#236 ‒ Neurodegenerative disease: pathology, screening, and prevention | Kellyann Niotis, M.D.

When you think of brain health, it's not just the cognitive piece, but it's the movement piece too.” ‒ Kellyann Niotis

Read Time 51 minutes

Kellyann Niotis is a neurologist specializing in risk reduction strategies for the prevention or slowing of neurodegenerative disorders. In this episode, Kellyann provides an overview of the various diseases associated with neurodegeneration, including, but not limited to, Alzheimer’s disease, Lewy body dementia, and Parkinson’s disease. She goes in-depth on Parkinson’s disease, explaining its pathology, role in movement capacity, very early warning signs, and the role of anxiety and sleep. Similarly, she provides an in-depth discussion of Alzheimer’s disease, including the latest in screening, genetics, and tools/strategies for prevention. She ties the discussion together by explaining the differences and commonalities among the various diseases of neurodegeneration and the potential causative triggers, and she highlights the importance of early screening, cognitive testing, and taking the proper steps to lowering the risk of disease.

Subscribe on: APPLE PODCASTS | RSS | GOOGLE | OVERCAST | STITCHER

We discuss:

  • Kellyann’s background, training, and interest in the brain [2:30];
  • A primer on neurodegeneration: different types, prevalences, interventions, and more [5:30];
  • Overview of Parkinson’s disease and neuromuscular disorders including ALS [16:00]; 
  • Parkinson’s disease: early signs, diagnosis, genetics, causative triggers, and more [17:30];
  • Interventions to delay or avoid Parkinson’s disease, and the role of sleep and anxiety [31:15]; 
  • The challenge of standardizing early interventions for Parkinson’s disease without a clear biomarker [39:45];
  • Alzheimer’s disease: pathophysiology and the role of the amyloid and tau proteins [47:45];
  • Can PET scans be informative for diagnosing Alzheimer’s disease? [51:15];
  • Tau accumulation in the brain, tau scans, serum biomarkers, and possible early detection of Alzheimer’s disease pathology [57:00];
  • Cognitive testing explained [1:03:30]; 
  • The challenge of identifying the stage of the disease and why drugs have not shown efficacy [1:14:45];
  • The association between hearing loss and dementia [1:17:45];
  • The relationship between oral health and neurodegenerative diseases [1:21:30];
  • Genetic risk for Alzheimer’s disease [1:24:45];
  • What one’s mitochondrial haplotype can reveal about their risk of neurodegenerative disease [1:32:30];
  • The positive impact of exercise on brain health [1:37:00];
  • High blood pressure as a risk factor [1:40:00];
  • Why women are disproportionately affected by Alzheimer’s disease [1:44:15];
  • Final takeaways: the future of understanding neurodegenerative disease and further reducing risk [1:46:45]; and
  • More.

§

Kellyann’s background, training, and interest in the brain [2:30]

Did you always know you wanted to become a doctor? 

  • She always wanted to be a doctor
  • She was always a nerd
    • In high school, the quarterback of the football team joked and said that “She was a waste of pretty,” because she never went to any parties and all she did was study
    • She was obsessed with biology and chemistry; she was a bookworm 

Did the brain always interest you? 

  • No, not at all
  • She’s first generation American
  • Her mom and dad didn’t give her a lot of coaching growing up, they simply told her, “Whatever you’re going to do, just love it because you’re going to do it for the rest of your life
  • When she was in med school, she just loved learning everything
  • But when she got into the clinical rotations, she found herself a little disappointed because she wasn’t interested in the algorithms of the disease and the actual treatments that were being offered
  • When she asked about things like prevention or exercise or diet, she pretty much just got shunned
  • When she was thinking about specialties, she thought about what she could read for the rest of my life and be fascinated by 
    • It was the brain

A lot of people will say neurology is a pretty depressing specialty because a lot of the patients you’re caring for have conditions that can’t really be reversed 

  • When Peter was in med school, neurology was not a core rotation
    • They were not required to do it
  • This was an elective for Kellyann and she agrees, “It is so depressing… not much has changed in the field
  • We don’t have effective treatments for sparing things like migraines and MS
  • Glioblastoma is a terrible disease with terrible treatment options
  • When you think about her specialty, neurodegenerative diseases, the diseases are devastating for both the patients and their families

Kellyann’s training 

  • Kellyann did her neurology residency at Cornell, which is how she met their mutual friend Richard Isaacson and how they became connected
  • She did a fellowship at Mount Sinai in movement disorders

 

