@WilliamAird4 Thank you for this. Now, if I could only teach the internists to stop giving iron when both Fe and TIBC are low.
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Lawrence Snetman
11K posts
Lawrence Snetman
@lsnetman
Radical Atheist Oncologist. Trying every day to be the person my dogs thought I was. We have two lives and the second begins when you realize you only have one.
Miami, FL Katılım Nisan 2008
444 Takip Edilen214 Takipçiler
The Fe Paradox: High Serum Fe in Fe Deficiency
Poll results are in (≈1,200 votes).
Iron deficient patient with:
Ferritin 20
Serum Fe 388
TSAT >100%
The PCP stopped oral Fe because the Fe looked “too high.”
Interesting split in responses.
Let’s walk through the physiology.
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It wont happen in my lifetime, but one day, there will be a tunnel under the Miami River at Brickell. The while city comes to a standstill every time that bridge opens during the workday.
Meach@meach_01
@Hernandez_A Miami needs to solve traffic asap. Should be the single biggest priority for city leaders. Public transport + more roads
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@WilliamAird4 I like this. Good starting point, unless competing etiologies, i.e., hemolysis with marrow suppression. Remember when we used to look at the smear?
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1/4
ANEMIA IS NOT A LIST OF DIAGNOSES
We’re taught to approach anemia by pattern.
We use mechanisms implicitly.
We rarely articulate them.
Few are taught to layer probability onto physiology.
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Lawrence Snetman retweetledi
I hope you've found this thread helpful.
Follow me
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for more.
Like/Repost the quote below if you can:
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@WilliamAird4 need platelet count, hydration status to make informed decision
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68-year-old woman with polycythemia vera on hydroxyurea admitted with acute TIA.
Hct = 51%.
In PV overall, clinical trials suggest a target Hct <45%.
Inpatient phlebotomy?
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Lawrence Snetman retweetledi
House hasn’t been to work in weeks so what’s he busy with? Grindr?
Aaron Rupar@atrupar
Mike Johnson says he's open to meeting with Adelita Grijalva but he's "been a little busy"
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Lawrence Snetman retweetledi
Trump is directing his Sec of War to send troops, using full force, into a US city, to fight a siege he made up, being fought by a group that doesn’t exist.
He’s declaring war on Americans exercising their 1st amendment rights to speak out and protest his attacks on democracy.
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@ImBreckWorsham if you “didn’t know it then” then you are either willfully ignorant, incredibly naive, or intellectually unfit to serve anyone, anywhere
English
And before anyone starts, NO, I would not have voted for Kamala Harris, and NO, things would not have been worse had she won. Betrayal to the oath is betrayal to the oath. It's a uniparty. I realize that now. If I knew then what I know now, I would not have voted at all.
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And now we are on the brink of WWIII.
I'm a 3 time Trump voter and a Constitutional Conservative.
I worked his presidential campaign.
I now regret all of the above, as from Epstein to Israel he has completely betrayed us all.
God help us.
We've been played.
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@WilliamAird4 the nephrologists have a point, but i think they overestimate the inflammatory stimulus in CKD. other things, like downtrending or low MCV, high RDW, may give better clues, and of course, examining marrow iron is the gold standard
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3/3
Nephrologists: in CKD, inflammation makes ferritin noisy. TSAT reflects what marrow can use. Low TSAT = functional deficiency → IV iron helps. (And yes, even ferritin >500 has sometimes been linked with absent marrow iron in CKD).
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FERRITIN THRESHOLDS FOR IV IRON
Why do nephrologists give IV iron at ferritin >500? It feels “anathema” to hematologists. The answer lies in different ways of reading iron labs.
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@WilliamAird4 this is a great review of small but clarifying point. Thanks a lot!
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4/6
LDH
🔹 HS: Splenic macrophages engulf intact spherocytes → cytosolic enzymes are digested inside the macrophage → LDH is almost always normal.
🔹 Warm AIHA: Opsonized RBCs fragment in circulation → cytosolic contents spill → LDH reliably elevated.
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Hemolysis footprints: comparing HS and warm AIHA
We all know extravascular ≠ intravascular hemolysis (HS ≠ PNH). But here’s a nuance: even within extravascular hemolysis, HS and warm AIHA leave very different lab signatures.
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Lawrence Snetman retweetledi
Good mourning. The release of the Epstein birthday card had trump filling his Depends like never before. The Charlie Kirk assassination provides the distraction he so desperately needs. Do not let them change the subject. Do not move on. Donald trump is a child-raping pedophile.
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@WilliamAird4 classic seems cleaner to me. Ineffective erythropoeisis is a production issue.
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ANEMIA PATHOGENESIS
Classic triad = ↓ production, ↑ destruction, blood loss.
Alternative = RBC-based (production, ineffective erythropoiesis, hemolysis) vs. Extrinsic (blood loss).
Cleaner? Stronger focus on the red cell system?
Curious if you find this framework valuable.
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Lawrence Snetman retweetledi
Lawrence Snetman retweetledi
Do fuck off, Mikey. No one is mocking prayer. Rather, I am mocking those fools and charlatans (like you) who consider it a legitimate policy action response.
Speaker Mike Johnson@SpeakerJohnson
Democrats mocking the power of prayer in the wake of tragedy is so disgraceful it’s hard to even summon words to describe. Millions of Americans know prayer brings strength in our darkest moments. For politicians to belittle faith to score cheap points shows just how out of touch they are.
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What takes longer- Djokovic hitting a serve or Cantlay hitting a golf ball?
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I've heard that Melania gives good tongue, errr, or speaks a lot of languages, but does anyone believe she wrote this letter? She had to steal Michelle Obama's speech. Einstein visa worthy ?
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This week on consults:
A 57-year-old man had a DVT + PE 4 weeks ago, then needed a splenectomy 3 weeks later. An IVC filter was placed and anticoagulation stopped for the surgery.
He is now post-op.
Does he need to restart anticoagulation, or is the IVC filter enough?
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@WilliamAird4 this is why the “best practice” of checking an H/H 30 minutes after a transfusion is a colossal waste of time.
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Hct/Hb are initially normal after hemorrhage 'cause we lose whole blood. However, over time fluid shifts from extra- to intravascular space.
In 1 study (PMID: 9063546), 1 unit phlebotomy resulted in Hct drop from 42.4 → 39.9% at 30 min.
How much fluid shifted into circulation?
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23-year-old who died of cancer after refusing chemo had ‘five coffee enemas a day’ trib.al/RG7FbDd
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@MikeLupica those drop shots from behind the baseline are otherworldly
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