Podcasts about sbp

Play Episode Listen Later Apr 7, 2026

We discuss this ominous complication of providing local anesthesia. Hosts: Elaine Jonas, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/LAST.mp3 Download Leave a Comment Tags: Critical Care, Toxicology Show Notes I. Pathophysiology & Mechanisms Definition: Systemic toxicity secondary to local anesthetic (LA) via accidental intravascular injection or excessive systemic absorption. Threshold: Occurs when plasma concentration exceeds the safety threshold for cardiac and neural tissue. Agent Profile: Bupivacaine (High Risk) Highly lipophilic with high protein binding. “Fast-on, Slow-off” Kinetics: Strong Na+ channel binding with extremely slow dissociation during diastole. Myocardial Depression: Direct inhibition of Ca2+ release from the sarcoplasmic reticulum, impairing contractility. Low CC:CNS Ratio: The dose required for cardiac collapse is very close to the dose that triggers seizures (narrow safety margin). Contributing Factors: Acidosis/Hypercapnia: Increases the fraction of free drug and promotes ion trapping in the brain/heart; shifts the LA-binding curve toward higher toxicity. Hypoxemia: Exacerbates myocardial depression and lowers seizure threshold. II. Risk Assessment & Prevention Patient-Specific Risk Factors Extremes of Age: Neonates (low α-1-acid glycoprotein) and elderly (reduced clearance). Body Composition: Low muscle mass/frailty (decreased volume of distribution). Organ Dysfunction: Hepatic: Reduced metabolism of amide LAs. Renal: Accumulation of metabolites; risk of metabolic acidosis lowering seizure threshold. Cardiac: Reduced cardiac output slows hepatic delivery/clearance; heart failure patients are more sensitive to Na+ channel blockade. Pregnancy: Increased sensitivity to cardiotoxicity. Procedural Risk Factors Vascularity of Site (Highest to Lowest Risk): Intercostal blocks (highest absorption rate). Caudal/Epidural. Interfascial plane blocks (e.g., TAP block). Psoas compartment/Sciatic. Brachial plexus. Technique: Large volume infiltration, lack of ultrasound, lack of incremental injection. Prevention Mandates Weight-Based Dosing: Lidocaine (Plain): Max 4.5 mg/kg. Lidocaine (with Epi): Max 7 mg/kg. Bupivacaine: Max 2.5–3 mg/kg. Incremental Injection: 3–5 mL aliquots with frequent aspiration. Intravascular Marker: Use Epinephrine (1:200,000) to detect accidental IV placement (HR increase >10 bpmor SBP increase >15 mmHg). III. Clinical Presentation Neurologic Phase (Early to Late) Subjective: Metallic taste, tinnitus, circumoral numbness/tingling. Objective: Visual disturbances, agitation, confusion, tremors. Critical: Generalized tonic-clonic seizures, rapid progression to CNS depression, coma, and apnea. Note: Early phases are often masked in patients receiving midazolam or propofol. Cardiovascular Phase Initial: Hypertension and tachycardia (if epi used) or transient stimulatory phase. Conduction Defects: PR prolongation, QRS widening (classic sign), bundle branch blocks. Dysrhythmias: Bradycardia (most common), VT/VF, PEA, asystole. Contractility: Profound, refractory hypotension and cardiogenic shock. IV. Immediate Management Algorithm Goal: Prevent hypoxia/acidosis and sequester the toxin. 1. Initial Actions Stop Injection: Immediately halt all LA administration. Call for Help: Specify “LAST Protocol” and “Intralipid Kit.” Airway Management: 100% O2. Hyperventilate slightly if needed to counter respiratory acidosis. Low threshold for intubation (hypoxia/acidosis rapidly worsen LAST). 2. Seizure Control First-line: Benzodiazepines (e.g., Midazolam). Avoid: Propofol if hemodynamically unstable (exacerbates cardiac depression). Neuromuscular Blockers: May be needed for ventilation, but remember they do not stop CNS seizure activity. 3. Lipid Emulsion Therapy 20% Indications: Start at first sign of serious toxicity (airway compromise, seizures, or CV instability). Bolus: 1.5 mL/kg IV over 1 minute. Infusion: 0.25 mL/kg/min immediately following bolus. If Instability Persists: Repeat bolus (up to 2 times). Increase infusion to 0.5 mL/kg/min. Upper Limit: ≈12 mL/kg total dose. 4. Modified ACLS Epinephrine: Use low doses (

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Federal Employee Retirement Guide – Simplified Breakdown for Civil Servants with Brigadier General Michael Meese

Retirement Revealed

Play Episode Listen Later Mar 31, 2026 30:28

Brigadier General Michael Meese details the critical decisions military families must make before retirement. Transitioning into retirement is a major life change for anyone. But for military families, that transition isn't just about leaving a job. It's about moving from one entire system of life into another. As Brigadier General Michael Meese explained, this shift requires more than just paperwork. It requires understanding your benefits, your options, and your goals—before the transition begins. “Understanding all of the military benefits and the circumstance that you’re in… and then aligning that with the goals that you might have” is essential to getting this right. That alignment is where good planning begins. Why Military Transitions Are Different Most civilian career changes are relatively straightforward. You move from one company to another, often with similar systems, benefits, and expectations. But transitioning out of the military is fundamentally different. You're not just changing jobs. You're shifting from a structured environment—with defined benefits, systems, and support—into a civilian world where many of those decisions are now your responsibility. That's why preparation matters so much. This isn't something you want to figure out for the first time when someone puts paperwork in front of you. You want to understand your options before that moment arrives. The Decisions That Matter Most There are several things that all former service members and their families need to evaluate before jumping into retirement. The Survivor Benefit Plan One of the most important decisions is whether to elect the Survivor Benefit Plan (SBP). This plan provides ongoing income to a surviving spouse, but it comes with trade-offs. While this benefit is valuable, it doesn't fully replace income: The maximum your survivor can get is a 55% payout once you're gone. How confident are you that your survivor's bills will drop by more than 45% when you're gone? That means SBP should be viewed as part of a broader plan—not the entire solution. Coordinating SBP with Social Security, savings, and other assets is essential to ensuring a surviving spouse is truly protected. Life Insurance Decisions Another key transition happens with life insurance. Many service members are covered under SGLI (Servicemembers' Group Life Insurance) while on active duty. After leaving the military, they may transition to VGLI (Veterans' Group Life Insurance). But that transition often comes with higher costs. The key insight is that timing matters. If you're in good health, you may be able to secure more affordable coverage through private insurance—but that process takes time and underwriting. That's why planning ahead is critical. You don't want to wait until after separation to explore your options. Don't Overlook Your TSP The Thrift Savings Plan (TSP) is another major asset for many service members. One of its biggest advantages is cost. It offers low expenses and access to unique investment options like the G Fund, which provides a stable return without the same price volatility as traditional bonds. That makes it a valuable component of a retirement strategy—even after leaving the military. The key decision isn't simply whether to keep money in the TSP or move it elsewhere. It's understanding how it fits into your overall plan. Advocate for Yourself Another important topic in the conversation was VA disability benefits. These benefits are designed to compensate service members for conditions developed during their time in the military. But receiving them requires active participation. This is a moment where service members need to shift their mindset: You've taken care of everybody else. It's time to make sure you get that disability determination. This isn't about taking advantage of the system. It's about receiving the benefits you've earned. Preparation Is the Advantage One of the most powerful insights from the episode came from a military principle itself. Preparation. When I was in ROTC training, a significant portion of time was spent preparing and rehearsing before any action took place. That same mindset applies to retirement. You don't want to improvise your transition. You want to prepare for it. Because when you understand your benefits, align them with your goals, and make decisions ahead of time, you reduce the chances of regret. And that's the goal. Not just to retire—but to transition with confidence into the next chapter of life. Don't forget to leave a rating for the “Retire Today” podcast if you've been enjoying these episodes! Subscribe to Retire Today to get new episodes every Wednesday. Apple Podcasts: https://podcasts.apple.com/us/podcast/retire-today/id1488769337 Spotify Podcasts: https://bit.ly/RetireTodaySpotify About the Author: Jeremy Keil, CFP®, CFA is a retirement financial advisor with Keil Financial Partners, author of Retire Today: Create Your Retirement Income Plan in 5 Simple Steps, and host of the Retirement Today blog and podcast, as well as the Mr. Retirement YouTube channel. Jeremy is a contributor to Kiplinger and is frequently cited in publications like the Wall Street Journal and New York Times. Additional Links: Buy Jeremy's book – Retire Today: Create Your Retirement Master Plan in 5 Simple Steps Brigadier General Michael Meese on LinkedIn Retirement Transition Timeline – Armed Forces Mutual Armed Forces Mutual Connect With Jeremy Keil: Keil Financial Partners LinkedIn: Jeremy Keil Facebook: Jeremy Keil LinkedIn: Keil Financial Partners YouTube: Mr. Retirement Book an Intro Call with Jeremy's Team Media Disclosures: Disclosures This media is provided for informational and educational purposes only and does not consider the investment objectives, financial situation, or particular needs of any consumer. Nothing in this program should be construed as investment, legal, or tax advice, nor as a recommendation to buy, sell, or hold any security or to adopt any investment strategy. The views and opinions expressed are those of the host and any guest, current as of the date of recording, and may change without notice as market, political or economic conditions evolve. All investments involve risk, including the possible loss of principal. Past performance is no guarantee of future results. Legal & Tax Disclosure Consumers should consult their own qualified attorney, CPA, or other professional advisor regarding their specific legal and tax situations. Advisor Disclosures Alongside, LLC, doing business as Keil Financial Partners, is an SEC-registered investment adviser. Registration does not imply a certain level of skill or expertise. Advisory services are delivered through the Alongside, LLC platform. Keil Financial Partners is independent, not owned or operated by Alongside, LLC. Additional information about Alongside, LLC – including its services, fees and any material conflicts of interest – can be found at https://adviserinfo.sec.gov/firm/summary/333587 or by requesting Form ADV Part 2A. The content of this media should not be reproduced or redistributed without the firm’s written consent. Any trademarks or service marks mentioned belong to their respective owners and are used for identification purposes only. Additional Important Disclosures

