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⚠️¿Cómo debería administrarse el ENALAPRIL para 👥HTA o IC💔?
🔹Observo en consulta constantemente indicaciones de Enalapril cada 24 hs💊🤨👇
¿Es correcto👨‍🏫?

📚Déjame que te cuente que dicen las evidencias y datos relevantes para tu práctica🩺
#CardioTwitter #MedTwitter Image
Antes que nada, ¿Por qué hablo de Enalapril💊?
Se sabe que es una droga superada en muchos aspectos por otros nuevos fármacos pero:
🔹Amplia y 🌐utilizado
🔸Es muy seguro y eficaz
🔸Demostró ⬇️mortalidad & morbilidad
🔹Es un buen anti hipertensivo inicial
🔸Es muy económico ImageImage
📌Enalapril es un⛔️inhibidor de la enzima convertidora d angiotensina (es decir ⛔️el paso de I a II)👉 así⬇️Angiotensina II (y su efecto sobre los receptores AT1),⬆️ACE2 y⬆️bradiquinina

🔸ACE2👉 ⬆️Ang(1–9) tiene propiedades cardioprotectoras y anti HT por ⬆️óxido nítrico ImageImage
Read 10 tweets
Why is a ketogenic diet a potentially effective treatment for refractory epilepsy?

There's something almost magical about the idea that a specific type of diet could reduce the risk of epileptic seizures.

Let's explore why that might be.

#medtwitter #tweetorial Image
First let's define a ketogenic diet.

Ketogenic diets have ⬆️ fat and ⬇️ carbohydrates. This leads to ⬆️ serum free fatty acids and ketone body production by the liver (acetoacetate, acetone, beta-hydroxybutyrate) for use as cellular fuel. Image
Ketogenic diets induce a pseudostarvation state, as carbohydrates = typical primary cellular fuel.

In the 1900s it was noted that fasting helped control epileptic seizures.

By 1921, RM Wilder proposed that ketogenic diets might replicate this effect.… Image
Read 18 tweets
Today's pearl is about Salicylate☠️!

Toxicity is most often seen with acetylsalicylic acid (Aspirin), but also methyl salicylate (Oil of Wintergreen- 5 mL = 22 aspirin), bismuth subsalicylate (Pepto-Bismol), teething gels, & headache preparations (BC Powder) ingestion
- Mechanism of Action:
Uncouples oxidative phosphorylation & ↑Renal NaHCO3 excretion➡️AG Metabolic Acidosis
Stimulates medullary 🫁 drive ➡️ 1° respiratory alkalosis

- Clinical: Tinnitus, N/V, Tachypnea/Hyperpnea, AMS & Hyperthermia (late)➡️⚠️RAPID DECOMPENSATION
- Labs: Order at minimum BMP, HFP, VBG, Salicylate /APAP lvl, EOTH, UA,EKG
Salicylate Lvls:
Acute Tox:
15 - 30 mg/dl = therapeutic range
>30 mg/dl = symptoms begin
> 90-100 mg/dl = severe toxicity
Chronic Tox:
40-60 mg/dl = severe toxicity
Read 12 tweets
Hi everyone, as an annual meeting chair, I get asked a lot about how to get invited to speak at conferences. I learned a lot in the process, so here's a 🧵on tips for increasing your visibility at #academic conferences.

#academictwitter #medtwitter #meded #FOAMed @ASRA_Society
1/ Most important first step: be a member of that society and regularly attend and/or volunteer at the conferences. Make sure you vibe with them in addition to them vibing with you! It's the best way for folks to get to know what you're all about.
2/ Meet people, whether at conferences, on Twitter, or via collaborations. Let them see your expertise. Find a sponsor who has a connection to the society and share that you're interested in taking on more. If that sponsor is unsupportive or ghosts you, move on to the next one.
Read 15 tweets
🚨 los médicos NO debemos usar la insulinoterapia como una amenaza o describirla como signo de fracaso del manejo o castigo personal (Ejemplo: si no se toma las pastillas y no hace dieta, tocará iniciarle insulina)

Aquí te enseño las indicaciones de iniciar insulina👇
Lo primero es que se debe enfatizar la utilidad y la importancia de la insulina para mantener el control glucémico una vez que la progresión de la enfermedad supera el efecto de otros medicamentos. Además se debe educar e involucrar a los pacientes en el manejo de la insulina.
Por ejemplo, la autotitulación de las dosis de insulina en función del control de la glucosa mejora el control glucémico en pacientes con diabetes tipo 2 que inician la insulina.
Read 10 tweets
In light of #MedTwitter's latest binfire (teabag-gate)