A primer on neurodegeneration: different types, prevalences, interventions, and more [5:30]

The breadth of the field of neurodegeneration 

Peter notes, “When you look at the actuarial statistics of mortality, neurodegeneration accounts for the 3rd leading cause of death

Within neurodegenerative disease, there are a lot of different types of pathology

  • We’ve talked a lot about Alzheimer’s disease (we’re going to talk about that again today)
  • Some diseases affect men more than women
  • We are better at discriminating between these diseases today than we used to
  • For example, in the past, Alzheimer’s disease and Lewy body dementia could only be distinguished on an autopsy (not clinically)
  • Peter used to never think about Parkinson’s disease in the same way that he would think about a cognitive disease
  • Until recently, he never understood the differences in the patterns of where the disease occurred in the brain and how that translated to deficits

Different diseases affect different parts of the brain 

  • Dementia is an umbrella term
  • Neurodegeneration encompasses dementias and other processes like Parkinson’s disease
  • When we think about neurodegeneration, everyone thinks about Alzheimer’s disease 
    • Because it’s the most prevalent
    • And chances are you know somebody who was affected by this disease
  • But the other diseases that we’re going to talk about today are also very common, and you’ve probably never heard of them, but you should because there’s a reasonable likelihood that they will affect you at some point in your life or a loved one

What falls under the umbrella of dementia? 

Neurodegeneration is a more broad term 

Parts of the brain where different types of neurodegeneration is occurring:

  • For things like frontotemporal dementia or vascular dementia, you’re talking about the frontal lobe primarily
    • The frontal lobe is involved in processes such as planning events, problem solving, speed of processing
    • These are all executive lobe functions
  • When we think about Alzheimer’s disease, we’re thinking about the temporal lobe 
    • That’s where the degeneration is mainly happening
    • And that’s mainly a memory problem, but it’s also a language problem
    • The language center is in the temporal lobe
  • For diseases like Lewy body, we’re thinking about the parietal and occipital lobe 
    • The parietal and occipital lobe are involved with visual spatial processing
    • You get symptoms like issues with depth perception, issues following plot lines of movies or following plot lines of books
    • Patients will have to reread passages over again to really fully comprehend what’s happening
    • And hallucinations are something that you can see later in the disease course

Is difficulty with depth perception part of what feeds into the movement disorder that we see which differentiates Lewy body from AD (Alzheimer’s disease)? 

  • Yes (we’ll come back to this topic)
  • Visual impairment is a risk factor for neurodegenerative diseases

And how does that relate to how we can prevent these diseases?  

  • It’s possible that the visual processing is needed to reinforce the neuronal circuitry

Our brain needs sensory input. It needs sensory stimulation. When we don’t have that, those neuronal circuits aren’t getting exercised, and they’re more likely to atrophy.”‒ Kellyann Niotis  

  • When we don’t have the proper sensory input, those neuronal circuits aren’t getting exercised, and they’re more likely to atrophy
    • If you don’t use it, you lose it
  • In relation to your question, yes, Kellyann thinks that that visual processing is why you have the depth perception issues that you see in Lewy body

How does vascular dementia overlap with frontal dementia? 

{end of show notes preview}

Would you like access to extensive show notes and references for this podcast (and more)?

Check out this post to see an example of what the substantial show notes look like. Become a member today to get access.

Become a Member


Kellyann Niotis, M.D.

Dr. Kellyann Niotis is the first fellowship-trained preventive neurologist at Early Medical.  She specializes in risk reduction strategies for patients seeking prevention or slowing of their neurodegenerative disorders including Alzheimer’s disease, Lewy body dementia and Parkinson’s disease.  Dr. Niotis completed her medical internship and neurology residency at NewYork-Presbyterian/Weill Cornell Medical Center, serving as Chief Resident during her final year and the inaugural McGraw Fellow in Neurology Research.  She has also completed a fellowship in movement disorders at the Icahn School of Medicine at Mount Sinai Union Square, as well as advanced training in cognitive disorders and preventive neurology under the mentorship of Dr. Richard Isaacson.  She currently leads the neurology program within Dr. Peter Attia’s medical practice, Early Medical, focused on the applied science of longevity.  The practice deals extensively with nutritional interventions, exercise physiology, sleep physiology, emotional and mental health, and pharmacology to increase lifespan (how long you live), while simultaneously improving healthspan (the quality of your life).  Previously, Dr. Niotis managed the country’s first Alzheimer’s Prevention Clinic at Weill Cornell Medical College/NewYork-Presbyterian Hospital.

