Discover and read the best of Twitter Threads about #covid4MDs

Most recents (24)

Do you manage the renal impact of #covid19 on general wards?

My summarised recommendations on;
✅ Volume status
✅ ACEi
✅ Transplant & dialysis patients

taken from @RenalAssoc, #eraedta, #nephjc & @UpToDate

= lots of relevant info in 8 tweets👇

#medtwitter #covid4mds

✅ Many potential factors;
✔️hypovolaemia due to fever / GI symptoms
✔️sepsis & cytokine release
✔️rhabdo, even without myalgia; check CK!
✔️direct viral tubule invasion?
✅ Low grade proteinuria & haematuria common
✅ Don’t miss ‘usual’ post-renal AKI; bladder scan +- US
Volume status

Assessment not easy at best of times!

Balance of maintaining volume to prevent AKI & avoiding hypervolaemia which impairs oxygenation in ARDS

🟠 UK Renal Assoc - “target euvolaemia”

🟠 Uptodate - “fluid goals conservative as per ARDS criteria” but individualise
Read 10 tweets
Proposed COVID-19 Pathophysiology [Part 3 of (now) 4]:

Coagulopathy Strikes Back.

What happens when #COVID19 clashes with the world of hematology?

Buckle up again for a long one.

...let’s dive in like this macrophage (exploring all directions):
First, what do you think is the predominant mechanism by which thrombosis occurs in COVID-19?
Where does thrombosis typically first occur?
Read 38 tweets
Theoretical Case #medtwitter #COVID19 #covid4MDs:

45 M with well-controlled HTN, DM2 (A1c 6.7%), and obesity (BMI 34) has been waiting for knee surgery for 1 year while trying to lose weight. As elective surgeries are resuming, he comes to for advice. You recommend:
Assume that no further cardiac testing is indicated and this question is being posed to you in the area you practice and with the #COVID19 info known to you as 4/25/2020.
or with the #COVID19 info known to you as of the time you vote. 🤷🏻‍♂️
Read 3 tweets
I was feeling overwhelmed by all the laypress articles about #moralinjury and #burnout in frontline health care workers during #Covid_19 so I decided to do a deep dive into the literature on the mental health of workers during pandemics.

Here's what I found. #thread

Seriously, so many laypress articles.

What evidence do we have on this, and further, what evidence do we have on strategies that mitigate these mental health issues in health care workers?

I presented these data the @UChicagoMed @UCCancerCenter grand rounds last week.

@UChicagoMed @UCCancerCenter But first, some definitions to set the stage:

Burnout, initially described by Dr. Maslach as the prolonged physical and psychological exhaustion related to a person's work. Not specific to medicine, although the definition has been honed for medicine (see slide). #burnout

Read 44 tweets
#COVID19 update 4/20/20. #covid4MDs
It’s a big country and a big world. Feel free to chime in with the situation in your area. This is how it looks from Colorado, USA:
1. A month ago we were headed directly in to a disaster of overwhelmed healthcare systems and massive unecessary deaths. We stopped most activities of daily living and mostly averted that tragedy.
2. The US planned poorly and we went short of PPE. We still don’t have enough and we are reusing masks inappropriately and shields and goggles from home.

Strangely this “works.” Nurses and doctors get sick but many don’t after daily exposure.
Read 23 tweets
Proposed COVID-19 Pathophysiology [Part 2 of 3]:

Enter the magnificent macrophage.

What do #COVID-19 and hemophagocytic lymphohistiocytosis (#HLH) potentially have in common?

...let’s continue our journey onward into the cytokine storm.
First, let’s briefly summarize what we covered before:

What mechanism may be partly responsible for heterogeneity of COVID-19 disease phenotype as well as its severity?
Correct! Antibody-dependent enhancement (ADE) is the result of producing sub-neutralizing antibodies which paradoxically enhance the rate of viral replication and severity of viremia.
Read 24 tweets
1/ Good morning, #medtwitter! This 1 goes out 2 everyone who hasn’t had to interpret a blood gas since Steps, prelim year or their last episode of ER (@DGlaucomflecken).

FYI: this ain’t a course on Winter’s Formula. We’re talking practical vent adjustments today. #covid4MDs
2/ There are 4 variables we might want to adjust on the vent based on our ABG results: PEEP, FiO2, RR and Vt. The first two we adjust to achieve appropriate oxygenation while the latter two we adjust to achieve adequate ventilation.
3/ Now that we’ve had that brief review, take a look at the following gases. What’s the problem, and how might you fix it?

