Discover and read the best of Twitter Threads about #Tweetorial

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Our weekly #tweetorial returns. This week’s paper is from last month’s NEJM - Haloperidol & Ziprasidone for Treatment of Delirium in Critical Illness…
Prepared by @Taffydoc1
ICU delirium remains a huge challenge, affecting 50-75% of our ventilated patients. The implications on patients and healthcare include a higher mortality, longer hospital LOS and periods on mechanical ventilation and long-term effects on cognitive function.
Despite over 40yrs of treatment by clinicians with antipsychotics, there remains little evidence for their use.
Haloperidol and Ziprasidone are dopamine D2 antagonists and are classed as typical and atypical antipsychotics respectively.
Read 20 tweets
Hepatopulmonary Syndrome - or is Portopulmonary hypertension? What’s the diff (brief #tweetorial)
Pulm complications of #cirrhosis can be devastating. This month on rounds, I was reminded that these conditions are confusing.
Step 1:
Recognize when a pulmonary complication could be present or clinically important (4 transplant)
This is how they looked when first described:
1. Portopulmonary: Dyspnea without hypoxia (Fig 1)
2. HPS: Hypoxia (Fig 2)

Step 2:
TTE (Fig 3)
Ordering "agitated saline" echocardiography will always be funny

TTE▶️most sensitive way 2 dx HPS(Fig1)
The bubbles dont go right▶️left immediately (like with septal defects) but do after a few heart beats
Bonus: do not rely on pulse ox!(Fig2)
Screen or go 2 TTE on by symptoms
Read 8 tweets
#GUpath puzzler time!
(for those of you familiar with this case, please keep 🤫!)

middle aged M found to have bilateral breast enlargement. Work-up revealed elevated serum PSA. MRI-guided prostate biopsy done of abnormal area seen on imaging.

my DDx:
▶️Gleason 5+5 prostatic adenocarcinoma (for all new bx cases, I always do confirmatory prostate #IHCpath)
▶️plasmacytoid urothelial carcinoma
▶️signet ring GI tract adenocarcinoma
▶️metastatic lobular carcinoma
not shown but negative were:
NKX3.1/PSAP, CK20, uroplakin2
Read 9 tweets
Are you still shaking off the holiday? I know I am!

How about a #cartooncausalinference #tweetorial about casual graphs to ease us into the new year?

#epitwitter #DAGsfordocs #FOAMed #MedEd #statstwitter #econtwitter
The most common type of causal graph (at least on #epitwitter) is the directed acyclic graph, or #DAG.

DAGs have two main components: variables (also called nodes), and arrows (also called edges).

In the DAG below, there are 3 variables: sleeping, Santa, and presents.
The variables are ordered based on time — you have to go to sleep before Santa can come to your house & then he’ll leave presents!

Causation and time both flow in the direction of the arrows.
Read 24 tweets
I will now proceed to go on a #tweetrant / #tweetorial with regards to #Pharmaceutical #biotech pricing (focus on #cancer).

Very timely, also see @WSJ… on price hikes.

For the record, no #COI / #FCOI. Feel free to contribute to this discussion.
Lets look at the problem from the @PhRMA / business perspective. And lets suppose you are a wonderful company, started by wonderful people who just want to make the world a better place (I know, not real, but stay with me for a minute).
You start with a great idea / or pipeline platform and start selling this concept to #VC #VentureCapital, and lets assume that this is actually a really good idea. What is the needed return on investment to make this worth while. A: further R&D must exceed the cost of capital.
Read 17 tweets
I’m glad that this article was written, it makes a LOT of great points about sun exposure and melanoma, but I think a few things need further discussion.

