Replay - Webinar - Chronic Fatigue and Burnout

Okay, we're going to start. I'm sorry for the delay, but we had to wait for the Spanish translation. Was there? So that's the good news. And, um, we have, um, first of all, I want to present you to Dr. Uh, Professor Johannes Berkens. Hello, Professor. Um, Professor will be interviewed at the end of my session. That would take about one hour, at 30 minutes. And, um, I think it's very exciting, even for physicians, extremely exciting because he's not going to talk on on treatment. We're going to interview him on accurate accomplishments, achievements in doing a better diagnosis of fatigue and other types of syndromes. And you will see there's really enlightening new information. So, Professor, uh, Jonas, you're you're ready? Okay. Pleasure to be here. See you in one hour and a half. And you, you will see it will be, um, for everybody very interesting, what you will see. So you can close your camera and your microphone, and I will start and share my screen.

So, uh, for the Spanish translation, uh, there you have to, uh, link to the link that is indicated there. And you will see it will be, um, it's a very good translator. So we're really happy to have, uh, Alexa doing it. And so now, um, I'm talking about, uh, acrylic energy. I'm going to talk all throughout here how to get energy. And you will see it's extremely important. You can get energy through improvements of diet, nutritional supplements, but also hormone therapies that are fundamental to make a real breakthrough in severe chronic fatigue syndromes.

So let's look a bit. What is accurate about fatigue? Well, it's the number one complaint, actually. When you go to my clinic, we did a survey many years ago, and we saw that the first complaint of patients, the main complaints, is accurate fatigue. The second being loss of resistance to stress, the third depression, and only the fourth on trying to stay young and healthy. So you, when you see a study here in Nijmegen in the Netherlands, they interviewed people, and two-thirds of them had no fatigue, but one-third was complaining of fatigue. And among them, some had just short-term fatigue, but the majority had added chronic fatigue. That was exactly a fatigue that is six months or more. And when you look at those who have acne chronic fatigue, 56% have disease. And those who have short-term fatigue, 34% have disease. So disease can create active fatigue easily. And when among those chronic fatigue syndrome patients, 1% of these that 31% accurate had chronic fatigue syndrome-like fatigue. So severe fatigue that is really debilitating with inflammation, pain, and things like that, following actually a very strict criteria. And, um, so, so this is really very common. And in consultations, when they are complaining, consultation, 30 to 50% of those complaints include fatigue. So it's really very common. And it's actually the most common, uh, complaint in the consultation. So that's why it's so important for health professionals, but also for patients, to learn what we're going to learn here. We're just going to overview, so you're not going to see everything, but you will have a good overview on and know exactly where, in what direction to go to correct a fatigue.

So chronic fatigue syndrome, there are actually many causes. There is, for example, can be hormone deficiencies. It can be nutritional deficiency. There can be an adequate diet. And it can also be just that digestion is not working better. But that's often also the result of an adequate diet. And also they could be just stresses, too much physical or psychological stresses. And they can only see multiple infections or they can be pollutants. And often many of those fatigues that don't go away are made by multi-factors, multiple of those factors. And so the physician and health provider has to tackle as much factors as possible as you can find in order to get the person back and energetic again. And I can tell you, even in the most severe chronic syndromes, we often have success by this multiple approach, not by just one miracle treatment that is often not enough in fatigue, as it is shown now in consultations.

So physical activity, uh, can increase energy. That we, we know people who move, they get more blood supply to the brain and the muscles, they can feel better. So this is one of the studies that shows association. So, for example, people who feel fresh, um, or actually those are good. But those who just feel average between fatigue and freshness have are 60% more likely to report insufficient physical activity. But when you go to more fatigue syndromes, like people really think tired, two times more a report insufficient physical activity. And those who feel exhausted, four times more report insufficient physical activity. So the more there is fatigue, the less there's physical activity. It's probably consequences, but it may also be partly a cause. If you don't move enough, you get more tired.

So, um, here, um, what diet changes? There are many diet changes that can increase energy. And interesting is that in multiple sclerosis patients, they who suffer actually a lot of fatigue, many of those are tired. Actually, when they receive, uh, a ketogenic diet with some medium-chain triglyceride that are known to give energy, they have no real significant change of fatigue. They don't get more tired or less tired. It doesn't seem to to to matter. And and they do have a lower fasting glucose, which normally will say that they may have more hypoglycemia and thus more fatigue. When you compare and you give to those multiple sclerosis patients a paleolithic type diet, and that's the diet that actually makes hormone therapies work better, and where you get the most of the nutrients. That's a diet based on fresh vegetables and fruits and a meat and fish cooked at low temperatures. So it's really a diet like our ancestors had with foods that existed millions of years on earth and are non-processed. When you give that, they have significant decrease in fatigue scores. Those patients with multiple sclerosis and and they also are actually, um, have a better cognitive function than if they would do, um, the, um, ketogenic diet, which is a high-fat diet and a low-carb diet.

Drinks, other drinks that give you energy? Yes, and it's very cheap. Water. Drink water, actually, because then blood supply is all over better in the brain and the muscles and in in organs. You see that actually the human body actually has and should normally have about 65 to 70% water. But in older persons, get about 50%. In a very young, uh, in the fetus or the newborn baby is higher. But basically, what we need to know for our patients, they need to go to the 65-70% of water in them. And if they are 50% dehydrated, and it's not only by a decreasing water intake, it's often by low, low hormones that keep water in the body. And and so we need this for energy to get this water because otherwise we're like a flower that that that goes away and seems to disappear, has no strength. If there's not enough water, we too, we are like flowers and and we need water like flowers do. So, for example, here's a study showing that people who have dehydration have a lower performance. And for example, these athletes, if they have, um, a slight fluid deficit, not much, like 2% decrease, they have a decrease in performance during physical exercise. But if there are substantial fluid losses, you get this sort of very severe fatigue with severe health risk. There's even, um, it was a woman who was, um, dehydrated, died actually in a marathon, not so long ago.

So also alcohol. You think alcohol is good, gives energy? Wow, you're wrong. Alcohol. And you see here in younger adults, when they have greater than usual alcohol use, those who drink the most alcohol actually have, um, more tightness. That's especially valid for younger adults, not so much for the older. And they also have a shorter sleep duration. So it could be that alcohol by impairing the sleep makes that these younger adults are more tired. So, but alcohol is not, um, a drink to give you more energy. And one of the reasons is that it decreases growth hormone levels during many hours. Did you imagine that? That's why people drink a lot of alcohol prematurely age because of a lack of growth hormone, lack of cortisol, lack of sex hormones, accompanied by alcohol intake. And the legs are not little. You have 70% lower growth hormone, for example. You will see this very important hormone for energy.

So vegetables, for example, if you eat more vegetables, especially green leafy vegetables and tomatoes, there's less fatigue. Here are cancer survivors. We need to know that cancer people who survive cancer often have more fatigue than normal. And when we, some fortunately, have not fatigue or little fatigue, and those are the ones who take more vegetables, have more vegetable intake, unprocessed vegetables, especially green leafy vegetables like the ones you see here, the salads, the lettuce, and, and tomatoes also give better energy. Probably because it's linked to people with no fatigue.

And what about proteins? Protein is very important because in amino acids, you have phosphorus, and the phosphorus actually provides energy. Most of our molecules that give us energy like ATP and NADPH actually have a phosphorus atom that separates, and when it separates, it provides energy. So a protein diet provides actually this type of phosphorus for energy. And when you look in male athletes, those who were put on high protein, low fat diet compared to moderate protein, moderate fat diet, had actually lower fatigue scores, more protein, more energy, and less stressful feelings and less mood disturbances. So, so this is the kind of food with proteins, you see. But also plant proteins that actually are good for energy. Put that in your mind, picture it, make it, make a photo. And then you have also low glycemic diets are acrylic diets with low in sugar.

And when you look at young Japanese women, etc., fatigue was linked to the consumption of instant foods, confectionary, or full of sugar and sugary drinks also. And between-meal snacking, which also often with sugar, are, uh, sugar derivatives. So that gives more fatigue. At least it's associated. So now you would say that's not true because when I take a candy bar, I actually feel better energy. So I like to eat candy bar because it provides me a kick. Yes, momentary kick. Initially, it decreases tiredness. I agree. But one hour later, what happens? You have increased tiredness compared to initially, and you feel also more tense. So it's not a solution. And the reason again is like alcohol, sugar. When there's a peak in the blood, it blocks the secretion of hormones that increase the blood sugar because they're not necessary. So it blocks the energy-giving cortisol, it blocks the sex hormones, it blocks the growth hormone. And that tiredness is not for 10 minutes, it's for many hours or throughout the day till the evening. So don't, don't take a snack full of sugar.

And what about high glycemic drinks and snacks? Well, here it may have a usefulness before exercise. It can increase the performance. So we need to have competence in knowing when to take something high in sugar before performance. Yes, but not when you're not, don't have to perform.

So we have not also nutritional supplements that increased energy. Diet, there are many more aspects of the diet can improve the energy. Now let's look at the nutritional supplements. And, um, we see here that energy, there's increased energy in daily activities, the whole day. Which other nutrients that can increase that? So you have a permanent energy all day. We're going to see that. We're going to see some, not all, because this is actually an overview of a model that has much more extensive information. I can tell you that two hours on nutritional supplements and diet are absolutely fascinating because it really will help you to help patients, uh, be better. And you'll know what exactly. There are supplements that also increase the energy in the afternoon, that may be different than the ones that increase the energy the whole day. And you also have supplements that increase the energy just in the evening or mainly in the evening. And then you have supplements to increase energy during physical exercise and performance. And there are differences. And I'll teach you that. And you will, when you will practice, you will see that what is said works in most patients. Also, there are supplements that create energy in myopathy, degenerative diseases of the nerves and muscles.

