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LICHEN PLANUS

A #dermtwitter, #medtwitter, and #medstudenttwitter #tweetorial! PC: @dermnetnz. Let's kick off this #MedEd #FOAMEd #medthread with a question.

With LP, which one of the following body sites is most commonly involved?

1/
The correct answer is wrists! LP lesions are most commonly seen on flexor wrists, trunk, medial thighs, and shins. It very rarely involves the face.

The mnemonic for the clinical appearance of LP is to remember the "Ps."
Pruritic (!!!)
Purple
Polygonal/Planar
Papules

2/
You can also make out white and gray lacy streaks and puncta. This is called "Wickham Striae" which helps confirm the diagnosis (1).

Notably, LP also can go to the oropharynx, which can cause erosive lesions that are painful. Wickham Striae are easier to see in the mouth (2).
3/
Read 14 tweets
1/
Hello #medtwitter & #dermtwitter, time for another #dermatology #tweetorial! Let’s go back to the basics and talk about:

#ACNE!

Hopefully this #meded/#foamed moment is helpful for all the #maskne in the #covid19 era!

Let’s start with a simple question:
What causes acne?
2/
All of the above! Often, every one of these factors plays some role. What’s important is knowing what treatment to emphasize based on what factor seems to be the biggest influencer.

For example:
-Retinoids for cell turnover
-Ocps for hormones
-Antibiotics for bacteria!
3/
Let’s talk exam. When I see an acne patient, I’m looking for what lesion I see most: comedones (white/blackheads), inflammatory papules, or cysts.

I’m also looking at distribution (where on the body) and the severity.

It’s critical to ask if it’s a good, typical, or bad day!
Read 16 tweets
1/
#AGEP (ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS)!

A #medtwitter #dermtwitter #tweetorial! #MedEd #FOAMEd

This is a drug reaction that we can see on inpatients, with an exam full of pustules!

Let's start with a question - How long after drug exposure does AGEP appear?
2/
The correct answer is 24-48 hours!

The other answers are typical time frames for other types of reactions.
Urticaria usually manifests minutes to hours after drug exposure.
Morbilliform drug eruptions occur 4-14 days after drug exposure.
DRESS occurs 2-6 weeks afterward!
3/
Unlike DRESS and morbilliform eruptions, AGEP doesn't require repeated exposure of drug. So one single dose can definitely cause AGEP. A typical place we see this is with perioperative antibiotics!

Common culprits are Penicillins, quinolones, sulfa, antifungals, and CCBs!
Read 12 tweets
1/

UK PM Boris Johnson has declared a “war on fat” after confronting the role his #obesity played in his harrowing encounter with #COVID.

In this #tweetorial, we’ll take a closer look at the studies sounding the alarm in the UK.

#medthread #MedTwitter

thetimes.co.uk/article/boris-…
2/

Ho et al. (pre-print) studied 428,225 subjects in the @UK_Biobank of which 340 had confirmed #COVID.

BMI had a risk ratio (RR) of 1.24 (per 1SD). Obesity itself had a RR of 2.29.

medrxiv.org/content/10.110…
3/

To put this in context: for every 4.5 point increase in BMI, the risk of hospitalization from #COVID increases by almost 25%!
Read 15 tweets
1/9

Here it is! My #tweetorial on my experience of pumping during MS3 rotations.

Read on for tips to successfully pumping as a medical student (applies to residents too!).

#medthread #medstudenttwitter #MedTwitter #mamainmedicine
2/9

My baby was born in May; took @TheUSMLE Step 1 in Aug (applied for extra break time to pump); then started rotations.

I pumped all of MS3 - you can too if it’s important to you. It helped me feel I was taking care of my baby when we were apart.

Easy? No. Worth it? Yes.
3/9

First - You do NOT need to ask for permission. Pumping is your RIGHT. Wasn't a big deal for me as an MS3.

Let your team know up front when you will need to step out to pump, and how long you will be gone (don’t underestimate your time).

eoaa.umn.edu/sites/eoaa.dl.…
Read 10 tweets
A #periopmedicine-meets-#COVID19 #tweetorial #Medthread

There has been a lot of overlap between the two areas in the last few months:
🦠appropriate PPE use
🦠intubation
🦠pre-op covid19 screening of asymptomatic patients
🦠telehealth
🦠OR & postop ward management/re-designs

1/
other topics have been explored, such as the safety of laparoscopic surgery v laparotomy given risk/benefit of
overall surgical risk, operative time, potential aerosolization of particles via gas suspension and pneumoperitoneum

one article:
jmig.org/article/S1553-…

2/
I’ve also captured my thoughts about how we resume “elective” surgical volume as states and countries start to “reopen” in this #tweetorial

I'm not going to revisit these subjects here. But...

