"Doctor, my vitamin D levels are only 9. I am always tired"

Frequent scenario in my clinic and this is how I approach this . A🧵

1,25(OH)2 VitD is the active form of vitD in our body. But the levels of 1,25(OH)2 is almost always normal in vitD deficiency. This is why we doctors always recommend checking serum levels of 25(OH) vitamin D to evaluate vitamin D deficiency.

You see, 25(OH) vitamin D is the primary form that circulates and gets stored in your body. On the other hand, levels of 1,25(OH)2 vitamin D, which is the active form, are seldom requested by physicians because they're not meant for diagnosing deficiency. Instead, they're useful for investigating elevated calcium levels due to conditions like granulomatous diseases, but let's keep our focus on vitamin D deficiency for now. Most crucially, remember that 1,25(OH)2 assays are available in labs, so avoid mistakenly ordering them just to screen for vitamin D deficiency.

I want to ascertain something here. There are myriad causes of tiredness, and I will not jump the gun here just by seeing a low serum vitamin D report and calling it. I would definitely rule out other causes of fatigue, but now will stick to vitamin D deficiency for the sake of our discussion here. Read on….

Vitamin D deficiency is mainly diagnosed by measuring serum 25-hydroxyvitamin D (25(OH)D), the key biomarker for vitamin D status, as it reflects skin production, diet, and supplementation effects.
Thresholds generally classify deficiency below 20 ng/mL (50 nmol/L), insufficiency at 20-30 ng/mL (50-75 nmol/L), and sufficiency at 30-50 ng/mL (75-125 nmol/L), though these lack full agreement and stem from observational studies rather than trials.

Routine checking isn't recommended for symptom-free people, but it's advised for high-risk groups like those with malabsorption, chronic kidney disease, obesity (BMI >30 kg/m²), dark skin, low sun exposure, or symptoms such as bone/muscle pain.

🔸Why is vitamin D important to our body?
Vitamin D plays a pivotal role in regulating calcium and phosphorus homeostasis by enhancing their intestinal absorption, promoting renal reabsorption, and supporting bone mineralization, which helps prevent conditions like rickets in children or osteomalacia/osteoporosis in adults. It also modulates your immune response by fine-tuning immunity, potentially reducing susceptibility to infections and chronic inflammation. On top of that, its pleiotropic effects extend to cardiovascular protection and lowering all-cause mortality, while optimizing maternal-fetal outcomes during pregnancy through various signaling pathways in cells.

🔸What causes vitamin D deficiency?
There are many causes of low vitamin D levels in the body. Here, I am strictly sticking to nutritional and lifestyle-related causes to avoid the risk of overwhelming you.

Older people often ask me this question: "Vitamin D deficiency was not common in our times. Why is it so common now? What changed?

Well, the short answer is nutritional choices and low sun exposure. You can understand this answer if you compare your lifestyle and food choices with the older generation.

🔸How does our body get vitamin D?
Vitamin D is more of a hormone than a vitamin if you have understood its action. The body is capable of creating its own vitamin D in the skin if it gets exposed to UV rays. When the skin is exposed to UV rays, an intermediate of cholesterol metabolism called 7-dehydrocholesterol, which is present in the skin cells, gets converted to vitamin D3 (cholecalciferol). This vitamin D3 then gets hydroxylated in the liver and finally in the kidneys to form the active form, 1,25(OH)2 vitamin D. Medical societies have come to the conclusion that merely sunlight exposure may not be enough for meeting the daily vitamin D requirements. Read on.... The other source of vitamin D is from the diet. It is obvious that if the diet is not proper and there is low sunlight exposure, the chances of vitamin D deficiency increases, as the daily recommended intake is 600-800 IU/day. So, supplementation may be required.

💥AMIODARONE is a class III antiarrhythmic drug which is widely used in ER for treating arrhythmias.

A 🧵 on situations where blind use of amiodarone in emergency can be counterproductive ⚠️⚠️⚠️

With alternate therapeutic options

Read on...👇
#MedTwitter #MedEd #MedX ❌️Arrhythmias secondary to prolonged QT interval.

Amiodarone can furthur prolong QT resulting in asystole or VF.

