Felipe Lara

🫠

[Alhassan Alyami @xloqpolx]

مغرم بالملخصات هذي بعد ما اختم المحاضره، برومبت رائع صراحه

[Abdul Muqtadir Abbasi @AbbasiMuqtadir]

I cannot stress more on this one single image. Every physician should emboss in their mind. You ll pick a lot of undiagnosed thal minors.

#x #medx #thal #cbc #ida

[Rhenals acuña @RhenalsMedint]

No es la primera vez que vemos como el sistema inmune se chinga a un tumor.

En radioterapia han documentado cosas como el efecto abscopal, irradian un tumor y “mágicamente” existe regresión de otro tumor a distancia. Es raro, pero ocurre.

La cosa es así,
La radioterapia no solo destruye células dentro del campo irradiado. También puede convertir ese tumor en una especie de alarma inmunológica:

Radiación → muerte tumoral → liberación de antígenos → activación de células dendríticas → expansión de linfocitos T → ataque de lesiones fuera del campo de radiación.

Eso hace que, en casos excepcionales, el sistema inmune recibe el mensaje en todo el cuerpo. Y aquí está lo interesante: probablemente el tumor irradiado no es solo la víctima. Puede convertirse en el lugar donde se inicia la respuesta contra los demás.

Raro, impredecible y difícil de reproducir clínicamente. Pero muestra como el sistema inmune es capaz de hacer cosas increíbles.

[Jonathan Chávez @JonathanNefro]

Simplemente no hay evidencia para prescribir espironolactona en personas en diálisis, aquí los ensayos clínicos que no demostraron beneficio:

•SPin-D❌
•MiREnDa❌

Y con más detalle👇🏻
•ALCHEMIST ❌
•ACHIEVE ❌

AJKD 2026
10.1053/j.ajkd.2026.04.020

[Abdul Muqtadir Abbasi @AbbasiMuqtadir]

How do hematologist know, which coagulation factor is the problem?

🩸 PT + aPTT + Fibrinogen: a practical clotting-factor algorithm

1️⃣ PT ↑, aPTT normal
→ Think FVII deficiency
→ Check FVII assay

2️⃣ PT normal, aPTT ↑
→ Think VIII, IX, XI, XII
→ Do a mixing study
• Corrects → factor deficiency → factor assays
• Fails to correct → inhibitor/heparin → investigate further

3️⃣ PT ↑ + aPTT ↑
→ Think common pathway (II, V, X, fibrinogen) or multiple-factor deficiency
→ Check fibrinogen, D-dimer, platelets, LFTs + medication history

4️⃣ PT ↑ + aPTT ↑ + fibrinogen ↓
→ Strongly consider DIC/consumption

🔑 Rule of thumb:
Screen → Mixing study → Factor assay → Confirm the diagnosis

#Hematology #MedTwitter #MedicalEducation

[Rhenals acuña @RhenalsMedint]

Efectos de fumar marihuana a en el cuerpo.
Si le gusta hágale, los internistas, neumólogos, cardiólogos y psiquiatras tendrán más pacientes. Pero no endiose eso.

[Nefro_Tweets @Doctor_Stewie]

Disfunción en Cateter de Hemodiálisis 🫤

✔️Causa importante de tratamientos sub-optimos y problema común en unidades de HD
✔️Temprana < 7 dias luego de inserción
✔️Tardía > 1 semana luego inserción
✔️Causas 👀👇🏼

Lazarus et al. JASN. 2025
#NephX #MedEd #MedTwitter

[Mustansir⚕️ @latrogenicMind]

Why age of presentation of febrile seizure is 6months to 5 years?
Why not less than 6 and more than 5

[Dr. A®️𝓍on Bill, MPS @PharmXOAB]

@SirD___ Salbutamol induced lactic acidosis.

High dose β₂ stimulation increases glycolysis and lipolysis, driving more pyruvate toward lactate production. The resulting lactate can mimic worsening sepsis, while tachycardia and tremor are typical β₂ agonist effects.

[tay de clinicagem @umistakeme4her]

Já diriam os sábios:

[Rhenals acuña @RhenalsMedint]

Si el azucar se baja, lo primero que aparecen son sintomas neurogenos (ansiedad, palpitaciones diaforesis, etc). Luego de esto vienen los neuroglicopenicos usualmente con valores de 40s o menos, aqui hay mas debilidad, confusion somnolencia, diastria, stroke mimic, etc

[Dr Ihab Suliman @IhabFathiSulima]

Which cancer type has the lowest mortality?

