Discover and read the best of Twitter Threads about #tweetorial

Most recents (24)

Beef with maintenance fluids.

This salty #tweetorial will pose some questions and explore common pitfalls of using IV fluids “for maintenance.”
Poll: how would you describe dripping 100 mL (a third of a coke can) per hour of NS or LR into a patient who has a heart rate of 100 and a high BUN?
Good choice!

If someone is volume down, give them a bolus.

“Maintenance fluids” are often the wrong choice because they’re not enough.
Read 15 tweets
You intubated the asthmatic! What to look for on the vent and what to do about it.

It gets complicated, but the basics are in the thread below

#foamcc #foamed #tweetorial mini
1/
The problem is bronchospasm and secretions narrow the airways and lead to obstruction, limitations in exhalation and high airway resistance.

On the vent, this is seen as a high peak pressure (high resistance) and a prolonged expiratory flow or incomplete exhalation.
2/
The high peak pressure isn’t really a problem unless the plateau (obtained by an end insp hold) is also high. The delicate alveoli only feel the plateau pressure. Best to keep the plateau pressure < 30 cm H20 by minimizing auto-PEEP as the auto-PEEP contributes to plat press
3/
Read 11 tweets
1/

In this #tweetorial, we'll walk through our approach to uncovering #acidbase disorders & our mnemonic #pLACO using this example:

pH 7.28, pCO2 30, pO2 75
Na 145, Cl 103, HCO3 18
Albumin 4 mg/dL

nephsim.com/acid-base/

Step 1: what does the "p" in pLACO stand for?
2/

#pLACO

The p is for pH, which tells us how acidic/basic a solution is.

Normal arterial blood pH is 7.4. Anything less than that is acidEMIC and anything greater is alkalEMIC.

In our example, the pH is 7.28. Thus, we have an acidemia.

nephsim.com/acid-base/
3/

#pLACO

Step 2: The "L" stands for ✅ labs (pCO2, HCO3).

In our example, the pCO2 is ⬇️ ( normal = 40 mm Hg). The bicarbonate is also ⬇️ (normal = 24 meq/L).

Acidemia and ⬇️bicarbonate suggest that the PRIMARY process is a metabolic acidosis.

nephsim.com/acid-base/
Read 11 tweets
1/22
Time for another #Pulmonology #Tweetorial that combines history, Oscar Wilde & questioning a long-held belief…

@OslerResidency @sanjayvdesai @DxRxEdu @CPSolvers @tony_breu @david_furfaro @ChadHoc @JohnsHopkinsDOM
2/
Let’s begin with a question:

Why does Lady Windermere Syndrome tend to affect the right middle lobe and lingula in older women without preexisting lung disease?
3/
Let’s start with a little history. Non-tuberculosis mycobacterial (NTM) lung infections have been reported as early as the 1950’s, traditionally in the immunocompromised or those with structural lung disease.
ncbi.nlm.nih.gov/pubmed/13184228
Read 22 tweets
What in the world is anti-smooth muscle antibody (SMA)!?

Join me for another quick-hit #livertwitter #tweetorial on this mysterious test used in the eval of autoimmune hepatitis

Second in a series on diagnostic testing for liver disease #meded
Autoimmune hepatitis is:
1⃣Rare, 2/100,000; higher with age.(Fig1)
2⃣Causes <1.8% of persistently elevated liver enzymes(Fig2)
3⃣Suggested by positive antibodies but best dx by biopsy. 👀diag criteria,Fig3
*nb: talking about Type1 AIH
Read 6 tweets
#Tweetorial: Diagnosis of Malignant Pleural Effusion (#MPE) to accompany publication in @AnnalsATS: bit.ly/2XM65pD

⚓️#MPE: Pl. Effusions (#pleff) w/ neoplastic cells/tissue
⚓️Paramalignant eff: related to malignancy but not due to it eg: endobronchial obstruction or PE
Answer me this dear folks!
Why is it important to diagnose #MPE?

While you ponder, LUNG and BREAST are commonest primaries metastatic to the pleural space! PMID: 24360987
#MPE = poor prognosis, change management & may help locate primary!

