Time ⏰ for Part #2 of the Tweetorial 🧵 on the DDI btwn PHT & VPA with a focus on drug metabolism 💊🔄

If you haven’t seen it yet - check out Part 1 by @JimmySuhMD on the albumin interaction btwn PHT & VPA
 
However, that’s only half of the story!⚠️
 

https://twitter.com/jimmysuhmd/status/1479099506515918852?s=21

1/n First, let’s discuss basics on phases of drug metabolism 🔄
 
Phase I: Oxidation (ex. CYP450 enzymes)
 
Phase II: Conjugation (ex. Glucuronidation)
 
🎯 Goal 👉🏻 covert drug to an active (pro-drug) or inactive metabolite and ⤴️ solubility ➕ ⤴️drug elimination via urine/bile

A #MedTwitter🧵on the frequently obtained, but ever mysterious🕵️‍♀️ Procalcitonin (PCT) 🦠

💡 What is it?
💡 Where does it come from?
💡 What factors/comorbid conditions may impact PCT?

#IDTwitter #TwitteRx 1/n First, let’s discuss the normal, physiologic role of PCT 🧬

✨116 chain amino acid
✨Neuroendocrine hormone
✨Produced by thyroid C-cells
✨Enzymatically cleaved to calcitonin
✨ Regulate Ca+2 & PO4- homeostasis

DOI 10.1093/ajhp/zxaa089

@AJHPOfficial @SESmithPharmD

Let’s talk CSF 🧠 💦

☝️ What is it & why is it important?
✌️ Key considerations in CSF sampling 🧪 & analysis 🧐 for suspected infection 🦠

A #NeuroTwitter 🧵 inspired by bedside rounds with attending @BuslKatharina & NCC team👏🏻 So to start, what is CSF? 🤔

CSF▶️clear, sterile fluid secreted by choroid plexus 💦 in the ventricles ➡️circulates throughout the subarachnoid space🧠 & spinal canal🦴

⭐️Function▶️ protective barrier 🛡 provides nutrients 🍎& facilitates removal toxins/metabolic byproducts⚠️

Now that the salty🧂debate on the TYPE of fluid to use in the ICU has largely been solved, how about the RATE of IVF? 🤔

Back to the BaSICS💦

✅The Balanced Solutions in Intensive Care Study📖 (BaSICS) ▶️compared 333mL/hr vs 999 mL/h

Does IVF rate impact 90-day mortality? 🤔 💡 10, 520 ICU pts randomized 🏥

Fluid volume:

1162 mL in the SLOW infusion group 💦
vs. 1252 mL in the FASTer group

🛑NO difference in☝️ outcome: 90-day mortality (HR 1.03, CI, 0.96-1.11)

🛑No difference in✌️outcomes: RRT, AKI, ventilator free days, ICU/hospital LOS

Alert 🎙Pharmacy Grand Rounds Thread Ahead! 🚨

Last week I had one of my final presentations of the year! With a catchy title😉

Urine for an Update! Updates in the management of metastatic urothelial cancer

Hold your bladders, this is an extensive update! 😂
#oncopharm Bladder cancer can be divided into two ✌️subtypes:
1) Non-muscle invasive: encompasses in-situ and localized disease➡️5-yr OS >70%

2) Muscle invasive: encompasses regional or metastatic disease➡️5-yr OS dismal especially for metastatic disease 😔

What medications 💊 are should be avoided 🛑 or used with caution ⚠️ in patients with Myasthenia Gravis? 🤔

See 👀 the thread 🧵below⤵️ that summarizes an amazing grand rounds presentation by @UKPharmRes PGY1 @AliW_PharmD on key 🔑 medication considerations in MG 1️⃣Antibiotics to avoid or use w/caution🦠 💊

🛑FQs = FDA BBW for ⤴️ risk of MG crisis ➡️ avoid use if possible
⚠️ Macrolides ⤴️ rate of MG crisis (case reports)
⚠️ AG linked to ⤴️ ICU acquired weakness & exacerbate ‼️ MG crisis
📝Risk⬆️ w/neomycin vs. tobramycin & amikacin

