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#Hematology fellow (DM) @SGPGI | MD Medicineโžก๏ธLTMC,Sion | @pinkfloyd fan | Drummer & #Wildlife #photographer | #Bombay boy | Tweets about #COVID | #Medtwitter
Dr. Ruby Ruprai ๐Ÿ’• Profile picture The outlaw Profile picture 2 added to My Authors
16 May
Want to know why #Mucormycosis is more common post #COVID19 and not so common after leukemia's or other illnesses treated with steroids ?

Read on !!
These are the major reasons in my opinion:

1. The NUMBER of #COVID19 pts is far GREATER than the number of leukemia pts we treat in a year. Thus a lot more people are getting steroids at this point in time and thus a lot more are at risk of steroid related complications.
Let's say 1/5k steroid treated pts get mucor, now if we treat 500k pts with steroids we will definitely have 100 mucor cases. SIMPLE MATH !!

Not convinced, read on.

2. A great number of #COVID19 pts have underlying CO-MORBIDITIES like diabetes which are WORSENED by steroids
Read 10 tweets
15 May
So there are a lot of people asking about the risk factors for #mucor post #covid.

The biggest risk factor isn't the steroid itself, it's the hyperglycemia that it causes. If the sugars are well controlled using insulin the risk is almost negligible. So STOP freaking out !!
The 2nd major risk factor is prolonged NEUTROPENIA but that's a problem in our #Hematology patient population and not in #covid patients, so we can safely ignore that for now.
Bring us back to hyperglycemia due to steroids. The sure shot way to prevent it is frequent monitoring of sugar levels and NOT self medicating with steroids. Steroids anyway don't have any benefit if one isn't hypoxic so don't use it because ur aunt/uncle/friend used it.
Read 6 tweets
11 May
#MedStudentTwitter might find it useful. Some common case scenarios !!

Case 1

72, male, on routine CBC is found to have โฌ†๏ธ WBC count. Asymptomatic.
CBC: 12.2 / 77k / 215k
Lympho: 88%
No HSmegaly

This is most likely CLL.
Q now is, does he need rx?
The answer in this case would be NO.

Always think about benefit vs risk when u want to start Rx. CLL many a times may not need rx at all.

Important learning pointโžก๏ธDON'T get ALARMED by a โฌ†๏ธTLC.
Case 2

42, male, p/w fatigue and dragging abdominal pain, โฌ‡๏ธappetite x 2months

CBC: 12.6/356k/405k
Baso: 4%
Spleen 4cm BCM

This is most likely CML.

DX is confirmed by FISH for 9;22 or BCR-ABL PCR
MC transcript type: p210
Read 7 tweets
8 May
CELLS in Hemat ๐Ÿ’ช๐Ÿป

Sickle cell=Drepanocyteโžก๏ธSCD
Tear drop=Dacrocyteโžก๏ธMF
Spur cell=Acanthocyteโžก๏ธLiver ds
Burr cell=Echinocyteโžก๏ธUremia/PK def
Target cell=Codocyteโžก๏ธHb'pathies
Bite cell=eccentrocyteโžก๏ธG6PD def
Pencil cell=ovalocyteโžก๏ธIDA
Pincered cellโžก๏ธBand 3 def
Prickle cellโžก๏ธPK def
Sickle cells, not hard to identify.
Can't miss these isn't it ?
Read 9 tweets
7 May
#FERRITIN is being widely ordered these days. Let's dive into the details and learn more about this protein. A short thread for those interested. Covers some history, biology and practical aspects about FERRITIN.

1/n
It was discovered in 1937 by Laufbรฉrger but it wasn't until 1972 that an assay was devised to measure serum ferritin.

Ferritin is present in 2 forms
๐Ÿ‘‰ Intra-cellular (in the cytosol)
๐Ÿ‘‰ Extra-cellular

2/n
It is a ~450kDa protein.
Has 24 subunits of 2 major types
๐Ÿ‘‰ H : gene on chr 11q
๐Ÿ‘‰ L : gene on chr 19q

Serum ferritin has โฌ†๏ธ L: H ratio.

3/n Image
Read 7 tweets
4 May
So mucor is on the rise, time for a quick revision. A short thread for those interested.

It's a bad infection with an unreasonably high mortality(40-80%) which depends on the organ involved.

