Discover and read the best of Twitter Threads about #Tweetorial

Most recents (24)

So, I suspect most don't really get what the big deal is in not reporting the primary outcome of a trial before commencing the trial, so here's a short #tweetorial..
So, let's say you're a competitor in a shooting contest, how do you measure your success? That's right - a target
Similarly, in clinical trials one starts with a target - aka primary endpoint. Generally this is the outcome of the trial you want to measure. These outcomes differ based on the kind of trial being planned. E.g. if we were planning a heart failure trial, some outcomes we might..
Read 14 tweets
I frequently say on rounds, “Giving a dose of amikacin is both a treatment and a diagnostic test for gram negative infection”

People just nod sagely & we move on

But am I right?

Time for a WHO, WHAT, WHERE, WHEN, WHY #tweetorial 🧵

#FiveW /1
WHEN should we use amikacin?

Well, it’s probably the best empirical choice for treatment of suspected gram -ve infections as it has wide activity across Enterobacteriaceae (e coli, klebs etc), pseuds & mycobacteria, and interestingly many staphs & TB /2
WHERE in the cell does amikacin work?

Well the answer is “kind of everywhere”

Downstream effects at the membrane allow more amikacin in to the cell do its primary work

A lot of the uptake steps are electron transport dependent hence why it doesn’t work against anaerobes /3
Read 8 tweets
A #tweetorial on proton pump inhibitors (PPIs)

Just for fun, which drug class is archetypal of a gastroenterologist? 😉

1/
2/
PPIs would be my pick!

The advent of these potent and effective acid suppression medications led to a paradigm shift in the mx of many GI conditions

The market for PPIs is MASSIVE! Just the projected 5 year growth from 2018 - 2023 estimated to be $3.24 billion!
3/
So how do #PPIs work?

A reminder on physiology: this class of drug acts on the gastric parietal cells by irreversibly blocking the hydrogen/potassium adenosine triphosphatase enzyme system (the H+/K+ ATPase, aka the gastric proton pump), hence the elegant name
Read 21 tweets
A #tweetorial #medtweetorial
@MedTweetorials

1/
3 AM: Pager Pager Pager

Me [very groggily]: Hey, what’s up?

Awesome overnight APP: Sorry to wake you! But, Mrs. Very-Small-Stroke-NIHSS-2-Had-Been-Clinically-Stable-All-Day just PEA arrested.

Me [not so groggily]:
2/
Awesome APP: We successfully got ROSC (bc team
@emoryneurocrit
= Flexed bicepsStar-struck) and have him stabilized. Going to scan now!

So, #neurotwitter, where’s the lesion?
3/
Trick question.

All of these areas through neurologic pathology – stroke/seizure/bleed - could all have caused a sudden death (or at the very least sudden LOC).
Read 24 tweets
Genetic testing: there are so many tests to choose from! Karyotype, Microarray, Whole exome sequencing, they all sound the same. What's the difference? Read on and hopefully things will become clear... 🧵
#meded #tweetorial #medgen
First, let's remember that our DNA is found in really nice organized packages called chromosomes. Humans have 23 pair of chromosomes = 46 in total. Each chromosome has a short arm (p=petit) and a long arm (q=comes after p).
Genes are segments of DNA where each codes for a specific protein.

Genes are found along chromosomes in a predictable location and order. For example, the CFTR gene is found on the long arm of chromosome 7 in all humans.
Read 21 tweets
What does a nephrologist need to know about stem cell transplants?🤨🤯

A little #tweetorial for the nephrologist on hematopoietic stem cell transplants (HSCT) and AKI
Incidence of AKI has a wide range of 15-73% of HSCT patients.

Why the wide range? Depends on type of transplant, conditioning, primary disease, age, etc

➡️💉So we do need to know a little heme.....

pubmed.ncbi.nlm.nih.gov/25386344/
pubmed.ncbi.nlm.nih.gov/31285665/
Stem cells come from the🧍patient (autologous) or 🧑‍🤝‍🧑 someone else (allogenic).

Sources:
📌peripheral blood (PB)
📌bone marrow (BM)
📌umbilical cord (UC)

Cells are collected via apheresis, stored, infused when a pt's own marrow is depleted with conditioningregimen +/- radiation
Read 20 tweets
I'm going to share my approach to taking a history from a multimorbid medical patient.

This is the approach I learnt preparing for my #RACP long case.

I start with an open-ended question. "What medical conditions do you have?"

