Paul Howard | Lightnews

Resuscitation Council UK @resuscounciluk.bsky.social · 13d

The 2025 Resuscitation Guidelines emphasise the importance of correct defibrillator pad placement - a simple step that gives someone in cardiac arrest the best chance of survival.

🎥 Watch the video to learn more
🔗 Read the full Guidelines at resus.org.uk/2025-guidelines

Paul Howard @paulhoward.bsky.social · 16d

For cancer-related VTE, unless specific reason for a LMWH (eg drug interactions), apixaban is safer (n=12 011; less major bleeding [RR 0.67; P= 0.0003], more effective (reduced recurrence of PE), kinder (some find LMWH v painful), cheaper, and saves nursing time.

journals.lww.com/annals-of-me...

journals.lww.com

Paul Howard @paulhoward.bsky.social · 16d

Apixaban is often the DOAC of choice for cancer-related VTE because its safer than rivaroxaban (quoted thread)
Its also cheaper in UK.
Further, this systematic review found reducing apixaban to 2.5mg BD after 6 months reduced bleeding risk without increasing VTE recurrence
doi.org/10.1016/j.th...

EPCIN @epcinetwork.bsky.social · 23d

If you're invested in high quality palliative care and haven't heard @drkathrynmannix.bsky.social speak, you are missing out!

If you have, you'll know what a fantastic opportunity this is to come and listen and engage with Kathryn on "Talking about Dying".

📣 Join us 13th November 6pm GMT

Barbara Sobel @barbarasobel.bsky.social · 26d

RFK Jr: We need to stop trusting the experts... Trusting the experts is not a feature of science or democracy, it's a feature of religion and totalitarianism.

Paul Howard @paulhoward.bsky.social · 29d

Just in case someone's never asked for mycoplasma serology, but isn't sure whether they're missing out, what would you tell them? Esp if they work with immunocompromised people who often have "inflammatory symptoms" (fatigue, sweats, wt loss, anorexia etc)
Asking for a friend.....

Magdalena Skipper @magdalenaskipper.bsky.social · Oct 2

Read our exclusive interview by @maxkozlov.bsky.social with the ex-CDC director - Susan Monarez -
In which she talks about the importance of the job and the reasons why she was fired

🧪 #CDC #MedSky
@nature.com

www.nature.com/articles/d41...

Exclusive: ex-CDC director talks about why she was fired

“I would never do that, as a scientist,” Susan Monarez says of being asked to approve changes to vaccine recommendations without knowing the details.

www.nature.com

Paul Howard @paulhoward.bsky.social · Sep 29

Important study examining effect of ethnicity on UK ED attendance outcomes in last 3 months of life.
Found white patients received more analgesia and were admitted less often.

www.nature.com/articles/s41...

Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a retrospective cohort study - British Journal of Cancer

British Journal of Cancer - Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a...

www.nature.com

Mark Hazelwood @palliativescot.bsky.social · Sep 29

@drkathrynmannix.bsky.social Edinburgh is famously accessible from the NE of England, & we are always delighted to welcome palliative care people across the border to our conferences. We have a great line up this year, closer & cheaper than London. www.palliativecarescotland.org.uk/content/annu...

Paul Howard @paulhoward.bsky.social · Sep 28

Database studies are prone to streaming; i.e. since apixaban is known to carry a lower bleeding risk, more likely to select it if higher bleed risk - can only control for coded risk factors, so some risk factors missed
So it's interesting that they still found apixaban's non-major bleed risk lower

Paul Howard @paulhoward.bsky.social · Sep 28

"In cancer-associated VTE, apixaban was associated with similar risks of recurrent VTE and major bleeding, and a lower risk of clinically relevant non-major bleeding compared with rivaroxaban"

journals.plos.org/plosmedicine...

Comparative safety and effectiveness of apixaban and rivaroxaban for treatment of cancer-associated venous thromboembolism: A retrospective cohort study

Jingjing Sun and colleagues compare the risk of recurrent venous thromboembolism, major bleeding, and clinically relevant non-major bleeding among individuals with cancer-associated venous thromboembo...

journals.plos.org

Paul Howard @paulhoward.bsky.social · Sep 27

I agree; in UK hospitals I see administration of fluids and drugs delayed for hours in those with difficult veins.
SC would often be a far faster option: fluids, many antibiotics, PPIs, TXA, metoprolol, corticosteroids; the list of drugs given SC grows yearly yet remains little used in UK hospitals

