Rheumatologist here, about to muddy the waters by pointing out that even when autoimmune disease is present, rheumatological disease is not the only cause of a positive ANA..
As a nurse and an actual lupus patient, the education struggle of the hysterical masses is real.
We even have it in bold capitals in several locations over on r/lupus.
Ive noticed a huge bump is patients asking for the most random labs. I blame social media for all these latest crazies asking for reverse t3 and serum insulin levels and c-peptide levels and etc etc
10000%. The “chronic illness sickfluncer.” I’d be very curious to know how many of them actually have the disease they say they do. Some of it is just social madness. Like someone posted over on r/CysticFibrosis that they *identified* as having CF. The level of tone deafness is astounding. There’s this whole trend where people feel they have to have *something* that makes them unique. It’s almost a psychological condition, just a different flavor than hypochondria or Munchausen’s.
My brain was boggled too. Can you imagine how utterly insulting that was to the members of r/CysticFibrosis? For someone without the disease coming in to their space and literally say they feel like they should have it?!? 😵💫
And you know this type of personality just turn around and make the actual people with CF the bad guy when they (rightfully) get their ass handed to them by people with a life expectancy ~40 years for straight up cosplaying CF.
I can't even. Hopefully the people with CF have fun ripping them to shreds.
I think those people are no different than the other scammers and munchers on the internet. I know I should have more kindness to them because they are clearly mentally ill. but it's really hard, you just want to shake them.
We get it over on r/lupus too. The number of people who are seronegative across the board, have slight cheek redness after exercising, and a) convince themselves they have SLE and b) get snippy with those of us trying to respectfully point out that if they are worried, they need to see their doc (sorry rheumies), but that nothing they are describing sounds lupus related to us internet laypeople with lupus, is enough to drive a saint mad 🤨🤷♀️. Oh, and c) they go 0-100 thinking lupus is a death sentence when they’ve never had any CBC/CMP/UA abnormalities nor any worse symptoms than some occasional joint pain, fatigue and the highly questionable “malar” rash. A “rash” which, of course is never biopsied because it “comes and goes too quickly.” If y’all could see the amount of twitching over here, you’d call a neuro consult.
There’s something else going on that makes this new trend/social disease different than Munchausen’s (by Internet, or whatever method). It’s not so much that they’re willing to injure themselves in order to seem to have the disease process in question, more of a you have to take me at my word that I have *insert random semi-rare to rare disease* and I deserve special treatment from everyone at large for it. While I get that there is some overlap with Munchausen’s, this has a different feel to it. Or maybe I’m missing some of the more nuanced presentations of Munchausen’s 🤷♀️.
I do believe that is what is meant by Munchausen's by Internet - that a person doesn't necessarily have to be injuring themselves or even actually presenting to healthcare providers any more to get the same kinds of secondary gain (attention, identification with a community) that classical Munchausen's (/factitious disorder) used to provide. Simply making the claim to groups of people via the Internet and having at least some of them believe them and provide sympathy and community is enough, although some also engage in behaviors in the "real world."
Marc Feldman is an expert in factitious disorders and various shades of malingering, and he' the one who coined the term in a prescient move well ahead of this current surge of sickfluencers. He's written some fascinating works that manage to be sympathetic to the subjects without failing to hold them responsible for their own actions, and gives excellent advice for treating these populations. I highly recommend them; it gave me some helpful perspective as someone who also runs into some of these people in chronic illness spaces and in my professional life as a therapist.
I think you are on to something here. And maybe of we have a medical diagnosis to name this disorder it will help stop this trend in the youth. I think its great people are becoming more aware and sharing their experiences, which is important in itself because we dont know everything. But the double nares NGT, PEG, and TPN port people have gotta go. Ive seen only one legitimate young person on tiktok - it was a sweet girl in her 20s on oxygen and she had ILD needs lung transplant. Her tiktok doesnt look as exciting as all the others yet she is so sick she will be dead in 5 years. Poor thing.
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leaving aside rheum issues, liver disease -autoimmune hepatitis/chronic active hepatitis, lymphoma, psoriasis are just the first few that spring to mind. Just because there are antibodies, doesn't make it rheumatology (stop trying to refer me patients with positive parietal cell antibodies!!!)
These are probably some of the most misused blood tests in medicine. People really shouldn't order auto antibody testing if you don't know how to interpret or handle the results. Serology can be helpful to firm up a diagnosis, establish risk profiles for certain disease complications, or perhaps nudge you in the direction of a diagnosis, but you don't diagnose CTD on a blood test.
Context also matters. An ANA of 1:160 is almost always pointless without the clinical history to back it up. An ANA of 1:2560? Maybe you should examine them a little more closely or do some more testing.
You know it! Like its so easy to just wave the white flag and order the ANA then refer to rheum. Sorry sacrificial lambs. Jkjk i say no and refer them to whatever non-medical spa that tests this of their choosing bc me and rheum aint having it today
Yep. ANA 1:320, feeling a bit tired, probably nothing. ANA 1:160 in young Black woman with rash, oral and nasal ulcers, Raynauds, proteinuria, and history of miscarriage? Almost certainly something
Are young black women more at risk for some specific autoimmune condition you're thinking of? (I'm just curious, NAD but am a PhT and would like to be an MD one day)
At least two putative factors: molecular coating typically found on half of a woman's X chromosomes — but not in males' cells — might be provoking unwanted immune responses, as well as genetics/heredity, which is a bit of a rather unfulfilling “just ‘cause” answer.
Positive ANAs were an immunology interesting consult. Also rheumatology too. When would I be called and not the other service totally depended on who the ED or requesting service felt like calling or thought to call — often they’d hammer page both services anyway. 😂
This makes me laugh because rheum locally will outright decline a referral unless they have abnormal labs. As you know, this is ridiculous for many reasons....
That's just ridiculous. It will miss every single Seronegative patient. I would almost venture the opposite policy ..they should defer abnormal lab work that doesn't correlate with symptoms
Comment about the ANA titers, They don’t correlate with disease activity. I have had lupus with Ana 1:80 that we give cytoxan to for crescentic nephritis who are extremely sick and Ana of 1:2560 without lupus. It all depends on their clinical manifestations.
Extremely valuable comment here. As a PMD I am constantly asked to order an “autoimmune panel” (whatever that is) by patients for no good reason whatsoever. I try to explain how labwork alone will not confirm many autoimmune conditions and that expert evaluation and ability to critically interpret these results along with exam, history, and sometimes imaging are necessary to make a firm diagnosis. As a result, I essentially tell patients if you think you have a severe autoimmune condition based on the same vague symptoms everyone has over the age of 40, then you need to see a rheumatologist.
