Mast cell activation syndrome

well welcome to this video and I'm so pleased today to welcome Dr Tina Pi Tina welcome and thank you so much for coming thank you very much for inviting me John very PR all now we've talked about lots of interesting things so chatting just before the the recording and and last week um maybe start off with a bit of background about yourself Tina if you don't mind yes of course so I qualified a long time ago in 1983 from gu Hospital medical school and um and I thought at that time that I really wanted to be a GP so I've trained in general practice and I worked in general practice for seven years but I actually didn't find it as satisfying as I had hoped because the appointment times were too short and um to actually get to know a patient and work find out what's really going on behind and causing the disease or the the symptoms that they're presenting with there just wasn't enough time so I found it wasn't very satisfactory really and at the same time I was very interested in women's health and I had um was doing a lot of contraceptive clinics and really enjoying those and then in in 20 sorry in 1994 I was asked if I would run the services for East s uh for contraception and so I said yes and there was there was no office or secretary or anything and I had to put all of that in place um develop the services which was great fun and then I was asked in 2002 if I would run mids as well so I said yes and then I was asked if I would run the H ofari contraceptive services in 2012 and I said yes oh no in 2005 actually when the so I said yes and I I did that and I had a fantastic team and we used to work very closely with the director of Public Health um I would meet the director of Public Health um so for 24 years I met the director of Public Health every 15 sorry every three months and we would discuss all the teenage pregnancies and the termination rates and the different Wards within the county where there were areas of dep ration and where we needed to really have a presence and help these the population and uh and then it was down to to me so we would decide the policies together the director and I and then it was down to me to put it in place to place and make it happen train the staff get the money find the locations to open the clinics and it was a very successful department and by 2012 we had brought down the teenage pregnancy rate to the lowest level for 20 over 20 years uh which was really quite something so we're very proud of that and had a fantastic team and it was really it was really going all going very well and then in 2017 they closed loads of clinics and sort of just decimated the service so they closed 36 weekly contraceptive clinics in Su um so from from 20 different sites and we went from 20 sites to three and Su is a big County it was very very difficult then to run a very good comprehensive service from just three sites and a lot of young girls couldn't get get there Etc which was really disappointing so I I left that service in 2017 and and the meantime I had also been developing um myself as a menopause specialist and I started to work at the Charon Westminster Hospital um I got my menopause specialist uh qualification and um and then I was working there until the first lockdown when they then closed that clinic um and then I decided I would just work privately so I see a lot of women for menopause now as a menopause specialist um but I have another string to my bow which is that um in 2016 my youngest daughter became extremely unwell and she had been chronically not great all her life and we had never quite got to the bottom of it so she had had terrible exma from 3 months old um she was always pale in photographs of my three children there would be this little ghost which was little Jesse she just looked like a ghost she always had a a sort of distended tummy um IBS type sort of picture and um and she was always cheerful always brilliant never complained but obviously wasn't terribly well and they we just kept being told it's eczema it's eczma it's eczema and she'll grow out of it and unfortunately she didn't grow out of it and when she was 13 it sort of got worse and um and then when she was 16 and went to college it became even worse when she got she caught swine flu and um and then she had a terrible migraine for four weeks and was having really became very much like a chronic fatigue syndrome me patient and tried to press on and do she did her a levels and she got anyway bless her heart she was um very uncomplaining but not very well at all and then in 2016 she was a student nurse um on the co Wards and um she was fed off of feeling chronically ill so she decided to um bullet um a lot of um superfoods and do lots of exercise and try and go on a sort of Health kick so she was um superf fooding and blitzing all this stuff which was actually very high in hist toy in this food and she was drinking it by the gallon and she became iller and iller and iller so it was like she had terrible flu but her eczema was all awful I mean it was just her arms her neck it just absolutely erupted everywhere when she turned her neck her head her skin would break and tear it was that bad it was absolutely awful so she was bleeding onto her sheet she was bleeding onto all her clothes it was just terrible and she but she was also feeling faint and dizzy so she had pots symptoms with Tachi cardia she was she had diarrhea um bloating abdominal pain she would wake up in the night with nausea and have to run to the bathroom thinking she was going to be sick she was covered in a tiny little histamine rash which was all over her body and very itchy as well as the eczema she was bloating like a balloon with lots of fluid retention um she had a migraine that again lasted for four weeks she went for seven days without any sleep at all she had total total insomnia even though she was exhausted she couldn't sleep not even for a second it was terrible and that's because her his was so high anyway and then she had she had the the migraine she had um oh just so many symptoms 30 symptoms affecting lots of different systems and uh she rang me up um and she burst into tears which doesn't like her at all and she said I can hardly open my eyes and I can't and my mouth is all cracked and I can't even really drink anything and I said right I'm coming around to get you so I jumped in the car picked her up brought her home and she had dermatographism um where you could just write on her skin and it would leave you know your signature for 20 minutes um she looked absolutely terrible and she we sat her down and um and I got her a straw and water with a straw so that she could try and drink and everything and my husband made the diagnosis actually because I said to her you haven't eaten anything all day I'm going to make you some organic carrots organic potato and I had some organic minced lamb and I said this will be very safe you know let's try and feed you so she had some carrots she was okay she had some potatoes she was okay she put a teaspoon of the minced lamb in her mouth and within seconds she flushed like we just set off a bomb in her head she just went absolutely bright red like a venisha beacon and and she started to sort of feel even worse and my husband um bless him said oh it's like she's allergic to everything it's like histamine and when he said histamine then it started to click for me because nine years before a a friend who was a chiropractor had said to me do you know anything about histamine intolerance and I said no and she said well I think maybe your Jesse's got it and she gave me a little piece of paper with this definition of histamine and tolerance on it and I went on to Google and in those days and this was nine years before 2016 um there was nothing nothing on the internet about his in tolerance so I couldn't really sort of progress my you know my research and I just filed it to the back of my head and then when my husband said she's got high histamine levels I think I suddenly thought she's got histamine intolerance and then when I looked again in 2016 there was more there was more information so I con I went through all of the bits that I could find on it and um see all the symptoms and she fitted all the symptoms were what she was expressing and um and so then I we were on a quest to find out how to treat it because there wasn't very much on the internet about treating it so I was using my little knowledge and common sense that I had was like well let's give her some antihistamines so we bought some Fexofenadine but we just gave her one a day which isn't sufficient at all when you've got such high levels toxic levels of histamine and um and I also tried to find out what was high