R to @anish_koka: The allergen isn't the meat itself as a whole. It's a specific sugar molecule — galactose-α-1,3-galactose — that is present on the surface of cells and proteins in virtually all non-primate mammals. It's a glycan modification, basically a carbohydrate tag that gets attached to mammalian proteins and lipids.
Humans, apes, and Old World monkeys don't make alpha-gal because we lost the functional alpha-1,3-galactosyltransferase gene somewhere in primate evolution. So our immune system is capable of recognizing it as foreign.
When the Lone Star tick bites you, it introduces alpha-gal (from its prior blood meals on deer, dogs, etc.) into your skin along with tick saliva, which is a potent immune adjuvant. Your immune system mounts an IgE response against the carbohydrate epitope specifically.
Then when you eat a steak, you're ingesting proteins and lipids decorated with that same alpha-gal sugar. The IgE recognizes the carbohydrate portion, not the protein backbone. That's what makes it mechanistically distinct from classic food allergies, which are almost always directed against protein epitopes.
The delayed reaction (3-6 hours) is also thought to relate to this — the alpha-gal is largely on lipid-associated glycoproteins and glycolipids, so it takes time for fat digestion and absorption to process and present the allergen to mast cells in the circulation.
Red meat is the vehicle, but the carbohydrate is the actual target of the immune response. That's also why some patients react to dairy, gelatin, and even mammalian-derived medications — anywhere that alpha-gal sugar shows up.
R to @anish_koka: Then you ask a question most doctors wouldn't think to ask:
"Any tick bites while you were in Texas?"
"Oh yeah, tons. I was hunting and hiking all the time. Pulled ticks off me every week."
Now you have your diagnosis.
R to @anish_koka: He's otherwise healthy. No prior allergies. No new meds. No new supplements.
You ask about his diet. He mentions he's been grilling a lot of burgers and steaks for dinner — "a Texas habit I brought home."
R to @anish_koka: He describes episodes of severe urticaria, throat tightness, shortness of breath and near-syncope — always between 2–5 AM.
He's been to the ER twice. Workup: negative troponin, normal echo, no arrhythmia on monitor.
Labeled "anxiety" and sent home with a Benadryl prescription.
🧵 A 35-year-old man presents after moving back to Philly from a 6-month stint in rural Texas.
"I keep waking up in the middle of the night feeling like I'm going to die."
Let's talk about a diagnosis (of particular interest to the keto community/cardiologists/CT surgeons) you might be missing. 👇
White guy kills a seagull: 8 months in prison
Black guy kills a man: misdemeanor, released
Black guy kills a pregnant mom and her unborn child: not guilty by reason of insanity, baby doesn’t count as a human
Asian woman kills family of 4: probation
Red guards in black robes have destroyed the value of justice and life - the purpose of a system is what it does.
An invading force with a completely different culture & religion invaded India , destroyed its temples, and used material from the temples to build their own places of worship in its place.
And yet it is rare to hear this referred to as colonization in “learned” circles.
Why?
R to @anish_koka: To clarify - Deaths from heart attack (CHD) not significantly different in VESALIUS , no difference in CV mortality for Fourier, ODYSSEY.
x.com/i/article/203587650580…
Even worse, is that the expanded budget isn't going to the patients.
A Medi-Cal patient is forced to wait 2 years for an ortho procedure, nearly 5 years for cataract surgery.
The money is ALL going to fraud.
If these surrogates were this clinically relevant with just 26 weeks of therapy.. the three large RCTs that had tens of thousands of patients with 4-5 years of follow up would show a really large benefit with regards to hard events.
You could actually run much smaller trials with much shorter follow up and still see a huge difference between control and treatment arm.
And yet VESALIUS, FOURIER, ODYSSEY show no clinically or statistically significant benefit in heart attack rate.
Which means I would commit zero dollars to any study attempting to use these surrogates as some proxy of clinical outcomes.
This is a junk study. But it is good for Instagram cred.
They buried a 19-year-old wrestler here, an athlete hanged by Iran's regime for protesting.
Saleh Mohammadi was one of Iran's valuable assets, part of the human infrastructure of its future but Islamic Republic destroyed that future.
It is painful and powerful to see people gathering to stand with his family, clapping for their hero.