Ferrer (PMID: 15764788): >=4 of these strongly suggest #MPE:
a) Dyspnea, chest pain, constitutional sympt
b) Symptoms >1 mo
c) No fever
d) Blood-tinged #pleff
e) CT suggestive (mass, atelectasis, adenopathy)
Read 18 tweets
Elevated ferritin? Is it hemochromatosis? Probably not!

Join me for a quick-hit #livertwitter #tweetorial?

First in a series on diagnostic testing for liver disease #meded
Patients will tell us their diagnosis - if we are listening
In this @JAMAInternalMed teachable moment a patient with ⬆️AST/ALT & alcohol abuse was tested 4 hemochromatosis.

Ferritin = off the charts
Homozygous for HFE mutations
But did she have hemochromatosis?

See below!

jamanetwork.com/journals/jamai…
Read 6 tweets
Hello #MedTwitter! Inspired by @tony_breu, this is a tweetorial on feeding tube indications, a technique for placement, and how to read the post film. Credit goes to Dr. @AvoArtinyanMD who taught me this technique @BCM_Surgery! @RASACS #FOAMed #Tweetorial @BehindTheKnife
The above is an image from a patient who I placed a tube on, and is being shared with the consent of (and actually at the request of) that patient. She endured 4 unsuccessful placement attempts, but was gracious enough to let me try when I came on to cover overnight-
- a reminder of the incredible courage and resilience of our patients. Which is another tip- whenever you are feeling run down slogging through the endless 80+ hr weeks, just think of your patients. No matter how bad your day is, they are enduring far worse, and deserve your best
Read 23 tweets
Our new @Health_Affairs DataWatch on CMS’ shift to payroll-based staffing data

We found facilities were below CMS’ expected case-mix adjusted levels on a large number of days

Paper with Fangli Geng (Harvard PhD student) & David Stevenson (@VUHealthPol)

#Tweetorial 1/
Staffing is the key input in the production of nursing home care. Yet, CMS historically has relied on facility-reported data collected at the time of nursing home inspection. New payroll-based data provide daily staffing totals year-round and they are audited by CMS.

2/
Following the great @nytimes piece by @jordanrau, we found direct care staffing was higher when facility-reported versus payroll-based (!), and over-reporting was relatively larger among for-profit facilities. And, staffing was lower on the weekends!

3/
Read 6 tweets
1/
Many think that Van Gogh was "dig toxic" and that it impacted his vision and painting. Was that really true? This #tweetorial explores whether the great artist was actually toxic on digitalis.

#medtwitter #FOAMed #meded #medicalhumanities
2/
First, we need to understand a couple of things:
▪️What ailed Van Gogh?
▪️How can digitalis affect vision?
3/
Many diagnoses have been applied to Van Gogh, from lead poisoning to porphyria.

Most historians believe his depression, mania, and convulsive episodes indicate:
⭐️Schizoaffective disorder
⭐️Epilepsy
Both of which were made worse by absinthe.

ajp.psychiatryonline.org/doi/full/10.11…
Read 13 tweets
At #ser2019, @zepidpy gave a very nice talk about how to avoid bias from left truncation.

But the whole talk I thought he meant left censoring. Turns out censoring & truncation are two completely different ideas! Who knew?!

In case you also didn’t, here’s a #tweetorial!
First, let’s make sure we’re all on the same page.

The setting: longitudinal data
The problem: not all data are observed
So, what is censoring?

Censoring is when you don’t know exactly when (or if) the outcome variable happens for someone.
Read 26 tweets
Part 5 #Tramadont #tweetorial
(in which #Tramadont remains a hilariously accurate descriptor of tramadol!)
@NarouzeMD @EMARIANOMD @toby_ashken @DavidJuurlink

CYP2D6 & tramadol is not overrated at all.
Here is a picture of the tramadol metabolism pathway (PMID 11454734) (1/7)
We can agree that M1 is the metabolite which provides opioid analgesic effects. (PMID 10961373) (2/7)
M1 is metabolized by CYP3A4 & CYP2B6 (not CYP2D6 as you suggested) to M5. (PMID 24849324) (3/7)
Read 7 tweets
#Tramadont”, a #tweetorial