Episode 221: High-Output Heart Failure

PEBMED - Notícias médicas

Play Episode Listen Later Mar 24, 2026

We discuss the diagnosis and treatment of one of EM's paradoxes: High-Output Heart Failure. Hosts: Nicolas Gonzalez, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/HOHF.mp3 Download Leave a Comment Tags: Cardiology Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: Credit: 12.5 AMA PRA Category 1 Credits™ Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics. Cost: Free for NYU Learners $250 for Non-NYU Learners Click Here to Register and Begin Module 1 1. Core Definition & Hemodynamic Profile Clinical Paradox: Congestive symptoms (pulmonary edema, JVD, peripheral edema) in the setting of a hyperdynamic, supranormal cardiac function. Hemodynamic Criteria: Cardiac Index (CI): >4.0 L/min/m2. Cardiac Output (CO): >8 L/min. Systemic Vascular Resistance (SVR): Pathologically low (vasodilated or shunted state). The “Warm” Phenotype: Unlike standard HFrEF/HFpEF (often “Cold and Wet”), HOHF presents as “Warm and Wet” due to low SVR and bounding pulses. 2. Pathophysiology: The Hemodynamic Paradox Primary Insult: Decreased SVR (either via peripheral vasodilation or arteriovenous shunting). Effective Arterial Blood Volume: Paradoxically low despite high total CO. Neurohormonal Cascade: Activation of Renin-Angiotensin-Aldosterone System (RAAS). Increased Sympathetic Nervous System tone. Increased Antidiuretic Hormone (ADH) secretion. Resultant State: Avid renal salt and water retention leading to massive plasma volume expansion. Cardiac Response: Chronic volume overload → eccentric remodeling → chamber dilation → eventual secondary myocardial failure/dilated cardiomyopathy. 3. Differential Diagnosis: Etiological “Buckets” Category A: Increased Metabolic Demand (Systemic) Hyperthyroidism/Thyrotoxicosis: Direct T3 effects: increased chronotropy/inotropy. Indirect effects: metabolic byproduct accumulation causing peripheral vasodilation. Myeloproliferative Disorders: High cell turnover and increased oxygen consumption drive compensatory CO increase. Sepsis (Hyperdynamic Phase): Cytokine-mediated global vasodilation. Note: Often transient; may transition to sepsis-induced myocardial depression. Category B: Peripheral Vascular Effects (Shunting/Vasodilation) Arteriovenous Fistulas (AVF) / Malformations (AVM): Most Common Cause: Iatrogenic AVF for Hemodialysis (ESRD population). Bypasses high-resistance capillary beds, dumping arterial blood directly into venous circulation. Chronic Liver Disease (Cirrhosis): Formation of “spider angiomata” and internal AV shunts. Impaired clearance of endogenous vasodilators (e.g., Nitric Oxide). Thiamine Deficiency (Wet Beriberi): Accumulation of pyruvate/lactate → systemic vasodilation. Histopathology: Vacuolation, myofiber hypertrophy, and interstitial edema. Chronic Lung Disease: Hypoxia/Hypercapnia-driven systemic vasodilation. Concomitant pulmonary HTN (RV remodeling) but preserved/high LV output. Others: Paget's disease of bone (extensive micro-shunting), Carcinoid syndrome, Mitochondrial diseases, Acromegaly, Erythroderma. 4. Special Focus: Hemodialysis Access-Induced HOHF Physiologic Phases of AVF Creation: Acute Phase: Immediate ↓ SVR. ↑ Stroke volume and Heart Rate (SNS-mediated). Endothelial shear stress → Nitric Oxide release → further arterial dilation. Subacute Phase (Days to 2 Weeks): RAAS-driven volume expansion. ↑ Right Atrial, Pulmonary Artery, and LV End-Diastolic Pressures (LVEDP). Natriuretic peptide surge (BNP/ANP) peaks around Day 10. Chronic Phase (Weeks to Months): Adaptive hypertrophy. Decompensation occurs when dilation exceeds contractility limits. 5. Point-of-Care Physical Exam & Maneuvers Nicoladoni-Branham Sign (Pathognomonic for Shunt-driven HOHF): Maneuver: Manually compress the AVF (or inflate cuff to >50 mmHg above SBP) for 30 seconds. Positive Result: Reflexive bradycardia or a transient rise in systemic BP. Significance: Confirms the shunt is a major contributor to the cardiac workload. Peripheral Pulse Assessment: Water Hammer Pulses: Rapid upstroke and collapse. Quincke's Pulse: Visible capillary pulsations in the nail beds. Traube's Sign: “Pistol-shot” sounds auscultated over the femoral arteries. Volume Status: Rales, S3 gallop, peripheral edema (standard HF signs). 6. Diagnostic Workup (Technical Targets) POCUS / Echocardiography: Left Ventricle: Hyperdynamic function; EF typically >60%. Left Atrium: Significant dilation (Left Atrial Volume Index >34 mL/m2; Case study noted 72 mL/m2). IVC: Plethoric with minimal respiratory variation. Doppler: High flow velocities across the AV access if applicable. Laboratory Evaluation: BNP/NT-proBNP: Often markedly elevated (e.g., >70,000 in severe cases), though mean values in literature hover around 700–800 pg/mL. Hematology: CBC to evaluate for severe anemia (trigger for HOHF if Hgb7–8 g/dL to reduce demand. Beriberi: High-dose IV Thiamine (100–500 mg). Thyrotoxicosis: Beta-blockers (Propranolol) + Antithyroid meds (PTU/Methimazole). Phase 3: Surgical/Interventional Salvage (Refractory AVF Cases) Closure of Accessory Sites: If multiple fistulas exist, close the non-dominant/unused sites. Flow Reduction (Banding): Surgical narrowing of the fistula to target flow

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Check-up Semanal #Pediatria: anemia ferropriva, aleitamento, derrame pleural, empiema e faltering weight

Play Episode Listen Later Mar 23, 2026 13:04

No episódio de hoje do Check-up Semanal, o Dr. Ronaldo Gismondi, editor-chefe médico do Portal Afya e do Whitebook, comenta os principais destaques recentes em Pediatria, com foco em anemia ferropriva, aleitamento em prematuros, manejo do derrame pleural e empiema, além de mudanças conceituais no crescimento infantil.Para mais conteúdos como esse, acompanhe nosso canal no Spotify!Leia na íntegra os artigos mencionados hoje:SBP 2026: Recomendações para prevenção e tratamento da anemia ferroprivaAAP atualiza diretrizes sobre aleitamento para RN muito baixo pesoNova diretriz aborda derrame pleural na pneumonia infantil pela IDSA e PIDS – Drenar ou observar?Nova diretriz publicada IDSA e PIDS aborda a conduta no empiemaNova diretriz da AAP e da NASPGHAN exclui o termo “failure to thrive”

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Resistant Hypertension. Target Aldosterone. Transform Care

Play Episode Listen Later Mar 7, 2026 3:35

Resistant hypertension remains one of the most stubborn challenges in cardiovascular medicine. The Bax24 phase 3 trial, published in The Lancet (2026), evaluated baxdrostat, a selective aldosterone synthase inhibitor, in patients already receiving multiple antihypertensive agents. Key findings: • −16.6 mmHg reduction in 24-hour ambulatory SBP • −14.0 mmHg placebo-corrected difference (p

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E89 - Should You Opt Into The Military Survivor Benefit Plan? (It Depends)

Remnant Finance

Play Episode Listen Later Mar 6, 2026 66:43

Book a call: https://remnantfinance.com/calendar ! Out Print the Fed with 1% per week: https://remnantfinance.com/optionsEmail us at info@remnantfinance.com or visit https://remnantfinance.com for more informationFOLLOW REMNANT FINANCEYoutube: @RemnantFinance (https://www.youtube.com/@RemnantFinance )Facebook: @remnantfinance (https://www.facebook.com/profile.php?id=61560694316588 )Twitter: @remnantfinance (https://x.com/remnantfinance )TikTok: @RemnantFinanceDon't forget to hit LIKE and SUBSCRIBE_____________________________Most service members walk into the SBP decision the same way: someone hands them a checkbox at out-processing and they default to yes. But the Survivor Benefit Plan is a 30-year financial commitment with no cash value, no inheritance, and no way out once the window closes — and most people never study it before signing.In this episode, Brian and Hans break down everything you need to know about the Survivor Benefit Plan before you're forced to make the decision — including when it makes sense, when it doesn't, and how whole life structured for IBC can make the conversation almost irrelevant if you start early enough.Chapters: 00:00 – Opening segment 01:00 – What SBP is and why it matters at retirement 08:25 – How the premium and benefit structure works 14:05 – The three major problems with SBP 18:55 – When SBP actually pays off 26:35 – DIC: the VA benefit that changed the math in 2023 37:00 – The whole life alternative: side-by-side comparison 42:50 – Starting early vs. starting at retirement: the 10-year difference 49:35 – Full SBP vs. partial vs. whole life only: running the scenarios 57:40 – The hybrid approach 1:01:00 – Who SBP is right for1:04:05 – Closing thoughtsKey Takeaways:The question isn't full SBP or nothing. Most people never realize they can elect a partial SBP — say 25% — and get a guaranteed annuity for their spouse at a fraction of the cost. The checkbox you get handed at retirement doesn't show you that option.Every dollar into SBP disappears into a government system and never comes back. There's no cash value, no policy loan, no asset to transfer. If your spouse dies before you, you've lost every premium paid with no refund and no recourse.The nightmare scenario for SBP isn't dying young — it's living long and watching your spouse die first. You pay 30 years of premiums, your spouse predeceases you, and the government keeps every dollar. With whole life, the asset survives.Know yourself before you decide. If Parkinson's Law runs your financial life and you'd spend the premium money anyway, take the SBP. Forced protection beats no protection. But if you have the discipline and cash flow to build something real, the whole life path wins on almost every timeline beyond the first few years.

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Biomass Beat: The Changing Compliance Landscape for US Biomass Producers

Argus Media

Play Episode Listen Later Feb 20, 2026 23:17

In this episode of the Biomass Beat podcast series, Argus' Hannah Adler speaks with Sarah Crow, CEO of New March Strategies, to discuss how the US biomass sector is responding to newly revised SBP risk ratings. They explore what these changes mean for forest owners, biomass producers, and the supply chains that link them. Tune in to hear insights on: What the new SBP risk rating revisions mean for US forest owners and biomass producers— including how the EU's land-use change and forestry (LULUCF) sector shapes US forestry perspectives. How sustainability standards interact across the Atlantic, and the biggest misconceptions Europeans hold about US forestry practices. What producers need do to adapt, from sourcing strategies and supply‑chain due diligence to the rising role of AI, remote sensing, and contractual safeguards. Argus offers biomass prices, news, analysis, and consulting. Get more information and request a free trial.

