توفيق مرعى

[Error ArbitraI @ErrorArbitralTR]

Argentina ganó su primer Mundial con la ayuda de la dictadura.

Argentina ganó su segundo Mundial con un gol de mano.

Argentina ganó su tercer Mundial con penales regalados y el apoyo de la FIFA.

Y ahora quieren ganar con más corrupción.

Argentina NUNCA ha ganado sin trampas . Esto es así. Lo lloré quien lo llore, le duela a quien le duela.

Asco.

[توفيق مرعى @legendarymen]

@abdulhamid_199 Scleroderma

[Ahmed Shoeib @ahmad_shoeib]

الدعاء المستجاب #إيمن_عبد_جليل
#توأم_رمضان

[توفيق مرعى @legendarymen]

@Leonizm351 @grok

[توفيق مرعى @legendarymen]

@nohayred @grok

[Dr. Chokri Ben Lamine @abouabdrahman0]

Volume Overload – 50 High-Yield Pearls 💧🫀📚
Based on: Drum et al., JAMA 2026 – The Rational Clinical Examination

⸻

1️⃣ Volume overload = intravascular sodium + water expansion 💧
2️⃣ Think: HF, CKD, cirrhosis, excess IV fluids 🏥
3️⃣ Pathophysiology: arterial underfilling → RAAS activation 🔄
4️⃣ Plasma volume expansion → ↑ hydrostatic pressure 📈
5️⃣ Peripheral edema = filtration > lymphatic drainage 🦵
6️⃣ Hypoalbuminemia ↓ oncotic pressure → worsens edema 🧪
7️⃣ Edema grading (0–4+) = subjective ⚠️ low reproducibility
8️⃣ Bilateral symmetric pitting → systemic cause 🦵🦵
9️⃣ Crackles = reopening of fluid-filled airways 🎧
🔟 Kerley B lines on CXR = interlobular septal edema 📸

1️⃣1️⃣ JVP >3 cm above sternal angle → LR+ 4.1 🎯
1️⃣2️⃣ JVD highly specific (~92%) but poorly sensitive ❗
1️⃣3️⃣ Lower extremity edema → LR+ 2.2
1️⃣4️⃣ Edema absence does NOT exclude overload 🚫
1️⃣5️⃣ Crackles → LR+ 2.7
1️⃣6️⃣ Absence of crackles insufficient to rule out ❌
1️⃣7️⃣ Physical exam = specific, not sensitive
1️⃣8️⃣ Best PE tool = JVP
1️⃣9️⃣ Obesity reduces PE accuracy ⚖️
2️⃣0️⃣ Combine signs, don’t rely on one

2️⃣1️⃣ Chest X-ray vascular congestion → LR+ 5.9 📸🔥
2️⃣2️⃣ Highly specific (~91%)
2️⃣3️⃣ Sensitivity modest (~51%)
2️⃣4️⃣ Peribronchial cuffing = pulmonary vascular congestion
2️⃣5️⃣ Hazy perihilar opacities suggest edema

2️⃣6️⃣ BNP ≥100 ng/mL → LR+ 6.9 🧪🔥
2️⃣7️⃣ BNP <100 → LR− 0.14 ✅ strong rule-out
2️⃣8️⃣ BNP sensitivity ~87%
2️⃣9️⃣ BNP specificity ~87%
3️⃣0️⃣ Obesity lowers BNP levels ⚖️
3️⃣1️⃣ Age & renal failure increase BNP 📈
3️⃣2️⃣ BNP best single lab predictor 🎯
3️⃣3️⃣ NT-proBNP cutoffs heterogeneous
3️⃣4️⃣ Lab results not immediate but rapid in ED settings
3️⃣5️⃣ BNP helpful in dyspnea differentiation 💨

3️⃣6️⃣ Lung POCUS: ≥3 B-lines in ≥2 bilateral zones = positive 📡
3️⃣7️⃣ B-lines LR+ 4.0
3️⃣8️⃣ Absence of B-lines LR− 0.09 🚀 very powerful rule-out
3️⃣9️⃣ Lung POCUS sensitivity 93% 💡
4️⃣0️⃣ B-lines not specific (ARDS/pneumonia possible)

