First I recall time served on the inpatient Cardiology service in residency. Then we review the evidence for salt and fluid restriction in acute and chronic heart failure. 

 Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013 Jun 24;173(12):1058-64. 

Herrmann JJ, Brunner-La Rocca HP, Baltussen LEHJM, Beckers-Wesche F, Bekkers SCAM, Bellersen L, van Eck JWM, Hassing HC, Jaarsma T, Linssen GCM, Pisters R, Sanders-van Wijk S, Verdijk MHI, Handoko ML, van der Meer P, Verbrugge FH, Januzzi JL Jr, Bayés-Genís A, Nieuwlaat R, Rodwell L, Gommans DHF, van Kimmenade RRJ. Liberal fluid intake versus fluid restriction in chronic heart failure: a randomized clinical trial. Nat Med. 2025 Jun;31(6):2062-2068. 

Hsu SM, Lin YH, Lin YC, Liu SJ, Liu CJ, Hung CL, Wang TJ. Fluid intake impact on heart failure: Systematic review and meta-analysis with trial sequential analysis. J Formos Med Assoc. 2025 Jul;124(7):650-659. 

Mullens W, Damman K, Dhont S, Banerjee D, Bayes-Genis A, Cannata A, Chioncel O, Cikes M, Ezekowitz J, Flammer AJ, Martens P, Mebazaa A, Mentz RJ, Miró Ò, Moura B, Nunez J, Ter Maaten JM, Testani J, van Kimmenade R, Verbrugge FH, Metra M, Rosano GMC, Filippatos G. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail. 2024 Apr;26(4):730-741. 

Urban S, Fułek M, Błaziak M, Fułek K, Iwanek G, Jura M, Grzesiak M, Szymański O, Stańczykiewicz B, Ptaszkowski K, Zymlinski R, Ponikowski P, Biegus J. Role of dietary sodium restriction in chronic heart failure: systematic review and meta-analysis. Clin Res Cardiol. 2024 Sep;113(9):1331-1342. 

More salt! Wait, less salt. Or at least the management of less salt. Let's review the evidence supporting the management of hyponatremia (or not)...

Aegisdottir H, Cooray C, Wirdefeldt K, Piehl F, Sveinsson O. Incidence of osmotic demyelination syndrome in Sweden: A nationwide study. Acta Neurol Scand. 2019 Nov;140(5):342-349.

Ayus JC, Moritz ML, Fuentes NA, Mejia JR, Alfonso JM, Shin S, Fralick M, Ciapponi A. Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2025 Jan 1;185(1):38-51. 

Chander S, Kumari R, Lohana AC, Rahaman Z, Parkash O, Shiwlani S, Mohammed YN, Wang HY, Chi H, Tan W, Kumar SK, Sindhu F. Urea to Treat Hyponatremia Due to Syndrome of Inappropriate Antidiuretic Hormone Secretion: A Systematic Review and Meta-Analysis. Am J Kidney Dis. 2025 Mar;85(3):303-319. 

Falhammar H, Andersson Franko M, Lindh JD, Skov J, Mannheimer B. Neurologic and psychiatric disorders following correction of profound hyponatremia - A cohort study. Eur J Intern Med. 2025 Oct;140:106394.

Krisanapan P, Vongsanim S, Pin-On P, Ruengorn C, Noppakun K. Efficacy of Furosemide, Oral Sodium Chloride, and Fluid Restriction for Treatment of Syndrome of Inappropriate Antidiuresis (SIAD): An Open-label Randomized Controlled Study (The EFFUSE-FLUID Trial). Am J Kidney Dis. 2020 Aug;76(2):203-212. 

Refardt J, Imber C, Sailer CO, Jeanloz N, Potasso L, Kutz A, Widmer A, Urwyler SA, Ebrahimi F, Vogt DR, Winzeler B, Christ-Crain M. A Randomized Trial of Empagliflozin to Increase Plasma Sodium Levels in Patients with the Syndrome of Inappropriate Antidiuresis. J Am Soc Nephrol. 2020 Mar;31(3):615-624. 

Refardt J, Imber C, Nobbenhuis R, Sailer CO, Haslbauer A, Monnerat S, Bathelt C, Vogt DR, Berres M, Winzeler B, Bridenbaugh SA, Christ-Crain M. Treatment Effect of the SGLT2 Inhibitor Empagliflozin on Chronic Syndrome of Inappropriate Antidiuresis: Results of a Randomized, Double-Blind, Placebo-Controlled, Crossover Trial. J Am Soc Nephrol. 2023 Feb 1;34(2):322-332. 

Rondon-Berrios H. Diagnostic and Therapeutic Strategies to Severe Hyponatremia in the Intensive Care Unit. J Intensive Care Med. 2024 Nov;39(11):1039-1054.

