Joe Pullara MS, MD

Free speech and bodily autonomy are core principles of a functioning democracy and fundamental values of anyone who values freedom. Either you believe that or you don’t. Don’t let the details distract you from that.

Disillusioning a generation and paving the way for Donald Trump by using his supermajority to break deportation records and drone weddings instead of passing universal healthcare or codifying Roe v. Wade.

@ThePowerAudit What have we won militarily?

Analysis of Iran's 14-point proposal to the US. This proposal is not a negotiation. It is a regime documenting that it "tried peace" before what comes next. Iran's 14-point response was delivered through Pakistan to a US 9-point proposal. The US wanted a two-month ceasefire. Iran demanded 30 days. They are bleeding $170 million daily under the blockade and cannot afford Washington's timeline. First, it demands phased steps toward lifting the naval blockade and releasing frozen assets. Earlier versions demanded full upfront removal. The fact that Iran is already softening its own opening position tells you who has the leverage. Second, it requires a permanent end to the war on all fronts including Lebanon and Yemen. Binding Iran's fate to Hezbollah and the Houthis guarantees US rejection. Third, it insists Iran retains uranium enrichment rights. This directly contradicts Trump's stated war objective that Iran will never have nuclear weapons. Fourth, it declares missile capabilities non-negotiable and rejects any international inspectors. Iran's stated reason is that they consider international inspectors to be spies for Israeli intelligence services. Given that Israel just killed their supreme leader using precise intelligence on his location, this fear is not irrational. But it still closes the door on the one verification mechanism Washington would require. Fifth, it demands US troop withdrawal from Arab countries and the entire region. Sixth, it demands war reparations and compensation from the country currently blockading it. Seventh, it proposes a "new Hormuz system" under Iranian management. Qatar's own FM told Araghchi tonight this deepens the crisis. Meanwhile, Iran's own parliament publicly declared nuclear negotiations banned. Iran's Foreign Minister Araghchi is burning through every back channel he has tonight, calling Qatar, Oman, Pakistan, and Russia. And this proposal was published by Tasnim, the IRGC's media outlet, not through presidential channels. The people negotiating and the people publishing are different factions with different goals. That is what Trump meant by 'disjointed leadership In summary, Iran's proposal asks Washington to give up everything it won militarily in exchange for promises from a regime whose supreme leader is dead, whose navy is destroyed, and whose own parliament contradicts its own foreign minister on live television. The proposal's real audience is Tehran, not Washington.

@LukeGromen @SmokinPowell @TotemMacro @PauloMacro And with enough job cuts, erosion of the “passive bid” from retirement accounts should also become a factor.

@SmokinPowell @TotemMacro @PauloMacro Wait until the first big company cuts their earnings outlook/numbers and says output is going to be constricted because they can’t get certain key inputs That moment is coming soon based on what I am hearing

the comments tell you everything

@realdocspeaks Yes, the norm is max tolerated dose rather than minimum effective dose. This is why the research into “adaptive chemotherapy” is so important. Of course funding of that approach is not a pharma priority. 🙄

One limitation is that pharma never runs trials to determine the lowest dose of a chemo agent that provides similar results with fewer side effects. They run trials to determine the highest tolerated dose.

Yes, mostly true in my experience as well. Although when patients are outliers with atypical disease or clinical course, oncologist discretion comes into play. They also have great discretion when it comes to decisions about when to transition to palliative or comfort only care. An important question is what influence does pharma have on development of national guidelines and on development and/or testing of new therapeutics?

Oncologists will usually use the National Cancer Care Network guidelines to determine what treatment options they recommend. I have worked closely with many oncologists and have never known any to offer or suggest chemotherapy that wasn't recommended by national guidelines.

