Discover and read the best of Twitter Threads about #twdfnr
Most recents (15)
First up, DON’T use Frank sign. The sign hypothesizes that a diagonal ear lobe crease signifies coronary artery disease. I’ve been meaning to post this since I saw it being promoted on Twitter. Here’s the problem #MedTwitter: 
As a diagnostic test, it is inaccurate with a +LR probably <2 and a -LR probably >0.5. These are woefully insufficient to change clinical management. The sign is very much associated with age… bit.ly/3SBuszj
And in cadaveric research is less specific than advanced age, so you might as well use that instead. bit.ly/3xTDDmO
1/ Do you prescribe Incentive Spirometry (IS) for postoperative patients?
Is the routine use of IS to prevent postoperative pulmonary complications (PPCs) a "Thing We Do For No Reason?"
Let's explore IS in the following #tweetorial!
#MedTwitter
Is the routine use of IS to prevent postoperative pulmonary complications (PPCs) a "Thing We Do For No Reason?"
Let's explore IS in the following #tweetorial!
#MedTwitter
2/ PPCs are extremely common and associated with a high rate of morbidity and mortality following surgery.
While no one agrees on which conditions we should include in PPCs, most agree that atelectasis (collapsed lung tissue) is the most common PPC.
While no one agrees on which conditions we should include in PPCs, most agree that atelectasis (collapsed lung tissue) is the most common PPC.
3/ Though it's common, the significance of postoperative atelectasis isn't always clear.
While there is no evidence to support the dogma that atelectasis causes early postoperative fever, atelectasis frequently accompanies more serious complications including pneumonia & death.
While there is no evidence to support the dogma that atelectasis causes early postoperative fever, atelectasis frequently accompanies more serious complications including pneumonia & death.
1/14
Rapid Response Series, #4: Altered Mental Status
Congrats to all the new interns who started this past week! 🥳 I saved a fun topic for this milestone—something all doctors will see regardless of specialty: encephalopathy
#MedTwitter #TipsForNewDocs
Rapid Response Series, #4: Altered Mental Status
Congrats to all the new interns who started this past week! 🥳 I saved a fun topic for this milestone—something all doctors will see regardless of specialty: encephalopathy
#MedTwitter #TipsForNewDocs
2/14
This one is hard to tackle because it runs the whole gamut of diagnoses, from benign things like sleep inertia 😴 to life threatening conditions like osmotic demyelination syndrome.
However, I’ll try to supply some frameworks I find to be helpful.
This one is hard to tackle because it runs the whole gamut of diagnoses, from benign things like sleep inertia 😴 to life threatening conditions like osmotic demyelination syndrome.
However, I’ll try to supply some frameworks I find to be helpful.
3/14
In medicine, pretest probability is always useful.🧮 But it’s especially useful for AMS.
What’s the most common cause of AMS in young individuals presenting to the ED?
In medicine, pretest probability is always useful.🧮 But it’s especially useful for AMS.
What’s the most common cause of AMS in young individuals presenting to the ED?
1/11 Congrats to those who matched! I tweeted about an inpatient pocket card set in 2020 and got great feedback. Here is the result of a big overhaul: bit.ly/pocketcardset
Let's review what's inside!
#MatchDay2021 #MedStudentTwitter #MedTwitter #TipsForNewDocs #FOAMed
Let's review what's inside!
#MatchDay2021 #MedStudentTwitter #MedTwitter #TipsForNewDocs #FOAMed
2/11 Many thanks to my colleagues @kelleychuang @FulchJen @SimonWuMD @TylerLarsenMD @MichaelAyoubMD @PamelaTsing for helping me create and refine this.
@dgsomucla @uclaimchiefs @UCLAAnes @michael_ong @DoctorNappyJ @LizzieAbyMD @ShreyaTrivediMD
@dgsomucla @uclaimchiefs @UCLAAnes @michael_ong @DoctorNappyJ @LizzieAbyMD @ShreyaTrivediMD
3/11 First up is a pre-rounding checklist. Be systematic and read all of the notes in your patient’s chart (interdisciplinary care is critical).
H/t @nickmmark for the idea to use a QR code to maintain an updated version! This QR code also has some additional resources.
H/t @nickmmark for the idea to use a QR code to maintain an updated version! This QR code also has some additional resources.
Today’s #BSTMode inspired by @JHospMedicine #TWDFNR was 🔥!! Our first ever @EmoryDeptofMed + @MSMEDU hybrid version—woot!!
