Nishant Rajendra Tiwari
@Nischistocyte
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HemOnc Fellow @OUHealth @StephensonCC . Small town boy in a big arcade 🌃 Shayari = Hobby ❤️ Tweets are not medical advice. Views are my own.
Oklahoma City, OK
Joined March 2017
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Four weeks of intense service and exponential learning on the Malignant Hematology service at
@OUHealth
@StephensonCC
.
The best mentors bring the talents out of you, including the ones you did not know you possessed! Special thanks to
@Taha_CancerDoc
and Dr Ibrahimi 🙌🏻😃
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@AaronGoodman33
Ankylosing spondylitis!
7 A's
Axial Inflammation
Arthritis
Anterior uveitis
Achilles Tendonitis
Atypical lung fibrosis
Amyloidosis
Aortitis (Rare)
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57
496
Educational 🧵 on hemophagocytic lymphohistiocytosis (HLH). Not medical advice. Always open for feedback and corrections. Inspired by and studied from the recent review from
@ASH_hematology
hematology education series 2023 edition.
#MedX
#Hematology
#HLH
#MAS
#Lymphoma
#oncology
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@nihardesai7
@BrownJHM
@MedTweetorials
@Torsadepointles
@NicoGagelmann
@PanktiMehta24
@drkeithsiau
@CPSolvers
@TikareNakul
Nifedipine
Cyclosporine
Phenytoin
Valproate
I think MMF also - but not sure
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Educational thread on complications of blood transfusion. Not medical advice. Open to feedback and corrections! The incidence rates are as reported in the USA.
#MedX
#Hematology
#Transfusion
#Bloodbank
#InternalMedicine
#MedEd
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Educational 🧵 on cytogenetics in common hematological malignancies. Not medical advice. Always open to feedback and corrections. From classical literature, some recent advances might be missed.
#medX
#internalmedicine
#hematology
#oncology
#myeloma
#leukemia
#lymphoma
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@AaronGoodman33
Also an additional point:
Amongst all Ankylosing spondylitis patients, close to 90% have HLA-B27 positivity!
However, if one has aortitis OR anterior uveitis - the HLA-B27 positivity percentage approaches 100%!
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Educational 🧵 on chronic myelogenous leukemia (CML). Not medical advice. I am a big fan of Dr. Druker, Dr. Cortes (
@GCC_Cortes
), Dr. Radich, and multiple others for their work in CML. Always open for feedback and corrections.
#Medtwitter
#hematology
#leukemia
#CML
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@NicoGagelmann
@BrownHospMed
@Sthanu5
@nihardesai7
@anujtiwari11
@arshiet
Acute chest syndrome would be a top differential, but also have to keep infections and volume overload in the differentials.
Treatment is with blood transfusion, often exchange! Should be covered with antibiotics as well.
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A short educational 🧵 on the basics of inherited bone marrow failure syndromes (IBMFSs). Not medical advice. Always open to feedback and corrections. I am a big admirer of Dr. Patnaik’s work on this topic.
@MrinalPatnaik
#MedTwitter
#Hematology
#Oncology
#IntMed
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@AaronGoodman33
@AvrahamCooperMD
@Sthanu5
'CLUBBING'
Cyanotic CHD, Cystic fibrosis
Lung cancer/abscess/empyema
Ulcerative Colitis
Bronchiectasis
Benign mesothelioma
Infective endocarditis
Neoplasia (Many others)
GI related (Cirrhosis, and Crohn's)
Nowhere near what Dr
@Sthanu5
does. But a rookie attempt 😅
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I feel ecstatic to announce that I will be going to OUHSC and
@StephensonCC
for a hematology and medical oncology fellowship - indebted to family, friends, and mentors for their support and love. A dream come true 😃
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Educational 🧵 on a topic very close to my heart - thrombotic thrombocytopenic purpura (TTP). Not medical advice. Always open to feedback and corrections.
