Essential reading for intensivists: things you didn't even dream were going on in your ventilated patients' lungs. With credit to @robertpdickson who does some very clever translational work on lungs

Firstly, we are aware of the inherent badness of oxygen. Here is protein content in alevoli after 48 hours of FiO2 95% (i.e. oedema), delightful.

Secondly, all those VAP's we get cross with (can someone silver impregnante the ET tube or something) that we think is just orally communicating flora/immunosuppression? Mais non. High FiO2 all but destroys weakling bacteria, leaving the redox-armoured king, staph aureus, to rule

Unmitigated staph surges and produces a truckload of PAMPs (pathogen associated molecular patterns). Being redoxically armoured, it is fairly happy to thwart oxidative burst from neutrophils attempting to kill them too.

Indeed the lung flora changes prior to the alveolar protein content - like both a canary in the coalmine moment, and then contributing to pathology.

Do people understand what I actually mean in my bio when I say I am a poster child for mental health. 😅

It means I experience a wide spectrum of mental health conditions, and I go to a lot of therapy. It doesn't mean I know everything (or anything). I have two full time treating clinicians. I speak from lived experience, and some days I feel like I know nothing.

Sometimes I am deeply unwell, and still so much risk I need to be hospitalised. Other times I can go speak at a national conference about suicide prevention. It isn't meant to be like some weird humble brag that I am the picture of perfect health.

At so much risk (see, still not proofreading).
I'm really thankful for the pocketfam, for the supports, the friendships, the jokes, the sometimes challenging ideas.
I have no certainty in what I say as being right (often I think it is wrong?) And I try to question and learn

All of the time. I am human, I make mistakes (much bigger ones than my endless typos), I try not to do harm, I try to acknowledge the privileges I have, and I try to use that privilege to improve the world.

Medical/Science Twitter - Do not trust IT hotshots with actual science data unless they have been trained in the real processes, know scientific method and their account/project/product managers approach with an established and medically respectable kind of taxonomy, plan, etc.

👋I will literally volunteer to sit in on these vendor pitches and translate snake oil sales pitches to make sure the stakeholder/end user requirements and needs and priorities are clearly defined so shit like this stops being a viable business model that does nothing but harm.👋

Very few people in IT at any actual level that is being given respect right now out of dire necessity have the kind of training or experience to handle this shit. Few if any of the data models that have been accepted and are being used follow the HIPAA-grade science methodology.

I only know this stuff because I built and managed informational and compliance portals for a pharmacy chain's operations team and designed/built/launched a ton of stuff for uses with ACA. And my best friend from home is doctor who keeps me in medical research journals if I ask.

But the need to approach this virus as a true unknown with constant expected variable shifts and false positives and correlating behaviors that may or may not even be related to each other as the real research work is being done is imperative. Don't buy IT's easy answers to this.

Quick thread about vaccine distribution—personal story

Mom is in a high-risk category and is eligible to receive a vaccine. I’ve been busy in the ICU and honestly assumed she was signing up to get vaccinated because she’s a responsible, conscientious person.

1/

After days of meaning to call, I finally remembered at a time of day when we're both awake and asked, just to confirm because of course she’s on it, right?

Nope. She’s not signed up.

2/

I’m in Arizona right now, she’s home in California. I haven’t kept close tabs on what’s going on with vaccines there (I've been busy), so I ask her why not. She says she doesn’t know what she’s supposed to do.

3/

Easy fix, I think! I'm a good daughter, I think. So I google “How to get COVID vaccine Santa Clara County”

This takes me to the County website. No big deal! I’ll get her the link in a sec, I think. I confirm she is eligible based on the current tier.

4/

Can’t schedule an appointment there. No problem—I’m sure they’ll tell us how to do it?

They say contact a healthcare provider. They then list several healthcare systems (not providers--I'm confused). Mom has Blue Cross Blue Shield. Maybe you’ve heard of it? Not on the list.