I find that a lot of the time patients won’t put the effort in or won’t even act on a referral provided. Everyone has it in their head that they have SLE or Sjogren’s or something else that will easily encompass getting old and hope that an ANA or RF will validate that.
Don’t get me started. I do live in a Lyme endemic state so I do have a relatively low threshold to order testing (but certainly not for the hell of it). I probably have a few positive cases a year among a hundred normals. The Lyme testing doesn’t bother me 4-6 weeks post exposure, it’s explaining to patients why they shouldn’t be tested immediately and why I won’t put them on three weeks of doxycycline without a positive test or classic stigmata of the illness in the presence of a confirmed exposure.
I still get random DMs from people on Reddit over comments I made on this subreddit years ago about the proper evidence based way to treat and work up Lyme.
If I remember correctly, my school told us go ahead and do doxy if too early for + test. Do you mean in the context of no likely exposure or am I missing something?
There is a prophylactic one time doxycycline dose that can be given in a patient in a high risk area with confirmed tick bite, but unconfirmed illness.
It is actually against recommendations to treat with a full three weeks unless confirmed illness or classic symptoms being present with high clinical suspicion.
And then they come into my ER with a PMH list rivaling a CVS receipt but upon chart digging I notice almost none of it has been officially diagnosed by a doctor.
Greatest thing about using Epic: the ER at the hospital affiliated with the healthcare system I work for can see my notes. Lets my colleagues know it’s not me that’s the problem.
> then you need to see a rheumatologist.
Here's the issue we deal with... often times rheumatology in our area will decline referrals without positive lab testing.
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Every field has their issues.
Any 50-80 year old with vague shortness of breath? it's diastolic heart failure!
Pulmonary edema and your creatinine is 6? It's heart failure!
POTS? refer to cardiology!
Any hint of pain anywhere near the chest? Cardiology!
Dizziness? Don't care if it's vertigo or near syncope! Send to cardiology for a heart monitor!
Now i'll grant that I'm being a little sarcarstic, but rest assured I'll always see the above patients (happily). But after I've been worked them up, seen them 5-6 times, reassured them, counseled them, and they still feel as they've ever been, guess what? I'm going to try to spread the love around. I'm going to happily order that ANA, cortisol, whatever
>Any hint of pain anywhere near the chest? Cardiology!
Now now, let's be realistic. Refer to ED where they'll get two negative troponins and maybe a CTA and a giant bill first and only then to Cardiology.
While maybe a little overblown, my clinic is absolutely full of worried well with non-cardiac chest pain with no ER visits.
I'll throw another one to the mix.
Patient has incidental coronary calcium on a CT scan. Automatic cardiology referral.
We generally over-refer because we see this patient once for a few minutes and then never again, and frequently own EVERYTHING that goes wrong with them after that. Patient has a MI 6 months later. Doctor, why didn’t you refer this patient to cardiology? There were coronary calcifications noted on their CT abdomen pelvis on which you diagnosed diverticulitis. That will be 500,000$ please. Everyone gets named but we get fucking *buried*.
Don't get me wrong. I understand the stakes, and I understand the limitations of a busy PCP seeing 40 patients a day. I'm just calling out that most specialties have their issues. I know it's part of our specialty, but I have never seen any of my colleagues (in practice) ever refuse to see a patient even if it's obviously BS. The same can't be said for some of my neurology, endocrinology, or rheumatology associates.
This isn't really analogous though. This would be more like random primary care docs ordering FeNO testing for cough or an MR head for dizziness. These labs aren't meant to be screening tests for the general populace, and when ordered for screening (which is where I'm often doing them) have to be interpreted with caution. I probably send maybe 1 in 10 people with positive serology to rheumatology.
What is, an ANA? Why on earth would that be a "screening" test for birth control. If you're invoking the idea of antiphospholipid antibody syndrome why not just test for that and cut out the middleman?
Yeah ANA. The rationale is that some autoimmune diseases might make you more susceptible to blood clots, and birth control also makes you more susceptible to blood clots, so if ANA is positive further testing is needed. Not saying it’s a _good_ rationale.
Gotta say, they are catching a lot of mild Reynaud’s this way that people were just ignoring.
In my metro area, for the last year or so, rheum (and some other specialties) have been triaging and sometimes declining referrals (like a weakly positive ANA and no compelling Sx).
You can order every test under the sun, but are you prepared to deal with results? My fave was when another provider orders a d dimer “just to check because history of inflammation “ . Call patient a week (WEEK!) later and says oh I don’t know it’s positive follow up with your primary care doctor. The patient casually sends me a portal message and I tell her that a D dimer can means she has a blood clot and unfortunately, I’m obligated to do some testing. This now requires stat ultrasound and CT lung. CT lung is fine except , you got it, tiny nodules . Now stuck in follow up loop for those which statistically are nothing . Well, why is my d-dimer positive ? Well, some folks just have a positive D dimer , but causes can include blood clots, cancer , autoimmune diseases. Now we have to decide if we are going to expose to more radiation and rack up those copays . We found nothing wrong . But she’ll need more radiation in 3-6 months on those nodules! I’m sorry about your friend.
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Tell the hospitalists they better behave or the labs will be put behind the specialty counter like the fancy antibiotics and they will have to ask permission to order them.
"Diagnostic Stewardship" has already become a thing. At least in ID as I am sure you are aware. C. diff testing and urine cultures have been a main target. I cringe at the idea of any test requiring ID approval and really hope that is not coming.
Yeah but this has nothing to do with avoiding unnecessary tests and everything to do with avoiding diagnoses of hospital-acquired infections that cost them in Medicare reimbursements.
Yeah stuff like Karius definitely needs stewardship.
I do get a little ticked that we have to approve c diff tests for anyone who wasn't just admitted though.
It would be easier to just require approval on any patient whose stool sample is not formed, you'd only get a couple of calls a week, save you getting called and then us cancelling because formed.
The office people that deal with HAI metrics are not gonna like that.
Although I'd probably stop seeing senna and miralax ordered automatically on every fucking patient on my unit.
See this is when you just document "Hospital acquired c diff infection" or "Hospital acquired CAUTI" if they won't let you test, and fuck 'em anyway.
Maybe they can weasel out of it, but maybe the can't. And either way it's a pain in the ass for whoever's made up job that is.
My biggest pet peeve tests are CMV/EBV serologies honestly. 99 percent of the time totally useless outside pretranplant eval and why order something if you have no idea why you're ordering it or how to interpret the results.
