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1/ Steroids in #COVID19?🧵

N=428. In 1 study we go from
1. statistically significant ⬆️ Deaths w steroids
2. to no difference by adjusting
3. to statistically significant ⬇️ Deaths by subgroup phenotyping of inflammation…

All in the same study? Let’s unpack this...
#MedTwitter Image
2/ Chen et al built on a 2014 @LancetRM study by Dr. Calfee of 1,022 pts, showing that sick people on a ventilator w ARDS (think #COVID19) are of 2 types, 1 of which is Hyperinflammatory (storm of inflammation) who might benefit from drugs like steroids. Image
3/ First Chen tried to overcome the biases associated with their observational data & showed that some observational methods (eg, multivariable regression including baseline SOI) can give the exact wrong answer (HR 1.97) because it does not include temporal biases.
Read 7 tweets
Today's #MyEDSChallenge is about doctors/nurses.
Epidemics, Book I, of the Hippocratic school says to doctors: "Practice two things in your dealings with disease: either help or do not harm the patient". Every chronic illness patient has seen doctors who have violated this. 1/6
First there were the doctors who didn't even bother to see us. Next the ones who saw but didn't care enough to do anything. After that came the ones who didn't know what they were doing but did it anyway, our bodies & minds be damned. 2/6 #MyEDSChallenge #NEISVoid
Later came the doctors who thought they knew best & asked us to not research about our own bodies. We were tossed & turned through CBT & GET repeatedly until our bodies & minds broke. If we are lucky & our stars align, we may find those rare doctors, #MyEDSChallenge #NEISVoid 3/6
Read 6 tweets
What is the most worthless electrolyte on the BMP, and why is it chloride?

A #tweetorial 🧵 to change your mind…

And if you’re thinking, why in the world is this a #neurotweetorial? Read on. #neurotwitter @MedTweetorials
First, this #tweetorial is based on a lecture given in @EmoryNeuroCrit didactics by one of our *awesome* teachers: Dr. Ofer Sadan (@neuro_intensive), and is shared in #tweetorial format w/ his permission.
So, again, why is a #neurologist interested in chloride?

Because neurologists ❤️ giving chloride.

Ur thinking, “No. I have literally never ordered chloride.” … But, think of all the 23.4% and 3% sodium you have ordered.

All that sodium comes with a bystander: Chloride. Image
Read 20 tweets
Im quoted in report on #2DG, drug by #DRDO, marketd by #DRreddys 4 #CovidIndia. Issues R well highlightd by @neutranino in @the_hindu 'Repurposed' use is questionable
This 'approval' doesnt bring ray of hope, but doubts on drug regulation in #india
#2deoxy2glucose is basically glucose molecule in wich 2-hydroxyl group replaced by hydrogen, so that it cannot undergo further glycolysis (which is the metabolic pathway that converts glucose to pyruvate and a hydrogen ion, during which, the free energy released in process... used to form high-energy molecules such as ATP or NADH that helps in various cell functions). So basically, by using 2DG, the normal glycolysis doesnt happen and cell functions get blocked. This is the reason it is used for cancers
Cancer cells depend heavily on glucose...
Read 11 tweets
3rd year of #MedSchool through Schitt's Creek #MedTwitter:
The first day of your first rotation:
What you feel like the attending says every time you answer their questions:
Read 20 tweets
A patient presents with weakness and you're asked to examine their upper limbs. On general inspection you notice that they appear to be sunburnt.

What would you be thinking?

Photos courtesy of @AndreMansoor and @PeteSullivanPDx

#MedEd #Tweetorial
#MedTwitter @MedTweetorials
The neurological examination is all about localising the lesion.

Neurological weakness can be cause by pathology affecting the:
1. Upper motor neuron
2. Lower motor neuron
3, Muscle

Each of these have a different pattern of tone, weakness, reflexes and sensory involvement.
You find symmetric proximal weakness with normal reflexes. This pattern of weakness is a useful clue.