So let's look at some of the nutritional supplements that increase the energy the whole day. And I'm going to give you an overview here of what charges your battery and that of your patients. You have vitamin B12. When it provides energy, you do have a better energy the whole day. It's mostly by injections that works better. But at least it is, it is one of the supplements that helps. We'll see in the model on, uh, with vitamin B12, what is the doses to give. Vitamin C also can be efficient. And when it's difficult to increase energy, it's the whole day. You have better energy. What I'm putting in red here are more important nutrients for energy. Vitamin D also helps for energy, makes a difference, especially muscular fatigue. But when it gives better energy the whole day. Chromium also, especially in diabetics, it helps. And copper also can be helpful. We'll see the studies, but not, not here, I believe. And selenium also can provide energy. Of studies that show significant improvement of energy with selenium. And zinc also. And coenzyme Q10 also quite important, this one. But you will see there's a special dose to give. And omega-3 polyunsaturated fatty acids also help. Omega-6 also. Omega-3 comes from fish or linseed oil, and omega-6 is more from plant oils. Carnitine also, one of the most important ones to give energy. Ornithine, NADH, and sodium. You see, I haven't put iron here because it's, it will give specifically more, more energy at certain times of the day, uh, that we'll see. I think now, otherwise I will tell you. Pycnogenol is an antioxidant that also is known to increase energy in studies. So you will have evidence, and you will have also practical tips.

Vitamin C. Let's see one of the studies that where it suggests that there's increased energy the whole day. This is high uses of vitamin C. Those who take daily vitamin C supplements, uh, compared to low users, actually have two times less fatigue symptoms. A little tablet of vitamin C every day as a supplement. And you see that, uh, in alcoholic patients, actually, they tend to have very low vitamin C. On coke abuse, consumes vitamin C, but also when you drink a lot of alcohol, you don't take so many fruits rich in vitamin C. So you have easily a deficiency. Only 30% of alcohol drinkers have actually an acceptable vitamin C level. So the, those alcohol drinkers, our abusers, are tended to have vitamin C deficiency. And the lower the vitamin C is, the greater there is a risk of having tiredness. I don't know what tired they are. And of the vitamin C supplementation, uh, when you give it together with alcohol withdrawal, actually, you, 89%, so almost all of these patients who are stopping alcohol and taking vitamin C report decreased hardness. So it's worth doing that.

Now, vitamin D can also increase the energy the whole day. And you see here, patients with fatigue actually have high prevalence of low serum vitamin D. You see here, adult patients, 174 with city, so just taken in a consultation, and 77, so three quarters of these patients had actually low serum vitamin D below the lower reference limit of the laboratory, where normally only two and a half percent are. And when you provide them with vitamin D, what happens is that it decreases. To you provide the vitamin D to those 77% who had low serum vitamin D. After you normalized the vitamin D, two-thirds of them had a lower total fatigue symptom score. So they were less tired. And they also improved in all those five sub-scales of fatigue that were assessed. And that includes that the physical fatigue was less, general fatigue was less, emotional fatigue was less, less mental fatigue, and more vigor. And actually, the changes were between, um, 30% less to 50% less of fatigue scores and 33% more vigor. So actually good effects of vitamin D supplementation. The dose you shouldn't use on general is at least 2,000 international units per day to make a difference.

Coenzyme Q10 increases the energy also the whole day, but also as we will see at exercise. And here's some a double-blind control trial where patients with myocardial infarction, they had acute myocardial infarction after them, they received coenzyme Q10 because coenzyme is really protective for the heart. And when it showed those who took 120 milligrams per day of coenzyme Q10 against placebo had six times less patients who are complaining fatigue. So in those patients with acute myocardial infarction, heart attack, 41% would complain fatigue, and only 7% were still complaining fatigue. And those who were taking coenzyme Q10. So 120 milligrams per day can be an efficient dose for background fatigue to decrease this whole day.

Fatigue for exercise, you need more carnitine. Increased energy the whole day. And you see that four grams per day of L-carnitine increased the physical fatigue score, as you see here, and more than placebo. And also the mental fatigue score more than placebo in old adults with fatigue that have fatigue. As soon as they start doing some physical activity. So it's helpful carnitine. But you need in general two to four milligrams of carnitine to make a difference. And so there are many. We know there are a lot more supplements that is seen in the, uh, session of the model on fatigue treatment.

Let's look at some of the nutrients that increase energy. Neptune, and the most important one of those is magnesium. And there are a lot of studies. We'll see in details in the session and the model of magnesium. But here's some of the references that show a significant decrease in fatigue when you provide magnesium treatment. And I can tell it's mostly in the afternoon. And why is because when you have a lack of magnesium, you are tense the whole morning. And and and when you, you contract your muscles, you get easier fatigue. And then that fatigue goes, appears clearly in the afternoon because of this tenseness. And so this is really a fatigue that goes away by providing magnesium. You generally have other complaints like irritability, that's very often linked to low magnesium. And that also go away with magnesium treatment. How much should you give? Well, you need at least two to 400 milligrams elemental magnesium to make a difference. So you really have to look at when you take a preparation, how much elemental magnesium in it. And don't take magnesium oxide. Most of the magnesium sold is magnesium oxide. But you are only absorb about 10% of that. So you need preparations like magnesium citrate, magnesium malate, or magnesium glycerophosphate to take because you absorb much more of the elemental magnesium for that than from magnesium oxide. Magnesium oxide is just good for get rid of constipation.

Now, how does magnesium increase energy and and improve fitness? Well, the mechanism of all these nutrients, of many of these nutrients, will be examined in the session. I won't do it here. But it works at the level of the mitochondria to improve actually, um, the, the fatigue and and and and improve the battery. And I'll tell you where exactly it it works here. It's good that you don't get confused. At a clear thinking, an overview of what you could do.

Now, there are supplements, they increase energy in the evening. And that is mainly, um, iron. Iron gives more energy in the evening. And you see that it decreases the fatigue in a woman without an anemia. So it's not the fatigue that you have is really due to lack of iron that is necessary as a core factor in many metabolic reactions. And you see that these women without anemia that have unexplained fatigue, when you provide them with iron compared to placebo, you have an improv, decrease after one month already of the fatigue score. So four weeks can be already sufficient. But generally, it's a treatment for six months. And gradually have better and better improvement. It works better in women occurring with a ferritin that is below the 50 micrograms per liter. So the reference in young woman of the ferritin is, is very low. Reference range is between like something like 30 to 110. And when you're below the 50 or at the 50 micrograms per liter, you already have fatigue. And you know that at that moment, with iron, you will decrease the fatigue.

Also, nutritional supplements that increase energy for sports. And one of those supplements here is vitamin B12. You really get up. And one of the reasons why B12 works is that it improves, um, the oxygenation of the red blood cells. They have a better volume, they're more mature, thanks to vitamin B12. So you can transport oxygen better, and that gives a better energy. And but it also works on the level of the nerves. The nerves have, when they have axons, it's surrounded by myelin sheets that make that you have quick impulses and and they can be quickly transferred to nervous impulses. And with vitamin B12, they're thicker, so you have a better conduction. So it works on several levels for energy. And vitamin C is also one that improves energy for sports. Well, scientific studies will be shown about that. Vitamin D also, iron, coenzyme Q10, and omega-3 polyunsaturated fatty acids, and carnitine, and acetylcysteine, and magnesium. They all work to improve the energy for sports. So if you want to improve your sports performance, here are many of the, um, nutrients that help. Potassium also, sodium, and pycnogenol. So basically, you really have a group that of molecules you can improve your sports performance. And it's not to improve your performance always, but it's basically to make you healthier. Because people who have, uh, more energy are usually people who are healthier. Until these molecules help to improve your health.

Here, let's look at one that is not so known, N-acetylcysteine. Well, when you have N-acetylcysteine, it converts in the body to the very potent glutathione, which is a very potent antioxidant, and that provides more energy for physical exercise. So N-acetylcysteine is the form easy to absorb of glutathione. If you give, take the thiol, it is easily broken down, uh, before it reaches the blood. N-acetylcysteine not. And so here in men, where athletic men, and as the acetylcysteine was supplemented, were given and when compared to placebo, and and it showed that actually there was a significant preservation of performance here. So if they did a certain repeated exercise, they kept on longer time having the same energy, while those who didn't receive the enzymes, tired quicker. And it also significantly increases the plasma creatine kinase over time, which is important for energy, an enzyme that helps for energy. It may have, if you give, um, those that were taking N-acetylcysteine, mild gastrointestinal side effects.

Then there are nutritional plans, they improve the energy for myopathy. Vitamin D is an important one. I won't go into details here. I just mentioned it, so you already have a tip where to go to. But get on the information. I really recommend you to go and subscribe for the model on, uh, chronic fatigue syndrome and burnout.

Now let's look at some of the hormone therapies that provide energy. When you think about hormone therapies, one of the major steps to do is think on where do they work the most. And when you know that, you also know when the fatigue that accompanies a lot of hormone deficiencies will be greater, for example. So you, what you need to know is what increases energy, uh, is, of hormone therapies, is morning energy, our afternoon energy, our evening energy. Different hormones, our evening energy, our whole day energy, ours improves the sleep quality, that improves the energy by by sleeping better, or improves energy and stress. It's generally a different hormone, are different hormones that provide this better energy. Also more energy for sports, and more energy at rest, more energy standing up, more ability to recover, and less exhaustion. Different hormones. And we won't look into all the details, but you will get some good information now already, but also decrease more burnout.

