“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.…

ECTOPIC PREGNANCY

A woman just lost her life due to ectopic pregnancy!

It's a pregnancy in which the embryo attaches outside the womb. It can be life-threatening.

But we can save lives by helping educate women on our Timelines with this.

THREAD 🧵

In the human body, a fertilized egg hardly survives outside the womb. If allowed to grow, it may damage nearby organs & cause severe blood loss.

The bulk of ectopic pregnancies occur in/along the Fallopian tubes.

Some in the ovaries, cervix or a random location in the abdomen.

The usual symptoms of ectopic pregnancy a woman may experience esp. in early pregnancy are;

* Abdominal pain
* Vaginal bleeding, &
* Amenorrhea (missing your period)

Other pregnancy symptoms like breast fullness & occasional nausea may be there too.

But the common DANGER SIGNS of ectopic pregnancy that may signify rupture are;

🔴 Rigid abdomen

🔴 Severe abdominal pain

🔴 Shoulder tip pain, &

🔴 Signs of shock such as cold hands & feet.

With these signs, immediate medical attention is needed to save the woman's life!

Your chances of having an ectopic pregnancy are higher if you have;

1. Previous ectopic pregnancy

2. STI's like gonorrhea

3. Fertility treatments like IVF*

4. Fallopian tube surgeries

5. Pregnancy while using an Intrauterine Contraceptive Device

6. Smoking history! 🚭

Ashtangha Yoga or the eight limbs of Yoga-

Many people think Yoga is just an Indian physical exercise but that's wrong. Yoga is a way to connect with the Supreme in Hinduism and attain Moksha(liberation).
The proper yoga as described in Hindu scriptures consists of 8 limbs:

1) Yamas- They are the 5 ethical rules of Hinduism. The 5 Yamas are:
i) Ahimsa: Nonviolence (this also includes not eating meat)
ii) Satya: truthfulness
iii) Asteya: non-stealing
iv) Brahmacharya: chastity, sexual restraint
v) Aparigraha: non-avarice, non-possessiveness

2) Niyamas- They are the 5 "do's". The five Niyamas are:
i) Shaucha: purity of mind, speech and body
ii) Santosha: contentment
iii) Tapas: austerity, self-discipline
iv) Svadhyaya: study of Vedas(Holy books of Hindus)
v) Ishvarapranidhana: contemplation of the Ishvara (God)

3) Aasana or the physical yoga-
Asana is a posture that one can hold for a period of time, staying relaxed, steady, comfortable and motionless. The aasana postures are believed to have been given by Mahadeva (Hindu God) himself. Hatha Yoga Pradipika mentions 84 aasanas.

@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.

Masks. A short thread. In June last year my GP advised me that wearing a mask even for a short space of time would be harmful for me on two fronts. One - I have painful rosacea on my face. It’s a horrible condition and it’s lifelong. I can at times look scary!

Putting on a mask simply makes it worse. Two - I have hypertension. Manageable and controlled. GP also advises that mask wearing even for short periods can raise cortisol levels and make them dangerous to me.

On that basis and given the dreadful treatment us non-maskers have to suffer and to appease the abusers I have three times asked my GP to issue me with a letter relating to my conditions.

On each occasion she has said that there is no need. Whilst she won’t admit it straight up, all conversations suggest she’s been told not to. I happen to agree that no-one should need to reveal their medical history to anyone other than medical professionals responsible for me.

I’ve researched mask wearing in relation to what they are supposed to be used for ref *Covid* - I’m no thicko - I prepare risk assessments (and I’m qualified to do so) every day (or did) - and the evidence *for* is weak. Very weak.

[Thread]: Old school "medicine" ads obviously created by aliens.

Let's begin with cocaine toothache drops, for only 15 cents.

Dr. Batty’s asthma cigarettes were not recommended for "children under 6.”

Best prescription for malaria, chills and fever: Grove's tasteless Chill Tonic, obviously.

"It is simply iron and Quinine in a tasteless form".