histamine food and what wasn't and it wasn't very straightforward to find it anyway cut a long story short we couldn't find any doctors who could help us because nobody seemed to know anything about it except one wonderful man called Professor Vic Kula who is a euro gynecologist and I came across him um by accident through a colleague at the Chelsea and Westminster menopause clinic and he he um I spoke managed to speak to him and I said all the lists of all the symptoms that she had and I was very worried about her and she looked terrible and I said to him I think she's got histamine intolerance and he said I think you're absolutely right and it was such a relief to have somebody sayou barking up the right tree and this is and then he G he said to me right what have you done for her and I said well we're trying a loow histamine diet we're trying antiy he said what are you giving her he said fanine 120 milligrams once a day he said oh no go up to 180 and give it to her four times a day and that's the maximum safe dose that the U European Society of Dermatology has said it's maximum safe do so we we did that he said also I we need to give her a type two antihistamine so we got some um for madine 20 milligrams twice a day take that and um and then he said right and then you know ring me up in a week's time let me know how she's doing well as soon as we started giving her those the type one and type two antihistamine in bigger doses she started to her skin started to calm down she didn't have the dermatographism anymore um she started to um over a two week period she lost half a stone in weight as she literally peed it out of her tissues she was going to the toilet every 15 minutes um just getting rid of fluid that had or from all this inflammation that she had been in she could then fit into her jeans again and things which had just she couldn't with before she'd become so bloated um and but it took four weeks for her to start looking like herself again for her face to go down and so on and uh and then I was on a quest really to find out more and more about this condition and um and when I discovered ma that's when I discovered Mast Cell Activation Syndrome because professor koua said histamine is usually associated with abnormal mast cells um and then he started teaching me uh really about the condition which was fantastic it was a great mentor um and I started reading as much as I could about it and then of course when when you when you see something you can't unsee it and um so I was just I had this all in my mind and then I would be seeing a patient in my contraception Clinic who was coming uh for some contraception I'd be taking a history from them to see which contraceptives they could use safely and and could choose from and then they would say well I've got IBS or I've got I've always had chronic headaches or I get funny rashes or whatever and I would be very interested in asking them more and more information about that and building up a picture of this sort of chronic inflammation in various different systems giving various different symptoms um uh of different severity at different times and then I would say to the patients I think I might know what you have and most of them John would burst into tears because they had maybe Decades of chronic ill health with no clue as to what was happening to them or why and no no understanding of how to improve their condition um and then I would just give them some basic lifestyle advice about avoiding High histamine Foods um and um and various vitamins and minerals to take which would support their system um and things like vitamin C which is an antihistamine a natural antihistamine um and also how to take a type one and maybe a type two antihistamine and they would come back and they would say I feel so much better I can't tell you all my diarrhea has stopped or my tummy isn't bloated anymore or whatever and it was very very satisfying and I was literally making this accidental diagnosis in three or four patients a week because actually it's very common um Professor molderings from Bon University who is probably the most knowledgeable man on the planet about Mel activation he's he's done research into it um with his um fellows and they they reckon it's 17 to 20% of the population that have abnormal mass cells that are overactive and can be you know in affected um when when they should just be ignoring certain chemical stimulants Etc they but they can't so it's a real life condition then absolutely and so every single doctor is seeing this these cases every day in their clinical practice but because it's not taught in medical schools and it's not really in any of the books it's not it's not something that they're aware of so they are struggling in the dark trying to help these patients um when actually if they have this knowledge you can then start to understand the mechanism the biology that's going on and therefore how to help and treat these patients and it's very satisfying it's very very satisfying to do that but and it's not the doctor's fault that they don't know about it because they haven't been taught um however I think when somebody has seen somebody like me and they go back to their doctor and they say this is what I've gotten I'm feeling much better on the treatment I think then I would hope that that doctor would have the Curiosity um to actually find out more about it you know and there but more and more doctors are now so when in 2016 when I started off apart from Professor viula I didn't know any other doctor in the UK there were some probably but I just didn't know of them and then but now you know I know of um several cardiologists who talk about mcel Activation Syndrome and recognize it in their patients several gastroenterologists who see it in their patients um and so there's more and more of us um who are helping U these people which is great um yeah so that's that's that's sort of background really then of course long Co came along I want to go on to Long Co but you you've you've tweaked my curiosity on on the on the histamine I mean I mean histamine is basically a fairly simple chemical I mean are people intolerant to histamine or is it that particular foods cause the mass cells to release their own endogenous histamine yes exactly so what tends to happen is um and it seems to be a double whammy in a lot of these patients so there are two conditions there's a condition called histamine intolerance and that's not a very good name for it really those group that group of patients if we do their genetics we can see and if we do blood tests we can see that they don't make enough diamine oxidase and diamine oxidase is an enzyme that metabolizes histamine out of your food so it's in the stomach and your body realizes that whilst histamine is good to have you don't want to have too much of it too much of it is troublesome and um so the body recognizes that and it has Diamond oxidase in the in the stomach to reduce the amount of histamine in the food so less is absorbed and doesn't push your your histamine levels too high um but so it and it's also a little bit in the bloodstream so it can be measured the diamond oxidase can be measured and most of my patients who have M cares are his uh or diin Ox stays deficient and they don't make enough so it's a bit of a double whammy you know they don't make enough diamin oxidates to reduce the histamine absorption so they have excessive histamine absorption from their food and they also have masked cells that release too much histamine too easily and so they end up with these high levels that the body can't really coope with and clear out very quickly those two things tend to go together the the lack of the the Diamond oxidase to get rid of the histamine so they're not getting rid of what there is there already and the the mass Cell Activation syndrome the mcass that they tend to go together they well it's interesting in in the um sort of literature it says that um histamine intolerance is uh in the instance is 35% of the population but we know that the Mel Activation Syndrome as um defined by professor molderings in Bon University is about 17 to 20% of the population now on a lot of my patients we do uh nutrigenomics on them we look at their genetics and we look at their methylation cycle and so on and we one of the things we do is look at their histamine metabolism and I must say that it is very seldom that my patients with who I suspect massin have a normal diamin oxidase production most of them have got deficiency a deficiency in the diin oxid spooky you wouldn't think there's no obvious reason in my mind why they're related it's uh the Gen are close together or something like that maybe maybe because we do know that