Risk factors: DM/ neutropenia/ HSCT

DM=rhino-orbital mucor
Neutropenia=pulmonary mucor
Mucormycosis is caused by fungi of order "MUCORALES" which includes rhizopus/mucor/licthemia/cunninghemela species. But DON'T WORRY species identification doesn't change treatment so we don't need to get to that.
Coming to the PRACTICAL POINTS that need to be remembered.

โžก๏ธIMAGING even at the slightest suspicion of mucor coz it's RAPIDLY PROGRESSIVE and kills quick.

โžก๏ธCT PNS/Orbits/ MRI Brain
โžก๏ธHRCT chest as per presentation
Read 8 tweets
1 May
Got #covid ? Don't worry it's not a death sentence.

Step 1: Isolate and monitor

I assume u must have started isolating even before you tested + , if not, do so immediately. Get the others at home tested ASAP. Monitor your temperature and oxygen saturation.

1/n
Step 2: Managing Co-morbidities

If u have any co-morbidity continue to take the meds you were already on. Don't STOP meds for ur diabetes or hypertension or thyroid d/o.

2/n
Step 3: Managing fever

Fever is a very common symptom. Please dont panic. Take a paracetamol. An adult may take upto 3gm/day i.e ~650mg 6 hourly. Continue to monitor your oxygen sats every 4-6 hrs.

3/n
Read 9 tweets
9 Oct 20
#MedTwitter how often do you use ๐๐ซ๐จ๐œ๐š๐ฅ๐œ๐ข๐ญ๐จ๐ง๐ข๐ง ?

A thread on ๐๐ซ๐จ๐œ๐š๐ฅ๐œ๐ข๐ญ๐จ๐ง๐ข๐ง for those interested ๐Ÿ˜‰

#MedEd #MedStudentTwitter #oncology #hematology #tweetorial
โšก๏ธProcalcitonin as the name suggests is a precursor of the hormone calcitonin

โšก๏ธCoded by the CALC 1 gene on Chr 11,its a 116AA peptide

โšก๏ธPrePCT >> PCT >> Calcitonin

โšก๏ธBact inf=โฌ†๏ธIL6โฌ†๏ธTNFaโฌ†๏ธIL1b=โฌ†๏ธProductn of PCT
โšก๏ธNormal PCT in health <0.1ng/ml

โšก๏ธIn patients with bacterial infections PCT โฌ†๏ธ corelates with severity of infection

โšก๏ธPCT starts toโฌ†๏ธ3-4hrs following an infection,
peaks at ~12 hrs post infection.
Read 11 tweets
20 Jul 20
Humanity has always struggled to fight #viruses , best exemplified by the ongoing #Covid_19 #pandemic ,so I thought of doing a thread on a #virus which frequently troubles #hematology patients

It's called #CMV or #HHV5
It wrecks havoc #posttransplant

#MedTwitter @BloodJournal
โšกDNA virus ,1 of the MC infections post SCT

โšกIt has the largest genome of any known human virus [230kb /200 genes]

โšกMost humans harbour latent CMV, infection MC aquired in childhood.

โšกSite of latency in humans- Not Known
In murine models - hepatic sinusoidal cells
โšกThe risk of reactivation depends on CMV sero status and is as follows:
D-/R+ > D+/R+ > D+/ R- > D- / R -

โšกThe other risk factors are
1๏ธโƒฃ T cell depletion
2๏ธโƒฃ HaploSCT
3๏ธโƒฃ UCB SCT
4๏ธโƒฃ GVHD requiring Rx

โšก So why not give prophylaxis to these patients ??
Read 10 tweets
28 Jun 20
So how safe is #Ibrutinib ?
A very relevant question given that it needs to be administered indefinitely.
41% discontinuation rate in the "real world", most d/t toxicity.

Thread [1/12]
So what are the major adverse events anyway ?
1. A fib
2. โฌ†๏ธ Risk of bleeding
3. โฌ†๏ธ Infections
4. Arthralgias
5. Htn
6. Diarrhoea
7. Pneumonitis

[2/12]
A very common concern is tox no.1 and 2 .
โฌ†๏ธA .fib = anticoag for stroke prophylax. but that's when tox no.2 comes into play.
Very difficult to โš–๏ธ it out .
In RESONATE trial >grade 3 afib in 3% of pts.
Most events occur within 3 mts of starting #ibrutinib

[3/12]
Read 13 tweets