I think it's useful to note that in an environment in which trusts are directly employing insufficient numbers of staff on unacceptable rates of pay; they need to consider non-pay factors which they can affect... 🧵
Transport/Parking: Paying to park at work is an additional tax on working that we resent. As potentially the largest employer in the local area what do you know about how staff get to work and why?
Do you have safe, reliable, green transport options which are acceptable to staff?
Food/fluid: Are there free tea/coffee/squash/cold water in your staff rooms?
Are there nutritious, delicious, cheaply-priced/free food options available for all your staff at all times of day and night?
Read 10 tweets
⭐️Everything you need to know about H. pylori: the Maastricht V/Florence Consensus Report summarized❗️ 🧵


#MedTwitter #GITwitter #IDTwitter #microbiome…
🦠HP gastritis is an infectious disease irrespective of symptoms/complications

⚠️HP▶️chronic active gastritis in ALL colonized individuals. This can▶️peptic ulcer disease, atrophic gastritis, gastric adenocarcinoma, MALT. Eradication prevents all of this
🦠Test-and-treat (versus endoscopy or empiric PPI) for uninvestigated dyspepsia. Subject to regional HP prevalence and 💰considerations. This does NOT apply to patients with 🚩symptoms or older patients.

⚠️Need EGD if🚩. Can also consider🔦in patients where HP prevalence is ⬇️
Read 63 tweets
🏴Escenas de Horror Médico

🚺69a, hipertensa, ingresa c/foco neurológico👉hemiparesia izq d 40 min d evolución. NIHSS no informado
⚠️El tomógrafo no funciona. Es derivada p/ TC 🧠s/cte a otro🏥
🚨Resultado: SIN sangrado🩸👉🚑regresa🏥 > 4 hs
#CardioTwitter #MedTwitter Image
El ECG no⛔️ esta informado en el resumen de egreso📄🏥, la pte refiere q se lo hicieron🤔
📌Es importante hacer un ECG a un pte con un evento/accidente cerebro vascular?
🔹Claro que sí, porque la fibrilación auricular es causa del 20 al 30% de los strokes
🔺Mas datos👉 la FA es la arritmia sostenida mas frecuente, aumenta con la edad🧓 y la hipertensión es el factor de riesgo💔 individual con el que mas se asocia (HR 1.42) ImageImage
Read 10 tweets
2021 marked the first change in 20 years in how we billed for OUTPATIENT visits

7 major changes in the new OUTPATIENT BILLING guidelines follow.

A #tweetorial that literally makes you money 💵

#medtwitter #neurotwitter

1. History & Exam does not count towards billing.

Only medical decision making (MDM) or time counts.

That does not mean no history or exam; medically appropriate history and exam is still needed,

But you don't have to obsess about 4 "qualifiers" for the chief complaint.
2. Billing by time is expanded.

Includes all activities for patient care.

Activities need to be done from midnight to midnight on the date of service.

Pro tip: Complete your note on date of service to add that time to the total time.

Can lead to a higher level of billing.
Read 9 tweets
Hi, @AnthemBCBS: I have a preemie baby who can’t get his life-saving medication because you won’t cover it without me speaking to someone about pre-authorization. For 3 days I’ve been leaving messages and getting lost in phone trees. Can someone please DM me? We need to talk.
UPDATE: thanks to #MedTwitter someone did reach out to me but we still have no resolution. At 3PM I was told that the situation was resolved but when the family called the pharmacy, they were told that it was actually NOT authorized.
Then I spoke with someone else an hour later and they told me that @AnthemBCBS 'escalated the claim' but it is still not approved. This patient's father and I have each spent hours on this and we are still no closer to getting this done.
Read 3 tweets
Yesterday someone who is on Medicare Part D asked in disbelief: Will my annual prescription drug costs really be capped because of the new Senate bill?

All drugs
Every drug
All drugs combined
Total $2000 for whole year

Shout it from the rooftops.
Bonus: Your $2000 will be spread over the year. Thank the people who supported this bill: Senators, AARP, P4AD, US of Care.
Right now 1.3 million people in the US pay >$6350 out of pocket. By 2025 expect this number to be much higher. So this is huge for families.
Read 3 tweets
#WCLC22 Highlights #CommunityOncology perspective:

1. #YESS Study - @RachM_UoN

2. #IMPower010 Update

3. #CALGB140503 - Sublobar resection

4. #SHAWL Study - @NarjustFlorezMD @jillfeldman4



#LCSM #MedTwitter @OncoAlert #OncEd @IASLC
1. #YESS Study @RachM_UoN: Lung CA screening with smoking cessation intervention concurrently:

- Smoking cessation is one of the most effective way to reduce lung CA mortality
- 33% quit at 3 months
- Women more likely to benefit

2. #IMPower010 Update: Atezo has been approved for adjuvant NSCLC, Stg II - IIIA post surgery and chemo.

