathyroid carcinoma. Parathyroid carcinoma patients usually present with incredibly high calcium and PTH levels. He notes that 4D CT is the most accurate imaging modality for parathyroid visualization; ultrasound is affected by air and bone and a SPECT scan will not detect small or flat adenomas. Next, Dr. Goldenberg discusses his surgical technique. He makes a clavicle incision at midline and uses the middle thyroid vein to find parathyroid glands. If he is manipulating the superior thyroid glands, he is careful not to damage the recurrent laryngeal nerve. For a 4 gland exploratory surgery, he finds all 4 glands before taking any of them out in order to make sure he is taking out the right one. He can usually distinguish the parathyroid glands from the surrounding tissues because of their unique brown color. If he is unsure about whether the sample he took out is a parathyroid gland or another type of tissue, he will send frozen sections for pathologic analysis. Other pearls he has are: picking up the parathyroid glands from their capsule to preserve blood supply, always using nerve monitoring, and common anatomical locations for missing parathyroid glands. He checks the PTH level before operating and again 15 minutes after parathyroid gland removal to see if he removed the offending gland. If there is at least 50% drop from the baseline PTH level, he considers the surgery a success. Then, Dr. Goldenberg summarizes his post-operative care. For patients who underwent exploration surgery, he usually keeps them in hospital for 23 hours. Simple parathyroidectomy patients can be discharged on the same day. Patients also receive a calcium taper with calcium carbonate because of the risk of hungry bone syndrome, a condition where serum calcium is depleted quickly because of rapid bone absorption, leading to hypocalcemic symptoms. Hyperparathyroid symptoms usually abate very quickly after surgery. Finally, he discusses his new textbook and atlas, which contains key points and pearls, quiz questions, annotated bibliographies, and surgical videos about head and neck endocrine surgery. --- RESOURCES Head & Neck Endocrine Surgery: A Comprehensive Textbook, Surgical, and Video Atlas by Dr. David Goldenberg: https://shop.thieme.com/Head-Neck-Endocrine-Surgery/9781684201464

A toddler is taken to his pediatrician because his parents are concerned he might be small for his age. The pediatrician diagnoses him with knock knees, but there's no cause for alarm.Although the child doesn't have any other known medical conditions, something is happening in secret, inside his DNA that won't be discovered until a diagnosis of hypophosphatemia is discovered some time later. And if this disease is ignored, it can quickly become deadly. But back to that first appointment. “At that time, he had a rather normal diet, was taking [multivitamins] so his intake of vitamin D was at the recommended daily allowance,” shares Dr. Michael Levine, a pediatric endocrinologist at the Children's Hospital of Philadelphia. “And because he had no other medical disorders and no other conditions that were of concern, his pediatrician decided that they would just watch him to see whether he could outgrow his knock knees, and whether this might improve his overall growth.”At the age of 7, there is little to no progress. He visits an endocrinologist. Nothing significant is found. At 10, an orthopedic surgeon operates on the child's knock knees. Two years later, he visits Dr. Levine for the first time. “When we first saw him, we were impressed by his prior history of knock knees, which had its onset in his toddler years, and we looked carefully at the evaluation that his pediatric endocrinologist had performed some years prior that disclosed normal levels of serum calcium, normal levels of PTH, normal alkaline phosphatase, and a normal serum 25-hydroxy vitamin D, which in the mind of the first pediatric endocrinologist had effectively ruled out rickets or osteomalacia.”But one test hadn't been done — a test for serum phosphorus level, and when the results come back showing hypophosphatemia, this becomes a key to the child's diagnosis. “When you have a child that doesn't respond as you might expect to calcium and vitamin D,” advises Dr. Levine, “you have to take that next step and begin to ask, could this be due to a genetic defect in the vitamin D system, or could it be a genetic defect in phosphate metabolism?” As it turned out, the child's disease was genetic, and this unlocked the path to treatment. And while everything worked out in the end, it's hard not to think about how this story could have been very different had one simple test been run, or if genetics had been considered sooner.