✅️Use DC shock in unstable , MgSO4 in stable TdP, treat underlying cause of prolonged QT.

image @LITFLblog

A 🧵 on chest Xray signs in pulmonary thromboembolism. The 𝗙𝗹𝗲𝗶𝘀𝗰𝗵𝗻𝗲𝗿 𝘀𝗶𝗴𝗻 is a prominent central artery that can be caused either by pulmonary hypertension or by distension of the vessel by a large pulmonary embolus seen on chest x ray.

The BRUGADA family has contributed immensely to field of
🫀Cardiology & Electrophysiology

A 🧵 on

💥𝗕𝗥𝗨𝗚𝗔𝗗𝗔 𝗘𝗣𝗢𝗡𝗬𝗠𝗦
☑️Brugada Syndrome
✅️Brugada Pattern
☑️Brugada Phenocopy
✅️Brugada Algorithm
☑️Brugada Criteria
✅️Brugada Sign

#MedTwitter #MedX
Read on👇 💥𝗕𝗿𝘂𝗴𝗮𝗱𝗮 𝗦𝘆𝗻𝗱𝗿𝗼𝗺𝗲 (BrS)
is a rare arrhythmogenic cardiac channelopathy characterised by ECG findings of ➡️

🔴 ≥0.2mV of ST segment elevation
➕️
🔴 Negative T-wave in more than one anterior precordial leads (v1 v2, v3)

💥Smith 𝘦𝘵 𝘢𝘭. reported draining a world record of 41 𝗹𝗶𝘁𝗿𝗲𝘀 of ascitic fluid in a single paracentesis session of a patient with decompensated cirrhosis.

How much Albumin would be needed in this case to prevent post paracentesis circulatory dysfunction ? 🧵 Read on👇

A 🧵 on important points to consider while performing Large Volume Paracentesis (LVP)

𝘏𝘰𝘸 𝘮𝘶𝘤𝘩 𝘢𝘭𝘣𝘶𝘮𝘪𝘯 𝘪𝘴 𝘵𝘰 𝘣𝘦 𝘪𝘯𝘧𝘶𝘴𝘦𝘥 𝘥𝘶𝘳𝘪𝘯𝘨 𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘪𝘯𝘨 𝘓𝘝𝘗❓️

𝘞𝘩𝘢𝘵 𝘪𝘴 𝘵𝘩𝘦 𝘮𝘢𝘹𝘪𝘮𝘶𝘮 𝘢𝘮𝘰𝘶𝘯𝘵 𝘰𝘧 𝘢𝘴𝘤𝘪𝘵𝘪𝘤 𝘧𝘭𝘶𝘪𝘥 𝘵𝘩𝘢𝘵 𝘤𝘢𝘯 𝘣𝘦 𝘥𝘳𝘢𝘪𝘯𝘦𝘥❓️

🛑Large Volume Paracentesis(LVP)
is arbitrarily defined as a paracentesis with >5 L of ascitic fluid drained.

In patients undergoing LVP, the use of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD).

The clinical manifestations of PPCD include renal impairment, including HRS, dilutional hyponatremia, hepatic encephalopathy and death.

Albumin infusion is particularly important if more than 5 L of ascites are removed to prevent the development of PPCD.

Paracenteses of a smaller volume(<5L) are not associated with significant hemodynamic changes and albumin infusion may not be required.

Although there has not been a dose‐response study on albumin use with LVP, the administration of 6‐8 g of albumin per liter of ascites removed has been recommended.

💥For example, after the fifth liter, approximately 40 g of albumin should be infused, and after 8 L removal, the amount of albumin given should be approximately 64 g.

It has been held that there is no limit for the amount of ascites that can be removed in a single session, provided an appropriate amount of albumin is administered.

However, the risk of PPCD increases with >8 L of fluid evacuated in one single session.

A study showed that by limiting the LVP volume to <8 L per session and providing a higher than recommended dose of albumin (9.0 ± 2.5 g per liter of ascites removed), renal function and survival may be better preserved over a mean period of 2 years despite the development of PPCD in 40% of patients.

In patients with hemodynamic instability (systolic blood pressure <90 mm Hg), hyponatremia (serum sodium <130 mmol/L), and/or the presence of AKI, albumin infusion should be strongly considered for paracentesis of a smaller volume.

LVP is a safe procedure even in the presence of coagulopathy. In a study that included patients with an international normalized ratio of >1.5 and a platelet count of <50 × 109/L, only 1% of patients experienced minimal cutaneous bleeding after LVP.