So let's look at fatigue upon awakening. When you get up in the morning and have early morning fatigue, and hypothyroidism is by far the most frequent cause of fatigue upon awake. When you wake up tired, think first, you are, are your patient is, uh, has a low thyroid function. And so it's a fatigue that is greater in the morning. When you have a low thyroid, and then improves during the day, up to in the evening. And, um, this is the thyroid deficient fatigue. And, um, it slowly erases during the day. And then when you're towards the evening, you, the patient doesn't want to sleep. He feels worse upon awakening, but he doesn't want to go to sleep in the evening because he feels the best at that moment. And the reason why is when you have a low thyroid function, blood flow is slow. If you stay still, so you get awakened in the morning, your blood flow is really at its lowest, you have the greatest fatigue. But once you move and you feel better and better, and then your blood flow is better, it compensates. People feel much less tired. So, so here, for example, it's a study that shows that to improve decreased fatigue due to low thyroid function, there are differences in preparations. The best preparations is those that have at least the two main thyroid hormones like T3 and T4. So when you switch a person from T4 alone to T3 T4 combination, what you see is that, and that's a study that I published actually, is I had patients who were on T4 therapy, the most frequent therapy, but it's not very much working. And at least here, these patients that came to my consultation, 94% of these patients were still tired despite they seemed to have an adequate dose of thyroxine. And when we gave the T3 to the T4 preparation, what we saw is that most of these patients, almost all of these patients, had a decrease in fatigue. And and about a third of them had no fatigue, or a quarter of them had no fatigue anymore with the treatment after two or three months of treatment only. And almost none did not improve. So really minimal. So really it works better with the T3 T4 preparation than just with T4 alone because T3 is the most active thyroid amount. When you go further, it works even better with desiccated thyroid hormone than a T4 preparation. So patients were trying the toad. They took L-thyroxine and and T3 and T4 combination or desiccated thyroid. And actually, only 19% preferred the L-T4. And desiccated thyroid was taken also for 16 weeks, so about almost four months. And what was showed that nearly 50% of the patients, of all these patients who had hypothyroidism, preferred the desiccated thyroid. They didn't know it was it. They said it's preparation A, for example, it's better than preparation A. It's desiccated thyroid. It's placebo-controlled study. And not only a better energy level, but they had a better concentration, better memory, better sleep, better decision-making capability. And why not better happiness? So if you want to be happier, take desiccated thyroid. I can tell you, I have hypothyroid. This is the one I take. As the one that I prescribe the most to my patients. You also had a better weight loss when you, this desiccated thyroid was given. And the reason is in desiccated thyroid powder, acrylic from thyroid gland of pigs in general, has actually not only T4, but has T3, the very active one, the most active thyroid, T2, T1, T0. And we'll see also with Professor Berkens that actually, um, even T3 can have different, uh, four-dimensional, uh, structure. So that it could be that you have several forms of T3 in those preparations that make acrylic thyroid therapy even better.

So thyroid supplementation, how quick does it decrease energy? First month, in general, there's little or no improvement in a patient. And second month, there's more energy and less fatigue. It becomes clearly apparent. And then when you see this patient becoming like this with more thyroid hormones, it's mostly the third, fourth, and fifth month that there's further increase of energy and fatigue. So I warn my patient, don't expect too much. The first month, second month, you start improving. And that shows out to be often true. Some improve very quickly, but that's an exception. So you have a certain delay and beneficial effects. And and it's also the case with other hormones, but it's even more with thyroid hormones because we always start at a low dose in the beginning and then squarely increase. So cannot have so much effect if efficacy.

So fatigue is a stressful condition. Can be due to cortisol deficiency. This is a fatigue that's the whole day. And you see that there are peaks of stress in the day. And at those stress peaks, patients feel, wow, too much for me. And in the evening, the cortisol storage is depleted. There's no cortisol enough left. There's aggravation of fatigue. And the patient is not able to work anymore and goes off and quick to bed. So fatigued stress is typical for a cortisol deficient fatigue. Cortisol is a very good molecule. If we don't have it, we die within 24 hours. Did you imagine? So it's, it's only that when cortisol is given, has to be given at the same time with DHEA that protects against the adverse effects of cortisol given alone. How does cortisol increase energy? Well, basically, it will increase the sugar in blood. So there's more sugar for all the cells. And it also, um, there's more, uh, sugar than that comes in the brain cells, in the heart cells, muscle cells, in the liver cells. It, it, it also increases the glycogen stores, which are actually stores of glucose. This is a glycogen molecule, and these are all sugars. And it also increases the blood ketone bodies. You see acetone, acetic acid, beta-hydroxybutyric acid. So it gives energy by by two ways. We know that when you're on a ketogenic diet, there's a diet with high fat and or carbs. The fat is getting released in the form of ketone and gives energy and supplies for the lack of blood sugar. And blood sugar and ketone bodies will increase the ATP production. And it feeds the energy molecule. We make a lot of ATP per day. And and and and so it, the stores have to be complete, constantly, uh, increased again. And that is helped with cortisol. It's really an energy hormone. And also cortisol increases the blood pressure. So you just mean more blood flow in the brain and more nutrients getting into the brain. There's more heart and the more blood flow and nutrients getting in the heart. And then the muscles. So it's cortisol, just a better blood pressure gives the better blister by all over and you have better energy.

Now, there, here's a study showing that 20 to 35 milligrams of hydrocortisone, um, improves well-being in chronic fatigue patients. Just to remember you, when we talk about chronic fatigue syndrome patients, we talk about the most tired people in a population, the 1% most tired people. And we give them hydrocortisone without even measuring the cortisol levels, but they are low anyway in most of these patients. Give them for 12 weeks, so about three months. And it, so they have actually higher levels of 30% more cortisol that gives us significant improve the self-rating wellness score. And they are taught that almost two times more patients reporting an improvement, more than five points, points in the wellness score compared to placebo. So very important hormone.

Now, there's also another very important hormone, and that supplies actually energy in prolonged upright position. It's aldosterone or fluorocortisol supplementation. And when you feel drowsy in your head when you stand up a long time or you're sitting a long time, that's usually because your blood pressure is too low. And that is usually due to low aldosterone. Now, it doesn't keep salt and water in the body. So it decreases blood pressure. So if you don't have enough aldosterone, you have low blood pressure. And when you give a treatment, for example, you provide fluorocortisol, and it's exactly what you can find in pharmacy. Aldosterone in the pure form, you don't find. And even if you have it, it gives a good effect, but it's not long-standing. While the fluorocortisol, it works on the morning towards the evening. So I have an aldosterone deficiency. This is the one I take. And I take 100 micrograms. It's the average dose, but there are some need more and some slightly less. But generally, 100 is what most need as a minimum. And here's a study showing that when you give to chronic fatigue syndrome patients fluorocortisol, you give 100 micrograms for a long time, almost half a year, you have much lower fatigue scores, less mental fatigue, two-thirds decreased lightheadedness that is typical for aldosterone deficiency, decreases more, better mental function, and more, better general sense of well-being. So you really have a difference.

Now, there's also hormone fatigue due to disturbed sleep. When you don't sleep well, and one of the reasons not to sleep well is that you have to go constantly to the bathroom. And so, desmopressin is the synthetic derivative of the vasopressin that you cannot get at the pharmacy, but you can get this vasopressin as a tablet. And you just put it under the tongue, let it melt, and improves your quality of life because you have less to go to the bathroom. It was given to patients at night had to often go to the bathroom, and you have less nocturnal voids. And actually, because they improved their sleep, they had better energy. This is in the double-blind placebo-controlled studies in adults with nocturia, that's the fact that I go to the bathroom at night often. Women with nocturia, men with nocturia, it's over and over again shown that this helps to improve the situation.

Now, there are hormone supplements that increase the energy the whole day. So when you see a patient, you need to ask the question, are you tired the whole day, or are you tired in the morning, or in the evening? And hormones, they give energy the whole day. Is estrogen? So what is red is really very typical. The fatigue due to low sex hormones is the whole day. It's not a severe fatigue, but it's all there, there all the time. Progesterone, uh, in the premenstrual period, when there's more premenstrual period, could be due to a progesterone deficiency. And it's healed than in these women with progesterone. Testosterone also very important. Thyroid and growth hormone, IGF-1. But those two also can give severe fatigue, but they're more marked by other characteristics. Direct results, really characteristic is that the fatigue is worse in the morning, by far more. And when they, they sit still, they don't move. Growth hormone, as we will see, is a fatigue when you are completely exhausted and you don't seem to recover over the years. DHEA, slow insulin also gives a whole day fatigue when it's there. And so let's look at the permanent fatigue that is provided due to sex hormone deficiency. So the usual cause, the most frequent one, is estrogen deficiency in women and testosterone deficiency in men. So it's really typical. You can just by knowing when the fatigue comes, know what is or likely is the cause of it, the hormone cause. So when you have a permanent fatigue that is whole day, it's not severe, so this is slight, but it is there. Think about sex hormone deficiencies. They're the same intensity. And provide them the missing hormones, of course, after doing the lab test, doing a more deep investigation by physical examination and by asking the questions that are on the symptoms of deficiency.

Here's just some information on the permanent fatigue that can be found in some women in the premenstrual period. You see that these women who have more, uh, premenstrual fatigue in the second phase of the cycle, before menstruation, have lower serum progesterone. So that this progesterone is lower in the blood. And it's an inverse relationship. The lower the progesterone, the more fatigue there is in the premenstrual period. And it's possibly because actually, when you have a low progesterone, you're nervous, so you tense your muscles, and you push a little bit too much, you, you move too much, so you have actually, um, you get tired from this, this sort of tenseness in your muscles. And also you don't sleep well, so you have a poor recovery during the night. Two reasons why progesterone may, when it's deficient, may increase fatigue.