#MedEd #Tweetorial
#MedTwitter @MedTweetorials
Patients will list a number of medical conditions.

In order to prioritise, I ask "Which one of these is most important to you right now?"

I find this a useful way to develop a shared agenda.
In the long case, you're also given the medication list to review.

This can be a clue to further risk factors or medical conditions that have been overlooked on the initial screen.

For example:
- Antiresorptives -> OP
- Antiplatelets -> IHD/CVA/PVD
- Antifailures -> CHF
Read 9 tweets
1/15 Hey #medtwitter! Have you caught our latest case for the month of April??Check it out 👉🏼

renalfellow.org/2021/04/23/ske…

🏁🏁Let’s Fill in the Gap together with a #tweetorial !

#NMSC #Nephtwitter #FOAMED @TheskeletonKG @NSMCInternship

#covid19 #acidbase
2/15
A 50-year-old man with DM on oral medications presented with respiratory distress and shock. He was diagnosed with #COVID-19 and ARDS requiring intubation. Labs are shown below 👇🏼

🤔🧐

🛑What would be your next step❓❓❓
3/15 You order an ABG:

ABG:
pH 7.14
pCO2 38.8 mmHg
pO2 80 mmHg
Bicarbonate: 16 mmol/L

My Approach:

⚡️pH acidemic or alkalemic ?

⚡️pCO2 respiratory or metabolic?

nephsim.com/acid-base/ h/t @jadav_md for the infographic
Read 15 tweets
What are your pearls for assessing the mechanism & severity of #mitralregurgitation by #EchoFirst?

#JACCIMG presents an imaging-based curriculum to review functional #mitralvalve regurgitation for #CardioTwitter.

Follow/share this #Tweetorial! (1/15) bit.ly/3gw5MZ2
#JACCIMG Tweetorial Mitral regurgitation (2/15)

Case 1: What is the pathology shown?
JACCIMG #Tweetorial (3/15)

Shown is an example of flail leaflet of the #mitralvalve at the P2 segment.

Surgical #mitralvalve repair is the gold standard; due to prohibitive risk, the patient underwent successful percutaneous repair #TMVR, guided by 3D #EchoFirst.
Read 15 tweets
1/

WHY is there a BABOON in my room?

A #tweetorial about the outcomes of hepatic coma, how far we have come, and how wild things got along the way
#livertwitter
2/

Up first: the lingo

Hepatic encephalopathy (HE) presents as a spectrum with subtle cognitive/motor deficits at one end (AKA "Covert HE") and coma at the other

HE/Coma can be caused by #cirrhosis (Type C, more common) and acute liver failure (Type A)
3/

What used to (1950s/60s) happen to patients with coma due to hepatic encephalopathy ("HE coma")?

1⃣Gabuzda said everyone died
2⃣Sherlock said it was 68% mortality, Stormont 63%
3⃣Prytz said it was 80% mortality at 6-months
Read 22 tweets
A #tweetorial on non-variceal upper gastrointestinal bleeding #NVUGIB

And an overview of why we do what we do

To warm up, which of the following is the most common cause of NVUGIB?

#gitwitter #livertwitter #medtwitter #MedEd

1/
2/

PUD it is...

Btw wt do we mean by "upper"?

This is defined as a bleeding source proximal to the Ligament of Treitz, also known as the suspensory muscle of duodenum, the landmark that separates the duodenum & jejunum Image
3/
Back to PUD, there are actually many well established causes and some associated factors related to its development, the most important being:

💊 Drugs - NSAIDs/aspirin, direct chemical/erosive agents etc
🦠 Bugs - H. pylori
♋ Thugs (if I may) - Neoplasm Image
Read 25 tweets
#Tweetorial estadístico #2🧵

⚠️Mitos y realidades sobre los modelos lineales

Un investigador desea investigar la relación entre una variable continua Y y las variables X1, X2 y X3. Se decide usar un modelo de regresión lineal múltiple

¿Cuál NO🚫es un supuesto del modelo?

1/n
La normalidad de variables no🚫es requisito para regresión lineal

✅El supuesto es de normalidad de los RESIDUOS/errores
✅Residuos de una regresión son la diferencia entre el valor predicho por el modelo y el valor real
✅Variables no normales pueden dar residuos normales

2/n
Cuando no🚫se cumple el supuesto de normalidad de los errores hay varias formas de solucionarlo

✅Transformación de variables para asegurar simetría de la distribución
✅Bootstrap para calcular intervalos de confianza
✅Usar regresión cuantílica
✅Corregir otros supuestos

3/n
Read 16 tweets
Our paper on antibody & memory B cell responses to SARS-CoV-2 #mRNA vaccines is out @SciImmunology

- 1 vs. 2 doses?
- What about age & side effects?
- Relationships btw/ antibody & memory cells?