3/

Read 24 tweets
1/8

Hey #medstudenttwitter! I just finished a virtual #familymedicine rotation, and wanted to share something I learned.

When should patients take their blood pressure pills?

#tweetorial #medthread #medtwitter @umnmedschool
2/8

Patients often ask when they should take their medications. The answer often depends on side effects, such as drowsiness (take these meds at night).

Did you know there's evidence that blood pressure medications actually WORK BETTER if taken before bed?
3/8

The results of a study of over 19,000 patients in Spain was published in October 2019. Patients were randomized to take their antihypertensives before bed or in the morning.

pubmed.ncbi.nlm.nih.gov/31641769/?from…
Read 9 tweets
There's been increasing discussions (on and off #medtwitter) re cancelled surgeries, financial impact on hospitals, and what "elective surgery" means

as some hospitals start to increase surgical volume and project how long it will take to catch up on the queue, some thoughts: 1/
the complexities of these decisions at the institution/health system level AND at the personal level for patients and their families only serve to highlight how complex & nuanced surgical decision making and planning can be...

2/
brief background

why were surgeries cancelled?
🚫preserve PPE
🚫increase available ICU and hospital beds
🚫staff deployment to other services incl COVID teams
🚫decreased spread
🚫decrease patient risk post op complications (esp if they were covid + preop or acquired it postop)
Read 20 tweets
1/ I haven’t written a #periopmedicine #tweetorial in a while, but last night @etsshow tapped me on the shoulder w a request for a #Medthread re preop evals via #telehealth

The specific❓was re assuaging surgeon (& I’ll add anesthesiologist) concerns re the lack of an exam

🧵
2/ Background 1️⃣–telehealth across the board has rapidly expanded given the challenges of providing care while keeping safe distances due to #covid19

We’ve had an incredible amount of institution level support for this at @OHSUnews @OHSUSOM!

news.ohsu.edu/2020/04/13/ohs…
3/ Background 2️⃣–telehealth for PREOP has been a goal for years w go-live in June.

Why?

To meet the care needs in a large, rural state—many of our sicker/older patients lived very far away & w limited socioeconomic means to get to preop clinic before surgery
Read 26 tweets
1/
Okay #medtwitter and #dermtwitter, you knew it was only a matter of time, didn’t you?! Let’s do this #COVID19 themed #medthread:

#COVID TOES, a #TWEETORIAL!

#MedEd #FOAMEd #dermatology #dermatologia @AADskin @AADMember @Meddermsoc @dermhospitalist
2/
First, a word of caution – this is one person’s thoughts on a new skin finding reported in a new disease that the medical community is still learning about! As such, nothing in the #tweetorial should be regarded as definite. Just wanted to share a thought process!
3/
So, who cares? #COVID19 is devastating, at times even for the young & healthy! But it’s all respiratory, right?

Well, as we're learning, there's so much more to #SARScov2, and as a #dermatologist, this is the perfect example of how the exam helps frame possible mechanisms.
Read 12 tweets
1/8
This #medthread is for those providing critical care in pop-up ICU's right now...

💥 A primer on the ABCDEF ICU liberation bundle 💥

Take home: less delirium = lives saved

#medtwitter #weareallintensivistsrightnow
2/
In 2013 @SCCM published the ABCDEF bundle to:

💡 Reduce ICU delirium
💡 Deliver high value care
💡 Improve short/longterm critical care outcomes

While individual components can be implemented, best practice uses the whole bundle w/ all patients.

sccm.org/ICULiberation/…
3/
A = Assess, prevent, and manage pain

ICU patients are often unable to communicate pain.

The CPOT (Critical-Care Pain Observation Tool) is a validated, non-verbal assessment to ensure pain is controlled (score of >2 = pain that should be treated)

ncbi.nlm.nih.gov/pubmed/16823021
Read 8 tweets
1/
#Obesity and #COVIDー19 have been in the headlines recently.

The link between the two is now undeniable.

Let’s take a look at WHY they are so tightly linked molecularly, physiologically, and anatomically in this #tweetorial.

#medthread #medtwitter

nytimes.com/2020/04/16/hea…
2/
We learned quite a bit about obesity and viral infection in 2009 during the #H1N1 epidemic. Obesity led to:

🔼risk of ICU admission
🔼viral shedding
🔼recovery times

But WHY?

ncbi.nlm.nih.gov/pmc/articles/P…
The story is complex, but inflammation plays a critical role.