There is a rule of thumb that:
- Proximal weakness -> myopathy
- Distal weakness -> neuropathy

This is because the most of the bulky muscle fibres are proximal.
Read 9 tweets
1/ #COVID19’s “Long Loneliness” was exacerbated by our flawed decision to separate pts from family at just the time they needed each other most. @doctor_oxford has captured the sorrow & pleads for us to come to our senses.
#medtwitter #PalliativeCare
2/ @doctor_oxford ✍🏻: “NHS did its best, but too many were isolated when they needed connxn most, leaving a legacy of deep trauma.” No doubt we dropped them “into Hades.” It was done w benevolent intent but in fear. PPE works & we must adjust visitation humanely.

3/ One daughter who lost her dad said, “Even when they told us they were going to withdraw Dad’s life support, no one from the hospital offered us the chance to come in or suggested a video call or a phone call.” This is flat out wrong at every level & we know it.
Read 4 tweets
1/ Typewriters & Stethoscopes:

Ann Patchett wrote a tantalizing @NewYorker piece on, among other things, tools of the trade. Reflecting on her cherished Hermes 3000 typewriter, my 🧠 wandered to the stethoscope. She ✍🏻

@ParnassusBooks1 @MedBookClub1
2/ “I didn’t need the glasses or silver, things that represented who I thought I’d become but never did, & I didn’t need dolls, which represented who I’d been & no longer was. The typewriter, on the other hand, represented both the person I had wanted to be & the person I am...” Image
3/ “Finding the typewriter was like finding the axe I’d used to chop the wood to build the house I lived in. It had been my essential tool. After all it had given me, didn’t it deserve something better than to sit on a shelf?”

#docswhoread #nurseswhoread
Read 11 tweets
How to identify doctors speciality
1. A Girl shouting on phone with apron pocket full of garbage, restless,irritable ,.........waddling gait.... multiple references to medicine jr
2.Brisk gait,white paste on pants and boot, loud voice,full of attitude,
Self arrogance...hurling abuse to juniors
3. Red stethoscope ,soft spoken,smart,
Calm, polite,generally a big smile,,sweet by nature
Read 10 tweets
Some tips for students & doctors who are keen to get involved in medical research 🔬 and get publications 🚀

A thread 👇


#MedTwitter #MedStudentTwitter

Systematic reviews are a fantastic way to get involved in research:

💻 Only need a computer & internet
👍 No issues with ethics or handling patient data (as analysing literature data)
📙 Follow a standard protocol
👀 No need for a supervisor…

Dont under-rate your work! ✋

Lots of work you do as a student or doctor is potentially publishable/presentable at a conference.

E.g. degree dissertation, audits/QIPs, essay competitions, case studies

Before starting a new project, think about what you've done already
Read 9 tweets
1/ 🧵 What is “Brain Fog” in #COVID19: discussion, papers & pts
 Brain Fog is a non-medical term but it works since it’s what pts describe. Whether in a ward, ICU on a vent, or months later as a #LongHauler w #LongCOVID, they are “in a fog.”

2/ Medically this is #Delirium acutely and #Dementia chronically + various forms of neuropsychological impairment coupled with #depression and #PTSD.
Our paper:
3/ Scientifically, it’s millions of neurons sick, dying or dead. This is depersonalizing & devastating. Fig A shows MRI 3 mos after ICU in pt w/out delirium vs B shows ICU pt w #Delirium. Duration of delirium predicted loss of 🧠 tissue.