Seethapathy H, Zhao S, Ouyang T, Passos C, Sarang A, Cheung PW, Waikar SS, Steele DJR, Kalim S, Allegretti AS, Ayus JC, Nigwekar SU. Severe Hyponatremia Correction, Mortality, and Central Pontine Myelinolysis. NEJM Evid. 2023 Oct;2(10):EVIDoa2300107.

Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, Orlandi C; SALT Investigators. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med. 2006 Nov 16;355(20):2099-112. 

Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E; Hyponatraemia Guideline Development Group. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014 Feb 25;170(3):G1-47. 

Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. 

This spring is all about salt!!! In part 1 I relive the saltiness of the emergency department while I was in residency and then get super nerdy about the pathophysiology of hyponatremia. 

Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. 

Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E; Hyponatraemia Guideline Development Group. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014 Feb 25;170(3):G1-47. 

First there is more fun on the Oncology service to be had by all. Then we discuss a landmark trial assessing the benefit of exercise as adjunctive therapy for colon cancer.

Most pertinent articles:

Bozzetti F. Potential Benefits from Physical Exercise in Advanced Cancer Patients Undergoing Systemic Therapy? A Narrative Review of the Randomized Clinical Trials. Curr Oncol. 2024 Dec 1;31(12):7631-7646. 

Courneya KS, Vardy JL, O'Callaghan CJ, Gill S, Friedenreich CM, Wong RKS, Dhillon HM, Coyle V, Chua NS, Jonker DJ, Beale PJ, Haider K, Tang PA, Bonaventura T, Wong R, Lim HJ, Burge ME, Hubay S, Sanatani M, Campbell KL, Arthuso FZ, Turner J, Meyer RM, Brundage M, O'Brien P, Tu D, Booth CM; CHALLENGE Investigators. Structured Exercise after Adjuvant Chemotherapy for Colon Cancer. N Engl J Med. 2025 Jul 3;393(1):13-25. 

Feng Y, Feng X, Wan R, Luo Z, Qu L, Wang Q. Impact of exercise on cancer: mechanistic perspectives and new insights. Front Immunol. 2024 Sep 13;15:1474770. 

Zylstra J, Whyte GP, Beckmann K, Pate J, Santaolalla A, Gervais-Andre L, Russell B, Maisey N, Waters J, Tham G, Lagergren J, Green M, Kelly M, Baker C, Van Hemelrijck M, Goh V, Gossage J, Browning M, Davies A. Exercise prehabilitation during neoadjuvant chemotherapy may enhance tumour regression in oesophageal cancer: results from a prospective non-randomised trial. Br J Sports Med. 2022 Apr;56(7):402-409. 

Join me as I first discuss annoying people, followed by a lot of annoying Medicine.

Bajaj JS, Pyrsopoulos NT, Rahimi RS, Heimanson Z, Allen C, Rockey DC. Serum Ammonia Levels Do Not Correlate With Overt Hepatic Encephalopathy Severity in Hospitalized Patients With Cirrhosis. Clin Gastroenterol Hepatol. 2024 Sep;22(9):1950-1952.e1.

Carlberg B, Samuelsson O, Lindholm LH. Atenolol in hypertension: is it a wise choice? Lancet. 2004 Nov 6-12;364(9446):1684-9. 

Espinel CH. The FENa test. Use in the differential diagnosis of acute renal failure. JAMA. 1976 Aug 9;236(6):579-81.

Hirota T, Fujita Y, Ieiri I. An updated review of pharmacokinetic drug interactions and pharmacogenetics of statins. Expert Opin Drug Metab Toxicol. 2020 Sep;16(9):809-822.

Osa-Andrews B, Sanchez M, Hashim IA. The Continued Need for the Routine Assessment of Folate Status. Lab Med. 2023 Jul 5;54(4):424-428.

Pan HC, Jiang ZH, Chen HY, Liu JH, Chen YW, Peng KY, Wu VC, Hsiao CC. Assessing the utility of fractional excretion of urea in distinguishing intrinsic and prerenal acute kidney injury in hospitalised patients: a systematic review and meta-analysis. BMJ Open. 2026 Jan 14;16(1):e100875.

Ripley TL, Saseen JJ. β-blockers: a review of their pharmacological and physiological diversity in hypertension. Ann Pharmacother. 2014 Jun;48(6):723-33.

Sobczyńska-Malefora A, Harrington DJ. Laboratory assessment of folate (vitamin B9) status. J Clin Pathol. 2018 Nov;71(11):949-956. 

