Paul Howard
@paulhoward.bsky.social
Consultant in Palliative Medicine (Isle of Wight, UK); Palliative Care Formulary Editor (neuropharmacology sections)
Reposted by Paul Howard
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
🎥 Watch the video to learn more
🔗 Read the full Guidelines at resus.org.uk/2025-guidelines
October 28, 2025 at 12:01 PM
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
🎥 Watch the video to learn more
🔗 Read the full Guidelines at resus.org.uk/2025-guidelines
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/annals-of-me...
journals.lww.com
October 25, 2025 at 8:19 AM
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/annals-of-me...
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...
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...
October 25, 2025 at 7:53 AM
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...
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...
Reposted by Paul Howard
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
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
October 18, 2025 at 9:57 AM
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
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
Reposted by Paul Howard
I've decided to stop trusting experts.
Really looking forward to my forthcoming surgery being carried out by my mate Dave.
He's not an expert surgeon, but he is quite good with a chainsaw and has watched several series of House.
Who needs experts?
Really looking forward to my forthcoming surgery being carried out by my mate Dave.
He's not an expert surgeon, but he is quite good with a chainsaw and has watched several series of House.
Who needs experts?
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.
October 16, 2025 at 1:31 PM
I've decided to stop trusting experts.
Really looking forward to my forthcoming surgery being carried out by my mate Dave.
He's not an expert surgeon, but he is quite good with a chainsaw and has watched several series of House.
Who needs experts?
Really looking forward to my forthcoming surgery being carried out by my mate Dave.
He's not an expert surgeon, but he is quite good with a chainsaw and has watched several series of House.
Who needs experts?
Reposted by Paul Howard
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...
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
October 2, 2025 at 9:57 PM
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...
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...
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...
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
September 29, 2025 at 8:12 PM
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...
Found white patients received more analgesia and were admitted less often.
www.nature.com/articles/s41...
Reposted by Paul Howard
@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...
September 29, 2025 at 11:18 AM
@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...
"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...
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
September 28, 2025 at 4:35 PM
"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...
journals.plos.org/plosmedicine...
Reposted by Paul Howard
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.
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
September 27, 2025 at 2:04 PM
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.
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.
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
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
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/
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
September 27, 2025 at 3:41 PM
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
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
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).
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).
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).
September 20, 2025 at 10:35 AM
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).
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).
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
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.
September 20, 2025 at 5:59 AM
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
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/10.6004/jncc...
dx.doi.org
September 15, 2025 at 7:10 AM
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/10.6004/jncc...
Reposted by Paul Howard
“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...
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
August 28, 2025 at 7:16 AM
“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...
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...
Reposted by Paul Howard
💡 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 👇
That’s unusual for a benzodiazepine. The trick lies in its imidazole ring 👇
August 30, 2025 at 5:52 AM
💡 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 👇
That’s unusual for a benzodiazepine. The trick lies in its imidazole ring 👇
Reposted by Paul Howard
💊💊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
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
August 27, 2025 at 5:55 PM
💊💊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
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
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)
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
August 20, 2025 at 6:01 PM
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)
Reposted by Paul Howard
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
August 20, 2025 at 8:36 AM
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
Reposted by Paul Howard
Reframing resilience in community healthcare. Our latest piece in BJCN
magonlinelibrary.com/doi/abs/10.1...
magonlinelibrary.com/doi/abs/10.1...
August 3, 2025 at 6:05 PM
Reframing resilience in community healthcare. Our latest piece in BJCN
magonlinelibrary.com/doi/abs/10.1...
magonlinelibrary.com/doi/abs/10.1...
Elinzanetant, a dual neurokinin 1 and 3 receptor (NK1/NK3) antagonist licenced in UK for peri-menopausal Sx, also now trialed for hot flushes due to endocrine therapy for breastfeeding cancer. Similar trial recruiting for fezolinetant (NK3 antagonist).
www.nejm.org/doi/abs/10.1...
www.nejm.org/doi/abs/10.1...
www.nejm.org
July 26, 2025 at 11:27 AM
Elinzanetant, a dual neurokinin 1 and 3 receptor (NK1/NK3) antagonist licenced in UK for peri-menopausal Sx, also now trialed for hot flushes due to endocrine therapy for breastfeeding cancer. Similar trial recruiting for fezolinetant (NK3 antagonist).
www.nejm.org/doi/abs/10.1...
www.nejm.org/doi/abs/10.1...
A small RCT (n=34) comparing memantine with an active placebo finding a reduction in both pain and PRN opioid consumption. Memantine’s of analgesic interest because of it’s NMDA action (i.e. ketamine-like)
doi.org/10.1080/1758...
doi.org/10.1080/1758...
Comparative efficacy of memantine and vitamin C in postoperative pain management: a randomized clinical trial
Acute postoperative pain affects most surgical patients, often delaying recovery. Memantine (Namenda®), an N-methyl-D-aspartate (NMDA) receptor antagonist, offers potential for effective pain relie...
doi.org
July 11, 2025 at 5:45 PM
A small RCT (n=34) comparing memantine with an active placebo finding a reduction in both pain and PRN opioid consumption. Memantine’s of analgesic interest because of it’s NMDA action (i.e. ketamine-like)
doi.org/10.1080/1758...
doi.org/10.1080/1758...
Reposted by Paul Howard
New evidence just out shows definitive link between mechanisms driving cancer in smoking with those caused by pollution. Common mechanisms included mutations in the TP53 and EGFR genes 🧪
The mutagenic forces shaping the genomes of lung cancer in never smokers - Nature
An analysis of data from the Sherlock-Lung study provides insight into the mutational processes that contribute to lung cancer in never smokers, and looks at the possible role of factors such as ...
www.nature.com
July 3, 2025 at 7:12 AM
New evidence just out shows definitive link between mechanisms driving cancer in smoking with those caused by pollution. Common mechanisms included mutations in the TP53 and EGFR genes 🧪
A review of the use of clonidine for agitated delirium from a psychiatry perspective
link.springer.com/article/10.1...
link.springer.com/article/10.1...
Clonidine for Management of Agitation in Delirious Patients - Current Psychiatry Reports
Current Psychiatry Reports - This review explores clonidine as a potential treatment for agitation across various clinical contexts, focusing on its application in patients with limited cognitive...
link.springer.com
July 2, 2025 at 2:35 PM
A review of the use of clonidine for agitated delirium from a psychiatry perspective
link.springer.com/article/10.1...
link.springer.com/article/10.1...