Eduardo Bruera @brueraeduardo.bsky.social · Sep 27

In 58 advanced cancer patients, hypodermoclysis provided safe, effective hydration for up to 14 days, with minimal local toxicity and frequent co-administration of opioids and potassium. And 30 ys later still not done in American hospices and hospitals

pubmed.ncbi.nlm.nih.gov/2384700/

Hypodermoclysis for the administration of fluids and narcotic analgesics in patients with advanced cancer - PubMed

Fifty-eight consecutive patients with advanced cancer who required parenteral hydration were treated with hypodermoclysis. A solution of two-thirds 5% dextrose and one-third saline was used in all cas...

pubmed.ncbi.nlm.nih.gov

c0nc0rdance @c0nc0rdance.bsky.social · Sep 27

The idiom "like a moth to the flame" dates to at least the 12th century, to Persian love poem "Layla and Majnun". Shakespeare references it in "Merchant of Venice."

But here's the thing. Moths DON'T fly to flames. And we're just now understanding that.

Let's talk about dorsal light response.

a picture of a mosquito killer hanging from the ceiling with the caption i can 't help it it 's so beautiful

Alt: a picture of a mosquito killer hanging from the ceiling with the caption i can 't help it it 's so beautiful

media.tenor.com

Eduardo Bruera @brueraeduardo.bsky.social · Sep 27

In 58 advanced cancer patients, hypodermoclysis provided safe, effective hydration for up to 14 days, with minimal local toxicity and frequent co-administration of opioids and potassium. And 30 ys later still not done in American hospices and hospitals

pubmed.ncbi.nlm.nih.gov/2384700/

Hypodermoclysis for the administration of fluids and narcotic analgesics in patients with advanced cancer - PubMed

Fifty-eight consecutive patients with advanced cancer who required parenteral hydration were treated with hypodermoclysis. A solution of two-thirds 5% dextrose and one-third saline was used in all cas...

pubmed.ncbi.nlm.nih.gov

Paul Howard @paulhoward.bsky.social · Sep 20

🙋‍♂️

Paul Howard @paulhoward.bsky.social · Sep 20

Points I learned were:
1."Normal" levels don't exclude deficiency. NICE suggest MMA if B12 180-350 (indeterminate) but our local haem suggests go straight to trial of Rx (MMA also problematic)
2.Many need maintenance more often than 2-3 monthly, so if Sx recur before next injection, shorten interval

Paul Howard @paulhoward.bsky.social · Sep 20

This is a really key point.
E.g studies of "high dose (1mg) B12" are uninterpretable because they use blood levels not symptoms as an outcome (oral replacement can increase blood levels without adequately correcting deficiency).

Rachel Howard @rachel-h-iow.bsky.social · Sep 19

Because the serum B12 can give surprisingly high levels of false positives (unnecessary painful injections) and false negatives (dangerous symptom progression due to missed diagnosis) neither clinical treatment nor scientific study should rely on blood test results alone (but both usually do).

Paul Howard @paulhoward.bsky.social · Sep 20

Hi Calum. Yes, partly that. Partly an "adjusted calcium" type issue (ie B12 levels generally include haptocorrin-bound B12 which is inactive and gets excreted; haptocorrin increases in cancer); partly, like iron, your handling of B12 is altered in inflammation; and partly it's poorly understood

Paul Howard @paulhoward.bsky.social · Sep 20

B12 deficiency is also really relevant in palliation. I'm seeing people with fatigue and apparently "normal" B12 levels respond really well to SC B12 replacement (i.e. fatigue in advanced illness but in the absence of cachexia/inflammation). So this thread is really interesting

Rachel Howard @rachel-h-iow.bsky.social · Sep 19

This afternoon at CluB12 a fascinating overview of the history of B12 deficiency/pernicious anaemia from the amazing Ebba Nexo who has spent her whole career working in this field.

Rachel Howard @rachel-h-iow.bsky.social · Sep 19

Because the serum B12 can give surprisingly high levels of false positives (unnecessary painful injections) and false negatives (dangerous symptom progression due to missed diagnosis) neither clinical treatment nor scientific study should rely on blood test results alone (but both usually do).

Rachel Howard @rachel-h-iow.bsky.social · Sep 19

This afternoon at CluB12 a fascinating overview of the history of B12 deficiency/pernicious anaemia from the amazing Ebba Nexo who has spent her whole career working in this field.

