@chestvasu induced sputum following inhalation of 3% saline
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@PulmCrit
Author of the Internet Book of Critical Care ๐๏ธ Board certified in critical care, pulmonology, and neurocritical care ๐ค Zentensivist ๐งโโ๏ธ No COI ๐ฐ
University of Vermont ๐ Katฤฑlฤฑm Ekim 2012
539 Takip Edilen64.8K Takipรงiler
as a general rule, IGRA (interferon gamma release assay) should NOT be used as a test for active pulmonary TB
if you're worried about active pulmonary TB --> isolate & get induced sputa
yes, this is effort-intensive, but it's the correct way to do it
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Publishing zillions of papers isn't the flex everyone thinks it is
Above a certain publication frequency, hyperprolific authorship has a limited differential diagnosis:
๐ซคRepetitive articles ("salami publication")
๐ซคPutting your name to others' work (coauthor network)
๐ซคFraud
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@joelwiens couldn't agree more!
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once encountered similar situation with a patient who repeatedly presented with "hypertensive emergency" that was actually opioid withdrawal
"he's presenting again with another hypertensive emergency... history of multiple ICU admits... so we inserted an A-line and started... "
IMCrit@IM_Crit_
After a frantic ๐ from the floor, I accepted a transfer to the ICU yesterday. Young โ with "HTN emergency" (BP 220/120, restlessness) and abd pain (I saw in her chart that she had recurrent pancreatitis). I gave her 0.5 mg dilaudid and 20 mg labetalol and next BP was 150/80...
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@BradSpellberg @DrToddLee @BJegorovic @ABsteward lots of patient struggle with oral iron in terms of adherence/tolerance, absorption, and Fe loss in excess of intake.
not uncommon to see patients with super-low ferritin despite attempts at oral repletion
Fe deficit won't kill people but fixing it can make them feel better
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@PulmCrit @DrToddLee @BJegorovic @ABsteward Why do they need iv iron? They arenโt going to die of the iron deficiency. Plenty of time to correct that over months to come.
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@DrToddLee @BradSpellberg @BJegorovic @ABsteward here's the real clinical question IMHO:
patient is admitted with GI bleed and iron deficiency anemia
they also happen to have some an infection that is well-controlled & *not* a prominent problem
is it OK to give them IV iron?
I think so.
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@BradSpellberg @PulmCrit @BJegorovic @ABsteward I can't imagine the iron definitely NEEDS to be corrected during the acute infection. The observational data seems likely confounded by indication and immortal time.
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@BradSpellberg @BJegorovic @DrToddLee @ABsteward ~5% of human enzymes use an iron cofactor.
this implies that iron deficiency could have broad and unpredictable effects.
I don't think it's possible to predict a priori what effect iron deficiency will have on clinical infection.
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@BJegorovic @DrToddLee @ABsteward Biologically implausible--my Bayesian priors are low. Blocking iron acquisition is a highly effective means of killing microbes. Giving iron stimulates microbial growth. The reason we don't have a therapeutic based on blocking iron is that it has been hard to find a non toxic one
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๐๐ค๐จ๐ ๐๐๐ง๐ ๐๐จ ๐ retweetledi
"I am the son of a nurse that spent 50 years caring for other people, and I've spent decades trying to do justice to what she, and the rest of you, actually do."
"The Pitt" and "E.R." actor Noah Wyle led a rally pushing for bipartisan legislation for healthcare workers on Capitol Hill.
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I'll start- the neutrophil/lymphocyte ratio (NLR) substantially outperforms the WBC for detection of infection
using WBC as an indicator of infection made sense 50 years ago. we have better instruments & its time to move on from the WBC
more on NLR here: emcrit.org/pulmcrit/nlr/
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what is your best pearl, or most useful reference, about interpreting a complete blood count with differential?
The blood count is one of the most commonly ordered tests in clinical medicine, but its subtleties are woefully overlooked.
