Controversial 3D. Probably none of you knows about Leber congenital amaurosis type 10, congenital blindness that affects 3 out of 100,000 children, condemning them to blindness for life. The only possible treatment is through gene therapy. 1/n

“Should I give them more fluid?”

Extremely common question during AKI referrals from junior docs.

⛔️ Fluid management is tricky, often misunderstood, & can cause huge iatrogenic harm ⛔️

We try to convey important principles in THREAD 👇

#tipsfornewdocs #medtwitter #tweetorial

Currently too often patients with high creatinine are given too much IV fluid, driven by an AKI ➡️ fluid reflex

We’ve seen 7 litres be given in one shift.

Medics & surgeons, juniors & seniors, it seems everyone loves to reach for extra IV fluid (especially if urine output poor)

Why does huge volume IV fluid ‘resuscitation’ consistently occur?

Lots of reasons, including FALSE beliefs:
🛑 IV fluid always “treats AKI”
🛑 Hypotension = hypovolaemia
🛑 Lactate >2 means fluid deficiency
🛑 Septic patients are very hypovolaemic

The rule with IV fluids and AKI is to remember this 5 word phrase:

💥 💥 Aim for euvolaemia, then stop💥 💥

Fluid status is like Goldilocks - hypovolaemia is bad for the kidneys BUT excess volume is also harmful for renal function and will cause other complications too.

It is easy to say “target euvolaemia” - but we agree it is more difficult to do!

Fluid status assessment is certainly made harder by a belief that we must only rely on a snapshot assessment of examination features which are NOT specific / sensitive / reliable to elicit like.…

@br0oklynzo0 @KatyMontgomerie @ElPolloDiabloX @AbigailShrier @chadfelixg Okay, so you haven't read the study in the British Journal of Sports Medicine, you've read a Guardian story about it.

I have now read the study, and I teach critical appraisal as part of my job, so let's dive into it a bit.

@KatyMontgomerie @ElPolloDiabloX @AbigailShrier @chadfelixg First things first, the sample size in this study is tiny. 46 people. Plus, the point of comparison was "all women and men under the age of 30 in the Air Force between 2004 and 2014" rather than a longitudinal group.

@KatyMontgomerie @ElPolloDiabloX @AbigailShrier @chadfelixg So no matching for age, background, or physical condition. The result of these is that you're going to get a lot of statistical artefacts.

@KatyMontgomerie @ElPolloDiabloX @AbigailShrier @chadfelixg Second of all, there were three points of comparison here and you're ignoring two of them. The researchers measured for push-ups and sit-ups as well, both of which showed physical advantage removed entirely by hormones. Which means you're cherrypicking.

@KatyMontgomerie @ElPolloDiabloX @AbigailShrier @chadfelixg So what do you get when you have a tiny sample size and cherrypicked results? That's right, you get noise in the data. Take a look at the results graph from this paper you haven't read.

Fun fact: the standard advice for if a dog, cat, or human bites your hand, is to feed the bite. Push your hand further into their mouth, forcing the jaw open.

Nurses, EMTs, veterinarians, etc are taught to respond this

The advice for a human biting you is to jam your hand or arm deeper into their mouth, and rub the spot under their nose back and forth.

If you attempt to remove your hand, or forearm, the teeth do what they're supposed to and gouge out a chunk.

This vicious wolf attack illustrates proper technique.

So: every EMT and nurse who gets bitten by a human, is trained to jam their hand or forearm deeper into the mouth, feeding the bite so the jaw widens enough to remove the limb

Also, every redneck learns this along with the advice of "never run from an angry dog"

Pathways to Public Policy Careers for those interested and looking for global opportunities

Public policy is made when a governing body attempts to address an issue of widespread public concern, such as health care. The process often runs in cycles and can take years.

■After new laws are created, Policy Implementation occurs, often involving federal agencies, state and local governments, bureaucratic entities, and NGOs. Courts get involved as laws and policies are challenged on a variety of fronts.

■Analysis and Evaluation occurs throughout the cycle and involves many players. Policies may be changed — and the cycle begins again.

What is the best advice for someone pursuing a career in public policy?

People often find their way to public policy careers because of an

interest in a particular substantive area. Public policy work can be found in virtually any subject area.

Your ears should perk up when you hear the words “Center for,” “Institute,” “Association,” and “Foundation” because they represent potential employers.

Public policy majors work in the public, private, and nonprofit sectors, such as a government agency or advocacy group.

Continuing education, such as a certification or fellowship, can also advance your career as someone interested in public policy and politics.

"Public health" isn't just about vaccinations, clinics and urgent care: it's a holistic discipline that encompasses all the contributors to health outcomes, which include things like housing, employment, transportation, pollution and more.

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A new working paper from @nberpubs estimates the number of US covid deaths that could have been prevented with a coherent, effective eviction moratorium and a ban on utility cutoffs:

The paper, written by a multidisciplinary group of Duke researchers from medicine and economics, found that housing precarity (a risk of losing your home) drove risky behavior that increased the spread of the disease and the resulting deaths.

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For example, it forced people to double-up on lodgings, making social distancing impossible, to say nothing of self-isolating after an exposure. It also drove people to tolerate high-risk workplace conditions, including illegal conditions.

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The authors used regression techniques to control for confounding variables, and used like-for-like counties with different utility and eviction policies to estimate the effect that these had on infection rates.

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