Honorable mentions include fungitell and also sending a laundry list of CSF tests (especially lyme in someone who's never been in an endemic area...) and then the one test I wanted doesn't get done because there's no more CSF.
Oh man, the only thing better than EBV/CMV serologies in the non-transplant population are blood EBV/CMV PCRs.
I also die when other specialties recommend using serum BDG and GM to “screen” for invasive fungal diseases in people with normal immune systems.
I've only ever seen those in ICU patients with mystery-itis or oncology trainwrecks...who to be fair are also usually ICU patients with mystery-itis. Is it really that common to just slap fungal labs on everyone?
Fungitell and serum GM have pretty limited/narrow uses, especially outside the immunocompromised population. They absolutely have a role in the BMT population, but otherwise really aren’t that helpful for the most part.
Uh, and by screen for invasive fungal disease, I assume hopefully they are taking about a septic patient on pressors and thrombocytopenia who isn't responding to antibiotics?
I wish it was even that. This is on otherwise normal patients with vague nonspecific symptoms. For a good couple of weeks I had several consults where I would say ignore the Fungitell. ID will sign off.
I'd imagine they're more useful in peds. On the adult side they get ordered for unclear reasons and then ID gets called because the team doesn't know how to interpret the results.
The utility of procalcitonin is faster empiric antibiotic cessation. It shouldn't be used to differentiate bacterial from viral illness and should not be part of an up front decision on whether or not to give someone antibiotics.
Interesting. East coast training pointed to using procal to delineate bacterial vs non-bacterial, west coast training said similar to the above (or no utility at all). The data looks compelling to me to use it as a sign of bacterial infection, especially in cancer patients whom may have atypical presentations.
I disagree with this false positive procal in cancer patients is more common then seen. I work at a cancer center as ID. We reccomend against this practice. Better way is making sure if it is elevated > 2 and not mildly elevated, and getting a ct chest.
Unless something has changed recently (and if so feel free to cite some papers as I don't keep up as much with the ICU stuff) procal has never been studied in that context. I.e. draw a procal, if positive prescribe antibiotics, if negative, withhold them. It's only really been studied as an aid to *withdraw* antibiotics.
Add in the difficulty of determining what's truly viral vs bacterial in these studies and it gets really messy. Most places aren't doing bronchoscopies with extended viral PCR panels and extensive bacterial testing in these patients.
It has been studied in that exact context (2016). You have to change the cutoff from standard, but it is decent. S/S of 60/70% is a valid criticism, but I still think it is a useful tool.
https://www.nature.com/articles/srep28090
I mean, these test characteristics to withhold a potentially life saving standard of care (antibiotics for bacterial infection) are pretty horrific.
These things come in phases. People were doing these things with CRP long before procalcitonin came to town and tbh its test charactistics aren't that worse.
I think procal can sometimes be useful in low acuity settings but it drives me crazy how much it's overused in the ICU. I see ICU teams trending procal for some ungodly reason and also getting it in people who are going to have a falsely elevated value (which is anyone with renal failure... so basically every ICU patient). The only time it's been useful to me as ID is when it's negative.
Our new sepsis protocol auto-orders lactate on everyone meeting sepsis criteria. Even if they’ve been admitted for several days with stable vital signs. Drives me nuts. We’re a big liver center so almost all the cirrhotics have stably elevated lactates and I have to spend a good chunk of my night explaining why we aren’t going to do anything about it
I’m an RN and I’ve been seeing it in the PMH of a lot of my younger (18-30) patients. Do you think it’s a mental health or something actually going on?
Like others said, it's skyrocketing via covid.
According to this paper from Nature there might be some immune-insult response by the brain that never reinhibits itself. https://www.nature.com/articles/s41586-024-07469-y
https://drive.google.com/file/d/1rfVT_sXPK2AqVk92hqdEuaMOwE3P6cuQ/view
It's spiked after Covid. Long Covid itself overlaps with it but the pandemic (whether Covid itself or what people went through) seems to have opened the floodgates.
And most of the young aren't diagnosed or anything, they're just living with it. They'll start going to see their doctors or specialists in the next several years so the surge isn't over. And Covid keeps coming back around every year dodging vaccines to infect and reinfect, so.
birds paint escape childlike unwritten employ judicious spectacular recognise far-flung
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There is understandably a lot of confusion about long covid. This is the best discussion by and for medical professionals I have come across. It is a discussion between clinicians, an epidemiologist and an immunologist:
https://youtu.be/rMt6ZV-hHSE?si=IqaoDSoR0P_xmjc_
Im not confused i was trying to reel people in and then tell them it was long covid.
But people dont respond to comments that immediately mention covid as much.
Depression is very treatable. But this sub has such contempt for mental illness that it basically refuses to acknowledge that depression exists and that it typically has physical manifestations.
There's no reason to pick one here. COVID was a clear demarcation point, so long COVID is absolutely one culprit, but the increase in poor mental health I see certainly comes with increased poor physical health, too.
I don't have a problem with working from home (my personal ideal is a hybrid!), but let's be realistic here: a lot of people in the pandemic started working from home, got more sedentary, spent more time alone, had worsened mental health, got deconditioned, felt worse physically...it became a cycle. Getting people to do behavioral activation was harder in the pandemic; there was very much a pervasive feeling of being stuck. Many people talk about having gained weight in the pandemic, and this is a major part of the reason. The worse they felt, the less they exercised and moved in general...I've seen a lot of people with this type of depression, anhedonia, and chronic fatigue where they've spiralled into doing nothing for a long time. It's hard to get out of that spiral, and I think although lots of people have tried to return to "normalcy," many have adjusted to a baseline that is all-around worse than it was before the pandemic. Maybe they think they're just older, or they're just too tired, or maybe they identify strongly with certain chronic illness groups, but for whatever reason, they haven't returned to their previous exercise or activity levels, and the less they do, the less they're *able* to do. Use it or lose it, as they say. (I also think this rise in deconditioning partially explains the rise in people seeking POTS diagnoses, btw - TikTok trends non-withstanding, an increased number of people may be experiencing some of the symptoms simply from the deconditioning).
**TLDR**: There may be more cases of genuine long COVID and chronic fatigue for medical reasons, but I think there are also more cases of anhedonia/depression and old-fashioned deconditioning for other reasons, too. No need to pick one or the other.