4️⃣1️⃣ IVC >2.1 cm + <50% collapse → LR+ 3.9
4️⃣2️⃣ IVC ≥50% collapse → LR− 0.22
4️⃣3️⃣ Measure 2 cm from RA junction 📏
4️⃣4️⃣ Positive pressure ventilation alters IVC ⚠️
4️⃣5️⃣ Ascites affects interpretation

4️⃣6️⃣ POCUS JVP >8 cm → LR+ 2.8
4️⃣7️⃣ POCUS JVP ≤8 cm → LR− 0.26
4️⃣8️⃣ Ultrasound JVP more sensitive than bedside JVP
4️⃣9️⃣ POCUS generates preservable objective images 📷
5️⃣0️⃣ Best exclusion combo: BNP <100 OR no B-lines ✅

⸻

🔑 Top Performers
•🔥 BEST single positive test: BNP ≥100
•🔥 BEST radiographic test: vascular congestion on CXR
•🔥 BEST rule-out tool: absence of B-lines

⸻

📚 Source:
Drum B, La Course B, Kelly M, et al. Does This Patient Have Volume Overload? JAMA. Published Feb 23, 2026.
DOI: 10.1001/jama.2026.0446

[توفيق مرعى @legendarymen]

@abdulhamid_199 Scleroderma

[توفيق مرعى @legendarymen]

@abw1069 @MwsstBn87306 لا حول و لا قوة الا بالله

[توفيق مرعى @legendarymen]

@MwsstBn87306 [أنا]

[توفيق مرعى @legendarymen]

@MwsstBn87306 الله يسعدك

[توفيق مرعى @legendarymen]

#صورة_جديدة_للملف_الشخصي

[توفيق مرعى @legendarymen]

@abdelhamed012 Can we conisder Classic AntiGBM as Good Pasteur disease ?

[eng mohamed ali @mohamed65676363]

الست الجميله دى
ناشره الفيديو ده عن رد فعل القط بتاعها بعد ما خربشها وبطلت تلاعبه
والله من أجمل الفيديوهات اللى ممكن تشوفها
القطط من أجمل الكائنات ❤️

[CME INDIA @CMEINDIA1]

(CKD): “From Failures to Future Therapies” (Kidney Int Rep, Dec 2025)

1) CKD = public health emergency

Huge prevalence + rising mortality; CV disease drives a major share of deaths → treat CKD as a cardio-renal syndrome, not “only creatinine”.

2) Biggest problem today: Know–Do Gap

Evidence + guidelines exist, yet uptake of proven therapies is low → patients miss kidney & heart protection.

3) Detect early or you can’t treat early

Prioritize case-finding in high-risk groups (DM, HTN, CVD, family history): eGFR + uACR are the minimum “2 tests” for CKD care.

4) RAS blockade remains the foundation

ACEi/ARB (maximally tolerated) for albuminuric CKD: don’t under-dose.

Do not stop for mild creatinine rise; manage the reason (volume, NSAIDs, RAS stenosis risk, etc.).

5) Hyperkalemia is a management issue, not a “stop drug” reason

Prefer K+ strategies (diet review, diuretics, binders like patiromer/SZC) rather than discontinuing RASi.

6) SGLT2 inhibitors = core CKD therapy (beyond sugar)

Kidney + HF/CV protection independent of HbA1c; now central to CKD algorithms.

7) The “eGFR dip” after SGLT2i is usually expected

A small early fall is hemodynamic, not AKI—avoid panic stopping.

Continue unless sustained >30% fall or intolerance.

8) Finerenone (nsMRA) adds residual risk reduction in DKD

Best fit: T2D + CKD with albuminuria (and acceptable K+), on top of RASi ± SGLT2i.

Monitor K+/creatinine after initiation; SGLT2i may reduce hyperkalemia risk when combined.