5/

1/ It's like the B117s are playing "Love Shack" there's so much dancing around whether it's here. Look at UK and Ontario case count and age infection charts. If you still think it's not circulating here then assume it is and take the appropriate action based on that "assumption".

2/ Government action, when they're finally motivated enough to do something, must be based on the worst case scenario, not the best case held together by prayer and duct tape. You cannot have 500 people wandering around Home Depot, Costco, Walmart etc. in a zombie like state.

3/ All retail, bar "true" grocery stores and pharmacies, must be curbside pickup only. Walmart and Costco are not grocery stores so must be closed for inside shopping. They, more than any others, will figure out an efficient curbside pickup strategy. Ford must ignore the retail

4/ lobby because pissed-off shareholders are acceptable whereas hundreds or thousands more unnecessary deaths are NOT. The list from the March lockdown was good but might not be enough to suppress case counts from the VOCs.

6/ We are not far away from an influx of vaccine supply and the return of warmer weather so now is the time to act firmly and quickly.
Businesses forced to close must be compensated from the 9-12 billion $$ of Federal funds the government are sitting on as must employees of

It is hard to overstate what a catastrophic failure the Govt & SAGE’s policy of continual restrictions & lockdown has been.

Not only has it caused economic devastation & misery for millions, it has not stopped high rates & surges in infections, hospitalisations & deaths.

Over the past 6 months, UK governments have tried mask mandates, curfews, local restrictions, regional restrictions, tiers, short *firebreaks*, national lockdowns, stricter tiers, extra tiers.

All have caused enormous costs yet look where we are at with Covid. Time to rethink.

“But it’s just obvious that lockdowns will work."

It’s past the time to indulge in wishful thinking about what you think *must* or *should* happen. Like it or not, we have to face reality: the continual lockdown/restriction cycle has failed on every possible measure.

“But things would have been even worse without the restrictions”

Hard to see how but, if you believe that, where is the evidence? e.g. have places with lighter restrictions had demonstrably worse Covid outcomes? Switzerland, Denmark, Sweden, Norway, Florida, Brazil?

“But it would have been different if we’d locked down more things/earlier/longer …”

More collateral damage & misery for certain, but where is the evidence Covid outcomes would be better? Look at Belgium, Italy, Peru, Spain, Czechia, New York, Illinois, France, Argentina.

So this weekend you heard from our friends @BukuRenal that mismanagement of IV fluids can cause harm.

A group we’d like to highlight who can come to serious harm from ⬆️/⬇️ fluids is patients with

💦DIABETES INSIPIDUS 💦

See below 👇

#medtwitter #FOAMed

Diabetes insipidus (DI) is the inability to hold onto water due to lack of /resistance to ADH.

Remember ADH is released as serum osmolality ⬆️ to ⬆️ renal water reabsorption, but in patients with DI this doesn’t occur and so they pass large vol watery urine - can be >10L/day!🛁

Note diabetes insipidus has nothing to do with glucose/sugar like diabetes mellitus! ⛔️❌⛔️

Misunderstandings are so common (even with HCPs) that there is a campaign to change the name to "pituitary insipidus"

#NoTimeToDI

Cranial DI (ADH not released) is usually due to pituitary/hypothalamic surgery, infiltration (inflammation/malignancy - rare) or head trauma. Can also be genetic.

Pituitary adenomas themselves can cause lots of hormone dysfunction, but don't typically cause DI.

Nephrogenic DI (ADH resistance) can be caused by
- renal disease
- electrolytes (⬇️ K, ⬆️ Ca – hence why hyperCa is dehydrating)
- drugs - can be seen with up to 15% of people taking LITHIUM 💊

Q: Why do we use a stethoscope?
A: For many reasons, and here’s one of them that I will argue is undervalued. And is still at the heart (hint hint) of some ongoing research…

First described by Potain in 1880, the gallop rhythm refers to the presence and cadence of abnormal diastolic cardiac sounds, namely S3 and S4.

In 1989, Stevenson and Perloff described the previously unestablished relationship between physical exam signs, increased ventricular filling pressures, and decreased cardiac output in chronic HF patients. Stevenson et al. JAMA. 1989.