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Military Transition Blueprint | Stop Being Locked Out of Your Own Money Ep:210

Wealth Warehouse

Play Episode Listen Later Feb 16, 2026 44:16

Are you a military member planning to transition in the next 1-3 years? Tired of being told to "max out your TSP" and wait until 59½ to access YOUR money?Former military officers David Befort and Paul Fugere know exactly what you're going through—because they've been there. They faced the same financial handcuffs, the same "conventional wisdom" that keeps your wealth locked away when you need it most.In this episode, you'll discover:Why the TSP/401(k) might be costing you opportunities during your transitionHow to build a "bridge" from military to civilian life with accessible capitalThe truth about the Survivor Benefit Plan (and a better alternative)How to create your own banking system using dividend-paying whole life insuranceReal numbers: Why putting $416/month into SBP might be leaving $1.75 million on the tableThis is NOT about choosing between investing OR insurance—it's about having BOTH, with one critical difference: access to your capital when opportunities arise, emergencies hit, or you simply want to live your life on your terms.The Military-Specific Challenges They Solve:✅ "I want to leave the military, but I can't afford to lose the paycheck"✅ "I have money in TSP, but I can't touch it without penalties"✅ "I'm worried about finding the right job after transition"✅ "I need life insurance before the VA destroys my insurability"✅ "I'm tired of being told what I can't do with my own money"ABOUT YOUR HOSTS:David Befort separated from active duty in 2014 after serving as a military pilot. Four years before separation, he discovered Infinite Banking and built three whole life policies that gave him the financial freedom to be selective about civilian opportunities—not desperate. He turned down the military bonus money (the "golden handcuffs") because he had created his own capital to bridge the transition. Today, he helps military families build the same financial freedom he created for himself.Paul Fugere retired after 20+ years of military service, having discovered Infinite Banking during his final years in uniform. He watched colleagues become "28-year lieutenant colonels" who couldn't afford to retire because they'd locked all their wealth in accounts they couldn't access. Paul capitalized his own policies and transitioned with confidence, knowing his family had liquidity, not just paper statements. His mission: ensure other military families don't make the same mistakes he almost made.Both hosts are licensed Infinite Banking practitioners who specialize in military transitions and understand the unique challenges of leaving service.WHO THIS PODCAST IS FOR:Military members 1-5 years from separation or retirementAnyone tired of the "fire and forget" 401(k)/TSP mentalityPeople who want to use their money NOW, not just accumulate for laterFamilies who need life insurance before VA disability ratings make them uninsurableAnyone seeking financial flexibility and control, not...

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REBEL CAST – RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure

REBEL Cast

Play Episode Listen Later Feb 5, 2026 19:11

🧭 REBEL Rundown 📌 Key Points 💨 HFNC met criteria for non-inferiority to BPAP for preventing intubation or death within 7 days in four of the five ARF subgroups.🧪 Bayesian dynamic borrowing increased power across subgroups but created variable certainty, especially in smaller groups such as COPD.🫁 The immunocompromised hypoxemia subgroup did not meet non-inferiority, leading to early trial stopping for futility.️ Rescue BPAP use, subgroup-specific exclusion criteria, and non-standardized BPAP delivery are important contextual factors that influence how subgroup results should be interpreted. Click here for Direct Download of the Podcast. 📝 Introduction Bilevel Positive Airway Pressure (BPAP) has long been a foundational modality in the management of acute respiratory failure (ARF), particularly in COPD exacerbations and cardiogenic pulmonary edema, where it can rapidly reduce work of breathing and improve gas exchange. It remains a core tool in our respiratory support arsenal.High-flow nasal cannula (HFNC), however, has expanded what we can offer patients by delivering many of the same physiologic benefits through a far more comfortable interface. With high flows, modest PEEP, and effective dead-space washout, HFNC can improve oxygenation and decrease work of breathing while preserving the ability to talk, cough, eat, and interact with staff and family. This combination of physiologic support and tolerability makes HFNC especially attractive in patients where comfort, anxiety, or cardiovascular stability are key considerations, and in settings where prolonged noninvasive support may be needed. Rather than competing with BPAP, HFNC broadens our options in ARF and allows us to better match the modality to the patient and their underlying disease process.The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure? 🧾 Paper Azoulay É, et al. High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA. 2025 PMID: 39657981 🔙Previously Covered On REBEL: HFNC: Part 1 – How It WorksHFNC: Part 2 – Adult and Pediatric IndicationsFLORALI and AVOID TrialFLORALI-2: NIV vs HFNC as Pre-Oxygenation Prior to IntubationThe Pre-AeRATE Trial – HFNC vs NC for RSI ️ What They Did CLINICAL QUESTION Is HFNC non-inferior to BPAP for rate of endotracheal intubation or death at 7 days in patients with acute respiratory failure due to a variety of causes? STUDY DESIGN Multicenter, randomized non-inferiority trial33 Brazilian hospitalsNov 2019 – Nov 2023Adaptive Bayesian hierarchical modeling with dynamic borrowingOpen label, outcome adjudicators blindedPatients were classified into 5 subgroups SUBGROUPS 1. Non-immunocompromised hypoxemiaSpO₂ < 90% on room air orPaO₂ < 60 mm Hg on room air plusIncreased respiratory effort (accessory muscle use, paradoxical breathing, thoracoabdominal asynchrony) orRespiratory rate > 25 breaths/min2. Immunocompromised hypoxemiaDefined as:Use of immunosuppressive drugs for >3 monthsOR high-dose steroids >0.5 mg/kg/dayOR solid organ transplantOR solid tumors or hematologic malignancies (past 5 years)OR HIV with AIDS / primary immunodeficiency3. COPD exacerbation with acidosisHigh clinical suspicion of COPD as primary diagnosisRR >25 with accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchronyABG: pH 454. Acute cardiogenic pulmonary edema (ACPE)Sudden onset dyspnea and rales± S3 heart soundNo evidence of aspiration, infection, or pulmonary fibrosisCXR consistent with pulmonary edema5. Hypoxemic COVID-19 (added June 2023)Added due to deviations between expected and observed outcome proportionsAny patient across the other 4 groups with PCR-confirmed SARS-CoV-2 infection in any of the above groups POPULATION Inclusion Criteria:≥18 yrs with ARF* in one of 5 pre-defined subgroups excluding COPD was defined by the following:Hypoxemia with SpO₂

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Liver Lineup: Advances in Portal Hypertension and Cirrhosis Management

DocTalk Podcast

Play Episode Listen Later Feb 4, 2026 28:00

In this episode of Liver Lineup: Updates and Unfiltered Insights, hosts Kimberly Brown, MD, and Nancy Reau, MD, break down several of the most consequential hepatology developments of 2025, focusing on practical advances in the management of patients with advanced liver disease. From renal protection in metabolic dysfunction-associated steatotic liver disease (MASLD) cirrhosis to long-debated questions around albumin dosing and emerging tools for monitoring hepatic encephalopathy at home, the discussion centers on how new data may begin to shift everyday clinical decision-making.Key episode timestamps:0:00:00 – Dapagliflozin in MASLD cirrhosis with ascites0:04:41 – Clinical perspective on dapagliflozin & management strategy0:06:37 – Albumin for hyponatremia in cirrhosis0:12:28 – How clinicians currently use albumin in practice0:18:43 – Low‑dose vs conventional‑dose albumin in high‑risk SBP 0:25:03 – Beacon device: at‑home critical flicker frequency for HE0:27:47 – Future of at‑home HE monitoring & closing remarks

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Rethinking CPR in Trauma: Insights from a Groundbreaking Study on Hemorrhagic Shock

EMS Today

Play Episode Listen Later Jan 22, 2026 35:10

By Bram Duffee, PhD, EMT-P For EMS providers who respond to a traumatic cardiac arrest, the instinct to initiate CPR is almost automatic. But could this life-saving intervention inadvertently hinder recovery in cases of severe hemorrhagic shock? A recent study, “Effect of Cardiopulmonary Resuscitation on Perfusion in a Porcine Model of Severe Hemorrhagic Shock,” challenges conventional wisdom and offers new insights that could reshape trauma care protocols. The Study: A Closer Look at CPR in Trauma-Induced PEA The research, led by Dr. Patrick Greiffenstein, professor of clinical surgery at LSU New Orleans and trauma ICU director at the Norman McSwain Spirit of Charity Trauma Center, addresses a critical gap in trauma care. While CPR is a cornerstone of resuscitation in cardiac arrest, its application in trauma-induced pulseless electrical activity (PEA) has not been rigorously validated. Trauma PEA, unlike medical cardiac arrest, is a low-flow state caused by severe blood loss (hypovolemia), where the heart shows electrical activity but fails to generate a palpable pulse. “CPR is a cornerstone of resuscitation and cardiac arrest, but its application in trauma-induced PEA has not really been rigorously evaluated,” explains Dr. Greiffenstein. “Trauma PEA is fundamentally a low-flow state caused by hypovolemia—insufficient blood volume.” The study aimed to determine how CPR affects tissue perfusion—specifically oxygen delivery to the brain and skin—during severe hemorrhagic shock. Using a porcine model, researchers simulated life-threatening blood loss and compared outcomes between two groups: one receiving automated CPR and the other left untreated during the shock phase. Key Findings: When CPR May Do More Harm Than Good The results were both surprising and concerning: No Improvement in Perfusion: CPR did not enhance oxygenation in the brain or skin. In fact, skin perfusion was significantly lower in the CPR group during both the shock and recovery phases. Adverse Hemodynamic Effects: While CPR increased systolic blood pressure (SBP), it significantly reduced diastolic blood pressure (DBP), which is critical for coronary and organ perfusion. Potential Harm: CPR caused a threefold increase in intracranial pressure (ICP), suggesting that chest compressions might disrupt normal blood flow dynamics in the brain. “Knowing now that extreme efforts like lining people up to do CPR can cause turbulence within the system is a significant advancement,” says Dr. Greiffenstein. “It's possible to have perfusion at these unreadable MAP scores, which is a critical insight for trauma care.” Implications for Trauma Care These findings challenge the one-size-fits-all approach to CPR in cardiac arrest scenarios. In cases of hemorrhagic shock, CPR might: Divert attention from more effective interventions, such as rapid blood transfusion or surgical control of bleeding. Worsen perfusion to vital organs, potentially exacerbating the patient's condition. “In military cases, field medics often don't have the opportunity to perform full chest compressions on the battlefield. Sometimes, all they can do is drag a person to a safe position,” notes Dr. Greiffenstein. This study underscores the importance of prioritizing interventions that address the root cause of trauma PEA—severe blood loss—over traditional resuscitation techniques. A Call for Updated Guidelines The American Heart Association's current guidelines broadly recommend CPR for all pulseless patients. However, this study adds to a growing body of evidence suggesting that trauma-induced PEA requires a different approach. By focusing on restoring blood volume and controlling bleeding, paramedics and EMTs can improve outcomes for patients in hemorrhagic shock. As Dr. Greiffenstein puts it, “This research is a step toward more tailored and effective trauma care protocols. It's about understanding the unique physiology of trauma and adapting our interventions accordingly.” For EMS providers on the front lines, this study serves as a reminder to critically evaluate the tools and techniques we rely on in emergency care. While CPR remains a vital intervention in many scenarios, its role in trauma-induced PEA warrants careful reconsideration by physician medical directors. By staying informed about the latest research, we can continue to improve outcomes for the patients who depend on us most. Click below to watch the full interview Reference Greiffenstein, P., Cavalea, A., Smith, A., Sharp, T., Warren, O., Dennis, J., Gatterer, M. C., Danos, D., Byrne, T. C., Scarborough, A., Deville, P., & VanMeter, K. (2025). Effect of cardiopulmonary resuscitation on perfusion in a porcine model of severe hemorrhagic shock. The Journal of Trauma and Acute Care Surgery, 98(2), 251–257.