Now, when you have DHEA deficit, you can also have background fatigue. Insulin deficiency also. We're not going to details here. Just go and look at the session in the model on chronic fatigue on hormone therapies and chronic fatigue. Let's look at some of the permanent fatigue can have, but that increases when there's physical activities. It can be due to hormone deficiency. And that is in the most of the cases that are number one cause, testosterone deficiencies. So when you're more tired when you do the sports than you should be, think that there's not enough testosterone. And you can do what you want, training will help, but it also will help to supply the missing hormone that you might have. And there are studies showing that when you overtrain, your testosterone levels go too low. When you are overtraining, it's sort of burnout for sports people. It is often linked with a lower testosterone. And you see, so the testosterone fatigue is a background fatigue, but that increases when there's sport activity. So the people who have to start the fish often do not want to do much sports because it tires them too much. Even if they do a lot of exercise, they don't seem to recover. So they end up by by stopping doing sports.

Now let's look at a study on women taking oral female hormones. Well, they usually have lower serum testosterone levels. And the lower the serum testosterone is, the lower the testosterone is in blood, the more, uh, the self-report, the more the self-report energy is. They have less energy. The lower their mood is. So the lower the serum testosterone is, is the more the quality of life is not good. There's really a significant association. They need testosterone. And actually, I'm, I'm not going to talk here, I think about that. But when you have a woman's collapse, has no energy, and you give treatments and it doesn't work, that woman needs testosterone. But that one needs to have higher levels of testosterone. So testosterone injections with a blocker like finasteride that blocks conversion of their cells to dehydrate testosterone, and so they don't get masculinization of their body, but they do fantastic with that sort of injectable treatment once a month. So testosterone gives really physical energy to men and power, especially to do physical activities in sports. And they want to do sports. Men who want to do a lot of sports often have a lot of testosterone. And so when there's testosterone deficiency, there's definitely more fatigue in men. And you see, for example, in obese men who have, um, who are snoring at night, have obstructive sleep apnea, if they have lower serum testosterone, that they have lower testosterone. Well, the lower the serum testosterone is in them, the more fatigue they have. So and so, um, when you have a low serum testosterone, you have more physical fatigue and you're less active. Of course, you're less active if you have more tired. It's really an energy hormone, testosterone.

And in women, you see some women are have this mental collapse. What I actually am, I'm seeing here, the extreme mental fatigue that responds to nothing. You give them growth hormone, you give them cortisol, give them thyroid, you give them nutrients, you improve their diet, and they stay collapsed. They are sick and tired of being tired. They really get down. They see no, not the end of the tunnel. They don't see the light in the end of the tunnel. The light at the end of the tunnel is going to your consultation. You're the genius, you're the good person who's going to help that person out. And how do you do it? You have a patient with five to twenty years in collapse situation. Give two to four months of testosterone injections, and they become brilliant women who can become prime minister, head of state, or at least very good businesswomen, dominant, self-determined, knowing what they want. They're going to do that. They feel they have the energy to do it, and they do it because they really have the energy. Determined, brilliant one. Men like to have brilliant women. That's the dream of men is to have a woman who's very dynamic, knows what she wants. They want to be dominated by, but they want to have a woman with strong personality. Testosterone gives a strong personality to women, leadership. It's even more remarkable in women than in men, the effects of testosterone.

Now, if the patient is physically exhausted, there's a mental fatigue that doesn't see a way out. And it's also mental and and physical. And and they need to stay long time in bed. That's very typical. They stay 12 hours in bed, and that's not enough to recover. They never are able to recover. That sort of the exhaustion that's growth hormone deficiency, for sure. And after age 50, most people also become IGF-1 deficient. They are not the same. IGF-1, insulin growth factor one, is produced by the liver. Growth hormone is produced in the pituitary gland. And growth hormone stimulates the production by the liver of IGF-1. But after a certain age, after age 50, it's not enough. You need to supply additionally IGF-1 to get out the fatigue. I was very good with growth hormone from age 38 to 50-52. Then suddenly I started to be tired, and I had no relief. When I took IGF-1, wow, in one month's time, my energy came back. So when you have a lack of growth hormone, the fatigue is severe, and it's all day long. But it activates towards the evening. And if they go too late to bed, it's worse the next day during several days. So, so this is really exhaustion syndrome that it gives. It worsens towards the evening, but is there in a severe state all the time. They also don't sleep well with it. With growth hormone, you get more sufficient sleep, that you don't seem to restore, unsufficient recovery. And so in chronic fatigue syndrome patients, the levels of growth hormone secreted at night are actually compared to controls, about 50% lower, two times lower levels. And because a marker of growth hormone activity is the IGF-1, growth hormone stimulates production of IGF-1. The IGF-1 is about 40% decreased in chronic fatigue syndrome patients. So no wonder they remain chronic fatigue because they cannot recover anymore. Between age 31 and 38, I couldn't recover anymore. I could work, but after seven or eight hours of sleep, I stayed tired all the time. And actually, I didn't really know that. But at age 38, when I took growth hormone, imagine my surprise. I took it because I need it for a patient. I want to check it. I wasn't tired anymore. And I re, I became fresh again as I was at age 25 in the spring. But I was in the winter when I took it for the first time, the few weeks. And so I could recover. And I, I was, I could, I slept five, six hours at night only. It shortened my sleep, but it was much better quality. And actually, I could do much more. I needed a sleep. Growth hormone. What are the doses to give? So just to show you that I usually give doses to give to you, you know exactly what to do. I'll give you some information about growth hormone. Growth hormone is a hormone produced in the pituitary gland that is consists of 191 amino acids. And the doses that to give is between 0.05 to 0.4 milligrams per day. The only thing you really need to be careful, uh, after doing a diagnosis, of course, you don't give growth hormone to any person. You have to have a diagnosis of growth hormone deficiency. But you need to be checked that that patient doesn't have an additional cortisol deficiency because growth hormone increases cortisol. And if it's already too low, it will, the patient will certainly collapse, have collapsed levels of cortisol, and then not feel good. Where do you inject growth hormone? You inject in places around the belly or on the external of the thighs. A little injection under the skin. In the abdomen, the external thigh, it's the most frequent place. You could put it somewhere all over your body, wherever you want. But basically, these are the places that mostly used. Need to change places all the time. And very important, when you inject, don't do it like it's shown on the internet. Extend the skin. You extend the skin, you don't pinch the skin, otherwise you get a blue spot by injecting in. So on the external side of the thighs or on the lower abdomen, no skin pinching. Don't do it like this, like it's shown on the internet. Strong.

Now, there's also fatigue due to the fact that you don't sleep well because the, you are, the patient is, uh, melatonin deficient. Melatonin makes you sleep better. So, for example, here it shows in patients with childhood craniopharyngioma, they may have low melatonin levels. And the lower their melatonin is in saliva, the more they suffer from data sleepiness. So you're at night, not having.

Enough melatonin, you don't sleep well, and thus you have more daytime sleepiness. So, at school, it's hard for them. So they actually need melatonin at night in order to sleep better and have less daytime sleepiness. So, melatonin treatment, for example, and when you give it to patients with chronic fatigue and the late sleep phase syndrome.

So, what is the late sleep phase syndrome? It's the fact that you go too late to bed because you don't, you cannot fall asleep earlier. And when you get five milligrams per day of oral melatonin, which is a high dose, but when you need to change the rhythm and make the sleep, the patient sleep earlier, you give a higher amount in the beginning. And you give this five hours before dim light melatonin onset, and they really improve. Their strength scores are better because they sleep better. They have less fatigue. They also have more activity, more concentration, and motivation, and a really normalized score. Fatigue and, and so that really helps.

Now, I would do it differently. In my experience, you just need to give melatonin before, half an hour to 10 minutes, and not five hours before going to sleep at bedtime. So, if your bedtime is 10 o'clock or 11 o'clock, you take a little bit before, close all the lines, and you will sleep well. And but you just need to give to people the latency, Pedro, a higher amount of melatonin the first month, and then you can go to lower doses after they have reset their circadian rhythm of melatonin. Of course, we'll see patient cases, etc., during all these sessions. At each session, they have patient cases.

And here's, for example, we'll see an example of Christian, who was a severe chronic fatigue syndrome, who stayed in bed all the time because the fatigue, since five years, and she had this is the picture of her fatigue from morning to the evening, a very intense fatigue. She was, it was a permanent background fatigue, a physical effort. So, she knew she has testosterone association, progesterone deficiency, and, um, it was also, um, per a severe fatigue. If she got too late to bed and poor recovery, um, in the morning, she had more fatigue. She had also more fatigue in vertical position, low aldosterone, at stress, and in the evening, she also had iron deficient things like that. So, basically, in order to help these patients, you need to provide all the hormones and nutrients they are missing. Of to really get them out of fatigue and succeed in getting her out of fatigue. But you will see in several stages. I, I didn't correct everything in the beginning, and, and you see that she kept part of the fatigue. But it was so severe that there's a one treatment to make the whole difference in this patient. I can tell you a fascinating, uh, growth. And, and I wasn't, it was almost, except one patient, it was the second patient I ever treated with growth hormone, but it was miraculous. Took out the exhaustion.

Now, let's look at burnout. And burnout, um, is really a pathology that is more and more, even more with the COVID-19 now. And so, you get supposedly get the COVID, and, and they don't seem to recover after. And now we have also people getting the vaccine and not recovering after. And when you look at the studies, but you look also on these patients, they have complaints and physical signs of hormone deficiency. And so, there's a suspicion that, uh, the burnout symptoms in physicians, for example, is studied on physicians here. When you look at the different, um, burnout symptoms that corresponds to hormone deficiency complaints, typical of hormone deficit, fatigue, exhaustion, the gastrointestinal troubles, the anxiety, the irritability, the aggressive stiffness, and also work-related symptoms, and, and interpersonal symptoms can be typical of hormone deficient.