In response to the last #pharmacyeducationboard about tramadol- some are still doubting whether it has earned the moniker “Tramadont”. Points have been made that as tramadol is metabolized by CYP2D6 in the liver, so are other drugs. Should we (1/11)
just not prescribe anyone anything metabolized in the liver? Touché. The problem with CYP2D6 specifically is that it happens to have the most polymorphisms of all the CYPs enzymes. What does this mean? It means it has the greatest potential variability in activity (2/11)
from one person to another. Not only this, but unlike the other CYPs, it’s expression can vary from being absolutely nonfunctional to being an ultrarapid metabolizer because of the very unique ability of it to be duplicated! No other CYP enzyme does this!! (3/11)
Read 11 tweets
⚡️ #YesCCT Coronary Plaque Assessment #Tweetorial ⚡️

By @CoronaryDoc + @AChoiHeart

✅ Why Plaque Assessment?
✅ High Risk Plaque Features
✅ Plaque Characterization/Quantification
✅ Supporting Clinical Data

#CardioTwitter #ACCImaging #SCCT2019 @heart_scct @journalCCT
1/14
2/14
As #SCD or #MI is 1st symptom of #atherosclerosis in 2/3 of pts, early ID of #CAD is of paramount importance

#YesCCT allows for
✅ ID of plaque
✅ Quant. of plaque
✅ Characterization of plaque
✅ Arterial remodeling

Lin, @LubbDup & @lesleejshaw: bit.ly/2x1b5Yz
3/14
Serial angiographic studies have demonstrated an accelerated & rapid plaque progression before most cases of ACS

Rapid plaque growth ➡️ plaque rupture ➡️ thrombus formation ➡️ MI

@LubbDup & @JonathonLeipsic et al: bit.ly/2WIt5Bj
Read 14 tweets
#Tweetorial time! 🚨 Looks like there’s another misconception about #cholesterol and #atherosclerosis making rounds again. This one has to do with the process of #LDL particles entering the arterial wall. So gather round friends and let me science the s*it out of this 🤓 (1/24)
For background, here’s a widely cited series of figures by Nakashima et al. (2007). They performed autopsies on 38 people aged 7-49, who died of non-#cardiovascular causes (2/24)
ncbi.nlm.nih.gov/pubmed/17303781
Nakashima et al. looked for atherosclerotic lesions at different stages, according to a previously published morphological classification scheme. They found them, took slices, stained them to find #lipids and #macrophages and organized them nicely (3/24)
Read 25 tweets
For all those unable to make my 7 AM presentation on Speckle Science yesterday, here's the requested #Tweetorial on Strain basics #ASE2019 @ASE2019 as promised.
Read 27 tweets
A brief #tweetorial for those curious as to why I spend countless hours on a non-specialty medical organization. The basic premise of the @AmerMedicalAssn House of Delegates is actually simple. #healthpolicy #publichealth #MembersMoveMedicine 1/
It’s a representative democratic body consisting of members of societies from the US states and subspecialties of medicine, convening twice a year as the @AmerMedicalAssn House of Delegates (HoD). The majority of each meeting is spent deliberating policy proposals. #AMAmtg 2/
Any member or organization can bring resolutions with various policy goals to the HoD to be debated and voted on. These go through a multistep vetting process where everyone has the opportunity to speak on and amend these policies under the rules of parliamentary procedure. 3/
Read 11 tweets
30-day Readmissions!

They can teach us a lot about the management of #cirrhosis
AND
Highlight the systems of care that benefit patients with cirrhosis

Join me for a #livertwitter #tweetorial?