Varghese V, Rivera MS, Alalwan A, Alghamdi AM, Ramanand A, Khan SM, Najul-Seda JE, Velez JCQ. Concomitant Identification of Muddy Brown Granular Casts and Low Fractional Excretion of Urinary Sodium in AKI. Kidney360. 2022 Jan 19;3(4):627-635.

Wiysonge CS, Bradley HA, Volmink J, Mayosi BM, Opie LH. Beta-blockers for hypertension. Cochrane Database Syst Rev. 2017 Jan 20;1(1):CD002003.

After arguing that Geriatrics really is a worthy subspecialty, I recount all of the poop I just can’t get away from… even after the patient is technically dead… Then prepare to be bombarded by the mounting evidence against and festering frustration with fecal occult blood tests being used just for funzies.

Lee MW, Pourmorady JS, Laine L. Use of Fecal Occult Blood Testing as a Diagnostic Tool for Clinical Indications: A Systematic Review and Meta-Analysis. Am J Gastroenterol. 2020 May;115(5):662-670. 

Bhatti U, Jansson-Knodell C, Saito A, Han A, Krajicek E, Han Y, Imperiale TF, Fayad N. Not FIT for Use: Fecal Immunochemical Testing in the Inpatient and Emergency Settings. Am J Med. 2022 Jan;135(1):76-81.

Román-Colón D, Rodriguez-Ramos R, Cerra-Franco J, De Jesús-De La Cruz H, Mirza ZT, Cepero-Jimenez C, Ramos-Marquez R, Martinez-Souss J, Toro DH. The Use of the Fecal Immunochemical Test in the Acute-Care Hospital Setting. P R Health Sci J. 2025 Dec;44(4):189-194.

After exploring the healing powers of dog saliva we dig into some evidence about one of the most common diagnoses we see in clinic and the hospital--cellulitis. It may be simple, but it's far from easy.

Prevalence of misdiagnosis of cellulitis: A systematic review and meta-analysis. J Hosp Med. 2023 Mar;18(3):254-261. 

 Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis. J Gen Intern Med. 2023 Aug;38(10):2396-2404. 

 A predictive model for diagnosis of lower extremity cellulitis: A cross-sectional study. J Am Acad Dermatol. 2017 Apr;76(4):618-625.e2. 

The Natural History of Antibiotic-Treated Lower Limb Cellulitis: Analysis of Data Extracted From a Multicenter Clinical Trial. Open Forum Infect Dis. 2023 Sep 29;10(10):ofad488. 

 Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med. 2020 Aug 13;383(7):630-639. 

 Risk of Infection in Older Adults With Type 2 Diabetes With Relaxed Glycemic Control. Diabetes Care. 2024 Dec 1;47(12):2258-2265. 

What's worse than bleeding relentlessly out of your butt because you're on oral anticoagulation for your afib and antiplatelet therapy for your cardiovascular disease? An intracranial hemorrhage for the same reason! But the times they are a changin'. Today we follow a personal journey of bleeding by Dr. Sam's dad. And then we review 4 RCTs that prove it never should have happened.

OAC-ALONE Study Investigators. Open-Label Randomized Trial Comparing Oral Anticoagulation With and Without Single Antiplatelet Therapy in Patients With Atrial Fibrillation and Stable Coronary Artery Disease Beyond 1 Year After Coronary Stent Implantation. Circulation. 2019 Jan 29;139(5):604-616. 

AFIRE Investigators. Antithrombotic Therapy for Atrial Fibrillation with Stable Coronary Disease. N Engl J Med. 2019 Sep 19;381(12):1103-1113.

EPIC-CAD Investigators. Edoxaban Antithrombotic Therapy for Atrial Fibrillation and Stable Coronary Artery Disease. N Engl J Med. 2024 Dec 5;391(22):2075-2086. 

AQUATIC Trial Investigators. Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation. N Engl J Med. 2025 Oct 23;393(16):1578-1588. 

After exploring some of humankind's basest instincts we delve into the true benefits and risks of testosterone therapy for older hypogonadal men, and are left feeling impotent...

Main publications:

Cardiovascular Safety of Testosterone-Replacement Therapy. N Engl J Med. 2023 Jul 13;389(2):107-117.

Effects of Testosterone Treatment in Older Men. N Engl J Med. 2016 Feb 18;374(7):611-24.

And a whole lot more...

What's more fun than public displays of urination? Discussing the benefits and risks of SGLT2 inhibitors! Then we review a recent article that tries to answer the question everyone has on their minds these days, is it safe to restart the SGLT2i after my patient has a UTI? And fails miserably...

Urinary tract infection and continuation of sodium-glucose cotransporter-2 inhibitors in diabetic patients. Wu MZ, et al. Eur Heart J. 2025. PMID: 41104542 

Social media is BUZZING about this article for all the wrong reasons! Reader beware!