John Shrestha

wanderer || Medical Doctor ||

Rochester General Hospital PGY-1

[CardiovascularCorner @TrackYourHeart]

Excellent video explaining cardiac axis determination

[Bishwa Prakash शर्मा @bishwaprakash77]

सांसदबाट भुपु भएपछि
के जागीर खाने ?
सरकार भन्छ `न्यायाधीश´
सपना मल्ल रोज्छीन् `न्यायाधीश´ !!

(शभामुख उसै जागेकी हैनन् )

[Internal Medicine @pgMedicine]

New 2025 TB Guidelines: 🩺

Old: 6 months (2HRZE/4HR)

New: 4 months (2HPZM/2HPM)

Major Changes:
❌ Ethambutol REMOVED
✅ Moxifloxacin ADDED
🔄 Rifampicin ➡️ Rifapentine
⌛ Duration: 6mo ➡️ 4mo

[David Broder, DO @DavidBroderDO]

The frequency with which you poop could actively shape your colonic microbiome.

Nutrition may be the hottest thing in health right now; but poop is a solid number two.

https://t.co/N8eeJ4u1XF @MDLinx @drkeithsiau #health #GITwitter #medtwitter #microbiome

[John Shrestha @shresthajohn32]

@DolpaliAkhanda Hey boss, let me know if such families are there! We have a foundation in our grandparents memory with goal to support education wherever necessary.

[DocXus @docxusofficial]

A 2 year old in the US was diagnosed with a disease from the 1700s

He was brought to the ER because he stopped walking.

No trauma. No fall. He just slowly stopped bearing weight on his legs over 6 weeks until he was crawling instead of walking.

His gums were swollen and bleeding. He had a rash. Pinpoint bleeding under his skin. Pain in both legs. Decreased muscle tone.

He kept his legs in a frog leg position and screamed when anyone touched them.

The doctors suspected everything.

First visit: possible fracture. Orthopedics recommended repeat imaging. Four weeks later he was worse.

Second visit: concern for leukemia. Then concern for nonaccidental trauma. Child protective services was called.

Then the workup began

> CT scan of both legs. No fracture.
> MRI of head and spine. Normal.
> lumbar puncture to rule out Guillain Barre. Normal.
> inflammatory markers. Normal.
> muscle enzymes. Normal.
> heavy metal screening. Negative.
> vitamin D and B12. Normal.
> bone marrow biopsy to rule out cancer. Normal.
> electromyography. Normal.
> muscle biopsy. Normal.

Weeks of testing. Multiple hospital transfers. Invasive procedures on a toddler. His parents watched their child get poked and scanned and biopsied while nobody could tell them what was wrong.

Then someone asked the right question.

What does he eat?

Chocolate milk and graham crackers. That was his entire diet. His mother had mentioned he was a picky eater at the very first visit. Nobody followed up on it.

His vitamin C level came back at less than 0.1 mg per deciliter.

He had scurvy.

The same disease that wiped out entire ship crews during the Age of Exploration. The same disease the British Navy solved in 1795 by issuing lemon juice to sailors.

Scurvy impairs collagen production and compromises blood vessel integrity. That explains the bleeding gums. The rash. The periosteal elevation on MRI. The bone pain. The inability to walk.

Every single symptom pointed to one thing and it took months to get there.

He was started on vitamin C supplements. Within a week he was moving his legs again. At 4 months he was walking and his hemoglobin was normal.

The entire workup could have been avoided with one detailed dietary history at the first visit.

We have MRIs and bone marrow biopsies and genetic panels. But the most powerful diagnostic tool in medicine is still asking a parent what their child eats for dinner.

All that extensive workup could’ve been replaced by a 5 minute conversation about food.

[Eric Topol @EricTopol]

"The term [provider] should not be used to describe physicians, nor should physicians use it to describe themselves, their team members, or their trainees."
https://t.co/C1hEu3mUr2 @AnnalsofIM @ACPIMPhysicians

[DocXus @docxusofficial]

A rare case where a surgeon accidentally developed his patient’s cancer

Cancer is not considered contagious. If cancer cells from another person enter your body, your immune system is supposed to destroy them.

But in very rare situations, biology doesn’t follow the rules.

A 32-year-old man underwent emergency surgery for an aggressive soft-tissue cancer called malignant fibrous histiocytoma. Sadly, he died shortly after the operation due to complications.

During the surgery, the 53-year-old surgeon accidentally injured the palm of his left hand while placing a drain. The wound was small, immediately cleaned, and properly dressed. No one thought much of it.

Five months later, the surgeon noticed a hard lump growing at the exact spot where his hand had been injured. It slowly enlarged to about 3 cm, roughly the size of a large coin.

The lump was surgically removed.

The diagnosis was shocking.

It was malignant fibrous histiocytoma, the same rare cancer the patient had.

The surgeon was otherwise healthy. Tests showed no immune deficiency. So how could this happen?

The DNA answered the question

Pathologists compared both tumors under the microscope and found them to be identical in appearance. But the real proof came from DNA testing.

