Some thought about DVT prophylaxis in ICU.
Part of my presentation on the same topic.

Question 1: What is the incidence of DVT and PE in current era of widespread thrombo-prophylaxis?
#FOAMed

Question 2: How do you diagnose DVT in ICU?
▶️I think, the best evidence is available for CUS with limited scope for Venography.
And no role of D-Dimer.
#FOAMed

Question 3: Is there any evidence supporting Heparin thrombo-prophylaxis in ICU?
#FOAMed

Yes.
1⃣Number needed to prophylax to prevent 1 DVT - 20
2⃣Number needed to prophylax to prevent 1 PE - 52
3⃣Overall no major bleeding. But bleeding risk need to be individualised.

Question 4: Is there any evidence of LMWH over UFH in VTE Prophylaxis?
#FOAMeYes.
1⃣LMWH decreases DVT. But no difference in Proximal DVT.
2⃣No difference in PE.
3⃣No difference in major bleeding.
4⃣Lower incidence of HIT in LMWH (PROTECT Trial).
5⃣Overall advantage LMWH.

Question 5: Is there any role of Mechanical Thromboprophylaxis?
#FOAMed

I am not full sure people appreciate the impact of B117 strain on the course of the pandemic. TL;DR B117 is "a pandemic inside a pandemic" and demands both monitoring and preparation for when it arrives in a location. Vaccination is even more of a priority due to B117.

Context: I am an expert on human genetics and computational biology. I know experts in viral evolution, testing, infectious epidemiology, clinical trials. I have COIs in that I am long established consultant to @nanopore and I am on the Ox/AZ vaccine trial.

B117 clearly transmits faster. This has been clear in a UK context now for over a month, with particularly insightful backtracking of growth of B117 from low levels through October/November; it is true in Denmark; it is true in Ireland.

(Shout out the fast responding science of @CovidGenomicsUK, of the analysis of @jcbarret and @arambaut, of clever genomics-epi models of @MoritzGerstung and @harald_voeh and on it testing / spidey sense of @The_Soup_Dragon)

(In Denmark their excellent genomic surveillance, similar to UK's allows Denmark to know about the growth of B117 from low level in the context of other strains - props to @MadsAlbertsen85 and colleagues; In Ireland it is becoming one of the dominant variants)

How do remedies work? Gemstones/ yantrās /Effectiveness / examples / astrological causes

Remedies for karmic debts can work effectively but they have to be exercised in certain manner. For example in case of certain rogā, the medicine cannot be given in raw form while in others

medicine should only be given in raw form only.

Therefore, the modus operandi of remedies is very important.
The quantity of japa, Pooja, homam, ḍeepa etc. has to be decided for their effectiveness. For example, a childless couple suffering from Sarpa dośa cannot have a child

by mere lighting a lamp in front of ṇagas. In other cases where case is small, the remedies are also small. Some remedies are expensive and strong but they have to be followed in same manner. Some remedies requires expert tantric etc. without which they cannot be done. The ten

Mahāvidhya requires a proper initiate or sadhak of mahāvidhya which is rare to find. Only he/she can solve the problem.

Mantras taken from book have no power either because they are nailed or because they lack the power of the Guru or initiate who lives with the mantra. That

power is transferred to student when the mantra is whispered in his/her ears. The mantra, homam, prayers etc requires expert mantraśastri or tantric who can do the Poojas. Ordinary purohits are not aware of the proper ritualistic procedure so their Poojas might not work.

Just got off the phone with a client who hasn’t been able to call because the jail has been taking his money for his meds.

In jail pretrial, they won’t continue you on any medicine you were on previously. You are abruptly taken off because you aren’t allowed to take your meds.

No regard for what abrupt discontinuation of meds will do (from what I’ve seen can range from delusions, delirium, psychosis, suicidal thoughts to actual suicide.) You stay like this while waiting to see medical which can take 20 days- month(s). Longest I’ve seen was 3 months.

After seeing medical, your scripts are often changed to different brands, doses reduced, and only administered once a week. So if you were prescribed something for bipolar— you’d get your one (smaller different brand) dose once a week.

You are then billed for that visit to medical + that medicine that’s administered once a week which is deducted from any money you have in your commissary. Then whatever remains is an open bill which will be taken should your family put more money on your books.

