06/18 Dear Jeff, B'H It was a pleasure to have the opportunity to speak with you last week. Just to review some of the key points of our discussion including your history: You relate a history of familial hypertriglyceridemia, spinal stenosis, pseudohyperparathyroidism with elevated PTH, normal calcium and negative thyroid nodules and repeated bouts of angioedema. You report success on a low carb diet and statins for your triglyceride elevation but these have been difficult to maintain based upon cognitive side effects. You have had a recent MRI of the LS spine which demonstrates significant spinal stenosis with venous engorgement. Currently, you do not have motor weakness but do have neurogenic claudication and paresthesias. You have had surgical opinions but are concerned and reticent about surgical interventions. Regarding the angioedema, you have had several episodes that were unprovoked by any identifiable food antigens. Your family history is remarkable for both parents having heart disease and renal disease You mentioned that you had 23andMe gene testing and that there were genes identified with abnormal triglyceride metabolism. Otherwise you are in good health but want my opinion about whether these conditions are related and how to approach them in the safest, alternative way. My impression: 1) familial hypertriglyceridemia 2) rule out MCAS 3) pseudo hyperparathyroidism 1) Recommendations: Regarding elevated triglycerides, high TG content up-regulates tumor necrosis factor-alpha, thereby inducing vascular cell adhesion molecules and are therefore potentially proinflammatory. TGs increase EFTA00804087