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

1/23 We haven't had a lot to celebrate during this pandemic. But achieving the milestone of offering vaccine to the over 70s, health and care workers and the most clinically vulnerable just before target date is a huge cause for celebration, given the scale of the achievement.

2/23 When Margaret Keenan got her first jab in Coventry on December 8th last year, who’d have thought that, by Valentine’s Day, we’d have vaccinated over fourteen million people across the UK in just ten short weeks? Amazing, extraordinary and truly, really, world class!

3/23 I’ve been struck by how much joy and relief has been brought to those doing the vaccinations and those receiving them. A GP told me yesterday that nothing had given him greater pleasure in his long career. And that the patient's relief was sometimes overwhelming.

4/23 It's vital to recognise the extraordinary contribution of the staff and volunteers who have made this happen. One of my close family had their jab yesterday and was in awe of the volunteer standing outside in the freezing cold for a four hour shift meeting and greeting.

5/23 What I wanted to share in this thread was the slightly untold story of some of the extraordinary challenges the NHS has had to overcome to deliver this target. Requiring superhuman effort from NHS leaders and staff, way beyond the call of duty. Five challenges set out below.

On December 29 we were dillucidating here if the drops meant "surprise, relatively neutral expression" or "a negative expression, horror" (Remember: https://t.co/J2gjQjAENw ). Well, December 22 drops seem to clarify it. First, the December 29 drop that generated the confusion 1/*

didn't appear in today drops, while several old ones have been posted again. I would say that all December 22 drops regarding facial expression mean and clarify "surprise". 2/*

More 3/*

And more. So, they didn't point to a negative event, just to one that generates surprise. 4/*

All these drops were completed with a Christmas gift one, confirming the surprise neutral meaning and adding a related positive one connected to the surprise. 5/*

“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.…

New NHS reforms announced today. Seems to be a story of two parts, plus a missing character. Quick thoughts (1/):

Part 1 of the story is a set of technical fixes wanted by NHS leaders to encourage collaboration in the health system. The direction here makes sense—and fits with what the NHS has been doing for ages. Competition is (mostly) out; collaboration is in: good (2/)

And the need for legal changes to tidy the mess left by Lansley’s 2012 Act has long been recognized. But... (3/)

The benefits of integration are often way overstated, and the risk of reorganizations underplayed. In its first 30 years, the NHS’s structure was relatively stable. But over the past 30, the NHS in England has been on an almost constant treadmill of reform and reorganization (4/)

Overall, evidence suggests that previous reorganizations have delivered little measurable benefit. They can also distract and disrupt, depending on how they’re done. The list of other things for the NHS to be doing during and after the pandemic is very long. So be cautious (5/)