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Will Preston @willpreston.bsky.social · 11/06/2026

75% of the patients met criteria for immune compromise based on the diagnosis of a solid malignancy… is it reasonable to extrapolate the finding to the much smaller number on chemo, chronic steroids and HIV/AIDS?

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Will Preston @willpreston.bsky.social · 21/05/2026

This is the smartest dog ever. She can solve complex equations but she chooses not to.

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Will Preston @willpreston.bsky.social · 19/05/2026

How did they treat typhoid fever then? Besides hydrotherapy (using cool water to lower the fever—which in case series appeared to lower mortality by 7-8%), 8 shots of good whiskey per day- less so is “hoisting the teetotaler by his own petard.” There’s otherwise instructions for good nursing care.

Alcohol is not necessary in all cases, but may be given when the weakness is marked, the fever high, and the pulse failing. In young healthy adults without nervous symptoms and without very high fever, it is not required; but when the heart-beat is feeble and the first sound becomes obscure, if there are a muttering delirium, subsultus tendinum, and a dry tongue, brandy or whisky should be freely given. In such a case from eight to twelve ounces of good whisky in the twenty-four hours is a moderate amount. It would be too much like hoisting the teetotaler with his own petard to attribute the high rate of mortality from Typhoid fever at the London Temperance Hospital — 15 to 16 per cent during the past twenty years— to failure to employ alcohol.

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Will Preston @willpreston.bsky.social · 19/05/2026

Also: stop calling it typho-malarial fever 😤 (this is at least the third time it’s come up in the first chapter)… sounds a bit like reading @pulmcrit.bsky.social commentary on the sepsis guidelines. Nor are all prolonged febrile illnesses in the pre-antibiotic era treated the same.

There is no such disease as typho-malarial fever—that is, a separate and distinct malady… there is now no excuse whatever for the continued use by practitioners of the term typho-malarial fever, and still less for the falsification of vital statistics by death certificates signed with this diagnosis. The principle is bad and the practice is worse, since it gives a false sense of security, and may prevent proper measures of prophylaxis.

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Will Preston @willpreston.bsky.social · 07/03/2026

You think he’s not alive? Look at how anxious he looks.

I googled furby and used the first image

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Will Preston @willpreston.bsky.social · 04/03/2026

Last year I got a MKSAP question wrong about PE management - vignette was a high risk patient likely needing intervention but without shock and I chose LMWH instead of UFH. I emailed the editor to complain and argue for my answer but they shut me down. Just want to say now completely vindicated.

Management diagram from new AHA/ACC PE guideline recommending LMWH for the situation in the post

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Will Preston @willpreston.bsky.social · 04/03/2026

True daily Ken, periorbital… WAIT😭

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Will Preston @willpreston.bsky.social · 23/10/2025

I hope this won’t affect the mural

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Will Preston @willpreston.bsky.social · 10/07/2025

Major innovation in medical education: the dyspnea pyramid is now the dyspnea rhombus

A diagnostic schema to help recall the causes of dyspnea arranged hierarchically by organ system (lung, heart, blood, acid/base) with another corner drawn on labeled ticagrelor

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Will Preston @willpreston.bsky.social · 14/06/2025

No, no. Wells is the scientist’s name, you’re referring to Wells’ monster. #emimcc

From MD calc: “The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with chest pain or dyspnea or to all patients with leg pain or swelling. This is the most common mistake made. Also, never never do the D-dimer first [before history and physical exam]. The monster in the box is that the D-dimer is done first and is positive (as it is for many patients with non-VTE conditions)”

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Will Preston @willpreston.bsky.social · 06/03/2025

Statistical significance aside, let's consider clinical significance. From VITAL: using events from the analysis excluding the first 2 yrs and the number at risk from the KMs: ARR would be 149/12,567 - 112/12,567 = 0.294% or 340 ppl needing to take vit D daily for 5 years to prevent 1 death.