there are apparently 50 mutations in the kit genes have been identified that can be caused what are the kit genes Tina the kit genes are the ones that are are giving the um code if you like for for M cells for the white blood cells so they they've identified 50 different mutations in those that can result in m activation and probably some people have different combinations of each of those and some people might just have a few some people might be unlucky and have more than a few it tends to run in famili so it's genetic for sure um and so there'll always be a family history of IBS or chronic fatigue in some family member or chronic headaches or ertic Carrier psoriasis rosacea exma um so yes or they'll have somebody with joint aches and pains fibromy Alia you see fibromyalgia is is a symptom isn't it and these patients are complaining of all of these things pots 80% are hypermobile 80% have hypermobility 80% of patients with mcast are female and 30% will suffer with Interstitial cystitis and that's why Professor VI Kolar is aware of the condition because he treats Interstitial cystitis as a Euro gynecologist that's his particular area of Interest wow is a lot of fascinating information I want to go back to that but let's just bring people up to speed a bit on mass cells so my simplistic idea is mass cells are a kind of white blood cell um maybe derived from basail type cells but they don't circulate they sit in the tissues and they store histamine and then when we want an inflammat response which of course is good the heat pain redness swelling will increase the circulation to an area get us more nutrients get us more blood supply help the healing process then when we want that then these cells degranulate and release the histamine is that so am I right roughly right in saying that mass cells are histamine storage units is that absolutely but unfortunately they store a whole lot more they have a thousand different cyto kindes in them so they've got a lot of chemical um potential and ability biologically and um so they you're absolutely right they are generally in the T in the tissues they are interstitial and they are everywhere where our body is in contact with the outside environment so they are all under our skin and when you when you understand and think about this then you can see why the symptoms manifest in the way they do so they are underneath the skin they are lining the nasal passages they're lining the sinuses they're lining our naso farings everywhere they line the lungs they line the gut from mouth to bottom all the way down they line the uh the the urogenital tract and they are I was think of them as like the bouncers in a club and they're just inside the door and they really want to stop the undesirables coming in okay but are in patients with mcass these bouncers are a bit overzealous and they start reacting and want to fight with anything that comes their way and there are some things some things they should just ignore and let in and they don't so they overreact and when they react they release some or all or different combinations of these cyto kindes and we don't even know what all of them do but a thousand have been identified thus far um and thousand cyto have been identified all together or thousand cyto from yes no a thousand cyto kindes have been identified um I think Bon University I I think of cyto as cellto cell hormones it's a chemical released by one cell that can have a kinetic an effect on another cell yes and then there are and then there are chemokines they release 350 chemokines which are little Messengers and these ones take little Messengers to the other mass cells so if there was an assault in one area the chemokines could be released and they rush over to other Marcels that are bit Dopey and tell to react as well and join in so they you know they create a why we can sometimes get a systemic uh histamine release which is yeah exactly exactly so so if somebody um if somebody's M cells also M cells line the nerves and histamine is a neurotransmitter and they are also present um in the stomach they release um acid in the stomach um the you know chromag graphine cells so they they've got a very important role to play in cognitive functions the Cadian Rhythm you know this is histamine histamine has an important role to play um but we don't want too much of it we don't want too much we want it just appropriately where it's needed at that time and then to be got rid of but in these poor patients it hangs around in vast quantities um plus some of the other cyto kindes uh which can cause uh bruising I mean my daughter when she was super sick she was bruising so easily she just had to touch her skin and she would leave her fingerprints in bruises and patients often it's a question I ask my patients do you bruise easily oh yes covering bruises easily don't even remember knocking myself and I've got a great big bruise on my leg itch itch mosquito bites big bruise develops you know so the so they get Hein is released Hein is one of the cyto kindes and that can cause bruising and you've got um elastase 2 can be is released and that causes membranes to break down um also there are some um some that cause CL are clotting factors that actually make blood clot so you've got bleeding you've got clotting you've got inflammation um and so on in in marel Activation Syndrome generally there is always inflammation um there may or may not be allergic type reactions including anaphylaxis but there may may not be and there is there can be Dr tropisms and dist tropisms are formations of new tissue um so and they may or may not be there so they could be things like cysts cysts in the in the breast in the pancreas and are often associated with it and they think that's a d tropism from the M cells um it can also be um poor healing poor wound healing um so it can affect the the healing process and other mechanisms normal mechanisms in the body it could be um what else so it could be um bleeding and also as I say um clotting problems so people can have a combination of these things um maybe they only have the inflammation or they can have the inflammation and Allergy type you know symptoms or whatever and depending on where this stimulation has the the M cells have released the the um the chemicals will depend on the symptoms they get so if it's in the lung they will get asthmatic type symptoms and a lot of my patients tell me they've been given inhalers which don't work because actually it's not constriction of the um the Airways that's causing the problem it's it's inflammation so the mechanism is different so what you need is the anti-inflammatories not not sorry the antihistamines to reduce that activity not anti-inflammatories anti-inflammatories make them worse right so go going through the the there's a wide range of symptoms here so we've got potential blood plotting bruises chronic inflammation that can express itself in different different systems such as irritable bowel syndrome maybe cardiovascular maybe respiratory inflammatory uh symptoms rashes ticaria which is like those itchy rashes isn't it uh hives sometimes they get hives like spread over the surface of the skin yes big big sort of swen are intensely itchy presumably very uncomfortable sometimes it can just be from their clothes rubbing they have very super sensitive you know so it can be where they've got a waste if they've got waste wasted trousers or something they take that when they open their trousers they've got this great big wheel all around their middle where their clothes have touched them going on with the symptoms headaches the swelling the edema um a variation over time seems to be a key feature I mean you seem to descri describing an incredibly wide spectrum of clinical manif ation here what is it that specifically draws your mind to the mass Cell Activation Syndrome diagnosis that's a very good question it's it's really you start to recognize patterns inflammatory patterns and um also what else could be explaining it you know so if you've got somebody if once you've seen a few patients like this you you start to really just recognize the patterns they you know have often they have sensitive skin and cut labels out of their clothes not all but most most of them do um often they have extremely sensitive sense because the label rubs on the back of the neck or something yeah yes yeah but often they have a very strong sense of smell so it's like their sense their senses are really heightened and they I mean really strong sense of smell a bit like a sort of Greyhound you know and then um then they often have don't like bright lights lights and loud noise es because they're intolerant to this hyp very the nerves have been sensitized by