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Episode 218: Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

Play Episode Listen Later Jan 17, 2026 12:45

We discuss the diagnosis and management of SCAPE in the ED. Hosts: Naz Sarpoulaki, MD, MPH Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/SCAPEv2.mp3 Download Leave a Comment Tags: Acute Pulmonary Edema, Critical Care Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: Credit: 12.5 AMA PRA Category 1 Credits™ Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics. Cost: Free for NYU Learners $250 for Non-NYU Learners Click Here to Register and Begin Module 1 The Clinical Case Presentation: 60-year-old male with a history of HTN and asthma. EMS Findings: Severe respiratory distress, SpO₂ in the 60s on NRB, HR 120, BP 230/180. Exam: Diaphoretic, diffuse crackles, warm extremities, pitting edema, and significant fatigue/work of breathing. Pre-hospital meds: NRB, Duonebs, Dexamethasone, and IM Epinephrine (under the assumption of severe asthma/anaphylaxis). Differential Diagnosis for the Hypoxic/Tachypneic Patient Pulmonary: Asthma/COPD, Pneumonia, ARDS, PE, Pneumothorax, Pulmonary Edema, ILD, Anaphylaxis. Cardiac: CHF, ACS, Tamponade. Systemic: Anemia, Acidosis. Neuro: Neuromuscular weakness. What is SCAPE? Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is characterized by a sudden, massive sympathetic surge leading to intense vasoconstriction and a precipitous rise in afterload. Pathophysiology: Unlike HFrEF, these patients are often euvolemic or even hypovolemic. The primary issue is fluid maldistribution (fluid shifting from the vasculature into the lungs) due to extreme afterload. Bedside Diagnosis: POCUS vs. CXR POCUS is the gold standard for rapid bedside diagnosis. Lung Ultrasound: Look for diffuse B-lines (≥3 in ≥2 bilateral zones). Cardiac: Assess LV function and check for pericardial effusion. Why not CXR? A meta-analysis shows LUS has a sensitivity of ~88% and specificity of ~90%, whereas CXR sensitivity is only ~73%. Importantly, up to 20% of patients with decompensated HF will have a normal CXR. Management Strategy 1. NIPPV (CPAP or BiPAP) Start NIPPV immediately to reduce preload/afterload and recruit alveoli. Settings: CPAP 5–8 cm H₂O or BiPAP 10/5 cm H₂O. Escalate EPAP quickly but keep pressures to avoid gastric insufflation. Evidence: NIPPV reduces mortality (NNT 17) and intubation rates (NNT 13). 2. High-Dose Nitroglycerin The goal is to drop SBP to < 140–160 mmHg within minutes. No IV Access: 3–5 SL tabs (0.4 mg each) simultaneously. IV Bolus: 500–1000 mcg over 2 minutes. IV Infusion: Start at 100–200 mcg/min; titrate up rapidly (doses > 800 mcg/min may be required). Safety: ACEP policy supports high-dose NTG as both safe and effective for hypertensive HF. Use a dedicated line/short tubing to prevent adsorption issues. 3. Refractory Hypertension If SBP remains > 160 mmHg despite NIPPV and aggressive NTG, add a second vasodilator: Clevidipine: Ultra-short-acting calcium channel blocker (titratable and rapid). Nicardipine: Effective alternative for rapid BP control. Enalaprilat: Consider if the above are unavailable. Troubleshooting & Pitfalls The “Mask Intolerant” Patient Hypoxia is the primary driver of agitation. NIPPV is the best sedative. * Pharmacology: If needed, use small doses of benzodiazepines (Midazolam 0.5–1 mg IV). AVOID Morphine: Data suggests higher rates of adverse events, invasive ventilation, and mortality. A 2022 RCT was halted early due to harm in the morphine arm (43% adverse events vs. 18% with midazolam). The Role of Diuretics In SCAPE, diuretics are not first-line. The problem is redistribution, not volume excess. Diuretics will not help in the first 15–30 minutes and may worsen kidney function in a (relatively) hypovolemic patient. Delay Diuretics until the patient is stabilized and clear systemic volume overload (edema, weight gain) is confirmed. Disposition Admission: Typically requires CCU/ICU for ongoing NIPPV and titration of vasoactive infusions. Weaning: As BP normalizes and work of breathing improves, infusions and NIPPV can be gradually tapered. Take-Home Points Recognize SCAPE: Hyperacute dyspnea + severe HTN. Trust your POCUS (B-lines) over a “clear” CXR. NIPPV Immediately: Don’t wait. It saves lives and prevents tubes. High-Dose NTG: Use boluses to “catch up” to the sympathetic surge. Don’t fear the dose. Avoid Morphine: Use small doses of benzos if the patient is struggling with the mask. Lasix Later: Prioritize afterload reduction over diuresis in the hyperacute phase. Read More

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The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation

REBEL Cast

Play Episode Listen Later Jan 8, 2026

🧭 REBEL Rundown 📌 Key Points 💀 Mortality: No statistically significant difference in 28-day mortality between ketamine vs etomidate for intubation in critically ill patients, though there was a ~1% absolute difference favoring ketamine. 📉🫀⚠️ Hemodynamics: Ketamine induction was associated with more cardiovascular collapse, mainly driven by new/increased vasopressor use (dose escalation or addition of a vasoactive agent). 💉⬆️ Click here for Direct Download of the Podcast. 📝 Introduction Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence intubation (RSI) has raged for years with no clear winner. Etomidate has been touted in the past for its rapid onset and minimal intrinsic effects on hemodynamics. However, the drug is well known as a transient adrenal suppressant though the impact of this suppression isn’t clear. Ketamine has risen in recent years as an alternative, due to its perceived hemodynamic stability, analgesic properties and absence of adrenal suppression. Additionally, recent data points towards improved mortality when ketamine was selected over etomidate (Kotani 2023). High quality randomized controlled trials are needed to further elucidate which agent should be selected in critically ill patients. 🧾 Paper Casey JD et al. Ketamine or etomidate for tracheal intubation of critically ill adults. NEJM 2025. PMID: 41369227 🔙Previously Covered On REBEL REBEL EM: The EvK Trial: Ketamine vs Etomidate for Rapid Sequence IntubationREBEL EM: From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate ️ What They Did CLINICAL QUESTION In critically ill adults undergoing tracheal intubation, does the use of ketamine instead of etomidate result in improved 28 day mortality? STUDY DESIGN Multicenter, randomized, open-label trial in both emergency departments and ICUs. POPULATION Inclusion Criteria:Critically ill patients > 18 years of age undergoing tracheal intubation with the use of an induction agentExclusion Criteria:Known pregnancyPrisonersPrimary diagnosis of traumaNeed for immediate intubation precluding randomizationClinicians determined that the use of ketamine or etomidate was either necessary or contraindicated INTERVENTION & COMPARATOR Intervention (HFNC Group):Ketamine administered based on a provided nomogram: full dose (2.0 mg/kg), intermediate dose (1.5 mg/kg) or reduced dose (1.0 mg/kg)Comparator (BPAP Group):Etomidate administered based on a provided nomogram: full dose (0.3 mg/kg), intermediate dose (0.25 mg/kg) or reduced dose (0.2 mg/kg) OUTCOMES Primary: In-hospital death from any cause by day 28.Secondary:Cardiovascular collapse during intubation defined as SBP < 65 mm Hg, receipt of new or increased dose of vasopressors or cardiac arrest.Exploratory Procedural:Lowest systolic blood pressureLowest systolic blood pressure below 80 mmHgHighest systolic blood pressure above 180 mmHgLowest oxygen saturationLowest oxygen saturation below 80%Successful first attempt intubationTime from induction to intubationExploratory Clinical:Number of ventilator free daysVasopressor-free daysICU free days Safety: Systolic blood pressure at 24 hours after enrollmentOngoing receipt of vasopressors at 24 hours 📈 Results: 2365 patients were randomizedKetamine: 1176Etomidate: 1189> 99% of patients received the drug they were randomized to receiveNMBA: 69% of patients in both groups received rocuronium~ 95% of patients had video laryngoscopy for the primary intubation attempt 💥 Critical Results 💪 Strengths Multicenter ED + ICU cohort of critically ill patients → improves external validityStrong randomization → balanced baseline characteristicsRight population for the question → appropriately focused on a sick cohort where induction choice matters mostHigh protocol adherence → most patients received the agent they were randomized toExcellent follow-up → minimal loss to follow-up / outcome capture ⚠️ Limitations No blinding → potential performance/resuscitation biasTrauma excluded → limits applicability to peri-intubation trauma careCase-mix skewed toward septic shock → may reduce generalizability to other shock etiologiesPower assumptions → designed to detect a 5% mortality difference (possibly overly ambitious)Equipoise-only enrollment → excluded patients with clear indication/contraindication → selection bias + reduced real-world applicabilityComposite secondary outcome with non-equivalent endpoints (e.g., cardiac arrest vs vasopressor titration)Ketamine dosing by actual body weight (vs ideal) → may have increased dose/exposure in some patients 🗣️ Discussion The increase in cardiovascular collapse seen with ketamine was driven by the “new or increased vasopressor use” piece of the composite outcome not by the more clinically relevant severe hypotension (SBP < 65 mm Hg) or cardiac arrest.The increase in CV collapse is a secondary outcome and hypothesis generating onlyCare beyond induction agent isn’t clearly delineated and may have varied between groupsReasons why there was more CV collapse in the ketamine group:Patients in the etomidate group were more likely to be on pressors or have pressor increases prior to induction agent administrationKetamine has analgesic properties which may affect hemodynamics (etomidate does not have analgesic effects)The standard ketamine dose of 2 mg/kg is higher than the induction dose used by most (1-1.5 mg/kg)Ketamine dosing was based on actual body weight though ideal body weight dosing is more accepted. This may have resulted in unnecessarily large ketamine doses that may have had a greater effect on hemodynamics.This is a study of patients with clinical equipoisePatients who the clinician determined would clearly benefit from one agent or the other or in whom one agent or the other was contraindicated were excluded from the study.This may add a selection bias to the results.Clinicians were not blinded to the induction agent administeredThe absence of blinding can introduce bias.For instance, knowledge of the agent the patient was randomized to may result in different resuscitative treatment prior to intubation.An induction agent nomorgram was provided to allow clinicians to choose their induction dose depending on patient stability.A 5% difference in mortality may be overly ambitious. As Josh Farkas points out in his post on this article, PCI for STEMI only has a 3% absolute difference in mortality versus standard care.The 1% absolute difference in mortality while not statistically significant would be clinically significant if it was real. The study would have to be much larger to show a statistically significant 1% difference.About 2% of patients in each group received additional medications during induction (propofol, benzodiazepines, opiates). It is unclear why these agents were selected in specific cases and how they may have affected the outcomes in question. 📘 Author's Conclusion “Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.“ 💬 Our Conclusion In this well done RCT, induction with ketamine did not result in a lower 28-day mortality when compared to induction with etomidate in critically ill adults. The secondary outcome of an increase in cardiovascular collapse is interesting and should be studied more in the future. 🚨 Clinical Bottom Line This data should not drive clinicians to abandon the use of ketamine in RSI. To the contrary, the study leaves open the possibility of a clinically meaningful difference in mortality favoring ketamine that may be borne out in a larger study. However, etomidate can be considered as a first-line option for RSI and may be the superior drug in patients at high-risk for cardiovascular decompensation. Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami) 📚 References Kotani Y et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: a meta-analysis of randomized trials J Crit Care 2023;77:154317. PMID: 37127020 👤Associate Author Anand Swaminathan MD, MPH All Things REBEL EM Meet The Team 🔎 Your Deep-Dive Starts Here The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence ... Resuscitation Read More REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED? Background: Standard rapid sequence intubation (RSI) in the emergency department involves administration of ... Procedures and Skills Read More The post The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation appeared first on REBEL EM - Emergency Medicine Blog.