Mental health issues are difficult enough to handle. But for the millions of people who are living with a physical disability too, the journey can be even tougher.  Today's guest, Alyssa Cleland, was born with a one-in-a-million condition called paraxial tibial hemimelia, which led to the amputation of her leg. But with the aid of a prosthetic, Alyssa has made a name for herself as a para-equestrian and social media influencer, helping to shine a light on all that she – and others with disabilities like PTH – is capable of.  In this episode, Alyssa talks about growing up with a disability, being adopted from Ukraine into a marathon-running, sports-loving family, and her journey of self-love.   “After doing a lot of healing and things like that – which like, obviously there's still more [to do] – I think I've just come so to terms with who I am, what I have going on and blah, blah, blah, that like, I just don't care, you know? And I'm gonna be myself. If you don't like it, then that's cool. We're not meant to be in the same, you know, atmosphere together. And I'm okay with that.” – Alyssa (42:48)   She also shares about her experiences with mental health, the strategies she uses to keep herself thinking positive, and how she became determined to live her best life.   “I was able to like, comfort myself in knowing that, ‘Hey, like I didn't cause this to myself.  I didn't ask for this. And I can't do anything about it.' So either I can sit and be shameful of something that I have no control over or I can get the f*ck over it and live my life to the best that I can. And that's what I decided to do. …  It's definitely a fight every day, but I think it's a fight worth fighting.” – Alyssa (06:20)    In This Episode (03:20) Competing as a para-equestrian (05:06) Growing up with a disability  (08:02) What is paraxial tibial hemimelia? (10:25) Being adopted and having a leg amputation in childhood (15:28) Alyssa's “sticky sock vacation” at nine (22:51) The journey to sharing her story on social media (26:57) How Alyssa keeps herself thinking positive (30:09) The role of faith in Alyssa's life (33:31) Life with prosthetics  (40:22) Dealing with strangers as an amputee   Our Guest Alyssa Cleland is an influencer, para-equestrian and disability rights advocate.   Resources & Links Off The Cuff https://www.offthecuff.fm/ https://www.youtube.com/c/OffTheCuffwithDannyLoPriore https://www.instagram.com/1and1otc/ https://www.instagram.com/dannylopriore/ Alyssa Cleland https://www.tiktok.com/@alcequine_ https://www.instagram.com/alyssatheamputee/

Leo Karl Hanke lives near Trent, in northern Italy. He was born in West Berlin in 1984. From the age of 1 he lived in Italy near Venice, where he grew up and went to school. After school he studied design in Milan for 2 years, and then he changed his mind and started medical school in Verona. While he was studying, in 2012 he got multiple sclerosis, which remained undiagnosed for 2 years. After the diagnosis in 2014, he was left with no therapy for one whole year, so he started to look for some alternatives to the standard therapy. In 2016 he started a protocol that uses high doses of vitamin D (Coimbra protocol), and thanks to it since then he has MS in total remission. The Coimbra Protocol revolves around the concept of resistance to vitamin D, which has been proven to be a real thing, and can easily be measured. At the same time, he also had severe GI problems (recurrent diverticulitis, IBS, reflux), and in 2017 he got his sigma removed because of that. The operation didn't fix the root cause of his problems, so he started to look for dietary solutions. He started keto in 2018, then carnivore in 2019 after watching the JRE episode with Shawn Baker. Before carnivore in addition to the GI problems, he was obese and suffered from insomnia, bad anxiety, hypertension, joint pain, and severe concentration and memory problems. All these symptoms totally resolved thanks to the carnivore diet and he lost 40 kg of weight. His memory and concentration came back, and he had plenty of energy, so in 2020 he finally graduated from medical school. Since 2021 he does night shifts as a MD for urgencies, and in April this year he started attending a school to become a family doctor. Last year he also got a Masters degree in ketogenic diets and started a small YouTube channel where he talks about medicine (mainly vitamin D). Timestamps 00:00 Introduction 01:12 Vitamin D 07:29 Kidney role in vitamin D metabolism 10:08 MS, ketogenic diet, vitamin D 13:40 Shawn Baker on Joe Rogan Podcast 20:12 Cholesterol and the immune system, vitamin D 26:38 Vitamin D versus diet 30:46 Weight-bearing exercise for bone health 31:30 NAFLD and vitamin D 33:50 Coimbra protocol 36:35 Neurologists and Coimbra protocol 40:39 Vitamin D toxicity, titrating vitamin D 43:54 Autoimmune disease and higher level of PTH 46:48 All autoimmune diseases respond to Coimbra protocol 49:19 Other improvements with Coimbra protocol and carnivore diet 53:02 Where to find Leo Hanke See open positions at Revero: https://jobs.lever.co/Revero/ Join Carnivore Diet for a free 30 day trial: https://carnivore.diet/join/ Book a Carnivore Coach: https://carnivore.diet/book-a-coach/ Carnivore Shirts: https://merch.carnivore.diet Subscribe to our Newsletter: https://carnivore.diet/subscribe/ . ‪#revero #shawnbaker #Carnivorediet #MeatHeals #HealthCreation   #humanfood #AnimalBased #ZeroCarb #DietCoach  #FatAdapted #Carnivore #sugarfree  ‪