the adjacent cell deactivation presumably yes presumably and um and so this is this is It's Worth saying this is quite it's a very new area that's being described and explored and the um the uh research is in is is it in its infancy and we're hoping that as biological tests become more available to measure some of the cytokines that are released it's going to make it easier for us to maybe see patterns of these cyto kindes are released to give this symptom and this treatment is best for that patient therefore etc etc there's a huge overlap and the the symptoms will vary time to time person to person and within the same person at different times you know so it's it can be confusing and often patients they accept their normal you know their symptoms as just me oh it's just me you know I'm always intolerant to that bit of food or I always go bright red when I have a glass of wine or and they just accept it as sort of you know um if they're not too bad it's just that's what I am but generally with this condition as their M cells are activated more and more they become more and more sensitive in a stepwise kind of fashion so with my daughter she was you know her mels were obviously unhappy from T from the word go uh well not from the wayo until she was 3 four months old she was fine six months old it was then that she developed it um and then then um she became much worse when she had swine flu at the age of 16 so that infection she never quite recovered her health to what it was before the swine flu she was sick for six weeks and then she just did not get back to she was worse you know she was more like an Emmy kind of picture and then when then she had chickenpox as an adult when she was like 19 and she was really ill and again she just did not get back she became worse and worse and worse her General Health you know um and um it was only really the crisis that made us realize exactly what it was and come to the diagnosis that we could then really help her properly um and uh yeah and when we did her diox days for example so normal Diamond oxidase is 30 to 200 the labs will say that it's unlikely that you have histamine intolerance if it's over 10 but I disagree with that I think if a normal is 30 to 200 then anything below 30 is not quite enough and with my daughter for example when we took her Diamond oxidase in when in her crisis it was it was undetectable as fast as her body was making it it was gone so it was undetectable and when we did it six months later it was 23.5 so if she had just had a 23.5 somebody would say you haven't got maral Activation Syndrome and hist intolerance which she does but it we got it to that level by working really hard on having no histamine Foods whatsoever and being you know taking antihistamines and everything else um and she managed to get it up to 23.5 but that's still not normal when people get the the cutaneous manifestations is it normally the same patch of skin on the same part of the body that's affected every time or can they get manifestations in different parts of the body it can be that they always get one particular patch or one particular place presumably there are a few more M cells there than everywhere else maybe I don't know but sometimes it can be just honestly it's almost like anything goes sometimes it can be different patches different areas and they can't really work out why it's suddenly appearing here whether it before it was there um so it's it's not it's not easy to completely understand understand you know exactly what is going on but you know the um a lot of people um if they are judged uh clinically under con what we call consensus one they will be told you haven't got M Activation Syndrome there's nothing we can do for you um and actually I think that's too hard and that we should be following I'm more in line with consensus to which is um that actually you don't have to have a a blood test to prove that they've got mcass you just need the clinical picture and then it's reasonable if you have Reasonable Suspicion to think that they have mcass to try some of the medications and um simple measures that we put in place to try a trial of treatment if you like and if they respond well then they have I want to I want to come on to the consensus in a bit more detail in a minute but um if we can just talk about there's a lot of people watching now who think oh just a minute so obviously if you suspect this go to your own healthc care provider and ask them that and ask for these tests that's quite reasonable but in terms of just treatment principles can we just kind of sketch out what treatments available diet wise is it just a matter of working out what's good and bad for you or are the particular uh usual Flyers of foods that cause problems quite regularly yeah that there's there's a very good website called whatthe bleep can I eat.com which is a great name and if you go on there you can put in the histamine you so you can get a list of histamine free foods that have no histamine in them at all and lwh histamine foods and that comes to about 200 and so it's very you can have a varied and healthy diet from these 200 so you're having a lwh histamine diet and there are certain things that are very high in histamine that you want to avoid as much as possible so things like tomatoes avocados spinach bananas a lot of the things that are very convenient to eat and people eat a lot and you would normally think of as being healthy well and they are indeed they are for most people but for about 20% of the population they will cause a problem and um so it's it's very I think it's a good advice to have a look at the list and see where you are so gluten is very high in histamine tea and coffee green tea alcohol and chocolate are double whammies because they're very high in histamine and they also block diamin oxidase production so you don't really want to be taking those and I think uh also processed foods are very high in histamine no surprise there and leftovers anything that's been reheated or been sitting around for a while when the bacteria grow on the surface of the food even if it's a lwh histamine food bacteria will will be on it and they convert histadine to histamine and so they will make it a high histamine food just by which was what happened with the minc meat so lamb doesn't have high histamine but minced it does because it's got a big surface area lots of bacteria on it so when she put that in her mouth she suddenly gave herself even more of the the M cells just perect sense and do some people become symptomatic do they get flareups even if it's a lwh histamine food that they just happen to be particularly sensitive or allergic to yeah it all depends I think where they are in their histamine bucket people talk about a histamine bucket so if they have been really good with their diet and they haven't been um near chemicals that have stimulated histamine and the histamine levels are very low they will probably get away with eating something um that is a little bit higher in histamine because if you imagine you know if it has to be over a certain threshold to cause symptoms and they're really low and then they eat it it just goes up a bit but they're still not high enough to cause symptoms whereas if they're crumbling along just underneath the threshold and they even just have a tiny bit of something that's histamine it goes right up so sometimes they could eat that food and get away with it and other times they won't be able to because of where they are with their bucket you see so that can confuse people they can think oh I could eat that yesterday and not to I understandable so dietary modifications um vitamin C and other vitamins is vitamin D a factor actually yes so just prior to that D you can actually take diamine oxidase you take it all right yes and that is yes there are Dao supplements and it's very helpful in most people for them to take that before any meal because it will help their you know their deficiency so you can buy Dao capsules and tablets there various different ones on the market which um you you know couple of those 5 10 minutes before the meal that can be very helpful too and peases people can grow peases on their window sills and have eight or nine little peash shho um lovely you know leaves before they eat their meal 10 minutes before they meal and that will have a reasonable amount of diamond oxidase in it so they can do that so that's the sort of basic thing the other thing is um it's probably a very good idea for them to have a Paleo ketogenic diet a certainly ketogenic diet so that they are not having too much in the way of carbohydrates but they are um having what we call an anti-inflammatory diet so it's helping their bodies um in that