The cheapest specific for the relief of cough: heroin.

There's also Dr Williams' Pink Pills for Pale People.

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"

We’ve done menstruation, let’s talk about the menopause! Because only women however they present can have the menopause although men who have had treatments for prostate cancer can have symptoms mimicking the menopause. There’s nothing scary about

the menopause. It’s a perfectly natural function of the body but it’s tied up with a thousand stereotypes of women, ageism and ‘old women are frightening’. True, old women are often very frightening to young men because look! A woman who doesn’t give a rat’s

arse what you think of her now all her mating hormones have gone and with it your charm as a potential mate. Now you’re just another annoying lad. That’s gotta hurt. Menopause means Wisdom, like it or not and it’s not always nice or cosy. Old women

are encouraged to refer to themselves as ‘young at heart’ and ‘as young as you feel’ and other such crap and told to ‘never give in to age’ which is ludicrous. Cosmetic surgery is now a thing but I can tell you what the surgeons and marketing

men won’t - it does not make you look young. You’re just an old woman who looks like at best, she’s had a great holiday and at worst like she was was trapped in a wind tunnel. Old is good. Old is meritorious. Old is survival. Old means you didn’t die young

A staple of anti-lockdown conspiracism in yoga/wellness is that public health measures are oppressive, authoritarian, and stifling what it means to be human. Masks suppress identity and speech. Vaccines assault the sovereign body. Influencers must rise up against tyranny! /1

Ironically, pandemic management in economies where yoga/wellness is lucrative has been a neoliberal, choose-your-own-adventure mess in which centre-right governments barter with public health to enact a patchwork of half-measures that punish the poor and marginalized. /2

The goal is not universal health rights, or protecting medical systems, or saving as many lives as possible. The goal is to return to business-as-usual, using public health as a pit stop on a productivity race off a cliff. The ice caps aren’t melting fast enough, I guess. /3

Right-leaning governments, like influencers, have assessed the COVID threat with the magical bias of limitless optimism. Then they work to normalize COVID casualties as a new cost of doing business. *This* is what alt-healthers and Qamoms call “socialist”, or “communist”. /4

Centre-right governments and wellness influencers share a goal: get back to the optimism of making productivity heroic and consumption virtuous, without any reflection on structural issues of injustice, or what universal health care funding and standards would look like. /5

I entered this conversation thinking that I already knew the story, in a way. Dr Wodarg had succeeded in preventing the WHO from creating a fake pandemic in 2009. He thought the world wasn't silly enough to be fooled twice, but he'd been wrong. 1/9

He'd previously had ready access to mainstream media and found this suddenly cut off when he opened his mouth to voice his concern about the hysterical mania of Covid. The comically corrupt whom he'd vanquished all those years ago had been waiting for him. 2/9

All sorts of web entries about his courageous and humane career in public health and politics had morphed into caricatures that painted him as a freak; a "denier", as the post-modern parlance goes, with no means of redress. 3/9

This much I knew before I even started asking questions. What I hadn't expected was to find political correspondence with him, & we found that all of a sudden towards the end of the interview. He calls himself a socialist, I call myself scale dependent, & stop there. But ... 4/9

... it turned out we'd kindled the same central concept—subsidiarity. Subsidiarity is a principle in social organisation holding that functions which are performed effectively by local organisations belong more properly to them than to a dominant central one. 5/9

In medicine, reckoning with racism includes reappraising the very syntax we use every day. Proud to add my voice w/ @J_Ikeme and @RWGrantMD in this @JAMAInternMed pub addressing:

Does race/ethnicity belong in the first line of the patient

Some background: I’ve struggled with this question since early in medical school

Medical syntax is designed to communicate information in a predictable sequence with key elements prioritized to facilitate efficient communication and formation of an assessment and plan

2/

From preclinical lectures to Qbank questions to clerkship rotations, race/ethnicity was often prioritized in the same sentence as age + gender.

