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How to read a cost-effectiveness paper

This is a powerful method. But poorly understood, often maligned. My goal is to improve critical appraisal and help good analyses get the appreciation they deserve

🧵#MedTwitter CEA: cost-effectiveness analysis
A decision must be made!

All CEA begins with a clinical decision where we are uncertain about the best path forward. Nevertheless, when we face patients we must do something, even if that something is nothing. CEA brings our dilemma to life. Helping us quantify trade offs
Usually we compare a fair description of usual care to an alternative - make sure you agree the choice is fair, realistic, and represents an actual clinical dilemma
Read 20 tweets
Threw out my back and couldn’t walk but still had to come in for a 24hr shift as I couldn’t find coverage. My unit nurses wheeled me down to ED to get a shot of toradol and dex to help me get through the shift. My ED colleague took one look at me and said 1/3
You shouldn’t be here. I’m writing you a note to send you home.

I consider myself a champ for self care & drawing boundaries. But this reminded me how deeply we are trained to sacrifice all at the altar of service. And some sacrifice is necessary—but we’re not taught when 2/3
…sacrifice turns into exploitation. I’m so grateful for my ED colleague reminding me of those boundaries and taking the onus off of me and onto the system to figure out staffing so I could focus on needed self-care. #MedTwitter #physicianwellness 3/3
Read 3 tweets
Hey #MedTwitter !

1. What does the image show?
2. Possible etiologies?

#RheumTwitter Image
It's a purpuric rash. The two most important DDs are:

🔹Small vessel vasculitis (lupus, ANCA, cryoglobulinemia etc) ♨️

🔹Infective endocarditis (janeway lesions) ❣️

Bleeding disorders often affect areas where the skin is soft and loose rather than the soles
Other causes of palmoplantar rash

1️⃣Infections- maculopapular, blanching

🔹Viral eg parvovirus, coxsackie, measles
🔹Bacterial- menigococcimia (purpuric, non blanching), syphilis (2°)
🔹Rickettsia- RMSF

#MedTwitter #MedEd Image
Read 6 tweets
Hey #medicine residents !!

Time to talk about EOSINOPHILS today. Not as common a consult as thrombocytopenia and anemia but important nonetheless.

A short 🧵 to touch upon all things eosinophilia 👇🏻

#MedTwitter Image
Before we go any further, it's important to know this

🩸Eosinophil ≥ 500 is ABNORMAL

Eosinophil is a predominantly tissue dwelling cell so 🩸 eosinophil DON'T correlate with tissue damage 🤷‍♂️

We see a few patients with ⤴️⤴️Eos and no 🫀🫁 injury !!
Where do eosinophils come from?

Short answer: Bone Marrow

They are cells of the granulocytic lineage, siblings of neutrophils and basophils, children of the myeloblast (image👇🏻)

IL5 is the cytokine responsible for it's production, important to know because we have anti IL5 mAb Image
Read 24 tweets
An older man comes to the ED with abrupt onset nausea, & diarrhea

He is joined by her daughter whom he is visiting from abroad

Testing is below
The diagnosis is unclear
Until his daughter got just as sick too
#livertwitter #liverstory #MedTwitter Image
ALT >1000 has a narrow differential diagnosis

There's lots of tests you can order.
But most diagnoses are made in the H+P

Like this one

In fact, in this case, my attending said the diagnosis was obvious from the beginning

Just not to me
When I meet someone with ALT>1000, I think:

1⃣Ischemic hepatitis. Right 🫀failure? 🫀-genic shock? Cool legs?
2⃣Biliary 🪨. Pain? imaging!
3⃣Drug induced liver injury. Tylenol? Run every med through
4⃣Viral hep. Hep A/B/C

But these weren’t the answers
Read 16 tweets
mSMART guidelines for management of CAR-T associated cytokine release syndrome, neurotoxicity, cytopenias has just been posted. #myeloma #MedTwitter