way and then then we go on to what do we do for them so with the supplements vitamin C is fantastically helpful because it is it's a it's an it has antibiotic type properties it's an antihistamine um and it um and it's a bit anti-inflam flry so it's really good for them to have a natural antihistamine um in the form of vitamin C so slow relase vitamin C is a good idea otherwise you have to drink it all day long and then vitamin D is also very important and with with some K2 um and then various uh we usually like to give them ask them to take magnesium so these are things to support the mitochondria because they get mitochondrial dysfunction and therefore um energ their energy production isn't very good and mitochondria are fascinating little organel they're absolutely amazing they're you know often thousands in each cell they're making ATP they uh they actually produce we actually produce 70 to 80 kilograms of ATP every know that do we really isn't that must be cycling at one heck of a rate exactly as soon as it's made it's gone the the energy currency of the cell yes but there's such a huge demand for it that we have to make 70 to 80 kilograms a day just to stay alive wow isn't that fascinating if they if we took all of our mitochondria out apparently and put them in a pile it would be 32% of our body weight I had no idea yes so interesting and our and our heart has got the most and our heart I I would have known that I think because of the and the and the liver of course I lose up so much energy absolutely so mitochondrial function is super super important and you know when patients who have me say they have post exertion Mala and they they do something and then they' absolutely wiped up it's because their mitochondria are just not apt up to the task they're bit they're dysfunctional uh from you know from everything that's going on with the high histamine Etc and these other cyto kindes we don't I get that all the time people say I'm fine but I get disproportionately tied after a small amount of exercise and that varies from time to time yes and we think it's all connected all all with the mitochondria and so on so you have to support the mitochondria and that's the energy production system of the body needs to be firing on all cylinders and so we we we give them uh the vitamin C vitamin D um magnesium um K2 um then co-enzyme Q10 understood that that's that's really good for your that's basically a nutrient isn't it you get it in food yes you do and also your body makes it a bit too so you you don't want to interfere with co-enzyme Q10 um production that's very important and then lartin which is an amine that's that's useful for the mitochondria and iodine very very important to have iodine now iodine most most of us are are we have insufficient iodine um generally in our diets and in us and it's so important for a number of reasons very important for all our glands so for the thyroid the bre the prostate well everyone knows the thyroid but but why do why do these other glands need it yes well I'm not quite sure to be honest but but we yeah they they need now whether it's because of the mitochondria that need iodine I'm not sure um but so iodine is something terribly important and um so it's we like the patients to have iodine and we asked them to take two or three drops of iodine lals 15% in some water before they go to bed and that helps to also ensure that the upper gut is sterile because our upper gut should be St does it does it really I disinfects the upper gut wow i' i' never thought of that it makes perfect sense because iine kills everything it does yeah you take two drops of water that's probably that's probably what four milligram something like that of iodine yes it is small amount yeah but but way higher than the recomend recommended guidelines yeah probably but but needed and if you don't need it what you if you live in Japan or South Korea or you like seaweed um you're going to get way more than that from your natural diet anyway it's just that in the UK we don't eat much seaweed and surprisingly fish contain surprisingly little iodine it's it's it's the seaweeds we really need to eat more seaweed yeah but as you say if they have that in their diet and it's not doing them any harm to have two drops at night in water is going to be absolutely safe and fine and so much of the inflammation um comes from the gut you know we've got so many Mar cells in our gut when they start to get upset then you are in for trouble really and then it spreads to other areas so that we really have to spend a lot of time trying to get the gut right I've been I've been talking to Professor Dow gich oncologist lately yes and he he was saying that you know probably you can't say all but in so many cancers chronic inflammation is a big causative factor and that chronic inflammation can come from uh bacterial breakdown products from the gut causing chronic inflammation different parts of the body I know most of it's broken down when it goes through the liver of course but but maybe not all and and so so that's a plausible mechanism because I've talked to other doctors who believe and I've got good evidence to say that regular iodine can reduce some types of cancer that that that fits together I'm not surprised yeah I'm not surprised because we also think there are theories aren't there about mitochondrial health and if you have mitochondrial dysfunction then you are more likely to get cancerous cells with M you know cancerous cells will have mitochondrial dysfunction so there's a whole node it's really complex picture but I what I in my simple mind mind I like to think of it like um if we get inflammation in the gut then we're in trouble because you get leaky gut do do you do you I didn't know right so gut inflamation can cause leaky gut which means that proteins rather than amino acids can get into the into the circulation exactly exactly so it's a perfect storm so the the lining of the gut is only one cell thick and if you've got all these M cells sitting underneath it and you've got things coming into in the diet Etc that are making it um them active and they cause swelling then they're going to the inflammation of the lining of the gut is going to make crevices and cracks form and that's leaky gut so then you're in big trouble because you've got semi digestive proteins you've got semi- digestive food you've also also because our diet isn't like the caveman's diet but it's got sugar and dairy and grains in it you've got um you've got bacteria that the upper gut is supposed to be sterile in caveman it was sterile the first 20 fet of our gut was just purely sterile therefore for digestion and absorption now with the sugars and the dairy product the bacteria that come in are not killed by necessarily by the um acid of nice sug multiply yes they they multiply and they produce gases and they ferment and make alcohol and so and then they pass through these crevices into the body and of course that's going to stimulate your M cells even more because they shouldn't be coming in um and that's going to set up inflammation in any any all all sorts of places in the body um and so we you've got to we've got to get the gut right and we've got to start with the diet and do a ketogenic lwh histamine diet for those who have histamine issues but for all of us we should be I think ketogenic low no sugar we I think I think it's fair to say everyone should un unless you're actually acutely hypoglycemic or you are severely malnourished sugars and car and sugars are also maybe good for children with uh with infections because or rehydration salts and things like that but but but apart from that I mean I mean for me I would be better on a completely zero sugar diet and to to massively cut down on carbs and and preferably eliminate all refined carbohydrates I'm try I'm trying I'm trying I'm just not very good at it but well Absol because you know why it's difficult they're addictive totally addictive they're so it giv it gives you that instant that instant hit so you get up in the morning and you want toast and marmalade and you get that instant sugar hit and and you think you can face the day as long as you've had a good cup of tea as well and it's just that it's just it's just that instant gratification but but if you eat other Foods it just T you feel better it just takes a little bit longer so if you had an egg for example we used to go to work on an egg didn't we and the children I mean I wish would the children could go to school on an egg because that would that protein would keep sustain them till lunchtime so they wouldn't get that dip of their blood sugar midm morning they wouldn't want then more sugary snacks which will do exactly the same and