1/🧵
Ever wonder why cutting onions makes you cry?

Something must be released that causes this irritating response, but what?

It turns out that cutting an onion jumpstarts multiple chemical reactions, in the air and right in front of your eyes.

#medtwitter #tweetorial 🧅
2/
💡Onions are actually one of the oldest cultivated crops, first entering the human diet ~5,000-7,000 years ago.

Ancient Egyptians worshipped onions (evoked eternity) and ancient Indians, Greeks, and Romans believed that they had medicinal properties.

onions-usa.org/all-about-onio…
3/
But as anyone who has ever cut or chopped an onion knows, the simple act of chopping them causes almost immediate eye irritation and tearing.

Why?
4/
First we need to confirm what occurs at the cellular level when an onion is cut.

🔑It turns out that with damage to the onion's cell walls, a specific sulfur compound is released into the air:

S-alkenyl cysteine sulfoxide

pubmed.ncbi.nlm.nih.gov/23443367/
5/
Along with S-alkenyl cysteine sulfoxide, an enzyme called allinase also gets released into the air from the onion.

Allinase converts the sulfoxide molecule into sulfenic acids.

💥This reaction occurs IN THE AIR, mind you.

pubmed.ncbi.nlm.nih.gov/23443367/
6/
Sulfenic acids happen to be very unstable and spontaneously rearrange to thiosulfinates.

Thiosulfinates give onions their pungent aroma/flavor and were once assumed be the source of onion-crying.

pubmed.ncbi.nlm.nih.gov/23443367/
7/
But it turns out that thiosulfinates, while the source of an onion's flavor, are not the source of eye irritation and crying.

In 1971, two chemists isolated a tear-inducing substance from onion extract, a so-called "lachrymatory factor".

pubs.acs.org/doi/abs/10.102…
8/
🔑The lachrymatory factor they found is actually propanethial-S-oxide.

It also derives from sulfenic acids, but requires enzymatic conversion by a second enzyme called lachrymatory factor synthase (LFS).

pubmed.ncbi.nlm.nih.gov/12384686/
9/
So we have established that the source of crying with onion cutting is propanethial-S-oxide, the lachrymatory factor.

How lachrymatory factor induces crying isn't well established but it seems to act as a direct corneal irritant.

iovs.arvojournals.org/article.aspx?a…
10/
Can we prevent this irritating effect?

Contact lenses block propanethial-S-oxide's access to the cornea via barrier action.

In this small study, contacts delayed the onset of irritation compared to no lenses after exposure to propanethial-S-oxide.

iovs.arvojournals.org/article.aspx?a…
11/
3 other potential strategies:

🧅 Goggles

🧅 Chilling onions may ⬇️ lachrymatory factor synthase activity and ⬇️ propanethial-S-oxide production.

🧅 Some believe that cutting onions under running water washes away propanethial-S-oxide as it forms.

pubmed.ncbi.nlm.nih.gov/3975593/
12/
Two final questions. First:

Garlic + scallions are closely related to onions, from the genus Allium.

Why don't we cry w/ chopping them?

💡Scallions + garlic can't make propanethial-S-oxide as they lack the lachrymatory factor synthase enzyme.

pubmed.ncbi.nlm.nih.gov/12384686/
13/
Finally, could an onion be modified to not produce propanethial-S-oxide, the lachrymatory factor?

An onion unable to ultimately produce propanethial-S-oxide should be non-pungent and "tearless".
14/
A group in Japan did genetically transform an onion strain to lack lachrymatory factor synthase.

When cut, these onions cannot produce propanethial-S-oxide and do not cause crying.

They also apparently taste fairly bland.

ncbi.nlm.nih.gov/pmc/articles/P…
15/
🧅Cutting onions ➡️ crying b/c of multiple enzymatic reactions in the air
🧅Allinase converts a released sulfoxide to
sulfenic acids, which rearrange to thiosulfinates
🧅Lachrymatory factor synthase converts thiosulfinates to propanethial-S-oxide (=source of onion-crying)
Thank you for reading and happy cooking!

Cc the legendary @Nigella_Lawson, who might find this interesting.
Correcting a small error in the summary tweet:

Propanethial-S-oxide is derived from sulfenic acids by lachrymatory factor synthase, not from thiosulfinates.

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More from @AvrahamCooperMD

3 Oct
1/🧵
Did you know that heparin can cause hyperkalemia?

But why would an anticoagulant like heparin increase serum K⁺ levels?