We look at all that & more... full #Tweetorial below 💉🧵

immunology.sciencemag.org/content/6/58/e…
As others (including @florian_krammer @Daltmann10 etc) have shown, folks who have recovered from COVID only need 1 dose to get peak antibody responses to full-length spike protein and the RBD. People who are SARS-CoV-2 naive need 2 doses for optimal responses
Similar data for neutralizing ability against wild-type (D614G) strain & the B.1.351 (S African) variant

2nd dose especially important in people w/o prev infx... 50/50 on neutralizing antibody against D614G & very little against B.1.351 after dose 1. Great response after dose 2
Read 10 tweets
A lot of talk about #CVST Rare to have neuro in the news, so here's a quick #neurology #Tweetorial on cerebral venous sinus thrombosis.

#MedEd #MedTwitter #neurotwitter @CPSolvers @rabihmgeha @DxRxEdu #EndNeurophobia
I will focus on the condition/neurology, not the possible association w/vaccine or hematology. I leave that to experts like @shemarmoore and her excellent thread here:
First, what are the cerebral venous sinuses?

They are the final pathway of venous drainage from the brain into the jugular veins.

They are formed from folds in the dura.
Read 16 tweets
1/ #NYACP #Tweetorial
#MedTwitter, let’s start with a ❓

56 yo man with type 2 diabetes mellitus and CAD for 7 years has a A1C 8.0%, and albumin:creatinine ratio 300. Which add-on diabetes med will have a protective effect on his cardiac comorbidities?

@MedTweetorials
2/ That’s right- Canagliflozin!

In this tweetorial we address: Why are we optimistic about SGLT2 inhibitors?

♦️ The -flozins let glucose “flow out: of proximal convoluted tubules of nephrons
♦️ Half of filtered glucose is excreted- more than 💯g in T2DM patients
#flozinate PMID: 26137213
3/ Okay, they work for T2DM. But so do all7⃣of our first line agents! Why all the hype?

SGLTi also:

✅ ⬇️ risk of cardiovascular mortality in chronic and decompensated failure
✅ Slow progression of diabetic and non-diabetic kidney disease
✅ Induce weight loss ⚖️ PMID: 31290126
Read 12 tweets
Time for another #MedTwitter #Tweetorial on murmurs.

You're examining a patient presenting with SOB. You get to the chest and you hear a blowing holosystolic murmur.

Now what?

@MedTweetorials
Consider the most common causes of a holosystolic murmur
- Mitral regurgitation
- Tricuspid regurgitation
- Ventricular septal defect
Response to manoeuvres is a useful point of distinction
- Louder on inspiration -> TR
- Louder on handgrip -> MR
- Louder on valsalva - HCM
Read 10 tweets
⏳for another #tweetorialERA 🥳 @HDiniz_

➡️Native kidney biopsy plays a crucial role in the diagnosis of many conditions and, while generally safe, can be associated with bleeding complications.

Would you biopsy a patient with aspirin exposure?🤔
Bleeding complication rates are low, with less than 2% of patients requiring transfusion and less than 0.5% requiring an intervention to control the bleeding.

⚠️These complication rates are higher in hospitalized patients and those with AKI.

cjasn.asnjournals.org/content/15/11/…
But not every patient has the same risk of bleeding 🩸

Risk factors include anemia, thrombocytopenia, frailty index, obesity, comorbidities, and kidney function.

cjasn.asnjournals.org/content/15/11/…
Read 15 tweets
1/ 🧵

Why can propofol infusion at high doses cause Propofol-related Infusion Syndrome (PRIS)?

To understand why we have to revisit the old adage of supply and demand.

#Tweetorial #MedTwitter
2/
Propofol is a sedative-hypnotic developed in the 1970s.

PRIS was first described in the late 1980s when several children had cardiovascular collapse and severe bradyarrythmias while on propofol.

