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Most recents (24)

How do you enhance recovery before surgery? Let's talk about preoperative #optimization initiatives with goal of #prehabilitation! #EB4S 1/

#MedThread #Tweetorial
@aoglasser @TomVargheseJr @KurtPfeifer @afedwardMD @Docbasia @dremilym @tony_breu @ruthi_landau
1st, goal is optimization for everyone, but that may not be possible in your place. You want to risk stratify your patients. We use the NSQIP Surgical Risk Calculator, Gupta MICA Calculator, and the Duke Activity Status Index DASI. 2/
riskcalculator.facs.org/RiskCalculator/
You can learn about risk stratification here:
Remember: it's not always just about the heart. Kidney, Lungs, Brain, etc. are at risk. 3/

@ruthi_landau threadreaderapp.com/thread/1177181…

sciencedirect.com/science/articl…

sciencedirect.com/science/articl…
Read 23 tweets
A #periopmedicine #tweetorial/#medthread

It’s that time of year again!
Sunday football?
ERAS applications?
Girl Scout cookies?
Well, yes…but for the purposes our discussion, it’s “COLD & FLU SEASON”

What do you do if a patient scheduled for surgery has a URI?

1/N
what is the theoretical concern?
That presenting for surgery, and the anesthetic management including intubation required to facilitate it, will lead to #perioperative complications if the patient has (or has recently had) an upper respiratory tract infection.

2/N
these concerns include the risk of periop pulmonary complications:
🔘respiratory failure
🔘airway hyperreactivity (during induction or emergence) ➡️laryngo/bronchospasm
🔘deeper infection like pneumonia

does this “biologic plausibility” translate into real-world events?

3/N
Read 23 tweets
Syphilis! RMSF! Hand-foot mouth!

Slow down there, Tiger! Let's dive deeper into:

ACRAL RASHES - a #tweetorial/#medthread
(aka rashes on the "palms and soles" - kind of 😉).

#MedEd #FOAMEd #medtwitter #dermtwitter #dermatology #dermatologia pc:@dermnetnz
1/
No where else on the body does a rash evoke more of a knee-jerk differential. That's not wrong per se, as we all learn this in med school, but it's more complicated then starting doxycycline and checking an RPR!

Let's start with a definition - what does "acral" actually mean?
2/
Technically, "acral" just means our distal body parts. So while we often think of palms and soles, it's actually inclusive of the whole hand, the whole foot, ears, and some include even the nose!

I actually didn't learn this until #derm residency, which was shocking to me.
3/
Read 20 tweets
#MedThread Day 10 (sorta). I'm sure most know this, which is why I consider this #BreadNButterMedicine. But, if you follow along, you might learn a little history as well! Today, we are going to talk about Central Venous Catheters.
2/ If you had your choice of central line sites (no contraindications), what would you choose?
3/ 1st, why would you want to place a CVC?
🔹CVP monitoring
🔹Resuscitation
🔹Emergency venous access
🔹Inability to obtain peripheral venous access
🔹Repetitive labs
🔹Need for hyperalimentation, caustic agents, or other concentrated fluids
🔹HD
🔹and MORE!
Read 20 tweets
Let's go back to the basics today, and talk about some #morphology in the #dermatology exam.

Today's #tweetorial/#medthread will be about evaluating....

SCALE!

#MedEd #FOAMEd #dermtwitter #medtwitter #dermatologia pc:@dermnetnz
1/
Before we get too far into it, how do we think about #scale? Meaning, which one of the following is it?
2/
When we say "primary lesion," we mean the most basic element of a lesion/rash (papule, macule, patch, plaque etc).

SECONDARY CHANGE (which scale is) means the extra exam element that occurs on top of the primary lesion!

Tertiary/Quaternary isn't a thing. I'm just a jerk.
3/
Read 15 tweets
1/8
It’s #ClimateWeek2019 so I thought I’d create a #MedThread/#Tweetorial of Explore The Space podcast episodes focusing on #ClimateChange.
Please scroll through!
2/8
Episode 152 w/ @MichaelEMann
A smashing layout of the current state of #ClimateChange & our response w/tons of resources for us to communicate more effectively. Also a premium @BillNye name drop!
#ClimateChange
explorethespaceshow.com/podcasting/mic…
3/8
Episode 132 w/ @Jamie_Margolin @ThisIsZeroHour
“The Teenager” (h/t @maryheglar) is tenacious, motivated, and inspiring.
She’s also just getting started!
#ClimateWeek
explorethespaceshow.com/podcasting/jam…
Read 9 tweets
I'm going to go outside of my regular comfort zone a bit today, and try out a #tweetorial/#medthread a bit more applicable to #medtwitter in general. So here goes....

