🧵 Can we have cardiac dysfunction despite a normal ejection fraction?

Even with a normal LV ejection fraction (LVEF), early myocardial damage can exist — especially in conditions like systemic sclerosis, lupus, or diabetes.

Let’s explore how we can detect it early — before symptoms appear.

Lets explore about Speckle Tracking Echocardiography (STE) 👇

#Cardiology #Rheumatology #Echo #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope #MedTwitter #RheumTwitter @CelestinoGutirr Tweet 2/6

The science behind it:

The LV myocardium has spiral architecture — fibers run longitudinally, circumferentially, and radially.
Each fiber layer contributes to a different “strain” during contraction.

When the myocardium weakens, strain changes before EF drops.

Image source-ecgwave

🧵 Have you ever heard of MGTS?
Let me tell you a story about a clotting disorder that doesn’t play by the rules 👇

@DrAkhilX @IhabFathiSulima @Janetbirdope #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/10

The patient who didn’t fit the pattern

A 55-year-old man came with repeated clots — in his legs, lungs, even the brain.
He was already on anticoagulants. Still, new thromboses appeared.

Platelets? Mostly normal.

No heparin. No recent vaccine.
Something didn’t add up.

🧵 Lupus Anticoagulant testing — explained like a story

Imagine you’re in the lab.

A patient’s APTT is prolonged.

Now the question begins:
Is it a factor deficiency or a Lupus Anticoagulant (LAC)?

There are 3 detective routes to solve this 🕵️‍♂️👇

@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/4

1️⃣ The Classic Detective

Starts simple — one clue at a time.
Screen → Mix → Confirm.
•If APTT prolonged → do a mixing test (add normal plasma).
•If it corrects → it’s a factor deficiency.
•If not → check with confirmatory test (extra phospholipid).
If it corrects now → LAC caught!

⚠️ Downside: weak LACs may hide; depends too much on the “normal plasma” used.

You think you know how to convert steroids into one another.

But if someone asks, you’ll be scrambling for the messy table or MDCalc 🤯

Here’s my own easy way to remember it… 🧵👇

#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/5

Steroid Equivalent Dose (Pred = 1)
PHMD → 1 / 4 / 0.8 / 0.16

🧠 PHMD = Pred • Hydrocortisone • Methylpred • Dexamethasone

👉 Pred 5 mg = HC 20 mg = Methylpred 4 mg = Dexa 0.75 mg

💡 Trick: 4 double = 8 → 0.8
8 double = 16 → 0.16
(don’t forget the dot!)

🔑 Explanation:

•Pred is the reference = 1
•HC needs 4× the dose
•Methyl is slightly stronger (0.8× Pred)
•Dexa is very potent (only 0.16× Pred)

Did you know histiocytoses are not a single disease but a family of >100 rare entities?

New classification reshapes them into 5 groups (L, C, R, M, H)—each with its own biology, pathology, and treatment implications. Let’s unpack 👇

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/7

L group = Langerhans cell histiocytosis (LCH), Erdheim–Chester disease (ECD), Indeterminate CH, Mixed forms

👉 Most cases carry clonal MAPK pathway mutations

How to manage Antiphospholipid Syndrome (APS)? 🤔

It’s not one-size-fits-all. Management depends on 3 key scenarios:

1️⃣ Asymptomatic carrier
2️⃣ With thrombosis
3️⃣ In pregnancy

Here’s the algorithmic roadmap 🧵

#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2- Asymptomatic carrier

How do you manage an asymptomatic aPL-positive patient? 🤔

Not everyone needs anticoagulation.

👉 Key:
• Identify CVD risks—>statin
• Look for autoimmune disease—->HCQ
• LDA only for high-risk profiles

APS management begins with risk stratification, not blanket treatment.

❓How can one tiny chemical edit in your proteins — replacing arginine with citrulline — trigger rheumatoid arthritis (RA)?

Here’s the story of citrullination and ACPA 🧵👇

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@CelestinoGutirr Tweet 2:

Proteins contain the amino acid arginine.
Enzymes called PAD (peptidyl arginine deiminases) convert arginine → citrulline.

This calcium-dependent reaction is called citrullination (or deimination).
It’s a normal post-translational modification — but in RA it goes wrong.

🧵How Clinical Trials Revolutionized ANCA Vasculitis Maintenance 💥

From cyclophosphamide to rituximab — this is the journey of evidence, one trial at a time. 🔁
Facts. Timelines. Game-changers.