Her research interest is in personalized risk reduction interventions in patients at-risk for neurodegenerative diseases.  Her work has been published in peer-reviewed journals including Neurology, Frontiers of Aging Neuroscience, Movement Disorders, Alzheimer’s & Dementia and Journal of the Prevention of Alzheimer’s Disease and has been presented at national and international conferences.  She has received numerous honors and awards, and her opinions have been featured in several popular media outlets including CNN.  

Instagram: @drkellyannniotis

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.
  1. Thank you. I was in healthcare for 36 years and touched on or was deeply involved in almost every specialty, my last years focusing on Movement Disorders. I worked primarily with two specialties, Neurology and Physiatry, in treating patients with these disorders. In many cases I was surprised how one specialty would be resistant to or refuse to collaborate with another. Sometimes even getting agreement on a referral to physical, occupational, or hand therapy would be like pulling teeth. I would advocate for collaboration or a more integrated therapeutic approach but depending on the too many factors to mention here, the patient was all too often short-changed. In listening to your presentation it is obvious that there are numerous specialties and disciplines needed to effectively treat neurodegenerative disease. It also sounds like, at least in Kelly’s case, that there is, or has to be, a very high level of collaboration. I know this is a comment section, so a question would be, well, out of the question. So my hopes are that Kelly was able to put together the team (obviously multidisciplinary) to achieve her goals, without having to suffer through too much institutional red-tape and lack of clinical cooperation. I look forward to hearing of future progress and successes.

  2. Hi Drs. Attia and Niotis. Great presentation! FYI. I am a dentist and wanted to let you know that it is very common for people to be in good health and look good on the exterior (clothes, makeup, hair etc) and have neglected their oral health. So poor oral health care is NOT a good predictor of the rest of the person’s overall health. However, a person with poor overall health, will often neglect their oral health. So I have seen and do see people who have been under stress be it lifestyle or health challenges that have neglected their oral hygiene and diet. For many people, spending money on vacations, nice purses/shoes, cars etc are a higher priority than seeing their dentist for routine cleanings and exams. I have had a pt that would rather buy a Tesla than invest a fraction of the cost of a Tesla in getting his bite corrected and his teeth aligned, so that it would be easier to keep his teeth clean to mitigate gum disease progression.

  3. Kellyann said at 1:31 that ApoE 4 is piece of cake in her clinic because she knows how to deal with it. Can you elaborate the protocols and general tips for ApoE 4 carriers to reduce their risk of AD, and/or to delay the onset?

  4. Thank you for a very interesting discussion.
    Many points within the discussion to agree with or debate. It’s a pleasure to see a more forward looking approach to neurodegenerative diseases than one often encounters.

    One question though: you discussed Parkinson’s disease (PD) is some detail and also had a brief discussion regarding the oral microbiome, However, there was no mention of the recent research (last 2 or so years) linking PD, alpha-synuclein misfolding and aggregation originating from the gut and subsequent transport to the brain via the enteric nervous system.

    I’m curious as to why this was not mentioned or discussed? Do you or Kellyann have a differing opinion here?

    Whilst the research is not conclusive it is nonetheless highly interesting and an area where actionable interventions abound (potentially decades before Sx’s) – diet, probiotics, prebiotics, targeted antibiotics, faecal transplants, exercise, etc.

    It would be a pleasure to hear your comments.
    Very cordially,
    CBR

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509446/
    https://pubmed.ncbi.nlm.nih.gov/33856024/
    https://pubmed.ncbi.nlm.nih.gov/34371014/
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9263276/
    https://pubmed.ncbi.nlm.nih.gov/34414447/

  5. Great podcast and so much great information! I am a PT and have been practicing for 25 years and specialize in treating people with movement disorders, mostly PD. I have seen first hand the benefits of exercise and have seen PWP get better in spite of a neurological progressive disease. As Kellyann discussed, getting diagnosed and referred to a health care provider early in the disease process is ideal but unfortunately not happening. I work closely with the Michigan Parkinson’s Foundation and one of the goals is to try to educate the PCP, NP, PA on PD and refer earlier than later. So much more work needs to be done and thanks to Dr. Niotis and everyone for all their hard work. My mom was diagnosed with PD 2 years ago and her father passed away of Alzheimer’s disease. The struggle is real!