9) GLP-1RA = metabolic + renal promise

Adds weight/BP/metabolic benefits; kidney benefit signal strengthened by newer outcome data; especially useful when ASCVD/obesity is prominent.

10) ERAs: “proteinuria killers” but watch fluid retention

Endothelin receptor antagonists can reduce albuminuria; safety (edema/HF) + cost are key barriers—combo strategies with SGLT2i are being evaluated.

11) Emerging pipeline: target fibrosis/inflammation/aldosterone

Late-phase trials may expand options → CKD care will become more personalized (who benefits most, who gets side effects).

12) “Rational” therapies can still fail

Example highlighted: urate-lowering for asymptomatic hyperuricemia has not shown consistent CKD-progression benefit → treat urate for gout indication, not “CKD slowing”.

Practical “CME INDIA action line”

✅ CKD = eGFR + uACR + BP + cardio-risk
✅ Triple pillar for DKD (where eligible): ACEi/ARB + SGLT2i + finerenone
✅ Add GLP-1RA when obesity/ASCVD/high metabolic risk dominates
✅ Don’t lose benefits due to fear: manage K+ / educate sick-day rules / avoid premature stopping

Source: Wehbe F, Elliott M, Levin A. CKDs at the Crossroads: From Failures to Future Therapies. Kidney International Reports, Dec 2025.
https://t.co/NbkAsyDVuF

[توفيق مرعى @legendarymen]

@abdulhafiz20111 صوصن

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

Gout Management in Patients With CKD: A Review ca. 2025 from @AJKDonline
#Nephpearls

👉 https://t.co/wUWR7QZDAv

[Dr.Mukesh , MD , DM @dr_immuno29]

🔹 Key Takeaways: Lupus Nephritis Updates (Dr. Manish Rathi, IRACON 2025)

1️⃣ Proteinuria Evaluation
•Use first morning midstream sample 🧪
•Prefer Urine ACR or Urine PCR (KDIGO 2024)

2️⃣ Assess Kidney Early
•Start at disease onset: History, microscopy (look for dysmorphic RBCs, casts), RFT/eGFR, USG KUB, serology & biopsy

3️⃣ 24-Hour Urine Protein
•Gold standard but prone to errors — measure creatinine clearance
•Normal: <20 mg/kg/day (men), <15 mg/kg/day (women)

4️⃣ Non-Immunosuppressive Rx
•All SLE pts need ☀️ Sunscreen + 💊 Hydroxychloroquine

5️⃣ Antiproteinuric Strategy
•RAASi, SGLT2i, MRA (Finerenone), GLP-1 analogues — protect nephrons beyond immunosuppression

6️⃣ RAAS Inhibitors
•Indicated if HTN/proteinuria >0.5 g/day
•Target BP <130/80 mmHg
•❌ Avoid ACEi + ARB combo

7️⃣ SGLT2 Inhibitors
•Reduce proteinuria via glomerular pressure ↓
•Useful even in non-diabetic LN

8️⃣ Finerenone Evidence
•↓ UACR & proteinuria significantly in LN (Kidney Int Rep, Aug 2025)

9️⃣ Weaning Immunosuppression
•Maintain ≥3 yrs CR before tapering
•Gradual withdrawal after 36 months
•🔍 Role of protocol biopsy & tapering sequence under evaluation

🔟 Refractory LN
•Resistant: No response to 1st-line SOC
•Refractory: Persistent activity despite ≥2 different 6-month therapy courses

⸻

✨ “Modern LN care = early detection + renal protection + smart IS use”
#IRACON2025 #LupusNephritis #Rheumatology #SLE #KidneyCare

[MedSprint  @MedSprint]

@Paul_Wischmeyer @DrAkhilX ✅ Answer: Vitamin B1 (Thiamine) deficiency

Explanation:
🔹 Loop diuretics (like furosemide) ↑ urinary excretion of water-soluble vitamins, especially thiamine (B1).
🔹 Long-term use → risk of Wernicke’s encephalopathy in susceptible patients (e.g., heart failure, alcoholics).

[توفيق مرعى @legendarymen]

@HanyBakhit2 مش صح التعميم