Permission to Heal Episode #76 - A Conversation with Dr. Stuart Shanker about Learning to Self-Regulate Stress. Dr. Stuart Shanker, Ph.D. is a Distinguished Research Professor Emeritus of Philosophy and Psychology, the Founder & Visionary of The MEHRIT Centre, Ltd., and Self-Reg Global Inc. One of his many books, “Calm, Alert and Learning: Classroom Strategies for Self-Regulation (2012)”, is a top-selling educational publication in Canada., Self-Reg: How to Help Your Child (and You) Break the Stress Cycle and Successfully Engage With Life (2016), has garnered enthusiastic reviews and media attention throughout North America, the United Kingdom, Poland, Germany, China, South Korea, Japan, the Netherlands, Georgia, and the Czech Republic. Dr. Shanker's five-step Self-Reg model, The Shanker Method®, is a robust process for understanding and managing stress in children, youth, and adults. His latest books are Self-Reg Schools: A Handbook for Educators (2019) and Reframed: Self-Reg for a Just Society (2020).Connect with Dr. ShankerHis website, Twitter, Facebook, and Instagram. Connect with MarciWebsite, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.Permission to Heal on YouTube.Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores.  The Permission to Heal podcast is a passion of mine. I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. This is where your PATREON subscription comes in. With your subscription, you get perks, swag, and meaningful contentment knowing you are helping me get PTH to the people who need it. Support the show Support the show

Permission to Heal Episode #75 - A Conversation with Lia Holmgren about Celebrating Your Authentic SexualityLia Holmgren has been an intimacy and relationship coach for more than a decade, guiding her clients through modern challenges and exploring the many facets of sexual fantasy. Known for her empathetic nature and direct style, Lia empowers her clients to feel safe in celebrating their authentic sexuality. Her New Book - Hookup Without Heartbreak - How to feel empowered after casual sex Lia wrote this book because people were always drawn to tell her their secrets and issues about their relationships, and she provides them with non-judgmental, honest feedback. She wanted to help people, and especially those who were scared and ashamed to talk to someone about outside-of-the-box intimate issues. Connect with LiaHer website, Instagram, Medium, LinkedIn, TwitterConnect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the showSupport the showSupport the showSupport the show

Permission to Heal Episode #74 - A Conversation with Kim Keane about helps parents & their daughters get through the tween & teen years.Kim is a life coach, Reiki & IET practitioner is the host of the podcast ONE OF A KIND YOU. As the founder of her life coaching business CHERISH & BLOOM. Her experiences as “that” teen, an educator, and a certified life coach have given her the perspective, knowledge, and skills that allow her to understand the causes of pre-teen and teen behavior while equally sympathizing with the reasons why parents react the way they do. Kim shares her experiences as a domestic violence survivor, educator, and parent. She shares her insight and deep understanding of what children may be experiencing, or parents might be experiencing along with strategies to help get to the root cause of the issue to create and solidify lasting change. Connect with KimHer website, Facebook, LinkedIn, IG, Pinterest, TikTok @KimvkeaneConnect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the showSupport the showSupport the show

“No matter what adversity you have, you can conquer it,” Kenny says. “No matter how big or small.”  Paul Smith and Kenny Tedford are professional speakers and storytellers, and their story is captured in the book, Four Days with Kenny Tedford: Life Through the Eyes of a Child Trapped in a Partially Blind & Deaf Man's Body. Buy your copy on Amazon or support local and independent authors at the Permission to Heal Bookshop.  Kenny Tedford is one of only two deaf people in the world with a master's degree in storytelling, which he earned at 55, almost half a century after being told by teachers and psychologists that he would never complete the third grade.Paul Smith is one of the world's leading experts in business storytelling. He is one of Inc. Magazine's Top 100 Leadership Speakers. Paul and Kenny met at a storytellers conference and became friends almost instantly. Kenny traveled from LA to Ohio to stay with Paul and his family so they could get to know each other in-depth and write their wonderful book - Four Days with Kenny Tedford: Life Through the Eyes of a Child Trapped in a Partially Blind & Deaf Man's Body.Connect with PaulWebsite, LinkedIn, Facebook, Twitter, YouTube, Instagram. Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the showSupport the show