[class^="wpforms-"]
[class^="wpforms-"]
[gravityform id="5" title="false" description="false"]
<div class='gf_browser_unknown gform_wrapper form--inline_wrapper gtm--newsletter-form-popup_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_5' ><form method='post' enctype='multipart/form-data' id='gform_5' class='form--inline gtm--newsletter-form-popup gform_legacy_markup' action='/kellyannniotis/' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><li id="field_5_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_1"><label class='gfield_label' for='input_5_1' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_1' id='input_5_1' type='email' value='' class='large' placeholder='Your email address' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_10" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_10"><label class='gfield_label' for='input_5_10' >CAPTCHA</label><div id='input_5_10' class='ginput_container ginput_recaptcha' data-sitekey='6LeuYQ0dAAAAAHQqB_Z3xNQAwCRlN5ykarrLsrZw' data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'></div></li><li id="field_5_2" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_2"><div class='ginput_container ginput_container_text'><input name='input_2' id='input_5_2' type='hidden' class='gform_hidden' aria-invalid="false" value='#236 ‒ Neurodegenerative disease: pathology, screening, and prevention | Kellyann Niotis, M.D.' /></div></li><li id="field_5_3" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_3"><div class='ginput_container ginput_container_text'><input name='input_3' id='input_5_3' type='hidden' class='gform_hidden' aria-invalid="false" value='https://peterattiamd.com/kellyannniotis/' /></div></li><li id="field_5_4" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_4"><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_5_5" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_5"><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_5_9" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_9"><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_5_8" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_8"><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_5_7" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_7"><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_5_6" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_5_6"><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' value='Sign up' onclick='if(window["gf_submitting_5"]){return false;} if( !jQuery("#gform_5")[0].checkValidity || jQuery("#gform_5")[0].checkValidity()){window["gf_submitting_5"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_5"]){return false;} if( !jQuery("#gform_5")[0].checkValidity || jQuery("#gform_5")[0].checkValidity()){window["gf_submitting_5"]=true;} jQuery("#gform_5").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='5' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_5' value='WyJbXSIsIjU1MGM3MDVmNDUwOTYxNmQyYTU0NTkwMjUzZjU2NGI1Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <p style="display: none !important;"><label>&#916;<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_4" name="ak_js" value="185"/><script>document.getElementById( "ak_js_4" ).setAttribute( "value", ( new Date() ).getTime() );</script></p></form> </div>
[gravityform id="1" title="false" description="false"]
<div class='gf_browser_unknown gform_wrapper form--inline_wrapper gtm--newsletter-form_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_1' ><form method='post' enctype='multipart/form-data' id='gform_1' class='form--inline gtm--newsletter-form gform_legacy_markup' action='/kellyannniotis/' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id="field_1_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_1"><label class='gfield_label' for='input_1_1' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_1' id='input_1_1' type='email' value='' class='large' placeholder='Your email address' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_11" class="gfield gfield--width-full ohnohoney field_sublabel_below field_description_below gfield_visibility_hidden" data-js-reload="field_1_11"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label' for='input_1_11' >H-o-n-e-y-p-o-t</label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large' aria-invalid="false" /> </div></li><li id="field_1_10" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_10"><label class='gfield_label' for='input_1_10' >CAPTCHA</label><div id='input_1_10' class='ginput_container ginput_recaptcha' data-sitekey='6LeuYQ0dAAAAAHQqB_Z3xNQAwCRlN5ykarrLsrZw' data-theme='dark' data-tabindex='-1' data-size='invisible' data-badge='bottomleft'></div></li><li id="field_1_2" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_2"><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='hidden' class='gform_hidden' aria-invalid="false" value='#236 ‒ Neurodegenerative disease: pathology, screening, and prevention | Kellyann Niotis, M.D.' /></div></li><li id="field_1_3" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='hidden' class='gform_hidden' aria-invalid="false" value='https://peterattiamd.com/kellyannniotis/' /></div></li><li id="field_1_4" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_5" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_5"><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_9" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_9"><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_8" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_8"><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_7" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_6" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_6"><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_12" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_12"><label class='gfield_label' for='input_1_12' >Email</label><div class='ginput_container'><input name='input_12' id='input_1_12' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_1_12'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Sign up' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjU1MGM3MDVmNDUwOTYxNmQyYTU0NTkwMjUzZjU2NGI1Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <p style="display: none !important;"><label>&#916;<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_5" name="ak_js" value="45"/><script>document.getElementById( "ak_js_5" ).setAttribute( "value", ( new Date() ).getTime() );</script></p></form> </div>
Facebook icon Twitter icon Instagram icon Pinterest icon Google+ icon YouTube icon LinkedIn icon Contact icon