@CoffeeBlackMD I feel ya. Been there. 👊🏼

It was kind of started as a slow week in the ICU. Busier the last two days. 7 out of the 10 patients I’ve admitted since Wednesday had stage 4 cancer. Two are now dead. One of them was 79 getting platinum based chemo therapy. Gone now. Probably one more tomorrow. The rest I’ll get tuned up and out for more. Look. I know I have some oncologist followers. And I’m not trying to get personal with you . But what the f*ck is this bullshit? I can’t help but feel bitter as a MFer when I’m the one bedside with the crying wife and son today after some hare brained Hail Mary bullsh*t. Hasn’t been an oncologist in sight all weekend. Do these patients even know what the end is going to look like in the hospital? Maybe there is a better way to approach these cases? Hang your chemo. Bill your weekly clinic full of multiple level 5 bills because it’s all toxic effects of the Hope. Get paid the big salary. And leave someone like me to shovel all the dogshit at the end. It’s a moral f*cking hazard. Seems like the decent thing would be to come in and see your patients as they die. And I couldn’t figure out what was eating me this week until tonight. And this just crashed on me. Over me. It pisses me off. I’m venting. Yes. I’m. Venting. And I’ll get over it. But f*ck guys. And that’s it. I get up at 5am on a Sunday. To do it again. For one last day this stretch of 7. You’re welcome.

⭕️Some thoughts on the current state of play on Iran: The next 48 hours will tell us a lot about the diplomatic realities of the Iran standoff. There is no question it is the U.S. that is seeking direct talks right now, not Iran. Tehran remains firm in its demand that the U.S. naval blockade be lifted as a condition to move forward. If that happens, a formal second round of top level direct talks can happen, Iran says. On Friday, the U.S. announced it would dispatch Witkoff and Kushner to Islamabad to try to force the Iranians into semi-formal talks while Foreign Minister Abbas Araghchi is in Pakistan. The Iranians have total disdain for Witkoff and view him as both ignorant of diplomatic processes and totally worthless in his understanding of technical issues. Kushner is viewed by Iran as Israel’s man at the table. Iran does not see any reason to deal with these two without a figure like JD Vance present. Whether Araghchi would participate in a meeting with them, or proximity talks or some secret meeting is unclear, though Iran says for now it’s not happening. Iran is not only focused on the U.S. talks. It is also engaged in a parallel track of talks with its strategic allies, including Russia and China, as well as Oman, a longtime mediator trusted by Tehran. Iran still believes it is likely the U.S. and Israel will resume the war and has indicated it has prepared new forms of retaliatory strikes and other actions, including in the Strait of Hormuz. Its military commanders have said that while the U.S. has moved more military assets into the region during the “ceasefire,” Tehran has also taken this period to prepare its own weapons systems for more fighting. Trump would be taking extreme risks by relaunching the war and the immediate costs will be in the Strait and in the Gulf nations. Iran would also resume missile attacks against Israel. The global economic situation would further deteriorate. And there is no indication more strikes will weaken the Iranian government. Tehran has made clear that capitulation isn’t an option and the idea of a domestic uprising hoped for by the U.S. and Israel has never materialized. The U.S. was caught completely off guard by Iran’s ability to fight on both an asymmetric and symmetric basis and Iran is likely to continue this pattern in the event of resumed attacks.

How the Media Sold a Genocide currentaffairs.org/news/how-the-m…

@DavidBCollum Agree. Complexity~>Efficiency~>Fragility. Simplicity->Redundancy ~>Antifragility.

This is very well said. I have used fragments of this logic at times but the collective rant is excellent. I want to know who the guy speaking is. Anyone know? (BTW-Tainter's "Collapse of Complex Societies" is a must-read book.) x.com/FinancialPhys/…

If Alex Karp had to say the quiet part out loud...

Well reasoned but with some faulty assumptions. 1)“Execute the threat and die” - How does Iran die? History has shown carpet bombing is not effective in such scenarios. This is existential for Iran - they only need to survive. Full US war mobilization with 500k + boots on the ground is not politically possible. Nuclear? Sure - Trump/Hegseth may be that insane but would the military carry such an illegal/immoral order? 2)If Iran does nothing more than hold the Strait, sure it bleeds lost oil revenue but after decades of US sanctions it can withstand that. They can afford to wait. The global economy cannot, 3)Hot escalation (goodbye GCC) in response to US military engagement only speeds up global economic pain and resultant political pressure. Sure US energy sector will reap large profits but that will not come close to offsetting the accompanying stagflation —>depression.