trial patients md results cv procedures clinicians ketamine pmid hg pci rsi rct icus nejm stemi sbp systolic equipoise rapid sequence intubation etomidate anand swaminathan j crit care

Episode 217: Prehospital Blood Transfusion

Wade Borth - Sage Wealth Strategy

Play Episode Listen Later Jan 1, 2026

We discuss the shift to prehospital blood to treat shock sooner. Hosts: Nichole Bosson, MD, MPH, FACEP Avir Mitra, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Prehospital_Transfusion.mp3 Download Leave a Comment Tags: EMS, Prehospital Care, Trauma Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: Credit: 12.5 AMA PRA Category 1 Credits™ Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics. Cost: Free for NYU Learners $250 for Non-NYU Learners Click Here to Register and Begin Module 1 What is prehospital blood transfusion Administration of blood products in the field prior to hospital arrival Aimed at patients in hemorrhagic shock Why this matters Traditional US prehospital resuscitation relied on crystalloid ED and trauma care now prioritize early blood Hemorrhage occurs before hospital arrival Delays to definitive hemorrhage control are common Earlier blood may improve survival Supporting rationale ATLS and trauma paradigms emphasize blood over fluid National organizations support prehospital blood when feasible EMS already manages high risk, time sensitive interventions Evidence overview Data are mixed and evolving COMBAT: no benefit PAMPer: mortality benefit RePHILL: no clear benefit Signal toward benefit when transport time exceeds ~20 minutes Urban systems still experience long delays due to traffic and geography LA County median time to in hospital transfusion ~35 minutes LA County program ~2 years of planning before launch Pilot began April 1 Partnerships: LA County Fire Compton Fire Local trauma centers San Diego Blood Bank 14 units of blood circulating in the field Blood rotated back 14 days before expiration Ultimately used at Harbor UCLA Continuous temperature and safety monitoring Indications used in LA County Focused rollout Trauma related hemorrhagic shock Postpartum hemorrhage Physiologic criteria: SBP < 70 Or HR > 110 with SBP < 90 Shock index ≥ 1.2 Witnessed traumatic cardiac arrest Products: One unit whole blood preferred Two units PRBCs if whole blood unavailable Early experience ~28 patients transfused at time of discussion Evaluating: Indications Protocol adherence Time to transfusion Early outcomes Too early for outcome conclusions California collaboration Multiple active programs: Riverside (Corona Fire) LA County Ventura County Additional programs planned: Sacramento San Bernardino Programs meet monthly as CalDROP Focus on shared learning and operational optimization Barriers and concerns Trauma surgeon concerns about blood supply Need for system wide buy in Community engagement Patients who may decline transfusion Women of childbearing age and alloimmunization risk Risk of HDFN is extremely low Clear communication with receiving hospitals is essential Future direction Rapid national expansion expected Greatest benefit likely where transport delays exist Prehospital Blood Transfusion Coalition active nationally Major unresolved issue: reimbursement Currently funded largely by fire departments Sustainability depends on policy and payment reform Take-Home Points Hemorrhagic shock is best treated with blood, not crystalloid Prehospital transfusion may benefit patients with prolonged transport times Implementation requires strong partnerships with blood banks and trauma centers Early data are promising, but patient selection remains critical National collaboration is key to sustainability and future growth Read More

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Military Retirement: Take Control of Your Benefits with Kent Kraiter

Play Episode Listen Later Oct 14, 2025 32:00

Today, Wade sits down with returning guest and former military member Kent Kraiter to discuss the realities of retirement planning for those who serve. Drawing from his own military career and master's research on retirement strategies in the U.S., Kent shares insights on how service members can better prepare for their financial future—long before retirement hits. Together, they unpack the complexities of military and federal benefits, survivor plans, and how to take control through education and alternative strategies like properly structured whole life insurance. Whether you're two years or ten years away from retirement, this episode will help you think differently about how to protect your family, maximize your benefits, and take ownership of your financial future. Episode Highlights 00:54 - Military retirement strategies: Serving those who serve. 02:00 - Common misconceptions about retirement planning. 03:03 - Transition assistance programs in the military. 05:00 - Key factors in military retirement decisions. 06:50 - Survivor Benefit Plan (SBP) overview and cost. 09:50 - Survivor Benefit Plan: Impact on surviving spouse. 11:30 - Comparing SBP with private insurance options. 14:30 - Importance of planning and control over benefits. 15:59 - Break-even point for whole life policy vs. SBP. Episode Resources: sagewealthstrategy.com https://www.sagewealthstrategy.com/planning-beyond-retirement-with-kent-kraiter/ Connect with Kent Kraiter kent.kraiter@factumfinancial.com

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Play Episode Listen Later Oct 11, 2025 5:12

Behind the Study: Social and Cardiovascular Risk Factors in Older Adults with Prediabetes

Aging-US

Play Episode Listen Later Oct 8, 2025 7:21

Dr. Leonard Egede, Dr. Rebekah Walker, and Dr. Obinna Ekwunife from the Department of Medicine at the University of Buffalo, NY, describe their #research paper #published in Volume 17, Issue 8 of Aging-US, entitled “Longitudinal relationship between social and CVD risk factors in older adults with prediabetes: the HRS 2006-2016.” #interview #authorinterview #aging #prediabetes #cardiovascular #health #openaccess #openscience #peerreviewed #journal #publication #publishing #meded DOI - https://doi.org/10.18632/aging.206308 Corresponding author - Leonard E. Egede - legede@buffalo.edu Video interview - https://www.youtube.com/watch?v=1MSTk3GQAGA Video transcript - https://aging-us.net/2025/10/08/behind-the-study-social-and-cardiovascular-risk-factors-in-older-adults-with-prediabetes/ Abstract Background: This study examines how multiple social risk factors influence cardiovascular disease (CVD) risk control over time in older adults with prediabetes using a nationally representative cohort. Methods: Data from the Health and Retirement Study (HRS) included 5,086 U.S. adults aged 50+ with prediabetes. Five social risk domains (economic stability, environment, education, healthcare, and social context) were examined as independent variables, while CVD risk factors included glycemic control (HbA1c), systolic blood pressure (SBP), and cholesterol ratio (total cholesterol/high-density lipoprotein). Mixed-effects models assessed relationships between social risk factors and CVD outcomes, adjusting for age, gender, race, and marital status. Results: The sample had an average age of 68.6 years, with 60.2% female, and 70.97% identifying as non-Hispanic Black. Average HbA1c was 5.7, SBP 129.4, and cholesterol ratio 3.85. Limited education was consistently associated with increased CVD risk—HbA1c (β = 0.03, 95% CI: 0.01–0.06, p < 0.001), SBP (β = 4.34, 95% CI: 2.96–5.71, p < 0.001), and cholesterol ratio (β = 0.08, 95% CI: 0.01–0.16, p < 0.05) —in the fully adjusted model. Medication cost-related non-adherence was significantly associated with higher HbA1c levels (β = 0.03, 95% CI: 0.002–0.06, p < 0.05). Difficulty paying bills and lack of health insurance were both significantly associated with higher cholesterol levels (β = 0.03, 95% CI: 0.002–0.06, p < 0.05) and (β = 0.22, 95% CI: 0.15–0.30, p < 0.001), respectively. Conclusions: Social risk factors, particularly limited education, significantly impact CVD risk in older adults with prediabetes. Sign up for free Altmetric alerts about this article - https://aging.altmetric.com/details/email_updates?id=10.18632%2Faging.206308 Subscribe for free publication alerts from Aging - https://www.aging-us.com/subscribe-to-toc-alerts Keywords - aging, prediabetes, social determinants of health, health equity, cardiovascular health, population health To learn more about the journal, visit https://www.Aging-US.com and connect with us on social media at: Facebook - https://www.facebook.com/AgingUS/ X - https://twitter.com/AgingJrnl Instagram - https://www.instagram.com/agingjrnl/ YouTube - https://www.youtube.com/@AgingJournal LinkedIn - https://www.linkedin.com/company/aging/ Bluesky - https://bsky.app/profile/aging-us.bsky.social Pinterest - https://www.pinterest.com/AgingUS/ Spotify - https://open.spotify.com/show/1X4HQQgegjReaf6Mozn6Mc MEDIA@IMPACTJOURNALS.COM

