1/Why do distal tube diuretics cause hyponatremia more often than loop diuretics? Important roles of the nephron include both the ability to dilute and concentrate the urine. The ability to concentrate the urine is maintained by hypertonic medullary gradient (d/t Na & urea). 2/Loop diuretics impair Na/Cl transport in the loop of Henle> loss of a hypertonic renal medulla. The nephron loses the ability of concentrate the urine causing increased water loss (hypotonic renal losses). However, the ability to dilute urine is maintained.

1/ #medtweetorial on bacteremia real or not real?
A 70yM comes in with SBO and tachycardia and leukocytosis. Blood cultures are sent on admission. 1 out of 2 comes back with Clostridium spp (not perfrigens/ septicum). To treat or not to treat? 2/While true bacteremia needs to be aggressively treated, there is also a high rate of contamination. Figuring out which blood cultures represent true infection can be tricky.

1/ Understanding #ANA #tweetorial a collab w/ @MithuRheum
You are seeing a 30yo patient in the clinic who is ? an elevated ANA titer. A few months ago she had 2 weeks of joint pains & a rash. As part of the evaluation, an ANA was+ with a titer of 1:80. What do you do next? 2/ The goal of this tweetorial is to understand the significance of ANA
What is ANA?
What are the rheumatological and non-rheumatologic causes of ANA elevation?
What is the significance of the ANA titer?
What is the significance of the pattern of ANA elevation?

#medtwitter Can you have a completely normal CSF profile in autoimmune encephalitis? (answer forthcoming) This table is from a 2019 review. Interestingly in LG11, IgLON5, and GlyR the majority have a completely normal CSF profile including oligoclonal bands. (ncbi.nlm.nih.gov/pmc/articles/P…)

1/#tweetorial coagulopathy in liver disease and the role of vit K

Thanks to all who responded to the poll.

https://twitter.com/AnnKumfer/status/1338939315586523139?s=20

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.

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?

#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?

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.

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

#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.

1/ #tweetorial Having doubt on gout? I teamed up with @MithuRheum to tackle the topic. Based on 2020 ACR guidelines (pubmed.ncbi.nlm.nih.gov/32391934/) and UTD. 2/ (made up case) Mr. G A 70yM w/ a PMH of PUD, CAD, T2DM, is hospitalized for HF. This morning, he developed a red, swollen knee. Cr 1.Arthrocentesis = 15,000 cells and – birefringent crystals. He had 3 gout flares this yr. You start:

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…

Really enjoyed @UnremarkableLab last night where we discussed HTN in the hospital.
You are an intern on night float and get called that a patient's BP is 195/110. You: For anyone who participated, I found this article a really helpful read. I also would suggest listening to the Annals of Call Podcast(acpjournals.org/doi/10.7326/A1…).

the-hospitalist.org/hospitalist/ar…

What infections are on your list for infection-induced thrombosis? Why do infections predispose to thrombosis?

Source: ncbi.nlm.nih.gov/pmc/articles/P… Here are some:
Bacterial: H. pylori, C. pneumoniae, M. pneumoniae, H. influenzae, S. pneumoniae, S.aureus, E.coli, Fusobacterium species, C burnetii
Vital: COVID-19, Influenza, EBV, CMV, HSV, VZV, HIV, Dengue, Hep A/C
What infections do you think of?
williams.medicine.wisc.edu/viral_coagulop…

11/ What if instead the pred dose is 7.5mg ? Should pt be given stress dose steroids? A JAMA review found in in patients on chronic steroids (pred doses 5-16mg) who received their usual daily dose of steroid on day of surgery, no cases of hypotension. pubmed.ncbi.nlm.nih.gov/19075176/ 12/ Who should be given stress-dose steroids and how much should be given?
1. Pts w/ adrenal insufficiency on physiological dose of steroids
2. Consider if receiving major surgery (ie cardiothoracic surgery or major abdominal surgery)

Table source: pubmed.ncbi.nlm.nih.gov/11779267/

#medtwitter You receive a pre-op request for consult asking about stress dose steroids:
A patient is on 50mg of prednisone for an inflammatory condition (started several weeks ago) & is undergoing an unrelated surgery. What steroid dose would you give on the day of surgery? 2/The first question is how much cortisol the body needs. Under normal circumstances, the body produces 10-12mg of cortisol a day (about 3 mg of prednisone). This occurs in a circadian rhythm:

Image source: slideplayer.com/slide/7644164/

#medstudenttwitter A review of syphilis testing
1/ Scenario 1: You are seeing a patient in clinic and obtain syphilis screening of HCM. For screening, a nontreponemaltest (RPR or VDRL) are usually sent first. What is the sensitivity of the RPR testing? 2/ RPR has on overall sens of 91, spec 95 but decreased sensitivity in primary syphilis (86%) RPR sens> VRDL (sens 78%). Nontreponemal can have false – in primary syphilis due to antibody formation or the prozone effect.

1/Having just finished residency, I am having morning report withdrawals. Thankfully, I was able to tune in yesterday for a great case.

https://twitter.com/uncimchiefs/status/1282717111295475718?s=20

.
Reposting my ANCA infographic below. I wanted to take some time to review drugs associated w/ vasculitis w/ + ANCA. 2/The morning report pearl is that with dual+ on Elisa ANCA testing (both MPO and PR3) consider a drug-induced vasculitis. When I think about dual + ANCA, levamisole-induced vasculitis comes to mind first.

1/The other day, I was looking at the chart of a patient who was admitted overnight for afib with RVR. Labs:
AST 11,000, ALT 8000, Tbili 7 (direct bili 5), Alk phos 230, INR 4.35 (not on AC)
Woah! I wanted to take some time to run through a differential. 2/ I find it is helpful to run through this check list
1. New or old? Hepatic panel 4 months ago was normal aside from mild alk phos 🔼
2. Hepatocellular vs Cholestatic process- This is hepatocellular pattern predominately although Tbili is elevated
3. Degree of elevation