@YiLinMDPhD @myelomaMD @MorieGertz @MayoMyeloma
CAR-T associated CRS #ASCO23 Image
CAR-T associated neurotoxicity #ASCO23 Image
Read 6 tweets
10 commonly asked questions about migraine answered
1. Is migraine hereditary?
Migraine is hereditary, so if one or both of your parents have it, there is a 50-75% chance you will too. However, in many patients, there is no family history of migraine.
#MedTwitter #migraine…
2. Can children get migraine?
Ans: Yes. Migraine occurs in about 3% of preschool children, 4-11% of elementary school-aged children, and 8-15% of high school-aged children. Incidence of migraine increases in adolescence.
3. What are the common symptoms of migraine?
Ans: Headache, nausea, vomiting, intolerance to bright lights and noise.
Some people can have flashes of light, zigzag lines or blurred vision prior to onset of headache (called as visual aura).
Read 11 tweets
Adverse effects of commonly used medicines (at their usual therapeutic doses)

1. Every medicine has adverse effects, especially if taken in higher doses. Some drugs can cause allergic reactions at the usual dose too. Here I describe non-allergic side effects of a few medicines.…
2. Vitamin B12 deficiency- can occur due to Metformin use for diabetes.
3. Headache and cerebral venous sinus thrombosis (clotting of blood in brain veins)- can occur in women after using hormonal pills (OCPs)
4. Confusion, disorientation and seizures with levofloxacin & similar+
+antibiotics, especially in people aged 60 or more.
5. Parkinsonism- due to use of anti-vomiting drugs; levosulpiride, and anti-psychotic drugs.
Levosulpiride is added to anti-acidity drugs and can be recognized with letter L, as in Pantocid-L, Razo-L, etc
Read 6 tweets
😱Emergencies in hematology😱

Malignant spinal cord compression (MSCC)

A short 🧵 #MedTwitter

1/11 Image
-true oncological emergency❗️
-up to 6% of cancer patients
-annual incidence of hospitalizations secondary to MSCC among patients with advanced cancer ~3.5%
-multiple myeloma and non-Hodgkin lymphoma with highest cancer-specific incidence
-prognosis poor
2/11 Image
Definition of MSCC:
-any radiologic evidence of indentation of the thecal sac or spinal cord compression, whether or not there are neurologic signs and symptoms associated with compression
-grading using the "epidural spinal cord compression (ESCC) scale" (Bilsky scale)
3/11 Image
Read 12 tweets
1/Understanding cervical radiculopathy is a pain in the neck! But knowing the distributions can help your search
A #tweetorial to help you remember cervical radicular pain distributions

#medtwitter #radres #FOAMed #FOAMrad #neurorad #Meded #meded #spine #Neurosurgery Image
2/First, a rule of thumb—or rather a rule of elbow! You have 10 fingers. If you divide that in half, you get 5.

If you divide your arm in half, that's at the elbow, you'll also get 5--C5 that is! C5 radiates to the elbow. So if it radiates below this, it's > C5 & above is < C5 Image
3/So let’s start with C2. C2 predominantly radiates along the dorsal aspect of the scalp, as it supplies the greater occipital nerve. I remember this bc the number 2 has a swan like neck that mimics the contour of the back of the head and its distribution Image
Read 9 tweets
Participated in a very interesting multidisciplinary POTS conference at @HopkinsMedicine on the topic of #FND, #syncope and #POTS where we discussed and debated the numerous issues surrounding FND diagnosis in our patient population. 1/🧵
#MedTwitter #NeuroTwitter
@HopkinsMedicine After conference, saw a patient who highlighted the issues discussed at conference.
👩‍🦽30 yo woman with POTS/MCAS/EDS triad with one TTT positive for POTS, but a 2nd TTT negative
❌ A neurologist diagnosed her with FND
💉 She is on allergy shots & many H1/H2 blockers.
@HopkinsMedicine 🚫 Neurologist didn't take into consideration neurologic and psychiatric manifestations of SYSTEMIC DISEASE (MCAS)
❌ This is not FND because there is underlying systemic disorder driving symptoms and signs.
🧠 Patient needs to be treated for the SYSTEMIC DISORDER first.
Read 6 tweets
During my Internal Medicine training, I wrote 100s of History and Physicals (H&Ps).