#MedX
#Hematology
#BenignHematology
#TMA
#TTP
#MedTwitter
#InternalMedicine
#Match2024
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@AaronGoodman33
Progressive multifocal encephalopathy, caused by JC virus. IRIS also has some association in HIV patients. Don't know the treatment for rituximab associated pml, but had seen a case of HIV patient, being treated in an acute episode with steroids
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@AaronGoodman33
The way I remember.
SeNsitivity and NPV both have N
SPecificity and PPV both have P
If you want a test to not miss a diagnosis, you need a good screening test, that is more sensitive, hence NPV should be a correct answer here!
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@AaronGoodman33
Peutz jehgers! STK11 mutation.
A tough question on this is the frequency of colonoscopy.
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@AaronGoodman33
Scary condition - Naegleria meningoencephalitis.
Almost fatal every time, some reports of intrathecal AMB and subsequent survival (But I think there are very few).
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Advice for my fellow IM residents:
You'll stand a chance of scoring perfect on the hematology part of the in-training exam if you follow
@AaronGoodman33
's tweets carefully. (I had my ITE today, and it's an individual observation - but I am certain many will agree 💯)
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@nihardesai7
@BrownHospMed
@MedTweetorials
@NicoGagelmann
@nihar_nayak2
@Torsadepointles
@DxRxEdu
@DoctorBhavsar
@Sthanu5
ICH.
I imagine likely due to warfarin since a heart surgery in that setting would likely be a rheumatic repair!
Treatment would be PCC, I think 1500U is the dose for emergent reversal? Also 10mg IV Vitamin K
Open to listening to other differentials as well 🙌
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@NicoGagelmann
@BrownHospMed
@Sthanu5
@PanktiMehta24
@nihardesai7
@AbbasiMuqtadir
@Kodiananda
@anujtiwari11
@arshiet
RBCs without a central pallor! Warm AIHA and hereditary spherocytosis are top considerations.
Warm AIHA is DAT +ve (For IgG)
HS is DAT -ve
Important to remember that in both cases, RBCs are cleared in Spleen (Unlike Cold agglutinin IHA, where they are cleared by the liver)
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Educational 🧵 on von Willebrand factor (VWF), congenital von Willebrand’s disease (VWD). Not medical advice. Always open for corrections and feedback. Common abnormalities are described and is not a comprehensive account.
#medtwitter
#hematology
#Classicalhematology
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Educational 🧵 on “clinical pearls in conventional chemotherapy.” Not medical advice. Always open for feedback and corrections. Information packed thread, please bear with me. These are basics, many nuances to these.
#oncology
#hematology
#MedTwitter
#OncTwitter
#bmtsm
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1/As promised, I compiled links to outstanding educational threads by
@NicoGagelmann
. That's all credit to him since I just copy-pasted the links. Will also copy
@nihardesai7
to this thread.
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@AaronGoodman33
Also, very important to remember that breast is a commoner site for cancer than colon.
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@NicoGagelmann
@BrownJHM
@Sthanu5
@nihardesai7
@anujtiwari11
Engraftment syndrome!
A close differential would be pneumonitis due to Nivo, although the CT scan doesn't look that impressive.
Treat both with steroids ✅
Also, the oliguric AKI swings it more in favor of engraftment syndrome in this case.
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@AdiG1993
I can tell about my seniors in medschools (BJGMC, Pune). I wasn't allowed to take my wallet out for any food for them, or even for myself when they are with me. My picture seems like an outlier though.
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1/Educational thread on Basics of Renal Cell Carcinoma (RCC), have included some advances that I was aware of. Not medical advice. Always open for feedback and corrections. Inspired by works and following of
@DrChoueiri
and
@montypal
.
(This was my reading topic for today!)
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Educational 🧵 on cytogenetics in common hematological malignancies. Not medical advice. Always open to feedback and corrections. Based on classical literature, not recent advances.