Kathy Davis is a Plant-based lifestyle and accountability coach.Kathy Davis is a plant-based lifestyle coach and recipe developer, the CEO of VegInspired.com, and the author of three cookbooks: The 30-Minute Whole-Food Plant-Based Cookbook, The Super Easy Plant-Based Cookbook, and The Budget-Friendly Plant-Based Diet Cookbook.  She helps people successfully transition to a plant-based way of eating that supports a fast-paced lifestyle, without requiring hours in the kitchen or added stress. Kathy has been eating and creating vegan meals for more than seven years. Over the past year and a half, she shifted her daily habits to follow a whole-food, plant-based lifestyle. She experienced amazing results: renewed energy, a newfound sense of joy, and a healthier mind and body! Kathy's brand, Veginspired, is dedicated to providing people with the resources to make a similar transformation. She is eager to guide others on their journey to get from where they are to where they want to be. Fun fact: Kathy and her husband, John, are living their plant-based dream while simultaneously traveling the United States in an RV with their cats. They've been to 22 states and 18 national parks so far and have a goal to visit all the US national parks!Connect with KathyInstagram, Facebook group, Facebook Page, Website, Blog.  Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the showSupport the show

Cheryl Ilov - The art of healing through movementShe is an author, speaker, physical therapist, martial artist, dancer, and former chronic pain patient.  She believes that everyone can enjoy vibrant health and vitality.  She is also a second-degree black belt in an ancient Japanese martial art called Ninpo Tai Jutsu. There is an incredible amount of strength and power in each and every one of us, just waiting to be unleashed.  Her award-winning and best-selling book, “Forever Fit and Flexible: Feeling Fabulous at Fifty and Beyond" in 2016.  In March 2022, she published "The Reluctant Ninja: How a Middle-Aged Princess Became a Warrior Queen." 1). As a physical therapist who recognizes the limitations of the traditional physical therapy model. She helps her audiences realize that there are many options available to them outside of the realm of traditional medicine and explore alternative health and healing. 2). Cheryl shares valuable tips and information that she learned in her 17 years as a martial artist to help people stand their ground, find their voice, choose their battles, establish clear boundaries, and keep themselves safe and healthy in mind, body, and spirit. 3). What we believe is what we become. It is based on the principle of neuroplasticity. Cheryl explains how it works, and how to use it to create positive change in every aspect of our lives.Connect with CherylWebsite, FemNinja Project, Facebook, Twitter, YouTube, LinkedInConnect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the show

Glen Dunzweiler is a filmmaker/producer and social entrepreneur who is on a mission to grow people into spiritual, strategic, and economic wealth one story at a time.  He has a background in live entertainment and teaching at universities. In 2015, he moved to Los Angeles to focus on the business side of entertainment and has made it his goal to get others the tools they need in order to succeed in this society that we have built. He does this because he's seen (first-hand) the change in people when they recognize that they have value.According to Glen, the biggest thing is to realize that you have to be able to value yourself. This deeply coincides with our mission here at Permission to Heal - inspiring people to give themselves permission to live their best lives. Connect with Glen DunzweilerLinkedIn, Instagram, Twitter, Facebook, and His Website.TEDx Talk,  His Podcast - Difficult Questions. His book - A Degree in Homelessness? Entrepreneurial Skills for Students.YouTube Series - Skid Row Speakers.“Deuce? Narrative feature trailer Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the showSupport the show