And so, in the fourth session, uh, in the chronic fatigue syndrome model, we'll go in depth on all these different hormone deficits. And what happens in these burnout syndromes is that they have too much stress too long, or they have an acute severe trauma, and where they overproduced hormones and they overconsumed hormones. And a certain time, the gland doesn't work anymore. It's, it's overused. It has, there was too much spilling of hormones, and you have a premature aging of the endocrine glands. And you get that multi-chronic multiple hormone deficiencies, and you get on the burnout. And what they, of course, will be better by doing much less activity because they're not able to do more. But it's because they have hormone deficiencies. It's not psychological. It's because the hormone deficiencies are there. So, as long as you don't correct them, you won't have an improvement.

So, burnout, as, and that's critical, as almost in all cases, low cortisol levels. There's the lack of punch that they have, the lack of fighting spirit that really is typical for cortisol deficiency. And when you give cortisol, results are good. But the problem is that they have multiple hormone deficiencies. So, if you just correct one and you don't correct the others, it doesn't work well. So, you need this again, multiple approach, including multiple hormones to get out of the syndrome and get back to work and to have a life worth living. Because being burned out is not pleasant living. It's suffering. Why would you suffer if you can solve it? And you're, as a health professional, as a physician, are able to correct that. And if you're a patient, you can find a doctor who's able to correct it. Because it's really worth it. It's your life. And your life is precious. You're, you're the star of your life. So, if you treat yourself well, you'll be able to treat others like they are also the stars of their life. So, that the half of life really worth living in the future.

So, when there's burnout, there are so stress feelings. It also may result from cortisol deficiency. Irritability, where it can get suddenly very aggressive. That's typical for cortisol deficiency with anger outbursts. And who has not been like this when being very tired? Because when you work too much and you're too much in stress, you end up by having cortisol deficiency. Again, the treatment is T.F. cortisol.

Let's look at the, and we'll see that in the session on burnout, that is really worth seeing, is that these are the levels of the cortisol in healthy persons. So, what you see here is that there is during the day, in the morning, there is an early morning period of cortisol. At night, there are lower levels. This is the evening, lower levels. At night and evening, low night nadir, that means lower point. And there's a gradual decline from the morning peak towards the evening, a gradual decline of cortisol levels. And they are during the day, short peaks in stressful situations. This is the healthy situation, being able to adapt and make more cortisol during stress.

In burnout patients, it's completely different. Their overall serum test cortisol levels are much lower. So, they have less cortisol in blood. And the lower the morning peak is of cortisol, the more severe the burnout syndromes are. So, you need this morning kick of cortisol, this peak level, to get the energy to be able to go into your day. So, this is a typical person with low cortisol. You see also that there are dark circles under the eyes here, that there's fatigue. So, low serum cortisol are found in high burnout patients. And the more severe burnout symptoms are, the lower the cortisol levels are, and the smaller the cortisol awakening responses. This peak level in the morning is called the cortisol awakening response. And the lower the cortisol to DHEA sulfate ratio, the highest serum DHEA levels are to compensate. So, when you're not able to make enough cortisol, the body tends to make other, more of the other adrenal hormones to compensate. But ideal is to make more cortisol. And so, the adrenals are weaker. If there, you can suppress their action easier by giving a synthetic derivative of cortisol that stays two hours, two days in the blood and suppresses then the adrenal function more than the identical one, the dexamethasone.

And what happens then in patients with burnout is that their levels are much lower. So, there's a lower morning serum cortisol peak. There's lower afternoon cortisol. There are not enough levels to have the energy to go through your day. And there are insufficient short-term stress peaks. They're almost not able to increase their, their secretion, cortisol turned out to the stress. So, uh, when you give a treatment, you give hydrocortisone, that's by identical cortisone. And burnout, what happens is that if you give them 35 milligrams of cortisone, they have less fatigue, more figure. And it also increases, this case, the serum prolactin, which is a stress marker. It works mostly in those who have high prolactin levels in burnout. That means that they are under stress. Actually, it works more in the burnout patients who are high under stress.

Burnout also can be linked to another hormone deficiency, adrenal deficiency, and aldosterone, like this person you see here. What he has is a sort of feeling like he's going to faint. And people who are fainting now by taking the vaccine, the COVID-19 vaccine, are actually low, have low aldosterone. Otherwise, it won't faint. They have that low blood pressure, easy, and faint easier. So, look, people, athletes who overtrain, seven runners here with this overtraining syndrome, typical of them, they had low aldosterone levels, as well as stress, as an exercise. Their blood pressure not high enough. Also had low cortisol levels. Cortisol is low in all these overtraining, burnout syndrome, etc.

Now, what about the burnout and thyroid hormones? Well, they're conflicting evidence. In some studies, there's too low levels, some studies, too high levels of thyroid. And then there are have heartbeats and things like that. So, basically, uh, we'll see how to distinguish between the two types during the session on it.

What about the sports fatigue? Well, sports fatigue, when you need to use your muscle, think first, in first place, testosterone deficiency. And, and burnout can also have growth hormone and IGF-1 deficiencies. And typical when it's due to growth hormone deficiency, there's a sort of feeling that you cannot, you don't have the power to confront what you have to come from. Because growth hormone gives you a sort of inner peace, and you see clearly, and you see you can do this and that. That is the solution for this. But if you don't have enough growth hormone, everything gets confused and looks to be too much. You're overwhelmed. You're drowned in the things. So, you feel powerlessness when you're allowing growth hormone. That's typical also feeling that people with burnout have. So, it may result from growth hormone deficiency. And people with, um, growth hormone deficiency tend to want to stay at home and sheltered because they have social anxiety. They can have panic attacks. Well, panic attacks, is that linked with people? His panic has 60% lower serum growth hormone because this is a reassuring hormone. So, if you don't have enough, you have easier panic attacks.

And then you have the post-traumatic stress disorder, which is, in my experience, due to trauma, of course. But the problem has created hormone deficiency, and you need to correct the hormone deficiency. Well, these Vietnam veterinarians were suffering from post-traumatic stress disorder. And what you see is that they have significant lower growth hormone secretion. You cannot detect growth hormone in most of men, and most of adults, actually, during the day, because it's, it's mostly secreted at night. And during the day, small little short peaks. So, you have to stimulate it with cloning, for example. And that stimulation doesn't get much growth hormone either in people with post-traumatic stress disorder. So, they grew their growth hormone deficient.

In burnout, there's likely also low melatonin. Because in burnout, they have sort of agitated sleep. They're nervous at night. They don't sleep well. And, and melatonin makes you sleep like a baby, calm and relaxed. Here, for example, again, post-traumatic stress disorder patient, then effectively personnel from the Canadian Armed Forces. You see here one. And when you, those who has post-traumatic stress, already compared to those who were not, have definitely lower serum melatonin levels. And, and either over four-hour period or eight-hour period, uh, depending if you have, uh, no light restriction. But when you have restricted evening light exposure, you just should be able to make more melatonin. And there, they really are not able to increase their melatonin at low serum melatonin, the whole night through them.

So, also in burnout, you might be surprised, but don't be surprised. It might be also oxytocin deficient. Well, oxytocin, you say, well, that makes you more socially interact, huh? But when you don't have enough oxytocin, you have social withdrawal, like here. And that is also found in the burnout syndrome. They isolate themselves from the others. And so, here, for example, intranasal oxytocin were given two weeks to patients with post-traumatic stress disorder. And when the student decreased this complaints of post-traumatic stress disorder, in particular, this avoidance of people, it also had beneficial effects on the heart rate, uh, when you were in stress. False put in several stressful situations. We'll see that more detailed in the, the session of the model on it. So, there's fatigue in social encounters. With oxytocin supplementation, you see this breastfeeding woman. And they were breastfeeding after four or five days after the liver of a baby. And salivary oxytocin was checked after breastfeeding or during breastfeeding and after and before breastfeeding. And what was seen is that breastfeeding significantly increased salivary oxytocin levels in general. And the vigor. So, the breastfeeding gives a sort of stimulation for oxytocin release. And oxytocin causes the milk to be excreted from the milk glands. But at the same time, increase the vigor in this woman, and increase the fatigue and the confusion. And actually, the higher the salivary oxytocin were found in these women during breastfeeding, and actually the lower the fatigue score were worse. So, it may indicate that oxytocin helps to have less fatigue, at least in breastfeeding women.

Now, oxytocin can tackle another problem in burnout syndrome patients. And when you give oxytocin, you can combat almost all types of substance abuse. And this has been shown in animals. But now we also have studies in humans. So, it can decrease substance abuse. How about sugar cravings? How many people don't have that? Alcohol abuse, tend to drink. If you want to stop drinking alcohol, you probably need to go on oxytocin. And cigarette smoking, also marijuana, cocaine addiction. So, all these major addictions that we have with the food or the drinks, or smoking, is combated by taking oxytocin supplements. So, oxytocin treatment can decrease the misuse of hallucinating drugs. And here are several studies, cannabis, cocaine, marijuana, ecstasy. So, you want to kick off it, it's helpful. And I don't really have many patients getting these type of severe drug addictions. But I had some physicians following my recommendations for them. And they said, we really have a very good success with our addicted patients. This helps them. It doesn't solve everything, but it does help great to kick off of these drugs. Because they also become more social. They're less anxious socially. And things like that. So, no need to take a drug when you get social anxiety. You just need to take some supplementary dose of oxytocin.