I grew accustomed to reading/hearing: a 70-year-old Black man w/ history of x, a 50-year-old Hispanic woman presented w/ y.

3/

However, when it came time for me to use race/ethnicity, there was always tension. Race/ethnicity are self/socially-ascribed identities that in clinical practice are almost always assumed by providers based on appearance. I was also concerned about the potential for bias

4/

I wondered how my own care would be impacted or not impacted by my ethnicity (Hispanic) – I have light skin so I’m not sure if my doctors would even identify me as such – but how would my care be different if I was presented as a 30-year-old Hispanic male?

5/

breaking my social media fast, which may or may not exist anymore, to share something i found really really helpful from today's therapy sesh. i figured out why i (we?) have so much trouble celebrating our wins

so ive been in therapy for 100 years. still anxious, but im pretty sure i was born that way so i'll stay that way. still depressed too, which i thought id be cured of by now. aa few sessions ago we talked about what i think a return to health 'should' look like

initially i figured itd look like being the person i was before i got depressed. energetic, not needing pep talks to do shit like go outside, cooking everyday, working out at least 30 mins at least 3 days a week, calling my mom everyday, etc.

that session i realized that im a completely different person than i was before i got depressed. also the world has changed a lot & things are just done differently now. not allowing for those things had me reaching for shit that was impossible.

so i make some concessions but say that i *still* want to be able to do some things that i dont want to do. like i cant just sit on the couch and never move in the name of accepting who i am, which is A Bitch Who Don't Like To Move. i still want to be able to eve if i dont want

Mistakes natural lifters make

THREAD ⬇️

1) Bro Splits

Let's start off with the big one.

A natural lifter needs the actual training session to trigger the increase in anabolism that a steroid user will get 24/7.

After a workout, anabolism/protein synthesis is elevated for roughly 30-36 hours.

So training a muscle once a week is sub optimal as you're getting 30-36 hours of enhanced growth out of a 168 hour week.

Whereas if you train a muscle 2-3x per week this goes up to 60-72 hours or even 90-108 hours of enhanced anabolism, leading to faster growth.

Obviously there will be some individual differences here, but as a natural, if you only train a muscle once per week, you're leaving a good chunk of gains on the table.

It's optimal to spread your total weekly volume out across the week by increasing your frequency.

2) Not getting strong

If you get strong on the basic lifts and their variations such as the squat, deadlift, presses, rows and chins, I guarantee your physique will show it.

Take your squat from 225lbs x 10 up to 315 x 10 your legs will be bigger.

Stop fucking around!

A thread on the latest Sturgeon-Salmond revelations. 👇
1/13

Evidence has emerged of a deliberate cover-up.

A crucial detail was apparently hidden from the public.

According to Sky, the official knew it would potentially end their career if it came to light.

This is important because it may undermine Nicola Sturgeon’s story. 2/13

Throughout the Alex Salmond affair, the First Minister has dodged questions at every turn.

She has tried to hide behind legalities, false narratives, straw men.

Every tactic in the book has been rolled out to stop the truth reaching the public. 3/13

To her utmost shame, the First Minister uses the women who were so badly let down by her government as a shield.

She argues they are being attacked, when nothing could be further from the truth.

We all want to get to the bottom of what happened here - for those women. 4/13

Instead of justice, those women have been caught in this uncivil war - that they never wanted to be part of.

They’ve been failed by basic, unforgivable errors from Nicola Sturgeon’s government.

And failed ever since by the SNP’s obstruction over what went on. 5/13

APL Apollo conducted their earnings con-call today at 2:00 pm

"Vision of capacity of 4 Million Tone till 2025"

@hiddengemsindia @gvkreddi

Here are the key highlights 😀👇

Business Updates:

• Net Working Capital Remains under 10 days which is best in the building material
• Continue expanding rural region.
• Added 15 new distributors.
• Value added products contributed 50-60% of the topline.