Now as a Cardiology fellow, I read every single H&P for a new consult.

Here are 7 tips and tricks for effective H&Ps. #arjuncardiology #MedTwitter #MedEd #Cardiotwitter #IMG Image
Read 10 tweets
A. Today, one person who recently turned 50 consulted me in OPD. He has no symptoms & is healthy. He has no known diseases. He wanted a check up & advice to ensure he does not convert into a patient for as long as possible. I love this concept of disease prevention.
B. It is possible to prevent most of the serious diseases by following healthy lifestyle and proper medical care.
These include:
1. Regular sleep: 7-8 hours per night
2. Regular exercise: 30-40 minutes daily for 5 or more days a week; 9-10 k steps/day; strength training
3. Healthy diet: low carb, high protein diet;
avoid sugar & ultraprocessed packaged foods;
eat fresh fruits & vegetables, handful of nuts per day; early dinner (3-4 hours before sleeping time);
reduce feeding time window;
intermittent fasting at least on a few days per month
Read 7 tweets
Studying for medical exams can be challenging.

Here are some of my notes I used to study for the IM Boards. Also high-yield for Step 2 CK!

Part #23: Dermatology: 5 High-yield facts! #arjuncardiology #medtwitter #MedEd #IMG Image
Read 7 tweets
1/ “Say Aaaaaaah!” I was explaining to my resident how I remember tongue anatomy on imaging & he said, “You have to put it on Twitter!”

So here's a #tweetorial about how to remember tongue anatomy on imaging.

#medtwitter #radres #medstudent #FOAMed #FOAMrad #neurorad #meded Image
2/ When you look on the coronal plane at the tongue, the first thing you notice are two column like structures that look like a pair of jeans—genioglossus—or as I like to say “jean-ee-o-glossus.” Genioglossus is latin for jeans of the tongue, right?  Image
3/Right below the jeans are what look like a pair of clown shoes—the geniohyoid. So you see a pair of legs going right into a pair of shoes. Image
Read 7 tweets
Me: "Mr Raj, your wife needs operation, and it needs to be done soon."
Mr Raj: "But none of the previous doctors who treated her depression even remotely hinted at this possibility (of surgery)".

1. 55-year old Mrs Viji had started feeling sad in August 2022.
2. Their only daughter had moved to the UK for higher studies. It was assumed that her sadness was related to missing her daughter. However, the feeling of sadness increased over time. She became withdrawn and stopped participating in get-togethers with family and friends.
3. Mrs Viji did not improve even after one month, she was taken to a psychiatrist.
After detailed history, she was diagnosed to have severe depression, and was started on anti-depressant medications.
Counseling by a psychologist was also started.
#psychtwitter #psychology
Read 11 tweets
Studying for medical exams can be challenging.

Here are some of my notes I used to study for the IM Boards. Also high-yield for Step 2 CK!

Part #22: Dermatology: 5 High-yield facts! #arjuncardiology #medtwitter #MedEd #IMG Image
Read 7 tweets
#HeartFailure (HF) is classified on the basis of ejection fraction (EF) and then into classes and stages. Let's have a look at what each of these mean to a physician in a clinical setting . A 🧵 (1/13)

#MedTwitter #MedEd #medicine
#CardioTwitter #Cardiology
#Heartfailure 💔 is a clinical syndrome that results from a structural or functional impairment of one or both ventricles. Ventricular filling and ejection are thus, hampered.
On the basis of EF, HF is classified into
1️⃣Heart failure with reduced ejection fraction(HFrEF)
2️⃣Heart failure with improved ejection fraction(HFimpEF)
3️⃣Heart failure with mildly reduced ejection fraction(HFmrEF)
4️⃣Heart failure with preserved ejection fraction(HFpEF)
Read 13 tweets
Quand évoquer et consulter pour une maladie d’#Alzheimer

- Quels sont les troubles qui appellent à une consultation ?
- Comment se préparer à la consultation ?