Guarantee @WSJ @statnews would have zero problems with this cardiologist as FDA head. Because the only thing that matters to them is the truth, Science and the rare disease community.
Apparently someone from Sinai took folks with cad and did IVUS before and after psck9 inhibitors and showed plaque melting away.
And yet a 12,000 strong RCT (VESALIUS) of pcsk9 inhibitors in high risk 1º prevention patients had a 13% adverse event rate at 4 years.
🤔
Single arm ? Given issues with CIMT would have to see a control arm.
And if the mechanism for plaque regression is blood thinning? Why should that regress plaque ?
This is the best Healthcare trend I have seen in a long time!
Optumserve, one of United HC's subsidiaries (they have 2000+ of them) has a history of getting hundreds of millions in government contracts, including some to to reduce fraud waste and abuse.
The @TheJusticeDept has an ongoing criminal investigation open on United HC for
1. fraud in Medicare Advantage,
2.billing practices at United's PBM Optum Rx and
3. How UnitedHC pays the 10% of USA🇺🇸 physicians they employ
It looks like they are getting less of our tax 💵 nowadays.
UnitedHealthcare now gets more than 77% of its revenue from taxpayer-funded programs like Medicare Advantage and Medicaid. I wonder🤔 what kind of 'connections' made that possible
From: https://govtribe.com/vendors/quality-software-services-inc-dot-optum-inc-dot-1tpv6
Here in Hagia Sophia, on May 29th 1453, after 900 years of being a Christian cathedral, in the final hours of the Fall of Constantinople, a large number of Christian men, women, children, nuns, monks, priests, and others sought refuge from the Muslim invaders.
The Ottomans surged inside and massacred them.
On its holy altars they enacted “perversions with our women, virgins and children” including “the Grand Duke’s daughter who was quite beautiful” and forced to “lie on the great altar of Hagia Sophia with a crucifix under her head and then raped”
Those who were not murdered were enslaved.
Hagia Sophia resembled a “public brothel” before it was turned into a “stable for their horses”, with toppled altars used as troughs.
The Hagia Sophia’s main Crucifix was then paraded “in mocking procession” with “spitting and blasphemies and curses”.
“Behold the god of the Christians!” They jeered
its a terrible disease. I've cared for patients with it
It's also why we need better evidence
They deserve it
a 12 person propensity score matched analysis is very worrisome when randomized control at 1 year showed no benefit and heterogeneity of disease progression and symptoms is high
if truly beneficial, 12-24 extra months of the concurrent control group will tell you
How the Office of the Texas Attorney General @KenPaxtonTX is violating federal law.
I was kicked out of medical school ostensibly for "professionalism" issues. But I knew this wasn't true. For months, I fought for access to my educational records.
Two months ago, I finally got a glimpse.
Then, last week, under the order of an attorney from the TX AG's office, my access was blocked again -- a violation of federal law.
The Office of the Attorney General under Ken Paxton is helping Texas Tech to violate federal law.
Given how terrible the record is, it's not hard to understand why Texas Tech -- and now the Texas Attorney General -- wants to cover it up and make it go away.
This is what my "professionalism coach" at Texas Tech med school wrote.
Cheryl Erwin, Director of the Center for Ethics, Humanities & Spirituality.
Her notes:
> She compared my case to the Trump indictment.
> She suggested that questioning the unscientific COVID pandemic response -- lockdowns, mask mandates -- was like Trump questioning the 2020 election.
> She said that I "imbibed the cultural atmosphere of conspiracy theories."
> She characterized my position on the pandemic response as believing in a "conspiracy."
> She wrote that my exercising my First Amendment rights was me "making an idiot of himself."
> When I insisted I shouldn't be punished for speaking freely about how the medical profession abused its power, she called me "combative."
To my face, she told me none of these things. She signed off her emails, "Your friend." She promised confidentiality. And just weeks before she gave devastating testimony against me in a rigged hearing, she told me: "I will not abandon you."
She never once talked about what I wrote about on social media to my face. But it's almost all she could write about behind my back.
This is just one part of what's in my records. I got access in January after months of delays. First, one hour to review 2,000 records. Then, after I filed a complaint with the Department of Education, I was able to review them, escorted into a building, university-controlled laptop.