An excellent point is made in this paper: “While the relationship between physical signs and hemodynamic profile has a firm basis for acute congestive heart failure, the chronic state is characterized by a host of compensatory mechanisms that may cause disparities, …”

“…such as the absence of rales and peripheral edema despite symptomatic elevation of ventricular filling pressures.”

This cohort had quite the notable med regimen: digoxin (84%), furosemide (84%), vasodilators (56%), and milrinone (4%); 39/50 were being evaluated for transplant

Good morning, early birds! The Oklahoma State Department of Health is considering privatizing at least the management of its new public health lab and the state's new pandemic center.

A letter to agency employees Tuesday from Commissioner of Health Dr. Lance Frye said, "This consideration will include the potential privatization of some functions, programs, services, units and/or divisions of the agency,"

A statement Wednesday by OSDH Deputy Commissioner Travis Kirkpatrick indicated the agency did not intend to privatize the lab as a whole and instead said it was considering a management agreement with Prairie One, a not-for-profit subsidiary of the OSU Research Foundation.

"This agreement, which has not been finalized, would allow OSDH to focus on and strengthen public health priorities to better serve Oklahomans and leverage public resources to maximize our capabilities," Kirkpatrick said.

"'Privatize' is broadly defined under state statute - it means to enter into a contract for the performance of a duty or function that is currently being performed by a state employee," he added.

Good morning @jidesanwoolu, how is your health now Sir? Thank God you are looking well and alive. We are grateful to God.

We want to bring to your remembrance the End SARS terrorist attack in Lagos on October 20, 2020. A lot are not satisfied with the responses from Lagos State.

The US version has an unprecedented response at the moment. Over 57 have been arrested and the appropriate charges have been proffered against them.

Just a few have been apprehended here and their arraignment has been a slap on the wrist, because it looks like a joke!

did a short and pregnant article, listing out the lives that were lost and the properties that were wantonly wasted in Lagos State.

Let's review them, Sir.

To many, these are disturbing images. Very disturbing till date.

When are the terrorists going to be ALL arrested and prosecuted, Sir?

@jidesanwoolu
@followlasg
@Mr_JAGss
@rrslagos767

While we appreciate the fact that you are all for due process and following the books, we are not satisfied with the silence.

Our long suffering is waning. Just the sight of this carnage is vexing to the blind!

Really trying to find the words I want to say in the letters I’m going to write to the ED and the GI clinic for 1. Minimizing my symptoms, asking me in a condescending way if I have tried icy hot. 2. Not treating my pain appropriately and making me feel like a drug seeker.

3. Brushing me off numerous times and not taking me seriously. And 4. Legitimately making me question myself and making me believe it was all in my head.
I cannot put into words how this experience had been.

The ONLY reason I was able to get a HIDA and get a confirmed diagnosis of biliary dysfunction was because I was working with a surgeon on ICU and I had an attack. I was double over in pain, pale, shaking, and diaphoretic when he sat down next to me

And started to do an assessment. He opened my chart reviewed everything and within 5 minutes was concerned about my gallbladder and ordered a HIDA through his clinic. If it was not for that encounter with him (which was all by chance) who knows where I would be.

I got lucky because I am a nurse and I was working with a surgeon who listened to me and decided to bypass all the BS and get me in for a scan that my PCP and 2 ED docs didn’t want to order. I could not imagine what would have happened if I didn’t talk to him about it.

So with all of our new followers, it seems sensible to tell you a little bit about who we are and what we do! EveryDoctor is a membership collective of doctors and medical students which is supportive of doctors and who believe in the NHS and what it does for all of us.

We have just over 1650 members, and we also run The Political Mess on Facebook, the largest private doctors' group of its kind, so that we can draw from as wide a pool as possible, with some small caveats.

We're an explicitly inclusive organisation, with a firm anti-racist, anti-bigotry platform which we seek to protect. We want to be a place where groups who're more vulnerable or marginalised for a range of reasons are able to speak up, so we hear their voices too.

