Auto peep - head out the car window at 80mph = approx 6mm hg of inspiratory pressure

Exercise and Thoracic Aortic Aneurysms: A Paradigm Shift Toward Informed, Personalized Activity Guidelines ahajournals.org/doi/epub/10.… #exercise #Sportscardiology #Aorticaneurysm

#Nephpearls #MedEd ⭐️A decline in kidney function during #heartfailure treatment is not necessarily bad. What matters is whether the patient is being successfully decongested. Apart from laboratory markers, how do you 'see' if the patient is decongested? #POCUS ! Interesting data from EVEREST study - 3,715 patients over 9.9 months follow up. Reference at the bottom of the figure. 🔴1. Top left: Declining eGFR looks bad when examined alone A 30% decline in eGFR was associated with a 19% higher risk of death (HR 1.19). This suggests worsening kidney function is associated with worse outcomes. But this analysis doesn't consider whether the patient was successfully decongested. 🟢2. Top right: Decongestion is associated with better outcomes The investigators looked at two indirect markers of decongestion: ⬇️ BNP: Suggests improvement in cardiac wall stress and congestion. Every halving of BNP was associated with a 22% lower risk of death (HR 0.78). ⬆️ Hematocrit: Suggests hemoconcentration, potentially reflecting plasma volume reduction during diuresis. Every 3% increase was associated with an 11% lower risk of death (HR 0.89). In other words, patients showing evidence of effective decongestion generally had better outcomes. 🔵3. Bottom panel: The most important finding The investigators examined the association between declining eGFR and mortality across different degrees of decongestion. When BNP declined very little: Declining eGFR was associated with higher mortality. This could indicate persistent congestion alongside worsening kidney function. When BNP declined substantially: - The association between declining eGFR and mortality became weaker, approaching neutrality. The same pattern was even clearer with hematocrit: When hematocrit increased very little: - Declining eGFR was associated with increased mortality. When hematocrit increased substantially: - Declining eGFR was no longer clearly associated with increased mortality. The hematocrit interaction was statistically significant (p = 0.012). The BNP interaction showed a similar trend but did not meet the conventional significance threshold (p = 0.074).

For podcast listeners seriously into health, fitness, and nutrition, @BarbellMedicine with the outstanding @Jordan_theCoach and @AustinBaraki and @sigma_nutrition with the always thoughtful @NutritionDanny are must listens. Some other great stuff out there in a vast sea of junk but these two pods are truly top notch.

The long term data on maintenance of weight loss *without* GLP-1 assistance is poor. Only roughly 20% of patients overweight or obese patients who’ve lost 10% or more manage to maintain at least 10% loss after 1 year. Programs that offer intensive lifestyle modification with ongoing support and contact can improve it, but the 10% is still hard to maintain. One T2D management study that had a mean loss of 8.6% at one year had 50% of patients retaining a mere 5% loss at 8 years (and 27% maintain 10% loss). The percentages for the less intensive control group were 36% and 17% respectively. Note that this is with generally modest amounts of loss to maintain. If this is the height of what’s possible without medication enabling even larger amounts of initial weight loss (well beyond what patients typically achieve on their own), then why would we expect patients who hit their goals with medication to do any better once they go off, even with tapering? Particularly given that the medications reduced their appetite burden and now they are going to fully experience a higher appetite burden because of the higher amount of weight their bodies now want to gain back? This would be like putting someone on an e-bike for a ride and then turning the motor off half way and asking them to maintain the same pace they’d had with the motor on. Exercise/lifting/etc is surely good as and will help (successful maintainers often get 200-300+ minutes of moderate activity per week), but it isn’t actually a simple recipe with guaranteed results. I think it’s one thing to say “let’s try”, but another to frame it as something that will truly be workable for most. “Portions you can keep for good” is actually pretty hard for many. Even ON the medication, but at plateau, I have to be very conscious of portions. Advice like this is asking them to turn off the motor but keep the same pace (the weight off). Slowly turning off the motor (tapering) will help the adjustment, but the chance of burnout as the motor goes to 0 is still pretty likely. Many patients who buy into this will end up feeling defeated, like they were a failure, rather than realize they were set up to fail.