Our MRI study -
Read 13 tweets
Perhaps experts publicly sharing their takes on AZ #CovidVaccine can consider a DM group chat. Remember your discourse on this public platform is open to everyone incl. non-experts who are fearful, confused & now feeling betrayed.
To the non-expert public a 🧵for you ⤵️ #COVID19
1) If you're feeling conflicted & having doubts/regrets re: taking the AZ #CovidVaccine esp. after a few comms failures & public expert discourse,
Please read 🧵⤵️, it will help explain what you're seeing & not take it as final word: h/t @thekimgauthier
2) This is an extremely important 🧵 by @MPaiMD who outlines all the things you need to know about the rare but serious side effect of AZ #CovidVaccine: what to look for & what to do if you have the symptoms. L
Read 8 tweets
#TotalTriage is failing patients w/ skin cancers which are often picked up by chance, when examining someone’s back, abdomen, limbs.
The normalisation of management without examination will lead to many more skin cancer diagnoses being delayed or missed.…
#TotalTriage is a “non-holistic” form of medicine, which bares no resemblance to the job I trained to do when I did my vocational training.

@NHSEngland @DHSCgovuk & @MattHancock need to listen to what so many experienced GPs are saying before “embedding” this model further.
Read 4 tweets
I challenge ur narrative tat alternative medicine works
It doesnt/#neem studies tat u keep quoting, are NOT peer-reviewed, NOT published/has been collecting dust in preprint server since Apr 2020
Tis makes ur argument invalid
But #science is kind, so lets discus
2 This is UR molecular docking study u uploaded to preprint. Y was this never published? Bcoz this is highly flawed from methods to results to conclusions. Molecular docking was blind - hence ligand optimization is not accurate...
...and grid coordinates wer computer generated. Hw did u correct for tis? U cud hav used predicted binding sites 2 improve accuracy/efficiency…
Predicted binding sites 4 #SARSCoV2 is widely published/ use of grid-based docking wud be better...
Read 14 tweets
Okay. Initially bit my tongue but after seeing this for a 2nd time, let's have it.

This ego-driven, self-adulating, horseshit of an excuse for comedy will likely prevent more vaccinations than it produces. Why?

B/c the vaccine-hesitant are not anti-vaxxers. 🧵/1
Simply put, imagine going to a doctor's office and expressing concern about the vaccine, or a treatment, or a procedure. - "Doctor, I'm a little nervous about the side effects."

"JuSt ShUt ThE F**k Up AnD dO iT!"

Forget about poor messaging, it's straight up unprofessional. /2
While there are those who no doubt will never vaccinate, they are fractious group. Beliefs towards vaccination are on a spectrum, not an on/off switch, and lumping them all together is a surefire way to deter those open to changing their minds. /3…
Read 6 tweets
Whole premise of #2deoxy2glucose is based on this SINGLE computational proteomics study…
No human trials until nw
1 of 'targets' hypothesized in reviews…
Last human trials on this molecule is from 1982-2007
@drcheruvarun @pash22
'Hypothesis' #Covid19 promot defective glucose metabolism (shown in controversial study never clinically proven tho. Low-glucose mimetic (2DG) reduces tis, wit additional anti inflammatory/interaction wit viral proteins - again, cell study
The anti-inflammatory/antiviral effect is thot 2 B due to glucose switching of 2GD - reversal of aerobic glycolysis to oxidative phosphorylation - is also in-silico study - not comprehensively shown in cell models.…
@drreddys jumped the gun quickly.
Read 6 tweets
CELLS in Hemat 💪🏻

Sickle cell=Drepanocyte➡️SCD
Tear drop=Dacrocyte➡️MF
Spur cell=Acanthocyte➡️Liver ds
Burr cell=Echinocyte➡️Uremia/PK def
Target cell=Codocyte➡️Hb'pathies
Bite cell=eccentrocyte➡️G6PD def
Pencil cell=ovalocyte➡️IDA
Pincered cell➡️Band 3 def
Prickle cell➡️PK def
Sickle cells, not hard to identify.
Can't miss these isn't it ?
Read 9 tweets
A little thread hypothesising why some of the beliefs about science can be polarising in the misinformation world (with some sneaky underpinnings of research paradigms).