Aims:
1. What
2. Why
3. How to address

#QI #meded
Readmissions are:
1. Common. >1⃣in4⃣ pts readmitted by 30days (Fig1) cghjournal.org/article/S1542-…)
2. Costly. >$700 million/year
3. Morbid. Independently associated w/⬆️risk of death (Fig2)
4. Barely predictable. No matter what variables go in2 the model the AUROC ~0.6-0.7 (Fig3)
Q: Why do patients with #cirrhosis get readmitted so frequently?
Read 12 tweets
Our latest @Lown Right Care article on Lung Cancer Screening: Pros and Cons is worth reading in its entirety aafp.org/afp/2019/0615/… But for those who won't, here's the @AFPJournal #Tweetorial version 1/
@lown @AFPJournal In 2013, the #USPSTF recommended annual low-dose CT screening for lung cancer in adults 55 to 80 years of age who have a 30 pack-year smoking history and currently smoke or quit within the past 15 years aafp.org/afp/2014/0715/… 2/
@lown @AFPJournal Caveats: LDCT screening "should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery." 3/
Read 11 tweets
1/#Medtwitter friends, we are thrilled to share a #tweetorial courtesy of @StephenieLe11 and inspired by @DrDanRestrepo's episode on intrarenal AKI #FOAMed
clinicalproblemsolving.com/2019/03/21/epi…
2/30M presented with MSSA native tricuspid valve endocarditis and lower extremity edema was found to have AKI. What are the renal manifestations of endocarditis?
3/There are numerous causes of AKI in patients with endocarditis. Let us know if you think of others!
Read 11 tweets
1/ Toxicologists are familiar with loperamide toxicity, but this hasn’t spread as much to other specialities. Thus, my 1st attempt at #tweetorial for #medtwitter . H/T to @jmmarraffa & @DavidJuurlink & @Pete_Wu for their earlier writings. Thxs to @officialdrk12 for the idea
2/ First a poll: Loperamide is/can be:
3/ Loperamide is a mu-opioid agonist with poor oral bioavailability with primary use as an anti-diarrheal. CNS effects are limited when p-glycoprotein (P-GP) is functioning normally at the blood-brain barrier.
Read 13 tweets
Time for a #tweetorial/#medthread on:

#CALCIPHYLAXIS!

This is a devastating diagnosis often seen in inpatients, so this goes to all the @DermHospitalist & #hospitalists out there!

#FOAMed #MedEd #dermatology #dermatologia #dermtwitter #medtwitter @SHMlive @DermHospitalist
1/
First of all, what is it? The exact mechanism is unknown. What we do know is that there is calcium in the arterioles of the skin, with arterial thrombosis. This interruption of blood flow causes painful ulcers and retiform purpura. Remember this?



2/
That interruption of blood flow causes the clinical picture of calciphylaxis - retiform purpura with a predilection for fatty areas, violaceous borders, necrosis with ulceration, and TERRIBLE PAIN. Without the pain, I really think one needs to reconsider the diagnosis!

3/
Read 17 tweets
50yo F p/w acute onset fever, diarrhea. On exam is hypotensive and mildly confused. Sx started 2 days after return from Zambia. No malaria ppx. Smear w/ 30% P falciparum parasitemia. MICU concerned for cerebral malaria (CM). How can we confirm on #PhysicalExam ?#IDConsults
Cerebral malaria is defined by WHO as coma with peripheral parasitemia after other causes ruled out. In endemic regions this predominantly affects young kids due to immunologic naivety. Unfortunately, this defn is nonspecific as 40-70% of asymptomatic ppl may be parasitemic 2/
Pathophys of cerebral malaria is related to sequestration of parasitized RBCs in the CNS blood vessels...thanks to Hermann von Helmholtz’s invention of the ophthalmoscope in 1851 (with just a few updates from the original), we have a window to the vasculature of the CNS! 3/
Read 11 tweets
1/20
Inspired by some amazing @JohnsHopkinsDOM & @OslerResidency colleagues (@Dr_DanMD, @david_furfaro, @DxRxEdu to name a few), as well as the master @tony_breu, I’ve decided to take a stab at my first #pulmonology pathophysiology #tweetorial
2/
Ever wonder why patients with cystic fibrosis (CF) tend to have more severe disease in the upper lung fields, especially on the right?

I have!

And the answer was not what I was expecting…
3/
First, it is important to remember that CF is caused by mutations in the CFTR gene, which ultimately leads to thick, viscous secretions due to the inability to secrete chloride.
Read 21 tweets

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