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Will Preston @willpreston.bsky.social · 06/03/2025

An updated meta-analysis (pmc.ncbi.nlm.nih.gov/articles/PMC...) included this new RCT and showed no difference in cancer mortality. But with subgroup analyses showing possible decreased lung cancer mortality as well as a difference between daily and monthly dosing-- with daily vit d showing benefit

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Will Preston @willpreston.bsky.social · 06/03/2025

Forest plot from their MA pubmed.ncbi.nlm.nih.gov/31733345/ -- similarly shows no decreased incidence of cancer or CVD but with decreased relative risk for cancer mortality (13% RRR rather than 25% shown in the VITAL secondary analysis and cited in the new review). Another then published same year..

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Will Preston @willpreston.bsky.social · 28/02/2025

Great graphic in the NEJM case this week (7-2025) for pancytopenia. Posting so I can find it later.

Graphic organizer for pancytopenia: white cells only- autoimmune neutropenia, medications like antipsychotics, copper deficiency, duffy null-associated; RBC only- bleeding, vitamin b12/folate/iron, kidney dz, low testosterone, pure RBC aplasia, inflammation (increased hepcidin), hemolytic anemia, medications; PLT only- ITP, gestational, medications esp abx, liver dx; WBC/RBC- Evan's syndrome; WBC/PLT- Splenomegaly, Evan's syndrome; RBC/PLT- Thrombotic microangiopathy, Evan's syndrome; Pancytopenia- hematologic malignancy, aplastic anemia, hematinic deficiency, restrictive eating, alcohol, medication (i.e. chemo), infection (EBV, CMV), and myelophtisis

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Will Preston @willpreston.bsky.social · 06/01/2025

More on Temporal Artery US: Suggestive findings are halo sign (superficial thickening of arterial wall) and compression (normally TA fully compresses) pmc.ncbi.nlm.nih.gov/articles/PMC...

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Will Preston @willpreston.bsky.social · 17/11/2024

In figure 2 they compare LRs of ferritin in inflammatory disease (includes kidney dz, liver dz, infection, malignancy, etc) and 'mixed' aka less-inflammatory disease states. For the inflammatory conditions, ferritin is expected to be very elevated, so has a higher LR for IDA at any given value.

Figure 2 from article showing curves of how ferritin comparatively suggests IDA in inflammatory (solid - bottom curve) and mixed disease (dashed - upper curve)

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Will Preston @willpreston.bsky.social · 17/11/2024

Their Table 3 shows likelihood ratios for IDA across ranges of common test results. As you can (hopefully) see -- it's all about the ferritin! They found a ferritin of <15 ug/L had an LR of 51 for IDA which is essentially diagnostic. And importantly, even what labs call "normal" can suggest IDA.

Table 3 from Guyatt et al's Laboratory Diagnosis of Iron-deficiency Anemia: An Overview published in JGIM 1992.

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Will Preston @willpreston.bsky.social · 13/11/2024

Remarkably, these POCUS findings are somewhat similar to what McGee reports in Evidence Based Physical Diagnosis for POPE (AKA Plain Old Physical Exam) findings of neck vein assessment with respect to measuring CVP >8cm H2O (>10cm was used in the POCUS study).

Picture from a table form Evidence Based Physical Diagnosis 3rd Edition showing +LR 9.7 for CVP >8cm water and -LR 0.3.

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Will Preston @willpreston.bsky.social · 13/11/2024

The simplest method they describe is measuring jvp in a person seated upright at 90-degrees, placing the probe just above the clavicle, and assess as a binary: positive if the IJ is at least as wide as the CCA and not collapsing through respiratory cycle. Left would be positive, right negative:

Two panels showing POCUS images; the first showing a large black circle labeled IJV (internal jugular vein) which is larger than the black circle measured CCA (common cartoid artery). The second panel showing a collapsed IJV next to the CCA.

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Will Preston @willpreston.bsky.social · 13/11/2024

Here is the full table if interested, but I find the 2/5/10 - 15/30/45 paradigm the easiest to remember.

A table showing Likelihood Ratios between 0.1 and 10 in the left column and Approximate Change in Probability as a % in the right colum.

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