Individuals with obesity are in a state of chronic low-grade inflammation as evidenced by altered levels of several cytokines such as TNFα, IL-6, and CRP.

ncbi.nlm.nih.gov/pubmed/22429824
Read 11 tweets
1/
Day 3 of #DistanceMedEd for #dermtwitter and #medtwitter! We've done 2 of the 5 reaction patterns so far, so let's focus in on the....

DERMAL reaction pattern!

#MedEd #FOAMEd #tweetorial #medthread PC: @dermnetnz
2/
As opposed to the papulosquamous reaction pattern, the dermal pattern implies the action is DEEP in the DERMIS. This means that without epidermal alteration, you shouldn't see scale!

There is of course an exception with overlying xerosis or if you have another process on top!
3/
When you see something dermal, you have to think about what is infiltrating the skin. A few possibilities/examples:

Edema/fluid 👉 urticaria (1)
Inflammatory cells (reactive) 👉 granuloma annulare (2)
Inflammatory cells (cancer) 👉 CBCL (3)
Collagen 👉 Morphea (4)
Read 8 tweets
1/ How infectious are various biological samples from COVID-19 patients? And for how long? @Nature pre-print paper out yesterday- what does it actually tell us? See this thread for analysis.
#tweetorial #medthread
nature.com/articles/s4158…
2/ Viral RNA in specimens tells if you are currently SARS-CoV-2 positive. Does not tell you if that is dead or live virus, i.e. actively replicating and infectious. This paper attempts to address the latter- a very important question.
3/ Methods: Nine COVID-19 patients in Munich, Germany infected late Jan. All patients had close contact to a single infected individual, so time of exposure is somewhat controlled. Outbreak cluster described in this report: papers.ssrn.com/sol3/papers.cf…
Read 20 tweets
1/
As the #COVID19 pandemic progresses, exactly why men get infected more frequently, and with greater severity, than women is unknown.

This #tweetorial examines a theory (emphasis on theory) that might explain some of this difference.

#medthread #medtwitter
2/
First, let's look at the gender distribution data for covid19.

It was noted early in the outbreak in China that more men than women were getting infected.

In this sample 58% of infections occurred in men (and they died at a slightly higher rate).

ncbi.nlm.nih.gov/pubmed/32109013
3/
A similar gender difference has emerged in Italy.

So far 59% of Italian cases have been in men.

statista.com/statistics/110…
Read 14 tweets
1/
HOW TO TREAT ACTINIC KERATOSES AT HOME, a #tweetorial/#medthread

AKA:how to keep practicing #socialdistancing in the era of #COVID19 by staying at home and taking care of those precancers without having to come to clinic!

#dermtwitter #medtwitter #MedEd #FOAMed pc:@dermnetnz
2/
1st, a caveat. Nothing subs for an in person exam, so this is not free license to tx things without a derm eval.

The reason for this #thread is that as the doctor seeing all urgent #dermatology pts today, I've gotten MANY calls from pts hoping to come get their AKs treated.
3/
Before we get to txs, let's start with the basics. What is an AK?

Clinically they are erythematous papules & plaques with gritty (sandpaper-like) scale. Some can be quite big. Then we call them "hypertrophic AKs."

These are precursor lesions to squamous cell carcinomas.
Read 13 tweets
1/
BULLOUS PEMPHIGOID, a #dermatology #tweetorial!

#MedEd #FOAMEd #medtwitter #dermtwitter #medthread pc:@dermnetnz

A patient with active bullous #pemphigoid comes to see you. What do you expect on your exam?
2/
#bullouspemphigoid (BP) is an autoimmune blistering disorder where the pt's immune system makes auto-antibodies targeting BPAg 1&2 (BP230/BP180). Since these Ags are in the hemidesmosome, the split is lower in the skin, making for tense blisters.

pc: sciencedirect.com/science/articl…
3/
Clinically, tense blisters (as seen in BP) usually go with a negative nikolsky, whereas flaccid blisters (seen in pemphigus) would have a positive nikolsky.

An easy mnemonic is:
pemphiguS = Superficial
pemphigoiD = Deep
Read 13 tweets
A Friday #tweetorial #medthread about patient privacy on
#medtwitter #SoMe

There are many facets of patient privacy & professionalism concerns in this communal space—I’m going to focus on this through the
lens of case-based teaching

🧵
1/N
We know that #medtwitter & #SoMe enhance learning based on tenants of adult learning theory—this includes the microsimulation, mini-challenges, & active discussion of case-based learning.

However, how can we make this effective safe for our patients AND ourselves?