A beginner's guide to the use of #PREDNISONE!

#MedEd #FOAMEd #dermtwitter #dermatology PC:@dermnetnz
1/
Ah, prednisone. One of the most frequently used drugs in our specialty, and in many across the board in medicine. Useful for quick suppression of an overactive immune system, whether that be because of autoimmunity, or acute infection. But how does it work?
2/
The point is that there are so many potential mechanisms, that it's hard to point at one particular enzyme or pathway to explain all its effects. This paper address many of them, but my main takeaway is that we don't know everything! ncbi.nlm.nih.gov/pmc/articles/P…
3/
Read 20 tweets
A #tweetorial/#medthread on…

CONSULT ETIQUETTE – for the consultant!

(This is the 2nd in a series on consult etiquette. See the end of this thread for a link to my other tweetorial for primary teams calling consults).

#MedEd #FOAMEd #dermtwitter #medtwitter #dermatology
1/
So you just got paged for a consult…. What do you do?

2/
Of course we all think #1, yes?! Realistically though, it can be stressful to get consults. They are unpredictable, can come at any time, & the primary team may or may not listen to what you have to say. Here are some tips I’ve come up with from my time on #dermconsults.
3/
Read 12 tweets
Bit of a different #tweetorial today, on:

CONSULT ETIQUETTE!

- TIPS for the PRIMARY TEAM calling the consult.

Caveat: Some examples are a little #dermconsult specific, but can be extrapolated to others!

#medthread #dermtwitter #medtwitter #meded #FOAMEd #tipsfornewdocs
1/
As both a #dermatologist & a #hospitalist, I have the pleasure of being on both ends of the #consult game.

So, your team has decided to call a consult, and you are the intern or student who has been tasked with contacting the team. Don't be nervous! Try these tips!👇👇👇
2/
First of all:

1)Have a consult question

Asking a consultant to see a pt w/o a ? is like having a pt see you w/o a chief complaint! The ? helps the consultant frame the note in a way that is most helpful for you & your team. Otherwise, I'm guessing at what you want to know.
3/
Read 11 tweets
Derm/Rheum Consult 1: 82yoW w/ HTN, breast can, new annular rash. Skin bx eosinophilic lymphocytic infiltrate. Gave 1mg/kg steroids.
ANA+ with centromere pattern, CREST?
==>#UnmaskSx with Steroids when tapering steroids.
==>Deep perivascular infiltrate on bx = Derm IDK!

1/
Derm/Rheum Case 2: 78yoF MGUS,HFpEF, rash on legs. ?purpura. w/u Cryocrit normal , RF+ skin bx C3 in vessel walls, LCV.
Dx: Type II Cryo
Learning Pearl: Retiform purpura "angular stellate rash" pic below and diagram -> VASCULITIS or VASCULOPATHY

#dermtwitter #rheumatology
2/
Derm/Rheum 3: Bullous Rash? DDx: Bullous Lupus vs. Epidermal Bullous Acquisita (EBA) vs. Bullous Pemphigoid
Learning Pearl:
Minimal trauma w/ blisters = EBA, treat with dapsone +/- prednisone
Consult Derm!

3/
Read 7 tweets
As voted upon, a #Tweeotorial #Medthread:
#perioperative medicine meets #backtobedside
.
.
.
so let’s talk about functional capacity and METS!

1/x
METS?
“metabolic equivalent of task”

Huh?

Have you ever seen that report out on exercise equipment? Usually a number < 10?
It’s a measure of physical activity via oxygen consumption

Again, huh? #backtobedside??
Stay with me…
2/x
en.wikipedia.org/wiki/Metabolic…
Recall that the 2007 and 2014 ACC/AHA perioperative guidelines both include a step in their algorithms that no additional ischemic testing is recommended for patients who can achieve > 4 METS

So...how about those METS???
3/x
Read 27 tweets
#TRAUMA: #medthread on the coagulopathic changes in severe trauma.

This is the WHY behind trauma resuscitation efforts.
#traumaanesthesia #damagecontrol #resuscitation
@uabsurgery @UAB_Anesthesia @uabmedicine 1/
Post-trauma hemorrhage and hypotension leads to a unique physiologic derangement called Acute Traumatic Coagulopathy. Resuscitation requires management of both hemodynamics and coagulation status. 2/
Why does this happen? If you were to simply cut your finger, your body would sense the injury and begin clot formation (platelet>factor signaling>fibrin net>more platelets). But to restore blood flow, it would need to break down that clot. 3/
Read 19 tweets
I had a bit of an “ah ha moment” while attending in our #dermatology resident clinic a month ago.