Keep scrolling through the thread for the answers!
Read 7 tweets
1/7 France has done the first pharmacokinetic (PK) study of HCQ for ICU patients of #COVID19, a fantastic job for dosage optimization.
🔸13 patients, average weight=82.7 kg
🔸46% pts BMI>30
🔸12 on mechanical ventilators
🔸1 on ECMO
🔸30.7% with medium/severe renal dysfunction
🔸2 pts had QT prolongations (>500ms ), but not related to HCQ levels.
🔸 Regimen D: 200mgX3/day for 7 days;
PK simulation shows HCQ reached the therapeutic level of 1mg/L on day 2.5 but exceeds 2mg/L (risk of ocular toxicity) on day 5
🔺In this D regimen, the average HCQ dose is ~7.5 mg/kg/day, which is above the well established safe upper limit: 6.5 mg/kg/day; meanwhile, the HCQ blood concentration exceeds the upper safe level: 2mg/L.
Read 7 tweets
Proposed COVID-19 Pathophysiology [Part 1 of 3]

What do #COVID-19 and #Dengue fever potentially have in common?

The answers have significant potential clinical implications in COVID-19.

Buckle up. It's a long one.

Let’s take a hematological walk on the zoonotic side.
Dengue is a flavivirus that is called “breakbone fever”, a nod to bone-breaking pains that occur during the infection.

There are four serotypes of the dengue virus.

Infection with one serotype does not fully protect one from contracting a different serotype.
True or false: The second or later infection with dengue is often much more dangerous.
Read 26 tweets
After spending the last four weeks working in an #ICU here in #Seattle, a final set of #COVID19 clinical and general thoughts:

#COVID4MDs #seattlecovid19 #medtwitter (1/10)
Last week’s diagnoses are this week’s admissions. We’ve started to see people admitted to the ICU with known #COVID19 diagnoses but whose condition has worsened. Sometimes, as others have observed, the worsening is quick—in a matter of hours. (2/10)
People admitted to the #ICU with #COVID19 stay for a long time. We have had people on ventilators for well over a week. They have bad ARDS but do seem to respond to LPV, NM blockade, and being proned. Still, most have yet to come off the ventilator. (3/10)
Read 10 tweets
[1/4] Anyone on #medtwitter or #covid4MDs started using steroids to treat #COVID19?

(At our institution we have moved away from the no-steroid dogma and anecdotally had good results in avoiding intubation with the use of high doses at the onset of worsening hypoxia or CRS)
[2/4] Currently we've been using:

1. Methylprednisolone 125 mg daily
2. Decadron 10 mg IVP or PO BID
3. Prednisone 1 mg/kg PO in less severe cases

Which have you been using? If other, leave a comment below.

Criteria for initiation are debated. We have been using:

1. Significant hypoxia at admission or worsening hypoxia.

2. Lab evidence of severe disease (i.e. ferritin >1000 mg/dL, rising inflammatory markers, lymph count <20%, thrombocytopenia, etc)

3. Evolving CRS.
Read 4 tweets
A quick primer for the non-medical field about the use of antibody tests and a possible scenario on how things evolve. This is only the concept. Not a timeline or accuracy. We do not know yet when things will end. 1/7

Why antibody testing is so CRITICAL!
#COVID19 #covid4MDs
There are many things we do not know about this infection. How many? etc.
Our biggest hope is that many more than we know have been infected and have recovered. 2/7
#COVID19 #covid4MDs
This is a graphic that shows where we are and the mixture of various stages. Again remember we do not know how many people are in each category. 3/7
#COVID19 #covid4MDs
Read 7 tweets
"Cytokine Storm". The idiot's buzzword of the week. It makes you sound smarter if you say it often enough. When I first heard of it in 1994 it sounded AMAZING! Then this RCT came out showing it increased mortality. Ouch…
Next came rhAPC (drotrecogin). Don't knock out the immune system: we need it to survive. APC has signalling properties to modulate inflammation. NEJM PROWESS was touted a success!…
Just as we were celebrating and retrospective analyses showed efficacy correlated with drotrecogin reducing Il-6 levels, bad news came in and the dream turned sour…
Read 33 tweets
A hematology @tony_breu-style tweetorial:

Why does lymphopenia occur in #COVID19?

A normal WBC count and lymphopenia are seen in patients affected by COVID-19, but why it occurs has bothered me since the pandemic onset.

The potential answer is surprising and interesting.
First, what do you think the mechanism is?
Does the degree of lymphopenia correlate with survival?
Read 26 tweets
1/ Good morning, #medtwitter, and welcome to another round of #readingroom #covid4MDs edition!