Your commissary is the only money you can access in jail— not only is this how you call home, how you video visit during a pandemic (because in person isn’t allowed), how you get utensils, paper, etc. to write home, but also how you buy necessities that the jail doesn’t provide

💥 Role of Stents in Dialysis Vascular Access - Tweetorial

⚡️Indications for Stent Use

⚡️Recent Clinical Trials of Stents in Dialysis Vascular Access

⚡️Complications associated with Stent Use

1/
@ASDINNews
#VascularAccessPearls

⚡️Arterio-venous (AV) Access
causes significant morbidity & mortality in patients on hemodialysis

⚡️Most AV access associated complications are due to vascular stenosis👇🏽
2/

⚡️Vascular Access care has evolved over the past 60 years:

-Scribner’s Shunt in 1960 ➡️
-Brescia-Cimino AVF in 1966 ➡️
-1st Balloon Angioplasty in 1981 ➡️
-1st Bare Metal Stent in 1988 ➡️
-1st Covered Stent in 1996 ➡️
-DCB use in 2012
3/

⚡️Despite these innovations, AV access stenosis remains a big problem

-Percutaneous Balloon Angioplasty (PTA) remains the 1st line therapy for stenosis but it is NOT very effective

-AVF patency after PTA is only 50% at 6-months & it is worse for AVGs👇🏽
4/

⚡️Neointimal Hyperplasia (NIH) causes vascular stenosis & it is due to:

-Hemodynamic stress
-Surgical trauma
-Cannulation needle trauma
-AVG

‼️But balloon angioplasty, the treatment for stenosis, can itself induce NIH & cause restenosis👇🏽
5/

@GoadGatsby WARNING: THIS POST CONTAINS INFO LIKELY TO MAKE STEAM COME OUT YOUR EARS
Personally, I don't use but I gotta ask b/as long time SA Counselor & Clinical Neuropsychologist,
What ARE these people so on re weed about? Theres NOTHING abt weed comes anywhere close to t/individual, 1/

relational, marital familial, societal and physical and mental health damage done by alcohol (ism) daily. PERIOD FULL STOP

& Research that was so long denied has found a plethora of bennies.

That's not to say no abuse occurs or is possible, (however, [stick with me here] 2/

I see a variety of WS groups currently abusing [t/great American symbol of home family & motherhood] MILK these days...
Hey, if it's a substance/any substance or something transduced or processes by your chemical brain [neurochemistry baby] use misuse, abuse addiction & 3/

deadly addiction is a thing, A BIG THING including "thought addiction," [we MH profs call this obsession] which seems a likely group DX for folks on the right who are virtually obsessed with weed as if it were Hitler, meanwhile they're tryna convince themselves he had a 4/

rational national plan on repeat. But I digress).
Bottom line: Cannabis Use/Abuse Disorder is far less (note t/word LESS) common, far less damaging both in t/short- & long-term & pop #s for Cannibis Use/Abuse are no where near those of alcoholics & the resulting death maiming 5/

[THREAD] I saw a few of us saying that their 2021 resolution was to improve their mental health. So I decided to write this guide in terms of what steps we can take to improve our mental health for 2021 and beyond. The most important step is to start some form of treatment.

While finances can be a huge barrier to getting treatment, there are a few things around that. Medications (especially those that have been around for a while) are generally much cheaper because they exist in generic form. They are safe, have decades of research behind them.

Antidepressants are not addictive at all and while there are a few side effects at the beginning, they tend to go away after the first few weeks. While it is hard to get rid of superstition and myths around meds, taking that first step of just taking it will help so much.

For therapy, there are always some free or low cost options. Sometimes, there are students about to graduate from their post grad who offer free or low cost therapy as experience (under the supervision of a fully licensed psychologist and legally).

They are the equivalent of a resident doctor, meaning they have the knowledge and expertise but lack the experience and both of you can benefit from working with each other. I remember when I was in that position and worked, I had my supervisor guide through every client.

I struggled with intense acne for 3 long years in high school.

During that time, Western pimple commercials eroded my self-worth in 30-second increments.

Here is the story and what it means for practicing self-improvement without judging yourself.

Time for a thread! 👇👇👇

The arc of the pimple commercials was always the same:

1. Guy with pimples hides from his crush

2. Someone tells him he's ugly

3. There's a party

4. Someone recommends some skincare product

5. Guy uses product, goes to party, kisses the girl

Ex:

The message this reinforced to people for whom the product didn't work (aka me) was also always the same:

As long as you have acne, the other sex won't be interested in you, so don't bother.

It's a pattern deeply embedded in Western culture:

Find a flaw, worry about it, try a quick fix. If it doesn't work, go back to worrying.

Repeat this cycle until you find an even bigger inadequacy.