The way I run this clinic means that when the timing is right, I try to have our senior resident precept the junior resident. I try to stay silent and literally say nothing.

1/
When this happened, we had a brand new senior and a brand new first year. Essentially both residents were settling into their respective roles.

In typical fashion, the junior resident presented the key points to the senior resident as I listened on.

2/
Jr: the patient doesn’t have a rash today, but the pictures look like wheals. He says that pressure causes it. Diphenhydramine doesn’t work that well. He doesn’t have dermatographism.

Sr: what do you think it is?

::both look at me to see what I’m thinking/about to say::

3/
Read 13 tweets
PYODERMA GANGRENOSUM – a #tweetorial/#medthread

After my recent #thread on Sweet Syndrome, I thought we’d continue our discussion of neutrophilic dermatoses with a focus on PG this time! Join me below!👇👇👇

#dermtwitter #medtwitter #dermatology #dermatologia pc: @dermnetnz
1/
#Pyodermagagrenosum is a rare ulcerating skin condition that most of us think of in conjunction with IBD. PG can be associated with other things too, so if there’s no IBD, we should also consider other triggers, like the possibility of paraneoplastic processes.
2/
PG is a neutrophilic dermatosis, so like Sweet Syndrome, it starts as a pustule, & ulcerates from there. Remember pathergy is a classic associated finding with neutrophilic derms. See my #tweetorial on sweet syndrome for a discussion of pathergy!


3/
Read 14 tweets
#Periopmedicine #Medthread!
Based on requests (esp @JenniferBrokaw), a long over-due #tweetorial with my advice & pearls for providing patient-centered care for the surgical patient with #ParkinsonsDisease
1/x
@JenniferBrokaw Caveats
1⃣I’m not an anesthesiologist & don’t care for pts w PD #intraoperatively
2⃣I practice outpatient #PREoperative medicine, so I am not providing inpatient postop care
3⃣There are several high yield publications/resources, & much of this is pulled from my own experience
2/x
@JenniferBrokaw Caveats out of the way, let’s chat about why understanding #periop #ParkinsonsDisease management is so foundational.
Remember how Osler said to know syphilis is to know all of internal medicine?
Yeah…PD meets #periopmedicine is potentially THAT informative.
3/x
Read 28 tweets
I hope you brought your appetite and have a strong stomach for...

A TASTING MENU OF DERMATOLOGY

This 5 course menu is a culinary journey through food-named skin signs. Bon appetit!

#prixfixe #tweetorial #MedEd #FOAMEd #dermtwitter #dermatology #medthread h/t @AdamRodmanMD
N.B. The MENU. Skip this tweet if you prefer delightful surprises. If you're one of those people who prefers to know what's ahead, here you go.
BREAKFAST:

CAFE AU LAIT MACULES (CALMs) are light brown patches seen in neurofibromatosis types I and II ("Coast of California"-type edges) and McCune-Albright syndrome ("Coast of Maine").

For NF, a diagnostic criterium is ≥ 6 CALMs of 5mm (prepubertal), 1.5cm (postpubertal).
Read 37 tweets
It's time for a #histmed #medthread about the discovery of microbes!

To say that mankind has a complicated relationship with the microscopic world would be an understatement, since a major selling point of many products is that they kill 99% of it.
For what it’s worth, there’s an awesome meme about the bacterial one percenters who somehow make it through the Lysol and Listerine apocalypse (this one is from itsthetie.com)
By the way, this #medthread is meant as a companion for Micrographia, the latest episode of @BedsideRounds (bedside-rounds.org/episode-48-mic…), since you can’t really see pictures through the radio.
Read 23 tweets
A Monday #Medthread:
#medtwitter colleagues—what gets your BP and HR up the most in terms of delivering “bad news”?
in my #periopmedicine world, it’s telling a patient we might need to postpone or cancel their surgery
So…a #tweetorial to share my learnings over the years
1/x
Take a step back—remember that there’s no such thing as “preop clearance”.
The value added is preoperative evaluation and risk assessment, with patient + procedure-specific optimization
Inherent to this is communicating risk and concerns for it
2/x
The overwhelming majority of patients I evaluate in preop clinic are stable/optimized at the time of my evaluation, though my assessment still adds value by empowering intraop and post-op care, as well as facilitating pre-op patient instructions and empowerment
3/x
Read 23 tweets
SWEET SYNDROME - a #tweetorial/#medthread!