So, burnout treatment, their basic principles is that you need to give to the hormones that cortisol, adrenal, gives you a very good decrease of the burnout syndrome. But growth hormone takes you out of the exhaustion. These hormones are important. Now, a little problem is that when you're really cortisol deficient, growth hormone increases the cortisol. And we tend to give IGF-1, which increases cortisol rather than growth hormone. It has similar effects, but you don't have IGF-1 easily in many countries. So, growth hormone gives them smaller doses of growth hormone and a slightly higher dose of cortisol to compensate that. Thyroid, estradiol, progesterone may have to be supplied. Testosterone may have to be supplied. And oxytocin to get out there. So, these hormone treatments is part of a whole program where you improve the food, you take out pollutants, you increase the, improve the lifestyle, you also give some nutritional supplements. But it's part of probe. But this is crucial to get fully out of the burnout forever.

Okay, um, now we're going to see, uh, Professor Johannes Burkist. Um, just see you if you are there. And I had your, um, questionnaire. Uh, you're there. Perfect. I'm going to take out, stop sharing my screen. Um, I think everybody sees you, uh, Professor Reed. Thank you for being here. Um, and I, what I found really exciting, uh, in your research is that you're searching for diagnostic markers, markers that show what's behind a chronic fatigue, but also, I think, a neurogenesis of diseases. And can you talk about more of those markers? You talked about lactate levels and energy markers. Can you give me some examples of markers and, and how you detect them, and in what sort of fluid?

Yes, so again, a pleasure to be with you tonight. Uh, so we have focused, where I focus a lot on myalgic encephalomyelitis, or also known as chronic fatigue syndrome. But I focus mostly on the neuroinflammatory part of, of this disease. So, what we are targeting when it comes to biomarkers are, yeah, energy markers, as you mentioned, lactate. We also look at hypoxia-related markers when we look at ratios between lactate and pyruvate. But also inflammation is one of the major targets. So, there we look for interleukins, cytokines, complement factors that are part of the innate immune system.

So, in your patients, you have, for example, a low lactate and a low lactate to pyruvate, uh, ratio, I believe? And then you have actually, actually opposite. So, myalgic encephalomyelitis patients typically have increased level of lactate, also during very mild conditions, mild exercise, or mental activity, activity. So, what we see is they produce lactate, but they don't manage to reduce the level of lactate as a normal individual would be after an exercise. And then for, um, inflammation, you have interleukin-6, I suppose? And are also using CRP, the CRP protein, also as a marker? Yeah. And, uh, what we typically see also, which is of course, uh, a problem for the patient with myalgic encephalomyelitis, if you take the normal panels that we get from the clinical chemistry laboratory all over the world, they typically don't show up as very high inflammatory markers. So, CRP, for instance, are typically not very high. So, that can lead us into a false estimation of that the patient actually don't have inflammation. But when we have a possibility to look more in detail in, for instance, cerebrospinal fluid, and we measure in cerebrospinal fluid, then a panel of neuroinflammatory markers, we can see that they actually have an ongoing inflammation, central nervous system related.

And so, you also, um, have talked to me about low energy markers. Which type of energy markers are you checking? Yeah, so we are trying to follow is also broad panels. So, we see, uh, energy markers like ATP and NADPH and so on, to see if the mitochondrial function is like activated and works as it should. And what we typically see is a deficiency in, uh, producing, producing energy, basically in the cells. So, so you're very interested in blood. You have a blood test that you do to get, that you can do it in blood tests, but you can also do it in, in cellular material, if you isolate blood cells, for instance. Oh, yeah. Or in some cases, there's a possibility to do small biopsies from muscle tissue, for instance. And can, for example, if patients are interested, can their physicians send samples to your lab? Yeah, we have samples sent to us from all over the world, actually. We have a collaborative research center with Harvard, Stanford. We have a center in Montreal, in Canada. And we now have one in Melbourne, in parallel with our Swedish, uh, center in Uppsala, at Dowsaw University. Is there a website where people can get more information? Yes, it's, you can find us easily at Uppsala University under my name. But also, there is Open Medicine Foundation organization in the United States that has collected these research centers under one umbrella. So, that's easy obtainable information about us.

Um, so, um, you had also some markers you checked by checking the cerebrospinal fluid. You go in the spine and you check with the liquid, a lumbar puncture. What are you checking as the neuroinflammation markers in, in this fluid, in the spine? Yeah, so the ones I mentioned, it's a, it's a broad panel. So, we actually have a panel of, uh, several hundred different molecules that we look at when it comes to the cerebrospinal fluid. So, it's a combination of complement factors from the innate immune system. It's a cytokines like, uh, neurotrophin, TNF, IL-6, IL-12, a lot of them that are important for us to see. But then also a cell damage molecules that are a panel of apoptotic signaling, uh, cell repair systems that are activated. So, cell damage, you mean, for example, malondialdehyde or like oxidative stress markers? Or it's more than that? We look at both proteins, larger proteins. If you come to the central nervous system, it could be a typical marker could be GFAP, so glial fibrillary acidic protein, which is a marker of cell damage. We have a neurofilament light, which is another cell damage marker that we monitor. When it comes to metabolites, typical one can look at a small molecule like glycerol, but also, as I said, lactate, pyruvate, small amino acids, yeah, neurotransmitters.

You talked also about neurological diseases that get antibodies that are due to antibodies. What sort of antibodies would you check? Can you give one or two examples of antibodies? Is it also in blood or is it in the lumbar puncture? Yeah, so what we are monitoring is autoantibodies, so antibodies that are directed against our own cells or certain proteins in our body, for instance, receptors. And in our patients with myalgic encephalomyelitis, we see an increase of autoantibodies against muscarinic receptor and the beta-adrenergic receptor. So, those receptors that are actually taking care of the signaling from acetylcholine and, uh, and norepinephrine and epinephrine. So, very important receptors. So, we see, yeah, are damaging their tissue with these antibodies. That's one theory we have to still prove that, I think, because, uh, it's not been exactly known yet how these autoantibodies are functioning. But there are some preliminary studies where one have shown that if you reduce the amount of these autoantibodies in circulation in blood, uh, some patients actually respond well on that kind of treatment. Now, the important thing though, that we have done, yeah, one important thing that we have found is that when we look at cerebrospinal fluid and the liquid surrounding the brain, we don't see the presence of these autoantibodies. So, it means that we probably don't have an intrathecal, they're autoantibodies, not no production in the central nervous system. And that's a good signal, because then it means that if we need to reduce these autoantibodies by some measures, it's going to be more easy to address this if it's in the periphery and not in the central. So, mostly in the blood that you detect them. And I mean, okay. And then you, you also talked about something, uh, also very exciting, is that, um, you also check the hormone markers or hormone deficiencies they have in myalgic encephalomyelitis. And which is, I think, severe chronic fatigue syndrome. Um, and, uh, you were talking about that you were also checking stereoisomers of thyroid hormone. Can you talk more about that?

Yes, this is an ongoing study that we are running right now. And we know that many patients with myalgic encephalomyelitis then report with with problems with the thyroid hormone regulation, as you, you also mentioned in your presentation. So, what is fascinating is that in the clinic, in the routine methods, we have T3, T4, and TSH typically measured. And in some cases, those are fine. We can monitor them and see deficiencies or problems regulation. But when you de dive a bit deeper into that thyroid hormone regulatory mechanism, you can actually find a multitude of different markers, both as you mentioned, also everything from T0 to T4. But you have also the isomeric forms, and you have iodide binding problems in certain of these forms. So, it's important to have a multitude of measurements done if you really want to understand this regulation. So, if I understand, if you, for example, the most potent thyroid hormone, D3, you could have several forms, two differential forms, structure, and maybe one doesn't really work, and a patient has too much of the one that doesn't work, and that's not enough of the one that, that works. So, you could have normal levels and still be not responding to a treatment, for example, because you don't have the good, um, the problem with doing the measurement is that you have to have quite a fancy and expensive instrumentation to do the measurement. So, you have to first separate the molecules with very high resolution liquid chromatography or supercritical fluid chromatography. And then you have to measure them with precise high resolution mass spectrometry. So, that of course, combination makes it less available to ordinary labs around the world, unfortunately. But, but you have a lab that does that. And you, you know, it's probably expensive to do it, but maybe if somebody is interested, it is possible to do it. Uh, that's interesting that at least we have the possibility of already measuring that, because that will probably lead to new, new information.

And then you were talking that when you check the adrenal function, we're not just checking the hormones, but you are checking, um, intracellular parameters of thyroid activity. Can you talk more about that? Can you give examples? Yeah, that's also very much ongoing, uh, research right now. We're trying to do measurements of, uh, potentially dysfunctional regulation in the tissue, uh, over 24 hours measurements, which is then of course, quite demanding, both for the measurements, but also for the patient. But what one can see is, we see this kind of dysfunctional regulation. We call it the vicious cycle in, in critically ill patients. And we are trying to learn from the critically ill patients in intensive care units and transfer that knowledge to what actually becomes, uh, myalgic encephalomyelitis or post-viral fatigue problems, as we are focusing on. And, um, so normally, when I check thyroid parameters of activity, I check, for example, sex hormone binding globulin, LDL cholesterol, alkaline phosphatase. But I think you have 18 or 20 different intracellular markers. So, you go a step further, much further. We have actually, for the, uh, hormones, steroid hormones, we have in our methanol, 36 different, uh, hormones that we can measure, wow, with our technique. So, that's of course, exclusive. But it's a way of understanding more the relationship between the different hormones, also how the enzymes that are regulating the levels actually are functioning, and how they are connected to each other. So, it's not only sufficient, it's not sufficient to just take the hormones. You should check the effective hormones on the cell activity. And that can be checked with other parameters in blood. That's more or less the basis of your, wow. Okay, very interesting.