Revenue breakup

• EBIDTA Margin Improvement: This was mainly because of cost structarize and better operational

• Working Capital Cycle as per mgmt should remain sustainable

• Blue Ocean: Company owns 100% subsidiary which contributes nothing but own property where corporate office is there

Improvement in Net Selling Realization:
• With expanding capacities at 2.6Million Tones and utlization of 75%, scalability has been affected.
• While the prices of steel has gone by by around 35%, due to shortage of steel.

• Apl Apollo being the dominant player past connection with steel companies worked well.
• Steel tubes supply from China is shrinking.
• Hence the discounting factor while selling the products has went away.

@73inlancs @janethooton_ @ErinInTheMorn @fifi_EY 1/ The 🏴󠁧󠁢󠁥󠁮󠁧󠁿 government decided pediatric gender care in England would be a monopoly contract (a Labour minister, in 2008), despite all other NHS patients officially being entitled to a choice of providers, & second opinions on diagnoses & treatment, & gave it to GIDS, which has…

@janethooton_ @ErinInTheMorn @fifi_EY 2/…always advocated that trans minors & their families must have no alternative source of care, & subsequent Tory ministers have personally put their signature on renewals of it, and even personally rejected proposals for improvement that have been put forward by NHS England…

@janethooton_ @ErinInTheMorn @fifi_EY 3/…as a result of wider & public consultation. They & their civil servants listen only to GIDS on trans minors - it was GIDS advised against <18s being allowed #GenderRecognition in 2004, & since, on the basis that no one under 18 can be certain of their gender identity, just…

@janethooton_ @ErinInTheMorn @fifi_EY 4/…as many other staff at their trust wrote⬇️ to the press in 2002 (when the first instigator of this case, psychoanalyst Susan Evans was on staff too) that no trans people should be allowed that recognition but needed

@janethooton_ @ErinInTheMorn @fifi_EY 5/…to "cure" us instead. Yet GIDS proved incapable of defending its super-conservative protocol in court - no doubt because GIDS has always expected challenges to be from patients seeking care more like that elsewhere, arrogantly ignoring that services in countries where the…

UAMS has taken the extraordinary step of asking leadership across our health system to refrain from traveling over the coming holidays and report to work or be available if needed. Other hospitals in our state are considering similar measures.

(1)

Although the health care system in the state of Arkansas is stressed right now, it is holding up, and additional surge capacity exists. But that capacity is not infinite.  Every day, we become more and more concerned about our ability to manage what lies ahead.

(2)

As health professionals, we are doing all we can. However, one thing is certain. We can’t meet this challenge unless you are with us. As Secretary Jose Romero of the AR Dept. of Health has said, we are in the midst of a “surge within a surge” in this COVID-19 pandemic.

(3)

Right now, the @UAMS_COPH COVID-19 forecasts, which have been strikingly accurate so far, indicate that the density of COVID-19 infections exceeds each of our abilities—yours & mine -- to avoid contact with actively infected individuals in our state...

(4)

...whenever we venture outside our homes. They predict an exponential increase in coronavirus deaths in the next two weeks, more than we saw in the first four months of the pandemic. We may soon exceed the number of beds, ventilators, & most importantly...

(5)

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

Thanks to Crispr-CAS9 technology we MODIFY the defective gene inside the patient eye ( they directly inject the treatment into the eye). Before CRISPR the treatment was based on Adenovirus carrying the correct form of the gene

In both cases, we MODIFY the patient DNA and that's the only way (today) to treat this disease. LCA10 is not the only genetic disease affecting kids unfortunately the list is long and the variety of diseases is terrifying.

Now think about a parent with a kid with a genetic disease, he/she would try and do anything to save him/her. ANYTHING and they would take some RISKS, gene therapy was a risk at the beginning, and any new experimental treatment shares a percentage of risk. 4/n

Now we come to #COVID19 and #vaccines. The new RNA vaccines are a HUGE scientific breakthrough, that may open new amazing therapeutic paths. And like ANY other human activity share a risk.