The only cards Iran holds are a suicide card that assumes they can convince the Houthis to enact it too. I do not think they would at this point. I also do not think the US will eliminate the power plants in Iran. Game theory says you don't, not unless you want the destruction of the entire region as mentioned. (there is a devastatingly sad benefit for the US economically long term to this) China is not going to let the IRGC harm them and make them even more indebted to the US by doing it either. The "cards" Iran holds are not actually leverage. It is more of a threatened suicide vest strapped to the region. If I aim the US, I would NOT take out the power plants or attempt to send Iran to the stone age. But if Iran does pull the pin, guess whose oil and LNG just became the hottest commodity in the world? US LNG at $20 JKM. US propane at $1.13/gal delivered ARA. US crude exports at a record 5.2 million barrels a day. That is the position Iran's suicide card actually strengthens. Here is the game theory. Iran has two choices. Execute the threat and die, which makes US energy the strongest card on Earth and hands Trump the strongest hand in a generation. Or do not execute, and keep bleeding revenue through the filter every day the blockade operates. Both branches favor the US. There is no Iranian move that improves Iran's position. A threat where every outcome helps your opponent is not a threat. What sort of leverage is that?

@abcampbell @prieur_simon Yeah

@jmpullara @prieur_simon sounds expensive and inefficient

just a reminder, the VLCCs oil tankers that have been taking crude from Saudi’s east-west pipeline are *too big* to go through the Suez Canal probably a good time to go long Suez-max vs short VLCC before they close “the Bab”

@abcampbell @prieur_simon My understanding is they must partially unload to bring draft down to Suez limits. Offloaded oil transits via SUMED pipeline - i.e. Unload at Ain Sukna then reload Sedi Kerir

@prieur_simon ok interesting, how much reduced capacity? still seems like that would be bullish suez-vlcc spread since the vlcc would be running at lower capacity,no?

Ghost Of Kiev Saves Wounded Airman From Iranians Who Accidentally Shot Down American Planes While Celebrating Regime Change

CNBC: "President Trump has threatened to destroy a civilization. How does an investor process that? Is it a bigger upside risk or downside risk?" What stage of corporate media is this? (h/t @paleofuture)

(Public) The US And Iran Ceasefire And What It Does To The Oil Market hfir.com/p/public-the-u…

Joe Biden financed, armed, diplomatically shielded and militarily protected Israel's genocide in Gaza -- one of the worst crimes of the 21st Century -- but yes, by all means, let's celebrate his renowned and inspirational empathy.

@silver207141 @maneco1964 @EricLDaugh Ah yes. I see you now.

@jmpullara @maneco1964 @EricLDaugh Swallows propaganda? I am not the one who blames America for fundamentalists overthrowing a secular government, darling. Moron assumption verified. MUTE.

🚨 JUST IN: Iran is facing MASSIVE pressure from President Trump, with the USS Tripoli and 3,500 US troops arriving in the region Iran is on Trump time! Surrender and make a deal!

Everyone should stop pretending Donald Trump singularly turned the presidency into a monarchy. Leaders of *both* parties colluded to ignore warnings and give him the power he’s now abusing. It’s annoying that this truth has been memory-holed.

How did the Shah come to power? Who did he replace? How did he rule? Why did Iranians rise up against him? Do you have enough integrity to answer those questions honestly? You seem to claim superior intelligence yet swallow propaganda without question (killed 30,000😂) I’m no fan of any mixing of religion with governance and it’s true that we are qualitatively different. Our constitution notwithstanding, denying that Christian Zionism is playing a large role in driving our Middle East warmongering is another test of intelligence you are failing.

Not understanding this basic differentiation means you have an extremely low IQ or don't mind obfuscating reality with lowbrow meme culture. I will give you the benefit of the doubt and assume you are in fact, a moron. Therefore, I will explain it to you once: Iran is a theocracy because the 1979 Islamic Revolution replaced the secular Shah with rule by Shia clerics. The Supreme Leader holds final power over government, military, and laws, which must follow Islamic principles under "Guardianship of the Islamic Jurist." America is not a theocracy because the Founders wrote the First Amendment to ban any official religion and keep church and state separate. Power comes from the people through a secular Constitution—no clerics, no religious tests for office. One fused religion and state by revolution. The other deliberately separated them to protect liberty.