Um, and, um, would you have a message for people? Do you have an advice for them if they have chronic fatigue? Could you help them, or would you just give a sort of sound advice, or are you mostly in the diagnosis? Uh, yeah, so it's hard to give a general advice that would fit everyone, because it's a very, very individual disease. We have millions of patients around the world, and each patient is unique in some way. But one recommendation that we typically give is that one try to find out what is the deficiency or the problem that could at least help you treat the symptoms, and also to get good contact with good specialists to help have the most supportive help with your the disease. Because what you have to do is, you have just keep your energy, and you have to make sure not to crash. When you have myalgic encephalomyelitis, unfortunately, many patients don't respond so well on medical treatments or therapies with drugs, typically. So, it is complicated in that sense. But what has been shown over, over the years, and what actually led to recovery, especially in younger patients, is that you, you maintain your energy level, and you're careful not to over-activate yourself. Uh, even if you feel very energetic, you should try to keep your sources and don't over-exercise, or don't physically or mentally exercise too much, because then you get what we call post-exertional malaise. So, know your limits and, and stay just below the lower, the upper limit, so that you can keep your energy as long as possible. Good, good advice.

What I propose, I'm going to show some slides, so you check out your video, and then if we can have you for the question and answer session, that would be perfect. So, just find five, seven minutes, be back, is that possible? Just to check, and then I can, okay, perfect. Okay, um, I'm going to show you my screen. I have some slides more to show and about information before we go to the question and answer session. And I know there are some questions, as these 23 questions we have now, is that, um, we're going to have for, um, a firm in Argentina, the VIP firm pharmacy. Actually, we're going to have a series of several sessions. They will be translated, but I will talk in English. So, um, everybody can go. There will be about, uh, two hours that I will personally give with a pass, and that will be in April and in May, usually on the average, once, uh, a week in the evening. And, so, we have also this, uh, question and answer session for postgraduate students. We have the formation called evidence-based hormone therapy. There's a lot of nutritional treatments also. And then every month, I have a question and answer session for those who have subscribed to the information. It's very interesting because we also some case studies now, and there are many, many questions. So, it's really worth to be part of the team and do these webinars. There's also a free live webinar like this on thyroid deficiency, excess, and autoimmune disease and hypothyroidism, very interesting on April 27th. And we'll are trying to have a very, um, interesting guest also, as we have now. And, so, there's a whole evidence-based hormone therapy program where it's beginning to translate into Spanish. So, if you're Spanish, it's also worth to be part of the teams, not only in English. And these are very exceptional, uh, courses. And we try to have a top expert also talking in the new models that are on the making now. We're going to have a first writer, going to have a professor from Harvard, Abraham Morgenthaler, on testosterone. So, it's really interesting. And we have within that, sort of evidence-based hormone therapy, a special part that is only nutritional, that has been separated, that you can also subscribe to. This nutritional program also, the evidence-based hormone therapy is the one that really gets a lot of success. And then there are books to order. You can order here on the website, hertalkmedicalschool.eu. If you're a physician or a health professional, you absolutely need this book. This is, if there's only one book, this is the book to have that talks about the hormone deficiencies and therapies of 18 hormone therapies. And it's really worth because you really know how to learn how to do it. And then we have this, my latest book, the assassin therapy for real gentle. We have everything about prostate cancer and patients taking testosterone, how to reverse prostate hypertrophy, everything you want to know and do about testosterone, reversing physical aging. It's my textbook on how to reverse the aging of the head, the hair, and the senses with a lot of interesting information. And then what is also helpful for physicians, athletes, often neurology, hormone therapy, have more than 650 pictures of hormone deficiencies, 20 hormone deficiencies, and 19 hormone excesses. Really, really worth if you work in the sector to have. This is unmissable, I would say. Hormone Handbook and Atlas are unmissable books. For general public, we have the hormone solution, the oxytocin book, that is also physician, where you have everything on oxytocin. And the patient hormone handbook, which is a reduced form of my best-selling hormone handbook for physicians. Really helpful because many patients get want to be their own health manager. That's the book to have. And then we have partners under, uh, which we, we have, um, also, uh, Nicolas Le Cordier. I think, uh, he's going to talk just one of our. And I'm trying to put here, yep, that's it. Ring and talk. Hello, I am gone from the family ambition. It's been 25 years now that laboratory made perceived health from different perspectives, present beyond healing, thanks to natural health products. All our team is every day doing its best to honor this holding principle by developing natural and high-quality products that have collaborated thanks to a recognized technical and scientific expertise. Our engagement is global. From content to packaging, our peel containers are indeed 100% vegetable and elaborated from sugarcane. Our capsules are also vegetable, as they are made from tapioca. Thank you for your attention. Thank you, Nicolas. It's a really firm that is, um, sustainable. I mean, looking in the future and getting organic and, and very sustainable things, so you don't get, uh, any pollutants in it. So, really good. We have a lot of other firms like Deuteria Nutrition, Cell Biosystem, Fossils, Hepatic Earth, Thyroid that help, Canada helps us, Knowledge that Solid Devil, Your Health, Anti-aging Systems, very, very good firm where you get what you cannot have elsewhere. Tiller Made Compounding, also interesting. Lymph's Label, Bionuri, so also it helps us with this, uh, Spanish translation. Really thank for them. They're really good partners. And then Pay Compounding Pharmacy, Laboratory Access Labs, Qualifita, etc. So, I'm surely forgetting some, but, but really, we're thankful, grateful to you. And then you can follow me on the social networks. But it's a whole movement. Uh, we're trying to get information out there. You have, uh, Facebook, you have, uh, the Twitter, you have LinkedIn, and, and YouTube videos, uh, interesting. And if you need additional information, you can go on the website, hertalkmedicalschool. Our email to the office.hertalk.eu, the office at hertog.eu, you can get the information that you need. So, really, thanks for your attention. But we're going into the questions now. So, don't leave. And I will look at the questions. And I'll stop sharing the screen. Professor Burkist, you can come back. And I will start with the questions here. Um, [Music] Okay, um, here's a question. Suggestions saw the spread of vitiligo. Well, vitiligo is usually with autoantibodies, and usually these patients have adrenal deficiency and may also have yeast infections. So, what I do is I treat the adrenal deficiency, and I give the, uh, eventually, uh, put locally anti-yeast proteins and stop the the priest. Pro. Hashimotos disease can be reversed? Yes, and I will talk more about that the next time. And it's, but you have to do a multiple treatment. In what lectins, oxalate, salicylates, histamine, phenols, sulfites intoxication? When we normally need vegetables, here's a patient asking that with vegetables, you can get some problems with histamine and other. I don't know if you can talk more about that, uh, Professor Burkist, but I personally, uh, we make patients avoid foods that give more histamine. But all the other things, I'm not so knowledgeable about. I don't know if you know more. No, no. There are many questions. So, there will certainly be other questions. Some people say that one should eat carbohydrates and proteins separately. They say we should eat proteins with vegetables or carbohydrates with vegetables. I think it's true that there's a basis that you should not mix too many different foods, and you shouldn't eat fruits, for example, during a meal or after meal, but before a meal, half an hour or three hours after. When should you take each supplement? It's good for energy all day. Should you take them early in the day? Yes, if it's the supplement that gives you energy, generally it's the first thing you do in the morning when you wake up, on awakening. Some supplements are fatty solutions, and they may be better absorbed during the breakfast or the meal. So, you eat them during the meal. But I usually always propose first thing in the morning when it's something that gives an energy the whole day. When you should you take iron? That's after the evening meal. It's better absorbed on an empty stomach, but the problem, you get much more problems of digestion. So, the iron is best to take then in order to avoid, uh, digestion problems after the evening meal. Then you don't eat anymore, and it's better tolerated this way in most people. How do you change the older of 18 years to this get turret from synthroid? Thyroid centroid that we have been on it for many years. So, patients who had taken thyroxine T4 only during, uh, many years has to switch to this get a third. Well, you do it very slowly. And this will also be discussed in the next, uh, free webinar. The switch over, uh, you have to go very slowly, decrease one, and you increase the other very slowly over two or three months. Prevent hair loss. Well, we saw that already earlier. There are many nutrients that help prevent hair loss, but this such a long number, there's a silicone, for example, just iron, and there are many hormones that prevent hair loss. But you can read my textbook of hormone therapy. Can you please expand on when two and a half milligrams of cortisol, it creates the headaches? If people get headaches with cortisol, even the slightest dose, um, it, it can depend. There are many different possibilities. Um, it's usually that they have other hormone deficiencies that are not corrected, like aldosterone deficiency. And the, it could be that the two and a half milligrams of cortisol, which is not much, if it's identical one, it can increase the blood pressure too much, and you get headaches by increase of blood pressure. So, we have to avoid salt in these patients, and, uh, to probably give a little aldosterone, which actually itself increases blood pressure. So, it has to be seen individually. It's too difficult to, to give a straight-out answer. Vasopressin, aldosterone, could these help a patient with chronic kidney disease? Or what would you look for in patients with chronic kidney disease? They could have aldosterone, vasopressin, but they often have high blood pressure. You need to be careful. You don't give aldosterone or fluidal horizontal patient who has high blood pressure. I'm going to see if I can find a question for you, Professor Burkist. How would you recommend chronic early awakenings? 3, 6 a.m. chronic early awakenings? Often, if people take too much melatonin, they have to lower the melatonin often. And then it's a sort of benign tumor in the brain. Can it be a source of fatigue? Yes, of course. But what to do? It, I don't know. It, that you probably have to take the tumor out. Is it the growth hormone injection that helps IGF-1? Or is there an IGF-1 injection? There is also an IGF-1 injection. I don't know if you know, Professor Burkist, but, um, we work with growth hormone and also insulin growth factor one, which is normally given to children with short stature. And both help to take exhaustion away. And after age 50, everybody gets deficient in both. And I create helps both people. Um, but that's in the most severe chronic fatigue room. You had actually, um, you, you examine mostly the most sick patients among the chronic fatigue. So, is there, um, a special definition to be, uh, labeled myalgic encephalomyelitis? Yeah, we use the Canadian criteria and also the Institute of Medicine have made the criteria that consensus criteria that we are using for, for the stages. And this criteria of myalgic, it's a mind, it's a criteria of chronic fatigue syndrome. Well, it's a bit of, I think it's a mix of, of, let's say, both. Yeah, because also there is another term called SEID, which is an exertion. So, it takes PEMs into to the picture also. So, it's a combination of different consensus criteria that we're using. But it depends on also if you're setting diagnosis or if you're selecting patients for research, for instance. You have to be different in your, how strict you are on the definitions here. Because myalgic encephalomyelitis means that you have pain in the muscles, and that you have an inflammation of the brain and the spine. Yeah, basically. But not all chronic fatigue syndrome patients have that, or do they have that? No, not everyone have that, or at least not measurable terms. So, I think there are definitely subgroups of patients in this cohort. So, that's why we need these measurements, the better diagnostic tools by molecular features. Because in my, um, latest workshop, um, some days ago, uh, for Mexico, there was a question. I said, um, they didn't say it, I'm desperate. They said, I have a myalgic encephalomyelitis. What can you do about it? And so, so I suppose it's a patient who has the diagnosis officially and has more inflammation than, than other chronic fatigue syndrome patients, I suppose. Yeah, so we still, there are different trials being tested around the world now for reducing inflammation. So far, none has been extremely successful, I have to say. Unfortunately, we had initially a positive effect of rituximab, which is done suppressing immune system and suppressing antibody production, but it turned out not to be a sufficient treatment. So, now it's okay. Yeah, it's not recommended. Well, um, need more research then. It's going to measure. Okay, okay. And then, can we use hormones to treat depression? Yes, and I'll probably have a whole model on depression, anxiety. Actually, one of my next books, I hope, if I have time, because I don't have so much time now, will be on how hormone therapies can help psychiatric diseases, including depression. So, let's say, if you have a whole day depression, it's usually sex hormone deficiency. You have a morning depression, mainly, it's usually thyroid deficiency that can be a cause of that. And in my experience, um, you have to know that I have, I started training as an assistant psychiatrist, and I saw so many hormone deficiencies in those psychiatric institutes, that I said, well, I'll be more efficient when I give hormone therapy. And I was indeed more efficient when I was started to work in hormone therapies. I have primary biliary cirrhosis. Will this make fatigue chronic? Yes, it can. But every fatigue can be decreased to my experience. So, um, keep the hope on. Can I see the previous website? All the free webinars are actually, uh, remained. Three have been recorded, so you can see all the other, uh, free, free webinars. But if you want to get in-depth information, it's better to go in the whole training program that is really worth. Um, because I usually do good conferences, but this is just a better level. Sorry, just joined. Will the recording be available? Yes, the recording will be available after we have actually, uh, two-thirds of people. After the last, uh, free webinar of the beginning of March, we had 8,000 people. And we had actually during the recording about a thousand. And then it was 7,000 more. I have seen it after. In chronic fatigue, if the hormone treatment is stopped, does the fatigue come back? Yes, it does. Because fatigue due to hormone deficiencies come again if you again have the hormone deficiency. So, it's a treatment that hormone treatments work as long as you continue taking them, taking them. Because in general, people with hormone deficiency have persistent fatigue. What about fatigue and sleepy once sit down? When you sit down and you get sleepiness, that fatigue is typically due to low thyroid. But if it's low blood pressure, get lightheadedness, that's due to low aldosterone. So, it goes away if you are corrected for the hormone deficiencies that has been behind it, if you have checked, of course, the hormone deficiencies and made the good diagnosis. Why doesn't hydrocortisone work even if fraction three times a day? If many people take it too low dose of hydrocortisone, so it cannot work. Uh, hydrocortisone is by identical cortisol. Has to be taken several times a day. I think it normally is twice a day sufficient. Three times cannot. But you need to take enough. And I have seen physicians only giving five milligrams at a time, and that for most patients is insufficient. Can you measure thyroid deficiency from heart rate? We'll probably have to stop a bit some of the questions because there is, uh, I've assigned that I may not continue too long. Can you measure thyroid deficiency from heart rate? Uh, of course, the heart rate is quicker when you have more tired ones, and slower when slow. But it's not a diagnostic test. This one just one parameter. I said here, um, say hello to beautiful Stockholm. So, you have a plan there. Thank you. I will. So, um, yeah, um, do you know more about polymorphism of the diodinase type 2 gene? You know it's a well, maybe I can not so much. Yeah, well, um, the T4 gets activated to T3 by what is called an enzyme, diodinase. And the type 2 diodinase makes most of the T3 for the body. And people that can have a genetic deficiency in this enzyme and not make enough T3. And those patients, patients have been shown in studies, they do much better if they get a T3 and T4 combination than T4. And there's a genetic test you can do by saliva. I lost audio when Dr. Berges began speaking. Okay. Has this been recording? Regarding burnout without.