#MedTwitter #MedEd #NurseTwitter #FOANed #FOAMed White text on black background reads: “Why do we have such
Some of the challenges around misinformation and the conflict surrounding responding to hot topics is all about world views. In research world we call this paradigms.
What this means is that there is a set of agreements about how a problem is be viewed - a set of assumptions and beliefs. The nuance here is that this worldview CHANGES the interpretation and/or weight of the problem or data.
Read 15 tweets
Updated guide from the @COVIDSciOntario to Vaccine-Induced Immune Thrombotic Thrombocytopenia #VITT Following Adenovirus Vector COVID-19 Vaccination!
Thank you for this lay summary! @MPaiMD
Key takeaways 🧵⤵️ 1/ #science #MedTwitter #scicomm #COVID19 #COVID19Vaccine
▶️ Blood clots can occur 4 to 28 days post 💉 & associated w/ ⬇️ platelets
▶️ These clots...are more aggressive and are more likely to cause death or severe disability...
▶️ Rate of VITT in Canada has been estimated to be ~1/ 100k doses 2/
Re: contraindication: It may be possible... people with a history of HIT or CSVT w/ ⬇️ platelets are at ⬆️ risk of VITT; they should receive an mRNA vaccine (Pfizer or Moderna) rather than an adenoviral vector vaccine. 3/
Read 8 tweets
Medical specialties as Pokemon, a thread. Yep. Another one of these.

..gotta catch em all...

1) Allergy/Immunology - Vileplume

An expert on poisons and dangerous dust, these creatures are ones to go to on anything red, itchy, and a little bit feverish.

Strengths: sedation, immune suppression
Weaknesses: sedation, immune suppression, microbiologists
2) Anesthetics - Drowzee

This wild beast excels at knocking out its enemies. Often found sleepy itself, it relies on caffeine and datix to stay awake

Strengths: sleep power, cannulation
Weaknesses: consciousness, conversation, nephrology
Read 23 tweets
This second wave of Covid associated Mucormycosis has been a brutal bloodbath

Have seen 18 cases in the last 10 days in Bangalore. If there's anything lose to black death, this fungal disease should be it

A pandemic within a pandemic

#MucorMycosis #COVID19 #India #MedTwitter
This tweet was just a week back and now the situation is pretty bad.

We did see post covid Mucormycosis in the first wave but this time round it is nothing like we have seen till now.

Read 4 tweets
1/ #Sleep & #Dementia: @NatureComms
Study of ~8,000 people followed for 25 years! Look at the figures. Sleeping <7 hrs per night chronically increases risk of dementia by 30%.  Get your sleep!

#MedTwitter #MedEd #Geriatrics
2/ Sleep and Dementia Risk: @nytimes

@PamBelluck wrote a great article on this NatureComm paper showing heightened risk of #dementia for “short-sleepers,” defined as <7 hrs of sleep a night.

#Aging #Delirium
3/ What’s the Mechanism?

Our brain’s “trash” clearance (like the body’s Lymphatic system but by brain’s “glial” cells & called Glymphatics) kicks into ⬆️ gear in sleep. So less sleep is like your waste management system going on strike. Kapische??

Read 5 tweets
3 years ago, I was being put to sleep before surgery & while I knew everyone in the OR, I was frightened. I was fighting back tears on the table.

Today, a patient gushed to my attending that a fellow held her hand before falling asleep

A thread 🧵1/
The patient said that she normally doesn't get scared. She works in healthcare. She's seen it all. But something about being alone, naked, while people mill about you without seeing YOU was scary.

I know, I felt it too. I felt childish asking someone to hold my hand.
I asked her where she'd be going during her "anesthesia holiday", to which she replied a beach🏖️. No friends. No family. A few books📚. Teeny, tiny bikini👙. Mai tai's.

My attending smiled & said, "you realize the fellow who held your hand is Dr Muldoon"
Read 12 tweets
Rheumatology Association of Gujarat has issued guidelines regarding role of immunomodulators in #COVID19 Attaching a summary here:

#MedTwitter #Immunology Image
DM for full version
Read 4 tweets

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