Join me for a discussion of this confusing eruption that we more commonly see on the inpatient side.

Bonus: a discussion on pathergy versus koebner phenomenon!

#MedEd #FOAMEd #dermtwitter #medtwitter #dermatology pc: @dermnetnz
1/
It helps to start by using the other name for Sweet Syndrome: Acute Febrile Neutrophilic Dermatosis. This pretty much sums up the whole syndrome.

Relatively sudden onset? ✅
Fever? ✅
Skin stuff? ✅

But what makes this diagnosis confusing is the differential diagnosis!
2/
If a patient presents with a fever + rash, we often start to consider infectious processes first, which is totally reasonable. What helps though, is the exam.

The rash in Sweet Syndrome is usually described as "juicy edematous papules and plaques."
3/
Read 15 tweets
CUTANEOUS LUPUS – a #tweetorial/#medthread!!

We all learn about Systemic Lupus Erythematosus (SLE) in medical school, but did you know there are multiple forms #lupus can take in the #skin?

#Meded #FOAMed #dermtwitter #medtwitter #rheumtwitter #dermatologia pc: @dermnetnz
1/
It wasn’t until #dermatology residency I learned about all the subtypes of cutaneous lupus (CLE)! I thought it was all just one disease: SLE. But in reality there are many forms of CLE, each with its own implications on systemic involvement and effect on the patient.
2/
Let’s start with the 3 subtypes:
Acute, Subacute, and Chronic Cutaneous Lupus Erythematosus (ACLE, SCLE, CCLE). CCLE is aka Discoid.
Each subtype "overlaps" with SLE in a different way.

Eg: ACLE overlaps completely with SLE, so they all have SLE! 👇
onlinelibrary.wiley.com/doi/abs/10.111…
3/
Read 17 tweets
There are many guides on how to write a personal statement. I thought I’d share my own thoughts for all those #premed & #medstudenttwitter folks. This is just my opinion, but it’s served me well.

So here goes: a #tweetorial on the PERSONAL STATEMENT!

#meded #medtwitter
1/
Unlike another recent #medthread on the PS, I don’t think we should be using it to scare our applicants or to expect that they entertain us. Applying for the next level be it med school, residency, or whatever is stressful enough! Let’s support our applicants through it!
2/
First of all, I think the PS when poorly written can definitely lose you an interview. When written in a super compelling way, it may tip you toward getting an interview, but in the vast majority of cases, it doesn’t move the needle much. So first rule: don’t get weird.
3/
Read 15 tweets
Friday #Medthread! I’ve been chatting lately that I should write a #tweetorial about how I’ve put my social media related/based activities on my academic/professional CV. So, without further ado... 1/x
these are excited times, & hopefully this won't be uncharted territory for too much longer as standards are set and more institutions embrace social media related activities...BUT for now...how do you show your uniqueness and innovations via #medtwitter #SoMe?? 2/x
Disclaimers:
1⃣these are my opinions (grounded in experience & many discussions)
2⃣I use the OHSU CV template (Scholarship/Service/Teaching)
3⃣employers may not be ready to embrace

PS--bonus points--name the TV show the GIF is from!! (probably not known/respected enough...)
Read 18 tweets
An anniversary #Medthread!
One year ago today, I gave my OHSU #GrandRounds about #medtwitter for academic clinicians and immediately posted its accompanying #tweetorial.
My goodness, what a year!!
Some reflections and musings 1/x
an incredible year indeed, professionally AND personally--and definitely in no small part thanks to #medtwitter and the opportunity to prepare and give this talk about #SoMe
pardon my if the argument is getting a little circular...the coffee is still kicking in... 2/x
I truly truly had no idea. In probably a poor exam of my "beginning of the academic year commitment to say 'no' more often", I told my boss that I could fill the August 7th #GrandRounds slot on only a few weeks notice.

"Don't you have a talk about twitter prepared?"... 3/x
Read 17 tweets
there 2 hours left in July 2019 on the west coast, so a belated/last minute #medthread w July-in-the-hospital thoughts in large part inspired by @ETSshow recent amazing episode w @drjenniferbest & the question--would YOU want to be a patient in the hospital in July? 1/x
@ETSshow @drjenniferbest brief background, I was born end of June in a teaching hospital, and grew up with stories that "it got different the day after you were born", so was aware that there was something "special" about July long before I considered a calling for medicine 2/x
@ETSshow @drjenniferbest back to the more recent past. Beyond being an intern, resident, attending, and patient myself in July, I have been the patient of a NICU BABY in July--a critically ill newborn in the neonatal intensive care unit 3/x
Read 9 tweets

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