The quite okay. I'm, I'm trying to find a question for you for sharing appointment. You have to clinic. You can always sell where do you see the overlap? The questions I have just started with a treatment. How to combine? Um, I'm not having any more questions. How to diagnose fatigue if it differs from day to day? Some days more in the morning, some days sometimes all day. Do you have an answer for that?

Uh, no. I mean, the typical, the patients we see have a constant fatigue. Most likely they can recover a bit during late late days, but it's, uh, 25% of the patients have a possibility to be fairly active. They can maybe maintain schoolwork or go to work. 25% will stay in dark rooms without any physical activity, any stimuli, and then there is everything in between there. So it's a big and very broad, uh, spectra of, uh, severity, I would say. Yeah, so you have mostly exhausted patients, I think about that. That's it. Yeah, that don't recover actually.

Um, I would say for people have less than exhaustion, if they vary their energy a day, it's often due to a wrong food intake because some food and so if they eat sugar, then they will be more tight all day after. If the too much or too little, they can may also make a difference. Fasting gives more fatigue, but if you eat too much, that kind of give also a post-meal fatigue. So I think it's mostly due to the food that they may have these differences. It also could be to some people have pollutants or typically, I mean, I'm being a generalist now, but typically they are very careful with their food intake and they are very, uh, they know about food intake a lot. So they're very careful with what what they eat and how much and so on. But that's the thing maybe why they don't have ups and downs in them. So that's at least a good thing.

I probably had COVID-19 February '22, just a negative on PCR. And I said since my then my lungs are crunching, special morning. I take alpha time as an off one. I've tried antihistamine. Nothing seemed to work. The lungs remains crunchy and I'm very exhausted. When the lungs are have been attacked, you need to repair them by anabolic hormones and it's actually a little growth hormone, but mostly IGF-1 that gives the best efficacy. So you need to go to IGF-1.

And then I think we're almost, oh, I mean, we have a question for you, professor. What is your experience with Nick Savier, former Kuta president, in the treatment of chronic fatigue syndrome and perhaps with this work was burned out? We haven't done any, as far as I know, there are no clinical validated tests on this or trials with placebo control studies. So it's very difficult to say.

I would, I would say in this case, I just wanted to comment on the COVID-19 since that's sort of on everybody's mind right now. So what we are doing currently is we are monitoring the most severe COVID patients, those that end up at the intensive care unit and in ventilation and long-term hospital treatment. And we, we see once they are released from the hospital, they also have post-viral fatigue and neurocognitive issues. So we try to learn from the most severe ill with the well-known now virus infection and see if we find any similarities, also learning potential treatments, strategies and mechanisms behind the fatigue that the viral patients have. So I think that is an option for us now in this catastrophic situation that we are living under. We can still learn something and actually create some new science here.

Yes, and, uh, is those questions, I think maybe from Sweden. What suggestion do you have for POTS? But I know what POTS is. Yeah, yeah. So, uh, POTS is, uh, dysfunctional regulation of blood pressure, you could say simply. POTS patients actually have the similar type of autoantibodies as we see in our ME patients. So they have this autonomic dysfunctional regulation of blood pressure, for instance. And treatment-wise, blood volume increase has been shown to have some, some good effects, but it's, uh, still there's no evidence for the treatment, I would say. So it's patients that have by time to time sort of drop in blood pressure event, but it's irregular because they have, they have also a combination of drop in blood pressure and and tachycardia. So yeah, yeah, that's that's often with low blood pressure.

Um, we had a patient from, I think Sweden, exactly like this, who had to be brought in a bed here with a provision constant infusion. And actually, it it was solved just by giving fludrocortisone. They had forgotten to treat the adrenal deficient. We then give cortisol by identical, which increased the blood pressure and fludrocortisone, and that helped. So that helps.

Here's a question about how many consultations, a blood test a year does it take to undergo treatment? Generally, the first year, there's four consultations if it's at my place, and then every nine months, we receive the patients, and they seem to do well. Sometimes when they go from very far, after the first year, it's every year that gives some information.

Okay, I think, um, we're at the end. There are many more questions. I'm sorry. I can also ask, not answer everything, but I'm really happy and I'm really honored to have had you, Professor Brent, because I did find that you really gave me, give to me also new insight, new information. And I think it's the case out for, uh, all people have learned. So really thank you and for your participation. All the best and take care. Thank you so much. Bye-bye. Bye-bye.