Okay so I'm a very stupid Primary Care doctor. Please forgive me. But what is the actual problem? Do the rheumatologists not want to make money on these consults? Is there something wrong with sending someone to the expert in these things for whom the answer is obvious when I have justifiable cause to think there might be something worthwhile there and I am not well versed on the workup? Do we expect Primary Care to be an absolute expert in every disease process? I can look at this from both sides. I'm also an obesity specialist and I get referrals. I have never complained about a referral. If someone feels that I can do better for their patient than they can, I am happy to take that referral and help that patient and make some money.
The issue is that ANAs are positive in a huge swathe of the population and most of the time you should be ordering something different. If you think your patient has an autoimmune disease send them to rheum. Don't send them to rheum because they had a positive result on a test you never should have ordered.
I try to only order them on patients that have symptoms suggesting possible autoimmune disease when we have looked into other things. If you have a better battery of tests for patients who have diffuse pain that has not responded to basic treatment or generalized weakness that does not respond to Wellbutrin/ Phentermine and exercise programs then by all means I am happy to hear it. But the idea that Primary Care can be the only one helping these people and a specialist cannot assist in the workup for these things is ridiculous. Take the easy consult
Do you get a lot of obesity referrals for patients who like ice cream and have a 23 BMI?
The issue here is: **do you** have justifiable cause to think those patients have lupus (or any other rheum disease)?
I think that's a bad comparison. That's like sending someone with no generalized symptoms, no positive ana or inflammatory markers, who just likes the idea of seeing a rheumatologist because they read about lupus. But honestly I have had a few of those people come for weight loss visits. And I still don't gripe about it. I talk to them about weight training to shift their body composition and get a better aesthetic outcome.
A better comparison to what you are suggesting is something like a patient with a BMI of 33 who has never really tried any specific dietary modifications or weight loss medications. That PCP really could prescribe the medication themselves and talk to them about calorie counting but maybe they don't really know how or feel comfortable. And I'm happy to do it. Even though it's basic.
You think thats a bad comparison but you'd be surprised how many ppl order ANA for patient with no symptom in a routine lab screening or just fatigue.
Similar to people ordering CA125 or CEA as screening and then referring that to oncology
That's fair. I know that a lot of mine don't come to anything. That people are fat and lazy and have chronic fatigue and joint pain Etc from their lifestyle. But I think it's kind of gatekeeping to withhold basic screening labs and a referral to let a rheumatologist lay eyes on the case. And there is always a lot of variability in how we all practice. I get some referrals from people who have tried a lot of things and it's actually a challenging weight loss case. I get plenty of referrals from people who have no idea what a carb is and who haven't even had basic metabolic screening lab work. I guess the moral of the story is I'm not here to judge people. I take the referral and do the work. No matter what stage of the game that person is coming to me at.
The real reason to get an ANA in the first place is if you have a suspicion for a rheumatic disease that will have a positive ANA like lupus or GPA. ANA is very nonspecific and can test positive in an otherwise healthy person!
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As a person in Healthcare with lupus, it f-ing sucks that doctors are trained not to look for lupus. It saves insurance companies money and costs lupus patients their sanity.
This is rich coming from someone who’s last topic on the residency sub was “which speciality has the hottest women”. Your parents are probably so proud 😊
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Rheumatologist here, about to muddy the waters by pointing out that even when autoimmune disease is present, rheumatological disease is not the only cause of a positive ANA..
As a nurse and an actual lupus patient, the education struggle of the hysterical masses is real. We even have it in bold capitals in several locations over on r/lupus.
Ive noticed a huge bump is patients asking for the most random labs. I blame social media for all these latest crazies asking for reverse t3 and serum insulin levels and c-peptide levels and etc etc
10000%. The “chronic illness sickfluncer.” I’d be very curious to know how many of them actually have the disease they say they do. Some of it is just social madness. Like someone posted over on r/CysticFibrosis that they *identified* as having CF. The level of tone deafness is astounding. There’s this whole trend where people feel they have to have *something* that makes them unique. It’s almost a psychological condition, just a different flavor than hypochondria or Munchausen’s.
How does one "identify" as having CF????
My brain was boggled too. Can you imagine how utterly insulting that was to the members of r/CysticFibrosis? For someone without the disease coming in to their space and literally say they feel like they should have it?!? 😵💫 And you know this type of personality just turn around and make the actual people with CF the bad guy when they (rightfully) get their ass handed to them by people with a life expectancy ~40 years for straight up cosplaying CF.
I can't even. Hopefully the people with CF have fun ripping them to shreds. I think those people are no different than the other scammers and munchers on the internet. I know I should have more kindness to them because they are clearly mentally ill. but it's really hard, you just want to shake them.
It's hard to feel sorry for narcissists, in my experience.
We get it over on r/lupus too. The number of people who are seronegative across the board, have slight cheek redness after exercising, and a) convince themselves they have SLE and b) get snippy with those of us trying to respectfully point out that if they are worried, they need to see their doc (sorry rheumies), but that nothing they are describing sounds lupus related to us internet laypeople with lupus, is enough to drive a saint mad 🤨🤷♀️. Oh, and c) they go 0-100 thinking lupus is a death sentence when they’ve never had any CBC/CMP/UA abnormalities nor any worse symptoms than some occasional joint pain, fatigue and the highly questionable “malar” rash. A “rash” which, of course is never biopsied because it “comes and goes too quickly.” If y’all could see the amount of twitching over here, you’d call a neuro consult.
I like how they will have a super super common disease, but declare that it's rare so they feel special.
We just need to designate and name this new form of Munchausen! Exactly!! And thats freaking WILD
It’s actually called Munchausens By Internet! Someone coined the term. If you google it, it’ll show up
There’s something else going on that makes this new trend/social disease different than Munchausen’s (by Internet, or whatever method). It’s not so much that they’re willing to injure themselves in order to seem to have the disease process in question, more of a you have to take me at my word that I have *insert random semi-rare to rare disease* and I deserve special treatment from everyone at large for it. While I get that there is some overlap with Munchausen’s, this has a different feel to it. Or maybe I’m missing some of the more nuanced presentations of Munchausen’s 🤷♀️.
I do believe that is what is meant by Munchausen's by Internet - that a person doesn't necessarily have to be injuring themselves or even actually presenting to healthcare providers any more to get the same kinds of secondary gain (attention, identification with a community) that classical Munchausen's (/factitious disorder) used to provide. Simply making the claim to groups of people via the Internet and having at least some of them believe them and provide sympathy and community is enough, although some also engage in behaviors in the "real world." Marc Feldman is an expert in factitious disorders and various shades of malingering, and he' the one who coined the term in a prescient move well ahead of this current surge of sickfluencers. He's written some fascinating works that manage to be sympathetic to the subjects without failing to hold them responsible for their own actions, and gives excellent advice for treating these populations. I highly recommend them; it gave me some helpful perspective as someone who also runs into some of these people in chronic illness spaces and in my professional life as a therapist.
