David Juurlink Profile picture
Jun 23, 2021 7 tweets 3 min read Read on X
ACIP's slides on mRNA vaccines and myocarditis are now available cdc.gov/vaccines/acip/…

Hard to argue this isn't causal
The signal by age and dose is not ambiguous
Risk clearly seems highest among young males
Important to note: anyone can report anything to VAERS

When they dig into 29 *confirmed* cases:
- majority were hospitalized
- 2 required ICU care
- all were eventually discharged
The rates here are a bit misleading because teens are lumped in with twenty- and thirtysomethings. (To be fair, they have to do this because counts are so low.)
It's fair to call vaccine-associated myocarditis rare or very rare. And it's reassuring that most of those who develop it do well.

Still waiting to see more detail from Israel sciencemag.org/news/2021/06/i…
I am a big proponent of vaccination, but I think it's fair to ask a question:

What is the incremental benefit of a second dose in young males (say, under 25), especially as more and more older people are fully vaccinated?

/ end

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More from @DavidJuurlink

Apr 1
Surprised to see losartan topping this list.

When starting an ARB, losartan is the last option I'd go with, for one simple reason.

🧵 /1
Losartan is a prodrug with two active metabolites, both of which have weirdly cryptic names.

Most of the hypotensive response is mediated by EXP3174 (usually abbreviated E-3174).

/2


shorturl.at/ehiuB
Image
Losartan's metabolism to E-3174 is catalyzed by cytochrome P450 2C9 (CYP2C9), which like many other CYPs is highly polymorphic.

The *2 and *3 alleles confer reduced and very reduced function, respectively. And they are fairly common.

/3


humgenomics.biomedcentral.com/articles/10.11…
Image
Read 8 tweets
Dec 17, 2022
"Is this serotonin syndrome or NMS?"

In a patient with hyperthermia, altered mental status and neuromuscular abnormalities, evaluating 3 factors makes the distinction easier

🧵

/1
#1: The drugs

SS: 5-HT agonists, either in large amounts (OD) or in combination - SSRIs, some TCAs, MAOIs (incl. linezolid), opioids, St. John's wort, MDMA, Li⁺, others

NMS: D2 blockers - antipsychotics, metoclopramide; also, withdrawal of dopamine agonists (eg. L-dopa)

/2
#2: The time course

Serotonin syndrome: Rapid onset, typically escalating over hours

NMS: Evolves gradually over days or even weeks. Can fluctuate dramatically over the course of the day (eg. mute, withdrawn and rigid in the morning; speaking and moving in the afternoon)

/3
Read 6 tweets
Sep 24, 2022
Saddened to learn of the death of David Bailey, Canada's first four-minute-miler and the scientist who discovered, by sheer serendipity, that grapefruit juice interacts with dozens of medications.

I'll tell the story as David related it to me.

theglobeandmail.com/canada/article…

/1
In the late 80s, David was running a volunteer study to determine whether alcohol influenced the effect of felodipine.

To mask the taste of alcohol, he tried mixing it with various juices: orange, grape, apple. None of those worked.

/2
His wife said "We have lots of grapefruit juice concentrate in the freezer. Maybe try that?" So he did.

It didn't mask the alcohol well either, but David noticed something he hadn't seen with the other juices.

/3
Read 13 tweets
Aug 29, 2022
Hearing reports of a mass poisoning event related to a Markham restaurant, possibly involving aconite

Aconitine is a highly toxic alkaloid derived from the genus Aconitum (monkshood, wolfsbane and others)

Quick thread:

/1
Effects occur quickly and are chiefly GI, neurologic and cardiac

GI:
- nausea, vomiting, cramping

Neurologic:
- numbness (face and mouth, progressing to limbs)
- muscle weakness
- coma

Cardiac:
- hypotension, life-threatening arrhythmias

tandfonline.com/doi/abs/10.108…

/2 Image
Aconitine is a sodium channel opener. It binds them tightly in the open state, preventing inactivation. Hence the clinical features.

Deep dive on Na⁺ channel openers by @SteveCurryMD here: toxandhound.com/toxhound/ff-pl…

/3 Image
Read 6 tweets
Apr 9, 2022
So, who knew that dimenhydrinate (Dramamine, Gravol) is actually two drugs?

A short drug history thread.

/1
The antihistamine diphenhydramine (Benadryl) was developed in 1940.

It was effective but very sedating, which is why it’s marketed even today as over-the-counter sleep aids like Nytol.

/2
A few years later, a chemist named John Cusic working for G.D. Searle had an idea: overcome the sedation by combining diphenhydramine with a stimulant.

The stimulant he chose was 8-chlorotheophylline, a methylxanthine not that different from caffeine.

/3
Read 6 tweets
Dec 17, 2021
Since posting this last week I've spoken with dozens of colleagues who have the same concern.
Guy's and St. Thomas' Hospital in London now has 350(!) staff off work due to COVID, 25% more than just one day earlier.

theguardian.com/world/2021/dec…
A large hospital system can presumably handle a shock like that only for a short period.

But what happens when more staff get sick?
Read 8 tweets

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