Using genetic markers and HLA typing (a way of identifying tissue origin), doctors showed that the tumor in the surgeon’s hand carried genetic material from the patient.

This meant only one thing:

👉 The cancer had been accidentally transplanted from patient to surgeon during surgery.

Cancer cells likely entered through the small hand injury and managed to survive long enough to form a tumor.

Fortunately, the tumor was completely removed.
At two-year follow-up, the surgeon was healthy, with no recurrence and no spread.

Why this case is so remarkable:

This case does not mean cancer spreads through touch or casual contact. It shows that direct implantation of living cancer cells, under very specific conditions, can rarely lead to tumor growth, even in a healthy person.

It’s a rare exception that reminds us:

- Cancer isn’t contagious, but biology has loopholes
- The immune system is powerful, not perfect
- Medicine still encounters situations that challenge long-held beliefs

[John Shrestha @shresthajohn32]

@Prof_NickTalley Thank you for an interesting read!
Never had ACNES as a differential in my mind before!!
While functional dyspepsia causes significant distress, coming up with an individualized plan is always need diligence!

[सुदीप खनिया @sudeepkhaniya]

कतै प्लाकार्ड बनेनन्‌। कुनै लेख लेखिएन। निकै थोरैका मन दुखे।

अरु बेला हल्ला गर्नेहरु पनि एक मजदुर कुटाईबाट मर्दा — लाशलाई चौरस्तामा जलाउँदा निकै थोरै मान्छे बोले।

हुँदा हुँदा थाहा भयो — माइतीघरको दुबो पनि पश्चिमतिर मात्रै फर्किएको रहेछ !

[Douglas G. Adler MD, FASGE, FACG, AGAF @DouglasAdlerMD]

Nice video of part of the pyloromyotomy during a recent GPOEM showing a layered approach to cutting a thick pyloric muscle. #gastroparesis #gpoem @Stentingwoman @DavidDiehlMD @NEndoscopy @EndoscopyOthman

[Eric Daugherty @EricLDaugh]

🚨 BREAKING: North Carolina members of Congress are pushing to REMOVE FROM OFFICE Judge Teresa Stokes, who was behind the RELEASE of the murderer of Iryna Zarutska.

This person has no business being in any position of power ever again.

Hold her accountable.

[Nick Mark MD @nickmmark]

It's that wonderful time of year when new residents are joining the ICU team!

Here are a few of my favorite @CritCareTime infographics to help you understand key concepts:
⚡️Undifferentiated shock
💉 Vasopressors
😮‍💨 The physiologically difficult airway &
🧪 Metabolic acidosis

[Ed Livingston @ehlJAMA]

NO ASSOCIATION BETWEEN PREPROCEDURAL FASTING AND WITNESSED PULMONARY ASPIRATION
A SYSTEMATIC REVIEW AND META-ANALYSIS

I want to bring to everyone's attention the publication of an article we have been working on for some time.

Ever been annoyed by having cases cancelled because a patient ate recently? I had this happen a couple of years ago. This motivated me to look at the preoperative fasting literature.

I was surprised to learn how little actual evidence there is to support fasting policies.

In our recent publication we point out that 1) aspiration rates are no different now than they were before fasting was imposed before administering anesthesia 2) The studies used in fasting research use surrogate outcomes that have never been shown to be relevant to human aspiration events.

See the article published in Surgery (@SurgJournal) here:

https://t.co/KzdmhSQ2UM

There is a pressing need to rethink preoperative fasting policies. New studies are needed that employ proper endpoints to provide guidance for how long patients really need to fast. My guess is, not very long.

[Ross Prager @ross_prager]

(2/5) Likely cardiogenic shock with ECG changes, newly reduced EF, and hypoperfusion?

Don't miss septic shock with cardiomyopathy. Most cases of shock in the ICU are septic. Default for shock patients should be antibiotics initially with rapid de-escalation in the coming hours/days as the clinical course becomes more clear.

[John Shrestha @shresthajohn32]

@theduskdoc Congratulations sirrr

[Hosun Chung @hosun_chung]

4. The Order Algorithm

"Clean your room" became Peterson's most famous phrase.

Not because it's profound. Because it's true.

Before you try to change the world, prove you can create order in your immediate environment.

Start small. Start now. Do this:

[John Shrestha @shresthajohn32]

@ToshimaKarkiDr All you do is cheap publicity stunts.

[John Shrestha @shresthajohn32]

@SumanaShrestha

[Doctorstory Nepal @DocstoryNepal]

महाराजगन्ज नर्सिङ क्याम्पसमा शैक्षिक वर्ष 2080/81 को BMS कार्यक्रमका लागि भर्ना भएका विद्यार्थीहरुको पाठ्यक्रम एक बर्ष बित्न लाग्दा पनि उपलब्ध छैन। विद्यार्थीहरुले बुझ्दै जाँदा BMS भन्ने कार्यक्रम संचालनको स्वीकृति विश्वविद्यालयमा पारित भएकै छैन।क्याम्पसले Bsc midwifery को

[John Shrestha @shresthajohn32]

@Doctorhouse90Dr Valentine day ko din dai?