#medtwitter
#internalmedicine
#hematology
#oncology
#malignanthematology
#leukemia
#lymphoma
4
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@NicoGagelmann
@MedTweetorials
@ManualOMedicine
@BrownJHM
@Innov_Medicine
@nihardesai7
@PanktiMehta24
@Torsadepointles
@arshiet
Arguably one of the best education threads on
#MedTwitter
/
#medx
Nico!
Read it three times already, very nicely done 🙌🏻
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#match2023
#medtwitter
#IM
I dedicate this one to my best friend, Dr. Suyash Ambekar, MD (Nephrology Fellow, SGPGI, Lucknow).
There can be many many great friends, but no one else can be him 💯
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1/Educational thread (29 tweets) on Hodgkin Lymphoma (HL) basics. Not medical advice. Open for feedback and corrections. Dedicated to Dr. Collins
@graham74GC
. I learned a lot about Hodgkin since following him.
#Medtwitter
#Hematology
#Oncology
#InternalMedicine
#lysm
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A 🧵 on my Hemeonc application!
I matched in hematology and oncology in this year’s match. Like everyone else, I had to work hard who apllied, I wanted to share some thoughts on how I approached application.
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This is a beautiful written book to learn the basics of benign and malignant hematology - I am learning a lot. Thank you Dr Steensma
@DavidSteensma
🙌🏻
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I got the 27th Edition of Goldman-Cecil Medicine textbook today - its time to start reading with the most favorite chapter from the previous editions, and arguably the finest written texts on plasma cell dycrasias in the literature - by Dr Rajkumar 🙌🏻
@VincentRK
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@nihardesai7
Can be all 4 right?
Allergic - type 1
Acute hemolytic - type 2
Serum sickness - type 3 (Rare)
GVHD - type 4 (again, rare)
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The rare people in your life, that root for you, and support you to acheive your goals, often end up becoming WAY more important than the goals themselves.
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My mentor in hemeonc, Vivek R Sharma, MD (UofL, KY) gifted me the ASH SAP book he used for his recertification in 2021!
I am going to listen to Dr. Goodman's advice on twitter, and read one page daily
@AaronGoodman33
Will also cc:
@marklewismd
because he motivates me daily 😎
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@AaronGoodman33
I can guess - Tuberous Sclerosis (By no means an expert in pathology, not even a rookie tbh). But I think that's an angiomyolipoma of kidney, and looks like an adenoma in skin.
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A minute of interaction can lead to a big influence on mindset 😍
Fanboy moment 2.0 at
#ASCO2022
Thanks Dr. Lewis for your kindness and motivation!
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ये कैंचियां हमें उड़ने से ख़ाक रोकेंगी,
के हम परों से नहीं..... हौंसलों से उड़ते हैं...
#NewProfilePic
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@AaronGoodman33
Sarcoid! Cells in granulomas have 1 Alfa hydroxylase, hence the Vit D increase
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Our case report got selected for presentation as poster finalist for annual ACP meeting to be held in Boston in April 2024! My friend and co-resident Dr Allam will be presenting it at the meeting - I am so incredibly proud of our team!
@MacNealIMRP
@ACPIMPhysicians
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Honored to be presenting a case at the
@isth
SSC on September 12th 2022!
Thanks to my mentors for this opportunity.
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I shall try my best to maintain consistency and quality in these! Keeps me motivated to study for myself and summarize what I have learnt succinctly 🙌🏻
💥TUESDAY TWEETORIALS with Dr. TIWARI💥
H.O.M.E is proud of our mentors, most of whom are newly matched Heme-Onc fellows. Since we all love Dr Tiwari
@Nischistocyte
from
@UofOklahoma
educational tweetorials, he will release them for trainees on Tuesdays 🌟
#MedEd
#MedTwitter
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@AaronGoodman33
Looks a lot like the disease described in house MD episode entitled 'All in'
Erdheim Chester disease
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I did a small chalk-talk on AML and ALL on Monday, and my friend Aviskar Sharma was very kind in capturing this one for me as I was talking.