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Military Divorce - What You Need to Know and Do with David Smith #196

The Military Money Manual Podcast

Play Episode Listen Later Sep 29, 2025 43:22

Think military divorce means automatically splitting everythign 50/50 and going to court? Wrong on both counts! Certified Divorce Financial Anaylst David Smith reveals what most military families get wrong and what it costs them! In today's episode, we'll discuss the complex financial and logistical aspects of military divorce, covering everything from pension division to healthcare benefits, tax implications, and emotional support strategies. Key Topics Jurisdiction & Legal Considerations Multiple state options for filing (voting state, property ownership state, driver's license state, tax filing state) Importance of consulting with an attorney early to determine proper jurisdiction Each state has different rules, formulas, and processes JAG office can provide consultation but cannot represent service members in divorce proceedings Types of Divorce Processes Four main options: DIY without professionals, mediation, collaborative divorce, litigation Court is NOT the only option Out-of-court processes (mediation, collaborative) are often more cost-effective, private, and less stressful Consulting attorneys vs. representing attorneys - different roles and costs Military Pension Division Division is not the only option - can use offsetting with other assets Must determine what portion is "marital" vs. "separate" property Not all pension components are divisible (e.g., VA disability) Requires a Military Retirement Pay Division Order through DFAS Differences between active duty, reservist, and guard member pensions Survivor Benefit Plan (SBP) Critical considerations: Only ONE SBP beneficiary can be named Previous spouses from earlier marriages may already occupy the "SBP chair" Premium costs must be negotiated Former spouse can be SBP beneficiary even without receiving pension payments Time-sensitive: Required forms must be submitted within specific timeframe or rights are lost Cannot be automatically transferred - requires proper paperwork TRICARE Benefits Courts CANNOT order TRICARE coverage - falls under federal rules Key rules: 20-20-20 (full benefits for life), 20-20-15 (transitional benefits) Based on: length of marriage, service member's creditable years, overlap period COBRA-like option available if don't meet other rules GI Bill Transfer Must be transferred WHILE married - cannot go to former spouse after divorce Service member can rescind the transfer Can be transferred to children as alternative Settlement agreement language is critical to protect this benefit Thrift Savings Plan (TSP) Multiple TSPs possible (civilian federal employee spouse, reservist who went active duty) Pre-tax and Roth portions have different tax consequences Must account for outstanding loans Requires Retirement Benefits Court Order (different from pension division order) Not always split - can use offset method with other assets Other Unique Military Assets to Consider Military leave - has monetary value on LES Credit card points and miles - can be worth $30,000-$40,000 USAA Subscriber Savings Account Pets - especially valuable show animals Life insurance policies Tax Implications Filing status changes Tax bracket shifts Capital gains considerations when dividing assets Pre-tax accounts (traditional IRA, 401k) vs. post-tax accounts have different real values Child tax credits and claiming dependents Early withdrawal penalties Marital vs. Separate Property Separate property: assets brought into marriage, inheritances, gifts (if kept separate and not commingled) Marital property: everything accumulated during marriage Characterization process is essential before division discussions Financial Mistakes to Avoid Making verbal agreements before completing full financial inventory Not understanding tax consequences of asset division Overlooking hidden assets (leave balance, points/miles, etc.) Rushing decisions - most divorce decisions have no do-overs Not considering pre-tax vs. post-tax asset values Misclassifying assets as marital or separate Practical First Steps Learn about all four divorce process options If abuse is present, seek legal counsel immediately Open credit card and bank account in your own name Create timeline of important dates and duty stations Gather supporting documents (tax returns, bank statements) in cloud storage Document account numbers, login credentials, passwords Consider consulting with CDFA before hiring representing attorney Supporting Someone Through Divorce Listen deeply and empathetically Avoid projecting your own divorce experience onto theirs Don't rush them into decisions Offer practical help (childcare, meals, house cleaning) Point them to resources (counselors, family services, professionals) Give them breathing room Key Takeaways Divorce in the military involves unique complexities beyond civilian divorces Court is not the only option - consider mediation or collaborative processes Complete financial inventory BEFORE making division decisions Everything accumulated during marriage is generally marital property Professional guidance (CDFA, attorney consultation) is an investment, not just a cost Most divorce decisions are final with no do-overs - take time to understand options Resources & Links David's website: sandoakdivorcesolutions.com Free 30-minute phone consultations available David's LinkedIn: linkedin.com/in/davidsmithcdfa/ Find a CDFA through Institute for Divorce Financial Analysts: institutedfa.com Spencer and Jamie offer one-on-one Military Money Mentor sessions. Get your personal military money and personal finance questions answered in a confidential coaching call. militarymoneymanual.com/mentor Over 20,000 military servicemembers and military spouses have graduated from the 100% free course available at militarymoneymanual.com/umc3 In the Ultimate Military Credit Cards Course, you can learn how to apply for the most premium credit cards and get special military protections, such as waived annual fees, on elite cards like The Platinum Card® from American Express and the Chase Sapphire Reserve® Card. https://militarymoneymanual.com/amex-platinum-military/ https://militarymoneymanual.com/chase-sapphire-reserve-military/ Learn how active duty military, military spouses, and Guard and Reserves on 30+ day active orders can get your annual fees waived on premium credit cards in the Ultimate Military Credit Cards Course at militarymoneymanual.com/umc3 If you want to maximize your military paycheck, check out Spencer's 5 star rated book The Military Money Manual: A Practical Guide to Financial Freedom on Amazon or at shop.militarymoneymanual.com. Want to be confident with your TSP investing? Check out the Confident TSP Investing course at militarymoneymanual.com/tsp to learn all about the Thrift Savings Plan and strategies for growing your wealth while in the military. Use promo code "podcast24" for $50 off. Plus, for every course sold, we'll donate one course to an E-4 or below- for FREE! If you have a question you would like us to answer on the podcast, please reach out on instagram.com/militarymoneymanual.

Episode 200: All About Ascites

Rio Bravo qWeek

Play Episode Listen Later Aug 15, 2025 17:48

Episode 200: All About Ascites. Jesica Mendoza explains the pathophysiology, diagnosis and management of ascites. Dr. Arreaza adds input about early detection and prevention of spontaneous bacterial peritonitis. Written by Jesica Mendoza, OMS IV, Western University, College of Osteopathic Medicine of the Pacific. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Welcome to our episode 200! It is an honor to welcome back a wonderful medical student, her name is Jesica, and she has prepared this topic, and she is excited to share this information with us. Jesica presented in June this year an episode about gestational diabetes (episode 193) and today she will talk about ascites. Jesica, please tell us who you are again. What is ascites?Ascites is the buildup of fluid in between the visceral peritoneum and the parietal peritoneum in the abdomen. This is often caused by cirrhosis of the liver due to the increased portal HTN which leads to increased nitrous oxide (NO) and prostaglandins which then causes splanchnic vasodilation and decreased effective arterial volume. The decrease in arterial volume then causes an increase in the renin–angiotensin–aldosterone system (RAAS) and antidiuretic hormone (ADH) from the renal system which leads to sodium and water retention. This then causes a net reabsorption of fluids and ascites.Evaluation of ascites.Once someone has been found to have ascites the next step will be a diagnostic paracentesis. This includes removing fluid from the peritoneal cavity in order to determine the SAAG (Serum Ascites Albumin Gradient) score. SAAG : (serum albumin) − (albumin level of ascitic fluid). The two values should be measured at the same time.This score helps determine the cause of the ascites with a score >1.1 g/dL indicating portal hypertension usually due to liver disease such as cirrhosis. A SAAG score of 250 PMNS/mL. Fluid should be sent to the lab for culture and then antibiotics should be started. IV 3rd generation cephalosporins are typically used. Fluoroquinolones are also used to prevent the recurrence of SBP.If you desire to learn more about SBP, listen to our episode 123. By the way, propranolol is a frequently used medication to prevent GI bleeding from esophageal varices in cirrhosis and also to decrease the development of ascites. It should be used in patients who have compensated cirrhosis and must be avoided in patients with refractory ascites, hypotension, renal dysfunction or active infection. So, to wrap things up we should remember that once we identify ascites with our physical exam of the patient, we should make sure to obtain a paracentesis as these results will be the main guide for our treatment. The treatment can then range from medical treatment such as spironolactone and/or loop diuretics to TIPS procedures, PleurX or even liver transplant. Always be on the lookout for SBP in patients with ascites and always remember to obtain a culture on the ascitic fluid prior to starting antibiotics. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Ascites, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/14792-ascites.Huang LL, Xia HH, Zhu SL. Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites. J Clin Transl Hepatol. 2014 Mar;2(1):58-64. doi: 10.14218/JCTH.2013.00010. Epub 2014 Mar 15. PMID: 26357618; PMCID: PMC4521252. https://pmc.ncbi.nlm.nih.gov/articles/PMC4521252/.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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Check-up Semanal #200: Guideline do ADA, colangiografias intraoperatórias e mais!

PEBMED - Notícias médicas

Play Episode Listen Later Aug 11, 2025 8:58

Confira os temas do Check-up Semanal de hoje: Vacina do Butantan é eficaz contra o sorotipo 3 da dengue; Fazer ou não fazer colangiografias intraoperatórias?; Atualização da SBP sobre doença do refluxo gastroesofágico; Insuficiência cardíaca de fração de ejeção melhorada: características e desfechos; Atualizações de 2025 do guideline de diabetes do ADA. Ouça agora e se atualize!