Today’s BSTs
Nour B., Emory PGY3
Krystal M., MSM PGY2
Joey S., Emory PGY2
Joi H., MSM PGY2
4 awesome talks + Q&A—all in under an hour! Let’s go! 👉🏽
Today’s BSTs
Nour B., Emory PGY3
Krystal M., MSM PGY2
Joey S., Emory PGY2
Joi H., MSM PGY2
4 awesome talks + Q&A—all in under an hour! Let’s go! 👉🏽
2/
Dr. Krystal Mills of @MSMEDU taught us about trending ammonia levels in hepatic encephalopathy—don’t do it. Shout out to her coach Dr. @TracyVettese of @EmoryDeptofMed. Read this article if you haven’t! 👉🏽
Dr. Krystal Mills of @MSMEDU taught us about trending ammonia levels in hepatic encephalopathy—don’t do it. Shout out to her coach Dr. @TracyVettese of @EmoryDeptofMed. Read this article if you haven’t! 👉🏽
3/
We learned from @dr_jsharp, Emory IM PGY2, that we need to pump the brakes on reflexive antipyretics in patients with a fever. His coach, Dr. Benjamin Renelus, @MSMEDU faculty supported in style! Want to know more? Read this paper. So good! 👉🏽
We learned from @dr_jsharp, Emory IM PGY2, that we need to pump the brakes on reflexive antipyretics in patients with a fever. His coach, Dr. Benjamin Renelus, @MSMEDU faculty supported in style! Want to know more? Read this paper. So good! 👉🏽
I agree; there’s a theme there to be explored.
We have a tendency to overcorrect, to gravitate to extremes.
And to get overemotional or snarky when advocating for what we think are best clinical practices.
I’m guilty too. But I think there are downsides.
1/8
We have a tendency to overcorrect, to gravitate to extremes.
And to get overemotional or snarky when advocating for what we think are best clinical practices.
I’m guilty too. But I think there are downsides.
1/8
First, our own practice & quality of care suffer when we think in extremes and absolutes.
Second, we can communicate oversimplified or wrong messages to learners who don’t have the same contextual knowledge.
Some examples of such misunderstandings...
2/
Second, we can communicate oversimplified or wrong messages to learners who don’t have the same contextual knowledge.
Some examples of such misunderstandings...
2/
#NeverFOBT 😡, people say.
What about CRC screening?
What about this stool, which might be blood or food pigment? Or the self-evacuated black stool of a patient who’s on iron or pepto, and is tachy today?
I’d Guaiac that, and change management if overtly + vs -.
3/
What about CRC screening?
What about this stool, which might be blood or food pigment? Or the self-evacuated black stool of a patient who’s on iron or pepto, and is tachy today?
I’d Guaiac that, and change management if overtly + vs -.
3/
1/
Him: "I need to leave."
Me: "Can we talk about it more? I'm concerned that you aren't well enough to go yet."
*silence*
Me: "Sir?"
Him: "I hear you. But I need to leave."
Him: "I need to leave."
Me: "Can we talk about it more? I'm concerned that you aren't well enough to go yet."
*silence*
Me: "Sir?"
Him: "I hear you. But I need to leave."
2/
Me: "There's
some things happening with your body that could be life threatening and--"
Him: *interrupting me* "Listen. I know I need some more tests. And I know y'all think it would be best for me to stay."
*wipes face with his hand and sighs*
Him: "I get that."
Me: "There's
some things happening with your body that could be life threatening and--"
Him: *interrupting me* "Listen. I know I need some more tests. And I know y'all think it would be best for me to stay."
*wipes face with his hand and sighs*
Him: "I get that."
3/
Him: "But away from this hospital? I got a WHOLE LOT going on. And you know what? That shit is life threatening, too."
Me: *listening*
Him: "'Scuse my language."
Me: "It's ok."
He sighed again. Hard. Then he started looking around his bed.
Him: "I got to go, man."
Him: "But away from this hospital? I got a WHOLE LOT going on. And you know what? That shit is life threatening, too."
Me: *listening*
Him: "'Scuse my language."
Me: "It's ok."
He sighed again. Hard. Then he started looking around his bed.
Him: "I got to go, man."
1/10
Why is the routine use of neuroimaging for hospitalized patients with delirium a #TWDFNR?
This #tweetorial is a supplement to the review published in the July 2019 issue of the @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
Why is the routine use of neuroimaging for hospitalized patients with delirium a #TWDFNR?
This #tweetorial is a supplement to the review published in the July 2019 issue of the @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
2/
To understand why the routine use CT/MRI to evaluate delirium is a #TWDFNR, we must first recognize that many acute neurologic processes assessed with neuroimaging DO cause delirium.