Un thread
#MedTwitter #gériatrie #psychogériatrie
Intérêt du diagnostic précoce

Plus la maladie d’#Alzheimer est repérée tôt, plus les traitements et l’accompagnement sont bénéfiques

C’est tout simple. Cependant, cela fait peur

#Alzheimer #gériatrie

La peur de l’#Alzheimer

D’après des enquêtes Ipsos de 2017 et de 2021
La maladie d’#Alzheimer est la deuxième la plus crainte par la population française
Juste derrière le #cancer

#Alzheimer #gériatrie

Read 36 tweets
😱Challenges in medicine😱

Thrombotic microangiopathy (TMA)

A short 🧵#MedTwitter
1/16 Image
TMA syndromes are extraordinarily diverse❗️
They may be
-hereditary or acquired
-occur in children and adults
-onset can be sudden or gradual
despite their diversity, they are united by common, defining clinical and pathological features
A short history of everything TMA
3/16 Image
Read 17 tweets
Classically placed in the arm
May be placed in the leg (eg in #pediatrics /neonates – which may then terminate in the infrarenal IVC/iliacs)
#criticalcare #cardiovascular
- Lower infection rate then central lines
- Used in the outpatient setting
- Can be used for several weeks to months
- Duration of PICC lines may be from 4 weeks to 6 months
(although they have been known to be functional for more than 300 days)
Read 20 tweets
If you are going to your first ICU rotation and you feel like you have no idea what to do:
I felt the same😄
I added a thread 🧵 with 8 tips for med students and new interns of #MedTwitter #IMG #ICU
Pls add your questions or tips in comments!
1️⃣ Ventilator skills are game changers! Review some basics before starting.
2️⃣Great resources for studying:
🔸️@OnePagerICU summaries of most important icu pearls in one page🥹
🔸️@MedCramVideos great videos 😎
🔸️Rebel EM
🔸️EMCrit project
🔸️Marino's ICU book🤠 Image
3️⃣Things to check for every ICU patient when pre-rounding:
🔸️Which drips/current rate
🔸️The RASS score
🔸️Ventilator settings (tidal vol., RR, FIO2, PEEP, mode)
🔸️Sedation and analgesics
🔸️Access lines and if they need to be removed
🔸️Blood gas
Read 9 tweets
Food addiction is real and is related to #obesity and #diabetes

1. Food #addiction (FA) syndrome can be diagnosed by using Yale Food Addiction Scale (YFAS). There are 11 possible symptoms, which can be used to diagnose FA, as well as grade its severity.
#Diet #MedTwitter Image
2. Clinical diagnosis of food addiction (FA)
Individuals can meet a “diagnostic” score for FA on the current versions of the YFAS by endorsing at least two of the 11 behavioral indicators of addiction plus clinical impairment/distress.
3. Severity of Food addiction
Severity thresholds for this “diagnostic” score are defined by the number of symptoms endorsed
(mild: 2–3 symptoms;
moderate: 4–5 symptoms;
severe: 6–11 symptoms)
Read 6 tweets
Effective treatment of #depression through psychological therapy is associated with lower risk of #stroke and #heartattack
1. 6,36,955 people with depression were treated with psychotherapy and were followed up for a median of 3.1 years.
#MedTwitter Image
2. Reliable improvement from depression was associated with a 12% decrease in incident risk of cardiovascular disease (CVD) at any given time, with similar results observed for coronary heart disease (CHD), stroke, and all-cause mortality (death).
3. Benefit was maximum in those aged 45-60 years. For this group, the improvement in depression was associated with a 15% decrease in cardiovascular diseases. In patients over 60 years of age, there was only a 6% decrease.
Read 7 tweets

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