The reference was a chart posted by Dr. Goodman
@AaronGoodman33
who is also amongst the most motivating teachers on
#medtwitter
#hematology
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Dr. Sullivan is one of the people, I owe a lot to. Impossible to fit it in 140 characters here, but her role was instrumental in me becoming an IM resident, and growing as I moved forward. We are going to miss you, Dr. Sullivan
@lsulliDO
. Hope to make you proud one day!
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@VincentRK
I wouldn't take my name in the same sentence as yours, Dr. Rajkumar. I haven't achieved anything, yet...but I received a 'fail' result about 3 years back in USMLE step 2 CS (Practical Exam). I had failed in the spoken English section. I presented a case at ISTH academy this week.
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Happy birthday Dr. Goodman
@AaronGoodman33
.
I wish I was born one day earlier so that I would be able to tell that I share birthdays with you!
Thanks for your prolific presence on Medtwitter, we learn a lot from you 🙏🙌
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@NicoGagelmann
@BrownJHM
@Sthanu5
@nihardesai7
@radRounds
Mercury!! Saw a recent NEJM report of this ✅
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@nihardesai7
@BrownJHM
@MorphologyAmigo
@CPSolvers
@AshutoshSinghMD
@DrAkhilRaghavan
Cold agglutinin disease, likely secondary to mycoplasma.
Treat the underlying cause in this case. (Secondary)
Avoid cold exposure, transfuse as appropriate.
Rituximab is used for primary disease. C1s inhibitor Sutimlumab is approved.
Splenectomy and steroids don’t help.
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Amongst the most lucidly written articles for myeloma. For someone like me who doesn't see myeloma patients routinely yet, as an IM resident - this is a go-to reference for updated guidelines on the topic.
Thanks Dr. Rajkumar for your efforts.
I review the diagnosis and treatment of myeloma for the American Journal of Hematology every year or two.
I put in a lot of effort. It’s rewarding to see that it’s always one of the most downloaded of my papers, year after year!
#MedTwitter
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@nihardesai7
@BrownJHM
@MorphologyAmigo
@Torsadepointles
@DoctorBhavsar
@ManualOMedicine
@NicoGagelmann
@Dishaar88241487
@adiv2711
@chandrachud_n
Hard to say based on images for me, but would guess severe malnutrition and pulmonary tuberculosis in the same patient.
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My uncle, late Dr. Sanjay Tiwari, he saw me get into medschool. He cleared USMLE in 1995, but couldn't apply to a residency due to some financial/family issues. Passed away in a tragic car accident on May 18, 2015 - I travelled to the USA join residency in May 2021 💪
He always had a regret of not being able to clear PMT thrice during his time. He was in total awe of medical profession, he is even today. The feeling that day of fulfilling his dream was so pure, I haven’t felt anything like it again. So
#MedTwitter
tell me about ur memories
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@AaronGoodman33
Vacuolization of erythroid precursors - Copper deficiency! A hemepath fellow taught me this recently 😃
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That is indeed me! Thanks to my wonderful program
@MacNealIMRP
, our leaders (Dr. Dudani, Dr Kaul, Dr Puri), my co-residents, and most importantly my patients to make me into who I am today! 😃
#MedX
#MedTwitter
#hematology
#oncology
#fellowship
#match2024
Fellowship application time❕🔝🚨We are excited to introduce Nishant Tiwari, MD. He is a Hemeonc fellowship applicant, Hometown: Pimpalgaon Baswant, India.
AAMC ID: 15083617
Interests: Teaching, Benign Hematology, GI/thoracic/breast oncology
#Hemonc
#HOfellow
#match2024
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@AaronGoodman33
7 A's of Ankylosing spondylitis!
Axial Inflammation
Arthritis (Axial + Peripheral)
Anterior uveitis
Achilles Tendonitis
Apical lung fibrosis
Amyloidosis
Aortitis
1
3
18
@NicoGagelmann
@BrownJHM
@nihardesai7
@Sthanu5
Acute GVHD is the top differential.