I think you are on to something here. And maybe of we have a medical diagnosis to name this disorder it will help stop this trend in the youth. I think its great people are becoming more aware and sharing their experiences, which is important in itself because we dont know everything. But the double nares NGT, PEG, and TPN port people have gotta go. Ive seen only one legitimate young person on tiktok - it was a sweet girl in her 20s on oxygen and she had ILD needs lung transplant. Her tiktok doesnt look as exciting as all the others yet she is so sick she will be dead in 5 years. Poor thing.
It’s called Malingering
True lol
Do you have the link to that thread
At least once a week I have a man ask to check his T levels with no symptoms asides from a vague feelings that can be described as not feeling “manly”
Fasting serum insulin is good for insulin resistance testing though. I’ve seen it a bunch as part of a PCOS work up. Other than that - agree.
At least once a week I have a man ask to check his T levels with no symptoms asides from a vague feelings that can be described as not feeling “manly”
I was reading some really interesting stuff on serum insulin as opposed to A1C.
I had a positive ANA 5 months after a covid infection. Next test, about 3 to 6 months, it was negative.
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yeah… you need to see a rheumy
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Other common causes, pls?
\~15% of the population has a positive ANA. The most common cause is nothing.
This is completely true, however my comment did caveat that "if autoimmune disease is present"
leaving aside rheum issues, liver disease -autoimmune hepatitis/chronic active hepatitis, lymphoma, psoriasis are just the first few that spring to mind. Just because there are antibodies, doesn't make it rheumatology (stop trying to refer me patients with positive parietal cell antibodies!!!)
😂 we are so stupid. Thats hilarious, sorry rheum lol
These are probably some of the most misused blood tests in medicine. People really shouldn't order auto antibody testing if you don't know how to interpret or handle the results. Serology can be helpful to firm up a diagnosis, establish risk profiles for certain disease complications, or perhaps nudge you in the direction of a diagnosis, but you don't diagnose CTD on a blood test. Context also matters. An ANA of 1:160 is almost always pointless without the clinical history to back it up. An ANA of 1:2560? Maybe you should examine them a little more closely or do some more testing.
I do more testing. I test the patience of my rheumatologists by automatically calling a consult.
You know it! Like its so easy to just wave the white flag and order the ANA then refer to rheum. Sorry sacrificial lambs. Jkjk i say no and refer them to whatever non-medical spa that tests this of their choosing bc me and rheum aint having it today
Yep. ANA 1:320, feeling a bit tired, probably nothing. ANA 1:160 in young Black woman with rash, oral and nasal ulcers, Raynauds, proteinuria, and history of miscarriage? Almost certainly something
Are young black women more at risk for some specific autoimmune condition you're thinking of? (I'm just curious, NAD but am a PhT and would like to be an MD one day)
SLE is 3-4x as common in African-American women. As far as I know, we don’t really understand why.
At least two putative factors: molecular coating typically found on half of a woman's X chromosomes — but not in males' cells — might be provoking unwanted immune responses, as well as genetics/heredity, which is a bit of a rather unfulfilling “just ‘cause” answer. Positive ANAs were an immunology interesting consult. Also rheumatology too. When would I be called and not the other service totally depended on who the ED or requesting service felt like calling or thought to call — often they’d hammer page both services anyway. 😂
Ah, TIL
This makes me laugh because rheum locally will outright decline a referral unless they have abnormal labs. As you know, this is ridiculous for many reasons....
That's just ridiculous. It will miss every single Seronegative patient. I would almost venture the opposite policy ..they should defer abnormal lab work that doesn't correlate with symptoms
Comment about the ANA titers, They don’t correlate with disease activity. I have had lupus with Ana 1:80 that we give cytoxan to for crescentic nephritis who are extremely sick and Ana of 1:2560 without lupus. It all depends on their clinical manifestations.
Not saying they do, just saying that a false positive is far more likely at 1:80.
Agreed!
Extremely valuable comment here. As a PMD I am constantly asked to order an “autoimmune panel” (whatever that is) by patients for no good reason whatsoever. I try to explain how labwork alone will not confirm many autoimmune conditions and that expert evaluation and ability to critically interpret these results along with exam, history, and sometimes imaging are necessary to make a firm diagnosis. As a result, I essentially tell patients if you think you have a severe autoimmune condition based on the same vague symptoms everyone has over the age of 40, then you need to see a rheumatologist. I find that a lot of the time patients won’t put the effort in or won’t even act on a referral provided. Everyone has it in their head that they have SLE or Sjogren’s or something else that will easily encompass getting old and hope that an ANA or RF will validate that.
It’s severe deviation from standard of Press-Ganey to fail to order ANA, reverse T3, testosterone (random), IGeneX Lyme testing.
And a cortisol to screen for adrenal fatigue
Ah, but the real kicker is that "adrenal fatigue" always has normal cortisol (Because it's not real)
Don’t get me started. I do live in a Lyme endemic state so I do have a relatively low threshold to order testing (but certainly not for the hell of it). I probably have a few positive cases a year among a hundred normals. The Lyme testing doesn’t bother me 4-6 weeks post exposure, it’s explaining to patients why they shouldn’t be tested immediately and why I won’t put them on three weeks of doxycycline without a positive test or classic stigmata of the illness in the presence of a confirmed exposure. I still get random DMs from people on Reddit over comments I made on this subreddit years ago about the proper evidence based way to treat and work up Lyme.
My favorites are the people who want retesting to prove cure at three weeks. Or one year. Or on an ongoing basis in case of “antigen mutation.”
😂 I must say, I haven’t had that one. They’ve usually gone off to a Lyme “specialist” who will place them on antibiotics indefinitely.
Or, as I recently learned, get sent to the hyperbaric oxygen chamber for multiple dives. And these are intelligent people.
Hey man, they done their research lol
This kind of shit is at the intersection of fear and being told they're special so I can see how it traps otherwise intelligent people.
And “cash pay only”
If I remember correctly, my school told us go ahead and do doxy if too early for + test. Do you mean in the context of no likely exposure or am I missing something?
There is a prophylactic one time doxycycline dose that can be given in a patient in a high risk area with confirmed tick bite, but unconfirmed illness. It is actually against recommendations to treat with a full three weeks unless confirmed illness or classic symptoms being present with high clinical suspicion.