Therefore, elevated prothrombin time or thrombocytopenia is not a contraindication for paracentesis, nor is transfusion of clotting factors or platelets recommended.

Possible exceptions may include patients with disseminated intravascular coagulation or uremia with thrombocytopenia.

1/3 👇 𝘾𝙤𝙣𝙩. 💥Ideal site for needle insertion in abdominal paracentesis

For patients with high blood pressure.

Please read !

If you have 𝙃𝙔𝙋𝙀𝙍𝙏𝙀𝙉𝙎𝙄𝙊𝙉 try to make the following diet and lifestyle changes.

1. Consider 🌺hibiscus tea, pomegranate juice, beetroot juice and cocoa as they are rich in nitrates and lowers BP.

1/16 2. Alcohol consumption should be zero for the best cardiovascular health.

Immediate adverse effects can lead to heart beat rythm disturbances, increase risk for accidents etc.

Long term consumption is associated with adverse effects on heart and liver & also can cause cancer.

🌟 MALAR RASH- A🧵

🔸️Malar rash is classically described in SLE as a "butterfly" shaped erythematous rash in the malar distribution, which includes the cheeks and crosses the nasal bridge but spares the nasolabial folds.

Let's look at the mimickers👇

Do read the whole🧵 🌟 Systemic Lupus Erythematosus

🔸️Classic finding in SLE

🔸️The ORIGINAL Malar Rash🦋

From Kelley's Textbook of Rheumatology, 9e

🌟 SGLT2i and UTI - A 🧵

There is ❌️ NO convincing evidence that the use of SGLT-2 inhibitors is associated with an increased risk of UTI according to this expert consensus statement. (PMID- 37153973)

Concerns about UTIs should not be a deterrent to initiating SGLT-2i...👇 ▫️In patients with T2DM and atherosclerotic risk factors, SGLT-2i should be used for its organ protective benefits such as reducing the risk of hospitalization for heart failure and kidney disease progression, regardless of glycemic control.

Honourable citizens, please read this!

A🧵 on Cardiopulmonary Resuscitation #CPR

When to start CPR in a person ❓️

How to do effective CPR❓️

What is this👇 device❓️ If you "feel" like somebody has collapsed and has a cardiac arrest, start CPR.

Before starting CPR ensure that the victim is positioned flat on ground/bed.

Ensure that you are in a safe space

Call Ambulance

Start CPR.

▪️
▪️
▪️
A🧵 on management of hypertensive emergencies.

The 𝗕𝗔𝗥𝗞𝗛 algorithm for management of hypertensive emergencies and end-organ damage

𝗕 - Brain
𝗔 - Arteries
𝗥 - Retina
𝗞 - Kidney
𝗛 - Heart

#MedTwitter #MedEd #MedX

Read on 👇 for BP Lowering rate and goals. Hypertensive urgency, hypertensive crisis & malignant hypertension are terms that have been used to describe severely elevated BP with no evidence of end-organ damage.

Hypertensive emergency is a clinical syndrome of significantly elevated BP that is assoc with end-organ damage.

If you have 𝙃𝙔𝙋𝙀𝙍𝙏𝙀𝙉𝙎𝙄𝙊𝙉 try to make the following diet and lifestyle changes.

⚠️ Discuss with your doctor before attempting. #hypertension

1. Consider hibiscus tea, pomegranate juice, beetroot juice and cocoa as they are rich in nitrates and lowers BP.

1/15 If you don't want a thorough read, just scroll through the images to get an idea.

I recommend to go through the whole 🧵 as it is an extract of recommendations from the apex global medical body on hypertension-
International Society of Hypertension ( ISH)

Let's go..

Pregnant lady with fever and chills.

Treated with Artesunate + Artemether

Requires radical therapy for eradication of hypnozoites.

How to give radical therapy for plasmodium vivax malaria in pregnancy❓️

Is primaquine safe ❓️

A🧵

#MedTwitter #MedEd #MedX Radical cure is given with Primaquine in P vivax and P. Ovale malaria.

Primaquine causes severe hemolysis in patients with G6PD deficiency.

So testing for G6PD is to be done before giving primaquine.

Lamotrigine, Levetiracetam & Oxcarbazepine prefered in pregnancy.

American Academy of Neurology, American Epilepsy Society, Society for Maternal-Fetal Medicine -

𝗚𝗨𝗜𝗗𝗘𝗟𝗜𝗡𝗘𝗦 on drug therapy of epilepsy in pregnancy just dropped.