Other differentials include - skin infection, and SJS/TEN.
A pearl on acute GVHD ⤵️
Acute GVHD severity based on three major organs involved:
Skin - % Body surface area involved, type of rash
GI tract - Volume of diarrhea in 24hrs
Liver - Level of total bilirubin
#hematology
#internalmedicine
#meded
#medtwitter
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I do feel proud as I remember struggling to publish my first paper after being rejected by at least six journals.
I also acknowledge there’s much more to do while taking really good care of our patients.
Onwards and upwards is the only way to go!
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@marklewismd
An elderly patient asking for my personal cell no. to be handed over to their grandkids to establish care with me when I graduate residency/fellowship...the patient was terminal,and I am going to remember this for the rest of my life.
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@nihardesai7
@BrownJHM
@MedTweetorials
@Torsadepointles
@NicoGagelmann
@PanktiMehta24
@drkeithsiau
@CPSolvers
@TikareNakul
I stand corrected, MMF has been used as an immunosuppressant in patients who had gum hypertrophy after taking Cyclosporine 👍🏻
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@AaronGoodman33
It can't be wrong when you say it!
Two other observations after seeing 100s of cases in India during my medschool is that:
1) The patients have disproportionately high total bilirubin compared to transaminitis.
2) If you suspect this, look for exposed wound in lower extremity!
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@acweyand
“Interpreting iron profile + ferritin” should be a mandatory class all physicians who treat patients with anemia.
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@AaronGoodman33
Marfan syndrome!
If you have these features with some tumors, that's when you think MEN2B
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Very informative, and comprehensive 🙌🏻
I have seen DLBCL, PTLD and Plasmablastic lymphoma, unfortunately as either medical urgencies or with significant morbidity.
Thanks
@NicoGagelmann
😱Gastrointestinal (GI) manifestations in hematology😱
A short visual 🧵with diagnosis
1/19
16
250
1K
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@NicoGagelmann
@BrownJHM
@Sthanu5
@nihardesai7
@Innov_Medicine
Milliary tb and metastatic choriocarcinoma will be amongst the top differentials - but calmly growing makes me think more in the direction of TB (Slow growing mycobacterium).
Treat with antitubercular drugs (6-9 months), 1 year if meningeal involvement!
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1/Educational thread on thrombocytopenia. Not medical advice. Always open for feedback, suggestions or corrections!
#medtwitter
#hematology
#oncology
#internalmedicine
#benignhematology
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I will be having my hematology consults elective in August. Can you please suggest me important topics to read or give any other imp tips? My only rotation before I apply for a fellowship, so I really want to show my interest as a good resident interested in hemeonc.
#MedTwitter
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I love to teach, and when the audience is engaging and enthusiastic on a difficult topic asking challenging questions - I like it even more!
From the talk on, "Initiation of care in the clinic for a newly diagnosed case of HIV"
#medtwitter
#hiv
#meded
#internalmedicine
#residency
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@nihardesai7
@anujtiwari11
@BijoyTelivala
@Geeky_Foodie
@NicoGagelmann
@Prasshmehta
@Satyayadav__
@nihar_nayak2
@tomam04
Second generation TKIs specific side effects(There's a lot of overlap, though):
Dasatinib-Pleural Effusions
Nilotinib-QTc prolongation black box warning
Bosutinib-Fluid retention
Ponatinib- Vessel occlusions black box warning
Please add/correct me
@nihardesai7
@NicoGagelmann
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Welcoming my mentor Dr. Sharma in Chicago for the first time since I started my residency. He was in town for a PNH advisory board meeting 🙏🏻🙌🏻
He is someone I owe everything to.