Example:
💥13%-48% of patients with acute stroke have delirium💥
journals.sagepub.com/doi/10.1111/j.…
To understand why the routine use CT/MRI to evaluate delirium is a #TWDFNR, we must first recognize that many acute neurologic processes assessed with neuroimaging DO cause delirium.
Example:
💥13%-48% of patients with acute stroke have delirium💥
journals.sagepub.com/doi/10.1111/j.…
3/
Regarding neuroimaging in hospitalized patients with delirium, the authors of the #TWDFNR review cover four studies and note that the overall diagnostic yield is 2.7%-14.5%.
How do these values inform your interpretation of the utility of CT/MRI in this setting?
Regarding neuroimaging in hospitalized patients with delirium, the authors of the #TWDFNR review cover four studies and note that the overall diagnostic yield is 2.7%-14.5%.
How do these values inform your interpretation of the utility of CT/MRI in this setting?
1/9
Why is “HIT Testing in Low Probability Patients” a TWDFNR?
This tweetorial is a complement to the review published in the June 2019 issue of @JHospMedicine by authors Amanda Li, Lisa Hicks, and @efan75.
journalofhospitalmedicine.com/jhospmed/artic…
Why is “HIT Testing in Low Probability Patients” a TWDFNR?
This tweetorial is a complement to the review published in the June 2019 issue of @JHospMedicine by authors Amanda Li, Lisa Hicks, and @efan75.
journalofhospitalmedicine.com/jhospmed/artic…
2/
As the authors note, the ELISA test has a sensitivity >95% when the optical density threshold is low. The high sensitivity of the ELISA may make one inclined to use it liberally to evaluate for HIT.
ncbi.nlm.nih.gov/pubmed/26518436
As the authors note, the ELISA test has a sensitivity >95% when the optical density threshold is low. The high sensitivity of the ELISA may make one inclined to use it liberally to evaluate for HIT.
ncbi.nlm.nih.gov/pubmed/26518436
3/
But, there is another way one can effectively rule-out HIT: the 4Ts score.
A 2012 meta-analysis determined that the negative predictive value of a low probability 4Ts score was 99.8%. And, it didn't matter who "performed" the scoring.
ncbi.nlm.nih.gov/pubmed/22990018
But, there is another way one can effectively rule-out HIT: the 4Ts score.
A 2012 meta-analysis determined that the negative predictive value of a low probability 4Ts score was 99.8%. And, it didn't matter who "performed" the scoring.
ncbi.nlm.nih.gov/pubmed/22990018
I want to put a 🙌 out to #MedTwitter
I may not tweet a lot but I do follow and gain quite a bit so I want to share how it has changed the way I carry myself and provide care.
It’s a thread.
I may not tweet a lot but I do follow and gain quite a bit so I want to share how it has changed the way I carry myself and provide care.
It’s a thread.
2/
Patient asks the case manager when the doctor is going to see him
I spent 30 minutes updating him earlier that day 🤔
Pre-twitter: ok
Post-twitter: Sir, I’m in charge of your care, tell me a bit more about why you didn’t think I was your doctor.
#WomenInMedicine @AMarshallMD
Patient asks the case manager when the doctor is going to see him
I spent 30 minutes updating him earlier that day 🤔
Pre-twitter: ok
Post-twitter: Sir, I’m in charge of your care, tell me a bit more about why you didn’t think I was your doctor.
#WomenInMedicine @AMarshallMD
3/
Overhear the nurses talking about a patient who made a veiled but serious threat to them during the course of care.
Pre-twitter: I’m sorry.
Post-twitter: 😠 that’s not OK. How can I support you?
#MedTwitter #NurseTwitter
@BrowofJustice
Overhear the nurses talking about a patient who made a veiled but serious threat to them during the course of care.
Pre-twitter: I’m sorry.
Post-twitter: 😠 that’s not OK. How can I support you?
#MedTwitter #NurseTwitter
@BrowofJustice
1/
Why is "Routine Echocardiography in Hemodynamically Stable Patients with Acute Pulmonary Embolism" a #TWDFNR?
This question was addressed in this month's @JHospMedicine by @PaulBerglMD et al.
Here's a thread to complement their awesome review.
journalofhospitalmedicine.com/jhospmed/artic…
Why is "Routine Echocardiography in Hemodynamically Stable Patients with Acute Pulmonary Embolism" a #TWDFNR?
This question was addressed in this month's @JHospMedicine by @PaulBerglMD et al.
Here's a thread to complement their awesome review.
journalofhospitalmedicine.com/jhospmed/artic…
2/
Let's start with a case and question. The case is taken from the review by @PaulBerglMD et al. Review it and answer the question in tweet 3.