- mFU: 46mos
- OS trend for stage II-IIIA PDL1≥1% (HR 0.71)
- BUT, meaningful OS with PDL1≥50% (HR 0.42)

Read 6 tweets
📌REVIEW. Urgente necesidad de tratar la enfermedad CV en forma mas precoz, + intensamente y con mayor precisión🧵

⚠️LDL normal/fisiológico 20-40 mg/dL
🔸Se requiere un cambio paradigma p/ comenzar mas temprano
🔹Guidelines 👉 aún importantes gaps👥

#CardioTwitter #MedTwitter
⚠️LDL normal/fisiológico 20-40 mg/dL
¿Estás de acuerdo con esta consigna?
🚩Importante no solo enfocarse en la enfermedad coronaria💔
🔸La ateroesclerosis también genera:
Read 8 tweets
Content Warning; death of a child.

I wanted to share about the single most salient experience I had deciding who I was as a physician from directly observing an attending. Tragically, it involved the death of a pediatric patient; a child about 18 months old.

2/ I was an intern on the FM medicine service; our hospital didn't have any other residency programs, so we typically went to every Code because we were frequently more readily available than other doctors in the hospital, and often the first to arrive to help.
3/ One morning our team ran to a Code Blue in the ER; an EM doctor was leading the team when we arrived. My co-intern and I both had 18 month old children at home, the same size and age of the child we were trying to resuscitate. We were both assigned to chest compressions.
Read 14 tweets
A 40-year-old woman from Brazil, AIDS, CD4 91 cells/μL: headache, diffuse cerebral edema, coma, respiratory distress, tracheal secretion with nematode
(1), alveolar hemorrhage, periumbilical purpuric rash (2), & death

🔬brain: 3
#MedEd #IDtwitter
🔬tracheal secretion: Strongyloides stercoralis (1)

Skin biopsy: S. stercoralis larvae at the dermis and hypodermis.


#microbiology #MedStudentTwitter
Strongyloidiasis occurs worldwide, but predominates in tropical and subtropical areas.

People acquire the disease from penetration of larvae through the skin.

#MedicalStudents #MedTwitter
Read 5 tweets
It really upsets me when doctors roll their eyes at patients who come into the office prepared. I bring with me:
- a binder with my records sorted by body system
- a "short copy" of the most relevant records
- recent labs
- a list of current meds, drs, and their contact info 1/7
I also bring a copy of an agenda that includes
- symptomology of current issue
- ongoing interventions
- questions I have regarding potential treatments.

I need all this because I don't have anyone to serve as a patient advocate. I have brain fog. 2/7
These records keep me on track for when a doctor asks a question about a surgery I had a decade ago, or an issue I saw twenty different practitioners for since childhood bc I moved frequently. I need these records. 3/7
Read 7 tweets
When is breastfeeding contraindicated? A thread 🧵 and list of contraindications

#MedTwitter #PedsTwitter 🍼
As pediatricians, we often default to recommending BFing for infants given the numerous health benefits that have been demonstrated for both the mother and child. 👩‍🦰👶

However, there are certain situations we should be mindful of.
For me, the 1st major contraindication is maternal preference.🗳️

Moms have various reasons for opting not to BF, incl. convenience, comfort, stigma, past trauma... Our jobs as pediatricians is to explore hesitations but also support whatever choice is ultimately made.
Read 19 tweets
1/Time is brain! So you don’t have time to struggle w/that "stroke alert" head CT
Here’s a #tweetorial to help you with the CT findings in acute stroke #medtwitter #FOAMed #FOAMrad #medstudenttwitter #medstudent #neurorad #radres @medtweetorials #stroke #neurology #Neurosurgery
2/CT in acute stroke has 2 main purposes—(1) exclude intracranial hemorrhage (a contraindication to thrombolysis) & (2) exclude other pathologies mimicking acute stroke. However, that doesn’t mean you can’t see other findings that can help you diagnose a stroke.
3/Infarct appearance depends on timing. In first 12 hrs, the most common imaging finding is…a normal head CT. However, in some, you see a hyperdense artery or basal ganglia obscuration. Later in the acute period, you see the insular ribbon & sulcal effacement
Read 13 tweets
Happy First Day of Medical School to everyone with orientation today!