This paper has several well-known MCAS quack authors - Weinstock, Afrin, Blitshteyn, and Kaufman. This is just another way to stigmatize mental health, and provide a reductive biomedical explanation for functional symptoms and psychiatric conditions despite the lack of biological plausibility for many of these symptoms. A tale as old as time. What stands out the most to me is the high OR for non-epileptic seizures and movement disorders symptoms. This almost certainly represents people with FND misdiagnosed with MCAS which we are seeing more of in the clinic. They are NOT experts in allergy and immunology. They use the consensus criteria 2 for diagnosis which is not based on any sound evidence and can apply to literally anyone. The actual experts in allergy and immunology conclude almost all of these reported symptoms should not be used to diagnose or be attributed to MCAS: jaci-inpractice.org/article/… link.springer.com/article/10… sciencedirect.com/science/ar… jaci-inpractice.org/article/… pubmed.ncbi.nlm.nih.gov/3073… pmc.ncbi.nlm.nih.gov/article… jaci-inpractice.org/article/… mdpi.com/2075-4418/13/21/330… jacionline.org/article/S0091…

In preparing for a podcast, I had to learn more. I think you'll find this intriguing Iron Deficiency Comes Before the Anemia: What a Ferritin less than 30 Should Mean to You leadingrounds.substack.com/p…

💡 This study in A&R shows SLE is not just a disease affecting young women. Highest incidence rate of SLE among men was 60-69 years: important not to miss in one’s DDx! Have diagnosed several cases of #SLE in older men and often present atypically. #Rheumatology #Lupus

Hospitalization for alcohol withdrawal is a critical opportunity to treat alcohol use disorder—not just manage withdrawal 🔗: doi.org/10.1002/jhm.70201 ✍️: Eden Y Bernstein MD, MPH et al 🖼️: #VisualAbstract @kovalenkojul #SHM #JHM #alcoholusedisorder #addictionmedicine

🫀 HF by stage (US): 
🟢 A: ~80M at risk, ~0.6%/yr mortality 
🟡 B: ~60–85M, ~0.8%/yr 
🟠 C: ~7.2M, ~6–10%/yr 
🔴 D: ~0.5M, 30–50%+/yr Mortality jumps ~10x once HF symptoms start 
🛡️ Prevent HF in Stage A/B 
💊 Get Stage C pts on full GDMT, now!

Does “severe” spinal #stenosis on MRI mean exercise is futile and surgery should happen sooner rather than later? Big new study says nope: how bad it looked on the scan didn’t predict who improved. At all. Or their symptoms! Study of the week, 3m read: painscience.com/blog/stenosi…

There is so much noise around testosterone levels, testing, & TRT. But how should test results actually be interpreted? And what cases would likely benefit or not from treatment? @AustinBaraki expertly discusses all this and more in the latest episode: sigmanutrition.com/podcast/e…

This is the wrong interpretation. Phenobarbital monotherapy was superior to diazepam monotherapy in reducing LOS. If you mix-and-match PHB & BZDs it’s less beneficial. (Though still right on the cusp of significant) My take-away is: use PHB *monotherapy* in EtOH withdrawal.

A new meta-analysis finds no good evidence for benefit of supplementing with collagen for skin aging. It audits previous widely cited meta-analyses claiming benefit which contained numerous errors. Once the errors were corrected, the findings no longer suggested a statistically significant difference. Such errors included: - Misrepresentation of methodology - Incorrect usage of percentage difference - Failure to convert standard error to standard deviation (standard errors treated as standard deviations, which can give a result too much weight) - Missing/Omitted studies, or even omitted data from found studies - Inclusion of studies with no placebo control - Inappropriate inclusion of studies (one papers hydration data was based on a survey question without any objective analysis which should not have been included) - Inconsistencies in effect size reporting/used - Listing incorrect numbers of subjects Furthermore the general quality of the trials themselves were poor. The underlying trials were often small and short, typically 8-12 weeks. Many did not adequately track other skincare, procedures or usual protein intake. Some gave little detail about the placebo, making it hard to judge how well participants were blinded. Few trials defined how large a change would matter to patients, which is important given a short-term change in a skin measurement mechanistic proxy does not establish a visible, let alone a lasting effect on aging skin. I continue to take the view that the recommendation of collagen supplements for general skin health / prevention of skin aging is not epistemically justified on the quality of the available evidence. It might be justified in a burn unit or wound healing context for very large wounds (where a massive amount of collagen synthesis is required), but that's a completely different discussion.