When the pandemic began, our petition of 45000 voices called on the Health Secretary to deliver masks, goggles, gowns and gloves to every NHS worker, not just frontline staff. Because of our persistence, NHS England changed its guidance on eye protection and procedures like CPR.

As the cases worsened, we stepped up our efforts. We ran 17 parliamentary briefings with MPs to give them the facts about the crisis. 104 cross-party MPs from every nation backed the #ProtectNHSworkers campaign. More details at:

There are two issues with the English variant, as it is now referred. One issue is "what it could do" and the other issue is "what it could represent". They are both important and we know just enough to make hyphoteses that can drive to experiments. I'll try and explain 1/

Let's start with the latter: what does it represent? Mutations happen all the time and variants have been recorded in the thousands. The website below shows several 1000s different variants recorded in different countries. Why is this SO special?

The most special aspect of this variant is that the number of changes it shows is a large disconnect from its parental line as if this lineage made a big sudden jump rather than the usual slow progress to which we are used. 3/

There are a few (certainly not many) scenarios that are compatible with this jump and one of them is the one in which the virus has tried to escape its way out from an organism that had a static and relatively weak immune response.

4/

Such an organism is an immunosuppressed patient who tries to fight the infection with injections of donated plasma from a recovered patient. Someone who cannot produce antibodies and can be helped with plasmapheresis from a donor who could. 5/

8 superfoods that will 10x your body mass:

1. Red Meat

Red meat is an excellent source of protein that aids in weight gain and muscular development.

It has leucine and creatine, which are substances important for increasing muscle building.

Protein and fat found in steak and other red meats contribute to weight gain.

2. Starchy Foods

Potatoes, sweet potatoes, corn, whole grain bread, oatmeal, whole wheat pasta, and brown rice are high-carbohydrate foods.

Carbohydrates, which have a protein-sparing effect, are essential for muscle growth along with proteins.

3. Eggs

Eggs are a powerhouse of protein, zinc, vitamins A, D, B 12, phosphorus, and folate.

Egg protein has a high biological value, which makes it the ideal post-workout snack.

There are 90 calories, 6.7 grams of fat, and 6.1 grams of protein in one large scrambled egg.

4. Fatty Fish

Essential fatty acids and proteins are abundant in fatty fish like salmon.

They aid in weight gain and immune boosting.

The finest source of omega-3 which is important for weight gain is found in these fish.

My uncle passed away from cancer when I was 16 years old.

I’ve since spent 100’s of hours researching how to avoid and fight cancer naturally.

Here’s what I found:

1) Boost your stem cells

Your body slowly regenerates using stem cells.

Foods that promote stem cell growth:

• Seafood & fatty fish
• Berries (black, blue, raspberry)
• Broccoli, cauliflower, brussels sprouts

More stem cells = lower chance of cancer

Fasting is also a viable option for increasing your stem cells.

You could do a 24 hour fast once a week.

Or go extreme like my business partner @taylinsimmonds

And fast for 4-7 days at a time.

I’ll stick with 24 hours tops ;)

2) Hack DNA repair for longevity

To amplify DNA repair:

• Sleep 7+ hours
• Exercise regularly
• Try intermittent fasting

Natural DNA repair prevents your cells from mutating.

Eat foods that amplify DNA repair:

• Greens
• Mangoes
• Greek yogurt

The best cancer cure is prevention.

Okay, I just found out the very name of the learning disorder that resonates with my condition

That’s me alright, shit

I had always known that there was something wrong with me, something I had had a hard time putting a name on. Apparently, I have auditory processing disorder. That is me to the bone. The bane of my existance

I had always been this child who can’t sit still in the classroom, listening to lecturers drone on. During my high school, I read comic books as I tried to listen to the classes. I was and am disorganized, it isn’t a surprise that I got into troubles with authority figure a lot

Even during my university year, I don’t listen at classes, I prefer to study by myself rather than processing the verbal information which I have a hard time processing as instantly as others. I am not a good listeners either in class setting or outside of it. And it shows