Urine Trouble: A review of Immune checkpoint inhibitor associated nephritis

See below some of the data I collected on this topic from a recent inservice! @OncoPharmPod #nephrotwitter #oncopharm Immune checkpoint inhibitors (ICI) ➡️revolutionized tx 💊 of various malignancies
✅Treatment that offers some pts🙋🏻‍♀️a chance of cure🤯

Also see a range of unique toxicities⚠️➡️autoimmune in nature

An emerging one of which is nephritis! (Insert a needed kidney emoji)

I would like to make a few points of clarification for yesterday tweet on Vasopressin for cardiogenic shock.

🔑 point: Vasopressin is not “preferred” nor 1st line in CS but “may be considered” in select cases

Please read further thread 👇🏻👇🏻 It should have stated “may consider” VP as the suggestion of benefit in the JAHA article on CS was based on theoretical benefit and a ☝️ post hoc analysis of the VASST trial which included septic shock patients, notably a VERY different pathophys than CS.
pubmed.ncbi.nlm.nih.gov/22518026/

#OTILT #IDtwitter #oncopharm

What factors do you have to consider while treating a cancer pt with a malignant pleural effusion and concurrent infection? 🤔

1/
🚨Cancer pts are at risk for MPE➡️consequence of metastatic involvement of the primary tumor in the pleura💨 💡Lung, breast, and lymphoma are the most common causes💡

Query of the pleural fluid with the use of the Lights criteria will help to determine the etiology (transudative or exudative)

Exudative=malignant OR infection

One of the criteria is a serum protein ratio >0.5

Mentor-Mentee SCCM CPP Spotlight: Dr. Andrea Newsome Sikora @AndreaSikora

“You should read better books.” 📚

The duality in this statement is a microcosm of mentorship:

You are enough right now & also you are capable of more.

An inspirational thread 👇🏻#PharmICU Mentors have double vision. 👀

Seeing you as you are and may be and celebrate the process of becoming.

Mentors are loyal to the person you are growing into, which reminds Dr. Sikora of Rumi:

“If you are irritated by every rub, how will you be polished?”
#mentorship

Abiraterone 💊 is an oral antiandrogen approved for metastatic hormone sensitive and castrate resistant prostate cancer

Why does abieraterone have to be coadministered with prednisone? 🤔 What if a patient wishes to avoid steroid therapy? 🤯

#oncopharm #pharmpearl Abiraterone is a CYP17 inhibitor that suppresses downstream non-gonadal androgen synthesis
As a consequence➡️ reflex↗️↗️ ACTH production leads to excess in mineralocorticoids

Early trials WITHOUT pred▶️pts developed severe hypertension, hypokalemia and edema 2/2 ↗️ aldosterone

Ever wonder how the BCG (Bacillus Calmette–Guérin) vaccine works against bladder cancer?🤔

BCG vaccine➡️approved for the tx of bladder cancer in 1990⌛️
✅Main intravesical agent shown to⬇️risk of progression of non-muscle invasive to muscle-invasive disease (>platinum chemo!)🤯 So, how does a vaccine for MYCOBACTERIUM work for bladder cancer!?🤨(dont worry, I was making the same confused face you are! Let me explain it to you!)

BCG=attenuated live strain of Mycobacterium🦠 bovis (which interestingly is related to the bacteria that causes tuberculosis)

Today I verified an order for clozapine for the very first time of my entire first year of being a pharmacist😳

Here are 5 clinical pearls I learned today about the use of clozapine for schizophrenia, important for new residents & interns to learn about this therapy! #pharmpearl 1⃣ Clozapine➡️second-generation, atypical antipsychotic➡️HIGHLY effective for treatment resistant schizophrenia

Unlike other antipsychotics➡️clozapine⬇️incidence of EPS or tardive dyskinesia➡️beneficial agent for pts who experience this debilitating ADE from other agents

SCCM CPP Mentor-Mentee program in action: 👏🏻

“Mentorship is a two-way street”