This may lead to some improvement, but it inevitably leads to self-loathing.

Now, let me present to you: Japanese skincare ads. They don't target teenagers.

Pimples aren't a flaw to be overcome, just a part of life.

"If you take care of your skin, acne might happen but won't ruin your day."

That's the message.

Ex:

ALL ABOUT PAAN

Paan, also called as betel leaf.

When we hear word paan , a constant image comes on mind as everyone who eat pan, will spit on walls with typical red color, paan will have all typical tobaccos ingredients and only some are exception which just have non tobacco

Here we all go wrong :

These 2 myths about paan is totally wrong.

First : Paan is mentioned in our culture from centuries , Paan should never have these tobaccos options, tobaccos paan was alteration after India was attacked by various foreigner

Portuguese[Introduced tobacco] , British[introduced cigarette filled with tobacco], before that Paan was only eaten as mouth freshener and digestive option.

History and significance -

Puranic Reference

There is a reference in Srimad Bhagavatam, that Lord Krishna chewed paan.

According to Skanda Purana, the betel leaves are said to have emerged during the Samudra Manthana or The Churning of the Ocean.

There is also a mention of betel leaves in Ramayana and Mahabharata.

In Lalita Sahasranama, there is a verse- “tambula purita mukhi” meaning, one whose mouth is full of chewing betel.

The use of betel leaves is mentioned in Charaka and Sushruta Samhitas,

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

Illusion: Thread
1/ Have you ever asked yourself
"Who advises WHO to make decisions on our behalf?"

Have any of you ever asked
"Who decided wearing masks & lock down is beneficial for our health?"

Have any of you ever wondered
"Who is ORDERING WHO to inoculate you?"

I know...

I transformed my body in 6 months.

People charge INR 25,000+ for this information. It should be free.

Just follow these simple fat loss rules:

Exercise:
• 3-4x per week
• Weights > Cardio
• Compound movements first
• Cardio after weights

Don't focus on burning calories focus on getting stronger

Video

Nutrition:
• 20-25% calorie deficit
• 1.6-1.8 g/Kg Protein
• 2x fruits & veggies daily
• Limit eating out

Food quantity determines weight loss. Food quality determines health.

Video

Sleep:
• Fix wake up time
• Sleep 8 hrs
• No caffeine after 2 pm
• Dinner 2-3 hours before bed

Have a routine, and be consistent. Routines save your time and maximise your energy.

Video

Simple is beautiful.

Don't bookmark and forget.

• Commit to the end goal
• Disappear for 6 months
• Build yourself in private

Before you go, I would love to give you 10 bonus tips to make you unstoppable-

(with step-by-step video tutorials)

BURNING STUBBORN BELLY FAT

(A Thread)

Stubborn belly fat can be 'stubborn' for a variety of reasons.

- Your genetics
- Your calories aren't low enough
- Your hormones suck
- Your metabolism has dropped too much

A calorie deficit WILL eliminate this eventually, but often it's not realistic.

Let's get into this...

1. Your Calories

You may just be eating too much food.

If you're 160 pounds, yet you're averaging 2500 calories on most days while not doing any cardio, then it's just too much food.

There's nothing wrong with you, you just need to eat nutrient-dense, calorie-sparse foods.

2. Your Hormones

If you've got low T, you may reach a point in the diet where a calorie deficit just leads to further muscle loss, rather than fat loss.

To combat this:

+ OBVIOUSLY train hard with weights
+ Make sure you're sleeping properly

TBC...

+ Get your vitamin D
+ Get on TRT if the above doesn't work
+ Take 1-2 months at maintenance, if all the above doesn't work

Stress/cortisol is directly linked to low T and lack of sleep.

SO the solutions are the same for high cortisol.

As US hospitals make the necessary shuffle to accommodate the current wave, I would like to remind leadership about the study done on the psychological status of frontline hospital workers during NYC's spring Covid surge (thread).

As expected, many participants reported stress, anxiety, and depression. But the study also looked into *what* exactly made participants feel distressed.

This graph is showing % of participants who found these factors "highly distressing." Note in the work environment section (blue) the number of things that rank higher than patient deaths.

These include:
- Perceptions of a lack of control and/or uncertainty
- Performing clinical work that is outside of your specialty
- The need/expectation for healthcare providers to provide social support to patients in lieu of their families (due to visitation restrictions)

- Difficult triage decisions or rationing of care (potential or actual) due to resource scarcity
- And also fears related to getting/transmitting Covid within the work environment - in particular, the uncertain Covid status of other healthcare providers