@tonybreu.bsky.social
Hospitalist, VA Boston Healthcare System. Co-host, Curious Clinicians Podcast
1/9
π€ Why doesn't an elevated BUN lead to extreme thirst? If increased serum osmolarity compels us to seek water, uremia should be a significant driver of this craving.
And yet, it isn't.
Let's examine why.
If Tony breu is here we are in the right place
28.11.2024 03:18 β π 20 π 1 π¬ 1 π 0
Portal hypertension and the development of varices
If only there was a way to block the alpha and beta adrenergic pathways to offset these changes
IF ONLY!!!!
#medsky #liversky
Glucose IS an effective osmole in the absence of insulin or insulin resistance. So hyperglycemia does lead to polydipsia (and polyuria due to osmotic diuresis)
28.11.2024 12:42 β π 4 π 1 π¬ 0 π 0
1/
Does the tryptophan in turkey really cause a food coma?
I've heard this repeatedly, while also being told that it is a myth. Let's have a look at the physiology of a Thanksgiving meal...
9/9
π§ An increase in effective osmoles (e.g., sodium) produces thirst via the movement of water out of cells (i.e., intracellular dehydration)
π§Urea and other ineffective osmoles don't produce the same shifts and, therefore, lead to less thirst
8/
The mechanism described above helps explain why other ineffective osmoles that increase serum osmolarity (e.g., glucose) are not independent drivers of thirst.
t.ly/odecD
7/
The explanation above leads to a beautiful symmetry of thirst promoters.
Either...
β€EXTRAcellular volume depletion
...or...
β€INTRAcellular volume depletion...
...will make you seek water.
6/
What is the "sensor" for cellular dehydration?
It appears that transient receptor potential vanilloid 1 (TRPV1) is key. TRPV1 is a non-selective cation channel that detects harmful stimuli like heat and capsaicin.
π‘ It is also activated by cell shrinking!
t.ly/lqhvy
5/
Based on this experiment, Gilman concluded that it is INTRAcellular dehydration that leads to thirst.
This results from a hypertonic extracellular space (e.g., hypernatremia) and the movement of water outside of cells.
t.ly/It2oB
4/
Gilman then made another crucial observation:
π‘Only NaCl led to a reduction in serum specific gravity. This suggested a shift of water from the intracellular to the extracellular space.
This only occurs with an effective osmole (e.g., sodium) and not an ineffective osmole (e.g., urea).
3/
After 30 minutes, the dogs were offered water, and had blood work drawn. Gilman made two key observations:
π The increase in serum osmolarity with hypertonic NaCl and urea were nearly identical
π Dogs drank significantly more water after hypertonic NaCl injection
t.ly/MIdqH
2/
We've known for nearly a century that an increase in serum urea is not a significant driver of thirst.
In 1937, Alfred Gilman published an experiment in which dogs received an IV injection of either:
β€20% NaCl
β€40% urea
Both are hypertonic solutions.
t.ly/MIdqH
1/9
π€ Why doesn't an elevated BUN lead to extreme thirst? If increased serum osmolarity compels us to seek water, uremia should be a significant driver of this craving.
And yet, it isn't.
Let's examine why.
Already done!
bsky.app/profile/tony...
I agree. Similarly, "tweetorial" can be applied to any set of threaded posts, no matter the site.
It's not too dissimilar to a Band-Aid. My kids call all adhesive bandages Band-Aids, even those not made by J&J.
It's already here!
What's cool is that it's got the original date I posted it too! This is thanks to @en.blueark.app
bsky.app/profile/tony...
Sigh. Only about half of veterans with cirrhosis hospitalized with SBP received guideline-directed IV albumin:
journals.lww.com/ajg/abstract...
Rates increased from 2008 to 2022, but disparities persistent: black patients were less likely to get albumin than white patients.
Lots of work to do.
I did the same.
Not expensive and provides me a way to reference "old work." The only issue has been splitting tweets into two posts when I have a long URL (BlueSky doesn't have a set character allocation for links).
I'm in favor of still calling them #tweetorials as well. It feels delightfully anachronistic and points to the roots/history on the other platform. #MedSky, who is with me?
21.11.2024 11:57 β π 9 π 2 π¬ 1 π 0
There appears to be some association (pubmed.ncbi.nlm.nih.gov/25270263/) though in a phase 2 trial the primary end point was not met (pubmed.ncbi.nlm.nih.gov/33754202/).
It seems like an RCT is complete though no results reported (clinicaltrials.gov/study/NCT050...)
Honey, stop what you're doing, new hyponatremia research just dropped!
What's it say?
It looks like slow correction is associated with worse outcomes, like death and length of stay!
Was it just a small study?
No, it was a meta-analysis of almost 12,000 patients!
jamanetwork.com/journals/jam...
4/4
It will be interesting to see if nemolizumab, an interleukin-31 receptor alpha antagonist, helps mitigate lymphoma-associated pruritus in the rare case when it becomes refractory.
This drug has been tested in atopic dermatitis with pruritus and was effective.
t.ly/-i6US
3/
The mechanism involves a cytokine unfamiliar to me: IL-31.
In one study of HL and angioimmunoblastic T-cell lymphoma, those with pruritis had higher serum levels of IL-31, IL-1Ξ², and IL-1Ξ± than those with lymphoma and no pruritis compared with controls.
t.ly/KxLw9
2/
The association between HL (and other lymphomas) and pruritus has prompted many to recommend a chest x-ray as part of the initial work-up when a primary skin disorder isn't present.
A 2013 NEJM review suggests this, as does Up-To-Date.
t.ly/wB5Xv
1/4
What is the mechanism of pruritus/itching in Hodgkin Lymphoma (HL)?
For today's Morning Report, Chief Resident Carter Baughman shared a case of HL that presented with months of pruritus. I was surprised to learn that up to 30% of patients with HL present with this symptom.
t.ly/RU2Qj
I did not realize we are 60% oxygen by weight until today
Makes sense though. Neat. π
This is fascinating. When can we expect to see this in print?
18.11.2024 23:57 β π 12 π 2 π¬ 1 π 0
This study by challenges dogma
@anandvkulkarni.bsky.social gave a tapering dose of prednisone for alcohol hepatitis instead of 40mg for 28 days
And it paid off with fewer infections
@tonybreu.bsky.social
I used @en.blueark.app to transfer tweetorials previously posted on Twitter here to @bsky.app. Very fair price and quick process.
If you do the same, note my previous comments, particularly regarding links and search.