I think one overlooked aspect of translating genetic estimates of Lp(a)-lowering into expected clinical benefit is the difference in LDL-C and Lp(a) trajectories across the lifespan. The estimates for Lp(a)-lowering are derived by extrapolating from how the effect of genetically lowered LDL-C on cardiovascular risk translates to MACE risk reductions in trials. LDL-C increases substantially with age, whereas Lp(a) remains largely stable over the lifetime. If we accept that atherogenesis is driven by cumulative exposure to atherogenic particles over time (“particle-years”), then the effect of Lp(a)-lowering over the same period should be smaller than the effect of LDL-C-lowering. A given reduction in Lp(a) represents a smaller proportion of lifetime cumulative exposure because Lp(a) levels are relatively high earlier in life, whereas LDL-C exposure accumulates progressively with age. This was not accounted for in the estimates used for the power calculations of Lp(a)HORIZON, which were partially based on genetic estimates derived through this LDL-C → Lp(a) extrapolation. This could be one reason why the eventual clinical effect of Lp(a)-lowering is smaller than expected.

🚨The Eloralintide + Tirzepatide Phase 1b in obesity presentation from EASD2026 is up, and it’s HUGE. TWO Phase 1b studies, but really 3 groups. ▪️Study 1: Titrated Eloralintide (ELORA) 9 mg + Tirzepatide (TZP) 15 ➡️ 24 Week WL: Elora alone - 14.2%, Tirz alone - 16.4%, Elora + Tirz 25.5% ▪️Study 2 Group 1: Un-titrated ELORA and TZP 5 mg ➡️ 15 Week WL: TZP alone - 10%, TZP + Elora 5mg - 17-20.5% ▪️Study 2 Group 2: Titrated ELORA and TZP 15 mg ➡️ 31 Week WL: TZP alone - 17.8%, TZP + Elora 15mg - 23.6-29% None of these show plateau Dropouts were significant AEs next post

🚨 Update to OMIGuide! Huge shoutout to Mriganka Nerkar, MS4, who led a major expansion of the guide - adding 100+ new cases from Dr. Smith’s ECG Blog since our original launch in 2023! Check out the updates at omiguide.org @smithECGBlog @PendellM @WillyFrick

86% of websites advertising testosterone therapy (TRT) contained at least one claim with erroneous or misleading messages, inconsistent with international guidelines. Only 28.5% of websites acknowledged testosterone therapy may impair fertility, despite it being well-known to suppress spermatogenesis and not recommended to men desiring fatherhood in the near future by multiple guidelines. These data demonstrate a need for more enforcement of laws by national regulators to address the inaccuracy of advertisements and the growing health problem of testosterone overprescribing. Commentary: academic.oup.com/jcem/articl… Original study: pubmed.ncbi.nlm.nih.gov/4148…

Arrhythmogenic right ventricular cardiomyopathy: @ESC_Journals 🥸 It is a great to find one review on ARVD with all info in 1 place - congrats to authors great on great work 😱 Highlights are below (read full article) 👇👇👇

hard cosign on this 👇 preferred outpatient management in asthma is SMART therapy (Single Medication As Rescue and maintenance Therapy) typically 🏆 formoterol/budesonide 🏆 (SYMBICORT), or perhaps formoterol/mometasone (DULERA) one inhaler is used both PRN and scheduled, this ensures that as patients get sicker they ramp up their inhaled steroid in parallel with inhaled albuterol