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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
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!
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…
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:…
Read 20 tweets
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
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).
A similar gender difference has emerged in Italy.

So far 59% of Italian cases have been in men.…
Read 14 tweets
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
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.
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
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?
#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.

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

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?

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


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
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?
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🤷🏻‍♂️
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
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

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

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.…

💥 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.
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

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
- 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:…
Read 10 tweets

Ever wonder why fever worsens brain injury after cardiac arrest?

I have diligently avoided fever in these patients for years but never knew the reason why.

#medthread #tweetorial #medtwitter

Let's review some of the early evidence that fever is actually harmful in this setting.

💥It was noted in the 1990s that hyperthermia after global ischemia in rats worsened neurological injury…

💥Shortly thereafter, a dose-response relationship between fevers and worsened neurological outcomes after cardiac arrest was observed.

The higher the fever, the worse the risk of poor outcomes, with an odds ratio of 2.26.…
Read 10 tweets
By request (incl @afedwardMD @SaraJPharmD @bethgarbitelli), a #periopmedicine #tweeetorial #MedThread about marijuana management

This is one of my longer tweetorials—there’s a lot to cover!

Also, no silly weed or "high" GIFs…my purpose here is to teach, not stereotype...

Why do we need to ask about how we can best manage marijuana use perioperatively?

❇️ use is increasing
❇️ multiorgan effects
❇️ potential for intoxication or withdrawal
❇️ interaction with anesthetic agents
❇️ risk of postop complications

What do we mean when we say “marijuana”?

the Cannabis plant (species incl sativa, indica, & ruderalis), which contains > 500 chemical compounds, 100+ of which are “cannabinoids”

Potential ”medicinal” effects:
Muscle relaxant

Photo Wiki

Read 28 tweets
STAPHYLOCOCCAL SCALDED SKIN SYNDROME - A #dermatology/#dermtwitter #tweetorial!

Let's start with a question: You are seeing a new patient with a rash you suspect of being SSSS, but aren't sure if it might be bullous impetigo.

What test will help you differentiate the two?
The correct answer is wound culture! SSSS should be sterile or skin flora; bullous impetigo will have lots of staph grow out. Keep reading to find out why! 👇

But before we get there, let's talk about the SSSS exam. The pic is a good example of "sad facies." pc:@dermnetnz
The other great clue you are dealing with SSSS is the predilection for skin folds. This eruption can cause a high BSA of erythema --> desquamation.

SSSS is more common in the #pediatrics population, especially in kids <5 years of age (for all the #tweetiatricians out there!)
Read 14 tweets

Pulmonary vasodilators are generally not used for patients with pulmonary hypertension due to COPD, even if severe.

Why would that be?

#medtwitter #medthread #tweetorial

💥Let's first review the main source of pulmonary hypertension (PH) in the setting of COPD: hypoxic vasoconstriction

Areas of the lung that are poorly oxygenated have relative arteriolar vasoconstriction, in order to improve V/Q matching.

@tony_breu has previously covered the mechanisms of hypoxic vasoconstriction, but it involves endothelial mitochondria not sensing O2 and shutting down nitric oxide production.

Read 14 tweets
A New Year’s (+1 day) #periopmedicine #medthread #tweetorial

What do New Year’s resolutions and pre-op optimization have in common??

Let’s warm up with a quiz
What is the most common New Year’s resolution?

According to this resource, the top resolution is to exercise more

This is certainly applicable to the subject of periop optimization... are other potential resolutions such as drink less, lose weight...

Read 22 tweets

There seems to be an association between the use of "normal" saline and acute kidney injury (when compared with other IV fluids).

Why would that be?

#medthread #medtwitter #tweetorial

We need to first understand 2 things:

💥What is the difference between saline and other "balanced" crystalloid IV fluids?
💥What is the evidence that saline is associated with kidney injury?

💥How is saline different from other "balanced" crystalloid IV fluids?