fat the fat keeps you full for longer as well absolutely so it would be yeah so anyway so we've got we've got to um yeah so so what we do I've just got a geeky question um the the IDE will only sterilize the first like 20 ft is probably about the first 60% or so of the gut the F just over half um it won it won't reduce the microbiome in in the coal on no no no it won't at all it'll be sorted out in the in the small intestine your microbiome should stay in the we want microbiome but we want it in the right place we want in the right place we don't want it in the other bit so yeah so that the we're confusing everything with our our poor diets and um so we're trying to encourage people to get back to or organic natural in season eating as we as our sort of primitive you know ancestors did I say primitive they probably be insulted if they heard me say that our ancestors you know and and how actually our bodies have evolved to want to eat and sugar is addicted for a reason because when when there was cave woman uh and cavan in the Autumn late summer autumn and all the fruits came they would start eating the fruit and the sugar would switch on an addictive gene that we have apparently which would make them want to eat and gorge on it because and then they would get a bit fatter which would just help them go through the winter but after two weeks of not eat of all the veeg you know all the fruits gone from the trees and the berries and everything have gone after two weeks you lose that addiction the addiction Gene switches off but in modern society it never SES off we keep feeding Mar bars yeah we keep feeding It Whatever chocolate oh I'll just have one of those and we we see it as a reward oh I'll just finish this horrible lot of emails and then I'll go and have a piece of chocolate and a cup of tea or I'll have a biscuit and you know so we're constantly rewarding our you just described me perfectly Tina I feel really self-conscious now oh no but it's if you just manage not to have sugar for two weeks you can break the addiction yeah the jeans off sense yeah yeah yeah so we're design we're designed to eat seasonally yeah yeah and yeah so so poor ceman and C would be sitting there in cold turkey for a few days when the fruit all went but after that yeah they fine yeah and they're were a little bit fatter so they go the winter that would that that would increase female fertility as well because they put a bit of weight on them yeah yeah yeah exactly yeah so you can sort of see so Okay so we've talked about that and obviously you want good probiotics you want to get good probiotics into the gut um which we've you've heard lots of discussion about but then then you want to bring down the um the histamine and you we generally try and it's the the treatment is a lot of trial and error you have to be very patient and you have to methodically go through different treatment regimes for the patient regimens because um what works in one person doesn't necessarily work in another uh but when you find something that works it's a Eureka moment it can be amazing so for example we would basically try type one antihistamines to block the type one receptors and um and the so those would be Loratadine cine Fexofenadine basically these are all over the counter medications yeah all over the counter um the top dose of fenine in this country has to have a prescription for 180 milligrams but for 120 you can buy it over the counter so we encourage people to try each one for a couple of weeks but not to take One A Day on the packets of lad un we'll say one daily and actually they only last for about four or five hours the effect in the body it's not long enough so you have to do one say three times a day for a couple of weeks and see if you feel that that's worked for you and if you think gosh yes it really my rashes have gone and I'm feeling better and I'm might you know my chest is a bit better and so on then carry on with that one you don't need to try any others but if you get to the end of two weeks and you think did that help or didn't it help it means it didn't because if it does help you know and in which case then try cine and do the same thing and if that doesn't help try fenine what works in one person doesn't necessarily work in another and then so having done that you then want to add in so we do it in a very slow low and slow way you add in say forine a type two and so the type two affect more hisory receptors do they just remind me so they're mostly in the gut and um so it can be incredibly lifechanging for their gut symptoms and but in some people it won't work at all it doesn't make any difference in which case there's no point in taking it so for some a lot of people who say they have acid reflux when they take phine or Nadine the acid reflux goes yeah yes the type two but I've also had patients who have had had chronic diarrhea urgent chronic diarrhea seven eight times a day for decades can you imagine how exhausting that is they have to know exactly where all the toilets are on their way to work because they have to literally hop toilet hop you know and I had one lady like that and I gave her the formidine and after one day of taking fine her diara stopped for the first time is the type two available over the counter as well you have to get those no in this country we have to get it by prescription and then after that we try M cell stabilizers so there's three that we can use in particular you can buy quatin over the counter which is a m cell stabilizer so that's one that's an easy one for people to try and you can take 500 milligrams three times a day of that if you wanted to or twice a day um and then there but the ones that we prescribe are ketotifen which is a very weak type one antihistamine but it's a very good mased cell stabilizer and people start off with half a mill at night because it makes you sleepy and then they go up as they feel their bodies getting used to it they go up another half a mil until they're on five Mills which is one milligram at night and for some that is an absolute GameChanger um for others it doesn't work at all or they don't get on with it for some reason and then there's rupatadine which is a tablet 10 Mill GRS once a day and again for some that will be really helpful and for some it won't so you don't do both reptin and ketotifen you do one or the other and then you if that doesn't work you try the other one if the symptoms are predominantly in the gut we uh suggest sodium chromoglycate now sodium chromoglycate is a very good Mass cell stabilizer for the gut it's not absorbed systemically uh only 4% of it is absorbed systemically the rest stays in the Lumen of the the gut but as the M cels are lining the just under the lining of the gut they will be affected by it so often patients who have got IBS type symptoms you know the that that cluster of symptoms affecting the gut will have tenderness across the epigastrium and sometimes yeah with the transverse colon and there's a lot of mar cells there and they get tenderness and bloating and if you give them um the sodium chromoglycate you can actually they suddenly they're like oh it's not hurting anymore I'm not bloated anymore fantastic doesn't work in everybody but again when you find what works this is a really dramatic benefit to these patients yes absolutely absolutely it can be very dramatic um and it's very rewarding to actually be able to pull this together for people and to be able to say I you know I think there's a pretty good chance that we're talking about your M cells that are overactive I think these are the triggers let's try this what do you think you know and do it in conjunction obviously discussion with the patient um and often there they have light bulb moments and go you're absolutely right you know that's that is me that's and then they get some symptom relief which is great so there's usually a cocktail that we can put together for each patient which will help them doesn't mean they're going to be on it forever because once their M cells start to settle down they can manage their symptoms their s their they can manage their condition much better they might go on to these things intermittently when they know they're going to eat out and will eat some things that are not so good there are there is a group of patients though who just have become super sensitive to almost everything and they are they can take longer to help um and the problem is the m cells can last two to four years does it a m Cell last for two lives for two to four years can do some are replaced within six months but if you're going to replace all of them it could be two to four years so you have to be very patient because what the what I how I always imagine