You should have a system for reading CXRs, and you need to approach each image systematically. Apply that system now and tell us: what do you see? Could this be #covid19?
2/ In short, yes, this could be COVID-19, and in this case it was. But it could’ve been something else. Or it could’ve been a normal CXR and they still might’ve had COVID-19.

Moving on, do you know what the current ACR recommendations are for imaging in suspected COVID cases?
3/ Each patient who goes to CT is followed up by a thorough scrubbing of the scanning room - a process that takes up valuable time and delays necessary scans. Only COVID patients with strong indications for CT should be sent to the scanner.
Read 7 tweets
Don’t take responsibility for decisions you didn’t make.

Escaping this pandemic psychologically whole and spiritually well is going to be a monumental task. It will require you to assign responsibility correctly.

First, you didn’t make this virus. It wasn’t your idea.

Nature did that. She does things like this from time to time. She is powerful and does things like this from time to time.
More than likely, you did not initiate the response of you country, state, city, or hospital. If you had, you might have done it differently, but you were not assigned that authority.
Read 16 tweets
Some thoughts on the spike of new cases in the US
Some of this is due to increased testing. We must do our part in continued mitigation, social distancing, etc. We won't know fully until later but for now, caution is warranted.
#COVID19 #covid4MDs
The # of known cases is highly correlated to how many tests you do - as you scale up testing the # of cases spikes. The data is linearly correlated!
Remember this is PCR testing - you need to detect virus in symptomatic cases. It does not tell you about past exposure.
We now have more "new cases per day" than Italy. This is likely a combination of exposure in the last 2 weeks but also due to increased testing! We cannot determine what percent each contributes. But increased testing contributes.(Our population is 5x that of Italy)
Read 15 tweets
We've been in full #COVID19 mode in my hospital in Alcorcón (Madrid), Spain for the past 2 weeks.

This crisis has forced us to adapt like we never thought possible. Here's how we're doing that on our units, in hope that it'll help others across the globe do the same #FOAMcovid
We've divided the hospital in COVID + or COVID - units. At the time of writing, almost all of our hospital is comprised of COVID + units, with the few remaining COVID - patients in the:

1) Day medical hospital (in-patients)
2) Day surgical unit (converted to a non-COVID ICU)
We've abandoned traditional rounding in favor of teams with multiple members with one coordinator (usually from ID or IM).

These teams consist of 6-8 doctors and include residents and attendings from different specialties.

Each team is in charge of a +/- 32 person COVID ward.
Read 21 tweets
Brilliant. I think this idea really has legs. If we can move the vent controls outside the room we can check/adjust ventilators without consuming PPE. Combine this with moving IV pumps to the hall and we may reduce ICU PPE consumption by 50%. #innovation #covid4MDs
Calling all #RespiratoryTherapist For which ventilators is it possible to separate the control unit from the ventilator? What type of extension cable is needed? Let’s #crowdsource these extensions. This is an effective low tech way to conserve PPE and save lives. #covid4MDs
Looks like this is the connector we need. Anyone know if these are widely available? Image
Read 3 tweets
#covid4MDs #math

Stay cool. ❄️❄️❄️
Read to the end.

According to the @JohnsHopkins map, the current COVID infection rates are:

🇮🇹: 1/1,900

🇺🇸: 1/51,000

~ Do not start screaming ~
The US numbers are useless because of our national testing failure.

The Italy numbers are probably more accurate.

Now you will day my math is wrong. You’ve seen the headlines and read the first hand accounts. I must be wrong.
I’ll say my math is good. The data might be bad but my math is good.

So why the discord between numbers and news?
Read 24 tweets
With recent #COVID19 impacts, there’s been a huge surge in telehealth utilization and interest.

Official Guidance:

Here are some Zoom tips and my HOME #telehealth set up #COVID4MDs 1/12
Set up a personalized Zoom link instead of a long number to remember, like Go to Zoom Settings > Advanced Features > View Advanced Features > Profile > Personal Link > Customize #COVID4MDs 2/12
So you don’t have to keep typing it, set up a keyboard shortcut. ESPECIALLY useful on mobile. Mac > System Preferences > Keyboard > Text. Whenever I type "myzm", it gets autocorrected to the full link. Great for ad hoc mtgs, start from Slack, iMessage, etc #Telehealth 3/12
Read 12 tweets
Oh shit. I finally read this. We are not ready for any of this. I’m not sure if we have the capacity to do this at this level. See the screenshots of the slides below. #covid4MDs
Read 8 tweets

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