Sabrina Runbeck - the Queen of Performance and Productivity Retrain Your Brain to Skyrocket Your Profitability and Productivity International Peak Performance SpeakerSabrina Runbeck, MPH, MHS, PA-C is a Cardiothoracic Surgery Physician Associate (PA) with more than 10 years of experience in psychology, public health, and neuroscience. After overcoming burnout and feeling stuck in a career that drained her, she became an International Peak Performance Keynote Speaker who empowers ambitious health practice owners to get back 10 hours of freedom per week and increase their team's productivity. Her clients stop having endless to-do lists, constantly putting out fires, or are not able to move steadily forward. She is still practicing surgically and empowering other healthcare leaders to have a double win in both work and life. Sabrina hosts the Powerful and Passionate Healthcare, Professionals Podcast and is an international bestselling author of the book, Asian Women Who BossUp: Secrets From Women Who Are Forging Their Own Path and Thriving. Women Who Boss Up .Connect with SabrinaInstagram, Facebook, LinkedIn, Twitter, Podcast, and Medium.  Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the show

Kimberly Friedmutter - Celebrity HypnotherapistAuthor of the book Subconscious Power, Kimberly Friedmutter CHT is a certified hypnotherapist, a member at large of the prestigious UCLA Health System Board, the American Board of Hypnotherapy, the Association for Integrative Psychology, the American Board of Neurolinguistics Programming, and the International Hypnosis Federation. She is also a certified Master Hypnotist and a certified Neuro-Linguistic Programming trainer, as well as a ‘Dame de la Chaîne' of Chaîne des Rôtisseurs.Kimberly is currently in private practice, dividing her time between Nevada and California, serving high-performing clientele who share her philosophy: “Expect the exceptional.”Kimberly is a former model and actress, appearing with Bryan Cranston, John Stamos, and Olympia Dukakis in such films as Evil Obsession, Time Under Fire, A Match Made in Heaven, The Russian Godfather, and Elvis Is Alive! She has also appeared in television programs, including Entertainment Tonight, CNN, FOX, TLC, BBC, The Doctors, Bethenny, Private Chefs of Beverly Hills, Art Breakers, Silk Stalkings, L.A. Heat, LateLine, and hosted a hit talk show on the Howard Stern station, KLSX 97.1 radio in Los Angeles.Connect with KimberlyBook: Subconscious Power: Use Your Inner Mind to Create the Life You've Always Wanted (Amazon) & through the PermissiontoHealBookshopInstagram, Facebook, YouTube, Twitter, her Website, and her course in Weight Management. Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the show

Christian de la Huerta Christian de la Huerta is a sought-after spiritual teacher, personal transformation coach, and leading voice in the breathwork community. He has traveled the world offering inspiring and transformational retreats combining psychological and spiritual teachings with lasting and life-changing effects. An award-winning, critically acclaimed author, he has spoken at numerous universities and conferences and on the TEDx stage. His new book, Awakening the Soul of Power, was described by multiple Grammy Award–winner Gloria Estefan as “a balm for the soul of anyone searching for truth and answers to life's difficult questions.” Christian's book, Awakening the Soul of Power, the first book in the Calling All Heroes series, rethinks what heroism means in the 21st century and reveals practical tools to help you embark on a journey to personal freedom. Connect with ChristianAwakening the Soul of Power.Website, Facebook, Instagram, LinkedIn, Goodreads, Newsletter, TEDxTalk, YouTube, Facebook Group Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. You get perks & the contentment knowing you are helping get PTH out to the people who need it.  Support the show

Dr. Christian Heim   Award-winning psychiatrist, Author of several booksThe 7 Love Types: Navigating Love in a Fractured World5 Steps of Men's Mental Health: MAKE YOUR MIND A BETTER PLACE 7 Steps to Forgiveness (using neuroplasticity)Dr. Christian Heim is an award-winning clinical psychiatrist, Australian music lecturer (= US professor), and a Churchill fellow. He is a senior lecturer at the University of Queensland in the School of Medicine and in music and has lectured at the Manhattan School of Music. During his 20 years as a doctor, he has heard the stories of thousands of people. He speaks globally in-person and virtually at law firms, medical organizations, leisure companies, and universities about preventative mental health. Dr. Heim speaks from a place of deep compassion and authority. His talks all combine science, music, and large doses of Australian humor.   Dr. Heim's podcast - The Dr. Christian Heim Podcast The Dr. Christian Heim Preventative Mental Health YouTube ChannelConnect with Dr. HeimWebsite, Facebook, Instagram, LinkedInConnect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. Permission to Heal is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. This is where your PATREON subscription comes in. You get perks & the contentment knowing you are helping get PTH out to the people who need it.   Support the show