My final #tweetorial of 2018! 👇🏾👇🏾👇🏾
In order to appreciate the complexity of this relationship (i.e. sun exposure and melanoma), one must remember that measuring sun exposure over time is HARD.
The sun is all around us making it difficult to measure exposure levels and thus draw conclusions with absolute certainty.
Read 21 tweets

Los mejores artículos #PedsICU (UCIP) del 2018 📖
La suma de lo más relevante publicado y un #Tweetorial acompañante

Selección colaborativa con entre @PICJournalWatch & @sgdambrauskas
Publicado en simultáneo Inglés/Español

Favor comparte. ¡Nos vemos en 2019!
Estudio PARIS en @nejm
Gran estudio que gatilló discusión en el ámbito del #CNAF. Incluso diferentes interpretaciones de resultados de sus coautores

¿Cambió mi práctica? NO
¿Mi investigación? SI

Lean correspondencia:…
ECA en @PedCritCareMed
@pus27 y cols encontraron que #CPAP precoz en niños inmunocomprometidos admitidos en #PedsICU no es mejor (incluso peor) que O2 estándar en 🇬🇧
¿Cambió mi práctica? Quizás
¿Mi investigación? NO
Read 21 tweets
Going to slowly tweet out 15 of the most interesting things I read, listened to and saw in 2018. With oncology/ health policy/ evidence themes

Starting with Same Dataset, Different Interpretations by @BrianNosek…
The point in this paper is if you give researchers the (a) exact same data set and ask the (b) exact same question you get a variety of answers.

Some point out that *some* of the point estimates are consistent....
Of course that is true, but other teams are reporting qualitatively different conclusions: some say no evidence of bias, others say bias

And, imagine a second what happens if...
Read 84 tweets
1/ Is my dream that future of medical research can include category for people-powered data collaboratives. Barbara Evans and I lay out a path. Here is #tweetorial.… @PCORI @EmCollective @gatesfoundation @NIH @EricTopol @wilbanks @YaleMed @sharonfterry
@PCORI @EmCollective @gatesfoundation @NIH @EricTopol @wilbanks @YaleMed @sharonfterry 2/First, we acknowledge most research done person at a time, w/individual consent. But what if people facing common conditions provided collective consent to their health data to researchers they choose. People powered.…
@PCORI @EmCollective @gatesfoundation @NIH @EricTopol @wilbanks @YaleMed @sharonfterry 3/What could it be like to speed research if people could gain agency over their data & seek others to move quickly & responsibly to leverage data for discoveries. To treat the community of people as partners. Respectfully. Appropriately. Sharing insights.…
Read 11 tweets
I love fries; you love fries; but should we only eat 6 per serving? Less is more is good advice but why 6 & not 5, or 7?

Unfortunately, there’s prob no way to know if 5 or 6 is better!

Why? Here’s a #tweetorial on estimating causal effects for nutrition. Grab a 🥗 & get comfy!
Imagine you want to reduce your intake of French fries with the specific goal of reducing your chance of a heart attack.

You need to make 2 decisions: how often should I eat any fries; and how many fries should I eat in a serving?
To help you live your best life (ie eating max safe # of fries), researchers need to ask a pair of causal questions:

•what is the best frequency of French fry consumption to prevent heart attacks?
•what is the best serving size of French fries to prevent heart attacks?
Read 27 tweets
#Tweetorial on hypoxemic #respiratoryfailure. #FITSurvivalGuide #FOAMed
1️⃣ Shunt
2️⃣ V/Q mismatch
3️⃣ Low FiO2/low O2 tension
4️⃣ Alveolar hypoventilation
5️⃣ Diffusion limitation
6️⃣ Venous admixture
1️⃣Shunt - can be intra or extrapulmonary. No V, only Q. Does not respond to O2 - shunt fraction not exposed to o2. Inflamm alveolar dz (eg PNA) can p/w shunt (imp. vasoconstr.) Think abt PFO w R➡️L shunt in PE, ARDS (elevation in R sided pressures), check bubble study. Aa grad ⬆️
2️⃣V/Q mismatch. More Q than V but regions with low V not entirely excluded from gas exchange. Can improve w increasing FiO2. Probably 75-90% of hypoxemia cases. Wide Aa gradient.
Read 7 tweets
Necrosis = cell death (unlike apoptosis, it does not occur naturally and is not programmed)

This short #Tweetorial shows you some of the histologic flavors of necrosis. The stain in each of these pics is hematoxylin-eosin (H&E)

#pathology #pulmpath #pathtweetorial
First a question to test your knowledge. Necrosis with large numbers of neutrophils is called:
And now a few examples. Necrosis in colorectal carcinoma is often described as “dirty” because it contains nuclear debris. This makes it look purplish instead of pink.

