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Tony Breu Profile picture
@tony_breu
Dec 17, 2019 • 12 tweets • 3 min read • Read on X
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I have grouped my MedTweetorials in separate Moments, each of which can be found in the following thread.

I hope it's easier to find content this way! Image
Cardiology

twitter.com/i/events/12067…
Pulmonology

twitter.com/i/events/12067…
Hematology & Oncology

twitter.com/i/events/12067…
Nephrology

twitter.com/i/events/12044…
Infectious Diseases

twitter.com/i/events/12067…
Gastroenterology & Hepatology

twitter.com/i/events/12067…
Rheumatology

twitter.com/i/events/12067…
Endocrinology

twitter.com/i/events/12067…
Pharmacology

twitter.com/i/events/12067…
Fun!

twitter.com/i/events/12067…
Tweetorials about Tweetorials

twitter.com/i/events/12239…

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More from @tony_breu

Tony Breu Profile picture
May 13
1/14
Why can't you use direct oral anticoagulants (DOACs) in patients with mechanical valves (MVs)?

DOACs have been one of the most important advances in my career. And yet, the presence of a MV is one of the few contraindications.

The reason highlights the unique nature of thrombus formation in those with a MV and provides insights into the evolution of human hemostasis.
2/
Early enthusiasm for DOACs in MVs was tempered by the results of RE-ALIGN, published in 2013 in NEJM.

252 patients with MVs were randomized to either dabigatran or warfarin.

╰┈➤ Patients in the dabigatran arm experienced more thrombotic and bleeding events.

pubmed.ncbi.nlm.nih.gov/23991661/Image
3/
PROACT Xa compared apixaban to warfarin in 863 patients.

╰┈➤ As with RE-ALIGN, patients in the apixaban arm had more thrombotic events, though bleeding rates were no different.

These findings have led to continued guidelines recommending vitamin K antagonists (e.g., warfarin) as the standard of care for patients with MVs.

pubmed.ncbi.nlm.nih.gov/38320162/Image
Read 14 tweets
Tony Breu Profile picture
Nov 28, 2024
1/9
 🤔 Why doesn't an elevated BUN lead to extreme thirst? If increased serum osmolarity compels us to seek water, uremia should be a significant driver of this craving.

And yet, it isn't.

Let's examine why.
2/
We've known for nearly a century that an increase in serum urea is not a significant driver of thirst.

In 1937, Alfred Gilman published an experiment in which dogs received an IV injection of either:
➤20% NaCl
➤40% urea

Both are hypertonic solutions.

t.ly/MIdqHImage
3/
After 30 minutes, the dogs were offered water, and had blood work drawn. Gilman made two key observations:

🔑 The increase in serum osmolarity with hypertonic NaCl and urea were nearly identical
🔑 Dogs drank significantly more water after hypertonic NaCl injection

t.ly/MIdqHImage
Read 9 tweets
Tony Breu Profile picture
Nov 16, 2024
1/14
🤔 Why do we use iodine as an intravenous contrast agent?

The answer requires a review of the composition of the human body and a brief tour of one of my favorites, the Periodic Table of Elements. Image
2/
 To begin, it's essential to understand which elements make up the human body. Amazingly, just six compose >98% of your weight:

➤Oxygen: 61% (varies based on water composition)
➤Carbon: 23%
➤Hydrogen 10%
➤Nitrogen: 2.6%
➤Calcium: 1.0%
➤Phosphorus: 0.6%

buff.ly/3YU4dIYImage
3/
 One thing you'll notice about these six elements is that they are relatively small (i.e., they have low atomic numbers, aka are low-Z elements).

In addition to being the most prevalent elements in the universe, their low atomic number allows them to more readily form stable chemical bonds.Image
Read 14 tweets
Tony Breu Profile picture
Jun 22, 2024
1/7 - The Mystery

A patient presents with fever and confusion. After multiple weeks without a diagnosis, an astute clinician suggests a random skin biopsy.

The patient has no rash or dermatologic symptoms. And yet, the biopsy reveals the diagnosis.

🤔What is the condition?
2/7 - The Diagnosis I

💥Intravascular Lymphoma (IVL)💥

IVL can be an elusive diagnosis, given that many patients present without lymphadenopathy.

Instead, non-specific symptoms (e.g., fever, fatigue, weight loss, confusion) are more common.

ncbi.nlm.nih.gov/pmc/articles/P…Image
3/7 - The Diagnosis II

Some have resorted to random skin biopsies to make the diagnosis of IVL.

And multiple case series have demonstrated that a diagnosis of IVL can be made this way, even when the skin appears normal.

pubmed.ncbi.nlm.nih.gov/18053461/Image
Read 7 tweets
Tony Breu Profile picture
Jun 20, 2024
1/11
🤔Why does chronic hepatitis C infection "require" the intermediary of cirrhosis in order to cause hepatocellular carcinoma (HCC)?

Chronic hepatitis B can "skip" this step, going directly from chronic infection to HCC.

Why the difference?
2/
 To begin, let's look at how frequently HCC occurs in patients without cirrhosis.

A 2019 study of United States (US) medical centers included 5144 patients with HCC.

💡12% had no underlying cirrhosis

pubmed.ncbi.nlm.nih.gov/31475372/
3/
 A 2022 study found a similar rate, with 13% of patients with HCC showing no evidence of cirrhosis.

When looking more specifically at hepatitis C (HCV) versus hepatitis B (HBV), they found varying rates:

➣ HCV: 6% of patients with HCC were non-cirrhotic
➣ HBV: 19% of patients with HCC were non-cirrhotic

pubmed.ncbi.nlm.nih.gov/34027591/Image
Read 11 tweets
Tony Breu Profile picture
Apr 9, 2024
1/12 - Mystery #1

You are seeing a patient recently diagnosed with heart failure and started on GDMT. You notice that their hemoglobin (HGB) has increased (12 → 13 g/dL) in the intervening weeks.

🤔Which medication is the likely cause of this increase in HGB?
2/12 - An Answer

Empagliflozin

💡All SGLT2 inhibitors have been associated with an increase in hematocrit/hemoglobin soon after initiation.

The average increase is 2.3% in hematocrit and 0.6 g/dL in hemoglobin.

ncbi.nlm.nih.gov/pmc/articles/P…Image
3/12 - An Initial Explanation (I)

The effect of SGLT2 inhibitors on HCT/HGB has been noted since the very first randomized control trial of dapagliflozin, published in 2010.

Initially, investigators assumed this was related to the diuretic effect of these drugs (i.e., a reduction in plasma volume led to an increase in HCT/HGB).

pubmed.ncbi.nlm.nih.gov/20609968/Image
Read 12 tweets

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