No copies. Even though all records were electronic.
I found things like the above. And so much more.
I filed an amended complaint in federal court using what I'd found in Texas Tech's own records.
Their response?
@KenPaxtonTX's litigation counsel sent me a letter telling me to stop contacting the university requesting FERPA access, that TTUHSC would provide no further access, and that my pending transcript amendment request would be paused indefinitely "until the litigation is resolved."
They said that I have seen the records enough. 1600 documents. Longer than Tolstoy's War and Peace.
They could just send the PDFs. Instead they insist on breaking the law.
They didn't cut off access because I was abusing it. They cut off access because their own records contain their own admissions -- and they would rather shut down a federal statutory right than let me keep viewing.
And here's the thing: what I have seen is only the tip of the iceberg. They have withheld many records. If this is what I have seen, what are they hiding?
I have filed a complaint, and now 5 supplements, with the Department of Education's Student Privacy Policy Office.
I will never, ever quit. Not this year. Not next. Not in 5. Not in 10. Not in 20 years. Not ever.
There will be justice.
@KenPaxtonTX -- Your office is breaking federal law; it is defending an agency that violated the United States constitution; you can withdraw your support any time if that agency's interests diverge with those of the state of Texas; that time is now.
@GregAbbott_TX -- Your university is punishing students for their speech for holding positions you agree with.
@CreightonForTX -- You are the new Texas Tech Chancellor. You are the "conservative". Prove it.
@EDSecMcMahon -- There is no litigation exception to FERPA. I was given 40 hours to review 1,600 documents. Now Texas Tech refuses any further access -- in writing. Your department has my complaint and 5 supplements. Enforce the law.
@EDUnderSecKent -- Texas Tech is breaking federal law, 20 U.S.C. § 1232g(a)(1)(A), 34 C.F.R. § 99.10(b), § 99.32. My complaint has been submitted months ago with supplements. When will the Department of Education do its job?
@TexasTech -- The truth will come out. And everyone will know.
Tomorrow.
The first of the secret recordings, published here. A senior Texas Tech official admitted to me that they didn't believe what they wrote about me in the official documents.
But that it was written in retaliation to my constitutionally protected speech.
His own words. On audio.
This is the hell that is Evin Prison in Iran, where political prisoners are held. This is actual CCTV footage from a hack showing what goes on there.
x.com/i/article/203535170682…
Important perspective.
Everyone has COI of one kind or another.
They destroyed his clan and the existence of Kashmiri Hindus from their state and thought they had won.
A Kashmiri Pundit destroyed their ecosystem and brainwashing of 70 years, in just six months and is smiling all the way to the Bank.
How it felt guarding your older cousin playing in grandma’s driveway
With utmost respect to all the authors, dear friends and respected clinicians, I agree with @venkmurthy and @anish_koka. It is important for clinicians to advocate for a better process for patient care guidelines.
Love the central message “lower LDL earlier” and much of the guideline. I would consider a follow-up step to advocate for over the counter statin - safe, effective, low cost, patients empowered and can discuss with clinicians when desired.
So bothered by inflated class 1 recs for baseless metrics like #CAC. 2 negative RCT, one with signal for harm. Cohort data showing prognosis but no data to demonstrate outcome benefit. This is not a class 1 level of evidence for benefit. Predominantly inappropriate testing causes harm and wastes limited resources in a nation $39 trillion in debt.
Institute of Medicine “Guidelines We Can Trust” urge class 1 recs to have strong RCT data for this very problem.
2/3 of replies to @gbiondizoccai ‘s brief poll agree that #CAC is used more inappropriately than appropriately.
Cardiologists should re-evaluate the guidelines process:
- need more diverse perspectives
- balance vocal proponents for testing or intervention with other perspectives and science
- uphold IOM standard for class 1 recs
We could really use a revitalized and objective USPSTF, which has always recommended these novel biomarkers have interesting potential but no evidence to routinely endorse.
Next we can expect a lobby for CMS to fund all these “class 1 tests, highest level of rec” with our taxpayer dollars.
Basically do the opposite of what advertising tells you to do, and you will live longer and healthier.
Expert opinion. Not based on RCT.
But it is a Class 1 Recommendation.