[Dr Stormtrooper @DrTr00per]

"Me lo mataron en el IMSS"

[casanchezcardiomd @casanchezcardi1]

Con orgullo presentamos el SCORE2-LAC, la herramienta más robusta para estimar el riesgo cardiovascular en América Latina y el caribe.
Calibración:
- >40 millones de individuos
- > 1 millón de eventos
Validación externa:
- > 100.000 pacientes
Debe utilizarse a partir de ahora.

[Rhenals acuña @RhenalsMedint]

Recuerda que cuando pienses en sarcoidosis debes buscar compromiso pulmonar (>80% casos).

Menos comunmente pero "frecuente" piel y corazón.

De ahi para alante (sistema nervioso por ejemplo) como unica manifestación es entre raro y anecdotico.

[Dr. Chokri Ben Lamine @abouabdrahman0]

🩸 Platelet Transfusion in 2025: Less Can Be Safer!
Key messages from the AABB/ICTMG international guideline 🧵👇

1/12 🎯 The central principle

Adopt a restrictive platelet-transfusion strategy whenever clinically appropriate.

✅ Similar bleeding and mortality outcomes
✅ Fewer transfusion reactions
✅ Less alloimmunization/refractoriness
✅ Better preservation of a limited resource
✅ Lower cost

Platelet count is important—but never the only decision-maker. 🧠

2/12 💪 Strong recommendations

🧬 Nonbleeding hypoproliferative thrombocytopenia during chemotherapy or allogeneic HSCT:

➡️ Transfuse when PLT <10 ×10³/µL
📚 Moderate-certainty evidence

A routine liberal threshold above 10 ×10³/µL provides no proven benefit in otherwise stable patients.

3/12 👶 Preterm neonates without major bleeding

➡️ Transfuse when PLT <25 ×10³/µL
📚 High-certainty evidence

Avoid the historical liberal threshold of 50 ×10³/µL—it offers no benefit and may cause harm.

4/12 💉 Lumbar puncture: a major practice-changing recommendation

➡️ Administer platelets when PLT <20 ×10³/µL
💪 Strong recommendation
📚 Moderate-certainty evidence

This is considerably more restrictive than the traditional 50 ×10³/µL threshold used by many centers.

⚠️ This is a transfusion trigger—not proof that every patient must achieve a post-transfusion count ≥20.

5/12 🧠 Why is the LP threshold lower?

Bleeding after lumbar puncture is remarkably rare:

📊 PLT <50 ×10³/µL: 42 hematomas among 4,418 patients across six studies
📊 PLT <20 ×10³/µL: 0 hematomas among 324 patients across four studies

The baseline risk is very low, although much of the procedural evidence remains observational.

6/12 🦟 Dengue thrombocytopenia without major bleeding

🚫 Do not transfuse platelets prophylactically—even with marked thrombocytopenia.

💪 Strong recommendation
📚 Moderate-certainty evidence

Trials show no clinical benefit and suggest possible harm. Treat the patient and bleeding—not the number.

7/12 🧫 Autologous SCT and aplastic anemia

For stable, nonbleeding adults:

➡️ Consider a no-prophylaxis strategy
⚖️ Conditional recommendation
📚 Low to very-low certainty

This requires careful clinical monitoring and may not suit patients with fever, infection, mucositis, coagulopathy or additional bleeding risks.

8/12 🏥 Critically ill adults

Consumptive thrombocytopenia without major bleeding, excluding dengue:

➡️ Transfuse when PLT <10 ×10³/µL
⚖️ Conditional recommendation
📚 Very-low certainty

Avoid reflexively transfusing merely because the patient is in ICU.

9/12 🩺 Central venous catheter placement

For adult CVC insertion at an anatomical site amenable to manual compression:

➡️ Transfuse when PLT <10 ×10³/µL
⚖️ Conditional recommendation
📚 Moderate to very-low certainty

📌 Prefer ultrasound guidance, experienced operators and a compressible site.

⚠️ Do not automatically extrapolate this threshold to noncompressible or technically difficult access.