🔑They all had received extended, high-dose infusions.

ncbi.nlm.nih.gov/pmc/articles/P…
3/
Subsequent case descriptions found that patients who developed PRIS also had:

❤️Severe rhabdomyolysis and diffuse skeletal and cardiac muscular necrosis
❤️Hypertriglyceridemia
❤️Lactic acidosis
❤️Multiorgan failure

Kids seem to be more susceptible.

pubmed.ncbi.nlm.nih.gov/10759487/
Read 18 tweets
#tweetorial: basic SVT Dx for those new to EP. Differentiate atypical AVNRT from AVRT. By no means complete, meant as an introduction #EPeeps #SVT @YoungDgk

1⃣ Go by a standard every time. Include programmed A and V pacing, to catch if the patient has dual AVN properties.
2⃣ why specifically aAVNRT vs AVRT? Because typical AVNRT is easy, it looks like this.

3⃣ A septal VA > 70ms is the harder differential diagnosis because it can be 3 things.

@DrBradleyKnight
4⃣ don't miss out on valuable observations BEFORE you even see the tachy. Include programmed ventricular pacing in your standard approach to SVT, so you catch non-decremental conduction (also in reference to 1⃣).
Read 8 tweets
Time for a #POCUS #tweetorial on optimization of Doppler. Very important for #VExUS enthusiasts. #MedEd
1/ Unlike greyscale imaging which depends on amplitude of the returned signal, Doppler depends on frequency information. This graphic explains why perpendicular angle is bad.
2/ other way of saying this, in relevance to color Doppler #POCUS
RBC moving away from the probe = Fr<Ft = negative Doppler shift = Blue color
RBC moving towards = Fr>Ft = positive Doppler shift = Red color
Rest of the images/videos from this excellent paper: pubs.rsna.org/doi/10.1148/rg…
3/ Anatomy (components) of a spectral Doppler waveform (carotid shown)👇
Above baseline is like red on color (towards probe), below = blue. As 0 degree angle is not always possible, <60 is considered OK.
Read 19 tweets
1/ Thought of doing a quick #tweetorial on image acquisition for #POCUS friends starting to do #VExUS
It's kind of "how I do it" guide and not necessarily optimized for research.
1st: Look at the IVC in both long and short axes
If big, do further scans 👇 #MedEd #FOAMed
2/ Lateral approach works best to obtain a straight segment of the portal vein (straight = best Doppler shift) and a nice hepatic vein too.
Place transducer approximately in the anterior axillary line pointing towards sternal notch. Then fan antero-posteriorly.
#POCUS #VExUS
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot.
#POCUS
Read 18 tweets
1/

WHAT the heck is GGT?

#tweetorial #livertwitter #medtwitter
2/

GGT = gamma-glutamyl transpeptidase

It’s an enzyme that transfers amino acids to proteins. It's found anywhere things need transferring (liver cells, bile ducts, kidneys, heart....)

No big deal, right?

Wrong!
3/

It did not take long to figure out that while lots of conditions raised the GGT, liver disease and biliary obstruction were the best at making high GGT
Read 13 tweets
1/
Attending: “But never anticoagulation for an intracranial dissection!”

Me as a resident: “Of course. Totally!”

Also me ⬇️: [googling “where do the internal carotid arteries and vertebral arteries become intracranial?”]

Feel familiar? A #tweetorial @MedTweetorials
2/
With the TREAT-CAD trial, lots of talk about dissection treatment. Whether your team anti-platelets or team anticoagulation (🙋🏻 Must. Give. Heparin (@MGHNeurology) 4 ever. I know you feel this, @namorris!) consideration about the location of dissection is possibly important.
3/
Also, regardless of your team… TREAT-CAD was not able to demonstrate non-inferiority of ASA, just saying.

Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiorit… pubmed.ncbi.nlm.nih.gov/33765420/
Read 12 tweets
1/
Ever wonder if all #DOACs were created equal? #GITwitter #livertwitter #MedTwitter

Let's start with a poll followed by a #tweetorial on direct oral anticoagulants. First things first, which is your go-to choice of #DOAC ? (COI: none):
2/
These agents work "directly" to anti-coagulate and since they are hardly "new' anymore the term #NOAC has become obsolete. Dabigatran is a direct thrombin inhibitor (factor IIa), whereas the others are factor Xa inhibitors (note the Xa in their names)

3/
In general they share many characteristics such as a quick onset of action, shorter half-lives, potential for drug-drug interactions (CYP3A4 & P-gp) and renal elimination (except apixaban) when compared with warfarin

ncbi.nlm.nih.gov/pmc/articles/P…
Read 18 tweets

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