it is that if you've got um if you've got Mar cells that have been constantly overactive uh they and new Mar cells come into that um environment where the histamine is high and the cyto are high they also become a bit sort of edgy and and jumpy so almost like an epigenetic isn't it the way that mass cell's programmed exactly exactly if you can calm the system down then the new ones that are coming and being made will be in a calmer environment and they will just be a little bit less edgy and so you you can gradually move towards everything being calmer and certainly that's what happened with my daughter you know she then became really we had to work on it though and she had to work on it really hard um and we actually did her genetics so how how is Jesse now um she's very pregnant okay well she's she's about to have her second child be pretty wonderful for a gr absolutely fantastic yeah best news ever so and she's she's okay she's she's she's well it's interesting she after her first pregnancy she felt like her immune system had been reset and she it wasn't nearly so sensitive there are certain things that will trigger not just infection okay so the M cells not just infection you have to be careful that you don't put everything down to Mar cels and you miss things so you mustn't miss things like uh which can be concurrent and adding to it like chronic in inflammatory response Syndrome from mold and so many people in this country have we we have quite M damp breathing in the the melium yes just and they will have MotoX sins and that will trigger their M cells and cause something called cir which is if you read about CS all the symptoms look just like Mel Activation so when I have a patient when we're talking about their symptoms we want to know all about you know their history but I also want to know have they ever been exposed to mold have they ever lived somewhere that's damp and so many students is heartbreaking say yes my student digs were really moldy and there was black mold behind my bed and oh dear dear so all these things are are really bad news uh t Lyme disease is another one that can give very similar symptoms and um the epan bar virus can be reactivated in some people and give similar symptoms The Chronic fatigue etc etc so so you've got to be make sure that you're not missing any of those um that need some help and then yeah so we we do that and um it's so interesting so when I used to teach uh anaphylaxis I used to teach all the intravenous therapy and of course the anaphylaxis lesson was standard and I always said um within the first hour or two of an anaphylactic reaction make sure you get a blood cell for Mass cell tripto oh yes so I think we better talk about Mass cell tripto and the the the consensus one and the consensus two guidelines yeah yes so so in 2012 a statement U was made and it was called consensus statement and it was put together by some of the people who've been working in this field and they in that statement they said that the serum tryptose needed to be elevated to diagnose M Cell Activation so this is basically the tripas is a an enzyme that's released from the mass cells absolutely yeah and they said it needed to be elevated to prove somebody's got mcass or diagnos them with mcass um and they presented it as consensus statement and that Pro meanwhile a year before before a different statement had been made by about 40 of the uh of of the um researchers and doctors working in this field who had made a broader definition um because based on what they were seeing in patients and they said they weren't so prescriptive with their with their consensus statement so they called consensus the consensus statement consensus statement one and their's consensus statement two to differentiate between the two and in consensus statement two it says that because it is in some parts of the world difficult to get lab tests done to help with the diagnosis and that certainly was the case until very recently in the UK um and because the serum tryptase can very often much more often than not be normal in patients with typical M Cell Activation symptoms and patterns and history it's not helpful to rely on the serum trip Tas so in this group this subgroup if you like you know and I I think both statements are probably have their place and are helpful but the the first statement consensus statement excludes so many people with this condition who then don't get a a diagnosis and don't get treatment and helped whereas the other consensus statement too is more all-encompassing so it actually helps more diagnosis really a clinical picture diagnosis yeah it's a absolutely it's a clinical diagnosis and you do recognize the patterns and you see it and then you you you say we suspect it let's try um treating and let's see how we go and learn behold they get better I think that's the diagnostic feature then really isn't it it's the fact that the particular treatment that you would expect to treat the the massel Activation Syndrome does and that that really helps your your diagnosis if if you've got if you got a pain in your finger and there's a splinter there and you pulled the splinter out and the pain goes away it's a good indication that the Splinter was causing the pain it's so yeah absolutely and and the the the consensus statement one doesn't seem to recognize the how common Mel Activation Syndrome is and uh whereas Professor M um molderings from Bon he um he's done the research there and it's 17 to 20% of the population so and and that would fit with what we see you know with your real world experience clinical experience that would fit different levels of severity though presumably yeah totally it will depend on which combination of genetic variations they've got um and you know and some poor people are just sensitive to everything they can't even take any vitamins and minerals you know there might be an excipient in a in a drug or or in a in a supplement that they can't tolerate and they will have a big serious reaction like an anaphylactic type reaction to something I some people could be that bad um and I have got lots of patients who have been you know very very severely ill but now they are very much better we've managed to very slowly very patiently calm things down um and there are certain things like lowd dose nxone that can be really amazing um very tiny doses of of LDN um seem very very anti-inflammatory and that can transform people's lives it doesn't work in everybody but it when it does work it really is very U compelling you know amazing stuff um also I'm using a lot now of um microtherapy medicinal mushrooms are very imuno Regulatory and they can uh calm ourselves down so there's some yeah we we've had some very very good results with those with patients I I want to come on to well there's a lot of things I'd like to come on to depends how long you want to St with us can can I just issue a bit of a challenge though how can mass cells degranulate and not release tripas I'm not sure or is the tripas metabolized more quickly in some people I I don't know how quickly tryptase is metabolized but I do know that a lot of the cyto kindes are released in very tiny tiny amounts which possibly wouldn't be very detectable um and they are metabolized very quickly away so they're sort of hit they're a bit hit and run you know they're there they create havoc and chaos and then they're gone but the chaos remain sure we all know people like that so yeah they probably have no idea that they're doing it and then so it's actually very very difficult and I don't think tryptase is I think if you've got different genetic it's reasonable to postulate that some people are quick tripas metabolizers and some people are slow tripas metabolizers and and and also that some people don't release tripas you know and the in mastocytosis which is quite different mastocytosis is very rare and it's it's neoplasm of the of the mass cells okay it's genetic it can be cutaneous with skin lesions it can be systemic when they have systemic symptoms the symptoms are exactly like m m Cell Activation Syndrome because it's the same thing but in mastocytosis there are excess numbers of abnormal mass cells and they there are so many of them they do release tripas and their their tripas will be elevated but really elevated so you know I have got some patients who have got Master cytosis I've got two and um and they uh respond incredibly well to the same treatment that the mcast patients do so they go to see the immunologist who examines their skin and does a thorough job of all of that and is fantastic at keeping an eye uh on that but they come to me for the for the type one antihistamine type two antihistamine maybe some LDN Etc and they they're