Some of your orientations are going to focus so much on how brilliant and accomplished your class is that you might start to feel like an imposter; like you got in by accident and soon everyone will figure that out.

It's not true. You belong there; we need more doctors like you.
"Look around, EVERYONE here was a valedictorian or salutatorian, top honors in college..."

Look I get it; med school is REALLY hard, and I needed that encouragement to work harder more than anyone; I wish I had listened then instead of waiting for Step 1 troubles to wake me up.
Read 6 tweets
Clinical features and novel presentations of human #monkeypox of 197 patients in a #London centre during the 2022 #outbreak

Median age: 38 years
All 197: men, &
196 identified as gay, bisexual, or other men who have sex with men
#IDtwitter #MedTwitter
Concomitant infection:
- 35.9%: HIV
- 31.5%: a concomitant sexually transmitted infection.

All presented with mucocutaneous lesions, most commonly on the genitals (n=111 participants, 56.3%) or in the perianal area (n=82, 41.6%).

#Doctor #MedStudentTwitter
86.3% participants reported systemic illness:
✔️ fever 61.9%),
✔️ lymphadenopathy (57.9%), and
✔️ myalgia (31.5%).

#monkeypox #resident
Read 14 tweets
⚠️¿Cómo debe administrarse el TELMISARTAN?
🔹Observo en consulta constantemente indicaciones de Telmisartan cada 12 hs💊🤨👇
¿Es correcto👨‍🏫?

📚Déjame que te cuente que dicen las evidencias y datos relevantes para tu práctica
#CardioTwitter #MedTwitter
Un poco de farmacología:
🔸ARA II con efecto de 24 hs (spoiler🚨)
🔹Pico plasmático 0.5-1 h, se modifica levemente con alimentos
🔸Máxima respuesta👉a 4⃣ semanas del inicio💊
🔹Metabolismo hepático
🔸Dosis mínima 40 mg/d
🔹Dosis máxima 80 mg👉 siempre una vez al día
El estudio mas grande fue el ONTARGET 25k ptes👉 Ramipril 10 mg/d vs Telmisartan 80 mg/d vs Ramipril + Telmisartan. Seguimiento ≈ 4.7a

🔹👥vasculares o diabéticos de⬆️riesgo
🔸No hubo diferencias significativas en eventos
🔹Combinar IECA+ARA II solo⬆️ efectos adversos
Read 7 tweets
"Your diagnosis is elevated uric acid. You need to stop eating 🍅🥗🥦🥪🥩🫘, basically everything"

Beware of these!!

Elevated uric acid doesn't always 🟰 gout

#MedEd #MedTwitter #gout #Uricacid
Gout is a form of arthritis due to deposition of excess uric acid in joints and it usually has (not always) high serum uric acid levels.
If one has gout, then avoid:

🍺 Alcohol
🥩 Red meat
🧃 packed juices, carbonated drinks (high fructose corn syp)
Read 4 tweets
👩‍🦳 in her 70s: on the L 🦶, initially appeared pruritic papules that evolved to fluid-filled blisters with tense and denuded bullae (Fig1).

Over the ensuing 6 weeks an expanding annular plaque with peripheral scale (Fig2).
#dermatology #mycology
🔬(KOH): hyphae
🧫: Trichophyton rubrum


The patient responded well to terbinafine cream and dilute acetic acid soaks.

#microbiology #IDtwitter
Bullous tinea, seen in adults and children, and most often affecting the feet, presents with an erythematous scaly rash with serous fluid-filled bullae, as opposed to the pus-filled blisters of bullous impetigo.

#MedTwitter #Doctor #MedStudentTwitter #MedEd
Read 4 tweets
”She's moody, probably because she's a teenage girl, but could it be the #BirthControl?”
"She's acting so hormonal."
"Her moods are crazy, she's PMSing all the time."
Moods have nothing to do with #gender and sex hormones! These #stereotypes only perpetuate #bias. 🧵 #MedTwitter
Let's start with #hormones. Hormones are chemicals released by certain organs that carry messages to other organs. Everyone has hormones. Changes in hormone levels can affect our moods but having hormones does not make someone moody.
The reproductive (and other) organs produce the sex hormones (#progesterone, #estrogen, and #testosterone) in all people, just in different quantities. These levels can vary throughout the day and over time.
Read 13 tweets

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