#gipath #MedEd
Read 14 tweets
Mini #tweetorial for anyone who wants to learn how to do a good PowerPoint presentation:

Tip 1: Look and sound bored. Sigh a lot.
Tip 2:
Look towards your PowerPoint and away from your audience. This way they will appreciate the back of your haircut and everyone can avoid awkward eye contact
Tip 3:
Put lots of fancy graphs and tables loaded with data in there that take 5-10 minutes to understand. Give your audience 15 seconds to admire them and move on to the next slide
Read 12 tweets
The results of my #tweetorial poll were pretty clear: from over 350 votes, 38% of you want to know about causal survival analysis. So, pull up a chair and let’s talk time-to-event!
First things first, what do we mean by causal survival analysis?

An answer to the question: How would the average time to event have differed if everyone had received some exposure, versus if everyone had received some other exposure?
We can measure that difference between in time to event in many different ways. I prefer survival curves with risk differences at the end of follow-up, adjusting for baseline and time-varying confounding.
Read 33 tweets
This is the beginning of a #tweetorial or #pathtweetorial on a mystery topic. Fear not, it’ll become evident soon what we’re talking about. But first I’ll show you an image. These serpiginous fibroblast plugs are diagnostic if organizing pneumonia (formerly BOOP)
In MOST cases of organizing pneumonia seen on lung biopsy, the etiology is not evident on histology. But sometimes, there is a clue. Examine this pic closely and then see if you can answer the quiz in the next tweet in this thread.
What does the pic in the previous tweet show?
Read 24 tweets
Why is the acute treatment of "hypertensive urgency" a #TWDFNR?

This #tweetorial is meant to complement the recent publication: "Acute Treatment of Hypertensive Urgency" in @JHospMedicine…
Case: A 71M with a history of HTN is hospitalized for cellulitis. On hospital day 2, the nurse pages you:

"Pt X with BP ____. Please advise". He has no symptoms or signs of end-organ damage.

What would be your threshold SBP to write for an as-needed anti-hypertensive?
The treatment of hypertensive urgency is based on an assumption: if we do not lower the blood pressure now, something bad (e.g. stroke, MI, aortic dissection) will occur in the next few hours.

We aren't giving IV hydralazine to prevent a stroke two years from now...
Read 15 tweets
1/Welcome to our third #OCTober #Tweetorial 🎃🤓. Here we’ll talk
about how #OCTImaging can help detect the mechanisms of in-stent
restenosis (ISR) to guide treatment. #imagefirst #imagelast

Important Safety Info:
2/ What causes ISR? Stent underexpansion and neointimal hyperplasia (NIH) are the two predominant mechanisms of stent failure, as cited in this expert consensus document of the European Association of PCI:

Important Safety Info:
3/Here’s how stent underexpansion and NIH are seen on angiography and OCT respectively. To spot NIH, look for a large layer of growth on top of an already fully expanded stent.

Important Safety Info:
Read 7 tweets
What’s Your “Shear Stress”?

Want to Know More?

Relax & Read ⤵️ #Tweetorial by @CoronaryDoc + @arnavkumar

⚡️Coronary Wall Shear Stress in 12 Tweets ⚡️

Main Readings:
#ACCImaging @ACCCardioEd
Wall shear stress (#WSS) is the frictional force of blood exerted tangential to endothelial surface of vessel wall & expressed in variety of units (1Pa=1N/m2=10 dynes/cm2)

It is derived from
• luminal geometry
• flow rate
• blood viscosity
• near wall velocity values
In vivo WSS calculations are derived from computational fluid dynamic (#CFD) simulations created from reconstructed 3D vessel geometries (from biplane angio/IVUS/OCT/CT/MR) combined with patient-specific pulsatile inlet/outlet velocity values (Doppler wire or other methods)
Read 12 tweets
1/#Tweetorial #papillary #fibroelastoma for
#ASEchoJC 10/23

🐙= #PFE 1975 named #papillary #fibroelastoma by #armed #forces #institute of #pathology

#papilloma 1973

#Collagen core with elastic fibers & matrix covered by endothelium sheath
Attached by stalk
multiple fronds
2/ What is the incidence of #PFE 🐙 compared to #myxoma (diagnosed in same time period)?