A 🧵 on recommendations👇

#MedTwitter Recommendations regarding the effects of antiseizure medications (ASMs) and folic acid supplementation on the prevalence of major congenital malformations (MCMs) & adverse perinatal outcomes in children born to people with epilepsy of childbearing potential (PWECP).

Read on.. 👇

A 🧵 on recommendations on steroid therapy

First a question ❓️

45 Yr male diagnosed with Tuberculous Meningitis was started on antitubercular drugs and 60mg presnisolone daily.

How do you plan to taper and stop steroids❓️

#MedTwitter #MedEd #MedX #steroid What is steroid eqivalence ❓️

How to taper steroids ❓️

What is fast and slow taper ❓️

How to monitor if tapering is optimal❓️

What is therapeutic taper and endocrine taper ❓️

Read on for answers ....

#MedTwitter #CPR #MedX

💥 𝗖𝗣𝗥

A🧵 on high quality Cardiopulmonary Resuscitation

The tempo of 1977 song "Stayin Alive" by Bee Gees has the same rate as chest compressions given during CPR

5️⃣ main components of high-performance CPR have been identified.....Read on👇 5️⃣ main components of high-performance CPR

👆Chest compression fraction (CCF)

✌️Chest compression rate

🤟 Chest compression depth

👊 Chest recoil

🤚 Ventilation

Uncomplicated Urinary Tract Infection ( UTI) in females is a spot diagnosis based on history alone.

A 🧵 on differences in approaching UTI on gender basis👇

#MedTwitter #MedEd #MedX UTI in the age group <1yr is more common in males as congenital urinary anomalies are more common in ♂️

In age group >50yrs the gender distribution of UTI is equal for ♂️ & ♀️

💥💥💥 Between 1- 50 years of age, UTI and recurrent UTI are predominantly diseases of ♀️

A 🧵 on 🏮𝗛𝗬𝗣𝗢𝗦𝗣𝗟𝗘𝗡𝗜𝗦𝗠

Few questions

🛑 46yrs old male patient with hypersplenism due to tropical splenomegaly is planned to undergo splenectomy.

What all vaccinations should he receive❓️

What should be the ideal timing for vaccinations❓️

#MedTwitter #MedX 👇 Asplenia and hyposplenism can be either anatomic or functional.

Anatomic asplenia is most often due to surgical removal of the spleen.

Functional asplenia and hyposplenism result from conditions that lead to atrophy, infarction, engorgement, or infiltration of the spleen.

A🧵 on
5️⃣ categories of ascitic fluid infection that can happen in long standing ASCITES
#MedTwitter #MedEd #MedX

First a question ❓️

A patient with ascites underwent difficult and traumatic paracentesis.
......contiunued in 🧵 👇 Ascitic fluid analysis had PMN count of 100/mm3 & multiple organisms were grown on culture of fluid.

Diagnosis❓️

A.SBP
B.Secondary bacterial peritonitis
C.Polymicrobial bacterascites

Did you know that the tunable diaphragm technology of
3𝗠 Littmann stethescopes🩺
helps you to convert the chest piece into a bell & diaphragm merely by application of pressure.

No need to turn it to hear different frequencies of sounds on auscultation.

More in 🧵
#MedTwitter First of all, let's review the parts of a conventional stethescope.

🧠 CSF HSV PCR is diagnostic of HSV encephalitis but may be negative if done during the first 72h of onset of illness.

A🧵 on

Why is it important to distinguish herpes simplex encephalitis from other viral encephalitis & how to do that❓️

#MedTwitter #MedEd #MedX The distinction of HSV encephalitis from other viral
encephalitis is important because in virtually every other instance the therapy is supportive, whereas
specific antiviral therapy💉 is available for HSV, and its efficacy is enhanced when it is instituted early.

A🧵

This 🇮🇳 doctor is the co-author of one of the most highly cited scientific papers in the world & also is credited with the discovery of

💥ATP
💥Folic acid
💥Methotrexate
💥Aureomycin (the parent of tetracycline)
💥Diethylcarbamazine

Do you know his name❓️

#MedTwitter Millions live longer, more satisfying lives because of folic acid vitamin, tetracycline antibiotics anti-filarial and anti-cancer drugs developed under the research direction of Dr. Yellapragada Subbarow🙏