Garyll Ryan ‏‎‏‎🍉

Physician.
Amicus Humani Generis.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@BlueDartCares kindly check dm

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@ABsteward @BradSpellberg Thank you

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

Sir, I am preparing for a talk on how biomarkers can help with deescalation of antibiotics. Can you recommend some articles/resources?
@BradSpellberg @ABsteward

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@BradSpellberg @ABsteward Thank you

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

Crazy scenes @theliverdoc

[Dr.Priyanshu Jaseja @PJaseja]

Everyday is new low here...
Ayurveda referral for thrombocytopenia, stroke, brachydactyly (calls it some issue with the umbilicus ‘dharan’).

What else I am left to see in the hospital🙈

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@TheReal_YRJ Please provide more clarity on this voluntary update to this latest ColorOS. What happens if we don't? What advantages do we get if we do etc etc

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@gautambhatia88 Tucheliban. This was the haraamball we get accused of playing in the PL.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@gautambhatia88

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@VinayakSoni07 @RishiAlwani What would be expected price? Unsure whether to try for the ps5 slim or wait for the pro.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@gautambhatia88 Rice looked knackered beyond belief. No way he plays for us again before October November minimum.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@VinayakSoni07 Should I get the ps5 considering prices are still stable or do I wait for the official launch of ps5 pro? Currently having a ps4 slim since 7 years

[Eric Topol @EricTopol]

The suppressed report that concluded there is no protective or safe level of alcohol consumption, now published. It was commissioned by US Congress
Report https://t.co/XmmsSo9q3q
Editorial https://t.co/8NuqBwkugM
"Despite the study’s adherence to its mandate, its findings were sidelined.”

[WhatsApp @WhatsApp]

we love you @arsenal, we do 🏆

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@TheReal_YRJ Official roll out when? I can't see it yet.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@DrNikhilMD One of the drugs used for Mushroom poisoning.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@ShishirShelke1 @qunpp @Zroutex Can you explain how to get this? Play store shows that app is for an older version of Android.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@SavageAryan007 Wait for the stock to come. The OP15 is an amazing device.

[Garyll Ryan ‏‎‏‎🍉 @drgaryll]

@TransferChecker Earlier this account was run by a Brentford die hard fan with value tweets. Seems he has sold the account to some random person who posts low value tweets aiming just for payout.

[H. Jack West, MD, FASCO @JackWestMD]

I’ll start by saying that Aaron is a friend, a remarkable educator, & reliably wise. But here, as w/discussion of guidelines, nuance & context help.

IMO, guidelines raise the bar if you don’t know enough to know when to deviate from them. I can’t imagine treating 10+ types of cancer every day, & if I’m outside of my limited range of expertise, following guidelines will help me deliver SOC in a competent way.

But if you have deeper knowledge, you know that guidelines are a witch’s brew of strong evidence, weak data, & faith-based bias. Ideally, you won’t follow them slavishly & can deviate based on your good judgment & insight.

I acknowledge that guidelines can lead ppl to be dissuaded from deviating, but I think you can effectively inoculate yourself from legal issues by documenting your sensible judgment well & communicating/aligning with the patient (I see tons of deviation from guidelines, data, & even optimal judgment that is sanctioned as a pact with the patient to justify irrational over-treatment; I’d even argue that it’s a cornerstone of practice at many centers).

I think the problem of medicine is that it exults rule-following, & ideally people like Aaron can help keep physicians from just becoming sheep and absolving themselves of thought. I’ve also tried to do this over the years. I don’t think it’s a requirement that being a physician means subjugating judgment to rule-following.

[Dr. Chacón-Lozsán F .'. @franciscojlk]

💧 Albumin in the ICU: life-saving drug… or expensive myth?

We’ve been using it since the 1940s.

Yet in 2026 we still don’t fully agree when it actually helps.

🧠 First principle

Albumin is NOT just a volume expander.

It does much more:

▪️ Maintains oncotic pressure
▪️ Protects endothelium & glycocalyx
▪️ Modulates inflammation
▪️ Alters drug pharmacokinetics

➡️ It’s a biologically active molecule, not “fancy saline”

⚠️ The uncomfortable truth

👉 50-70% of albumin use is inappropriate
👉 In some studies: >90% misuse

Yes… even in modern ICUs

🔥 Where albumin actually WORKS

✔️ Hepatorenal syndrome (HRS)
→ Albumin + terlipressin = better renal outcomes

✔️ Spontaneous bacterial peritonitis (SBP)
→ ↓ AKI + ↓ mortality

✔️ Large-volume paracentesis
→ Prevents circulatory collapse

⚖️ Where evidence is… mixed

🟡 Septic shock
→ No mortality benefit vs crystalloids
→ BUT better hemodynamics in some patients

🟡 ARDS
→ Improves oxygenation (if hypoalbuminemic)
→ No survival benefit

🟡 Major surgery
→ ↓ fluids, ↓ complications
→ BUT watch renal risk (especially 20%)

🚫 Where you should think twice

❌ Traumatic brain injury
→ ↑ ICP
→ ↑ mortality

➡️ Albumin crosses disrupted BBB → worsens edema

💡 Key ICU insight

Albumin is NOT about:

❌ “giving protein”
❌ “correcting labs”

It’s about:

✔️ hemodynamics
✔️ endothelial integrity
✔️ patient selection

📉 Hypoalbuminemia matters

Every ↓10 g/L:

▪️ ↑ mortality
▪️ ↑ complications
▪️ ↑ length of stay

➡️ But correction ≠ automatic benefit

🎯 Clinical decision rule

Use albumin when:

✔️ Cirrhosis-related complications
✔️ Refractory shock after crystalloids
✔️ Severe hypoalbuminemia with instability

Avoid when:

❌ Routine resuscitation
❌ TBI
❌ “just low albumin”

🧠 Take-home

➡️ The question is NOT
“Does albumin work?”

➡️ The real question is
“In which patient, at which moment?”

📚 Rubio-Baines I et al. (2026)
Journal of Clinical Medicine
DOI: 10.3390/jcm15051981