Doctors in large centers don't realize what a life-changer fast operating room turnover times are.
For those that don't know, the turnover time in OR's varies widely between hospitals. That's the time it takes to clean the room and set up for the next case.
In efficient hospitals, especially those that are physician owned, it can be as quick as 20 minutes. In large academic hospitals, it can push 4 or even 5 hours.
Think of the difference that makes for quality of life, patient care, and revenue.
A doctor who has a large waitlist of patients might be at the hospital until 8pm and still only get two surgeries done because the turnover time is so long. That same doctor could get 3 or 4 surgeries done in a more efficient hospital, getting home in time to have dinner with his family.
A physician owned hospital would never tolerate a 4 hour turnover time. That's money being lit on fire. Yet hospitals tolerate this all the time because they don't face competition. There's no incentive to run efficient.
So the patients have to wait longer for their surgery, the doctors get frustrated, and everybody loses.
Yep. @drdanchoi just had a great conversation on this and it’s covered in a chapter in my new book coming in next 4 weeks. Why we are educating the public on importance of seeing private practice doctors. Check us out at http://ThePrivateDocs.com and sign up your practice today 😃
Right but just doing something because there’s nothing else to do is pretty problematic as well.
Speaking as a loved one of a rare disease patient.
Patient today came to see me to discuss possible tonsillectomy. @TexasChildrens quoted her $15,000 as a "discounted cash price." My price is $3760.
Every physician and hospital in the country could list their prices on their website. It's not hard.
I've never heard a better description of modern healthcare:
I needed Chat for this
7. Critique of current research direction
The author is criticizing the field for:
Studying lower-risk patients
Making incremental tweaks
Using expensive versions of the same mechanism (more LDL lowering)
Translation:
“We’re squeezing tiny gains out of the same idea instead of finding new ones.”
. . .
Bottom line in plain English
Lowering LDL works—but we’re hitting diminishing returns
Even with very low cholesterol, many patients still have events
That remaining risk comes from other mechanisms
The field needs new ideas, not just better cholesterol drugs
Excerpt:
The bigger message to the cardiology research community is one worth taking to heart. Even taking the 4-point MACE outcome in VESALIUS at face value — the most favorable composite, the softest endpoint — the treatment arm still had a 13% event rate despite achieving a median LDL of 45 mg/dL. Thirteen percent of patients on evolocumab, with LDL driven to levels that would have seemed impossibly low to the trialists of the 1990s, still had a major cardiovascular event within five years. The LDL hypothesis has yielded remarkable results — it is one of the genuine success stories of modern preventive cardiology — but the curve is flattening. We may be approaching the limit of what cholesterol lowering alone can accomplish. The residual risk that persists despite aggressive lipid lowering is driven by inflammation, by plaque biology, by factors that circulating LDL levels do not fully capture. That is where the next generation of trials needs to go — not into ever more granular risk stratification of ever lower-risk populations to justify ever more expensive versions of the same mechanism, but toward genuinely new targets. Vesalius did not refine Galenic anatomy. He replaced it. The field may need a similar reckoning.
x.com/i/article/203458975322…
R to @anish_koka: open.substack.com/pub/anishk…
AI churning more patient $ and ☢️ with no data on clinically meaningful outcomes.
Absolutely disgraceful.
Analyzing the new lipid guidelines in the context of the recently completed VESALIUS trial
Honestly, as someone who has traveled a lot, India is the best country I have ever traveled to. It’s incredible. I will have been here for 9 days when I leave, and there is still so much to see and do. My experience has been amazing and India is portrayed negatively in the media as a place Amercians should avoid, but I realize a lot of that is completely made up.
The people, food, culture and hospitality culture are just incredible. I have felt safe and comfortable the entire time I have been here and India will truly be the next big super power. This country has incredible potential and you have to see it yourself to understand because the media only makes it out to be 3rd world.
That couldn’t be further from the truth.
Indian people are the nicest people I have ever met. I am very grateful for my time in India. I have enjoyed it so much and I hope I can come back every year.
Next time I want to visit South India. I have tried to do as much as possible these last 9 days but there is still so much to see and do.
All good things come to an end. I’ll be back (hopefully soon).
I love India. My misconceptions have been corrected. I have nothing but nice things to say. 🇮🇳