Samir Panvelker, MD

Melanie Cree (@cree_green) with an amazing review of the anti-obesity therapy landscape, including work in PCOS and upcoming therapies.

Blandine Laferrère with an excellent review of different methods of diagnosing obesity, including the limits of BMI and a review of @TheLancetEndo guidelines in which she participated.

@LoewenthalMd One of the weaker agents in the class, too! Will be so interesting to see how widespread GLP-1 receptor effects may be outside of what we initially thought.

crazy! GLP-1 agonist reduced motor disability in Parkinson's disease

@thecurbsiders Great episode! For diagnostics, I'll add that many hospitals are using newer higher-sensitivity cortisol assays and the cutoffs for 'normal' cosyntopin stims are changing: pubmed.ncbi.nlm.nih.gov/33768189/

⚠️ New EPISODE!! #411 Adrenal Insufficiency w/ Dr. Atil Kargi 💪 Feel confident diagnosing adrenal insufficiency. Learn how to accurately interpret a stimulation test, differentiate primary from secondary adrenal insufficiency, + more! #MedEd #MedTwitter thecurbsiders.com/curbsiders-pod…

@Dr_Oubre There's a concept in golf that you fix two divot marks on the putting green - one you made when your ball landed and another someone else never fixed. The same logic applies to the problem list - clean up your diagnoses that are no longer relevant and that others left behind!

We need to fix the problem list. It's a worsening problem every year. Yet no one is taking responsibility. But who should? What are your thoughts?

We know antibiotic stewardship. But it's time for chart stewardship. The chart, like antibiotics, if not used properly can have negative unintended consequences. This is from inaccuracies + information overload & scatter. It requires a redesign, but until then...

@COREIMpodcast @caseyjkim @ACPIMPhysicians @GlassHealthHQ @ShreyaTrivediMD @BethIWallace @MWeintraubMD @nickmmark @KWyshamMD @samwoodworthmd @sacalle1 Dex Methylpred(Soludedrol) Pred Hydrocortisone: Don't Stop Pred Hastily!

1/ 🚨 Steroids: 5 Pearls Episode 🚨 TY @caseyjkim for the mnemonic H-P-M-D to help keep the directionality of relatively potencies straight 🎧: link.chtbl.com/Steroid 🗒️: bit.ly/3NQTNpe CME: @ACPIMPhysicians Sponsor: @GlassHealthHQ

I'm just a physician, again asking a major television show @succession @HBO to please just properly depict good CPR technique. Proper depth of compressions and switching off every 2 minutes are so important - don't mislead the audience otherwise!

@DanielJDrucker Excellent graph. This is what I review with all patients newly starting therapy. Aside from medico-legal fears, is there then any reason to avoid offering GLP-1A therapy to patients with a history of chronic pancreatitis?

There are now hundreds of authoritative experts that opine daily on the risk of GLP-1 therapies, often scaring people about the risk #pancreatitis Yet after 18 years in the clinic for #T2D there is no signal for pancreatitis in RCTs or real world data thelancet.com/journals/landi…

@DudzLightLime @BevTchangMD @Bianco_Lab He is certainly a proponent for the increased utilization of T3 in primary hypothyroidism but these labs are not consistent with hypothyroidism. He wouldn't use your regimen for this patient.

@BevTchangMD Well the idea is more T4 is getting converted in rT3 so ⬆️ T4 is going to worsen the problem, so I will ⬇️ T4 and add T3 and continue to adjust both to maintain TSH gen b/t ~0.04-2 based on sx. Anything from @Bianco_Lab is excellent - his book is great. pubmed.ncbi.nlm.nih.gov/32279609/

For didactics, we went through "It's Not Your #Thyroid" Cases. Here's one for the #obesity #medicine docs. 45F with #obesity with 10% #weightloss from lifestyle changes c/o fatigue and wants more weight loss. Exam/labs wnl except: TSH 2.0, free T4 1.0, total T3 60(L) You...

@mendesthiagob This is a great analogy!

If it does not make sense to you, think about diabetes! ✅For someone with glucose in the 500s, symptoms of hypoglycemia may emerge with glucose in the 200s, but this is not hypoglycemia! Same for decreasing high-dose steroids! Our body transiently changes threshold for Sx +

She was taking prednisone 60 mg/d for a long time, now reduced to 10 mg/d. She has nausea, malaise, weakness. 🧐Can this be adrenal insufficiency? ‼️No! Prednisone 10 mg is supra-physiologic! Can the symptoms be attributed to decreasing steroid dose? ✅Absolutely yes! +

@BevTchangMD Yeah... Definitely did the math wrong there 😉 I see new TSH suppression frequently but always assumed it was the weight loss. Good to know it may occur independent of that!

@spanvelker With increase absorption and lower weight, you’d be at more risk of over treatment. I don’t see it but I think it’s bc I’m endocrine and we check TSHs so often anyway, per pt request lol

🔥tip: GLP1s can affect absorption of other #medications eg) Rybelsus ↑ levothyroxine absorption by 33% If your patient is experiencing new side effects that you can't attribute directly to the GLP1, they might be absorbing more of their other medications #medicine #endocrine

@HadleyFreeman Look at these results. The placebo group received weekly counseling related to weight loss. But you think it's 'surreal' and 'myopic' to recommend a therapy that was so much more effective?

@HadleyFreeman I'm sorry you struggled with anorexia and I'm glad you are better. But to say the root cause of obesity is 'emotional' ignores the extensive data showing aberrations in hunger signaling for many patients. To deem the use of GLP-1As like semaglutide as 'self-harm' is ridiculous.

In this week’s column I’ve added my tuppence to Wegovy discourse thetimes.co.uk/article/53c7b1…

@BrownJHM @InternAtWork Nice overview. Patients should aim for moderate calcium intake (800-1000 mg elemental) and enough vitamin D supplementation to maintain normal (>30) levels - low Ca intake + 25-OH insufficiency can both worsen PTH secretion!

Approach to parathyroid adenomas @InternAtWork #Medtwitter

What a great discussion from @thecurbsiders!

@WilliamAird4 Do you think similarly for the opposite problem of erythrocytosis/polycythemia? Endocrine Society guidelines emphasize monitoring Hct, not Hgb, in testosterone replacement - are there any drawbacks to this approach?

To those who insist on using Hct over Hb to describe a patient with anemia (I hope they are few in number), does this patient have anemia or not?

@tmodarressi @AnandVaidya17 The main concept I'm struggling with is why the discordance between plasma and urine aldo levels can be so vast. Eg, a patient with PRA <1 and aldo in high teens had a UrAldo of ~4-5 despite low UrNa on collection. Seems too large a discrepancy?

@tmodarressi @AnandVaidya17 I'm seeing the same issue in workups. I think the Umakoshi paper used captopril challenge as gold standard for diagnosis, so maybe their flaw was assuming 100% sensitivity for this test? I'm not sure how PRA <1 and aldo >20 could really be anything but hyperaldosteronism.

@AnandVaidya17 outside of expanding workup, what do you do for pts negative on PA confirmatory testing? I have a growing cohort w neg oral salt loads. Do you ever still try MRA empirically? Any role for repeat confirmatory testing or trending renin+aldo levels over time? Thanks.

@gu_girl Congratulations and well-deserved. I just met your former cochief/cofellow Farah - y'all are doing amazing things!

Honored to receive this award knowing the amazing physicians who have previously received it. Humbled to be included with them. Thank you to my division chief (Dr. McCartney) who put me up for this. He epitomizes #HeForShe.