Cross-sectional imaging often reveals unexpected pancreatic cystic lesions, it is a frequent clinical problem, Should we observe or remove it? What's the diagnosis? Is our patient in danger of malignancy?
Don’t miss this @aegastro @my_ueg #EducAEG #UEGambassador twitter thread

Importance of Pancreatic Cystic Neoplasms (PCN):
Most are asymptomatic at diagnosis, frequency increases with age
Symptoms: acute pancreatitis (Wirsung obstructed by the cyst or mucus), pain, obstructive chronic pancreatitis, jaundice
> symptoms, >malignancy risk!

Classification of PCN:
Mucinous: intraductal papillary mucinous neop. and mucinous cystic neop.
Nonmucinous: serous cystic neoplasm, solid pseudopapillary neoplasm and cystic neuroendocrine tumours
Endoderm- derived columnar epithelium is characteristic for mucinous lesions
👇

Intraductal papillary mucinous neoplasms (IPMN)
Characterized by papillary proliferation+mucus production. It may involve Wirsung (becomes dilated) and/or branch ducts (cysts connected to the ductal system). It may evolve to pancreatic cancer particularly if Wirsung is involved

IPMN subtypes :
Intestinal: main duct, head, 40%->coloid/tubular adenoca
Pancreatobiliary: main duct,head, 68%->tubular adenoca
Oncocytic: rare, nodules,50%-> coloid/tubular adenoca
Gastric: most frequent, branch-type, uncinate, 10%->tubular

https://t.co/ZLzH00ba8Q

“Men . . . go mad in herds, while they only recover their senses slowly, and one by one.”

Mijn dagelijkse portie 'sanity' and 'mental health'

#coronamaatregelen #coronavirus #vaccination

"So wrote Scottish journalist Charles Mackay in his 1841 book Extraordinary Popular Delusions and the Madness of Crowds, which for good reason to this day remains in print."

"The Covid-19 hysteria, scientifically called mass psychogenic illness, that began in March has yet to peak. And if some have it their way it will continue indefinitely, merely going, in medical terminology, from epidemic to endemic."

"That is, it will never fully go away no matter what."

"Except. For. One. That’s total elimination of the disease."

"That may be close to impossible and incredibly expensive to even try, but like eliminating all carbon emissions in a decade it is a goal."

"The problem, of course, is that we’ve never eliminated an airborne virus by quarantining healthy people and there’s no scientific breakthrough that has made that any more possible now than it’s ever been."

A day in the life of a junior doctor on covid ward. By Jane Smith (not her real name) in the UK. /thread
"I begin my shift at 8am. Before I can even head to my allocated bay, a nurse is already asking for a doctor to help her. One of the patients won’t put on his mask

and his oxygen levels are dropping. It takes me a few moments to get on my PPE before I can get to him. I try to talk to the man, but it’s difficult for him to hear me through my mask and the noise of all of the CPAP oxygen machines. He tells me that he’s tired of fighting,

and that he wants to be left alone. I have to be sure that he understands the risks, so I ask him to explain to me what he expects will happen if he takes off his mask and doesn’t put it back on. He says he doesn’t know. I tell him that he has to understand that he will die

and that he needs to say those words to me if that is what he really wants. Eventually we compromise; he will put his mask on for another hour, then phone his wife and tell me his decision. This man is 61.

I am allocated B Bay, in which there are five patients. My patients are mostly men, ranging from their early 30s to their 60s. This is younger than normal on HDU because — as I explained to the man — we only have beds for people with a fighting chance.

Dear #MedTwitter please, please, if you are a licensed medical professional and/or in school to be, do NOT delete your tweets or comply with anyone telling you to do so. It will harm you far more than leaving them up and explaining. Nothing is ever deleted. Can be used in court.

When I was at Harvard Med School and at an esteemed children's hospital, a case against an esteemed professor, that NO lawyer would touch cuz this was someone who had WRITTEN the textbooks and trained every expert, was won ..based on "a document was deleted" - creating suspicion

"Sunlight is the best disinfectant" you will hear me say OVER and OVER - wins & losses *should* be on data/standards but unfortunately wins & losses are in the court of public opinion. So be reliable, credible, and trustworthy. Transparency is one way to achieve that reputation.

The tweets I delete typically have a typo or the link did not populate the image as I wanted and I *immediately* repost THE SAME tweet, corrected. That way if anyone with "dark web" capacity were to try to "find dirt", ain't none. What you see is what you get.

I have been around the block enuf times, been a public servant w/ strict COI & scrutiny of my every word, & have been "in the room" when we have been deciding billions of dollars of state funding in Medicaid

You can decide whether you trust my

LONG TWEET. The WGN report by Rich McHugh set off a firestorm. The American Association of Nurse Practitioners(AANP) is on the defensive, claiming it disparaged NPs. Doesn't matter that WGN's anchorman clearly stated it was about transparency in health care, which all HCPs should

2)support. Nope, they had to resort to the predictable victimhood role and gaslighting to which we all have become accustomed. No comment about the parents and the fact that they were lied to, didn't even register on their radar. What became apparent after that story is that Full

3)Practice Authority(FPA) aka: "independent" practice aka: practicing medicine w/o a medical license should never have been an option in the U.S., because it represents two-tiered care. Now the AANP has set out to prove they are being discredited because physicians had the

4)unmitigated gall to question their "evidence". Something lazy a** legislators should have done but didn't. There is no "alarmist" agenda or conspiracy by "organized medicine". There is simply presentation of facts and disputation of alleged "facts". The high quality care the

5)AANP claims they provide is indeed disputable(https://t.co/ik0LfLYHAI). NP education USED to be of high quality. Not anymore. Why? Because the nursing educational system chose not to maintain their former excellent standards. When one devalues their own education, the

"Dependency" and "personality disorder" in mental health services: a thread.