Tia Graham, Certified Chief Happiness Officer,  is the author of the brand new book - Be a Happy Leader: Stop Feeling Overwhelmed, Thrive Personally, & Achieve Killer Business ResultsTia Graham is an international speaker, author, and consultant on positive psychology. She has worked with dozens of global companies to elevate employee engagement and drive bottom-line results. Prior to founding her company, Arrive at Happy, she led teams at luxury hotels in the United States and Europe. With multiple certifications in neuroscience, positive psychology, and employee retention, and over 14 years of leadership experience, Tia is widely regarded by business leaders in her field. She partners with organizations to increase retention and boost productivity & business growth - using the science of happiness.Her new book, Be a Happy Leader, teaches her proprietary 8-step methodology on driving productivity and business growth through a culture of happiness.Connect with TiaLinkedIn, Instagram, Facebook, and check out her FREE Happiness Class. Connect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook -      Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores.  The Permission to Heal podcast is a passion of mine. I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. This is where your PATREON subscription comes in. With your subscription, you get perks and swag and the meaningful contentment knowing you are helping me get PTH to the people who need it. Support the show Support the show

Phoebe Leona Miller - Emotional Recovery and EmbodimentStoryteller. Author. Dancer. Mover. Teacher. Mentor. Public SpeakerPhoebe's mission is to empower people through movement & storytelling to fully embody their bodies, stories, and lives to co-create a world that is radiant from the inside out.  Phoebe is a dancer, yoga teacher, and transformational guide who helps men & women feel more embodied through somatic movement and expanded awareness practices to become more empowered in who they are, who they are becoming, and have a greater sense of belonging. She has been a teacher and guide for most of her life, but it was after a year of extreme loss in 2013 when she found herself in the vast open space in between her old life and a new life, that she dove deeply into her practices and began her company, nOMad to help others through their own transitions and spaces in between.  Throughout that time, Phoebe also developed her own movement/somatic practice, Mvt109™ for students to fully embrace the freedom of moving in their bodies, transform old and held patterns, and reclaim the vibrations & stories they want to bring to life. Connect with PhoebeHer website The nOMad Collective, Instagram, nOMad on YouTube, Phoebe Leona on YouTube, FacebookHer NEW book - Dear Radiant One: An Emotional Recovery Story and Transformational Guide to Embody the Dance of Life   Buy on Amazon.Her first book - Caged No More.  Her TEDx Talk Connect with Marci Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.Permission to Heal on YouTube.Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores. The Permission to Heal podcast is a passion of mine.I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. This is where your PATREON subscription comes in. With your subscription, you get perks & meaningful contentment knowing you are helping me get PTH to the people who need it. Support the show Support the show

Chuck Garcia  - Your Mountains of Endless Possibilities Leadership coach, Podcaster, Author, MountaineerChuck Garcia is the founder of Climb Leadership International and he coaches executives on leadership development, public speaking, and emotional intelligence. He is also an Adjunct Professor at Columbia University where he teaches Leadership Communication in the Graduate School of Engineering. A 25-year veteran of Wall Street, he spent 14 years in sales and marketing at Bloomberg in a variety of leadership positions. He was Director of Business Development at BlackRock Solutions, an arm of the world's largest investment manager, and was a Managing Director at Citadel, a prestigious alternative investment manager. He is also a mountaineer and has climbed some of the world's tallest peaks, including Mount Kilimanjaro, Mount Elbrus, the Matterhorn, as well as mountains in Alaska and the Andes. His podcast - A Climb to the TOP: Stories of Transformation- A C Suite Radio Broadcast My episode on Chuck's Podcast - A Climb to the TopHis book - A Climb to the TOP: Communication & Leadership Tactics to Take Your Career to New Heights His coaching agency - Climb Leadership InternationalTraining & Courses - Climb Leadership InstituteConnect with Chuck GarciaInstagram, LinkedIn, Facebook, TwitterConnect with Marci·       Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.·       Permission to Heal on YouTube.·       Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook ·       Permission to Land: Personal Transformation Through WritingPermission to Heal Bookshop - Buy books from the episodes & support independent bookstores.The Permission to Heal podcast is a passion of mine.  I need your help to bring more inspirational episodes to the world; please consider becoming a patron through PATREON. This is where your PATREON subscription comes in. With your subscription, you get perks & meaningful contentment knowing you are helping me get PTH to the people who need it. Support the show Support the show