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Big 4 weeks are coming for me as I go to
@LoyolaOnc
for a heme consult rotation starting monday! Please wish me luck 😃
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1/Acute hemolytic transfusion reaction
-Due to ABO incompatibility
-Incidence: 1:110000 transfusions
-70% of cases due to RBCs and 30% due to platelet transfusion
-50% of ABO-incompatible RBC transfusions are inconsequential, and 5% are fatal
-Positive Direct antiglobulin test
1
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Educational 🧵 on basics of high penetrance hereditary breast cancer. Not medical advice. Always open to feedback and corrections.
#medtwitter
#internalmedicine
#oncology
#breastcancer
@AaronGoodman33
@Sthanu5
(Bosses of medical education on twitter)
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@acweyand
My niece, 4.5 months old! Starting shopping for her soon - to have all of my luggage filled with toys, clothes and many other things for my next trip to India in February 2023. Haven't met her yet, and I am super excited ❤️😍
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Won the first prize in clinical challenge competition at the Loyola Medicine-MacNeal Hospital IMRPs annual resident research day!
Lucky, grateful, and Indebted!
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5/HLH-Lab Dx
-Cytopenias, deranged LFTs
-Elevated serum triglycerides
-Decreased fibrinogen
-Elevated ferritin (Typically in thousands)
-Elevated soluble CD25 levels
-Hemophagocytosis features on bone marrow aspirate (RBCs, WBCs in macrophage cytoplasm) - ASH image bank image ⬇️
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Sunday off on a ICU block ✅
The session by Dr. Pal
@montypal
and Dr. Jain
@ShikhaJainMD
on 'Presenting Yourself' ✅
Picture with Dr. Pal (Fanboy moment 😎) ✅
Plan well executed at
#ASCO2022
✅
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1/I am a PGY3 IM resident at
@MacNealIMRP
. I love to teach. I had given myself the task of consolidating the educational Twitter threads I designed over the last 18 months or so. They follow this tweet. But let us begin by remembering a quote about knowledge and its importance.
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This is going to be a LEGENDARY source for learners like me 🥇
Many have asked me for all my educational tweets over the last 3 years to be made available in a user friendly format. We are currently working on getting them all uploaded to the Substack platform free for anyone who wants to see them.
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@AaronGoodman33
HTLV
Tropical Spastic Paraplegia and T cell leukemia.
I think it's common in the Caribbean
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Throwback to my interview day at MacNeal, exactly two years back - grateful to the program for believing in me when not many did!
@MacNealIMRP
@aditipuri84
. Will always remain indebted to Dr. Sullivan
@lsulliDO
and all other faculties for their faith and trust in me!
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@AaronGoodman33
For PRCA - the most intriguing cause I ever read about was Anti-EPO antibodies in ESRD patients receiving EPO.
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@AaronGoodman33
Just checked, it's monocytic! Missed the bonus points, but won't forget this ever.
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23/Reference:
(A gold standard article for better understanding)
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@NicoGagelmann
Just looked this up!
Age < 1 y - metronidazole
Age 1 to 3 years - Nitazoxanide
Age > 3 years - Tinidazole
Metronidazole or nitazoxanide can be used if tinidazole isn’t available
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Attended this wonderful session today. Looking forward to many more if such sessions. Thank you
@NitinJainMD
@doctorpemm
@Anand_88_Patel
@mpdrc
@KMirza
@sanamloghavi
@HemeReports
Register for our inaugural session! Dr. Ruben Mesa (
@mpdrc
) joins the
@HemeReports
team to discuss the case of a middle-aged man with fatigue & abdominal fullness
#HemeReports
#StationHeme
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March 1, 2022 | 6:30 PM CST
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4/HLH-clinical features
*Unremitting fever
*Cytopenias, especially thrombocytopenia
*Hepatosplenomegaly
*Elevated LFTs
*CNS symptoms
-Difficult to distinguish from other systemic diseases, multiple laboratory tests available to help with this distinction
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