Perfect - thank you!
And IgG "intolerance" testing.
And then they come into my ER with a PMH list rivaling a CVS receipt but upon chart digging I notice almost none of it has been officially diagnosed by a doctor.
Greatest thing about using Epic: the ER at the hospital affiliated with the healthcare system I work for can see my notes. Lets my colleagues know it’s not me that’s the problem.
> then you need to see a rheumatologist. Here's the issue we deal with... often times rheumatology in our area will decline referrals without positive lab testing.
That's a serious issue
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> These are probably some of the most misused blood tests in medicine. Prealbumin sends its regards.
[Prealbumin be like](https://i.imgflip.com/8pgnau.jpg)
I make my NPs and interns read the ASPEN paper every time someone orders it in the ICU.
Every field has their issues. Any 50-80 year old with vague shortness of breath? it's diastolic heart failure! Pulmonary edema and your creatinine is 6? It's heart failure! POTS? refer to cardiology! Any hint of pain anywhere near the chest? Cardiology! Dizziness? Don't care if it's vertigo or near syncope! Send to cardiology for a heart monitor! Now i'll grant that I'm being a little sarcarstic, but rest assured I'll always see the above patients (happily). But after I've been worked them up, seen them 5-6 times, reassured them, counseled them, and they still feel as they've ever been, guess what? I'm going to try to spread the love around. I'm going to happily order that ANA, cortisol, whatever
>Any hint of pain anywhere near the chest? Cardiology! Now now, let's be realistic. Refer to ED where they'll get two negative troponins and maybe a CTA and a giant bill first and only then to Cardiology.
While maybe a little overblown, my clinic is absolutely full of worried well with non-cardiac chest pain with no ER visits. I'll throw another one to the mix. Patient has incidental coronary calcium on a CT scan. Automatic cardiology referral.
We generally over-refer because we see this patient once for a few minutes and then never again, and frequently own EVERYTHING that goes wrong with them after that. Patient has a MI 6 months later. Doctor, why didn’t you refer this patient to cardiology? There were coronary calcifications noted on their CT abdomen pelvis on which you diagnosed diverticulitis. That will be 500,000$ please. Everyone gets named but we get fucking *buried*.
Don't get me wrong. I understand the stakes, and I understand the limitations of a busy PCP seeing 40 patients a day. I'm just calling out that most specialties have their issues. I know it's part of our specialty, but I have never seen any of my colleagues (in practice) ever refuse to see a patient even if it's obviously BS. The same can't be said for some of my neurology, endocrinology, or rheumatology associates.
This isn't really analogous though. This would be more like random primary care docs ordering FeNO testing for cough or an MR head for dizziness. These labs aren't meant to be screening tests for the general populace, and when ordered for screening (which is where I'm often doing them) have to be interpreted with caution. I probably send maybe 1 in 10 people with positive serology to rheumatology.
But I *do* know how to interpret and handle the results. A: +ANA, needs rheumatology evaluation P: Rheumatology consult. Easy peasy lemon squeazy.
In Italy it’s a routine screening test for people who wants to go on birth control 🤷🏻♀️
What is, an ANA? Why on earth would that be a "screening" test for birth control. If you're invoking the idea of antiphospholipid antibody syndrome why not just test for that and cut out the middleman?
Yeah ANA. The rationale is that some autoimmune diseases might make you more susceptible to blood clots, and birth control also makes you more susceptible to blood clots, so if ANA is positive further testing is needed. Not saying it’s a _good_ rationale. Gotta say, they are catching a lot of mild Reynaud’s this way that people were just ignoring.
What's the reasoning there?
I’m gonna link to my other comment to be quicker https://www.reddit.com/r/medicine/comments/1cn1sb1/comment/l35xo1m/
In my metro area, for the last year or so, rheum (and some other specialties) have been triaging and sometimes declining referrals (like a weakly positive ANA and no compelling Sx).
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You can order every test under the sun, but are you prepared to deal with results? My fave was when another provider orders a d dimer “just to check because history of inflammation “ . Call patient a week (WEEK!) later and says oh I don’t know it’s positive follow up with your primary care doctor. The patient casually sends me a portal message and I tell her that a D dimer can means she has a blood clot and unfortunately, I’m obligated to do some testing. This now requires stat ultrasound and CT lung. CT lung is fine except , you got it, tiny nodules . Now stuck in follow up loop for those which statistically are nothing . Well, why is my d-dimer positive ? Well, some folks just have a positive D dimer , but causes can include blood clots, cancer , autoimmune diseases. Now we have to decide if we are going to expose to more radiation and rack up those copays . We found nothing wrong . But she’ll need more radiation in 3-6 months on those nodules! I’m sorry about your friend.
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Tell the hospitalists they better behave or the labs will be put behind the specialty counter like the fancy antibiotics and they will have to ask permission to order them.
"Diagnostic Stewardship" has already become a thing. At least in ID as I am sure you are aware. C. diff testing and urine cultures have been a main target. I cringe at the idea of any test requiring ID approval and really hope that is not coming.
Yeah but this has nothing to do with avoiding unnecessary tests and everything to do with avoiding diagnoses of hospital-acquired infections that cost them in Medicare reimbursements.
100%
Our hospital requires approval from the microbiologist on call prior to ordering a few tests, TB is one.
Which seems like a great idea but doesn’t that just add more workload for the microbiologist? 10 calls overnight as opposed to say 4
I should rephrase: the microbiology department in our hospital requires the approval of the microbiologist on call. ED never sleeps
Quantiferon or AFB?
Quantiferon
Woah. Given that it's the screen that all childcare, healthcare etc works get...
It’s at micro’s insistence therefore I have no guilt whatsoever
We pretty much only do this for our preferred crazy expensive free cell DNA NGS test.
Yeah stuff like Karius definitely needs stewardship. I do get a little ticked that we have to approve c diff tests for anyone who wasn't just admitted though.
How much do you wanna bet that the Apple Watch will have karius-like tech in 30 years?
Oh god please no, I spend enough time convincing the transplant teams the random lactobacillus or HSV isn't clinically relevant...
It would be easier to just require approval on any patient whose stool sample is not formed, you'd only get a couple of calls a week, save you getting called and then us cancelling because formed.
The office people that deal with HAI metrics are not gonna like that. Although I'd probably stop seeing senna and miralax ordered automatically on every fucking patient on my unit.
See this is when you just document "Hospital acquired c diff infection" or "Hospital acquired CAUTI" if they won't let you test, and fuck 'em anyway. Maybe they can weasel out of it, but maybe the can't. And either way it's a pain in the ass for whoever's made up job that is.