10/12 🩻 Interventional radiology procedures

🔹 Low-risk procedure: transfuse if PLT <20 ×10³/µL
🔸 High-risk procedure: transfuse if PLT <50 ×10³/µL

⚖️ Conditional recommendation
📚 Very-low certainty

Procedure-specific bleeding risk, anatomy, operator experience and the possibility of compression remain crucial.

11/12 🔪 Major non-neuraxial surgery

➡️ Transfuse when PLT <50 ×10³/µL
⚖️ Conditional recommendation
📚 Very-low certainty

This recommendation does not define thresholds for neurosurgery or other especially high-risk anatomical procedures.

12/12 ❤️🧠 When platelets should not be given routinely

🚫 Nonthrombocytopenic cardiovascular-surgery patients without major hemorrhage—including cardiopulmonary bypass

🚫 Adults with spontaneous or traumatic nonoperative intracranial hemorrhage and PLT >100 ×10³/µL, including those receiving antiplatelet therapy

There is no established benefit, and transfusion may cause harm.

[Almudena Castro Conde @almucastro01]

🚨 𝗣𝗢𝗟É𝗠𝗜𝗖𝗔 𝗘𝗡 𝗟𝗔𝗦 𝗡𝗨𝗘𝗩𝗔𝗦 𝗚𝗨Í𝗔𝗦 𝗘𝗦𝗖 𝟮𝟬𝟮𝟲 𝗗𝗘 𝗜𝗡𝗦𝗨𝗙𝗜𝗖𝗜𝗘𝗡𝗖𝗜𝗔 𝗖𝗔𝗥𝗗𝗜𝗔𝗖𝗔

La nueva ESC 2026 de IC agrupa MRA esteroideos y no esteroideos en HFpEF:

➡️ 𝗖𝗹𝗮𝘀𝗲 𝗜 | 𝗡𝗶𝘃𝗲𝗹 𝗔

Pero… ¿𝗹𝗮 𝗲𝘃𝗶𝗱𝗲𝗻𝗰𝗶𝗮 𝗲𝘀 𝗲𝗾𝘂𝗶𝘃𝗮𝗹𝗲𝗻𝘁𝗲? 🤔

🟢 𝗙𝗜𝗡𝗘𝗥𝗘𝗡𝗢𝗡𝗔 | 𝗙𝗜𝗡𝗘𝗔𝗥𝗧𝗦-𝗛𝗙
✅ Ensayo positivo
✅ FE ≥40%
✅ ↓ eventos de empeoramiento de IC / muerte CV

🟠 𝗘𝗦𝗣𝗜𝗥𝗢𝗡𝗢𝗟𝗔𝗖𝗧𝗢𝗡𝗔
❌ TOPCAT → objetivo primario neutral
❌ SPIRIT-HF → sin beneficio
⚠️ Señal desfavorable de hospitalizaciones y eventos adversos

Entonces…

¿𝗘𝘅𝗶𝘀𝘁𝗲 𝗿𝗲𝗮𝗹𝗺𝗲𝗻𝘁𝗲 𝘂𝗻 “𝗲𝗳𝗲𝗰𝘁𝗼 𝗱𝗲 𝗰𝗹𝗮𝘀𝗲 𝗠𝗥𝗔” 𝗲𝗻 𝗛𝗙𝗽𝗘𝗙?

La evidencia sólida es de 𝗙𝗜𝗡𝗘𝗥𝗘𝗡𝗢𝗡𝗔.

Extrapolarla a los MRA esteroideos parece, como mínimo, 𝗴𝗲𝗻𝗲𝗿𝗼𝘀𝗼. 👀

Las 𝘀𝗼𝗰𝗶𝗲𝗱𝗮𝗱𝗲𝘀 𝗰𝗶𝗲𝗻𝘁í𝗳𝗶𝗰𝗮𝘀 tenemos una responsabilidad: cuestionar y debatir las recomendaciones cuando la evidencia no parece respaldarlas plenamente.

Porque las guías trasladan la evidencia a la práctica clínica y deben ayudarnos a ofrecer 𝗲𝗹 𝗺á𝘅𝗶𝗺𝗼 𝗯𝗲𝗻𝗲𝗳𝗶𝗰𝗶𝗼 𝗮 𝗻𝘂𝗲𝘀𝘁𝗿𝗼𝘀 𝗽𝗮𝗰𝗶𝗲𝗻𝘁𝗲𝘀.