Let's start with a case and question. The case is taken from the review by @PaulBerglMD et al. Review it and answer the question in tweet 3.
3/
Would you order suggest that this patient with stable pulmonary embolism (PE) undergo echocardiography (echo)?
Would you order suggest that this patient with stable pulmonary embolism (PE) undergo echocardiography (echo)?
1/
Why is "Prescribing Docusate for Constipation in Hospitalized Adults" a #TWDFNR?
This thread is a complement to the recently published review of the same name, appearing in February 2019 issue of @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
Why is "Prescribing Docusate for Constipation in Hospitalized Adults" a #TWDFNR?
This thread is a complement to the recently published review of the same name, appearing in February 2019 issue of @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
2/
Before discussing the review by Robert Fakheri and Frank Volpicelli, let's gauge current practice.
How do you currently use docusate in hospitalized adults with constipation?
Before discussing the review by Robert Fakheri and Frank Volpicelli, let's gauge current practice.
How do you currently use docusate in hospitalized adults with constipation?
3/
If you use docusate, you're not alone.
One single-center study found that docusate accounted for 64% of laxative doses. The cost: $60,000/year.
ncbi.nlm.nih.gov/pubmed/27323235
If you use docusate, you're not alone.
One single-center study found that docusate accounted for 64% of laxative doses. The cost: $60,000/year.
ncbi.nlm.nih.gov/pubmed/27323235
1/
Why is the routine use of intermittent pneumatic compression for the prevention of venous thromboembolism in medical ward patients a #TWDFNR?
This thread is meant to complement the recently published article appearing in @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
Why is the routine use of intermittent pneumatic compression for the prevention of venous thromboembolism in medical ward patients a #TWDFNR?
This thread is meant to complement the recently published article appearing in @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
2/
First, a question: how often do you use intermittent pneumatic compression (IPC) for venous thromboembolism in medical ward patients?
First, a question: how often do you use intermittent pneumatic compression (IPC) for venous thromboembolism in medical ward patients?
3/
One reason why you might be inclined to use IPC: it has proven effectiveness in high-risk populations (e.g., surgical, trauma, stroke).
For pulmonary embolism:
RR 0.48, 95% CI [0.33-0.69]
NNT = 63
ncbi.nlm.nih.gov/pubmed/23852609
One reason why you might be inclined to use IPC: it has proven effectiveness in high-risk populations (e.g., surgical, trauma, stroke).
For pulmonary embolism:
RR 0.48, 95% CI [0.33-0.69]
NNT = 63
ncbi.nlm.nih.gov/pubmed/23852609
1/ Why is "Prealbumin Testing to Diagnose Malnutrition in the Hospitalized Patient" a #TWDFNR?
This #tweetorial is meant to complement the recent publication of the same name in @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
This #tweetorial is meant to complement the recent publication of the same name in @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
2/
Let’s start with two questions...
First: Do you use prealbumin as a “marker” of malnutrition?
Let’s start with two questions...
First: Do you use prealbumin as a “marker” of malnutrition?
3/
Second: How did prealbumin get its name?
[GE = gel electrophoresis]
Second: How did prealbumin get its name?
[GE = gel electrophoresis]
1/
Why is the acute treatment of "hypertensive urgency" a #TWDFNR?
This #tweetorial is meant to complement the recent publication: "Acute Treatment of Hypertensive Urgency" in @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
Why is the acute treatment of "hypertensive urgency" a #TWDFNR?
This #tweetorial is meant to complement the recent publication: "Acute Treatment of Hypertensive Urgency" in @JHospMedicine
journalofhospitalmedicine.com/jhospmed/artic…
2/
Case: A 71M with a history of HTN is hospitalized for cellulitis. On hospital day 2, the nurse pages you:
"Pt X with BP ____. Please advise". He has no symptoms or signs of end-organ damage.
What would be your threshold SBP to write for an as-needed anti-hypertensive?
Case: A 71M with a history of HTN is hospitalized for cellulitis. On hospital day 2, the nurse pages you:
"Pt X with BP ____. Please advise". He has no symptoms or signs of end-organ damage.
What would be your threshold SBP to write for an as-needed anti-hypertensive?
3/
The treatment of hypertensive urgency is based on an assumption: if we do not lower the blood pressure now, something bad (e.g. stroke, MI, aortic dissection) will occur in the next few hours.
We aren't giving IV hydralazine to prevent a stroke two years from now...
The treatment of hypertensive urgency is based on an assumption: if we do not lower the blood pressure now, something bad (e.g. stroke, MI, aortic dissection) will occur in the next few hours.
We aren't giving IV hydralazine to prevent a stroke two years from now...