📚 A must-read for every physician, rheumatologist, nephrologist, pulmonologist & ophthalmologist.
This is how science shaped the standard of care 👇
@rheum_doctor @zach_wallace_md @VasculitisOrg @ACRheum @EULAR_org @vasculitis_UK @LoyolaRheum @DrChrisWincup
#ANCAVasculitis #Vasculitis #Rheumatology #MedTwitter #Autoimmune #NephTwitter #Immunology #SteroidSparing #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter

Thank you to George Deva Raja for the brilliant image design 1/
📍Why we needed trials
In the 90s, patients with ANCA vasculitis had to stay on oral cyclophosphamide (CYC) even after remission.
🧨 Yes, it worked — but came with…
• Infections
• Infertility
• Cancer risks

We needed safer maintenance options. Let’s see what trials found 👇

🧵She was 17. Her fingers turned white in the cold.

A doctor ordered an ANA.
It came back positive.
She stopped sleeping.
She was sure she had an autoimmune disease.
Then she met me.
Here’s what I told her—and why it matters👇

#VEDOSS #Raynauds #Rheumatology #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 1/
She had:
Raynaud’s (cold-induced finger color change)
No pain, ulcers, disability
ANA: Positive

Google made her believe she had Scleroderma.

But the truth?
Not every ANA-positive Raynaud’s means disaster.
Let me explain.

🧵 PAH in Systemic Sclerosis: What You Don’t See Can Kill

1/
A 45-year-old man with SSc asked me in clinic:
“Am I at risk for pulmonary hypertension? How will we catch it early?”

This is how I approach that critical question 👇

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter 2/ Definition of PAH

Confirmed via right heart catheterization:
•mPAP ≥ 20 mmHg
•PCWP ≤ 15 mmHg
•PVR ≥ 2 Wood units

Why it matters:
🔴 PAH is a leading cause of death in SSc
📊 PHAROS registry:
•3-year survival ~75%
•5-year survival ~63%
•8-year survival ~49%

🕒 Early detection is key.

🧵 Rheumatoid Factor (RF): When Antibodies Turn on Each Other

In a healthy immune system, antibodies target foreign invaders.
But sometimes, antibodies start targeting each other.

That’s the beginning of the story of Rheumatoid Factor (RF) — an autoantibody directed against the Fc portion of IgG.

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/
So why would the immune system make RF?
It may not be a mistake.

Originally, RF evolved as a clearance mechanism to remove immune complexes by making them larger and stickier → easier for the system to eliminate.

🧵1/
Yesterday, I saw a young woman with SLE & lupus nephritis, on steroids + mycophenolate, who came in with sudden right hip pain radiating to the knee.

She could barely walk.

What’s your first thought?

👉 AVN – Avascular Necrosis of the femoral head.

AVN is common in:
• SLE
• Patients on long-term steroids
• Also seen with alcohol, trauma, transplant, HIV

🦴 Most common site?
→ Femoral head (due to precarious blood supply).
Let’s decode AVN step by step 🔍

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/

🎯 Key X-ray Features of AVN:

📍Early:
• Normal or subtle geographic lucency
• Flattening of the articular surface

📍Advanced:
• Collapse of femoral head
• Thinning of acetabular cortex
• Joint space narrowing
Image -Radiology masterclass

1/
Today, I saw a patient in OPD—referred from Pulmonology to rule out CTD-ILD.
On history and examination, there were no overt features of connective tissue disease.
What to do now? Let’s walk through the clues.
#MedTwitter #RheumTwitter #ILD #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/
Sometimes ILD (Interstitial Lung Disease) can precede other CTD features.
This is called forme fruste ILD—when lung involvement is the first or only manifestation.
So, yes, we must still keep CTD on the radar.

Do you know why inflammatory arthritis flares with maximum stiffness in the early morning?
Why prednisolone is best taken at 2 AM?
Or why vaccines work better in the morning?
It all comes down to your circadian rhythm.
Let’s explore the science.
#MedTwitter #Chronobiology #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter Tweet 2:
Our body runs on a ~24-hour cycle called the circadian rhythm, controlled by genes like:
•CLOCK
•BMAL1
•PER (Period)
•CRY (Cryptochrome)

These regulate sleep, hormones, immune responses, and even inflammation.

1/
Starting a new series: How to interpret MSK X-rays using the ABCDE-S approach!

A systematic method every rheumatologist, radiologist, & learner should know.

Simple. Visual. High yield.
Let’s dive in!

#Radiology #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/
What is ABCDE-S?

A structured tool to read joint radiographs:

A – Articular (erosions: marginal / subchondral)
B – Bone
  ▶️ Productive: osteophytes, sclerosis, enthesophytes, syndesmophytes
  ▶️ Diminished: osteoporosis, cysts, focal osteolysis
C – Cartilage: joint space narrowing
D – Distribution: symmetry, joint pattern, small vs large joints
E – Extras: systemic clues (labs, age, sex)
S – Soft tissue

Today’s focus: Articular Erosions

🧵 Methotrexate: A Drug Born from Mistakes That Changed Medicine Forever

1/ When you hear Methotrexate (MTX), you probably think of Farber or Gubner. But the story actually begins in 1945 with Subbarow, an Indian-American scientist most people have never heard of.