[Muthu Vaduganathan @mvaduganathan]

Spironolactone Outcomes RCTs in the Last 20y

#TOPCAT (HFpEF) ❓❌
#SPIRITHF (HFpEF) ❓❌
#CLEAR (Post-MI) ❌
#BARACKD (CKD) ❌
#ALCHEMIST (ESKD) ❌
#ACHIEVE (ESKD) ❌

One day we will hopefully have a positive RCT

to elevate eminence based medicine to evidence based medicine!

[AHA Science @AHAScience]

In case you missed it, here are all late-breaking trial results from #ESCCongress

[Dr. Chokri Ben Lamine @abouabdrahman0]

🧬 Hypogammaglobulinemia in Hematology – comprehensive review 🩸
(Adults | practice-focused)

📌 Definition
⬇️ Low IgG (± IgA/IgM) → impaired humoral immunity
⚠️ Infection risk correlates best with IgG <4 g/L

⸻

🧠 Major causes (hematology)
🟣 Malignancy-related
• CLL / MM / indolent lymphomas
• Heavy marrow/plasma cell dysfunction

🟠 Therapy-related
• Anti-CD20 (rituximab, obinutuzumab)
• CAR-T / BsAbs → B-cell aplasia
• Purine analogs, bendamustine
• Prolonged steroids

🔵 Post-transplant
• Allo-BMT (delayed B-cell recovery, cGVHD)
• Auto-BMT (transient)

🟢 Other
• Protein loss (nephrotic / enteropathy)
• Primary antibody deficiency (less common in heme clinics)

⸻

🚨 When it matters clinically
❗ Recurrent sinopulmonary infections
❗ Severe / invasive bacterial infections
❗ Chronic viral shedding (e.g. post-SCT)
❗ Hypogammaglobulinemia + ongoing immunosuppression

⸻

🧪 Assessment (practical)
🧫 IgG level (baseline & trend)
🦠 Infection frequency/severity (more important than number)
💉 Vaccine response (when relevant)
📆 Post-CAR-T / post-BMT timeline

⸻

💊 Treatment: IVIG / SCIG

🎯 Indications (adult heme practice)

✅ IgG <4 g/L AND recurrent/severe infections
✅ Peri-CAR-T with B-cell aplasia + infections
✅ Chronic GVHD with infections
🚫 Do NOT treat lab value alone (unless special setting)

⸻

🧴 IVIG concentrations – key differences

🟦 5% IVIG (50 mg/mL)
• Larger volume
• Slower infusion
• Preferred in:
🫀 Cardiac disease
🧠 Thrombotic risk
🌡️ Frail patients

🟥 10% IVIG (100 mg/mL)
• Half the volume
• Faster infusion
• More convenient outpatient use
⚠️ Slightly ↑ viscosity → caution in thrombosis risk

🧠 Efficacy = same (concentration choice is logistics & safety)

⸻

💉 Dosing (by indication)
🔹 Replacement: 0.4 g/kg every 3–4 weeks
🔹 Target trough: ≥5–6 g/L (individualize)
🔹 CAR-T / BsAb: tailor to infection history rather than fixed IgG target
🔹 SCIG option: weekly / biweekly for stable long-term replacement

⸻

🧬 Peri-CAR-T specific pearls
🧠 Anti-CD19 → prolonged B-cell aplasia
⏱️ Hypogammaglobulinemia may last months–years
🎯 Give IVIG if:
• Recurrent infections
• Severe infection regardless of IgG value
🚫 Routine prophylactic IVIG without infections = controversial

⸻

🧬 Post-BMT pearls
🟣 Early allo-BMT: low IgG common → observe unless infections
🔥 Chronic GVHD: lower threshold to treat
🧫 Monitor immune reconstitution, not numbers alone

⸻

⚠️ Adverse effects & precautions
🤕 Headache, fever
🫀 Fluid overload
🩸 Thrombosis (dose, viscosity, infusion rate!)
🧪 Renal injury (rare; avoid sucrose formulations in CKD)

⸻

🧠 Bottom line
💡 Hypogammaglobulinemia is clinical, not numeric
💡 Treat patients with infections, not IgG alone
💡 5% vs 10% IVIG = volume & speed, same efficacy
💡 CAR-T & cGVHD patients need individualized strategies

#Hypogammaglobulinemia #IVIG #SCIG #Hematology #CART #BMT #GVHD #InfectionRisk