Paul Howard @paulhoward.bsky.social · Sep 15

Follows inclusion of olanzapine in ASCO's recommendations in 2023 after another "positive" RCT:
doi.org/10.1200/JCO....

Cancer Cachexia: ASCO Guideline Rapid Recommendation Update

ASCO Rapid Recommendations Updates highlight revisions to select ASCO guideline recommendations as a response to the emergence of new and practice-changing data. The rapid updates are supported by an ...

doi.org

Paul Howard @paulhoward.bsky.social · Sep 15

Here, an RCT showing olanzapine improves cancer-related loss of appetite. That said, like other current appetite stimulant options, it's improving enjoyment of food, but not muscle/strength (here, handgrip strength decreased)

dx.doi.org/10.6004/jncc...

dx.doi.org

Pharmacopalliation @pharmacopalliation.bsky.social · Aug 30

💡 Midazolam is actually water-soluble in its vial, but becomes lipid-soluble once it enters the body.

That’s unusual for a benzodiazepine. The trick lies in its imidazole ring 👇

Magdalena Skipper @magdalenaskipper.bsky.social · Aug 28

“We don’t see an epidemic of autism, but we see an ‘epidemic’ of diagnoses”

A fresh journalistic look at the rise in autism that brings together perspectives from the researchers & the autism community
🧪 #MedSky

@nature.com by @helenpearson.bsky.social

www.nature.com/articles/d41...

Autism is on the rise: what’s really behind the increase?

RFK Jr has vowed to find out what’s responsible, but scientists say he is ignoring answers from decades of research.

www.nature.com

Pharmacopalliation @pharmacopalliation.bsky.social · Aug 27

💊💊ALFENTANIL💊💊
Alfentanil’s pKa ~6.5, much lower than fentanyl (~8.4) or morphine (~8.0)

At physiologic pH (7.4), ~90% of alfentanil exists in the unionised, lipid-soluble form → crosses the blood–brain barrier very rapidly

This explains why alfentanil has the fastest onset of action of any opioid

Paul Howard @paulhoward.bsky.social · Aug 20

Hi Sarah, you could get the same outcome with a series of 200mg IM loading doses. I think the key point is that if, say, an initial total of 600mg is sufficient, then the maintenance dose needed is very much less than 800mg/day; or perhaps not necessary at all

Paul Howard @paulhoward.bsky.social · Aug 20

The initial 600mg loading can be given in 50mL of NaCl as a single short subcut infusion. In this series, 85% responded to the first dose, despite being used in those with agitation refractory to multiple other drugs (midazolam, levomepromazine, clonidine)
pubmed.ncbi.nlm.nih.gov/37798082/

Short subcutaneous infusions for symptom control in palliative medicine - PubMed

SSCIs appear to be a promising additional option for administering medicines that are too irritant or large in volume for SC bolus injection. For medications with longer half-lives (eg, phenobarbital,...

pubmed.ncbi.nlm.nih.gov

Paul Howard @paulhoward.bsky.social · Aug 20

Really useful paper. Traditional dosing strategies (200mg IM loading, followed by 800-1200mg/day) don't reflect its half-life. Typical loading doses of around 600mg may not need any follow-on regular dose (or a very-much-less than 800mg/day dose if used)

Pallmedpro @pallmedpro.bsky.social · Aug 20

Did you know, that the half life of phenobarbitone is an average of 4 days?! The way we use it in palliative care needs to be proportionate, specialist-led, and congruent with known pharmacokinetics. @bmj.com Supportive and Palliative Care has more: spcare.bmj.com/content/earl... #palliativecare

Novel staggered loading of phenobarbitone for refractory seizures and agitation at the end of life

Background Seizures and agitation are distressing symptoms commonly encountered at the end of life and may require treatment with phenobarbitone when standard therapies fail. Current phenobarbitone do...

spcare.bmj.com

Pallmedpro @pallmedpro.bsky.social · Aug 20

Did you know, that the half life of phenobarbitone is an average of 4 days?! The way we use it in palliative care needs to be proportionate, specialist-led, and congruent with known pharmacokinetics. @bmj.com Supportive and Palliative Care has more: spcare.bmj.com/content/earl... #palliativecare

Novel staggered loading of phenobarbitone for refractory seizures and agitation at the end of life

Background Seizures and agitation are distressing symptoms commonly encountered at the end of life and may require treatment with phenobarbitone when standard therapies fail. Current phenobarbitone do...

spcare.bmj.com

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