Pullia

[Pullia @emedfocus]

@statnews Give me the differential diagnosis for why this is happening.

[Pullia @emedfocus]

I think endos hate T replacement because 1 Too many guys historically trying to get T to get big and ripped 2 Cultural bias, almost political, that testosterone associated with 'toxic masculinity' behaviors 3 Longstanding fear of cardiovascular and thrombotic risk, even though the TRAVERSE study debunked that

[Pullia @emedfocus]

@UsingLyft 5

[Pullia @emedfocus]

"every doctor is already secretly using chatGPT in the exam room. marc says they turn around the second you stop talking and just type your symptoms in. some of them are doing it while you're still sitting there. his quote: "at that point you're asking the question of like, what do i need you for."
😂😂😂

[Pullia @emedfocus]

Not saying it's a 'strong guideline,' but there was an appeal to the authority of experts so I cited it.

Having said that, there are studies that show patients with bacteremic UTIs often don't have urinary symptoms. Typically elderly population. The only reason that I engaged in this topic is that I see these cases fairly often where I work.

Do you have specific critiques of these studies?
https://t.co/BCHuDT6sek
https://t.co/mQ7YnKu2g5

[Pullia @emedfocus]

Draft reply:

The IDSA guidelines contradict what you are saying here, and make more sense and are more consistent with published studies.

Here's the main point: ascending UTI can cause fever and systemic symptoms without lower urinary tract symptoms. This is well established. When bacteriuria causes fever and concordant bacteremia, it's a UTI, not asymptomatic bacteriuria. The original post advising not to culture urines on febrile patients without urinary symptoms is not good advice.

Things I agree with: catheter associated bacteriuria or incidental non-catheter associated bacteriuria (in patients lacking local OR systemic symptoms) does not need to be treated or cultured.

[Pullia @emedfocus]

1. Sure it is possible that bacteremia causes bacteriuria in some cases but that does not exclude scenarios where bacteriuria causes bacteremia. Which in fact is more likely and evidence supports this.
2. Appeal to authority, weak argument. I have decades of acute care clinical practice, and I am pushing back on 'expert' opinions that don't make sense. (see 'Surviving Sepsis')
3. Look at IDSA guidelines: When urinary pathogens cause systemic symptoms, we get to call it a UTI, regardless of whether there are urinary symptoms. And good studies show this is common. Here is another one: https://t.co/G5SvWiWBMK
"The absence of local urinary tract symptoms in elderly patients with a bacteraemic urinary tract infection is less frequent but common in those mentally intact, and should not preclude the need for a urine culture or antibiotic therapy."

[Pullia @emedfocus]

@radiokeller @BradSpellberg @DrToddLee @ABsteward We start empirically and adjust prn when sensitivities come back, usually in 24 hrs or so.

[Pullia @emedfocus]

@BradSpellberg @DrToddLee @ABsteward Not true:
https://t.co/Nf5BBrIwf4
In bacteremic UTI: "Urinary tract symptoms and signs were absent at initial contact in 144 patients (50.5%; 95% CI 44.7-56.4%)."

[Pullia @emedfocus]

I work in the ED, not inpatient. But a frequent theme is a 60 plus yo M with chills/malaise/plusminus fever. No acute urinary symptoms. Culture informs antibiotic choice/adjustments.

I agree that if UA is negative culture becomes unnecessary.

Hard to imagine similar patient in hospital for some other reason couldn't also develop the same problem.

[Pullia @emedfocus]

@thejaewilliams Analogy is more similar to the draft. It's like if certain ethnic groups always got drafted higher than others despite lower 40 yard dash times, fewer 225 lb bench press reps and less productivity at the college level.

[Pullia @emedfocus]

@Angrydomo @BrandonLBradfor Those studies have been debunked.

[Pullia @emedfocus]

@drterrysimpson Admission to medical school is not easy. It can become impossible if the color of your skin is being held against you.

[Pullia @emedfocus]

@grok @Dogetothemoon @elonmusk @mattvanswol illegal?

[Pullia @emedfocus]

@EPotterMD '...where her mother says confirmed medical negligence and neglect cost her life.'

call me skeptical. until someone can provide more evidence this is hearsay.

[Pullia @emedfocus]

@Megankstack your reputation right now:

[Pullia @emedfocus]

@anurag_ce @RapidResponse47 @POTUS Trains that no one uses and cities full of empty buildings, disastrous command economy dependent on foreign investment that has now stopped.

[Pullia @emedfocus]

@jun_song unobtainium.

[Pullia @emedfocus]

@Don956746234971 @ConceptualJames Pallywood.