#PFE 511 vs. #myxoma 112

#PFE incidence ~1/1000

common “benign”primary ❤️tumor #modern #EchoFirst (Most common @MayoClinicCV)

#myxoma (autopsy based prevalence)
3/How to tell if a #PFE🐙by #echofirst ?
(Vs.Atypical myxoma,SBE,
small mobile mass attached #endocardial surface frondlike extensions #independent motion stippled border
Usually on atrial surface of AV valves or either side of semilunar valves,🚫interfere valve Fxn
Read 10 tweets
Closing the loop on #Diagnostics #Tweetorial with example #AppleWatch #AFib #Screening. From a company website: "Atrial fibrillation is a silent killer. The heart arrhythmia causes more life-threatening strokes than any other chronic condition, and will affect 1 in 4 of us."
"But the sad fact is that atrial fibrillation often goes unnoticed: It is estimated that 40% of those who experience the heart condition are completely unaware of it."
Using #AppleWatch technology and #DeepLearning #AI #ML, a device algorithm can reportedly detect atrial fibrillation with high accuracy (c-statistic 93%).
Read 44 tweets
What happens after you inhale Histoplasma into your lungs? Is #histoplasmosis always a deadly disease?

Here’s a #tweetorial or #pathtweetorial

You are at risk if you live in the Ohio or Mississippi River valleys, go spelunking, or work with chicken coops
Many (maybe most) people who inhale Histoplasma remain asymptomatic. Many have symptoms that mimic “the flu” and are treated as such. Only a minority of immunocompetent folks are seriously and acutely ill at first exposure. This is called acute pulmonary histoplasmosis.
What do you think happens next in the vast majority of infected individuals?
Read 31 tweets
1/Welcome to our second OCTober #Tweetorial 🎃🤓. We’ll talk about diagnosing and treating calcific plaque with #OCTImaging. #imagefirst

Important Safety Info:
2/The absence of intravascular imaging may lead to underestimation of calcium and improper diagnosis, as seen in the chart below, courtesy of Richard Shlofmitz, MD. #OCTImaging #imagefirst

Important Safety Info:
3/Calcific plaque is characterized as having low attenuation (light penetrates deep, can see tissue) & clear, delineated edges (appear as “islands” or “rocks”). In this image, calcific plaque is observed from 12 o’clock to 3 o’clock.
Important Safety Info:
Read 12 tweets
It’s time for a #tweetorial on hypersensitivity pneumonitis. It’s a greatly misunderstood entity. Potentially treatable, so can be very good news. OTOH, misdiagnosing UIP as chronic hypersensitivity pneumonitis can be very bad.

Follow this thread for a #pathtweetorial
Let’s start with a poll regarding a common misconception. What is the predominant inflammatory cell in hypersensitivity pneumonitis?
Hypersensitivity pneumonitis is an inflammatory reaction that occurs in individuals (classically never-smokers) who are exquisitely sensitive to an organic antigen.

Obvious exposures (moldy hay=farmer’s lung) can be fairly straightforward to recognize clinically.
Read 20 tweets
Antibiotic testing. Let's go.

Tentatively calling this #tweetorial "Antibiotic testing: why and how and huh?"

Important caveat: this is a HUGE topic. I’m mostly going to focus on 1) basic rationale and 2) laboratory methods. And 3) try not to say anything wrong/misleading!
Question #1: Why would a person want to know if bacteria A is resistant to antibiotic B?
And the answer is ...

All are legit answers! But it's very situation dependent and you'd have different reasons for each. Let’s go through them.
#tweetorial #pathtweet #asmclinmicro
Read 28 tweets

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