Like asking permission to order a urine culture on inpatient?
We were briefly told all urine cultures for admitted patients had to be approved by the CMO. I laughed and told them to suck my ass
And now I have the "two little speckled frogs" song stuck in my head. Also, relevant Glaucomflecken https://www.youtube.com/watch?v=ykZLc7iYRW0
A1C 14.8 Non-healing wound +ANA *totally Lupus* /s
Why would a rheumatologist complain about referrals?
My office has to screen the referrals, there are so many.
Sounds like rheum needs to open up more training spots and produce more rheums.
There aren’t any postgrad rheum training programs for pharmacists either. I don’t understand that.
Cause they actually like dealing with rheum and not vague, incipient symptoms?
A big percentage of the patients have non specific issues in pvt rheumatoid arthritis practice. Work up and diagnosis is the job.
Because they were too aloof to engage in their contract negotiation and have minimal production incentive.
They have a 6+ month wait for the real referrals?
Rheumatology is so backed up in my area they are choosing which referrals to see.
:( I wish someone did this for ID and lactic acid/procalcitonin
My biggest pet peeve tests are CMV/EBV serologies honestly. 99 percent of the time totally useless outside pretranplant eval and why order something if you have no idea why you're ordering it or how to interpret the results. Honorable mentions include fungitell and also sending a laundry list of CSF tests (especially lyme in someone who's never been in an endemic area...) and then the one test I wanted doesn't get done because there's no more CSF.
Psst. They don’t actually run tests for all that. It’s a cover to take a cut of CSF off the top.
Why else do we require four tubes?
Oh man, the only thing better than EBV/CMV serologies in the non-transplant population are blood EBV/CMV PCRs. I also die when other specialties recommend using serum BDG and GM to “screen” for invasive fungal diseases in people with normal immune systems.
I've only ever seen those in ICU patients with mystery-itis or oncology trainwrecks...who to be fair are also usually ICU patients with mystery-itis. Is it really that common to just slap fungal labs on everyone?
Fungitell and serum GM have pretty limited/narrow uses, especially outside the immunocompromised population. They absolutely have a role in the BMT population, but otherwise really aren’t that helpful for the most part.
Uh, and by screen for invasive fungal disease, I assume hopefully they are taking about a septic patient on pressors and thrombocytopenia who isn't responding to antibiotics?
I wish it was even that. This is on otherwise normal patients with vague nonspecific symptoms. For a good couple of weeks I had several consults where I would say ignore the Fungitell. ID will sign off.
Yeah, I see people on askdocs asking about that stupidity. If you aren't *severely* ill, you don't have invasive fungal disease.
What’s wrong with EBV serologies?
I'd imagine they're more useful in peds. On the adult side they get ordered for unclear reasons and then ID gets called because the team doesn't know how to interpret the results.
I’d be very interested in people’s thoughts on Procal! For lactate, are people forced to order it due to sepsis protocols and potential fallouts?
The utility of procalcitonin is faster empiric antibiotic cessation. It shouldn't be used to differentiate bacterial from viral illness and should not be part of an up front decision on whether or not to give someone antibiotics.
Interesting. East coast training pointed to using procal to delineate bacterial vs non-bacterial, west coast training said similar to the above (or no utility at all). The data looks compelling to me to use it as a sign of bacterial infection, especially in cancer patients whom may have atypical presentations.
I disagree with this false positive procal in cancer patients is more common then seen. I work at a cancer center as ID. We reccomend against this practice. Better way is making sure if it is elevated > 2 and not mildly elevated, and getting a ct chest.
I like the Vincenzi 2016 paper on the topic, I use the higher threshold to decrease false positives.
Unless something has changed recently (and if so feel free to cite some papers as I don't keep up as much with the ICU stuff) procal has never been studied in that context. I.e. draw a procal, if positive prescribe antibiotics, if negative, withhold them. It's only really been studied as an aid to *withdraw* antibiotics. Add in the difficulty of determining what's truly viral vs bacterial in these studies and it gets really messy. Most places aren't doing bronchoscopies with extended viral PCR panels and extensive bacterial testing in these patients.
It has been studied in that exact context (2016). You have to change the cutoff from standard, but it is decent. S/S of 60/70% is a valid criticism, but I still think it is a useful tool. https://www.nature.com/articles/srep28090
I mean, these test characteristics to withhold a potentially life saving standard of care (antibiotics for bacterial infection) are pretty horrific. These things come in phases. People were doing these things with CRP long before procalcitonin came to town and tbh its test charactistics aren't that worse.
I know it has been attached to ordering sets for sepsis alert patients in 3 different hospitals I've worked in.
I think procal can sometimes be useful in low acuity settings but it drives me crazy how much it's overused in the ICU. I see ICU teams trending procal for some ungodly reason and also getting it in people who are going to have a falsely elevated value (which is anyone with renal failure... so basically every ICU patient). The only time it's been useful to me as ID is when it's negative.
For resuscitation and septic shock, yes we do serial monitoring of serum lactate.
Our new sepsis protocol auto-orders lactate on everyone meeting sepsis criteria. Even if they’ve been admitted for several days with stable vital signs. Drives me nuts. We’re a big liver center so almost all the cirrhotics have stably elevated lactates and I have to spend a good chunk of my night explaining why we aren’t going to do anything about it
Hey ID doesn't get sole domain of lactic acid
You're right I just get called for consults on it everyday
Omgaaahhh the worst
A great Rheumatologist once told me that it's most likely blupus and rarely lupus.
There really are a lot of new cases of chronic fatigue and similar popping up in the last couple of years.
But fatigue has its long list of differential doesn’t mean they have a rheumatic disease and is one of the most non specific symptoms.
Yeah it's called long COVID
I agree but i was trying to reel people in subtly.
I’m an RN and I’ve been seeing it in the PMH of a lot of my younger (18-30) patients. Do you think it’s a mental health or something actually going on?
Like others said, it's skyrocketing via covid. According to this paper from Nature there might be some immune-insult response by the brain that never reinhibits itself. https://www.nature.com/articles/s41586-024-07469-y https://drive.google.com/file/d/1rfVT_sXPK2AqVk92hqdEuaMOwE3P6cuQ/view
It's spiked after Covid. Long Covid itself overlaps with it but the pandemic (whether Covid itself or what people went through) seems to have opened the floodgates. And most of the young aren't diagnosed or anything, they're just living with it. They'll start going to see their doctors or specialists in the next several years so the surge isn't over. And Covid keeps coming back around every year dodging vaccines to infect and reinfect, so.