💡Saline has⬆️levels of Na/Cl
💡Bc of this difference in composition, when used in large volumes saline⬆️serum Cl levels and causes a hyperchloremic metabolic acidosis
Read 13 tweets
Why exactly do the lesions in pityriasis rosea appear in the “Christmas Tree” pattern?

Well, in honor of today being #Christmas, let’s do a brief #dermatology/#dermtwitter #tweetorial on…


So what say you? What’s the reason for the Xmas Tree pattern?
PR presents in "Langer's Lines," aka the skin tension lines. This paper notes diseases in this pattern seem to have activated leukocytes in the pathophy, which could be explained by other papers looking at how skin stretch impacts immune response!…
This same paper points out a limited group of skin diseases that can have this distribution:

- PR
- Secondary syphilis
- Sign of Leser Trelat
- Mycosis Fungoides

Ultimately, the cause of this distribution might have to do with skin tension, but is best described as unknown.
Read 11 tweets
Hey #medtwitter and #medstudenttwitter! A while ago, I gave a #dermatology presentation on the intersection of derm and #trans health.

I learned a lot. So here's a #medthread on some of the takeaways I found most valuable.

Let's start with our transfeminine pts.

Derm can provide a number of facial feminization procedures (FFP): e.g. botox, soft-tissue augmentation.

These FFPs can be more affordable/less invasive than feminizing surgeries such as forehead or mandibular contouring.

Note: tho traditionally considered "cosmetic", these interventions have MATERIAL psychosocial benefits – studies show that facial feminization has a demonstrated positive impact on QoL + mental health outcomes.

Read 10 tweets
Ever wonder why a "STEMI" causes ST elevation on EKG?

The answer is mind-bending.

#medthread #tweetorial #medtwitter
We need to review a few basic EKG facts.

💡 If electrical signals travel away from an EKG lead they appear as negative deflections
💡 If electrical signals travel toward an EKG lead they appear as positive deflections

Recall that the ST segment represents electroneutrality in the cardiac cycle, between depolarization and repolarization, w/ no voltage gradient.

That's why the ST and TP baseline segments are normally flat on EKG (aka isoelectric).
Read 11 tweets
Ever wondered why doctors and people with type 2 diabetes are getting so excited about low carbohydrate diets? 🤔

73 patients at my surgery have now reversed their type 2 diabetes 🙌

#medthread #tweetorial #medtwitter

Here's a tweetorial of how it's done👇
As Diabetes Lead GP at my surgery for 25 years I achieved little/no success with @PHE_uk recommended "Eatwell Plate"
One day @lowcarbGP shared some success he had with offering LCHF (low carb, healthy fat) eating to people with type 2 diabetes

Does it work?🤷‍♂️

How? 🤷‍♂️
Important to understand if there's > 1 teaspoon (5g) sugar/glucose in your blood then insulin PUSHES it into cells where it is deposited as FAT and TRIGLYCERIDE
Read 16 tweets

Ever wondered about the evidence base for longer [or shorter] GP consultation lengths and how they impact on healthcare outcomes?⏱️

The evidence is fascinating and well worth considering in relation to your own practice.💡

#medthread #tweetorial #medtwitter

First, lets take a look at average consultation lengths around the world.

⏱️ There is considerable variation internationally ranging from less than a minute in Bangladesh and Pakistan to 22.5 minutes in Sweden!

🌍Over half the worlds population have a consultation length less than 5 mins!
Read 19 tweets
1/ This is the 4th #tweetorial #MedThread on contrast nephropathy from my grand rounds. For more information take a look here:…
2/ The 1st #Tweetorial dealt with the lack of evidence tying contrast to AKI. The 2nd looked at the outcomes of patients who develop AKI after contrast. The 3rd looked at cholesterol emboli as an etiology of AKI after cath. Links to all the tweetorials are at the blog post above
3/ This #tweetorial is a response to the concern that “All of that epidemiology information showing contrast is okay is fine and well but I’d rather be safe than sorry so I will avoid contrast in my CKD patients anyways”
Read 8 tweets

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