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The AI Gamble: How Losing 50% of Clients Made Charlie Felker Millions

The Small Business Mentor Podcast by Alan Pentz

Play Episode Listen Later Jul 29, 2025 26:22

When Charlie Felker made the audacious decision to pivot his entire call center overnight to AI—losing half his clients in the process—he wasn't just gambling on technology. He was betting on a fundamental shift in how businesses operate. In this riveting episode of SBP, Alan Pentz explores Felker's calculated risk that transformed Free to Grow from a traditional service provider into an AI powerhouse delivering 75% cost savings while matching human performance. This isn't just another AI success story—it's a masterclass in strategic disruption, market timing, and the courage to cannibalize your own business model before competitors do it for you. Whether you're skeptical about AI or already planning your own pivot, Felker's insights reveal why the window for transformation is rapidly closing.

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SPORTS: PSC, SBP meet with FIBA in China | July 21, 2025

The Manila Times Podcasts

Play Episode Listen Later Jul 20, 2025 1:44

SPORTS: PSC, SBP meet with FIBA in China | July 21, 2025Subscribe to The Manila Times Channel - https://tmt.ph/YTSubscribe Visit our website at https://www.manilatimes.net Follow us: Facebook - https://tmt.ph/facebook Instagram - https://tmt.ph/instagram Twitter - https://tmt.ph/twitter DailyMotion - https://tmt.ph/dailymotion Subscribe to our Digital Edition - https://tmt.ph/digital Check out our Podcasts: Spotify - https://tmt.ph/spotify Apple Podcasts - https://tmt.ph/applepodcasts Amazon Music - https://tmt.ph/amazonmusic Deezer: https://tmt.ph/deezer Stitcher: https://tmt.ph/stitcherTune In: https://tmt.ph/tunein #TheManilaTimes#KeepUpWithTheTimes Hosted on Acast. See acast.com/privacy for more information.

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I HATE my Wife and Kids!

Stay By Plan

Play Episode Listen Later Jul 4, 2025 39:45

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Play Episode Listen Later Jun 27, 2025 7:00

Review of the CIBIS II Trial

Play Episode Listen Later Jun 17, 2025 5:17

The Lancet Volume 353, Issue 9146 p9-13 January 02, 1999Background: Accumulating data at the time suggested functional benefits of antagonism of beta-adrenoreceptors in patients with heart failure. Multiple specific beta-blockers were being tested in trials. The CIBIS 1 trial found a trend towards 20% lower mortality in the bisoprolol (a highly cardio-selective beta-blocker) group and 30% fewer admissions to hospital for worsening heart failure. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II) trial was designed to test this evidence further.Patients Eligible patients had New York Heart Association Class III-IV symptoms with LVEF ≤ 35% and were stable on diuretics and ACE-inhibitors. Exclusion criteria included recent MI or coronary intervention, AV block or resting heart rate less 60 bpm and systolic BP < 100 mmHg. Patients already on beta-blockers or with planned therapy with beta-blockers were also not enrolled.Cardiology Trial's remains independent, free of industry ads, due to reader generosity. Please consider becoming a free or paid subscriber.Baseline Characteristics The mean age of patients was 61 years, 81% male, and 83% Class III. The mean LVEF was 28%. About half the patients had ischemic heart disease, 12% primary dilated cardiomyopathy and nearly 40% had a mixture of valvular heart disease, hypertensive heart disease or unproven ischemic disease.The mean SBP on enrollment was 130 mmHg and resting HR was 80 bpm. The mean duration of heart failure before enrollment was 3.5 years. About 20% had AF at baseline. Nearly all patients were on ACE-I and half were on digoxin.Trial Procedures There was no run-in period. CIBIS II was double blinded. Slightly more than 2,600 patients were randomized 1:1 to bisoprolol or placebo in 274 hospitals across 18 countries.Patients in the bisoprolol group were started at 1.25 mg daily and titrated up weekly to as high as 10 mg daily. The goal was to attempt the highest tolerated dose. Patients were seen every 3 months.Endpoints The primary endpoint was all-cause mortality. Secondary endpoints included all-cause hospital admissions, cardiovascular mortality, combined CV death and CV hospital admissions, and premature treatment withdrawals.The authors estimated a 11.2% mortality in the placebo group and powered the trial to find a 25% reduction in death in the bisoprolol arm over 2 years.Results The trial was sopped early (mean follow-up 1.3 years) after the planned second interim analysis for benefit. The primary outcome of all-cause death occurred in 11.8% in the bisoprolol group vs 17.3% in the placebo arm (HR 0.66 (95% CI 0.54-0.81, p < 0.0001)).Bisoprolol reduced sudden death (3.6% vs 6.3%), all-cause hospitalization (33% vs 39%), CV death (9% vs 12%). Permanent treatment withdrawal occurred in 15% of both arms.The subgroup analysis showed no substantial treatment heterogeneity. The most common dose was 10 mg daily reached in 43% of patients.Conclusion The 34% reduction in death was clinically meaningful and statistically robust. Our confidence in such a large effect size stems from a) previous data on beta-blockers, which found similar effects, b) the 42% reduction in sudden death in the bisoprolol arm and c) the large reductions in all-cause hospitalization. In addition, the trial conduct appeared strong with almost no lost-to-follow up. The lack of run-in period strengthens the external validity of CIBIS II.The same caveats seen in the US carvedilol trial also apply to CIBIS II, namely that patients were ambulatory, outpatients, mostly with Class III symptoms. Patients enrolled in the trial had a mean SBP of 130 mmHg and a resting heart rate of 80. Nearly all patients were tolerating ACE-I and half were taking digoxin. In addition, patients were started on low-dose and gradually titrated higher. The majority of patients were on higher than 5 mg daily.The authors warned against applying these results to non-ambulatory patients with Class IV symptoms, especially if there was recent instability. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

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14th ACC 2025 Congress Coverage: SBP < 130 mmHg Linked to Reduced CV Mortality in Adults +80 Y

Daily cardiology

Play Episode Listen Later Jun 9, 2025 2:12

14th ACC 2025: SBP < 130 mmHg Linked to Reduced CV Mortality in Adults +80 Y

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Play Episode Listen Later May 29, 2025 2:58

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Review of the MERIT-HF trial

The Soldier For Life Podcast

Play Episode Listen Later May 22, 2025 10:36

Lancet 1999;353:2001-07Background: Beta-blockers directly reduce cardiac contractility and myocardial oxygen demand. For decades, they were avoided in patients with acute and chronic heart failure over concerns they would facilitate decompensation of the condition. The therapeutic cornerstones of treatment, prior to the modern era of clinical trials, focused on managing symptoms and quality of life with diuretics and inotropic agents like digoxin; however, new paradigms were arising that focused on addressing neurohormonal mechanisms of chronic disease that were over-activated in the failing heart. The first major success came with inhibition of the renin angiotensin aldosterone system with angiotensin converting enzyme inhibitors whose effect on mortality for patients with mild and severe forms of chronic heart failure were demonstrated in the V-HEFT II, CONSENSUS, and SOLVD trials. Additional benefits were demonstrated with the mineralocorticoid receptor antagonist spironolactone in the RALES trial. These drug classes primarily work by reducing afterload and volume retention. Appreciating why they work for improving cardiac performance and managing symptoms in heart failure patients is straightforward when we consider the major factors that effect cardiac stroke volume - preload, afterload and contractility; however, it is also noteworthy the effects these agents have on sudden death. How beta-blockade benefits the failing heart is less obvious (outside prevention of sudden death). Mechanistic studies in patients with chronic heart failure have consistently shown that when beta blockers are used for more than 1 month, left ventricular function improves. Beta blocker therapy appears to restore the density of beta-adrenergic receptors after they have been downregulated by the chronic overactivity of the sympathetic nervous system. The first major placebo-controlled RCT to demonstrate a mortality benefit used the non-selective beta blocker carvedilol. The trial was small and not originally designed to test mortality and was stopped early without clearly predefined stopping rules. Furthermore, 8% of total patients selected for participation in the trial were excluded prior to randomization after a 2 week, open-label run-in phase with the study drug, which saw 2% of all patients experience worsening heart failure or death representing 24 patients (the difference in total deaths between groups was 9 when the trial was stopped). The Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) was the first large scale trial designed to test the hypothesis that beta-blockade with metoprolol controlled/extended release (CR/XL) added to optimum medical therapy reduces mortality in patients with chronic systolic heart failure.Patients: Patients were recruited from 313 sites in 13 European countries and the United States. Eligible patients were men and women between the age of 40 to 80 years with symptomatic heart failure (NYHA class II-IV) for >/= 3 months before randomization. They had to be on a diuretic and ACE inhibitor for at least 2 weeks. Other drugs, including digoxin, could also be used. Patients also had to have an EF of /=68 beats per minute.Patients were excluded if: they had an MI or unstable angina within 28 days; had an indication or contraindication for treatment with beta-blocker; beta blockade within 6 weeks; heart failure due to systemic disease (i.e., amyloidosis) or alcohol abuse; scheduled or performed cardiac transplant; an ICD; procedures such as CABG or PCI planned or performed in the past 4 months; 2nd or 3rd degree AV block unless a pacemaker was present; unstable or decompensated heart failure defined by pulmonary edema or hypoperfusion or supine systolic BP 25% deviation of the number of observed versus expected consumed placebo tablets during the run-in period.Baseline characteristics: The mean age of patients was 64 years and approximately 78% were male. Slightly more than 30% of patients were above the age of 70. The average EF was 28%. The average SBP was 130 mmHg and heart rate was 82 bpm. Most patients had mild to moderate heart failure, with 41% in NYHA Class II, 56% in Class III, and only 3% in Class IV. Ischemic cardiomyopathy accounted for 65% of cases and nonischemic causes accounted for 35%. Most patients were on an ACE inhibitor or ARB (95%) and diuretic (90%). Digoxin was used in 63%. Trial procedures: Prior to randomization, the study was preceded by a single-blind, 2-week placebo run-in period. Patients meeting eligibility were then randomized to placebo or metoprolol CR/XL. The starting dose of placebo or metoprolol CR/XL was 12.5 mg daily for patients in NYHA class III or IV and 25 mg daily for patients in NYHA class II. The dose was doubled every 2 weeks until the target dose of 200 mg daily was reached. Patients were followed every 3 months.Endpoints: The primary outcome was all-cause mortality. It was estimated that 3,200 patients would need to be followed for 2.4 years to detect a 30% relative reduction in mortality based on annual mortality rate of 9.4% in the placebo group. This would achieve at least 80% power with a 2-sided alpha of 0.04. Patients were recruited faster then planned and so the final sample size of 3,991 patients increased the power of the study.The study was monitored by an independent safety committee and predefined stopping rules for efficacy were based on all-cause mortality, done when 25%, 50%, and 75% of expected deaths had occurred. Results: The trial was stopped early after the 2nd preplanned interim analysis when 50% of expected deaths had occurred. The mean duration of follow-up at the time of stopping was 1 year. The mean daily dose of metoprolol CR/XL was 159 mg once daily, with 87% receiving 100 mg or more and 64% receiving the target dose of 200 mg daily. In the placebo group, the corresponding values were 179 mg daily, 91% and 82%. The study drug was discontinued permanently in 14% of patients in the metoprolol group and 15% in the placebo group. Six months after randomization, heart rate decreased by 14 bpm in the metoprolol group compared to only 3 bpm in the placebo group. Systolic blood pressure decreased less in the metoprolol group (-2.1 vs 3.5 mmHg).Compared to placebo, metoprolol significantly reduced all-cause mortality (7.3% vs 10.8%; RR 0.66; 95% CI 0.53—0.81). Cardiovascular mortality accounted for 91% of all deaths; with sudden death accounting for 58% and death from worsening heart failure accounting for 24% of all deaths. All 3 of these causes of death were significantly reduced by metoprolol. The relative and absolute effects on death were greatest for patients with NYHA class III heart failure.Conclusions: In this trial of stable patients with mild to moderate chronic systolic heart failure, who were optimized on an ACEi or ARB and diuretic, metoprolol CR/XL significantly reduced all-cause mortality. Approximately 30 patients would need to be treated with metoprolol compared to placebo for 1 year to prevent 1 death. This trial represents a significant win for beta blockade in patients with chronic systolic heart failure. While the NNT in this trial is slightly higher than in SOLVD, it is important to appreciate that follow-up time in SOLVD was more than 3x longer. Limitations to external validity in this trial include the run-in period and stringent inclusion and exclusion criteria. Our enthusiasm is also tempered by early stopping, which has been found to be associated with false positive or exaggerated results but this concern is mitigated to some extent in this trial because the rules for early stopping were clearly defined in the protocol.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

