Share this page!

Ann Marie Kumfer Profile picture
Twitter logo
16 Dec, 7 tweets, 3 min read
1/#tweetorial coagulopathy in liver disease and the role of vit K

Thanks to all who responded to the poll.
2/ Pts with cirrhosis are at higher risk of bleeding d/t ⬇️ factors, right? Not necessarily. In cirrhosis, there are ⬇️ in both anticoagulant and procoagulant factors in the liver. Additionally, factor VIII and VWF are usually increased.
3/ INR is only measuring a small part of the coagulation cascade, the extrinsic pathway (Factor VII). Additionally, variceal bleed is driven by ⬆️ portal pressure primarily.
4/ Study of patients with cirrhosis showed that there was no significant difference of VTE risk between INR quarterlies. ⬆️ INR was not protective against VTE.

pubmed.ncbi.nlm.nih.gov/20040609/
5/ TWDFNR suggested against checking/correcting INR prior to routine paracentesis.
journalofhospitalmedicine.com/jhospmed/artic…
6/ Things like thromboelastography (TEG) have been shown to ⬇️ blood product usage in variceal bleed (pubmed.ncbi.nlm.nih.gov/31148204/) but has not been shown to predict long-term mortality (pubmed.ncbi.nlm.nih.gov/32722691/) . TEG may be used more in future in defining bleeding vs vte risk.
7/ A brief review table from the below article posted by @k_vaishnani.
Summary: Pts with cirrhosis can have increased bleeding or clotting risk that is difficult to assess with standard coagulation factors.

journals.lww.com/ajg/Abstract/2…

• • •

Missing some Tweet in this thread? You can try to force a refresh
　

Keep Current with Ann Marie Kumfer

Ann Marie Kumfer Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @AnnKumfer

Ann Marie Kumfer Profile picture
15 Dec
Do you give vitamin K to pts with cirrhosis presenting with elevated INR? I would love to hear your thoughts about the topic.
Here are a few questions about Vit K in cirrhosis I wanted to answer. Please post additional articles on the topics that you know of. Question 1: Is there proof that patients with cirrhosis are Vit K deficient?
3/ It is proposed that patients w/ cirrhosis are at ⬆️ risk for Vit K def. I could find very few studies about this. This study of pediatric pts w/ cholestatic liver disease had high prevalence, but very different pop from most adults w/ cirrhosis. pubmed.ncbi.nlm.nih.gov/19502999/
Read 19 tweets
Ann Marie Kumfer Profile picture
7 Dec
#tweetorial To obtain blood cultures or not to culture? This was inspired by the ? from @reverendofdoubt and @GermHunterMD reply.

A pt w/ a hip fracture on POD1 has fever of 100.8. HR 90, BP 110/75, SpO2 96% ambient air. No localizing symptoms. Do you obtain blood cultures?
2/My reflex when I hear fever is to order blood cultures. It’s not wrong to make sure, right? As a resident, I remember grumbling at the ED for not ordering cultures on that CAP patient. First, what are the harms of ordering unnecessary blood cultures?
3/ Aside from the cost, there is a high rate of contamination on blood cultures from 0.6% to over 6%. In conditions with a low pretest probability of bacteremia, this represents a large prob that a + culture is contamination. ncbi.nlm.nih.gov/pmc/articles/P…
Read 15 tweets
Ann Marie Kumfer Profile picture
8 Nov
1/ #tweetorial Next on the skeptical diagnosis series, I wanted to address cellulitis. I always feel a little angst when I am called to admit a patient w/ cellulitis. Does the patient really have cellulitis? In what % of pts diagnosed with cellulitis is the diagnosis incorrect?
2/ Here, I will focus and diagnosis and mimics. I plan to discuss mng of cellulitis later. Studies show that in 30-33% in patients diagnosed with cellulitis, the diagnosis is incorrect.
3/ Of those with an incorrect diagnosis, around 85% percent do not need hospitalization and 92% did not need antibiotics. Misdiagnosis is associated with millions in increased healthcare costs and up to 9000 nosocomial infections.
pubmed.ncbi.nlm.nih.gov/27806170/
pubmed.ncbi.nlm.nih.gov/29453874/
Read 15 tweets
Ann Marie Kumfer Profile picture
6 Nov
1/Recapping some teaching points from @CPSolvers VMR today to keep me from refreshing NYT and 538 every 2 minutes. Thanks to @Flower_freeland for presenting an awesome case today.
clinicalproblemsolving.com/morning-report…
2/ Case: A 28yM diagnosed w/uveitis about 4-5 weeks prior p/w N/V, weight loss, diffuse weakness. Most uveitis is anterior involving the iris (iritis). Anterior usually painful (front of eye in innervated). Infections commonly unilateral, autoimmune may be bilateral Image
3/ Up to 50% of anterior uveitis is HLA-B27+. Lymphoma is an important mimic. Because the patient is from Vietnam, TB is the first thing that came to my mind. With TB, you should also thing of histo (and other funi). Knowing an immune status is important is working-up infection
Read 9 tweets
Ann Marie Kumfer Profile picture
20 Oct
#medtwitter 1/What are the top three diagnoses of which you automatically skeptical? My top 3 are UTI, cellulitis, and CAP. Before talking more about "UTIs:, I must repeat the mantra:
PYURIA DOES NOT = UTI.
I will focus mostly on pyuria
2/ Let's consider the following scenario: A young female comes in fever. Urinalysis is obtained that shows 10WBC, - nitrite negative. Boom! You have diagnosed UTI, done. Just kidding, if only it was that easy.
3/I highly suggest listening to the @thecurbsiders episode on UTI (thecurbsiders.com/podcast/231). An important point they make is that UTI is bacteruria + signs and symptoms that localize to the urinary tract. Bacteruria alone is not enough for treatment.
Read 15 tweets
Ann Marie Kumfer Profile picture
13 Sep
1/ #medtwitter #tweetorial Raise your hand if you have ever inappropriately checked an ammonia level.🙋
1. Why is ammonia ⬆️ in liver failure and how is this connected w/ encephalopathy?
2. When should levels be checked?
3. Aside from cirrhosis, what other conditions ⬆️ammonia?
2/ Ammonia is primarily produced by bacteria w/ urease enz in intestines but is also produced in muscle and the kidneys.

Table source: ccjm.org/content/76/4/2…
3/ 85% of ammonia is cleared by the liver through the urea cycle. 15% is cleared by muscle/kidneys. If the ammonia (/other nitrogenous waste) not metabolized it passes through the blood brain barrier glutamate>glutamine> astrocyte swelling and free radicals>encephalopathy.
Read 19 tweets

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!

Follow Us on Twitter!

Like this author's thread?

Get emails when @AnnKumfer has new unrolls!

Check out other threads from @AnnKumfer!

Read all threads by @AnnKumfer