Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...
How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?
This is a challenging scenario that we often see in clinical practice with our current multiplex assays. A great reference is the following ACR abstract: Clinical Significance of RNP Antibodies in Diagnosis of Systemic Autoimmune Rheumatic Disease When Detected By Multiplex Immunoassay. As demonstra...
When is a paraneoplastic panel indicated when working up patients with neuromuscular conditions?
How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?
Another important consideration is the methodology by which the anti-dsDNA antibody was assessed. Most commercial labs use EIA, which is sensitive but not as specific as Farr or Crithidia assays. Many positive EIA results are negative when checked by these more specific methodologies.
How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?
This could easily be a person with early (evolving) ANA-negative SLE (depending on the dsDNA titer) or early UCTD. If the dsDNA titer is low my concerns are somewhat diminished. I certainly would not assign a diagnosis of SLE given the information provided, with special reference to the person's anx...
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
Is there a role of maximizing GDMT medications for patients with durable VADs?
Yes. There is a role both to (1) reduce morbidity and mortality in patients with heart failure supported with durable LVADs and (2) the potential to promote myocardial recovery concomitantly with mechanical unloading provided by the LVAD. There is no published, prospective, RCT outcomes data yet to ...
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
Do you use direct oral anticoagulants to treat port-a-cath related VTE in patients with an active malignancy?
The initial trials that established DOACs as effective and safe in most patients with cancer-associated thrombosis (Agnelli et al., PMID 32223112, Planquette et al., PMID 34627853) only included patients with lower-extremity DVT or PE but clearly showed equivalence to low-molecular weight heparin (w...
In patients with possible Bartonella henselae infection and elevated IgG titer, what is the best way to confirm the diagnosis: tissue biopsy with Warthin-Starry staining, tissue sent for Bartonella henselae PCR, or tissue sent for culture?
First of all, it is important to only test people with a compatible clinical syndrome. If the syndrome is not that of babesia, then any positive tests are likely to be false positives. This is a basic testing principle. A very low pretest probability is likely to lead to false positive testing. The ...