2/N
I want to introduce this concept—the term came to me a couple of weeks ago:

“POST THE PEARL, NOT THE PATIENT”

3/N
Read 25 tweets
A #medthread #tweetorial on assessing goals of care. People often say “tell me your goals” and are confused when the response is “get better and go home” and conversation over.
First, until patients have been given reason to consider a goal beyond this (new bad news, disease progression, etc.), there probably isn’t any reason for a person to feel the need to reasses their own goals.
Second, “goals of care” is jargon and those words may not have meaning to a patient. What you really want to know our their values, hopes, and what gives life meaning. Ask about hobbies. How is life outside the hospital? Where do they get their strength?
Read 7 tweets
1/
ATOPIC DERMATITIS - a #dermatology #tweetorial/#medthread!

For all the #tweetiatricians, #primarycare, #medtwitter, & #dermtwitter! #MedEd #FOAMEd pc:@dermnetnz

1st, a question:
How do you think of the term atopic dermatitis (AD) in relation to the term eczema?
2/
If you're a purist, "eczema" is a description. When a #dermatologist says something looks eczematous, it doesn't mean it's AD. It means it has a certain appearance.

So the right answer for purists is "AD can cause eczema."

That said, we so often just use eczema to mean AD🤷🏻‍♂️
3/
As annoying as that might be, it's an important distinction. If you see an eczematous rash, you need to consider possible causes:

- Atopy
- Allergy/irritant contact
- Medications
- Venous stasis
- Dry skin

For more on contact dermatitis, check out @patchtestYu!
Read 16 tweets
1/ Do you mentor or are you: a learner wanting to improve exam scores? Dx the reason for low test scores in today’s #MedEdMethodsMonday!

Inspired by @thecurbsiders ep193 featuring @Missydoc0128

#MedEd #MedThread #MedEdPearl #MedTweetorial #FacDev #Medtwitter #medstudenttwitter
2/ Self-Regulated Learning Microanalytic Assessment and Training (SRL-MAT) - a tool that can identify 6 test-taking problems, described by Dr. Andrews @williamkellymd @GenesseyFlint & Dr. Dezee from @USUhealthsci in @AcadMedJournal

tiny.cc/SRLtool
3/ The tool is used between a mentor & learner in a 60-min session.

The learner 1st reads & thinks aloud while going through a vignette appropriate for their level, with the actual question and answers covered.

They then talk through a Question Review Form:
Read 9 tweets
1/

Why is cystic fibrosis (CF) one of the most common genetic diseases? Could heterozygous carriers have a selective advantage?

The infection that CF carriers may be protected against is absolutely astounding.

#medthread #medtwitter #tweetorial
2/

Three types of supporting evidence are required to determine whether CF carriers plausibly have a selective advantage against an infectious pathogen:

💥 Historical/geographical
💥 Clinical/population
💥 Molecular

Let's examine these one by one.

ncbi.nlm.nih.gov/pmc/articles/P…
3/

💥 Historical/geographical

The first inkling that CF carriers may have a selective advantage came from observations that patients w/ cystic fibrosis rarely get tuberculosis (TB).

TB infection is so rare in CF patients that it's case-reportable.

ncbi.nlm.nih.gov/pubmed/26110137
Read 13 tweets
1/ Time Management is today's #MedEdMethodsMonday #MedThread

As junior faculty & a #GIM fellow working on a #MedEd Masters, life is often a precarious juggling act. How do you stay on track in #academics?

#Medtwitter #MedEdPearl #FOAMed
2/ Components of Time Management
Gordon & Borkan’s lit review highlights 4 principles of time management tiny.cc/MedEdTime:

1. Set goals
2. Prioritize competing responsibilities
3. Plan & organize activities
4. Minimize wasted time
3/ Set Goals
- Set short- (1-3yr) & long-term (5-10yr) goals for your career
(see tiny.cc/MedEdGoals)
- Break long-term ends goals into bite-sized means goals
- Monitor past & current activities for goal compatibility
Read 11 tweets
#meded #Thread @nelkassabany starts #AnesGR with his take home points:

➡️ Always think about adding value
➡️ Measure outcomes that matter to patients
➡️ Involve all stakeholders
➡️ Bust silos

#medthread #regionalanesthesia
#regionalanesthesia takes commitment!

@nelkassabany quotes @aboezaart1: "A block is not a one night stand..."
Developing a comprehensive enhanced recovery protocol means considering all phases of patient care. Patient education and engagement are key!

See free materials from @ASRA_Society here: asra.com/page/40/patien…
Read 10 tweets

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