I'm thinking today about Courtney Porter who died earlier this year, just three days after being discharged from inpatient care against her wishes. 1/

She was 20 years old. At her inquest, @CNWLNHS defended their decision to discharge Courtney by stating that people with a diagnosis of EUPD could not stay indefinitely due to the "risk of developing a dependence on the service." 2/

"Risk of dependency" is a phrase used very commonly to deny or withdraw support and care from certain mental health patients - most often those bearing a personality disorder label. But why? Why are this huge heterogeneous group of people, labelled with PD, 3/

supposedly all at risk of developing dependency, more so than anyone else, and what is so terrible about dependency that it's actually preferable for people to die than to be dependent..? 4/

Mental health services in the UK reflect the western culture of viewing autonomy and independence as key to personal development and success. Since the rise of individualism and self-care in the NHS moved us away
5/

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.

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.

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.

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 💊

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!

A lot of talk about NHS comms
I’m not sure sure that showing pictures on the news of busy ICUs or Ambulance queues will convince the naysayers and covid deniers of anything
They would still say it was staged or a hoax
Of course we need robust and honest information

But having a communications strategy based purely on images to fight the conspiracy theorists and covid hoaxers is a recipe for disaster
What we need is a high profile, properly funded public health campaign, but perhaps more than that we need ...

To accept that nhs isnt t a film set and patient confidentiality is important
Everyone says they love the NHS - show it by following advice

When working in nhs Comms I always took the view that media access and cooperating with media requests was important, this was often unpopular and at times I was a ‘lone voice’ often fighting both medics and the ‘corporate’ NHS side of things on the issue

And I think most health or other journalists who know me will say that I was fair and arranged access where others refused
One thing I never did was to forget it was a hospital/clinic/etc and patients were at the centre of it all

@KathyGrants @slomoshun1966 @kk131066 @foe_us @nature_org @jane__eden @impakterdotcom @sillymickel @vegix @how_sustainable @JamesrossrJames @climatemessages @sustainableuni1 @LolaGayleC @ResisterForever @mmpadellan @AdamParkhomenko @glennkirschner2 @morethanmySLE All the clinical Neuropsychological and forensic testing manuals that match the clinical measures we use...
Then made cheat sheets. (ok geek comment alert) the reason to do this is because if you don't understand the base rates and how they were derived, the populations 1/

@slomoshun1966 @kk131066 @foe_us @nature_org @jane__eden @impakterdotcom @sillymickel @vegix @how_sustainable @JamesrossrJames @climatemessages @sustainableuni1 @LolaGayleC @ResisterForever @mmpadellan @AdamParkhomenko @glennkirschner2 @morethanmySLE sampled to gain those "norms" and the year in which this was done, your interpretation of testing data will be significantly "off". If you can't assess the accurate diagnosis (meaning you misdiagnose) you end up causing pain and suffering not to mention treatment especially 2/

@slomoshun1966 @kk131066 @foe_us @nature_org @jane__eden @impakterdotcom @sillymickel @vegix @how_sustainable @JamesrossrJames @climatemessages @sustainableuni1 @LolaGayleC @ResisterForever @mmpadellan @AdamParkhomenko @glennkirschner2 @morethanmySLE if it involves psychopharm (meds)doesn't treat what actually ails the patient. When this happens, at best no one's treated for the actual illness they have which causes undue pain & suffering, at worst symptoms are exacerbated and or meds cause adverse reactions that can 3/

@slomoshun1966 @kk131066 @foe_us @nature_org @jane__eden @impakterdotcom @sillymickel @vegix @how_sustainable @JamesrossrJames @climatemessages @sustainableuni1 @LolaGayleC @ResisterForever @mmpadellan @AdamParkhomenko @glennkirschner2 @morethanmySLE have lasting effects (more pain and suffering) not to mention totally messing with the outcomes of legal cases
In short an inaccurate Diagnosis totally messed with people's lives.
. ..... So, if I use a measure you can bet Ive read the manual and understand the cautions, and 4/

@slomoshun1966 @kk131066 @foe_us @nature_org @jane__eden @impakterdotcom @sillymickel @vegix @how_sustainable @JamesrossrJames @climatemessages @sustainableuni1 @LolaGayleC @ResisterForever @mmpadellan @AdamParkhomenko @glennkirschner2 @morethanmySLE when to augment via clinical judgement. That often puts me at odds with folks in terms of opinions but I can back it all up via research and what's written in the manuals which often have caveats re use and application that people miss. More, as I went along it became obvious 5/