GIF
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IMHO, linezolid has replaced the awkward combination of {vanc + clinda} for toxin suppression & MRSA coverage in toxigenic skin/soft tissue infections
๐ฅeasy dosing
๐ฅno nephrotoxicity
๐ฅlittle resistance among GAS
so the final regimen is {linezolid + beta-lactam}
Kevin Mercer, PharmD, MPH@ohsnapimginger
Toxin suppression vs toxin suppression โ๏ธ Great #AEMP26 debate featuring @MGottliebMD and @wardamnPharmD on clindamycin vs linezolid for NSTI. Strong arguments, evolving evidence, and plenty for the #EMPharmD to think about at the bedside. #AEMPlify @SAEM_AEMP @SAEMonline
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@vitorborin_ @BradSpellberg @DrToddLee the best evidence & guidelines are with regard to CAUTI (see: #top" target="_blank" rel="nofollow noopener">emcrit.org/ibcc/cauti/#top)
observational studies show that patients with a foley will get colonized with bacteria but that doesnt correlate with clinical deterioration
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@PulmCrit @BradSpellberg @DrToddLee Interesting โ and genuine โ question: how would we study this?
In inception cohorts of febrile inpatients, a nontrivial proportion of fevers are usually attributed to urinary tract infections and respiratory infections.
That said, I agree with you that clinicians are probably falsely attributing fever to asymptomatic bacteriuria, which is highly prevalent in our patients.
How would you prove this hypothesis? Iโm not doubting it โ I agree. Iโm just trying to think through the study design.
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again for the people in the back:
urinary tract infection is an EXCEEDINGLY rare cause of nosocomial fever or sepsis.
most such โcasesโ are probably misdiagnoses.
cystitis happens, for sure, but isolated cystitis doesnโt cause fever or sepsis.
Brad Spellberg@BradSpellberg
@emedfocus @ABsteward I think youโve missed the point. Iโve been doing inpatient medicine for 27 years. Iโve never seen a hospital onset pyelonephritis. No one else i know has either. What youโre talking doesnโt happen. You are being fooled by urine and missing the actual source.
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@BawarKurdistani the annual risk of urosepsis is low (estimated maybe on the order of .001 per pt-year)
given the massive number of pt-years *outside* the hospital, eventually this occurs and people get urosepsis
the risk of randomly getting urosepsis while in the hospital is extremely low
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@PulmCrit What about non-nosocomial and all those urosepsis diagnoses?
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@namorrismd @NeurosurgeryCNS LP and EVD occurred up to 3 months apart? hard to take this too seriously. lots can occur in that time frame.
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Lumbar Puncture may overestimate ICP compared to parenchymal monitors in #IIH. @NeurosurgeryCNS journals.lww.com/neurosurgery/aโฆ
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@rmohty @ATSCritCare seriously, a limited number of academics have been promoting this for decades and clinicians have zero interest in it.
the data is weak and it would
be an antimicrobial stewardship catastrophe.
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@ATSCritCare become more familiar as in never use it? x.com/PulmCrit/statuโฆ
๐๐ค๐จ๐ ๐๐๐ง๐ ๐๐จ ๐@PulmCrit
new, larger RCT on selective decontamination of the digestive tract in NEJM shows that its ineffective SDD would eventually lead to drug-resistant organisms (beyond the timeframe of RCTs) SDD is an intellectual wasteland that ignores the whole field of antimicrobial stewardship
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NEW recommendation for Selective Decontamination of the Digestive tract (SDD) in mechanically ventilated patients, which all of us in the US will have to become more familiar with.
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USA MICU age scale:
18-30 YO = baby
30-50 YO = young
50-80 YO = average adult
80-100 YO = older adult
>100 YO = geriatric
Anil Makam@AnilMakam
We just need fewer guidelines Reserve standardizing care unless we know something helps Similarly, hospital medicine is geriatric care What geriatricians recommend for 65+ applies to most of my patients - remove lines, don't wake up unnecessarily, get out of bed, etc
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Frequentist statistics have limitations, but the limitations are well known & the rules of the road are generally fair
Itโs increasingly common for Bayesian statics go WAY off the rails due to excessively optimistic priors
Swapnil Hiremath @hswapnil.medsky.social@hswapnil
@brian_rifkin @Nephro_Sparks @NephRodby @kdjhaveri @javo_neyra @asnpublications Here it is @CristinaDeReins breaks down the polymyxin and Bayesian voodoo nephjc.com/news/2026/shorโฆ
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Good takedown of a dumb guideline.
Bottom line: Demanding a geriatrics consult for every elder ICU patient is both mathematically impossible (not enough geriatricians!) and unnecessary (critical care *IS* geriatric care). Focus on providing better care not calling more consults!
PulmCCM@PulmCCM
open.substack.com/pub/pulmccm/p/โฆ New Guideline on care for older adults in the ICU. Isn't that just "care in the ICU"?
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