Dr. Carter(mentee) & Dr. Rose(mentor) have collaborated on scholarly projects 📚 in their area of shared specialty and broadened their professional networks 👥 as a result of their partnership. 🤝 Both Dr. Rose and Dr. Carter feel that their successes were be attributed to having a proactive mentor who follows the program guidelines and keeps the mentee on track with goals. 🎖

Thank you for sharing your story @CRosePharmD @ccarterpharmd

#PharmICU #CritCare #mentorship

So many pressers to choose from, oh my! 🤯

Let us help you learn about the important differences between agents with our vasopressor pocket guide!✏️📋

Hoping this will help assist new residents:interns starting in July 😊 ✅Check out these awesome resources for additional in depth learning on vasopressors to get ready for July!

@PulmCrit @iBookCC (amazing podcast) podcasts.apple.com/ca/podcast/the…

Our favorite review article 💯 journals.sagepub.com/doi/full/10.11… #pharmICU

@SCCM VP Tool Box sccm.org/Communications…

#Tweetorial

“Building Your Digital Brand” 👩🏻‍💻📱

How YOU can leverage the use of SoMe as a platform for professional development! 🚀

Key 🔑 pearls from Brooke’s Grand Rounds Presentation 🙌🏼 @UK_HealthCare #1️⃣ What is a digital brand? & why is it important for you?

Your brand is a synonymous term for your reputation! This resembles the intersection of how you see yourself & how others see you 👩🏻‍⚕️👨‍⚕️

#OLILT #IDtwitter
ESBL vs AmpC🦠what is the difference in resistance & tx?

Resistance
ESBLs ➡️ encoded by plasmid genes
AmpC ➡️encoded by plasmid genes OR "inducible resistance" via derepression of chromosomal🧬genes
⚠️can👀susceptible but resistance develops ON therapy! Treatment➡️Carbapenems➡️𝟏st line💊of choice

However➡️rate of carbapenem resistance is📈➡️today I was asked about cefepime tx

AmpC➡️typically resistant to some/ALL cephalosporins BUT cefepime is STABLE against AmpC! (unless other mechanisms of resistance are present)

History can teach us a great lesson here➡️As described in the @ACCP front line heroes page➡️pharmacists are undergoing heroic🦸🏻‍♀️feats&acts of bravery on a DAILY basis

Beyond COVID➡️we need to continue advocating for our profession to benefit healthcare & most importantly patients

https://twitter.com/JACCPJournal/status/1260956298570608640

Similar to uncovering legendary figures like Rosie the Riveter who said “We can do it” does our profession need our own mascot?

Here is our proposed hero, let’s make them real because “we know” we can do this!

Incredible drawing skills by @AndreaSikora

As virtual meetings take over all means of social interactions, not sure if I’m just the observer type, but I’ve recognized there is quite the spectrum of “Zoom personalities”

A thread 👇🏻 1️⃣The so called apologetic interruptor “oh I’m sorry you go ahead”🤭

Need ways to keep your children👶🏻 occupied & educated🧠 during quarantine?🤔

✅Check out this AMAZING list of resources put together by my apartment building for virtual zoos🦒, museums🎭, & cooking tutorials to keep children engaged during #COVID19

dropbox.com/s/oeb16nojosf6… @MurerCorrigan @sandersonrx @beaverspharmd @iEMPharmD @DaveDixonPharmD @ZNoelPharmD @nbennett04 @mtbastin @GlorimarRx @Aliik2411 @JGPharmD @JasonMordino @Berninini @RSPugliese

Let’s be real, #COVID19 consumes every. single. aspect of our lives.. from 🏠➡️🏥➡️📲➡️🖥 ... 24/7

We are all feeling the pressure&stress but☝️thing we forget to address is OUR wellness👩🏻‍⚕️

How do we COPE w/COVID19?

Join us & @AJWPharm for needed #COVIDbreak 💡 With a 🌎 full of unknowns & an unforseeable future.... we understand&feel a similar fear.

Our mission is to let the #Twitterverse know we are ALL in this together &
We want to provide you with a well-deserved #COVIDbreak ⏰ to discuss life outside of COVID19 (it exists!)