Nick Mark MD Profile picture
Apr 15 5 tweets 3 min read Twitter logo Read on Twitter
Here’s a fun medical puzzle: what does this antidote (Sugammadex) have in common with this cleaning product (Febreze)?

1/ ImageImage
The answer is the chemical structures for both are cyclodextrins!

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Sugammadex Febreze ImageImage
Cyclodextrins are rings of glucose molecules linked together by α-1,4 glycosidic bonds.

Depending on the size, these ring can trap other molecules inside it.

For example, a 7 glucose (beta) cyclodextrin called Febreze can trap small odor molecules & neutralize smells.
3/ ImageImage
Sugammadex reverses neuromuscular blockers like rocuronium by trapping the medication inside the cyclodextrin ring, away from the acetylcholine receptor.

This reverses NMB without cholinergic side effects.
pubs.acs.org/doi/10.1021/jm…
4/ ImageImage
Anyway, hope you enjoyed the connection between pharmacology & home cleaning.

I thought this structure looked so cool that I made it into a clock!

(Aside: It’s pretty hard to read base 12 time on a clock with 7-fold symmetry)

5/5 Image

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More from @nickmmark

Apr 13
This is an important & thought provoking meta-analysis about the potential harms of propofol.

I think this should (& almost certainly will) inspire important future studies.

But it won’t change my practice in the ICU quite yet. Here’s a 🧵 about why.
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First, this finding was driven by OR mortality, particularly in cardiac surgery patients.

ICU mortality was non-significant. (p=0.5). Additionally this is an unadjusted p-value, so if we correct for multiple comparisons it’s even more insignificant.

2/ Image
The OR and the ICU are different places & propofol is used differently: higher doses & boluses are frequent in the OR whereas low doses with daily interruptions are common in the ICU.

In short, I don’t think it’s reasonable to extrapolate an OR finding onto an ICU population.
3/
Read 9 tweets
Apr 2
Much has been made of the declining life expectancy in the US.

The reality is regional. Think of the US as two countries:

Some blue counties with increasing life-expectancy better than 🇯🇵 (84) & many red counties with plummeting life expectancy worse than 🇷🇺 (71).
1/
Compare the narrow variation between prefectures in Japan (range 82-84) with the wide variation among US states (range 71-81).

🇺🇸 cdc.gov/nchs/pressroom…

🇯🇵 en.wikipedia.org/wiki/List_of_J…

2/
It’s not that the “US healthcare system is bad” it’s more that access to healthcare varies wildly.

The latent confounder is poverty. This is illustrated by this @FinancialTimes comparison of life expectancy in the 🇺🇸 & 🇬🇧:
3/
Read 12 tweets
Mar 12
The usual anti-vax suspects are talking about a paper “proving masks raise CO2 to harmful levels.”

Well I read it and it’s a bunch of non clinical wackos who used the wrong equipment to accidentally measure end tidal CO2.

A debunking 🧵

1/
Before we get to the paper with it’s very flawed methods & conclusions, let’s talk about the authors.
2/
The lead author - Harald Wallach - a psychologist with no training in respiratory medicine or physiology, previously won a prize for “most astonishing pseudo-scientific nuisance of the year”

His prior pandemic publications were retracted within days.

en.wikipedia.org/wiki/Harald_Wa…
3/
Read 14 tweets
Mar 3
In 2021, Stella Immanuel wrote over 69,000 prescriptions for hydroxychloroquine & almost 32,000 prescriptions for ivermectin.

This continued in 2022, with 30,996 prescriptions for hydroxychloroquine & 16,085 for ivermectin.

Why don’t medical boards act?
medpagetoday.com/special-report…
To put this another way 69k / 365 = 189 Rx per day

Even if she worked 12 hours every day, that’s 14 Rx per hour. Or one every 4 minutes.

There is simply no way she could have taken a history, reviewed medications/allergies & adequately counseled about the risks/benefits.

2/
With almost 150k ineffective prescriptions there is a statistical near certainty that this doctor has caused significant harm.

How many people had cardiac arrhythmias, allergic reactions, or other side effects?

3/
Read 7 tweets
Feb 26
Like all quacks, the FLCCC’s claims about their miracle cures get ever bigger with time.

Now, despite a glut of negative RCTs in COVID, they claim that ivermectin cures influenza & RSV.

Anything to keep the snake oil gravy train running.

washingtonpost.com/health/2023/02…
Fact check: Marik was fired (he claims he resigned) from EVMS in late 2021. With no institution willing to hire him, he was *unable* to renew his university limited license. His license to practice medicine expired in 2022.

TL/DR: as interest in ivermectin wanes, this group of disgraced former ICU doctors will say & do anything to stay relevant.

Reminder that Kory charges between $1250-1600 for a 5 minutes phone consult & ivermectin prescription.
Read 4 tweets
Feb 25
Here’s a critical care puzzle & illustrates some important cardiopulmonary physiology:

These two pictures were taken just an hour apart. What intervention was done in between that changed the respiratory pattern? (Red box)

Multiple choice & answers in the 🧵.

1/ ImageImage
The intervention was:

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This is Cheyne-Stokes Respirations (CSR) in a person with heart failure.

The intervention was dobutamine (an inotrope).

Cheyne-Stokes is a characteristically regular crescendo-descresendo respiratory pattern with interspersed periods of apnea.
3/ ImageImageImage
Read 25 tweets

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