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1457. Ireland’s One Trillion Euro Tax Mirage

The Echo Chamber Podcast

Play Episode Listen Later May 17, 2025 33:35

Please join us at patreon.com/tortoiseshack "Ireland, once a proud republic of ideas and insurgents, now resembles a serfdom for supranational capital. It is time – long past time – for a reckoning. The question is not whether this gilded scaffolding will crumble. It is whether we will have the courage to build something real in its place." Business Post editorial May 2025 That's not a paragraph we expected to read from the SBP, so we had to dig into what was behind it. Joining us to do so is one of the authors of the Tax Mirage report, UCD Professor, Aidan Regan, and he breaks it down brilliantly. Don't miss this episode. Read the report here:https://democracychallenged.com/2025/05/07/irelands-1-trillion-mirage-how-a-nation-became-a-vault-for-global-profits/ Prof Richard Murphy on Keir Starmer - "Keir Starmer came out as a full-on racist" interview out now here:https://www.patreon.com/posts/patron-exclusive-129009639 Donate to Dignity for Palestine:https://www.patreon.com/posts/dignity-for-to-126186702

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S15E7 Planning for Your U.S. Army Retirement

Play Episode Listen Later May 13, 2025 39:32

Are you planning for your U.S. Army retirement? If so, this week's Soldier for Life Podcast episode includes everything that you will need to know for your retirement planning journey! Listen as CW3 (Ret.) Lynn Peterson - the RSO Program Manager for the Army Retirement Services Office and our all-around retirement planning guru - shares LOADS of information and resources about planning steps, retirement resources and where to find them, major things to consider (including financial considerations, employment, healthcare, retirement locations, family considerations), veteran benefits, and SO much more! There were WAY too many great resources and links to websites/pages included in the podcast to include them all in this post, but here are a few to get you started (be sure to listen all the way through so you don't miss any of the fabulous resources that are available to you!):

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Review of the V-HEFT I Trial

Play Episode Listen Later Apr 29, 2025 12:58

N Engl J Med 1986; 314:1547-52Background Into the mid-1980's, digoxin and diuretics were the mainstay of chronic disease management for congestive heart failure. Vasodilator agents were also commonly used based on limited data of their favorable hemodynamic effects. No sufficiently powered trials in this space had been performed to assess whether administration of vasodilators or any other agents improved long-term morbidity or mortality for heart failure patients. The V-HEFT trial was undertaken to test the hypotheses that 2 widely used vasodilator regimens (prazosin or a combination of hydralazine and isosorbide dinitrate) were superior for reducing death versus placebo. The trial was sponsored by the Veterans Administration and only enrolled men.Patients Men between the ages of 18 and 75 were recruited from 11 participating Veterans Administration hospitals and had to have chronic congestive heart failure based on either evidence of cardiac dilatation or left ventricular dysfunction (EF 0.7 ng/mL and euvolemic volume status. Clinical evaluations and exercise-tolerance tests on 2 consecutive visits, two weeks apart, had to reveal clinical and exercise stability before randomization could occur. Following randomization, patients continued to receive the optimal dose of digoxin and diuretic along with 1 of 3 study regimens. The placebo group was given placebo tablets and placebo capsules and instructed to take them 4 times a day. The prazosin group took 2.5 mg prazosin capsules and placebo tablets 4 times a day. The hydralazine-isosorbide dinitrate group took 37.5 mg hydralazine capsules and 20 mg isosorbide dinitrate tablets 4 times a day.In all groups, therapy began with 1 capsule and 1 tablet to be taken 4 times a day. In the absence of side effects, this was increased to 2 capsules and 2 tablets 4 times a day for a total of 20 mg of prazosin or 300-160 mg of hydralazine-isosorbide dinitrate. If drug-related side effects occurred, the dose could be reduced to half a tablet 4 times per day or to one capsule 2 times per day. If the dose was reduced, an attempt was made later to reinstitute the full dose.In order to limit dropouts, rigorous criteria were established for “treatment failures.” Physicians were advised to hospitalize patients with worsening symptoms, and, if appropriate, to use temporary intravenous vasodilator or inotropic interventions for stabilization. Physicians were encouraged to resume study medications upon discharge. At least 2 such hospitalizations were required, along with objective evidence of deterioration, before the study medications were discontinued and replaced with known therapy.Endpoints The primary endpoint was all-cause mortality.Results 642 patients were enrolled (273 in placebo group, 183 in prazosin group and 186 in the hydralazine-isosorbide dinitrate group). Excluding discontinuations that took place within 1 month before death, 47 patients (17%) discontinued one or both types of placebos, 43 patients (23%) discontinued prazosin, and 60 patients (32%) discontinued either one or both drugs in the hydralazine-isosorbide group. Six months after randomization, the average prescribed doses were 18.6 mg per day of prazosin, 270 mg per day of hydralazine, and 136 mg per day of isosorbide dinitrate. More than 85% of the prescribed drugs were taken in each treatment group.The mean follow-up was 2.3 years (range 6 months to 5.7 years). Only 4 patients were lost to follow up (2 in placebo group, 1 in prazosin group, and 1 in hydralazine-dinitrate group). There were 120 deaths in placebo group (44%; 19 per 100 patient years), 91 in the prazosin group (50%; 22 per 100 patient years), 72 in the hydralazine-dinitrate group (39%; 17 per 100 patient years). A reduction in mortality over the entire follow-up period was observed in the hydralazine-nitrate group compared with placebo (p = 0.093 on the log-rank test and p = 0.046 on the generalized Wilcoxon test, which gives more weight to treatment differences occurring in the earlier part of the mortality curves and less weight to the latter part, where the numbers are smaller). The absolute difference in mortality between these groups increased during three years and then began to diminish. The absolute difference in mortality between the placebo group and hydralazine-isosorbide groups at years 1 through 4 was 7%, 9%, 11% and 4%, respectively.Prespecified subgroup analysis in CAD vs no CAD stratification showed no significant treatment effect heterogeneity for hydralazine-nitrate among those with CAD although the absolute difference in mortality between groups was numerically higher for patients with CAD.At 8 weeks and 1 year, SBP (-4.1 and -4.6 mmHg) and DBP (-3.2 and -2.7 mmHg) decreased the most in the prazosin group compared to placebo. Hydralazine-nitrate was not associated with a statistically significant nor clinically significant difference in BP with exception of DBP at 8 weeks. The EF rose significantly at 8 weeks and 1 year in the hydralazine-nitrate group (+2.9 and +4.2) compared to placebo but not in the prazosin group.Side effects were reported in 4.0% of placebo patients, 11% of prazosin patients and 19% of hydralazine-nitrate patients, respectively. The most common side effects were headache and dizziness. Headache was reported in 12% of hydralazine-nitrate patients.Conclusions This study compared the combination of hydralazine-isosorbide dinitrate or prazosin to placebo in patients with chronic congestive heart failure who were optimized on digoxin and diuretic therapy. In what appears to be a young (58 years) and highly selected population of clinically stable, male veterans with dilated cardiomyopathies and low symptom burdens, the combination of hydralazine-isosorbide reduced death by 2 per 100 patient years, increased EF by 4% at 1 year and did not significantly alter BP compared to placebo. Side effects were reported in approximately 1 out of 5 patients with the most common being headache and approximately 1 out of 3 discontinued 1 or both study drugs. Prasozin did not reduce death or increase EF but did reduce BP compared to placebo. The internal validity of the study is high with only a few minor imbalances in baseline characteristics, which do not appear clinically relevant nor to consistently favor any one group. Less than 1% of patients were lost to follow up with no significant imbalances between groups. The external validity is limited by the fact that this is a population of male veterans and the etiologic distribution of cardiomyopathy and heart failure is likely different from a general heart failure population; etiologic causes of death are also likely to be different. Furthermore, the population is highly selected and its unclear how many patients from the general heart failure population would meet study criteria.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

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Sens analyst Chris Stevenson says there was plenty of gamesmanship at the end of Game 1

TGOR

Play Episode Listen Later Apr 21, 2025 19:48

Sens analyst Chris Stevenson on the atmosphere at SBP, hijinks at the end of Game 1, Dzone coverage and Ullmark, turning point of the game and Claude Giroux.

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Review of the CULPRIT-SHOCK Trial