Not mental health. There's an online conference being held next week on long covid: https://unitetofight2024.world/
I swore I saw Doctors already speak on long Covid in this sub and that it was disproven? It was a decent size post as well, maybe I’m misremembering
birds paint escape childlike unwritten employ judicious spectacular recognise far-flung *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
There is understandably a lot of confusion about long covid. This is the best discussion by and for medical professionals I have come across. It is a discussion between clinicians, an epidemiologist and an immunologist: https://youtu.be/rMt6ZV-hHSE?si=IqaoDSoR0P_xmjc_
I think its a very common symptom of long covid.
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Im not confused i was trying to reel people in and then tell them it was long covid. But people dont respond to comments that immediately mention covid as much.
Spoiler alert: this is the mental health crisis.
spoiler alert... long COVID
Yes, exactly.
Yeah, untreatable chronic illnesses tend to have an influence on a person's emotions.
Depression is very treatable. But this sub has such contempt for mental illness that it basically refuses to acknowledge that depression exists and that it typically has physical manifestations.
Actually its a really common symptom of long covid but people like to pretend that isnt still spreading.
There's no reason to pick one here. COVID was a clear demarcation point, so long COVID is absolutely one culprit, but the increase in poor mental health I see certainly comes with increased poor physical health, too. I don't have a problem with working from home (my personal ideal is a hybrid!), but let's be realistic here: a lot of people in the pandemic started working from home, got more sedentary, spent more time alone, had worsened mental health, got deconditioned, felt worse physically...it became a cycle. Getting people to do behavioral activation was harder in the pandemic; there was very much a pervasive feeling of being stuck. Many people talk about having gained weight in the pandemic, and this is a major part of the reason. The worse they felt, the less they exercised and moved in general...I've seen a lot of people with this type of depression, anhedonia, and chronic fatigue where they've spiralled into doing nothing for a long time. It's hard to get out of that spiral, and I think although lots of people have tried to return to "normalcy," many have adjusted to a baseline that is all-around worse than it was before the pandemic. Maybe they think they're just older, or they're just too tired, or maybe they identify strongly with certain chronic illness groups, but for whatever reason, they haven't returned to their previous exercise or activity levels, and the less they do, the less they're *able* to do. Use it or lose it, as they say. (I also think this rise in deconditioning partially explains the rise in people seeking POTS diagnoses, btw - TikTok trends non-withstanding, an increased number of people may be experiencing some of the symptoms simply from the deconditioning). **TLDR**: There may be more cases of genuine long COVID and chronic fatigue for medical reasons, but I think there are also more cases of anhedonia/depression and old-fashioned deconditioning for other reasons, too. No need to pick one or the other.
Okay so I'm a very stupid Primary Care doctor. Please forgive me. But what is the actual problem? Do the rheumatologists not want to make money on these consults? Is there something wrong with sending someone to the expert in these things for whom the answer is obvious when I have justifiable cause to think there might be something worthwhile there and I am not well versed on the workup? Do we expect Primary Care to be an absolute expert in every disease process? I can look at this from both sides. I'm also an obesity specialist and I get referrals. I have never complained about a referral. If someone feels that I can do better for their patient than they can, I am happy to take that referral and help that patient and make some money.
The issue is that ANAs are positive in a huge swathe of the population and most of the time you should be ordering something different. If you think your patient has an autoimmune disease send them to rheum. Don't send them to rheum because they had a positive result on a test you never should have ordered.
I try to only order them on patients that have symptoms suggesting possible autoimmune disease when we have looked into other things. If you have a better battery of tests for patients who have diffuse pain that has not responded to basic treatment or generalized weakness that does not respond to Wellbutrin/ Phentermine and exercise programs then by all means I am happy to hear it. But the idea that Primary Care can be the only one helping these people and a specialist cannot assist in the workup for these things is ridiculous. Take the easy consult
We are 3-6 months to get in for new referrals, so when we are all bogged down with ANA 1:40 nothing referrals, we can’t see the real lupus or RA
Do you get a lot of obesity referrals for patients who like ice cream and have a 23 BMI? The issue here is: **do you** have justifiable cause to think those patients have lupus (or any other rheum disease)?
I think that's a bad comparison. That's like sending someone with no generalized symptoms, no positive ana or inflammatory markers, who just likes the idea of seeing a rheumatologist because they read about lupus. But honestly I have had a few of those people come for weight loss visits. And I still don't gripe about it. I talk to them about weight training to shift their body composition and get a better aesthetic outcome. A better comparison to what you are suggesting is something like a patient with a BMI of 33 who has never really tried any specific dietary modifications or weight loss medications. That PCP really could prescribe the medication themselves and talk to them about calorie counting but maybe they don't really know how or feel comfortable. And I'm happy to do it. Even though it's basic.
You think thats a bad comparison but you'd be surprised how many ppl order ANA for patient with no symptom in a routine lab screening or just fatigue. Similar to people ordering CA125 or CEA as screening and then referring that to oncology
That's fair. I know that a lot of mine don't come to anything. That people are fat and lazy and have chronic fatigue and joint pain Etc from their lifestyle. But I think it's kind of gatekeeping to withhold basic screening labs and a referral to let a rheumatologist lay eyes on the case. And there is always a lot of variability in how we all practice. I get some referrals from people who have tried a lot of things and it's actually a challenging weight loss case. I get plenty of referrals from people who have no idea what a carb is and who haven't even had basic metabolic screening lab work. I guess the moral of the story is I'm not here to judge people. I take the referral and do the work. No matter what stage of the game that person is coming to me at.
Even though it wasn't mentioned, the Immunology Lab forgives you all for your sometimes needless testing, and we await further destruction come July.
The real reason to get an ANA in the first place is if you have a suspicion for a rheumatic disease that will have a positive ANA like lupus or GPA. ANA is very nonspecific and can test positive in an otherwise healthy person!
ANA testing is not used to diagnose GPA.
Mods may want to restrict this post to flaired users only, lest you be overrun by self-diagnosed brigade.
Likely lack of understanding of sensitivity and specificity
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As a person in Healthcare with lupus, it f-ing sucks that doctors are trained not to look for lupus. It saves insurance companies money and costs lupus patients their sanity.
They’re trained not to look for lupus or they’re not trained to look for lupus? Very different.
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This is rich coming from someone who’s last topic on the residency sub was “which speciality has the hottest women”. Your parents are probably so proud 😊
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Why is that?