The answer also has a wild implication - that heparin may itself have a diuretic effect...

#medtwitter #tweetorial
2/
The first report of heparin-associated hyperkalemia occurred in 1964.

A patient had extended heparin exposure and developed progressive hyperkalemia (peak K⁺ level was 6.4 mEq/L), without another explanation.

pubmed.ncbi.nlm.nih.gov/14142415/
3/
Multiple subsequent case series reported hyperkalemia after heparin exposure.

💡While the exact incidence of heparin-associated hyperkalemia is unknown, it has been estimated at about 7%.

pubmed.ncbi.nlm.nih.gov/7778574/
Read 19 tweets
6 Sep
I just finished reading One by One by One by @AaronLBerkowitz

4 thoughts:

1️⃣ This is a beautiful book. Aaron writes with lucidity and a deep sense of shared humanity

#medtwitter Image
2️⃣ I ❤️ the way he zooms in on individual stories and then zooms out. One chapter he’s in a ramshackle hut in rural Haiti, the next he’s building Haiti’s first neurology residency or meditating on the sociocultural basis for global health inequities
3️⃣ Through the stories he tells he actually manages to teach a decent bit of neurology (whether intentional or not)
Read 4 tweets
5 Sep
1/🧵
Why does Wenckebach AV nodal block (aka Mobitz type 1) present with progressive prolongation of the PR interval and eventually a non-conducted P wave? 

What causes this unique EKG pattern to arise?

#medtwitter #tweetorial
2/
Karel Frederik Wenckebach, a Dutch anatomist/physician, noticed a patient’s irregular pulse in 1898.

He astutely noted a repeating cycle of:
🫀 Progressive delay b/w the 𝑎 jugular venous wave and carotid pulsation
🫀 An 𝑎 wave w/o carotid pulsation

ncbi.nlm.nih.gov/pmc/articles/P…
3/
The pattern Wenckebach observed corresponds exactly w/ the progressive PR prolongation, followed by a non-conducted P wave, that characterizes what we call “Wenckebach” heart block.

💥 Amazingly, he observed this BEFORE the AV node was discovered.

litfl.com/karel-frederik…
Read 14 tweets
11 Jul
1/🧵

This is the incredible story of an anesthesiologist who, in 1946, purposefully paralyzed himself using curare.

Though conditions were controlled, by the end of the experiment he was wide awake and fully paralyzed, without any sedation.

#histmed #medtwitter #tweetorial
2/
Context:
Purified forms of the neuromuscular blocker curare came into clinical use for general anesthesia in the 1930s and 1940s.

There was an active debate at the time about whether curare causes paralysis alone or if it also sedates.

pubmed.ncbi.nlm.nih.gov/15402044/
3/
This question had major implications for the nascent field of anesthesiology.

Some practitioners began to use curare alone during surgery, without sedation, believing that curare adequately sedated patients in addition to paralyzing them.

pubmed.ncbi.nlm.nih.gov/15402044/
Read 23 tweets
23 May
1/🧵

Ever wonder why severe hypertriglyceridemia causes acute pancreatitis?

Are triglycerides themselves toxic to the pancreas or is there something else going on?

#tweetorial #medtwitter
2/
The association b/w ⬆️ triglycerides and pancreatitis was proposed after a 1975 study.

11 patients w/ previous pancreatitis volunteered to receive lipid-rich diets, increasing triglyceride levels to >600 mg/dL.

7/11 got recurrent pancreatitis. 

pubmed.ncbi.nlm.nih.gov/1145440/
3/
Hypertriglyceridemia actually accounts for up to ~10% of acute pancreatitis cases.

There is even a dose-response relationship, w/ the risk of pancreatitis increasing with higher serum triglyceride levels.

pubmed.ncbi.nlm.nih.gov/22898632/
Read 14 tweets
4 May
5:30 pm.

3rd year of medical school.

Internal medicine clerkship.

Medically “routine” evening discharge.

The patient happened to be homeless.

Tasks my resident gave me to do: make sure the patient had their prescriptions, a place to stay and a way to get there.
First I headed straight to the hospital pharmacy before they closed and picked up the scripts.

Then a taxi voucher from the nurses station.

Quick Google search and printed off 3 shelter options.

All of it went in a bag that we gave to the patient.
The whole thing took maybe 15 minutes.

I can still remember the look on her face when we gave her the bag.

Like she’d been seen and heard and cared about for the first time in a long while.
Read 4 tweets

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