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History But few know about the brilliant scientist who paved the way for its success—Dr. Yellapragada SubbaRow. Let’s uncover his story. 👇

2/ Born in rural India (1895), Dr. SubbaRow’s life was full of struggles.
•He studied at Madras Medical College, but due to his ties with the Indian independence movement, he was denied a full MBBS degree.
•Instead, he received a lesser Licentiate of Medicine & Surgery.

🧵 THREAD: Atlantoaxial Dislocation (AAD) in Rheumatoid Arthritis (RA) – The Silent but Dangerous Complication! 🦴💀

1/ What is Atlantoaxial Dislocation (AAD)?

AAD refers to instability between the atlas (C1) and axis (C2), leading to excessive movement and potential spinal cord compression. A serious but often overlooked complication of Rheumatoid Arthritis (RA). 🚨

#Rheumatology #Spine #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History 2/ Why does the cervical spine get involved in RA?
RA is a systemic inflammatory disease affecting any synovial joint, including the atlantoaxial joint (C1-C2). 🔥

📌 Chronic synovitis
📌 Bone erosions
📌 Ligamentous laxity
📌 Pannus formation
📌 Cranial migration of the odontoid (BI)

🧵 The Lifestyle & Autophagy Connection: How Your Habits Influence Cellular Health

1/ Did you know? 🧬 Your diet, exercise, sleep, and even stress levels can influence how well your cells clean & recycle themselves through autophagy.

Let’s dive into how lifestyle choices boost or block this essential process. 👇

#Autophagy
#Longevity
#CellularHealth
#FastingForHealth
#AntiAging
#Biohacking
#IntermittentFasting
#HealthOptimization
#ScienceTwitter
#SelfCareScience 🍽️ Diet & Autophagy: Food as a Cellular Switch

2/ What you eat directly affects autophagy!

✅ Foods that boost autophagy:
•Nutrients (Omega-3s, polyphenols, vitamins, minerals, CoQ10).
•Whole foods (fruits, veggies, fish, eggs).
•Mediterranean diet (rich in anti-inflammatory foods).

❌ Foods that block autophagy:
•Ultra-processed foods 🏭
•Refined sugar & unhealthy fats 🍟
•Excess salt & additives 🚫

📢 Thread: The Mechanism of Action of Glucocorticoids (GCs) – A Deep Dive 🧵

We all use steroids regularly to control inflammation. One day, I asked my intern:
“What is the mechanism of steroids?” 🤔

He confidently replied, “They are anti-inflammatory.”

Curious, I asked more interns—and got the same answer!

Yes, steroids are anti-inflammatory, but how do they actually work? Let’s break it down! 🔽

#MedTwitter #Rheumatology #Sullysrounds #steroid #Pharmacology 1️⃣ Glucocorticoid Basics – What Are They?

🔹 Produced by the Zona Fasciculata of the adrenal cortex
🔹 Derived from cholesterol
🔹 Basic steroid structure:
•3 Six-carbon rings
•1 Five-carbon ring

💊 Glucocorticoids (GCs) regulate inflammation, immunity, metabolism, and more!

Let’s look at dosage classifications first. 👇

Tweet 1:

🚨 Safety Considerations for JAK Inhibitors – What You Need to Know! 🚨

JAK inhibitors are powerful immune-modulating drugs, but their safety profile is complex.

Let’s break down infection risk, hematological changes, cardiovascular events, VTE, and cancer risks in a simple yet scientific way! 🧵👇

#JAKSTAT #Rheumatology #Autoimmune #Trump #Sullysrounds Tweet 2:

✅ JAK Inhibitors – Clearance & Risk Factors

✔ Rapidly cleared by liver & kidney

✔ Risk considerations include:
🔹 Infections
🔹 Hematological changes
🔹 Cardiovascular risk
🔹 Thromboembolic risk
🔹 Neoplastic risk

📌 Let’s analyze each risk one by one! ⏬

Tweet 1:

🚀 The JAK-STAT Pathway – A Key Player in Cytokine Signaling!

Did you know that >40 receptors use this pathway? It’s critical for immune function, hematopoiesis, and inflammation!

Let’s break down JAKs, STATs, inhibitors & their clinical impact in a simple & engaging way! 🧵👇

#JAKSTAT #Immunology #Rheumatology #Sullysrounds #Trump #MedX #MedTwitter Tweet 2:

📌 JAK-STAT Basics

✔ 4 JAKs: JAK1, JAK2, JAK3, TYK2
✔ 7 STATs: STAT1, STAT2, STAT3, STAT4, STAT5A, STAT5B, STAT6
(See 5 A and B)

💡 These drive gene expression in response to cytokine signaling, shaping immune responses!