they're so much so much better really is quite quite quite impressive um um I think I think we'll probably leave that there for today too now there's so many things I want to ask you about but we're on an hour and seven minutes already so um maybe just tell us a little bit about the microtherapy I'm so curious what what what mushrooms are you using okay so um you got to use very good quality mushrooms that's first of all and mushrooms per se are very high in histamine but there are various chemicals within the mushrooms that can be extracted without bringing the histamine bit as well and they um so particularly um the sunshine mushroom is a massed cell stabilizer and it um reduces histamine and cyto Rel familiar with edible mushrooms it's just yeah I mean there are there are hundreds and hundreds of there are thousands of different mushrooms do not go and pick mushrooms in the wild only get them from an expert we don't want anyone dying a mushroom poisoning after watching this video no way and then the other one I like to use so I use a company am I company's name yeah okay um hasta it's a Spanish company I really like them they've been going for 25 years everything is organic everything is tested um there's no fillers there it's absolute pure you know active ingredient and they test every single batch before they let them go to for um to make sure they haven't got any pesticides or insecticides in the soil that they've been growing them in they grow their own they also do research in patient groups to to to prove that it does what they say it can do so there's lots of clinical data behind all of the claims so I like patients to use one called mosol which is the sunshine mushroom but or and mco5 and M5 has got five different mushrooms in it so you get a very good deal with that one you get the you get the sunshine mushroom you get um RI mushroom and the ri mushroom um what does that do that Balan hormon lower anxiety levels can't it yeah absolutely helps makes you feel relaxed a little bit more chilled out helps improve sleep it's also got anti-inflammatory properties and it's an has analgesic properties um and then there's the um Shaga is in there and Shaga helps cancer cells to into apoptosis basically I always describe suicide absolutely cell suicide is pressed by suar if the cells are abnormal um so that's been used now in some studies to help with as an adant for cancer treatments and then there's two shitake matake and I can't remember which one of them but one of them treats mot toxins so if somebody has been exposed to um even as CH as a child to mold they will still probably have the mot toxins in their body and taking the M5 can really um help clear it out so it's it's a really and people can feel it John honestly they take it and sometimes even by 10 days sometimes two weeks sometimes six weeks but mostly people are saying I feel more balanced I can feel my body isn't so reactive so I much prefer to use natural things if possible um and things that people can source for themselves and don't rely on prescriptions and so on so you know if we can get them balanced and I find that if people take those then often they don't need to take some of the other things that they were you know some of the other medications and there's no doubt that that that various sorts of microtherapy various mushrooms I mean there's so many amazing functional properties of so many different mushrooms this is going to be a huge thing in the future the problem is of course that it's you can't patent mushrooms so big farmer aren't doing a lot of the research unfortunately but what what we really need is is a lot of more people to start growing mushrooms because they're really good for you anyway um the the microbiome various nutrients and um I think I think we talked briefly about Lion's main mushroom uh which Chinese called monkey head mushroom because it's like um got like which like Shaggy like like a lion's man and um yeah that that has properties which do cross the blood brain barrier and there are there are chemicals in there which do stimulate ner nerve growth cyto kindes it really is quite incredible and then of course there's the whole the whole Professor David nut thinking on um cocy and other other things like that which have got um and I I I have talked to uh psychiatrists that are starting to use psilocybin actually so a whole a whole new field of medicine there coming but I really would be really nice to to get more people grow mushrooms locally I've been trying to encourage a few people locally to start just growing them and uh you know the legal ones of course we wouldn't not not dream of telling anyone to grow class A drugs but uh more to come on that story I am sure Tina that was just fascinating my mind is is is a is a wash with information here I'm just sure there's going to be a lot of patients recognizing these symptoms in the themselves so if you do recognize it do make a note of your symptoms keep a diary of your symptoms when they're good when they're bad the fluctuations come up with this kind of pattern and then when you go to your doctor which you must do of course um you've got a whole load of things ready to tell them and if they're prepared to give you the time then they can make make this potentially make this diagnosis and start trying these things that would confirm the diagnosis and um there's just so many people that just are under the weather so much of the time uh I'm not I'm not entirely satisfied with the way I feel most of the time to tell you the truth you know uh well just you know sometimes you're anxious and sometimes your brain's not quite with it and uh uh you know it's just to think you know you know I mean I mean a lot of it's lifestyle with me of course but same with a lot of people but you know if these specific pathologies that could be treated it's um yeah just absolutely absolutely marvelous yeah thank you so at another time what I'd like to talk about this is just a teaser if if if you decide you'd like to do it at some point um one thing that's really stood out for me there is the importance of taking a patient history um I'm not going to don't want to talk about it now because we're well over time now um and uh and just this whole philosophy of of natural therapies is is such an interesting one and the way ahead um you know so so many of the drugs we have at the moment my British national formul is my bottom book there but I've got a big red one there um it's it's um it's very very often drugs that have been through the clinical trial process that have often been sponsored by the pharmaceutical industry I'll just there we go needed two hands this one so all the drugs that you can prescribe are in there but these are and of course many of these drugs are absolutely wonderful and Brilliant and and life-saving but you just get the the impression there's so many more things like this Lion Man Lions man um that can be so beneficial that we don't have ready access to and it just seems a Pity that there's this whole class of uh therapeutic Lifestyles that we we we're not using at the moment so a whole whole new field there if people are interested John in finding out more about Mar Activation Syndrome the the big names are Dr Lawrence afren um who's in New York um then um Dr Dempsey um she's um she's very big she works with him um professor molderings in Bon University and uh Winestock Dr Weinstock they've produced a lot papers and and uh case studies and doing research into it um and um I'm very very fortunate because we have a group where we exchange ideas and and questions and new new uh bits of science all the time and literally twice a day I get an email from from this group it's an international group and it's getting bigger and bigger and bigger as more and more doctors and Physicians clinicians nurses nutritionists dieti you know are getting to know about it and then applying it to their patients and seeing the successes and the improvements and uh and then you know want to know more so it's a really great group but Dr Lawrence afron has got some very good presentations on YouTube if you can send us some links Tina we'll just put put yeah any links you send we'll paste them of course yeah yeah okay great good marvelous thank you so much for that so so interesting and uh we can certainly talk about doing some other things if you'd like to that was really really brilliant thank you so much a pleasure

Channel: Dr. John Campbell

Views: 378,146

Keywords: physiology, nursing, NCLEX, health, disease, biology, medicine, nurse education, medical education, pathophysiology, campbell, human biology, human body

Id: qYUV5cwysM8

Length: 77min 5sec (4625 seconds)

Published: Thu May 23 2024